Chronic back pain: does bed rest help?

If your patients with uncomplicated back pain get relief with bed rest and pain relievers yet you are told that bed rest doesn't help, you are not alone in your belief. When researchers from the University of Washington surveyed several thousand physicians about back pain management, most believed in the utility of prolonged bed rest along with muscle relaxants and narcotics.^1,2 Despite a plethora of research intended to guide physicians in their management of back pain, physicians still hold strong non-evidence based beliefs dating back to the 19th century.

Uncomplicated back pain is common—the fifth most frequent reason patients visit their doctor, accounting for nearly 3% of all office visits.³ By uncomplicated we are referring to back pain that does not radiate below the knee in an otherwise healthy person between the ages of 20 and 55. Of course, primary care physicians treat only a small proportion of uncomplicated back pain; many patients go to orthopedists, chiropractors, physical therapists, and massage specialists. In fact, when studies have looked at outcomes of uncomplicated back pain, 95% of patients recover in 6 months (most within 30 days) regardless of health care provider or intervention. The specialty of the provider, however, was strongly linked to the number of visits, the cost of care, and patient satisfaction. Orthopedists had the fewest number of office visits, the greatest costs associated with care, and the least patient satisfaction. Chiropractors had the lowest cost per visit (although total care was equal to primary care physicians) and the greatest patient satisfaction. Orthopedists and chiropractors were far more likely to order tests and radiographs than primary care providers. The cost of care for uncomplicated back pain for orthopedists was $756 compared to $783 for chiropractors and $508 for primary care physicians.⁴.

There is strong evidence that prolonged bed rest does not improve outcome (pain, disability, days missed from work, or functional ability). One randomized controlled trial⁵ comparing bed rest, exercise, and routine care showed that bed rest was associated strongly associated with three negative outcomes (more days off from work, intensity of pain, and disability). The next question is, if bed rest does not help, is there benefit to active exercise/physical therapy? The answer is less strong, but 14 of 18 controlled studies do report that active exercise can improve outcomes.⁶ Further, research suggests that specially tailored active exercise may result in fewer episodes of back pain in the future.⁷

Is there a role for imaging studies? Not in uncomplicated back pain, so say the studies and expert consensus panels.⁸ What about TENS units, ultrasound, massage, and cosset use to treat back pain? The one randomized controlled trial that looked at these treatment modalities found that those with more intensive contact with a provider resulted in the greatest satisfaction but that there were no significant differences in objective outcome measures.⁹

So although some patients may need to temporarily modify their activity during the acute phase of back pain, most should be encouraged to avoid bed rest and resume normal activity as soon as possible. For those so motivated, an active exercise program appears to improve outcomes and speed recovery.