Bed rest

The Invalid (ca. 1870), painting by Louis Lang in the Brooklyn Museum

Bed rest, also referred to as the rest-cure, is a medical treatment in which a person lies in bed for most of some period of time to gain health benefits. Bed rest refers to voluntarily lying in bed as a treatment, and not being confined to bed because of a health impairment which restricts a person from leaving the bed. The practice is still commonly used for an array of conditions although a 1999 systematic review found no benefits in any of the 17 conditions for which it had been prescribed.^[1]

Bed rest is especially used when prescribed or chosen. Even though most patients in hospitals spend most of their time in the hospital beds, bed rest more often refers to an extended period of recumbence at home. In the United States of America, nearly 20% of pregnant women have some degree of restricted activity prescribed at some point during pregnancy^[2] despite the growing volume of data showing it to be dangerous, causing some experts to call its use "unethical".^[3][4][5]

Indications

While some studies claim that bed rest has not been proven to have beneficial effects for any condition,^[1] it does have some benefit in certain situations such as:

• Allowing raising of lower limbs to reduce swelling, post-operative or where severe inflammation occurs owing to a medical condition such as broken bones, sprains, water retention etc. In these case bed rest is essential to ensure limbs are raised, reducing micro vascular inflammation, allowing reduced pain, reduction in swelling and less restriction on damaged nerves, vessels and organs. Bed rest also reduces pressure on broken bones allowing healing to occur without further damage.

Bed rest continues to be commonly prescribed in certain cases:

• For sufferers of acute pain in the spine or joints; for example, in the case of backache the unloading of the corresponding spinal segment decreases the intradiscal pressure, and it would bring relief in cases such as compression of spinal nerve. The prescribed duration of bed rest vary and opinions differ.^[6] As a treatment for low back pain, bed rest should not be used for more than 48 hours.^[7]
• Bed rest is prescribed for some maternal or fetal complications of pregnancy, such as preterm labor, high blood pressure, incompetent cervix, short cervix, fetal growth restriction, preterm premature rupture of membranes (PPROM), placenta previa or placental abruption.^[8] Regarding the effectiveness of bed rest in preventing preterm birth a Cochrane review found no evidence one way or the other.^[9]
• Women pregnant with twins or higher-order multiples are at higher risk for preterm labor, preeclampsia ([toxemia), and other pregnancy complications, thus bed rest is common in these cases. About 50% of women pregnant with twins will be on some form of bed rest for at least part of their pregnancy. Recent studies have shown that routine bed rest in twin pregnancies (bed rest in the absence of complications) does not improve outcomes; however, bed rest is almost always prescribed for women carrying triplets or more.^[10]
• Heart diseases
• Bed rest is an important measure in the cases of chorea. In the mild cases it may suffice for treatment.^[11]
• Acute gout, as early ambulation may precipitate a recurrence.^[12]

Inclined bed rest is a common practice for people suffering from some forms of Gastroesophageal reflux disease^[13][14] and heart disease ^[15] and for patients who are on a ventilator.^[16] Despite its prevalence, several studies exploring the effects of tilting the head of a bed have found no support for beneficial health claims.^[17][18]

Adverse effects

Prolonged bed rest has long been known to have deleterious physiological effects, such as muscle atrophy and other forms of deconditioning such as arterial constriction.^[19] Besides lack of physical exercise it was shown that another important factor is that the hydrostatic pressure (caused by gravity) acts anomalously, resulting in altered distribution of body fluids. In other words, when getting up, this can cause an orthostatic hypertensive, potentially inducing a Vasovagal response. Even physical exercise in bed fails to address certain adverse effects.^[20]

It is also a major cause of thrombosis,^[21] mainly by reducing blood flow in the legs.^[22]

Technique

This man in 1945 England has been prescribed complete bed rest, and accepts assistance so as not to sit up to drink

Complete bed rest refers to discouraging the person in treatment from sitting up for any reason, including daily activities like drinking water.^[23]

Placing the head of a bed lower than the foot is sometimes used as a means of simulating the physiology of spaceflight.^[24]

