Rest in Chronic Low Back Pain – The Gap Between Practice and Guidelines
DOI:
https://doi.org/10.55707/jhs.v12i2.185Keywords:
chronic low back pain, rest, clinical guidelines, biopsychosocial model of care, physiotherapyAbstract
Chronic non-specific low back pain is common, and represents a public health and economic challenge. The current guidelines recommend maintaining activity, limiting prolonged bed rest, and appropriately adapting work participation. Misconceptions about rest can influence physiotherapists’ recommendations and patient recovery. In a cross-sectional study, 104 physiotherapists from primary care in Slovenia completed the HC-PAIRS, Back-PAQ, and clinical case questions (activity, work, rest) via an online questionnaire. The highest adherence to guidelines was observed for physical activity (54%), while recommendations regarding work (non-adherent in 89%) and rest (non-adherent in 64%) were largely inconsistent with the current guidelines. Most physiotherapists still recommended restrictions on bed rest, despite evidence of the harmful effects of prolonged rest. The results highlight the need for improved professional education to promote an active approach and guideline adherence, which may enhance patient outcomes.
References
1. Arendt-Nielsen, L., Morlion, B., Perrot, S., Dahan, A., Dickenson, A., Kress, H. G., Wells, C., Bouhassira, D. in Drewes, A. M. (2018). Assessment and manifestation of central sensitisation across different chronic pain conditions. European Journal of Pain, 22(2), 216–241. https://doi.org/10.1002/ejp.1140
2. As-Sanie, S., Till, S. R., Schrepf, A. D., Griffith, K. C., Tsodikov, A., Missmer, S. A., Clauw, D. J. in Brummett, C. M. (2021). Incidence and predictors of persistent pelvic pain following hysterectomy in women with chronic pelvic pain. American Journal of Obstetrics and Gynecology, 225(5), 568.e1–568.e11. https://doi.org/10.1016/j.ajog.2021.08.038
3. Bishop, A., Thomas, E. in Foster, N. E. (2007). Health care practitioners’ attitudes and beliefs about low back pain: A systematic search and critical review of available measurement tools. Pain, 132(1–2), 91–101. https://doi.org/10.1016/j.pain.2007.01.028
4. Bombardier, C. (1995). Primary care physicians’ knowledge, confidence, and attitude in the management of acute low back pain (ALBP). Arthritis & Rheumatism, 38(9), S385.
5. Brummett, C. M., Urquhart, A. G., Hassett, A. L., Tsodikov, A., Hallstrom, B. R., Wood, N. I., Williams, D. A. in Clauw, D. J. (2015). Characteristics of fibromyalgia independently predict poorer long-term analgesic outcomes following total knee and hip arthroplasty. Arthritis & Rheumatology, 67(5), 1386–1394. https://doi.org/10.1002/art.39051
6. Burton, A. K., Balagué, F., Cardon, G., Eriksen, H. R., Henrotin, Y., Lahad, A., Leclerc, A., Müller, G., van der Beek, A. J. in COST B13 Working Group. (2006). Chapter 2. European guidelines for prevention in low back pain: November 2004. European Spine Journal, 15(2), 136–168. https://doi.org/10.1007/s00586-006-1070-3
7. Christe, G., Crombez, G., Edd, S., Opsommer, E., Jolles, B. M. in Favre, J. (2021). Relationship between psychological factors and spinal motor behaviour in low back pain: A systematic review and meta-analysis. Pain, 162(3), 672–686. https://doi.org/10.1097/j.pain.0000000000002065
8. Christe, G., Nzamba, J., Desarzens, L., Leuba, A., Darlow, B. in Pichonnaz, C. (2021). Physiotherapists’ attitudes and beliefs about low back pain influence their clinical decisions and advice. Musculoskeletal Science & Practice, 53, 102382. https://doi.org/10.1016/j.msksp.2021.102382
9. Clauw, D. J. (2024). From fibrositis to fibromyalgia to nociplastic pain: How rheumatology helped get us here and where do we go from here? Annals of the Rheumatic Diseases, 83(11), 1421–1427. https://doi.org/10.1136/ard-2023-225327
