Commentary

Boden, Scott D. MD

Journal of Bone & Joint Surgery - American Volume:
Evidence-Based Orthopaedics
Author Information

The Emory Spine Center, Emory University School of Medicine, Atlanta, Georgia

Article Outline

Low-back pain is endemic in civilized countries and is the most costly musculoskeletal ailment in patients receiving Workers' Compensation 1. Few treatments for acute low-back pain have survived the test of evidence-based medicine and demonstrated an improved outcome superior to that of the natural history, which is generally quite favorable. Bed rest is one of the oldest treatments for acute low-back pain and remains a recommendation in many treatment protocols.

The study by Rozenberg and colleagues adds to a growing trend in the literature to question the utility of bed rest as a treatment for acute low-back pain. In 1980, a study suggested that bed rest was beneficial for acute low-back pain in military personnel 2. Deyo and colleagues showed that 2 days of bed rest were equivalent to 7 days of bed rest 3. Malmivaara and colleagues concluded that continuation of normal activities was superior to bed rest or mobilization exercises 4. Thus, the results reported by Rozenberg and colleagues should not be a surprise.

A relevant clinical question is whether bed rest is advisable for any individual patient with acute low-back pain. All of the aforementioned trials studied groups of patients. If there were a small subset of patients who would do better with brief bed rest, it would not be possible to determine. Thus, common sense should prevail, and individual patients who desire bed rest or who appear to be candidates who might benefit from bed rest should be considered for treatment with up to 24 hours of bed rest followed by increased activities as tolerated. Patients should be told that rapid return to normal activities is associated with less disability and does not seem to increase the risk for relapse. We must ensure that patient counseling involves accurate information, not old ideas or misinformation.

1. Wiesel SW, Boden SD, Feffer HL. A quality-based protocol for management of musculoskeletal injuries. A ten-year prospective outcome study. Clin Orthop , 1994;301: 164-76.
2. Wiesel SW, Cuckler JM, Deluca F, Jones F, Zeide MS, Rothman RH. Acute low-back pain. An objective analysis of conservative therapy. Spine     , 1980;5: 324-30.
3. Deyo RA, Diehl AK, Rosenthal M. How many days of bed rest for acute low back pain? A randomized clinical trial. N Engl J Med , 1986;315: 1064-70.
4. Malmivaara A, Hakkinen U, Aro T, Heinrichs ML, Koskenniemi L, Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V, et al. The treatment of acute low back pain-bed rest, exercises, or ordinary activity?. N Engl J Med , 1995;332: 351-5.
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