History

As a treatment, bed rest is mentioned in the earliest medical writings. The rest cure, or bed rest cure, was a 19th-century treatment for many mental disorders, particularly hysteria. "Taking to bed" and becoming an "invalid" for an indefinite period of time was a culturally accepted response to some of the adversities of life. In addition to bed rest, patients were secluded from all family contact in order to reduce dependence on others. The only person that bed rest patients were allowed to see was the nurse who massaged, bathed, and clothed them. Not only were patients to be isolated in bed for an extended period of time, but they were advised to avoid other activities that may mentally exhaust them such as writing or drawing.^[25] In some extreme cases electrotherapy was prescribed. The food the patient was served usually consisted of fatty dairy products in order to revitalize the body with new energy. This cure as well as its name were created by doctor Silas Weir Mitchell, and it was almost always prescribed to women, many of whom were suffering from depression; especially postpartum depression. It was not effective and caused many to go insane or die. In the middle of the 20th century, bed rest was still a standard treatment for markedly high blood pressure. It is still used in cases of carditis secondary to rheumatic fever. Its popularity and perceived efficacy have varied greatly over the centuries.

In 1892, feminist writer Charlotte Perkins Gilman published "The Yellow Wallpaper", a horror short story based on her personal experience when placed under the rest cure from Dr. Silas W. Mitchell himself. She wasn't allowed to write in a journal, paint a picture, or release her imagination in any way whatsoever, though she was artistically inclined. If she ever felt ill, she was simply told to return to bed. Her specific instructions from Dr. Weir Mitchell were to "Live as domestic a life as possible. Have your child with you all the time... Lie down an hour after each meal. Have but two hours' intellectual life a day. And never touch pen, brush or pencil as long as you live."^[26] Gilman abided by Mitchell's instructions for several months before practically losing control of her sanity. Eventually, Gilman divorced her husband on as good of terms as can be expected and pursued a life as a writer and women's rights activist. Gilman later explained in her biography The Living of Charlotte Perkins Gilman that she could not be restrained to the domestic lifestyle without losing her sanity, and that "it was not a choice between going and staying, but between going, sane, and staying, insane."^[27]

The narrator in Gilman's "The Yellow Wallpaper" reflected her own authentic account. The narrator was advised by her husband to perform the rest-cure and avoid creative activities while struggling with fits of depression. After becoming obsessed with the yellow wallpaper in her room, the narrator suffers a mental breakdown and frees a "woman behind the wall," metaphorically resembling Gilman's own mental break and release from female expectations. Gilman later sent her short story to Dr. Mitchell, hoping that he might change his treatment of women with mental health and help save people from her own experience.^[28] The short story became a symbol of feminism in the 1970s at the time of its rediscovery.^[29]

Some negative effects of bed rest were historically attributed to drugs taken in bed rest.^[30]

