Cochrane Database of Systematic Reviews

Advice to stay active as a single treatment for low-back pain

and sciatica (Review)

Hilde G, Hagen KB, Jamtvedt G, Winnem M

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 2006, Issue 2. Art. No.: CD003632.
DOI: 10.1002/14651858.CD003632.pub2.

www.cochranelibrary.com

Advice to stay active as a single treatment for low-back pain and sciatica (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
REASON FOR WITHDRAWAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Advice to stay active as a single treatment for low-back pain and sciatica (Review) i
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Advice to stay active as a single treatment for low-back pain

and sciatica

Gunvor Hilde1 , Kåre Birger Hagen2 , Gro Jamtvedt3 , Michael Winnem4

1 Calgary, Canada. 2 National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, 0319 Oslo, Norway.
3 Norwegian Knowledge Centre for the Health Services, Oslo, Norway. 4 GSK, Pb, Oslo, Norway

Contact address: Kåre Birger Hagen, National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, PO
Box 23 Vindern, 0319 Oslo, Norway. k.b.hagen@medisin.uio.no.

Editorial group: Cochrane Back and Neck Group.

Publication status and date: Withdrawn from publication for reasons stated in the review, published in Issue 6, 2010.

Citation: 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 2006, Issue 2. Art. No.: CD003632. DOI: 10.1002/14651858.CD003632.pub2.

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

The editorial group responsible for this previously published document have withdrawn it from publication.

