The Role of Activity in the Therapeutic Management of Back Pain

Note: This report is a translation of the original Paris Task Force report, written in French and entitled “Place de l’activité dans la prise en charge thérapeutique des rachialgies.” This translation is completely faithful to the original text and has been endorsed by the entire Task Force. The translation was entrusted to Steven Sacks, Les Services Organon (Montreal, Canada). SUMMARY AND RECOMMENDATIONS Rest and Activities of Daily Living For years, rest has been an essential therapeutic recommendation in cases of low back pain with or without sciatica. This spectacular analgesic effect has led to the development of a sort of medical dogma concerning the prescription of rest in cases of low back pain, and even to its imposition on patients who think it unnecessary. It is only recently that the evolution of low back pain has been objectively studied in clinical trials, most of which have concluded that prolonged rest serves no purpose and delays return to work and activity. The Task Force recommends (Table 1), on the strength of its literature review that in acute cases in diagnostic Categories 1, 2, and 3, bed rest should neither be enforced nor prescribed, but may be authorized if the pain indicates it. If authorized, it should be of as short a duration as possible and should be intermittent rather than continuous. After 3 days of bed rest, patients must be strongly encouraged to progressively resume their activities.Table 1: Recommendations Concerning Activity and Back PainThe consensus of the Task Force, in the absence of specific data in the literature, is that bed rest is contraindicated in subacute and chronic cases in diagnostic Categories 1, 2, and 3— i.e., not only must bed rest not be prescribed, but it must be stopped in patients still resting in bed at this stage. The previous recommendations appear, however, to be inapplicable to cases in diagnostic Category 4, given the absence of specific data in the literature. Patients whose pain is intense enough to justify bed rest must be referred for a specialized back pain evaluation if they have not begun to progressively resume their daily activities after 10 days of strict bed rest (getting up only to go to the bathroom) and adequate pain therapy. Because these recommendations stand accepted clinical practice guidelines on its head and necessitate significant changes in physicians’ attitudes toward common forms of low back pain, they are likely to be greeted with strong reservations. Their implementation clearly requires a major education campaign aimed at the entire range of and their as as a major education campaign the The of of the of after that this is and of of specific to low back pain however, be in to and in is and in cases of low back The for the Task recommendations should be a than medical is in cases of acute low back pain, and have that it to of It is to a campaign concerning the of most cases of low back pain, the that most cases the of of and the of prolonged the for and have to this to patients the of but this has not been The of patients with has been but this is and requires that are It is accepted that low back a back pain patients to their and of which patients to rest as as the pain It is not to patients that their pain not a or that of their activities not the of Because of the analgesic effect of rest, patients are likely to these recommendations with The in the clearly that patients who not to rest for a For these the Task Force that rest should be but neither nor patients rest, should be to that it is of as short a duration as in cases of low back pain without of Categories to patients must be strongly encouraged to or resume their as as pain of the low back pain with and it is the in low back pain without are to cases in which is the is Category rest to be an in cases of low back pain with in that it likely to to with that it to rest 10 days in the absence of This recommendation is the consensus of the Task Force. It not the implementation of a for in cases of and to to the practice no is For diagnostic Category 4, given the absence of specific data in the literature, or of activities of daily is authorized in acute and subacute cases and is in chronic the range of and the that most of have not been is still for low back pain, with and without sciatica. have the significant of in the of acute low back The Task Force no that has therapeutic in the of acute cases of low back pain of than It the prescription of or to be the in acute cases of low back pain Categories 1, 2, 3, and in This recommendation is clearly likely to with possible to this may be to for of this in have the of in cases of subacute low back pain and and in have the of in the of intermittent low back It is that patients who have subacute intermittent or subacute low back pain be encouraged to an This recommendation the that the of in the of the of back that is a therapeutic to chronic low back pain than even if is no consensus on the specific or The Task Force that is to that patients who have chronic low back pain or in that no specific or is to of this recommendation should not be it is The Task Force is to a specific even have been It that the to is of than specific activity. The Task recommendation that is in of strength and is likely to a of and and may be to the implementation of This therapeutic must be on a medical by a and on the evaluation of the with the of and the and is of The must be to the to the of these are not and an in the and of Activity The Task recommendation concerning in cases of acute low back pain, the recommendations concerning activities of daily to return to activities are a of in its most that patients in diagnostic should or resume their work activities as as the pain of this recommendation should not be as as the are of the of the duration of work absence of a return to work as the duration of work absence and are no of return to The Task Force that should be the if the of activities not of activities of daily cases of acute low back