Health: Back pain? Don't take it lying down: Exercise, not rest, may be the best remedy. Sheila Menuhin reports on new research and returns to a centre that put her on her feet again after an injury

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DOCTORS are largely responsible for the current epidemic of long-term back problems, according to Professor Gordon Waddell, an orthopaedic surgeon at Glasgow's Western Infirmary. By advising patients to rest, they are not only ignoring recent medical research but they could be prescribing disability as well.

There is no doubt that back pain can destroy people's lives and generate profound fear in sufferers. The number of working days lost through back pain has doubled in the last 10 years, and doubled in the 10 years before that. In 1970 the figure was 15 million; by 1980 it had reached 30 million; in 1990, 60 million.

'Since the war, time off for back pain has just gone up and up and up and there's no biological explanation for it. Historically, people were not disabled to anything like the same extent, so it must be something we're doing,' says Professor Waddell.

Professor Waddell believes that prolonged inactivity is at the root of this epidemic. Doctors recommend rest and a social support system exists that allows people to have extended bouts of time off, because of their bad backs.

'If an athlete has a minor injury and stops world-class running for six months, he or she will have a terrible job getting back to form. But if such athletes can return within a week or two, they regain their fitness fairly readily. The longer they are off, the harder it is to overcome the physical barriers, the training barriers and the psychological barriers,' he says.

One of the confusing factors is that after injury some rest is necessary, to allow tissues to recover. But how much? Most doctors will say: take it easy, or stay in bed, for up to six weeks, until the healing process is complete. But the latest thinking is that this may well leave the injured person with a weak back, vulnerable to a cycle of repeated injury and permanent disability.

Over the last decade, researchers in the United States, Scandinavia and the Netherlands have mounted around 20 research projects to investigate the 'rest versus exercise ratio'. The consensus is that two or three days in bed is far more effective than seven days, unless there has been serious disc damage. The research shows that patients who then start a rigorous exercise programme improve 74 per cent more quickly than those left to nurse themselves back to health.

Yet Professor Waddell estimates that 90 per cent of doctors remain sceptical about these results. 'Medicine is conservative and doctors take a lot of convincing. Also, the trials are largely buried in foreign journals, and it takes time for them to surface and become accepted into medical folklore.'

Lack of resources is another problem. Professor Waddell says a family doctor in the Midlands may well have read the research but have no place nearby that runs an exercise programme. He is likely to tell the patient to come back in six weeks if the pain has not gone, when he will make a referral to a surgical orthopaedic clinic - probably with a wait for an appointment of three to six months.

Professor Waddell says, 'Once there, the patient will probably be told that an operation is not necessary.' The patient may then be told that physiotherapy could be arranged instead. 'The therapist will probably say: 'It's still a bit sore. I don't want to exercise it. I'll put some heat on your back instead.' By that stage, it is six months or a year since the injury and it's far too late.'

What is needed, he argues, is a system for treating patients early, offering outpatient rehabilitation, giving people advice and exercises two to six weeks after an initial attack. Such provision would be expensive, but only in the short term. 'Back pain costs the United Kingdom something like pounds 3bn a year. That's a hell of a lot of money. If we could halve that, we would be saving pounds l 1/2bn.'

Would such programmes really make that kind of difference? Helen Frost, a physiotherapist at Nuffield Orthopaedic Centre, Oxford, has spent the last two years trying to find out. Funded by the Back Pain Association, she is looking at whether active rehabilitation really is the answer.

Her patients are all referred with a minimum of six months' pain. 'They've given up sport; they've given up the things they enjoy; they may have lost their job; they may be depressed or anxious; and they're afraid of moving.'

All receive an initial three hours' education in ergonomics, seating and lifting; then members of the control group are just given gentle exercises to do at home, while those in the trial group do a one-hour supervised exercise session, twice a week for four weeks. 'Warm up, stretching, a circuit of 15 exercises, and then cool down. Nothing special,' she says.

Eight hours of exercise does not seem much, yet she feels that is enough to get people moving again. 'One of the big issues is that people are afraid of exercise, because everybody tells them to rest. 'But just advising them to exercise is not enough. You need to get them doing something fairly strenuous, so that they can see they can actually move without causing more problems. But you do need supervision.'

Ms Frost is reluctant to draw many conclusions until her results are collated in April. None the less, from having studied the similar research to date, she is adamant about the need to change attitudes. 'Long-term rest is just no good for people. You've got to break into that cycle.'

Professor Gordon Waddell, Biopsychosocial Analysis Of Low Back Pain 'Bailliere's Clinical Rheumatology', Vol 6, No 3.

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