Staying active beats bed rest for a bad back, just not by much

Low back pain is one of the most common reasons people see a health professional, and the advice given about daily activity is a core part of how it is managed in primary care. For decades the instinctive prescription was rest, with patients told to lie up until the pain settled. Whether that advice actually helps, or whether simply telling people to carry on with normal life works as well or better, is a question with consequences for millions of sore backs. This Cochrane review set out to test advice to stay active as a treatment in its own right.

The reviewers searched electronic databases, contacted trial authors and combed reference lists for every randomised study comparing advice to stay active against advice for bed rest in acute low back pain or sciatica. Two reviewers independently selected trials, judged their quality and extracted the data, contacting investigators where information was missing. Four trials met the bar, covering 491 patients in total. Two of the trials were judged to have a low risk of bias and two a moderate to high risk, and the results across them were mixed.

In the strongest trial of acute, simple low back pain, staying active beat two days of bed rest by 6.0 points on a 0 to 100 functional scale and shortened sick leave by 3.4 days. The other high-quality trial, in people with sciatica, compared staying active against 14 days of bed rest and found no differences between the groups. One high-quality trial also compared advice to stay active against advice to exercise, and staying active won on both function and sick leave. Crucially, no trial found any evidence that staying active caused harm.

This review helped cement the shift away from bed rest as a treatment for back pain. The benefits of staying active are honestly small, and for sciatica they may be nil, but the comparison never favours the bed. The reviewers are careful to note that their conclusions rest on single trials for each comparison, so the precise numbers should be held loosely. What tips the balance is the other side of the ledger: prolonged bed rest has potential harms of its own, which makes staying active the sensible default even where its direct benefit is modest.

For a straightforward episode of acute back pain, this is a reason to expect that carrying on with normal activity will serve you at least as well as resting up, and probably a little better. For sciatica the evidence suggests activity neither helps nor hurts compared with rest, which still removes the argument for staying in bed. The honest framing is permission rather than promise: moving will not fix a bad back quickly, but there is no evidence it makes things worse, and the days spent horizontal buy you nothing.