References

1. Bed Rest Ineffective as Therapy : The Journal of Family Practice
2. Bed Rest During Pregnancy
3. Allen C, Glasziou P, Del Mar C (October 1999). "Bed rest: a potentially harmful treatment needing more careful evaluation". Lancet 354 (9186): 1229–33. doi:10.1016/S0140-6736(98)10063-6. PMID 10520630. Lay summary – University of Queensland News Online (October 9, 1999).
4. Is It ‘Unethical’ To Prescribe Bed Rest For Pregnant Women? | CommonHealth
5. http://arms.evidence.nhs.uk/resources/qipp/664578/attachment
6. Weiner, Richard (2002). Pain management: a practical guide for clinicians. Boca Raton: CRC Press. p. 741. ISBN 0-8493-0926-3.
7. North American Spine Society (February 2013), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation (North American Spine Society), retrieved 25 March 2013, which cites
   • Dahm, Kristin Thuve; Brurberg, Kjetil G; Jamtvedt, Gro; Hagen, Kåre Birger; Dahm, Kristin Thuve (2010). "Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica". Cochrane Database Syst Rev (6): CD007612. doi:10.1002/14651858.CD007612.pub2. PMID 20556780.
   • North American Spine Society (2014). "Acute Low Back Pain". knowyourback.org. Retrieved 25 March 2014.
8. • Bowers, Nancy (2001). "Bed Rest". The multiple pregnancy sourcebook: pregnancy and the first days with twins, triplets, and more. Chicago: Contemporary Books. ISBN 0-7373-0306-9.
   • Sosa, Claudio; Althabe, Fernando; Belizán, José M; Bergel, Eduardo; Sosa, Claudio (2004). "Bed rest in singleton pregnancies for preventing preterm birth". Reviews. doi:10.1002/14651858.CD003581.pub2.
   • Meher, Shireen; Abalos, Edgardo; Carroli, Guillermo; Meher, Shireen (2005). "Bed rest with or without hospitalisation for hypertension during pregnancy". Reviews. doi:10.1002/14651858.CD003514.pub2.
   • Aleman, Alicia; Althabe, Fernando; Belizán, José M; Bergel, Eduardo; Althabe, Fernando (2005). "Bed rest during pregnancy for preventing miscarriage". Reviews. doi:10.1002/14651858.CD003576.pub2.
9. Sosa, CG; Althabe, F; Belizán, JM; Bergel, E (30 March 2015). "Bed rest in singleton pregnancies for preventing preterm birth.". The Cochrane database of systematic reviews 3: CD003581. doi:10.1002/14651858.CD003581.pub3. PMID 25821121.
10. Crowther, Caroline A; Han, Shanshan; Crowther, Caroline A (2010). "Hospitalisation and bed rest for multiple pregnancy". Reviews. doi:10.1002/14651858.CD000110.pub2.
11. NINDS Sydenham Chorea Information Page of the National Institute of Neurological Disorders and Stroke
12. Page 251 in: Elizabeth D Agabegi; Agabegi, Steven S. (2008). Step-Up to Medicine (Step-Up Series). Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-7153-6.
13. Richter, Joel E.; Donald O. Castell (April 1981). "Current Approaches in the Medical Treatment of Oesophageal Reflux". Drugs 21 (4): 283–291. doi:10.2165/00003495-198121040-00004.
14. Hamilton, John W; Ronald J. Boisen MD; Dennis T. Yamamoto MD; Joanne L. Wagner; Mark Reichelderfer MD (May 1988). "Sleeping on a wedge diminishes exposure of the esophagus to refluxed acid". Digestive Diseases and Sciences 33 (5): 518–522. doi:10.1007/BF01798350. PMID 3359906.
15. Reynolds, Sharon RN, CS-ACNP, MSN; Waterhouse, Kathleen RN, CS-ACNP, MSN; Miller, Kathleen H. RN, CS-ACNP, EdD (2001). "Head of bed elevation, early walking, and patient comfort after percutaneous transluminal coronary angioplasty". Dimensions of Critical Care Nursing 20 (3): 44–51. doi:10.1097/00003465-200105000-00013. PMID 22076400.
16. • Niël-Weise, Barbara S. (2011). Petra Gastmeier, Axel Kola, Ralf P Vonberg, Jan C Wille, and Peterhans J van den Broek. "An evidence-based recommendation on bed head elevation for mechanically ventilated patients" (PDF). Critical Care 15 (2): 1–9. doi:10.1186/cc10135. Retrieved 30 June 2013.
    • Keeley, Libby (November–December 2007). "Reducing the risk of ventilator-acquired pneumonia through head of bed elevation". Nursing in Critical Care 12 (6): 287–294. doi:10.1111/j.1478-5153.2007.00247.x. PMID 17983363.
    • Peterson, M ME; Schwab, W PhD; McCutcheon, K CCN; van Oostrom, J H. PhD; Gravenstein, N MD; Caruso, L MD (November 2008). "Effects of elevating the head of bed on interface pressure in volunteers". Critical Care Medicine 36 (11): 3038–3042. doi:10.1097/ccm.0b013e31818b8dbd.
