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Acute low back pain is one of the most common reasons for consulting a primary care physician in the industrialized countries. The direct cost of medical care and the indirect costs to society of absenteeism from work due to backache are huge. Physicians commonly prescribe bed rest for acute low back pain, although only a few controlled trials have assessed its effectiveness. Among military recruits with acute low back pain, bed rest led to more rapid recovery than remaining on foot. In a family practice, patients presenting with acute low back pain did not benefit from either bed rest or isometric flexion exercises. Two days of bed rest produced as good clinical recovery as did seven days of rest and, moreover, was associated with fewer days lost from work. In patients with acute low back pain, back-extension exercises were superior to education about back care, but a study comparing exercise therapy with placebo found no difference.

The controversy persists over the relative merits of bed rest and exercise in the treatment of acute back pain. Many leading experts suggest two days or less of bed rest, whereas others advocate back-extension exercises. The present study was designed to compare bed rest with rapid mobilization in the management of acute backache. We conducted a randomized, controlled trial of the effectiveness and costs of two days of bed rest as compared with those of light back-mobilizing exercises in patients with acute low back pain. A third group of control patients was advised to avoid bed rest, not to engage in mobilizing exercises, and to continue normal activity to the extent that they were able to tolerate it.

Article title:
THE TREATMENT OF ACUTE LOW BACK PAIN – BED REST, EXERCISES, OR ORDINARYACTIVITY?

Authors:
Antti Malmivaara, M.D., Ph.D., Unto Häkkinen, M.Sc., Ph.D., Timo Aro, M.D., Ph.D., Maj-Len Heinrichs, R.N., Liisa Koskenniemi, M.D., Eeva Kuosma, M.Sc., Seppo Lappi, M.D., Raili Paloheimo, M.D., Carita Servo, M.D., Vesa Vaaranen, M.D., Ph.D., and Sven Hernberg, M.D., Ph.D.

Journal/Source:
N Engl J Med 1995; 332:351-355

Discussion:
Acute low back pain is one of he most common primary care physician consults in industrialized countries.  This study looks at three modalities for treatment: bed rest for two days, back extension exercises, and continue with ordinary daily activities as tolerated as the control.  Most experts suggest up to two days of bed rest, while others advocate for extension exercises.  Here, a randomized study was performed to evaluate the most cost effective method for treating acute low back pain.  The findings were that having the patients continue with ordinary activities within their limit of pain lead to more rapid recovery at both three and 12 weeks from the initial visit, in terms of missed days from work, the ability to work, and tolerance for back flexion.

Questions:
What were the exclusion criteria for the study?
Even though the study was randomized, how were the groups different?
In what spinal pathologies would you prescribe flexing exercises, and when would you prescribe extension exercises?

Reviewer:
Richard C. Swedarsky, OMS-IV, NYCOM, Educational Committee Co-Chair, AOCPMR Student Council