In Defence Of The Advice To Remain Active For Back Pain
There has recently been some discussion around a lack of evidence for the advice to remain active during back pain. I personally believe there is a lot of value in the advice to stay active and here is why!
Firstly this HERE is from the folks over at Cochrane.
“Moderate quality evidence shows that patients with acute LBP may experience small improvements in pain relief and ability to perform everyday activities if they receive advice to stay active compared to advice to rest in bed. However, patients with sciatica experience little or no difference between the two approaches”
It is important to highlight the current state of play with regards to the evidence base, that there is MODERATE evidence of a SMALL relief for pain and this pretty much is in line with most other current recommendations/treatments that we have for back pain at this point.
Now I am going to give you a bit of my opinion as well!
Being active, IMO : ), is NOT a treatment. It’s about being a human being and getting on with your life even though you have this very normal part of the human condition…..back pain.
It’s About Belief
Certainly, we don’t want to demonize the idea of resting or taking it easy if things are too painful, that is not evidence-based either, but we also know that the dominant view of back pain seems to be that we should rest it out and that for quite a few people the belief is that activity can be problematic for back pain.
This is highlighted in the two papers below that look at people’s opinions around what affects pain in the positive AND negative.
Darlow 2014 – Beliefs about back pain: The confluence of client, clinician and community.
Setchell 2019 What decreases low back pain? A qualitative study of patient perspectives
We also have two recent papers that form an interesting pairing when viewed together. Firstly we have a self-reported perspective of what triggers back pain flares from anyone who had had back pain at any previous time point (so maybe more a test of perceptions?). Here they found that physical activities and movements dominated the vast majority of the cited reasons for flare-ups
Costa 2019 – What Triggers an LBP Flare? A Content Analysis of Individuals’ Perspectives
Then we have a paper that looked at the same subject but asked the people to report it in a different way (longitudinally), at 3-7 day intervals over 6 weeks, and they found that physical activities were not so related to flares of back pain.
Suri 2018 – Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?
The implication might be that when we ask people to remember what triggered their back pain it is a simple ‘go-to’ blame physical activities (especially when other things are not considered), but when the flare-up is more recent, 3-7 days, and presented with different reporting options the association between physical activity and flare-ups seems to decrease.
This highlights for me societal beliefs around the back and its relationships with activity and that we should be counteracting this idea in healthcare as much as possible!
It’s About Positive Messages
Overcoming some of the negative beliefs that we have around the body, pain and physical activity should be a goal of healthcare interactions. There are SO many NEGATIVE messages that we need some positive ones too.
I think the advice to remain active is such a message. Trust your body, get on with things, you will be OK! This is a strong, simple, and important message from my perspective.
There is the very real potential that there is not that much that can be done in the short term for acute back pain with advice and reassurance being pretty much all we have.
But could our short term attitudes impact on the longer term?
Short Vs Longer Term
What we do seem to have some data on is that having low pain self-efficacy, or the ability to go about our lives WITH back pain, does appear to have some relationship with outcomes of back pain in the longer term (this also seems to be apparent in other MSK conditions). In this paper HERE from Foster – 2010, we see that low pain self-efficacy is related to worse disability outcomes at 6 months.
The question is how do our own attitudes, and other people’s attitudes as well, towards our backs influence our behaviours? Food for thought perhaps?
Key Messages From Advice To Remain Active
Hurt does not equal harm – It’s OK to function with some pain, especially if it is not worsening and within tolerable levels. Pain does not give a reliable indicator of what’s happening within our bodies.
Rest is not the best treatment – Resting the back is unlikely to simply make it better and not much is likely to significantly change how the back responds in the short term.
Activity is not bad – Activity is not simply related to pain or damage. In fact limiting activities you enjoy might actually make the impact of back pain on your life worse.
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