    • Frank Lyerla, RN, PhD, Cynthia LeRouge, PhD, CPA, Dorothy A. Cooke, RN, PhD, Debra Turpin, RN, MSN, ONC and Lisa Wilson, RN, BSN (2010). "A Nursing Clinical Decision Support System and Potential Predictors of Head-of-Bed Position for Patients Receiving Mechanical Ventilation". Am J Crit Care 19 (1): 39–47. doi:10.4037/ajcc2010836. PMID 20045847.
17. Wojner, Anne W.; El-Mitwalli, Ashraf; Alexandrov, Andrei V. (February 2002). "Effect of Head Positioning on Intracranial Blood Flow Velocities in Acute Ischemic Stroke: A Pilot Study". Critical Care Nursing Quarterly 24 (4). Current nursing practice for the care of patients with ischemic stroke advocates routine elevation of the head of the bed (HOB) to 30°. Evidence supporting this practice is lacking, and it may reflect inappropriate generalization of findings from studies conducted primarily on traumatic brain injury patients with associated increased intracranial pressure to the ischemic stroke population.
18. Vincent J. Miele MD, Ali Sadrolhefazi MD, Julian E. Bailes MD (May 2005). "Influence of head position on the effectiveness of twist drill craniostomy for chronic subdural hematoma". Surgical Neurology 63 (5).
19. Bleeker MW, De Groot PC, Rongen GA; et al. (October 2005). "Vascular adaptation to deconditioning and the effect of an exercise countermeasure: results of the Berlin Bed Rest study". Journal of Applied Physiology 99 (4): 1293–300. doi:10.1152/japplphysiol.00118.2005. PMID 15932956.
20. Woods, Susan L. (2005). Cardiac nursing. Hagerstwon: Lippincott Williams & Wilkins. p. 921. ISBN 0-7817-4718-X.
21. Mitchell, Richard Sheppard; Kumar, Vinay; Robbins, Stanley L.; Abbas, Abul K.; Fausto, Nelson (2007). "Chapter 4". Robbins basic pathology (8th ed.). Saunders/Elsevier. ISBN 1-4160-2973-7.
22. Hypercoagulability during Pregnancy Lab Lines. A publication of the Department of Pathology and Laboratory Medicine at the University of Cincinnati. September/October 2002 Volume 8, Issue 5
23. Mayo Clinic Staff (2011). "Bed rest during pregnancy: Get the facts - Mayo Clinic". mayoclinic.org. Retrieved 27 March 2014.
24. • Atsunori Kamiya, Satoshi Iwase, Daisaku Michikami, Qi Fu, and Tadaaki Mano (1 March 2000). "Head-down bed rest alters sympathetic and cardiovascular responses to mental stress". AJP: Regu Physiol. To examine effects of microgravity on vasomotor sympathetic and peripheral vasodilator responses to mental stress, we performed 10 min of mental arithmetic (MA) before and after 14 days of 6° head-down bed rest (HDBR), a ground-based simulation of spaceflight.
    • Millet, C.; Custaud, MA; Maillet, A; Allevard, AM; Duvareille, M; Gauquelin-Koch, G; Gharib, C; Fortrat, JO (March 2001). "Endocrine responses to 7 days of head-down bed rest and orthostatic tests in men and women". Clinical Physiology 21 (2): 172–183. doi:10.1046/j.1365-2281.2001.00315.x. PMID 11318825.
    • Edgell, Heather (December 2007). "WISE-2005: adrenergic responses of women following 56-days, 6° head-down bed rest with or without exercise countermeasures". Environmental, Exercise and Respiratory Physiology.
    • Randa L. Shehab; Robert E. Schlegel (August–September 1998). "The NASA performance assessment workstation: Cognitive performance during head-down bed rest". Acta Astronautica 43: 223–233. doi:10.1016/s0094-5765(98)00156-8.
    • Wilson, Thad (4 January 2003). "Effects of 14 days of head-down tilt bed rest on cutaneous vasoconstrictor responses in humans". Journal of Applied Physiology.
    • Meck, Janice V.; Dreyer, Sherlene A.; Warren, L. Elisabeth (May 2009). "Long-Duration Head-Down Bed Rest: Project Overview, Vital Signs, and Fluid Balance". Aviation, Space, and Environmental Medicine 80 (Supplement 1): A1–A8. doi:10.3357/asem.br01.2009.
    • Shibasaki, Manabu (November 1, 2003). "Exercise throughout 6° head-down tilt bed rest preserves thermoregulatory responses". Journal of Applied Physiology 95 (5).
25. Geller, Jeffery L. (1994). Women of the Asylum: Voices from Behind the Walls 1840-1945. New York: Anchor Books. pp. 161–168.
26. Gilman, Charlotte Perkins. "The Yellow Wallpaper". The Norton Anthology of English Literature. New York: Gale, 1996. 230‐37. Print.
27. Geller, Jeffery L. (1994). Women of the Asylum: Voices from Behind the Walls 1840-1945. New York: Anchor Books. pp. 161–167.
28. Gilman, Charlotte. ""Why I Wrote "The Yellow Wallpaper"". Charlotte Perkins Gilman.
29. http://www.lonestar.edu/yellow-wallpaper.htm
30. Dock, William (1944). "THE EVIL SEQUELAE OF COMPLETE BED REST". Journal of the American Medical Association 125 (16): 1083. doi:10.1001/jama.1944.02850340009004. ISSN 0002-9955.