Advice to stay active for people with acute low back pain

Staying active can improve pain relief and ability to perform everyday activities (functional state), reduce sick leave and enable an earlier return to work.

Specific diagnoses should be considered for patients with clinical features of infection, malignancy, fracture or history of trauma.

Patients can be advised to reduce, alter or modify certain painful activities (e.g. lifting) for a few days as certain activities may exacerbate back pain. Patients need to be reassured that an exacerbation of pain is not an indication of damage and fluctuations in pain can be expected in the course of recovery from acute low back pain. Patients should feel confident to get back to their normal everyday activities over a period of days to weeks.

Staying active means continuing with normal daily activities as much as possible, including going to work. It also means trying to reduce long periods of inactivity. No specific exercise(s) is needed at this stage.

People with low back pain who remain active, even when in pain, do better in the long term. In fact, it appears that the longer a person stays in bed because of low back pain, the worse their ability to work and/or return to work becomes.

1. There is often confusion about what ‘staying active’ means. It means different things to different patients. For an office worker it might mean getting up and moving around more often, while for an athlete it might mean lighter or modified training for a period of time.
2. Patients should be encouraged to find the balance between not resting completely and letting the back pain settle. At the same time, they should be advised that it is important not to wait for all pain to be gone before they start moving. Having a strategy where they either reduce or alter certain painful activities (e.g. lifting) for a few days, and then gradually build up these activities again can be recommended.
3. Patients often fear that pain is a sign of deterioration and/or further damage. They are often anxious about returning to physical work or activities that are high impact or involve bending, twisting or lifting. Patients may need to be reassured that the back is strong and while they may need to reduce, alter or modify how they do these activities, these activities can still be undertaken. They may also need reassurance that the pain is likely to subside and that ongoing pain is not an indication of further damage.
4. Ways to communicate to patients about the benefit of activity over bed rest may include the following:
   1. Bed rest encourages stiffness and pain. Stay moving so that you stay strong.
   2. Things heal quicker with some movement.
   3. Gentle activity may create some discomfort. If the pain is worse after activity and persists, you should modify your activity. Any activity can be modified by changing:
      • How long you do the activity for e.g. if you usually sit for long period of time at work you might modify this by standing up, going for a short walk or marching on the spot every 20 minutes or so to keep your back moving.
      • How vigorously you do the activity e.g. if you usually like to run you might choose to walk or jog at a pace that is more comfortable for your back.
      • How often you do the activity or the type of activity you do e.g. if you usually swim 3 times a week you might continue going to the pool but choose to walk or do other water exercise.
      • How you do the activity e.g. when carrying the shopping you might have to make each bag lighter and do one or two more trips.

NHMRC Level 1 Evidence.

• NPS Medicinewise: 10 things you need to know about low back pain
• My Back Pain

Other resources

The Australian Prescriber has published a care pathway for low back pain with first- and second-line management strategies.

The RACGP gratefully acknowledge the following contributors:

• Mary O’Keeffe, Institute for Musculoskeletal Health, University of Sydney
• Zoe Michaleff, Institute for Evidence-Based Healthcare, Bond University

1. Dahm K, Brurberg K, Jamtvedt G, Hagen K.Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database of Systematic Reviews. 2010;(6):CD007612. DOI: 10.1002/14651858.CD007612.pub2.