Your low back pain has now spread down one leg, and the pain is bad enough for you to feel like staying in bed for a few days. Do you think you really should?

Many textbooks recommend bed rest as the main treatment for sciatica, but this isn't based on good scientific evidence. A group of Dutch physicians have studied their patients with sciatica (pain extending down one leg, sometimes to the outside of the ankle), to see if bed rest for 2 weeks is any better than so-called 'watchful waiting'.

Methods

The study was performed in 183 patients suffering from sciatica of recent onset - i.e. it started within 2 days of onset of leg pain. To be included in the study, patients had to have at least two of the following signs or symptoms: pain distribution typical for sciatica (i.e. down the back and side of the leg), increased leg pain on coughing, sneezing or straining, decreased strength in the leg, loss of sensation, loss of knee-jerk or ankle-jerk reflexes, or pain and limitation of straight-leg-raising. Anyone with severe pain requiring morphine or rapidly losing muscle strength were not allowed to take part into the study. The aim of the study was to compare bed rest to watchful waiting on the development of the condition.

The bed rest group patients were instructed to stay in bed, lying on their back or side for most of the time, except to bathe or to use the toilet. The patients in the watchful group were told to stay up and about as much as possible, but also to avoid straining the back or doing anything that made the pain worse; these patients could go to work, but they could also rest in bed if they wanted.

All patients were allowed to take pain-killing drugs as well as muscle relaxants. The strong painkiller codeine was also permitted. A tranquilizer was also prescribed for insomnia.

All patients were seen after 2 and 12 weeks. Both physicians and patients recorded their impressions of improvement. Many other measurements of pain and function were also taken, such as the intensity of leg pain, the bothersomeness of symptoms, a pain score (the McGill Pain Questionnaire), and a score for effects on low back function (the Oswestry Questionnaire).

Results

The patients on bed rest lay in bed for an average of 20 hours out of a 24-hour period, whereas the watchful group spent an average of 10 hours in bed in each 24 hours. The intensity of leg pain decreased in both treatments group over the 2-week course, with no difference between the bed rest and the watchful groups in this respect. 'Great improvement' was reported by 37% of patients in the bed rest group, and by 35% in the watchful group, after 2 weeks. At 12 weeks, 87% of the patients in both treatment groups reported improvement.

Six-month follow up was available for 40% of these patients. A similar proportion of patients in both groups (17% and 19%) underwent surgery (removal of an intervertebral disk, or diskectomy). The average number of days missed at work was 46 in one group and 47 in the other.

Recommendations

Lack of activity when lying in bed for 14 days decreases muscle strength and muscle mass, and may be bad for the blood circulation. Imposed bed rest is also a psychological inconvenience for many. The results of this research indicate that the outcome of sciatica is no better with bed rest than a regime of watchful waiting. Keeping up some activity, while avoiding straining the back and instigating pain, is as good as taking to your bed for two weeks, and can be recommended as a way to avoid the possible side effects of bed rest.

Source

Lack of effectiveness of bed rest for sciatica. PCA. Vroomen, M. de Krom, JT. Wilmink,  et al., N Engl J Med, 1999, vol. 340, pp. 418--423

Links

• "Oh - My Aching back!" -- Part 3
• Up and About!
• Disease Digests - Low Back Pain and Sciatica