Bed Rest No Longer the Best Option for Back Pain

July 6, 2009, Cindy Tan, Senior Physiotherapist

Low back pain is one of the most common reasons for consulting a physician. Despite little supporting scientific evidence, bed rest was considered the primary treatment for low back pain from the late 19th century. What has changed now is how back pain is understood and managed.

How Bed Rest Started as the Recommended Approach for Back Pain

Source: flickr amanky

Rest was first proposed as a treatment by John Hunter (1728-1793), a Scottish surgeon, in his study on wounds and inflammation. He believed that the first and most important requisite for restoration of inflamed, injured parts is rest, as rest is necessary for repairing injured parts. This proposed idea of rest as a treatment was further amplified by John Hilton (1804-1878), a British surgeon, in his 1862 series of lectures on "Rest and Pain" to the Royal College of Surgeons. He claimed that it is the natural treatment for the inflammation of injury and wounds.

Their theory of injury leading to an inflammatory response that requires rest to heal the body had a huge influence throughout the field of medicine even though their works revolves around only on inflammation and wounds. Physicians all over the world started to use rest as a treatment for a wide range of conditions, from myocardial infarction to normal childbirth.

TThroughout the 19th century, the orthopaedic principle of rest became dominant. The rationale of rest for back pain started from the idea that pain was due to injury. With injury, inflammation occurs and thus rest was essential for healing. If the primary injury was not properly treated with rest, chronic pain would develop. It was believed that movements, physical activities and repeated back injuries during the inflammatory phase may increase pain and so must be harmful, and thus should be avoided. This thinking was later applied in the treatment of a ruptured disc, where the disc "comes out". The idea was that with bed rest, i.e. lying down, disc pressure is the lowest and the disc will somehow "go back". Unfortunately, there was no scientific evidence back then to support bed rest as treatment. Orthopaedic doctors just followed with what was taught to them, i.e. bed rest. By 1900, a standard orthopaedic text was published and recommended two to six weeks of bed rest for acute back pain.

Doubts Began to Form in Approach to Back Pain

Although some doctors during the 19th century did question the use of bed rest, it was not until the 1980s that its efficacy as a treatment for back pain began to be seriously questioned. However, many then still felt that some rest was necessary, and initial studies only questioned the amount of rest that was needed rather than whether it was needed at all

In 1986, Deyo et al were the first few to investigate the use of bed rest in low back pain. The study compared the functional status and symptoms of a group that received 7 days of bed rest with a second group that received 2 days of bed rest. No difference was found between the two groups in terms of the functional status and symptoms. This later formed the basis for several guidelines that advise no more than 2 days of rest for patients with acute low back pain

Over the years, studies have emerged showing that bed rest of any duration is not effective for low back pain and that it often delays recovery. In fact, other than delayed recovery, prolonged bed rest can also have detrimental effects on the body. Patients with prolonged bed rest may end up with osteoporosis (bone calcium loss), muscle wasting due to muscle protein loss, deep vein thrombosis and undesirable psychological effects

Current Approach to Back Pain

So the question now is, if bed rest has been shown to be detrimental and ineffective in the treatment of low back pain, would early activity be better?

Several studies have looked at the effects of advice to stay active in the treatment of acute low back pain and found that advice to stay active was better or similar to advice to rest in bed. In an update of a 2004 Cochrane Review of trials on bed rest for acute low back pain and sciatica, it was found that for patients with acute pain, advice to rest in bed was less effective in reducing pain and improving an individual’s ability to perform every day activities than advice to stay active. For patients with sciatica, there was little or no difference between advice to rest in bed and advice to stay active.

For chronic back pain sufferers, exercise therapy has been supported by good evidence to reducing time taken to return to work and improving functional status. Patients prescribed with graded exercises have been shown to return to work sooner, have less disability, and have fewer pain complaints than patients treated with medications and bed rest.

No More than Two Days Bed Rest

Given the extensive research done in recent years on back pain and rest, there is rising evidence to point towards avoidance of bed rest for the management of back pain. Advice on early, progressive activity, with no more than 2 days of bed rest, will serve as the current approach to the management of back pain.

References

Allan, David B. and Waddell, Gordon(1989). A historical perspective on low back pain and disability, Acta Orthopaedica,60:3,1-23.
Deyo RA, Diehl AK, Rosenthal M. How many days of bed rest for acute low back pain? The New England Journal of Medicine 1986; 315:1064-1070.
Gorden Waddell. The Back Pain Revolution, Churchill Livingstone, New York. 1999.
Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-back pain and sciatica. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD001254.
Lindstrom I, Ohlund C, Eek C, et al.Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain: a randomized prospective clinical study with a behavioral therapy approach. Spine 1992; 17:641-652.
Lindstrom I, Ohlund C, Eek C, et al. The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavorial approach. Physical Therapy 1992; 72:279-293.

This work by Musculoskeletal Consumer Review is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 Singapore License. This article was contributed by Core Concepts - Back and Neck Pain Specialists. In the spirit of promoting health education, you may copy, distribute and transmit the work under the conditions specified by the license. For articles re-printed with permission, copyright remains with the original copyright holder (author or publisher). MCR's Creative Commons License does not apply in such cases.

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Comments

Dr Phil

Interesting background on the history of back pain treatment and advice, surpising that bed rest was only seriously questioned so recently.

Of course, prevention is always better than cure, and improving your posture is key. If you spend hours per day hunched over a keyboard and want to prevent back pain (or recover from your existing aches and pains and prevent them coming back) then try PostureMinder software to help you improve your posture and adopt healthy, common-sense computer habits. There's a free 30-day trial available for download on my website.