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Medium firm mattresses reduced pain related disability more than firm mattresses in chronic, non-specific low back pain

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Abstract

Q u e s t i o n What is the effect of different firmnesses of mattresses on the clinical course of chronic, nonspecific, low-back pain and disability? D e s i g n Randomized (allocation concealed)*, blinded {patients, clinicians, data collectors, outcome assessors, data analysts, and monitoring com-mittee} †,* controlled trial with follow-up at 90 days. S e t t i n g Spain. P a t i e n t s 313 adults who were ≥ 18 years of age (73% women), had ≥ 3 months of chronic low-back pain, and had pain while lying in bed or on rising. Exclusion criteria were referred pain; habitual prostration; possible systemic disease, inflammatory disease, or cancer; diagnosis or suspicion of fibromyalgia; pregnancy ; habitually sleeping in a different bed ≥ 2 nights/wk; use of antiinflammatory medication with a 24-hour effect; or use of hyp-notic analgesic, antiinflammatory, or relaxant medication from 1700 hours to the time at which pain on rising was assessed. 310 patients (99%) completed follow-up. I n t e r v e n t i o n 155 patients were allocated to medium-firm mattresses (European Committee for Standardization scale firmness rating 5.6 [1.0 = firmest and 10.0 = softest], and 158 patients were allocated to firm mattresses (firmness rating 2.3). M a i n o u t c o m e m e a s u r e s Self-reported pain intensity while lying in bed and on rising (visual analogue scale) and degree of disability (Roland Morris questionnaire).
Therapeutics
12
©ACP July/August 2004 | Volume 141 • Number 1 ACP Journal Club
Question
What is the effect of different firmnesses of
mattresses on the clinical course of chronic,
nonspecific, low-back pain and disability?
Design
Randomized (allocation concealed)*, blinded
{patients, clinicians, data collectors, outcome
assessors, data analysts, and monitoring com-
mittee}†,* controlled trial with follow-up at
90 days.
Setting
Spain.
Patients
313 adults who were 18 years of age (73%
women), had 3 months of chronic low-
back pain, and had pain while lying in bed or
on rising. Exclusion criteria were referred
pain; habitual prostration; possible systemic
disease, inflammatory disease, or cancer;
diagnosis or suspicion of fibromyalgia; preg-
nancy; habitually sleeping in a different bed
2 nights/wk; use of antiinflammatory med-
ication with a 24-hour effect; or use of hyp-
notic analgesic, antiinflammatory, or relaxant
medication from 1700 hours to the time at
which pain on rising was assessed. 310
patients (99%) completed follow-up.
Intervention
155 patients were allocated to medium-firm
mattresses (European Committee for Stan-
dardization scale firmness rating 5.6 [1.0 =
firmest and 10.0 = softest], and 158 patients
were allocated to firm mattresses (firmness
rating 2.3).
Main outcome measures
Self-reported pain intensity while lying in
bed and on rising (visual analogue scale) and
degree of disability (Roland Morris question-
naire).
Main results
Analysis was by intention to treat. Patients
who used medium-firm mattresses were
more likely to have improvements in pain-
related disability than were patients who used
firm mattresses (Table). The groups did not
differ for improvement in pain while lying in
bed or improvement in pain on rising
(Table).
Conclusion
In patients with chronic, nonspecific low-
back pain, medium-firm mattresses reduced
pain-related disability more than firm mat-
tresses, but did not affect pain while lying in
bed or on rising.
Sources of funding: Kovacs Foundation. Mattresses
were provided by FLEX.
For correspondence: Dr. F.M. Kovacs, Kovacs
Foundation, Palma de Mallorca, Spain. E-mail
kovacs@kovacs.org.
*See Glossary.
†Information provided by author.
Medium-firm mattresses reduced pain-related disability more than firm
mattresses in chronic, nonspecific low-back pain
Kovacs FM, Abraira V, Peña A, et al. Effect of firmness of mattress on chronic non-specif-
ic low-back pain: randomised, double-blind, controlled, multicentre trial. Lancet.
