Am Fam Physician. 1999 Jun 1;59(11):3212-3214.
Few studies support the recommendation that bed rest be instituted for the treatment of low back pain and sciatica. Nonetheless, many patients and physicians seem to favor this form of therapy, especially in the acute period. Vroomen and colleagues performed a randomized, controlled, blinded trial to evaluate the efficacy of bed rest in the treatment of sciatica.
The 183 patients entering the study presented to their primary physicians with back pain that radiated into the leg. Excluded were persons who had previously undergone spinal surgery, were involved with workers' compensation claims or had severe coexisting disease. History, physical examination and magnetic resonance imaging (MRI) of the lumbar spine were obtained. Patients who did not have strong clinical evidence of sciatica or were found to have an indication, such as cauda equina syndrome, for immediate surgery were excluded.
Patients were randomized to bed rest or watchful waiting for two weeks. Patients treated with bed rest were instructed to stay in a supine or lateral recumbent position as much as possible. They were only allowed to get out of bed to go to the bathroom and to bathe. Patients in the control group were allowed to perform routine activities but were asked to refrain from any activities that caused significant strain to their backs. The two groups were demographically similar with respect to clinical findings.
Patients kept diaries of their functional status and the number of hours they spent in bed each day. A visual analog scale was used for self-reports of the degree of pain. Patients were allowed to take 1,000 mg of acetaminophen three times a day, supplemented by 10 to 40 mg of codeine six times a day or 500 mg of naprosyn three times a day. Follow-up office visits to assess pain and functional status were made at two and 12 weeks. A home visit was made during the third week. The investigators who did the assessments did not know the patients' treatment status.
At the two- and 12-week evaluations, no significant differences were noted between the two groups with regard to the patients' and the examiners' assessment of improvement. At two weeks, 37 percent of the bed-rest group and 35 percent of the control group reported “great improvement” in symptoms. Overall, 70 percent of the bed-rest group reported some degree of improvement at two weeks, compared with 65 percent of the control group. At 12 weeks, 87 percent of the patients in each group reported improvement. The investigators' assessment of improvement at two weeks was 73 percent for the bed-rest group and 65 percent for the control group. At 12 weeks, the investigators' assessments were 86 percent improvement for the bed-rest group and 89 percent improvement for the control group. Diary entries revealed that the bed-rest group spent an average of 21 hours daily in bed, compared with 10 hours for the control group.
Regarding secondary outcomes, the median number of missed days of work was the same for both groups, as was the percentage of patients who went on to have surgery (17 percent in the bed-rest group and 19 percent in the control group). The rate of acetaminophen use was the same for both groups. The control group, however, reported using heat on an average of five occasions compared with twice for the bed-rest patients.
The authors conclude that bed rest is not more effective than watchful waiting in patients with sciatica-type symptoms related to lumbosacral injury. This finding is in keeping with the findings of at least three other previously published studies
Vroomen PC, et al. Lack of effectiveness of bed rest for sciatica. N Engl J Med. February 11, 1999;340:418–23.
Copyright © 1999 by the American Academy of Family Physicians.
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