pain, however, the absence of the Task Force to rather than return to The significant effect of as the of and and on the return to work should not be in have the of these in the development of chronic low back they are and significant should be to the medical and of their return to work on of their work or should the or and this should be It is that evolution toward the of the subacute should in the absence of and The Task Force the of the return of their patients to activities as as possible as a therapeutic after or 3 of a to to should the or if not This recommendation is of the of the duration of work to the of to should be as as in to the It is for to the to the of patients than is the The of to work is only after of work absence and is only after an absence of for the effect of rest and of in patients who have low back pain with Category and with which to the therapeutic of of activity. and to the prescription of to patients who have back pain and the evaluation of therapeutic in these to the of or the of rest in the the of return to work as return to and of the Paris Task Force the and of the Paris Task Force recommendations by patients with acute and subacute low back for to the prescription of in medical and in medical education the of activity. in in medical For a to go to bed The of la of have been by patients of that was to but bed of was its prescription after has led to this essential in cases strict bed rest was the accepted practice the practice is to patients to of bed as as evolution of attitudes be and is of the medical of low back pain has this the of in its has been the of The is to the that activities are for low back pain and to the to an of back pain has to the that the pain that may be the that it is to the that back pain are not for The the low back pain by and low back Because rest is in the of has been a to the in the however, for a low of cases of low back pain, and is no consensus on the of a the of The to pain it is common to if not specific and pain it is to that the absence of specific pain rest the only possible are at the of an toward low back pain that is by or it is a without rest bed and are effect of this is its of the that this of back pain is this is the The to be a for the of back pain and its evolution to a chronic clearly the of this have studied this in The the of the of the Task Force on which the of the practice of rest, and the of in The of which no in the duration of rest to work in this the literature that at the of the Task Force was it by the to in the the and to as of the of low back as are the however, is a not only by but by the if not of toward recommendations in of as a return to as The Task by and by was that is at to the absence of data concerning the implementation of the rest for is a enough to even if pain which for which by with this report, the Task Force to at on to these the of the it that the previous recommendations may have their of The Task Force has to this in by previous in the to the data to the of recommendations for The a of which have to the and activities of daily and activities activities to the activities that be by of and most to and the of the the Task Force the Task clinical This the Task Force to with a and with which to major and to recommendations on the of in the of clinical was to recommendations on of this recommendations may be by of of the for which data are not is This not only to the but even to most therapeutic to the of back pain, which have been without the or the medical to the the of may be than It is for this that the Task in the is of AND This the and back pain of This is has been to be a for back pain, a for back pain and a in the of back it to a range of and no review has in been of the and back It essential to the a than that of back pain and to the specific back pain and the of and activities of daily and activities activities Activity and the the medical of back pain and the with this it is to the of on and the of activity. Activity in Activity is in its to the by The of on are with bed of even short duration a of changes that to not only the but the and This is not with the of the of have been and this has led to significant changes in the practice of in the of the of the medical bed rest should only be if prescribed, should be of as short a duration as of these bed rest guidelines should the of that are at as as the on the and development of The and is on to and the of an bed rest development and to of and with and on of these are in who prolonged in to a the duration of which is to the duration of their in the of the for by and chronic of the in the to and are even is on a is the to the and of in patients who have Activity in The of to is a with and a who their are most likely to the are the who may the their literature that the to an is by the of is a of of and have in in the of The of as a not only on but on their the and of activities they or on for are the likely to and The prescription of should as as the of their Activity and Back It is to that or not only on but may back that the the of and back pain a that or is for is only in the literature on back pain to this 1: and back and Activities of Daily The of in this is by who the of bed rest of and duration to in a of patients in a back pain the Task of this it that it was in of the that bed rest is to the of back concluded that if bed rest is it should be of as short a duration as has been back pain and activities or activities of daily of activities have been of rather than in their of the back pain and or activities of daily this The was a of patients who chronic back Activities as and to pain, activities as and a to it. The pain and the of was the and the was pain and to be to in the that pain in the is to the a of the a was back pain and Activity was or and and This was and is not by Back pain was with intense to and with to the and back pain in the and the pain activities and the of a in the patients who a the back pain activities at the of an acute of low back pain and the of to activity. the of low back pain was