Introduction

Many textbooks recommend bed rest as a mainstay treatment for sciatica, although this is not based on good scientific evidence. A group of Dutch physicians have conducted experimental observations in their patients, and they conclude that bed rest for sciatica is unlikely to provide any benefits over watchful waiting.

Methods

The study was performed in 183 patients suffering from sciatica that had lasted for less than 2 days. The clinical diagnosis required at least two of the following signs or symptoms to be present: radicular pain distribution, increased radiating pain on coughing, sneezing or straining, decreased muscle strength, sensory loss, loss of reflexes, or a positive straight-leg-raising test. Patients with very severe pain requiring morphine or those with rapidly progressing loss of muscle strength or with cauda equina syndrome were not allowed to take part into the study. The aim of the study was to compare the effects of bed rest to 'watchful waiting' on the evolution of the signs and symptoms.

The bed rest patients were instructed to stay in bed, lying on their back or on one side most of the time, except to bathe or to use the toilet. The patients in the watchful group were instructed to stay up and about as much as possible, but also to avoid straining the back or inducing pain. These patients could go to work but they could also rest in bed if they so wanted.

All patients were allowed to take analgesic/anti-inflammatory drugs as well as muscle relaxants. Strong analgesics such as codeine were permitted and a tranquilizer was also prescribed for insomnia. All patients in the two treatment groups were then seen after 2 and 12 weeks. Both physicians and patients recorded their impressions of improvement after 2 and 12 weeks. Many other measurements of pain and function were also made, such as intensity of leg pain, and 'bothersomeness' of symptoms, the McGill Pain Questionnaire, and a functional low back pain questionnaire (Oswestry).

Results

Compliance with bed rest prescription was good; the patients in this group lay in bed for a mean of 20 hours over the 24-hour period, as compared with 10 hours in the watchful group. Leg pain intensity decreased to the same extent and equally rapidly in both treatments group over the 2-week course. '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 groups reported improvement. Six-month follow up was available for 40% of these patients. Eventually, 17% of the patients in the bed rest group required surgery (removal of an intervertebral disk), compared with 19% in the watchful group. The median number of days missed at work was 46 in one group and 47 in the other one.

Recommendations

Two full weeks of bed rest is not without inconvenience, and can have detrimental effects on the microcirculation, muscle mass and strength, and also on the quality of life and well-being. The present study is one piece of evidence that bed rest should not be recommended to patients with sciatica to improve prognosis or evolution of symptoms. Recommending some activity while avoiding straining the back and inducing pain is just as effective as imposing two weeks full bed rest, and avoids the potential adverse effects of bed rest.