To avoid both undue back irritation and debilitation from inactivity, recommendations for alternate activity can be helpful. Bedrest is reserved for patients with the most severe limitations (due primarily to leg pain).15 This should not exceed 2 days. In general, especially if no red flags have arisen, patients should be instructed to return to their usual daily activities including work as soon as able. The AHCPR guidelines outline the approach described below to activity limitations.
AVOIDING UNDUE BACK IRRITATION Activities and postures that increase stress on the back also tend to aggravate back symptoms. Patients limited by back symptoms can minimize the stress of lifting by keeping any lifted object close to the body at the level of the navel. Twisting, bending, and reaching while lifting also increase stress on the back. Sitting, although safe, may aggravate symptoms for some patients. Advise these patients to avoid prolonged sitting and to change position often. A soft support placed at the small of the back, armrests to support some body weight, and a slight recline of the chair back may make required sitting more comfortable.15
AVOIDING DEBILITATION Until the patient returns to normal activity, aerobic (endurance) conditioning exercise such as walking, stationary biking, swimming, and even light jogging may be recommended to help avoid debilitation from inactivity. An incremental, gradually increasing regimen of aerobic exercise (up to 20 to 30 minutes daily) can usually be started within the first 2 weeks of symptoms. Such conditioning activities have been found to stress the back no more than sitting for an equal time period on the side of the bed. Patients should be informed that exercise may increase pain slightly at first. If intolerable, some exercise alteration is usually helpful.15
Conditioning exercises for trunk muscles are more mechanically stressful to the back than aerobic exercise. Such exercises are not recommended during the first few weeks of symptoms, although they may later help patients regain and maintain activity tolerance.15
There is no evidence to indicate that back-specific exercise machines are effective for treating acute low back problems. Neither is there evidence that stretching of the back helps patients with acute symptoms.15
WORK ACTIVITIES When requested, clinicians may choose to offer specific instructions about activity at work for patients with acute limitations due to low back symptoms. The patient's age, general health, and perceptions of safe limits of sitting, standing, walking, or lifting (noted on initial history) can provide reasonable starting points for activity recommendations. Ta.bie,,2Z4.-3. provides a guide for recommendations about sitting and lifting. The clinician should make clear to patients and employers that even moderately heavy unassisted lifting may aggravate back symptoms. Any restrictions are intended to allow for spontaneous recovery or time to build activity tolerance through exercise. Activity restrictions are prescribed for a short time period only, depending upon work requirements (no benefits are apparent beyond 3 months' restriction).15
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