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Panel findings and recommendations: 
 -   A gradual return to normal activities is more effective than prolonged bed rest for treating low back problems.  (Strength of Evidence = B.) 
 -   Prolonged bed rest for more than 4 days may lead to debilitation and is not recommended for treating low back problems.  (Strength of Evidence = B.) 
 -   The majority of low back 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.  (Strength of Evidence = D.)  
  Bed rest is a frequently used treatment for low back pain.  The therapeutic objective is to relieve symptoms by reducing intra-discal pressure and/or pressure on nerve roots.  Studies have shown that intradiscal pressures are lowest when subjects are lying supine in the semi-Fowler position, on the back with hips and knees moderately flexed.8 
Bed Rest 
Literature Reviewed     Evidence on Efficacy    Potential Harms and Costs      Summary of Findings      Author's Example 
Bed Rest 
  Literature Reviewed.  Of 12 articles screened for this topic, 5 reporting on 4 RCTs met criteria for review. 
75, 85, 117, 229, 230  All these studies evaluated patients with low back problems.  Other articles contained information used by the panel, but did not meet selection criteria.8, 231, 232 
 Evidence on Efficacy.    Evidence is limited regarding efficacy of bed rest versus no treatment for patients with low back problems.  One study involving military recruits compared forced bed rest to an alternative treatment of forced ambulation.117  Although the bed rest group returned to full activity sooner, methodological problems with this study made interpretation difficult.  Outcome assessments were not blinded, and patients in the hospitalized group were deprived of their peer-group activities, possibly confounding results.  Two articles compared groups receiving either a recommendation for bed rest (of at least 4 days duration) or some other treatment (such as exercise, education, or manipulation) but no bed rest recommendation.75,85,230  These two articles found no statistically significant differences between bed rest and other treatment modalities.  Bed rest of more than 4 days and the resulting deactivation were worse for patients than a gradual return to normal levels of activity.  Deyo, Diehl, and Rosenthal229 compared two groups receiving recommendations for either 2 days or 7 days of bed rest. No differences were found between the groups in pain relief or in time to resumption of normal activities, except for earlier return to work in the 2-day group for those employed at baseline. 
  One problem with these studies is that the actual amount of bed rest reported by the subjects often differed greatly from the amount recommended.  Deyo, Diehl, and Rosenthal229 found that 74 percent of the 99 subjects assigned to the 7-day bed rest group reported fewer than 7 days of actual bed rest.  The study reported by Evans, Gilbert, Taylor, et al.75 and Gilbert, Taylor, Hildebrand, et al.230 found that subjects who did not receive a bed rest recommendation also reported trying bed rest, but the duration was less than for the group receiving the recommendation. 
 Potential Harms and Costs.  Potential physical side effects from prolonged bed rest are many, including muscle atrophy (1.0 to 1.5 percent of muscle mass lost per day), cardiopulmonary deconditioning (15-percent loss in aerobic capacity in 10 days), bone mineral loss with hypercalcemia and hypercalciuria, and the risk of thromboembolism.232  There are also social side effects, such as perception of severe illness and economic loss due to increased time lost from work.231  
 Summary of Findings.  There is no evidence to support the efficacy of bed rest compared with no treatment in patients with low back problems.  Deactivation resulting from prolonged bed rest (more than 2 to 4 days) appears to be worse for patients than a gradual return to normal levels of activity. 
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