Bed Rest for Backs, Is it So Wrong?

When treating acute nonspecific low back pain (LBP), bed rest is often not recommended.

In fact, many clinical practice guidelines for the care of acute nonspecific LBP in primary care say to avoid bed rest. Arnau et al.1 conducted a systematic study that evaluated national guidelines from 13 different nations, with recommendations ranging from “discouraging even if the pain is severe” to deeming bed rest “hazardous for more than 2 days.” There is consistent evidence that telling people with acute LBP to stay active leads to better short-term and long-term clinical and functional outcomes.

When leg pain from the lumbar spine is added to the picture, the evidence becomes less convincing. In reality, only a minority of the guidelines included in Arnau et al.’s review adapted their advice to distinguish between acute nonspecific LBP, acute LBP with radiating leg pain, and the combination of both. “Only three guidelines [out of thirteen] offered recommendations for pain radiating in the leg,” the authors write. This shows that immediately extending the same advice for acute nonspecific LBP to patients with radiating leg pain may not be acceptable in a clinical setting.2

THE SIMPLE ACT OF RECUMBENCY (BED REST) WITH SCIATICA

This difference in evidence could be because of two important parts of the research on LBP that is made worse by leg pain that spreads. First, very few studies look directly at bed rest as a treatment for radiating leg pain. In 2010, a Cochrane review looked at the effects of telling people with sciatica, which is defined as “low back pain with proven neurological impairments,” to stay active instead of resting in bed. Only two of the ten randomized controlled trials on bed rest for LBP were identified in the review (Vroomen et al. and Hofstee et al. 3)looking into leg pain.

Sciatica, an archaic word used interchangeably by clinicians and the general public to refer to back-related leg discomfort, is neither diagnostic nor epistemologically accurate. Sciatica is an older term that doctors and people in general use to describe leg pain that comes from the back. It is neither a good diagnostic term nor a good way to describe what people know.

This is likely owing to a lack of agreement on a universally accepted definition of sciatica, the absence of widely accepted diagnostic criteria, and a limited understanding of the pathophysiology underlying the condition. This is probably because there isn’t a universally agreed-upon definition of sciatica, there aren’t widely agreed-upon diagnostic criteria, and we don’t know much about how the condition works. At the moment, sciatica is known as a disorder of the peripheral nervous system that is linked to lumbar radiculopathy. This indicates that the symptoms originate from disruption or pathology of the lumbosacral spinal nerves, as opposed to somatic referred pain from the lumbar osteoarticular or musculotendinous tissues.

Although sciatica has been reported to afflict up to 43% of the general population, this lifetime prevalence estimate may be exaggerated; a detailed study reveals that the prevalence of leg pain caused by a disease of the peripheral nervous system is closer to 4.8%. Also to be considered are the inclusion criteria of the two randomized controlled trials evaluating the effects of bed rest on radiating leg pain, which did not account for the location of the pain in the lower limbs or the presence of neurological signs, which are mandatory requirements for the diagnosis of painful radiculopathy. Also to be taken into account are the inclusion criteria of the two randomized controlled trials that looked at the effects of bed rest on radiating leg pain. These trials didn’t take into account where the pain was in the lower limbs or if there were neurological signs, both of which are needed to diagnose painful radiculopathy.

In contrast, only one-fourth of the chosen participants displayed neurological impairments. This may explain the inconclusive results regarding bed rest’s influence on patients with leg discomfort connected to the lumbar spine.This may explain why there aren’t clear answers about how bed rest affects people with leg pain from their lumbar spine. The relevance of increasing activity and engagement in work and daily life to improve long-term outcomes in individuals with acute nonspecific LBP has been well established from a biopsychosocial approach.

BED REST CAN’T BE THAT BAD

However, it is premature to conclude that bed rest has a negative impact on the pain and functional status of patients with radiating leg pain or radiculopathy, especially when neurological impairments are present. But it’s too soon to say that bed rest makes the pain and function of people with radiating leg pain or radiculopathy worse, especially when there are neurological problems. However, this has yet to be demonstrated in humans. In a separate animal trial, there is evidence that delaying exercise up to four weeks after the onset of nerve injury did not influence the activity’s positive benefits on nerve repair and neuropathic pain reduction. Short recovery periods in antalgic postures, including lying in bed, are not expected to be as damaging and may represent an essential self-management technique for patients. To identify limb pain according to existing evidence-based categorization systems and to assess whether different kinds of neurological diseases respond similarly to bed rest in patients with acute nonspecific LBP, additional study is required.

BEST REST IN SHORT COURSE MAKES SOME SENSE

Typically, leg pain caused by neural tissue involvement is an incredibly unpleasant condition.

So, in a clinical setting, it may not be wrong to allow short recovery periods in bed as a way to manage pain while discouraging long periods of rest as a form of therapy. This is especially true when the alternatives, like drug management, don’t seem to be much better than a placebo and when opioids may make neuropathic pain last longer or lead to addiction.

Via Dr. Jerome Fryer - Dynamic Disc Designs

At ddd, we create models demonstrating disc dynamics that include the dynamics of disc height changes with bed rest and standing/sitting. Helping patients understand their symptoms and the appropriate solutions is what we work to do to fill the toolkits of professionals and their patient education materials.

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