a of and of the in these for than indicates the of a with the of the to the of of the effect that low back pain that activities is an of of the back pain and and is no on the back pain and or activities of daily is that the of the range of is in patients in back pain the of activities of daily even if only in the acute and For an back pain and or are no and and The of 3 the by in a this a than a a than a of the are with the by of the back pain and and and not the of the of not who have for This may the toward the of the the with activity. concluded that the that back pain for studied the of a of in of and the 3 after the of the the of back was in the in the and in the however, for as a by of back in a of than in a of who for for and of are in the of likely to have back pain, of the specific activity. It should be however, that this of whose of was no at and that the the and the of the 10 to a significant in this by in a of of a was the of duration of by the of and the of after for and that in and may back It is to that and activities but activities a for back was in this concluded that the of to back pain has not been in these is the on the back pain and and activities have that are at with a of and the be by the of in the of and the range of studied and in their literature review on for back pain, concluded that the of of that or to the of back the of and specific to the work The of is in 4, data the of and work to and in they are in of and for and data and is no for the and of data to the back pain and and of the back pain and activity. and it has been that back pain in The however, are to be in the of back pain, in of Activity for Back the 10 years, in than a have that the duration of back be by a return to activity. The Task of these indicates that they of is to patients who have back It should be that these are given their and the of the and of in of back pain return to work is an and therapeutic Concerning the Activity and Back Activity and back pain and of may back who have back pain their for the duration of which on the of pain, the and of their and their and The this the the of the The medical to the of back pain to a return to activities to be a clinical than pain in that an in the and activities of daily and of patients who have back pain, but not in their return to are to to patients who have back pain, with for which is a therapeutic The prescription of of of clinical recommendations of and that to the of their and This report the RECOMMENDATIONS The to the Task Force on have not the of that This the recommendations of the Task Force and the evolution of the and Task Force on the Task Force its work in the of back pain was that it was a rather a than an or clinical the by that of for are to back pain, and that of for back pain are for by only of cases chronic led to a significant in This of has been in most The of the Task Force and of is a with evaluation of by the Task Force not this evaluation and of the of the Task Force was that was no strong most of the common diagnostic and therapeutic for the and of back The Task Force a range of diagnostic and clinical that it on the and duration of and The was a that to their and in a common The by on bed rest for the Task by in the absence of and even in the of back pain, a return to should be This recommendation was greeted with by the medical and the and is than 10 with it was the recommendation most by in its the of the Task Force. The for and Task Force after the of the Task report, an for the a of the After the literature to of the Task Force, the of a the the and of back pain the for diagnostic and therapeutic to back pain that patients who have back pain be by an and after work the of to even in the of pain Because the back a to be to only after a of of back pain in its recommendations in the by the of and and the of these recommendations led and to their recommendations and guidelines that to the guidelines concerning acute low back in and Task the literature on acute low back pain for the of and a of recommendations concerning its clinical Their are to of the previous but of for of back pain work absence the previous of pain to the strength and of of of or or or of and to be in a The of of of the recommendation that patients be referred to for a and The and the and of these recommendations and to be with which to with back pain of to duration The recommendation that the of to should be and the of in cases in which to back pain The recommendations the and in The and the of a given in the absence of clinical was the and in the to This is by the that in of patients who have back pain, the pain and they for most and with back the this requires of the and of back pain by specialized and The consensus of the the clinical and of back pain was that patients should resume their activities as as this is by a of clinical of the recommendations is given the of in this to be major The recommendations not the of and in not at For no has of activities is at as as the of and The neither nor with which to The that therapeutic to the to This recommendation not the than of the and of of the the or clinical of the or in to should their This recommendation is on in and that no and The Paris Task work is a of the of of and and recommendations concerning the and of back recommendations are and of the recommendations of the Task Force on The that of the Task Force of at of the in the work the Paris Task is with that by previous and the of the work and the are of previous the of the Paris Task work diagnostic and The most common forms of back pain but and and The was 1: back pain no than the with no back pain is in this may be intermittent or are of and are by back pain no than the with no this pain to the of the may be but in the of the and back pain the with no to Category 2, pain in this is it may of the back pain to a and entire with or without This as which most by may of the This that of the Task Force, it the of patients by rather than For the of this report, these diagnostic are enough to be with most diagnostic in clinical of The