Reason for withdrawal from publication
May 11th, 2010
Merged with: Hilde G, Hagen KB, Jamtvedt G, Winnem M. Advice to stay active as a single treatment for low‐back pain and sciatica. Cochrane Database of Systematic Reviews 2002 , Issue 2 . Art. No.: CD003632. DOI: 10.1002/14651858.CD003632.pub2. to form new review: Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low‐back pain and sciatica. Cochrane Database of Systematic Reviews 2010 , Issue 6 . Art. No.: CD007612. DOI: 10.1002/14651858.CD007612 .
The editorial group responsible for this previously published document have withdrawn it from publication.
Feedback
from Dr Roderick MacDonald, UK, Oct 6, 2004
Summary
There are many problems with this review, the most important being that it comes to the wrong conclusions that have been translated into sloganised advice for patients that probably harms many.
Derived from this review is the statement that bed‐rest may bring symptomatic relief for sufferers but is not a treatment [RCGP Guidelines pamphlet]. Wiesel's trial [1] contradicts that by showing that the rate of recovery of function is doubled by bedrest in most sufferers and in those who cannot stand without pain this effect is many more than twofold ‐ many will not recover until they recline and unload the dysfunctioning structures. Twenty years later Wiesel stands by the results of his trial and few specialist in the field of back pain who manage acute patients would disagree.
However this trial is criticised for being an unrealistic experiment whose results cannot be extrapolated to clinical practice. It is indeed unusual in accessing such a homogeneous group of sufferers whose subsequent management can be controlled so precisely within the milieu of military discipline and apart from many of the psycho‐social pressures that impact on back sufferers. It is unusual in the prescription of bed‐rest until full recovery rather than a graded return to activity. However it is these unusual features that reduce the mass of uncontrolled variables that afflict most trials in this area and allow the effect of bed‐rest alone to be studied. It is therefore the most fastidious of trials and one could postulate that it is for that reason that the supposedly heterogeneous "simple" back pain shows such clear divisions between the various strata and treatment groups. Wiesel's trial is on the record as demonstrating the largest of any treatment effect so far measured in the field of back pain. Its results should only be discounted if stronger trials contradict it; there have been none.
The major problem with the trials used to counter Wiesel's findings is that they do not test the option of avoiding bedrest; control groups have taken bed‐rest often to an extent that exceeds the amount that proponents of bed‐rest as a treatment would advise.
One wonders whether the BMJ would have accepted Gilbert's paper [2] purporting to demonstrate the ineffectiveness of bed‐rest if they had known that the non‐bedrest group had had on average over five days in bed, a figure omitted from the paper and now beyond the author's recollection when questioned. It is however contained in his physiotherapist colleague's paper published two years later [3].
Deyo's paper [4] advises patients in the bed‐rest group to take seven days of rest compared with two for the control group. In the event the controls take more than advised and the rest group less. The main outcome measure of return to work is surely hopelessly contaminated when the average bedrested subject returns to work one and a half days before the protocol suggested they should even get out of bed.
Vroomen's study [5]is concerned with patients whom the researchers had already decided were suffering from a lumbosacral radicular syndrome so are in strange territory in a review used to inform those managing non‐specific low back pain.
The importance of accepting the influence of rest in the recovery from back pain is in educating patients to take control of a process of appropriate rest followed by progressive resumption of activities. Inaccurate information about this process that is contradicted by their experience leads to loss of confidence in medical advice and confusion. Those doctors in general practice vocational training who wish to practise evidence‐based medicine according to guide‐lines are also becoming confused when they find their experience clearly confounding the "evidence" they must regurgitate in order to succeed in their specialty.
The format of this response is not ideal for a full review of the situation; I would be happy to forward my discussion paper on this subject that has already been sent to the principal authors of the RCGP Guidelines, the RCGP Journal, the Lancet, and the BMJ. No criticism of the factual content of this paper has been offered to me by reviewers or authors. The consensus response has been that at community level the simple advice, to stay active and confront pain, reduces disability and its social costs so that no criticism of the supporting reviews is acceptable. For those concerned with the management of individuals this cannot be accepted as ethical practice.
