Ronald L. Rupert
The medical community has considered bed rest to be one of the primary therapeutic approaches for low back pain. However, there are published works that challenge the wisdom of bed rest, especially if it is prolonged. The December 1994 guidelines developed by AHCPR for the treatment of acute low back pain in adults noted the following: "1) A gradual return to normal activities is more effective than prolonged bed rest for treating acute low back problems. 2) Prolonged bed rest for more than 4 days may lead to debilitation and is not recommended for treating acute low back pain. 3) The majority of low back pain patients will not require bed rest. Bed rest for 2 to 4 days may be an option for patients with severe initial symptoms of primarily leg pain."
If we want to look at the research upon which AHCPR based these 1995 guidelines, or if we want to look at more recent work related to the value of bed rest, we must review the published literature. Because many health providers (DCs and MDs) do not keep current with the literature there is often a gap between the attitudes they have about the value of a specific treatment and the facts. So in addition to looking at research evaluating bed rest, it would be interesting to see what physicians' attitudes are as well.
Let's take a moment to look at the appropriate strategies needed to conduct an online computer search for information about attitude and clinical studies related to the use of bed rest. The first component as in all searching is to look in the right place. Medline and Chirolars would be the strongest starting places. If a very comprehensive search is desired then Embase, CINAHL, SPORT and several other biomedical databases could be included. Both Medline and Chirolars permit the use of similar search terms (MeSH headings and subheadings and similar logic). Productive search logic would include "bed rest," and "low back pain" as well as a separate search for "bed rest," "low back pain" and "attitude of health personnel." These two searches do in fact locate over one hundred articles related to the desired subject.
From the abstracts below you will note that although many MDs have confidence in and prescribe bed rest (75% of emergency room physicians) and other unsupported modes of treatment, fewer than 50% believe manipulation is effective. The current research since the 1994 AHCPR guidelines continues to question the value of bed rest.
If you are interested in having an online search made for you or have questions about conducting your own literature search, call 1-800-28-FACTS.
Cherkin D., Deyo R., Elam K., How Emergency Physicians Approach Low Back Pain: Choosing Costly Options, Journal of Family Practice 1995; 41(1):96-7.
To determine ways in which emergency physicians approach the diagnosis and treatment of the common presenting complaint of low back pain, responses of emergency physicians to a questionnaire dealing with three hypothetical patients with different types of low back pain were taken from a stratified national random sample of eight medical specialists.
For severe acute (with and without sciatica) or chronic low back pain, physicians were asked which tests and consultants they would use in pursuit of the diagnosis, and which treatments and specialty referrals they would recommend in each of the three scenarios.
For diagnosis in the acute cases (pain less than 1 week), up to 22% of emergency physicians recommended computed tomography (CT scan) and 36% recommended magnetic resonance imaging (MRI). Specialist consultation would be sought for 61% of the acute sciatica patients, 32% of the acute nonsciatica patients, and 47% of the chronic patients.
In approaching treatment, over 75% of emergency physicians would advise bed rest for an average of 3.5 to 4.5 days. Between 16% and 40% suggested physical therapy for the acute patients.
Referrals to surgical specialists (orthopedist or neurosurgeon) were highest (81%) for acute sciatica, compared with 52% for chronic low back pain, and 41% for acute nonsciatica low back pain.
In conclusion, given that most cases of acute low back pain resolve with minimal intervention, diagnostic imaging, laboratory testing, and early specialist consultation favored by many emergency physicians would add little except expense to understanding its etiology. For treatment, emergency physician recommendations for bed rest were longer than necessary and, for physical therapy, of no proven benefit.
Wikinson M., Does 48 Hours' Bed Rest Influence the Outcome of Acute Low Back Pain?, British Journal of General Practice 1995;45(398):481-4.
Background: Bed rest is a traditional treatment for back pain, yet only in recent years had the therapeutic benefit of this been questioned.
Aim: The aim of this pilot study was to ascertain whether or not 48 hours' bed rest had an effect on the outcome of acute low back pain.
Method: The study was conducted as a randomized controlled trial to compare a prescription of 48 hours' strict bed rest with controls; the control subjects were encouraged to remain mobile and to have no daytime rest. Nine general practitioners from practices in the West Midlands recruited patients in the age range 16-60 years who presented with low back pain of less than seven days' duration, with or without pain radiation. The outcome measures assessed were: change in straight leg raise and lumbar flexion after seven days, Oswestry and Roland-Morris disability scores after seven days and 28 days, and time taken from work ...
Conclusion: The results of this pilot study did not indicate whether bed rest or remaining mobile was superior for the treatment of acute low back pain; however, the study sample was small. Subjects in the control group possibly faired better as they appeared to have better lumbar flexion at day seven. It appears that 48 hours' bed rest cannot be recommended for the treatment of acute low back pain on the basis of this small study. Large-scale definitive trials are required to detect clinically significant differences.
Cherkin D., Deyo R., Wheeler K., Ciol M., Physician Views About Treating Low Back Pain: The Results of a National Survey, Spine 1995; 20(1):1-10.
Study Design: Physicians were surveyed regarding their beliefs about treatment efficacy for patients with low back pain.
Objectives: To document physician beliefs about the efficacy of specific treatments and the extent to which these beliefs correspond to current knowledge.
Summary of Background Data: Little is known about physician beliefs regarding the efficacy of specific back pain treatments.
Methods: A national random sample of 2897 physicians were mailed questionnaires that asked about 1) the treatments they would order for hypothetical patients with low back pain and 2) the treatments they believed were effective for back pain. Responses were compared with guidelines suggested by the Quebec Task Force on Spinal Disorders.
Results: Almost 1200 physicians responded. More than 80% of these physicians believed physical therapy is effective, but this consensus was lacking for other treatments. Fewer than half of the physicians believed that spinal manipulation is effective for acute or chronic back pain or that epidural steroid injections, traction, and corsets are effective for acute back pain. Bed rest and narcotic analgesics were recommended by substantial minorities of physicians for patients with chronic pain. The Quebec Task Force found little scientific support for the effectiveness of most of the treatments found to be in common use.
Conclusions: The lack of consensus among physicians could be attributable to the absence of clear evidence-based clinical guidelines, ignorance or rejection of existing scientific evidence, excessive commitment to particular modes of therapy, or a tendency to discount the efficacy of competing treatments.
Cinque C., Back Pain Prescription: Out of Bed and Into the Gym; Physician and SportsMedicine 1989, 17(9) p.185-8.
Bed rest and pain pills, the traditional remedies for back strains and sprains, do not always work. Physicians are looking at alternatives like exercise to get patients out of bed and moving again.
Ronald Rupert, MS, DC
Editor, Chirolars
Extension Faculty & Research
Cleveland Chiropractic College