10. Comachio, J., Ferreira, M. L., Mork, P. J., Holtermann, A., Ho, E. K., Wang, D. X. M., Lan, Q., Stamatakis, E., Beckenkamp, P. R. in Ferreira, P. H. (2024). Clinical guidelines are silent on the recommendation of physical activity and exercise therapy for low back pain: A systematic review. Journal of Science and Medicine in Sport, 27(4), 257–265. https://doi.org/10.1016/j.jsams.2024.01.003
11. Darlow, B., Fullen, B. M., Dean, S., Hurley, D. A., Baxter, G. D. in Dowell, A. (2012). The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: A systematic review. European Journal of Pain, 16(1), 3–17. https://doi.org/10.1016/j.ejpain.2011.06.006
12. Darlow, B., Perry, M., Mathieson, F., Stanley, J., Melloh, M., Marsh, R., Baxter, G. D. in Dowell, A. (2014). The development and exploratory analysis of the Back Pain Attitudes Questionnaire (Back-PAQ). BMJ Open, 4(5), e005251. https://doi.org/10.1136/bmjopen-2014-005251
13. do Prado, T., Parsons, J. in Ripat, J. (2022). Evidence-based practice for non-specific low back pain: Canadian physiotherapists’ adherence, beliefs, and perspectives. Physiotherapy Canada, 74(1), 44–53. https://doi.org/10.3138/ptc-2020-0038
14. Dumuid, D., Pedišić, Ž., Palarea-Albaladejo, J., Martín-Fernández, J. A., Hron, K. in Olds, T. (2020). Compositional data analysis in time-use epidemiology: What, why, how. International Journal of Environmental Research and Public Health, 17(7), 2220. https://doi.org/10.3390/ijerph17072220
15. Evans, D. W., Foster, N. E., Underwood, M., Vogel, S., Breen, A. C. in Pincus, T. (2005). Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: The COMPLeMENT trial. BMC Musculoskeletal Disorders, 6, 41. https://doi.org/10.1186/1471-2474-6-41
16. Fitzcharles, M. A., Cohen, S. P., Clauw, D. J., Littlejohn, G., Usui, C. in Häuser, W. (2021). Nociplastic pain: Towards an understanding of prevalent pain conditions. The Lancet, 397(10289), 2098–2110. https://doi.org/10.1016/S0140-6736(21)00392-5
17. Fourré, A., Vanderstraeten, R., Ris, L., Bastiaens, H., Michielsen, J., Demoulin, C., Darlow, B. in Roussel, N. (2023). Management of low back pain: Do physiotherapists know the evidence-based guidelines? International Journal of Environmental Research and Public Health, 20(9), 5611. https://doi.org/10.3390/ijerph20095611
18. Gardner, T., Refshauge, K., Smith, L., McAuley, J., Hübscher, M. in Goodall, S. (2017). Physiotherapists’ beliefs and attitudes influence clinical practice in chronic low back pain: A systematic review. Journal of Physiotherapy, 63(3), 132–143. https://doi.org/10.1016/j.
jphys.2017.05.017
19. GBD 2021 Low Back Pain Collaborators. (2023). Global, regional, and national burden of low back pain, 1990–2020, its attributable risk factors, and projections to 2050. The Lancet Rheumatology, 5(6), e316–e329. https://doi.org/10.1016/S2665-9913(23)00098-X
20. Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., Hoy, D., Karppinen, J., Pransky, G., Sieper, J., Smeets, R. J., Underwood, M. in Lancet Low Back Pain Series Working Group. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 2356–2367. https://doi.org/10.1016/S0140-6736(18)30480-X
21. Houben, R. M., Vlaeyen, J. W., Peters, M., Ostelo, R. W., Wolters, P. M. in Stomp-van den Berg, S. G. (2004). Health care providers’ attitudes and beliefs towards common low back pain: Psychometric properties of the HC-PAIRS. The Clinical Journal of Pain, 20(1), 37–44. https://doi.org/10.1097/00002508-200401000-00008
22. Ladeira, C. E., Cheng, M. S. in da Silva, R. A. (2017). Clinical specialization and adherence to evidence-based practice guidelines for low back pain management. Journal of Orthopaedic & Sports Physical Therapy, 47(5), 347–358. https://doi.org/10.2519/jospt.2017.6561
23. Macdonald, M., Vaucher, P. in Esteves, J. E. (2018). The beliefs and attitudes of UK registered osteopaths towards chronic pain. International Journal of Osteopathic Medicine, 30, 3–11. https://doi.org/10.1016/j.ijosm.2018.07.003
24. Marras, W. S. (2008). The working back: A systems view. John Wiley & Sons. https://doi.org/10.1002/9780470258576