REASON FOR WITHDRAWAL

May 11th, 2010
This review has been merged with:Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-back pain and sciatica.
Cochrane Database of Systematic Reviews 2000 , Issue 2 . Art. No.: CD001254. DOI: 10.1002/14651858.CD001254.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 .
__________________________________
Feb 3/06 - contact author notified that review will be withdrawn in the submission this month since last lit search was in 1998. Updated
review will be published once submitted and approved. VEP
~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Cochrane Review: Advice to stay active for low back pain and sciatica
A Commentary by the Editorial Board of the Cochrane Back Review Group.
This is a methodologically sound review that has produced what to many readers will appear to be a surprising conclusion. Although the
authors qualify it in the detail of the text, the main message that comes across is that there is no scientific evidence or significant clinical
benefit for patients with back pain to stay active! This is contrary to all other systematic reviews (Abenhaim et al 2000, Nachemson
& Jonsson 2000, Waddell & Burton 2000) and international clinical guidelines (Koes et al 2001) which state there is strong evidence
that patients with acute LBP should be advised to avoid bed rest if possible (certainly for more than a few days), to stay active, and to
get on with their ordinary activities as normally as possible.
The reason appears to be methodological. This review focuses very specifically on RCTs where one group had advice to stay active
as a single treatment with no co-interventions. That review design originally appeared logical and reasonable and was approved by
the editorial group of the Back Review Group, but it has had unforeseen consequences. In clinical practice and scientific trials, it is
unusual to offer such advice in isolation without any other symptomatic or supportive measures, so it is understandable that criteria has
Advice to stay active as a single treatment for low-back pain and sciatica (Review) 1
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
included a very limited group of four, highly selected and heterogeneous RCTs in the review. Only one of the four trials (Malmivaara
1995) was a balanced study of three interventions, one of which was specific ’advice to stay active’ - to ’continue their routines as
actively as possible within the limits permitted by their back pain’ - and that was the most effective intervention. The other three
RCTs were actually trials of bed rest and the control groups were given various alternative instructions contrary to bed rest. Wiesel
(1980) used an unrepresentative group of army recruits in an army setting (which is the only RCT in favour of bed rest compared
with remaining ambulatory): that control group was ’assigned a restricted-duty status that eliminated all physical exercise’. The control
group in Wilkinson (1995) were simply ’encouraged to keep mobile and to have no daytime rest’. Vroomen (1999) was a trial of acute
disc prolapse and the control group consisted of ’watchful waiting’ with ’instructions to be up and about whenever possible but to
avoid straining the back or provoking pain’. With these very different interventions, it is hardly surprising this review of four RCTs did
not show any clear effect of ’advice to stay active’.
This illustrates the tension frequently encountered in Cochrane reviews between lumping or splitting of the available evidence: broad
inclusion criteria may lump together trials that are too heterogeneous while narrow inclusion criteria, as in this review, result in an
incomplete analysis of the available evidence. Putting the four trials included in this review into the broader available evidence about
rest or staying active produces very different conclusions.
The Cochrane Review of bed rest for acute back pain (Hagen et al 2000) included 9 RCTs which showed unanimously (with the
exception of Wiesel) that bed rest was ineffective. That review concluded there was strong evidence against bed rest and indeed is the
only Cochrane review in this field to state that the evidence is now so strong there is no need for any further studies. If there is such
strong evidence against bed rest, the corollary is that patients should stay active instead.
The exclusion of any trials with co-interventions also discounts the large number of RCTs which show that multi-disciplinary inter-
ventions are effective in sub-acute LBP (Waddell et al 1997). A key element of these packages is progressive increased activity and
rehabilitation (Abenhaim et al 2000, Nachemson & Jonsson 2000, Waddell & Burton 2000). It ignores the evidence on the effectiveness
of exercise for chronic LBP (van Tulder et al 2000). It ignores recent evidence on innovative educational approaches based on advice
to stay active and get on with normal life (Burton et al 1999, Moore et al 2000, Buchbinder et al 2001).
There are a number of areas where the evidence is unclear and further research is required. There is lack of conceptual clarity between
avoiding bed rest, positive advice to stay active and simply letting patients get on with normal life. There is lack of evidence on the
exact nature and form of advice that is most effective. What is the relation between advice, information and education? How should
advice to stay active be combined with symptomatic measures and what is the best package of interventions? How does advice to stay
active relate to work? That all needs to be set in the context of the entire time course from acute to subacute to chronic low back pain
and disability. Clinical management must be integrated with occupational health management.
Most important, however, this Cochrane review should not undermine current teaching. The best scientific evidence available at present,
and all evidence-based guidelines agree, is that patients with acute LBP should be advised to avoid bed rest if possible (certainly for
more than a few days), to stay active, and to get on with their ordinary activities as normally as possible.
References
Cochrane Review multidisciplinary rehabilitation
*Abenhaim L, Rossignol M, Valat J-P, et al. The role of activity in the therapeutic management of back pain. Report of the International
Paris Task Force on Back Pain. Spine 2000; 25: Suppl. 4S: 1S-33S.
*Buchinder R, Jolley D, Wyatt M. Population based intervention to change back pain beliefs and disability: three part evaluation. Brit
Med J 2001; 322:1516-1520.
*Burton, A. K., Waddell, G., Tillotson, K. M., & Summerton, N. Information and advice to patients with back pain can have a positive
effect: a randomized controlled trial of a novel educational booklet in primary care, Spine 1999; 24: 2484-2491.
* Hagen, K.B., Hilde, G., Jamtvedt, G., Winnem, M.F. The Cochrane review of bed rest for acute low back pain and sciatica. Spine
2000;25(22):2932-2939.
*Koes, B. W., van Tulder, M. W., Ostelo, R., Burton, A. K., & Waddell, G. 2001, Clinical guidelines for the management of low back
pain in primary care: an international comparison, Spine 2001; (in press).
*Malmivaara A, Häkkinen U, Aro T, et al.. The treatment of acute low back pain: bed rest, exercises, or ordinary activity? N Engl J
Med 1995;332:351-5.
Advice to stay active as a single treatment for low-back pain and sciatica (Review) 2
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
*Moore J E, Con Korff M, Cherkin D, Saunders K, Lorig K A randomized trial of a cognitive-behavioral program for enhancing back
pain self care in a primary care setting. Pain 2000;88:145-153
*Nachemson A, Jonsson E, (Eds). Neck and back pain: the scientific evidence of causes, diagnosis and treatment. Philadelphia:
Lippincott, Williams & Wilkins 2000. ISBN 0 7817 2760 X
*Tulder, MW Van, Malmivaara, A., Esmail, R., Koes, B. Exercise therapy for low back pain: a systematic review within the framework
of the Cochrane Collaboration Back Review Group. Spine 2000; 25(21)2784-2796.
*Vroomen P C A F, De Krom M C T F M, Wilmink J T, Kester A D M, Knottnerus J A Lack of effectiveness of bed rest for sciatica.
New Eng J Med 1999;340:418-423
*Waddell, G. & Burton, A. K. Occupational health guidelines for the management of low back pain at work - Evidence review Faculty
of Occupational Medicine, London. 2000, www.facoccmed.ac.uk
*Waddell, G., Feder, G., & Lewis, M. Systematic reviews of bed rest and advice to stay active for acute low back pain, British Journal
of General Practice 1997; 47: 647-652.
*Wiesel S W, Cuckler J M, Deluca F, Jones F, Zeide M S, Rothman R H Acute low back pain. An objective analysis of conservative
therapy. Spine 1980;5:324-330
*Wilkinson M J B Does 48 hours bed rest influence the outcome of acute low back pain? British Journal of General Practice 1995;45:
481-484

WHAT’S NEW
Last assessed as up-to-date: 30 November 1998.

Date Event Description

11 May 2010 Amended This review has been merged with:Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-
back pain and sciatica. Cochrane Database of Systematic Reviews 2000 , Issue 2 . Art. No.: CD001254.
DOI: 10.1002/14651858.CD001254.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 4, 1998
Review first published: Issue 2, 2002

Date Event Description

10 June 2008 Amended Converted to new review format.

31 January 2002 New citation required and conclusions have changed Substantive amendment

Advice to stay active as a single treatment for low-back pain and sciatica (Review) 3
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
SOURCES OF SUPPORT

Internal sources
• The National Institute of Public Health, Norway.

External sources
• The Norwegian Fund for Post-graduate Training in Physiotherapy, Norway.

Advice to stay active as a single treatment for low-back pain and sciatica (Review) 4
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.