2003;362:1599-604.
Commentary
Don’t recommend a firm mattress for someone with chronic low-back
pain. And, despite the findings of Kovacs and colleagues, dont recom-
mend a medium-firm mattress, either. The ideal mattress, if such exists,
is still unknown. Advice to sleep on a firm mattress to palliate persistent
regional backache exits the ranks of the unproven and joins the ever-
growing ranks of the disproved. Hundreds of other methods have suf-
fered this fate. Based on the evidence, little more than over-the-counter
analgesics (1) and advice to stay active (2) should be offered.
The firmer mattress has now lost its competitive edge, thanks to the
findings of the trial by Kovacs and colleagues. The between-group dif-
ferences are persuasive but must be interpreted cautiously because most
study patients correctly perceived the firmness of their new mattress,
meaning that blinding was unsuccessful. More impressive is that > 70%
of patients had improvement in back pain regardless of the type of new
mattress they received. This trial of a treatment method was itself a
treatment. The nonspecific (Hawthorne and placebo) effects dwarfed
the small between-group differences.
How is it that simply participating in the “trial” could be palliative?
Clearly, participation overcame whatever thwarted recovery from many
months of back pain. The context of the trial must have engendered a
sufficient sense of wellness in patients such that they could downplay,
ignore, or even forget their pain. The pain is in their backs, but the suf-
fering is in their minds. There are less expensive means of coping than
buying a new medium-firm mattress (3).
Nortin M. Hadler, MD
University of North Carolina at Chapel Hill and UNC Hospitals
Chapel Hill, North Carolina, USA
Arthur T. Evans, MD, MPH
Cook County Hospital and Rush Medical College
Chicago, Illinois, USA
References
1. van Tulder MW, Scholten RJ, Koes BW, Deyo RA. Nonsteroidal anti-inflam-
matory drugs for low back pain: a systematic review within the framework of
the Cochrane Collaboration Back Review Group. Spine. 2000;25:2501-13.
2. Hagen KB, Hilde G, Jamtvedt G, Winnem MF. The Cochrane review of
advice to stay active as a single treatment for low back pain and sciatica. Spine.
2002;27:1736-41.
3. Hadler NM. The Last Well Person. Montreal: McGill-Queens University
Press; 2004.
Medium-firm mattress vs firm mattress for chronic, nonspecific low-back pain‡
Outcomes at 90 d Medium-firm mattress Firm mattress RBI (95% CI) NNT (CI)
Improvement in pain while lying in bed 83% 78% 6.1% (6 to 15) Not significant
Improvement in pain on rising 86% 80% 6.8% (4 to 20) Not significant
Improvement in pain-related disability 82% 68% 20% (7 to 30) 8 (5 to 23)
‡Abbreviations defined in Glossary; RBI, NNT, and CI calculated from control event rates and unadjusted odds ratios in article. Improvement = a positive
change in pain intensity between baseline and 90 days.
Article
Full-text available
This study compared sleep quality and stress-related symptoms between older beds (>/=5 years) and new bedding systems. A convenience sample of healthy subjects (women = 30; men = 29) with minor musculoskeletal sleep-related pain and compromised sleep, but with no clinical history of disturbed sleep, participated in the study. Subjects recorded back discomfort and sleep quality upon waking for 28 consecutive days in their own beds (baseline) and for 28 consecutive days (post) on a new bedding system using visual analog scales. Following baseline measures, participant's beds were replaced by new, medium-firm beds, and they again rated their sleep quality and back discomfort. Stress was assessed by a modified stress questionnaire. Repeated-measures analysis of variance was used to treat sleep quality and efficiency and factored responses of the stress items. Results indicated that the subjects' personal bedding systems average 9.5 years old and were moderately priced. Significant (P < .01) improvements were found between pre- and posttest mean values in sleep quality and efficiency. Continued improvement was noted for each of the 4-week data gathering period. Stress measures yielded similar positive changes between pre- and posttest mean values. Based on these data, it was concluded that, in this population, new bedding systems increased sleep quality and reduced back discomfort, factors that may be related to abatement of stress-related symptoms.
