Bed rest used to be a key part of treatment for back pain, in fact many still believe that it is *HERE*! Now the guideline advice is to “remain active” and it would seem that rest is yesterday’s news and even a ‘bad’ thing to do for some clinicians.

The world of MSK pain & injury can become polarised very quickly. If something is not superior then it can quickly become inferior, even though it is not. Think core stability exercises for example, they have fallen off the MSK cliff into the abyss but they still ‘work’ as well as anything else in treating back pain, even if the narrative can be unhelpful.

So both advice to rest and remain active are probably a bit rubbish as blanket statements. Part of the role of a clinician should be to help people understand and manage their pain a little better, what is THIS person’s individual presentation and limitations. Not all back pain is the same even if it is labelled in a similar way. This of course is not a revelation or particularly new information with Maitland’s “aggravating factors” still being a key part of understanding and helping others understand their painful problems.

By identifying those things that actually aggravate the problem we can perhaps rest a bit more from those whilst remaining active in other things that don’t aggravate the problem so much. This is really not any more than basic common sense I feel, but given that many people are told either to rest or carry on through painful things without much analysis , this common sense may sometimes be lacking.

Example

As an example I recently had someone with pretty painful Sciatica that tended to flair up at night after gym sessions in the day. Obviously carrying on like this was a problem and rest in some capacity seemed to make sense, to me anyway. One of the bigger problems was that from a psychological coping perspective complete rest was not really an option, as can be  the case with some very active folk. Here a targeted approach of reducing intensity and volume levels to reduce aggravation was helpful whilst also keeping the person moving and (reasonably) happy. Some times persistent/endurance behaviours can be rooted quite deeply and this can be challenging to a complete rest based approach.

Guidance

Maybe this is where guidance is required and giving people the tools to monitor and adapt aggravating things can be a huge influence on their ability and belief in their ability to manage their problem. Again this is not new, we can go back to the 90’s and the work of Indahl *HERE* to see that basic information about the problem and managing pain was a mainstay of his groups approach.

Now if pain was REALLY bad in a whole bunch of different activities then I see nothing wrong at all with entirely resting for a few days to let the worst pain pass (as it generally does) and equally I see no real need to rest entirely if the pain is pretty mild and only with specific activities. The real nuance comes with the majority of pain presentations in the middle. Painful enough to be limiting and potentially aggravating but maybe not enough to warrant complete rest which can also come with its costs.

I use a really simple grading scale using VAS although irritability of the problem is also another factor to be considered. Hopefully it considers the U shaped nature of physical activity intervention.

Simple scale (VAS)

8-10 - Rest

4-7 - Activity modification

1-3  - Remain active

These are some questions we might ask ourselves with our clinical reasoning for activity modification:

• Can we do something different entirely?
• Can we alter volume?
• Can we alter intensity?
• Can we alter frequency?
• What effect does this have?

It is also super important that we make sure to grade a return to full activity as pain changes to avoid creating potential avoidance behaviours in the future. How many people are told to stop doing things and never resume them? A lot in my experience.

Key points

• Blanket advice is a bit crap
• Non superiority is not inferiority
• Basic pain management advice is helpful
• How can you adapt/modify aggravating activities