Strict Bed Rest’ Bites the Dust—Again
ABSTRACT & COMMENTARY
Source: Vroomen PCAJ, et al. Lack of effectiveness of bed rest for sciatica. N Engl J Med 1999;340:418-423.
"Evidence-based medicine" challenges us to substitute therapies based on scientific data for those based on conventional wisdom. To this end, this multicenter study from the Netherlands challenged the common, but unproven, practice of recommending strict bed rest for patients with sciatica. Sciatica was defined as the presence of two of the three following signs: radicular leg pain, increased pain with straining, sensory loss, reflex loss, or a positive straight-leg-raise test.
Patients were excluded if they needed urgent surgical intervention for severe pain, weakness, or cauda equina syndrome. Patients were randomized either to be instructed to rest in bed at all times (except to use the toilet or bathe) or to resume their usual activities as much as tolerated, return to work immediately, and not to rest in bed except for sleep. All patients were allowed to take acetaminophen, codeine, and/or naproxen as needed for pain.
The 92 patients in the bed-rest group ultimately spent a mean of 21 hours a day in bed, while the 91 patients in the watchful waiting group spent only 10 hours a day in bed. At assessment two weeks following initial presentation, there was no difference in symptom improvement between the bed rest and normal activity groups. About 70% of patients in both groups had symptom improvement at two weeks and 87% had improved at 12 weeks. There was no difference in work absenteeism or the need for surgical intervention, which was ultimately necessary for one-fifth of patients in each group. The presence of nerve-root compression on MRI did not affect the outcome. Vroomen and colleagues conclude that bed rest is no more effective than cautious resumption of usual activities for patients with sciatica.
Comment by David J. Karras, MD, FACEP
This article bears striking similarity to another European study published in the same journal.1 In that study of patients with low back pain, immediate resumption of usual activities (as tolerated) led to more rapid recovery of low back pain than did bed rest. Several other recent analyses should make us very skeptical of the value of strict bed rest for patients with back or sciatic pain who do not have motor weakness or other "hard" neurological deficits. Recommending that such patients be "up and about" appears to be the best—and most cost-effective—medicine. The cost of nonsteroidal antiinflammatory drugs and mild narcotics is relatively small. The cost savings from averting missed days of employment is enormous, and the value of not making people act like invalids for weeks is incalculable.
1. Malmivarra A, et al. Treatment of acute low back pain—Bed rest, exercises, or ordinary activity? N Engl J Med 1995;332:351-355.