References:
[1]Wiesel SW, Cuckler JM, Deluca F, et al. "Acute low back pain. An objective analysis of conservative therapy." Spine 1980: 5 : 324‐30
[2] Gilbert JR, Taylor DW, Taylor W, Hildebrand A. "Clinical Trial of common tretaments for low back pain in family practice." BMJ 1985; 291 : 791‐4.
[3] Evans C, Gilbert JR, Taylor W, Hildebrand A. "A randomized controlled trial of flexion exerrcises, education and bedrest for patients with acute low back pain." Physiotherapy Canada 1987; 39 : 96 ‐ 101.
[4] Deyo RA, Diehl AK, Rosenthal M. "How many days of bedrest for acute low back pain." New England Journal of Medicine 1986; 315 : 1064‐70.
[5] Vroomen PC, de Krom MC, Wilmink JT, Kester AD, Knottnerus JA. "Lack of effectiveness of bed rest for sciatica." New England Journal of Medicine 1999; 340(6): 418 ‐ 23.
Reply
Thank you for taking the time to read and comment on our review.
I draw your attention to the fact that the review has been updated in The Cochrane Library 2004, Issue 4. Based on the new analysis of the data, the authors reached the conclusions that: 'Advice to rest in bed is less effective than advice to stay active for people with acute LBP. Further research is unlikely to change our confidence in this result. For patients with sciatica, there is little or no difference between advice to rest in bed and advice to stay active.' The authors still chose not to incorporate the data from Wiesel's trial into their meta‐analysis because the trial had a high risk for potential bias when assessed for quality of internal validity and the setting and the population was quite unique compared to the general population.
Cochrane reviews analyze the data and base their conclusions on these results. They are not recommendations for care. Guideline developers use the results as an evidence base to provide recommendations for care, but take a number of factors into account besides the evidence.
Contributors
Dr Kåre Birger Hagen, 1st author of the review, submitted his response October 28, 2004. It was included in The Cochrane Library Issue 1, 2005
What's new
| Date | Event | Description |
|---|---|---|
| 11 May 2010 | Amended | Merged with: Hilde G, Hagen KB, Jamtvedt G, Winnem M. Advice to stay active as a single treatment for low‐back pain and sciatica. Cochrane Database of Systematic Reviews 2002 , Issue 2 . Art. No.: CD003632. DOI: 10.1002/14651858.CD003632.pub2. to form new review: Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low‐back pain and sciatica. Cochrane Database of Systematic Reviews 2010 , Issue 6 . Art. No.: CD007612. DOI: 10.1002/14651858.CD007612 . |
History
Protocol first published: Issue 1, 1999 Review first published: Issue 2, 2000
| Date | Event | Description |
|---|---|---|
| 23 November 2009 | Amended | Contact details updated. |
| 10 June 2008 | Amended | Converted to new review format. |
| 1 August 2005 | New citation required and conclusions have changed | Aug 2005: For comparison 2, the level of evidence for the results "that advice to rest in bed has little or no effect on pain, compared to advice to stay active" was upgraded from moderate quality to high. |
| 19 October 2004 | Feedback has been incorporated | See Feeback section. Feedback added: 06/10/04 Response to feedback added: 19/10/04 |
| 31 July 2004 | New citation required and conclusions have changed | There is now high quality evidence that bed rest is less effective than staying active for patients with acute low‐back pain. For patients with sciatica, there is high quality evidence that bed rest,compared to staying active, will have little or no effect on pain and functional status. |
| 31 July 2004 | New search has been performed | Compared to the previous version of this review, three substantial changes have been made. First, two new studies (Hofstee 2002 and Rozenberg 2002), with a total of 528 patients, have been included. Second, based on the feedback and criticism on the previous version, we have done separate analyses for patients with acute (simple) low‐back pain without neurological deficits and patients with verified neurological deficits (sciatica). Finally, the quality of evidence was assessed according to a recently developed systematic and explicit method (GRADE system, The GRADE Working Group). These changes altered the conclusions in this review. |
Sources of support
Internal sources
Directorate for Health and Social Affairs, Norway.
External sources
No sources of support supplied
Withdrawn from publication for reasons stated in the review