Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica

Background Acute low-back pain (LBP) is a common reason to consult a general practitioner. Debate continues on the comparative effectiveness of advice on bed rest and staying active as part of the primary care management. Objectives To determine the effects of advice to rest in bed or stay active for patients with acute low-back pain or sciatica. Search strategy We searched the Cochrane Back Review Group Trials Register, CENTRAL, MEDLINE, EMBASE, Sport, and SCISEARCH to May 2009, reference lists of relevant articles, and contacted authors of relevant articles. Selection criteria Randomised trials of the effectiveness of advice to stay active or rest in bed for patients with acute LBP or sciatica. The main outcomes were pain, functional status, recovery and return to work. Data collection and analysis Two authors independently selected trials, assessed the risk of bias and extracted data. The trials were combined qualitatively or statistically, depending on data availability and presentation. Main results We included ten RCTs with varying risk of bias. For patients with acute LBP, results from two trials (N = 401) suggest small improvements in pain relief (SMD 0.22 (95% CI: 0.02 to 0.41) and functional status (SMD 0.29 (95% CI: 0.09 to 0.49) in favour of advice to stay active. For patients with sciatica, there is moderate quality evidence of little or no difference in pain relief (SMD -0.03 (95% CI: -0.24 to 0.18)) or functional status (SMD 0.19 (95% CI: -0.02 to 0.41)), between advice to rest in bed or stay active. Low quality evidence (3 RCTs, N = 931) suggests little or no difference between exercises, advice to rest in bed or stay active for patients with acute LBP. Low quality evidence (1 RCT, N = 250) suggests little or no difference between physiotherapy, advice to rest in bed or stay active for patients with sciatica. No trials that compared different ways of delivering advice. Authors' conclusions Moderate quality evidence shows that patients with acute LBP may experience small benefits in pain relief and functional improvement from advice to stay active compared to advice to rest in bed; patients with sciatica experience little or no difference between the two approaches. Low quality evidence suggests little or no difference between those who received advice to stay active, exercises or physiotherapy. Further research is very likely to have an important impact on the estimate of effect and is likely to change our confidence in it.