Prescribing Restrictions for Patients with Low Back Pain

Activity Alteration

To avoid both undue back irritation and debilitation from inactivity, recommendations for alternate activity can be helpful. Most patients will not require bed rest. Prolonged bed rest (more than 4 days) has potential debilitating effects, and the efficacy in the treatment of acute low back problems is unproven. Two to four days of bed rest are reserved for patients with the most severe limitations (due primarily to leg pain).

Avoiding undue back irritation

Activities and improper posture can 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 increases stress on the back. Sitting may aggravate symptoms for some patients as well. Advise patients to avoid prolonged sitting and to change position often. A soft support placed at the small of the back, armrests to support some bodyweight, and a slight recline of the chair back may make required sitting more comfortable.

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 avoid debilitation from inactivity. An incremental, gradually increasing regimen of aerobic exercise (up to 20-30 minutes daily) can usually be started within the first 2 weeks after symptoms have resolved. Such activities have been found to stress the back no more than sitting for an equal period of time on the side of a bed. Patients should be informed that exercise might increase symptoms slightly at first. If intolerable, some exercise alteration is usually helpful.

(a) Specific 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.

(b) 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.

Sitting and unassisted lifting

When prescribing work restrictions, remember that even moderately heavy unassisted lifting may aggravate back symptoms. Restrictions are intended to allow for improvements in recovery time. Restrictions should only be for a short period of time, and should never exceed 3 months since no benefit is apparent after 3 months.

Recommendations for sitting periods and weight lifting

(a) Employees without low back symptoms should not sit for more than 50 minutes without getting a break to get up and walk around.

(b) Employees with mild pain should not sit more than 30 minutes

(c) Employees with moderate pain should not sit for more than 20 minutes.

(d) Workers without back symptoms should not routinely be lifting more than 80 pounds (men) and 40 pounds (women).

(e) Workers with severe or moderate symptoms should not lift more than 20 pounds.

(f) Workers with mild symptoms should not lift more than 60 pounds (men) and 35 pounds (women).