Article
A systematic review of randomized and double-blind controlled trials was performed. Nonsteroidal anti-inflammatory drugs are the most frequently prescribed medications worldwide and are widely used for patients with low back pain. To assess the effects of nonsteroidal anti-inflammatory drugs in the treatment of nonspecific low back pain with or without radiation, and to assess which type of nonsteroidal anti-inflammatory drug is most effective. For this study, the Cochrane Controlled Trials Register, Medline and Embase, and reference lists of articles were searched. Two reviewers blinded with respect to authors, institution, and journal independently extracted data and assessed the methodologic quality of the studies. If data were considered clinically homogeneous, a meta-analysis was performed. If data were considered clinically heterogeneous, a qualitative analysis was performed using a rating system with four levels of evidence: strong, moderate, limited, and no evidence. This review involved 51 trials and 6057 patients. Of these trials, 16 (31%) were of high quality. The pooled relative risk for global improvement after 1 week was 1.24 (95% confidence interval [CI] = 1.10-1.41), and for additional analgesic use was 1.29 (95% CI = 1.05-1.57), indicating a statistically significant but small effect in favor of nonsteroidal anti-inflammatory drugs as compared with a placebo. The results of the qualitative analysis showed that there is conflicting evidence (Level 3) that nonsteroidal anti-inflammatory drugs are more effective than paracetamol for acute low back pain, and that there is moderate evidence (Level 2) that nonsteroidal anti-inflammatory drugs are not more effective than other drugs for acute low back pain. There is strong evidence (Level 1) that various types of nonsteroidal anti-inflammatory drugs are equally effective for acute low back pain. The evidence from the 51 trials included in this review suggests that nonsteroidal anti-inflammatory drugs are effective for short-term symptomatic relief in patients with acute low back pain. Furthermore, there does not seem to be a specific type of nonsteroidal anti-inflammatory drug that is clearly more effective than others. Sufficient evidence on chronic low back pain still is lacking.
Article
A systematic review was conducted within the Cochrane Collaboration Back Review Group. To assess the effects of advice to stay active as a single treatment for patients with acute low back pain or sciatica. Low back pain is a common reason for consulting a health care provider, and advice on daily activities constitutes an important part in the primary care management of low back pain. All randomized studies available in systematic searches (electronic databases, contact with authors, reference lists) were included. Two reviewers independently selected trials for inclusion, assessed the validity of the included trials, and extracted data. Investigators were contacted to obtain missing information. Four trials, with a total of 491 patients, were included. In all the trials, advice to stay active was compared with advice for bed rest. Two trials were assessed as having a low risk of bias, and two as having a moderate to high risk of bias. The results were heterogeneous. The results from one high-quality trial of patients with acute, simple low back pain found small differences in functional status (weighted mean difference on a 0 to 100 scale, 6.0; 95% CI, 1.5-10.5) and length of sick leave (weighted mean difference, 3.4 days; 95% CI, 1.6-5.2) in favor of staying active, as compared with advice to stay in bed 2 days. The other high-quality trial compared advice to stay active with advice to rest in bed 14 days for patients with sciatic syndrome, and found no differences between the groups. One of the high-quality trials also compared advice to stay active with advice to engage in exercises for patients with acute, simple low back pain, and found improvement in functional status and reduced sick leave in favor of advice to stay active. The best available evidence suggests that advice to stay active alone has little beneficial effect for patients with acute, simple low back pain, and little or no effect for patients with sciatica. There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica. Because there is no considerable difference between advice to stay active and advice for bed rest, and there are potential harmful effects of prolonged bed rest, it is reasonable to advise people with acute low back pain and sciatica to stay active. These conclusions are based on single trials.
The Last Well Person
  • N M Hadler
Hadler NM. The Last Well Person. Montreal: McGill-Queens University Press; 2004.