Posted on 26 Nov 2010 20:25
By Sylvia Ho
Principal Physiotherapist, Core Concepts Group
Low back pain is one of the most common reasons for consulting a physician. Despite little supporting scientific evidence, bed rest was considered the primary treatment from the late 19th century. What has changed now is how back pain is understood and managed.
History of Back Pain and Rest
Rest was first proposed as a treatment by John Hunter (1728-1793), a Scottish surgeon, in his study on wounds and inflammation. He believed that the first and most important requisite for restoration of inflamed, injured parts is rest, as rest is necessary for repairing injured parts. This proposed idea of rest as a treatment was further amplified by John Hilton (1804-1878), a British surgeon, in his 1862 series of lectures on "Rest and Pain" to the Royal College of Surgeons. He claimed that it is the natural treatment for the inflammation of injury and wounds.
Their theory of injury leading to an inflammatory response that requires rest to heal the body had a huge influence throughout the field of medicine even though their works revolves around only on inflammation and wounds. Physicians all over the world started to use rest as a treatment for a wide range of conditions, from myocardial infarction to normal childbirth.
Throughout the 19th century, the orthopedic principle of rest became dominant. The rationale of rest for back pain started from the idea that pain was due to injury. With injury, inflammation occurs and thus rest was essential for healing. If the primary injury was not properly treated with rest, chronic pain would develop. It was believed that movements, physical activities and repeated back injuries during the inflammatory phase may increase pain and so must be harmful, and thus should be avoided.
This thinking was later applied in the treatment of a ruptured disc, where the disc "comes out". The idea was that with bed rest, i.e. lying down, disc pressure is the lowest and the disc will somehow "go back". Unfortunately, there was no scientific evidence back then to support bed rest as treatment. Orthopaedic doctors just followed with what was taught to them, i.e. bed rest. By 1900, a standard orthopaedic text was published and recommended two to six weeks of bed rest for acute back pain.
Doubts Form in Approach
Although some doctors during the 19th century did question the use of bed rest, it was not until the 1980s that its efficacy as a treatment for back pain began to be seriously questioned. However, many then still felt that some rest was necessary, and initial studies only questioned the amount of rest that was needed rather than whether it was needed at all.
In 1986, Deyo et al were the first few to investigate the use of bed rest in low back pain. The study compared the functional status and symptoms of a group that received 7 days of bed rest with a second group that received 2 days of bed rest. No difference was found between the two groups in terms of the functional status and symptoms. This later formed the basis for several guidelines that advise no more than 2 days of rest for patients with acute low back pain.
Over the years, studies have emerged showing that bed rest of any duration is not effective for low back pain and that it often delays recovery. In fact, other than delayed recovery, prolonged bed rest can also have detrimental effects on the body. Patients with prolonged bed rest may end up with osteoporosis (bone calcium loss), muscle wasting due to muscle protein loss, deep vein thrombosis and undesirable psychological effects.
So the question now is, if bed rest has been shown to be detrimental and ineffective as treatment, would early activity be better?
Several studies have looked at the effects of advice to stay active in the treatment of acute low back pain and found that advice to stay active was better or similar to advice to rest in bed. In an update of a 2004 Cochrane Review of trials on bed rest for acute low back pain and sciatica, it was found that for patients with acute pain, advice to rest in bed was less effective in reducing pain and improving an individual's ability to perform every day activities than advice to stay active. For patients with sciatica, there was little or no difference between advice to rest in bed and advice to stay active.
For chronic back pain sufferers, exercise therapy has been supported by good evidence to reducing time taken to return to work and improving functional status. Patients prescribed with graded exercises have been shown to return to work sooner, have less disability, and have fewer pain complaints than patients treated with medications and bed rest.
Given the extensive research done in recent years, there is rising evidence to point towards avoidance of bed rest for the management of back pain. Advice on early, progressive activity, with no more than 2 days of bed rest, will serve as the preferred current approach.
1. Allan, David B. and Waddell, Gordon(1989). A historical perspective on low back pain and disability',Acta Orthopaedica,60:3,1-23.
2. Deyo RA, Diehl AK, Rosenthal M. How many days of bed rest for acute low back pain? The New England Journal of Medicine 1986; 315:1064-1070.
3. Gorden Waddell. The Back Pain Revolution. Churchill Livingstone, New York. 1999.
4. Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-back pain and sciatica. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD001254. DOI: 10.1002/14651858.CD001254.pub2.
5. Lindstrom I, Ohlund C, Eek C, et al. Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain: a randomized prospective clinical study with a behavioral therapy approach. Spine 1992; 17:641-652.
6. Lindstrom I, Ohlund C, Eek C, et al. The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavorial approach. Physical Therapy 1992; 72:279-293.
About Core Concepts - Musculoskeletal Health Group
Core Concepts is a leading private physiotherapy group specialising in musculo-skeletal health. Core Concepts group was established in 2003 to specialise in musculo-skeletal health. Today with over 7,000 clients and 3 clinics centrally located in Shenton Way, Parkway Parade and Novena Square, Core Concepts is one of the largest private musculo-skeletal group in Singapore. Core Concepts group has 5 divisions catering to the 5 distinct areas of health related to the human muscle and skeletal system:
- Core Concepts - Physiotherapy Centre (http://www.coreconcepts.com.sg),
- Back2Sports for Sports Injury management (http://www.back2sports.com.sg),
- Strong Massage - Sports Massage for Sports People
- Etonia for Pregnant Women and
- Cerebral Care - Home Based care for Stroke and other Neurological conditions.
For more information, please contact:
Core Concepts Pte Ltd
73 Tras Street, #02-01 Singapore 079012
Tel: +65 6226 3632
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This page created 26 Nov 2010 20:25
Last updated 29 Jan 2017 01:31