25. Martin-Carbonell, M., Sequeira-Daza, D., Checa, I., Domenech, J., Espejo, B. in Castro-Melo, G. (2024). Evaluation of the psychometric properties of the HC-PAIRS in health professionals and students from Chile and Colombia. Heliyon, 10(14), e34652. https://doi.org/10.1016/j.heliyon.2024.e34652
26. Muller, R. D., Schielke, A., Gliedt, J. A., Cooper, J., Martinez, S., Eklund, A. in Pohlman, K. A. (2024). A scoping review to explore the use of the HC-PAIRS. PM&R, 16(11), 1248–1263. https://doi.org/10.1002/pmrj.13186
27. National Guideline Centre (NICE). (2016). Low back pain and sciatica in over 16s: Assessment and management. https://www.nice.org.uk/guidance/ng59/chapter/Recommendations
28. Qaseem, A., Wilt, T. J., McLean, R. M., Forciea, M. A. in Clinical Guidelines Committee of the ACP. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain. Annals of Internal Medicine, 166(7), 514–530. https://doi.org/10.7326/M16-2367
29. Rainville, J., Bagnall, D. in Phalen, L. (1995). Health care providers’ attitudes and beliefs about functional impairments and chronic back pain. The Clinical Journal of Pain, 11(4), 287–295. https://doi.org/10.1097/00002508-199512000-00006
30. Rankin, L. (2020). Chronic pain: From the study of student attitudes and preferences to the in vitro investigation of a novel treatment strategy [Doktorska disertacija, Umeå universitet]. https://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-173854
31. Rizzo, R. R., Cashin, A. G., Wand, B. M., Ferraro, M. C., Sharma, S., Lee, H., O’Hagan, E., Maher, C. G., Furlan, A. D., van Tulder, M. W. in McAuley, J. H. (2025). Non-pharmacological and nonsurgical treatments for low back pain: An overview of Cochrane reviews. Cochrane Database of Systematic Reviews, 3(3), CD014691. https://doi.org/10.1002/14651858.CD014691.pub2
32. Sheeran, L., Sparkes, V., Caterson, B., Busse-Morris, M. in van Deursen, R. (2012). Spinal position sense and trunk muscle activity during sitting and standing in nonspecific chronic low back pain. Spine, 37(8), 486–495. https://doi.org/10.1097/BRS.0b013e31823b00ce
33. Smart, K. M. (2023). The biopsychosocial model of pain in physiotherapy: Past, present and future. Physical Therapy Reviews, 28(2), 61–70. https://doi.org/10.1080/10833196.2023.2177792
34. Soni, A., Wanigasekera, V., Mezue, M., Cooper, C., Javaid, M. K., Price, A. J. in Tracey, I. (2019). Central sensitization in knee osteoarthritis. Arthritis & Rheumatology, 71(4), 550–560. https://doi.org/10.1002/art.40749
35. Stochkendahl, M. J., Kjaer, P., Hartvigsen, J., Kongsted, A., Aaboe, J., Andersen, M., Andersen, M. Ø., Fournier, G., Højgaard, B., Jensen, M. B., Jensen, L. D., Karbo, T., Kirkeskov, L., Melbye, M., Morsel-Carlsen, L., Nordsteen, J., Palsson, T. S., Rasti, Z., Silbye, P. F., Steiness, M. Z. in Vaagholt, M. (2018). National clinical guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. European Spine Journal, 27(1), 60–75. https://doi.org/10.1007/s00586-017-5099-2
36. Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., O’Sullivan, P. in O’Sullivan, K. (2015). Physiotherapists may stigmatise or feel unprepared to treat people with low back pain. Journal of Physiotherapy, 61(2), 68–76. https://doi.org/10.1016/j.jphys.2015.02.016
37. Zavod za zdravstveno zavarovanje Slovenije. (2024). Podatki o izvedenih obravnavah po zdravstvenem delavcu: Fizioterapija. https://partner.zzzs.si/zdravstvene-storitve/podatki-oizvedenih-obravnavah-po-zdravstvenem-delavcu/fizioterapija
38. Zhou, T., Salman, D. in McGregor, A. H. (2024). Recent clinical practice guidelines for the management of low back pain: A global comparison. BMC Musculoskeletal Disorders, 25(1), 344. https://doi.org/10.1186/s12891-024-07468-0
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Alenka Groboljšek, Maja Frangež
This work is licensed under a Creative Commons Attribution 4.0 International License.