Task Force studied activities that are likely to be by back pain and to have an on of to daily and and and of which is in its Activities of daily daily activities of The literature was the of for the the the diagnostic and of The was by the of review the of the literature of the of the Task Force in the of and review of the in a of in or The with to original This review but of which was by of the Task Force an specific to of with of or a without a The to the of of back pain, duration of and at the of the Task work with the and with the most common to of the of the was to of the Task Force by and after was to for the for clinical with a than of their or they the only of data on a given the of the enough to the for The of their and clinical is in of of of Recommendations The of the Paris Task Force was for of the of activities of daily and studied the and to their their a 3 was on the of duration of low back acute low back pain subacute low back pain chronic low back pain and the diagnostic by the Task Force specific was for of the on in its the consensus of the of the Task Force. the concerning the of of activities of daily and a The is by an text the that the for the recommendations of the Paris Task Force. The was For Activity should be should be neither nor of or rest are on Patients should be or the of the Task For The and of the by the Task Force no at this of the of the data but no strong this of the is a significant of in the or with of the absence or of the Task Force was to a consensus on clinical and of the literature. AND is the of as and of as enforced bed the of that is for given a was the of that in patients who in with a with of activity. of low back pain and to with an to to activity. The in French as the and Back The activities for up or a a and (Table of the was by the that or of only short For the that was of in and these a of activities that may be in a return to activities was (Table of Activities on and of Daily The of daily activities with and daily The for was to a of daily The in French as the Back and was the for the in which these are not activities are to the to a given or the of of the and only to The Task Force activities of daily to be by the and and and the for up The for of the activities of daily are in and of of Activities of Daily the activities in the literature, it was to a to that for the to a specific be as or and the of is to the of activities the is of in the absence of of and activities of daily in the literature, it was to these of in to and For of was a of was may have diagnostic and in the of cases of low back pain and may be in a return to Recommendations Concerning For years, rest has been an essential therapeutic recommendation for patients with low back pain, with or without sciatica. This recommendation was on that on the is bed for patients who are of an at at the of an of back pain, rest is clearly the only that of pain This spectacular analgesic effect has led to the development of a sort of medical dogma concerning the prescription of rest in cases of low back pain, and even to its imposition patients who it unnecessary. It is only recently that the effect of rest on the evolution of low back pain has been objectively studied in clinical of these have concluded that prolonged rest serves no purpose and delays return to clinical of adequate in the of the literature. of these the of rest of the of rest, or to the of rest with of common and and with of a The a specific of in Rest was in of and in the of bed rest of and duration in a of patients who acute of or chronic low back pain, with or without evaluation the of the the only significant was a duration of work absence in the with the the duration of rest the the however, was in the duration of rest in the the was was no significant in the in to and the return to at 3 or 3 of these it to than days of and studied the of rest of 3 and duration in a of patients and in pain or by was the in this to or 3 days of rest patients who low back pain with or without to the most of these acute Patients to of rest days of bed and and and no specific patients rest nor nor education to It should be however, that the duration of bed rest in the days to days Patients in the rest to return to patients who low back pain of than 3 duration with or without to the but without of bed rest for education and and of activities as as pain but no bed the and of the the by the duration and of pain, work and duration of work in a of patients who acute low back pain with or without rest, and a the was to be the most rest was than but than the It should be that no the evaluation was an of and and the of rest only studied a of with acute low back pain with no who to bed rest in a or to of activities and and of The bed rest to activities than the the of the duration of low back pain the and not the studied is and the be to the This is the only however, in which rest was enforced in and in the that is for in of the of rest on low back pain must patients in pain is intense that it This of patients is but of the of the patients in the for The only in which rest was the was the in which the the of the in rest or and in the of rest and of activities as as pain the of of the low back pain to the or low back pain with sciatica. It is the in low back pain without are to cases in which is and the is that the effect of rest in of patients who low back pain with no in was these and their For acute cases in diagnostic Categories 1, 2, and 3 (Table rest must not be enforced or but is authorized if the pain indicates it. rest must be of as short a duration as possible and should be intermittent rather than continuous. 3 days of bed rest, patients must be strongly encouraged to progressively resume their For subacute and chronic cases in diagnostic Categories 1, 2, and the absence of specific data in the literature, the consensus of the Task Force is that bed rest is contraindicated in these i.e., bed rest must not only not be prescribed, but it must be stopped in patients

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