What’s Up DOC?

“A cuppa tea, a Bex and good lie down”, was Australia’s universal panacea of days gone by. Well it appears that at least the first two ingredients, tea and Bex, an aspirin based analgesic, may be good for many ailments. But not so for bed rest.

It wasn’t too long ago that the standard medical treatment for low back pain was 1-2 weeks of complete bed rest. Bed rest has also been prescribed for many other ailments including hypertension and hepatitis, as well as many postsurgical conditions. I can remember when it was recommended that women should remain in bed for 5 or more days after uncomplicated childbirth.

The recommendation of bed rest for various conditions has changed considerably over the past few years, and this change has been largely due to anecdotal evidence combined with a smattering of minor research papers. However, recent research should put the bed rest theory out to pasture once and for all and as one researcher puts it “bed rest hasn’t proven to be an effective treatment for much of anything”. (1)

Allen et al (2) conducted a systematic review of the literature from 1966 to 1998, comparing bed rest with early mobilisation for any medical condition. They found randomised controlled trials (RCT’s) for various medical conditions and where bed rest was the primary treatment there was no statistically significant advantage to bed rest. A 1944 paper, appropriately titled, “The evil sequelae of complete bed rest” concluded that “complete bed rest is a highly unphysiologic and definitely hazardous form of therapy, to be ordered for specific indications and discontinued as early as possible” (3). However, the authors also add that further studies are needed to establish the benefit or harm of bed rest as a treatment and go on to say “Even when it is not an effective therapy it may be an unavoidable consequence of illness”.

With respect to back pain, a recent large randomised study from France could find no evidence that bed rest provides any therapeutic advantage over advice to stay active (4). Rozenberg et al found that when they compared bed rest to advice to stay active for subjects with acute low back pain, bed rest did not speed recovery or pain relief and appeared to adversely affect long term outcomes. In the trial, those subjects who were assigned to receive bed rest as their treatment had more frequent and longer periods of sick leave than those assigned to the “stay active” group. This conclusion is remarkably consistent with the findings of the Cochrane Collaboration review of bed rest as a treatment for low back pain and/or sciatica.

Bed rest may be one of the most damaging treatments for back pain, with rest and immobility causing detrimental effects on multiple body systems. Even 2-3 weeks of bed rest can have significant effects on the cardiovascular system , and on muscle and bone density. To prove the point, a new study on the systemic effects of bed rest concludes that just 20 days of bed rest is equal to thirty years of aging (5).

In 1996, five healthy 20 year old men underwent 20 days of complete bed rest followed by 8 weeks of dynamic training, to determine how quickly the body would lose aerobic capacity. The study then assessed how quickly physical exercise could restore their fitness. Thirty years later researchers again looked at this population and discovered some rather astounding and sinister findings.

These men, 30 years after the initial study, had put on an average of 25% body weight, an amazing 100% body fat, and their VO2 max. was also reduced. The authors stated that “The most remarkable finding of the study is the observation that 3 weeks of bed rest in 1966 caused a greater deterioration in cardiovascular and physical work capacity than did 30 years of aging in these men”. On the positive side, these 5 men undertook a 6 month endurance training program and regained their 1966 cardiovascular fitness and lost a significant amount of body weight and body fat.

Finally, it must be remembered that sometimes bed rest is needed when people have severe back pain. The research also supports this statement for severe back pain, but recommends only 2-3 days. As a practitioner who sees many people with low back pain and as a previous sufferer myself, I for one would advocate a few days bed rest when the pain is so severe that weight bearing causes severe pain and when relief is gained with recumbence.

John Reggars

References:

1. The Back Letter. Wiesel SW ed. Hagerstown MD, Lippincott Williams & Wilkins 1999; 14/12: 135.
2. Allen C et al. Bed rest: A potentially harmful treatment needing more careful evaluation. The Lancet 1999;354: 1229-33.
3. Dock W et al. The evil sequelae of complete bed rest. JAMA; 1944:125: 1087-90.
4. Roenberg S et al. French multicenter prospective, randomised, open study comparing advice to stay active and bed rest in acute low back pain. Proceedings of the Annual General Meeting of the International Society for the study of the lumbar spine. Edinburgh 2001. In press.
5. McGuire et al A 30-year follow-up of the Dallas bed rest and training study: Effect of age on the cardiovascualr response to exercise. Circulation 2001; 104:1350-7.