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Should You Rest or Stay Active With Lower Back Pain?

For ordinary low back pain, the research favors staying active over resting in bed. In the main comparison the difference is small and favors staying active. Bed rest did not help people recover faster, and in a Helsinki trial recovery was slowest with bed rest. Keep as much of your normal day as the pain allows, and stop short of pushing through a sharp increase.

I had low back pain for about ten years and have no medical credentials. The trials and guidelines are listed at the end of the page.

What the trials found

The main summary is a 2010 Cochrane review by Dahm and colleagues, which included 10 randomised trials comparing advice to rest in bed with advice to stay active.

One of the trials behind this is a 1995 study from Helsinki by Malmivaara and colleagues, published in the New England Journal of Medicine. City employees with acute, non-specific low back pain were assigned to 2 days of bed rest, back-mobilizing exercises, or carrying on with ordinary activities as tolerated. At 3 and 12 weeks, the ordinary-activity group had recovered best, on pain, disability and days off work. Recovery was slowest with bed rest.

In that trial the back-mobilizing exercise group also recovered more slowly than the ordinary-activity group, though across three trials the Cochrane review found little or no difference between exercises and staying active. For the first days of a new episode, the moderate-quality evidence favors advice to stay active over bed rest.

What the guidelines say

NICE NG59 (recommendation 1.2.1) tells clinicians to give people advice and information to help them self-manage, including "encouragement to continue with normal activities". The American College of Physicians 2017 guideline notes that most people with acute or subacute low back pain improve over time regardless of treatment, and recommends superficial heat as a first option.

The 2018 Lancet series on low back pain summed up the guidelines as recommending education that supports self-management and a return to normal activities and exercise. It listed rest among the things used too often in practice, alongside imaging, opioids, spinal injections and surgery.

What staying active looks like on a bad day

• Keep the parts of your day you can manage: getting dressed, light chores, work if it is possible, even if you do them more slowly.
• Walk a little, several times a day, at whatever pace you can. The walking page has the trials.
• Change position often. Short spells in a tolerable position are often easier than staying in one position for a long time.
• Lie down when you need to. A rest to get through a bad hour is different from staying in bed for days.
• Use heat if it helps. For acute or subacute low back pain, ACP recommends superficial heat as one non-drug option (moderate-quality evidence), along with massage, acupuncture or spinal manipulation.
• Skip the heavy or new things for a few days, then bring them back in small steps.

If you are scared to move because you think it will cause damage, the hurt versus harm and fear-avoidance pages cover why pain and damage often do not track together.

Long-running pain: rest or exercise?

The bed-rest trials were about new pain. For pain that has lasted more than about 3 months, the question changes to which kind of activity to do. ACP 2017 includes exercise among the first non-drug options for chronic low back pain, and WHO's 2023 guideline recommends exercise programs for chronic primary low back pain. NICE NG59 says to consider a group exercise programme for a specific episode or flare-up. The 2021 Cochrane review of 249 trials found exercise probably reduces chronic low back pain by a modest average amount compared with no treatment, usual care or placebo. The chronic low back pain exercises page compares the main types.

Resting from one specific load can still make sense in a flare. Low Back Pain Coach works that way in its flare-up mode: bench sessions pause, and the plan says to walk as tolerated, change positions often and keep logging. Training resumes automatically at an eased volume after two days at or below your baseline (your usual pain on an ordinary day). The flare-up plan has the details.

When rest and a doctor come first

Staying active is advice for ordinary back pain. It does not apply if you were recently injured, had surgery, or have signs that need a doctor. If you had a recent fall, accident or operation, follow the recovery plan your doctor set.

Go to emergency care now for new numbness, tingling or change in feeling in the saddle area (groin, inner thighs, genitals or anus), new changes in sexual function, new bladder or bowel changes, new pain, tingling, numbness or weakness in both legs, leg or foot weakness that is getting worse, or back pain after a recent serious accident. See a clinician today (urgent care if you cannot get an appointment today) for other new weakness or numbness in one leg or foot, fever or chills with the back pain, new pain after a recent smaller fall or knock, unexplained weight loss or a history of cancer, pain that is rapidly getting worse, or pain that is constant at rest and worse at night, not tied to movement. The red-flag checklist has the full list.

If none of those apply and a flare is not clearly improving after 7 to 10 days, see a clinician. The appointment questions page lists what to ask.

Common questions

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