It would seem intuitive that back pain is a symptom with
a myriad of underlying causes; hence, studies would show no difference
between the effects of rest and non-rest as the treatment of choice.
However, it would also seem that a patient with true sciatica should
benefit from rest. Since the root pain is brought about by irritation
or inflammation of the nerve, that irritation should settle if there
is reduction of mechanical pressure through either the decrease
in discal pressure as a result of recumbency or a lack of stretch
on the root. The meta-analysis by Hagen and colleagues suggests
otherwise.
Can the conclusion be explained by the bias of the reviewing group?
The web page of the Cochrane Collaboration Back Review Group (www.iwh.on.ca/Pages/Cochrane/about.htm)
suggests otherwise or at least shows cognizance of this bias; they state
that the Institute for Work and Health helped to establish the Back
Review Group and also contributes to its support with grant funds.
The web page of the Institute for Work and Health (www.iwh.on.ca/Pages/Contactinfo/about.htm)
states: "The Institute was established by the Ontario Workplace
Safety & Insurance Board (WSIB) and still maintains an
arm’s-length contractual relationship, as well as play[s] an
active role in the WSIB Research Advisory Council."
Is the meta-analysis then methodologically flawed, or are the selected
studies biased? As a practicing spine surgeon reviewing the material
presented, I do not think so; perhaps a psychometrician would feel
otherwise.
It is my opinion that the key to understanding the conclusion reached
is that what is studied here is the advice given the patient. It
is presumed that the patient carries out that advice to the letter.
However, extrapolation from brace-usage studies as well as personal
observation of returning patients indicates that patients will rest
as they feel appropriate and will resume activity as their symptoms resolve.
This review is helpful to me in deciding whether to recommend compulsory
bed rest for the treatment of back or leg pain in such patients.
Staying as functional as possible seems to be the best medicine.