Advice to Stay Active Markedly Increases Activity Level in Patients with Acute Severe Low Back Pain
Patricia Olaya-Contreras, PhD—Lead Author Comments
Chris G. Maher, PhD provides Study Commentary
Patients with acute severe low back pain who were advised to stay active in spite of pain were significantly more active than their counterparts who were advised to adjust their activity to pain level, according to a prospective randomized study reported in the August 27 issue of BMC Sports Science, Medicine & Rehabilitation. Pain level decreased at the same rate in both groups, suggesting that the stay active advice did not alter the course of acute low back pain.
“The results of the investigation and associated discussion could lead to patients taking a more active role and taking responsibility for their treatment,” said lead author Patricia Olaya-Contreras, PhD, a guest researcher in the Unit of Health Promotion, at the Southern University of Denmark, Odense, Sweden.
Ninety-nine patients (age 18 to 65 years) with acute severe low back pain (>50 mm on the Visual Analog Scale) were randomized to 1 of the following 2 groups within 48 hours of pain onset:
- Stay active group: patients were advised to stay active in spite of pain
- Adjust activity group: patients were advised to adjust their activity to the pain
All patients underwent extensive physical examination, X-ray, and magnetic resonance imaging to rule out disc herniation or spinal stenosis requiring surgery. “In this way, we were able to ask patients to be as active as possible. In other cases, the treatment and handling should be different,” Dr. Olaya-Contreras said.
All the patients completed a 7-day diary in which they recorded daily step counts recorded by pedometer, pain intensity, pain location, and pain-related disability during the following 7 days.
Stay Active Group Showed Significantly Greater Increases in Activity
At day 7, the stay active group showed a significantly greater step count than the adjust activity group (9,865 vs. 6,609; P=0.008). The groups showed a different change trajectory in step count: the step count was similar between the 2 groups on day 1, increased steeply in both groups by day 3, but then increased further at day 7 in the stay active group only.
The change trajectory in pain intensity was similar in the two groups and decreased from 5.0 to 2.8 in the stay active group (P<0.001) and from 4.8 to 2.3 in the adjust activity group (P<0.001).
“To be active is a personal decision in all ways,” Dr. Olaya-Contreras noted. “I also believe that it can help patients to focus more on the positive resources they have to handle the pain and master various physical movements even though it hurts,” she said.
“I feel that first and foremost, the health service should introduce a routine investigation to determine the underlying psycho-social causes of patients’ back problems,” Dr. Olaya-Contreras said. She added that the problem could be related to postural problems at work or during leisure time activities, such as when watching television, carrying bags, playing sports, etc.
“It could be important to measure the degree of anxiety and fear of movement among persons with acute lumbago,” Dr. Olaya-Contreras suggested. This assessment “could prevent the chronification of pain and suffering from back pain,” she added.
Commentary about The Study
Chris G. Maher, PhD
Director, Musculoskeletal Division
The George Institute for Global Health
Professor, Sydney Medical School
The University of Sydney, Australia
Evidence-based clinical practice guidelines uniformly recommend advising patients with acute low back pain to remain physically active and avoid bed rest. It is pretty clear from clinical trials that activity is better than bed rest, but we lack research to judge how to prescribe activity resumption. A common dilemma for clinicians is whether they should encourage the patient to push on regardless of the back pain or to avoid activities that cause pain. This is not a trivial issue as the pain with acute low back pain can be quite severe and distressing to the patient. Until now, no trials have examined this issue for acute low back pain, and so some clinicians have adopted the “pacing” approach used with chronic pain where activity is increased in time-contingent rather than pain-contingent manner. Critics of this approach have argued that it risks exacerbating the patient’s pain and slowing their recovery.
In the Olaya-Contreras trial, 99 workers with severe acute low back pain were randomized to “stay as physically active as possible regardless of the pain” or “to adjust their activity levels according to pain and to avoid activities, movements or positions that exacerbated their pain.” Patients who wanted medication were provided with paracetamol (acetaminophen) and/or an NSAID. Over the next 7 days, patients completed a diary to record pain intensity and their daily step count measured with a pedometer. The step count data showed that while both groups increased their physical activity levels, the greatest increase was in the stay active group. What might be surprising was that there was no between groups difference for pain outcomes. Pain reduced rapidly in both groups, but at much the same rate.
There are probably 2 clinical implications of this study. Firstly, encouraging patients with acute low back pain to remain as active as possible does not seem to interfere with pain recovery. This approach got the same pain outcomes as the more cautious approach, but it had the benefit of achieving greater physical activity. Secondly, clinicians can use simple tools such as a pedometer and pain diary to monitor their patient’s recovery from acute low back pain. Many people already have their own activity tracker, or could readily borrow one, so it is feasible and definitely more reliable than asking the patient to recall their activity levels 1 to 2 weeks later at their follow-up clinical review.
The strengths of the study are the use of an objective measure of physical activity rather than self-report and the close monitoring of pain in the first week. The limitations of the trial include that it was not prospectively registered and the lack of longer-term outcomes or work absence outcomes.