'Bed rest is ineffective in treating anything'

So reads the title of the clinical POEM presented in Essential Evidence (www.essentialevidence.com) in January 2000. The poem is a summary of a study published in the Lancet by Allen et al entitled, 'Bed rest: a potentially harmful treatment needing more careful evaluation'. In this study, Allen and associates perform a meta-analysis of bed rest studies up to that time and found that bed rest was ineffective in improving outcomes for a variety of medical conditions, including pregnancy complications, and in many instances caused patients to have worse outcomes.

Judith Maloni, PhD, RN, FAAN, nursing professor at the Frances Payne Bolton School of Nursing at Case Western Reserve University has studied high risk pregnancy and ante partum bed rest since 1989 and has found that despite its prevalence, there is no scientific basis for the bed rest prescription. In 'Antepartum Bed Rest for Pregnancy
Complications: Efficacy and Safety for Preventing Preterm Birth' (2010) Malonialso shows that in addition to being ineffective at preventing preterm birth, bed rest actually has many negative health effects on both mother and baby. In mothers prescribed bed rest, many experience muscle atrophy, cardiovascular problems, bone loss, insufficient weight gain and depressive symptoms. For babies born to mothers on bed rest, many are born at low birth weight and many end up in the NICU with complications. Maloni also shows that hospital bed rest is no better than bed rest at home and that bed rest at home often has better outcomes as mothers feel more secure and comfortable in familiar surroundings.

Where did the 'bed rest' prescription come from?

Bed rest has been described in medical literature since the beginning of time. However, in the 19th century, Silas Weir Mitchell, a prominent neurologist at the time, introduced 'the bed rest cure' which consisted of isolation, confinement to bed, a high fat diet and massage. The bed rest cure was initially indicated for those suffering 'nervous injuries and maladies' as a result of fighting in the Civil War. Later, the bed rest cure was specifically prescribed to people (primarily women) with mental disorders, particularly hysteria. Most physicians abandoned the bed rest cure when it became apparent that it did not help their patients and in many cases made them more mentally unstable.

Charlotte Perkins Gillman, a 19th century feminist, sociologist and writer was treated by Mitchell with the bed rest cure. Best known for her semi-autobiographical short story The Yellow Wallpaper, Gillman wrote the story after her own ordeal with post partum psychosis. Interestingly, the narrator in the story is driven insane by her rest cure.

So why is bed rest prescribed and given the lack of evidence, why does it persist as a treatment for preterm labor? Most other medical disciplines have abandoned bed rest as a treatment. Most heart patients are sat up and ambulated almost as soon as they are extubated, because it has become common knowledge that prolonged bed rest can lead to complication, notably pneumonia.

In orthopedics, post operative back and joint patients are quickly started on physical therapy so that they can achieve the optimum function and range of motion in the area treated. Yet, we persist in putting pregnant women on prescribed bed rest. Why?

Bedrest persists as a 'treatment' for high risk pregnancy primarily because of litigation and lack of research (or more aptly, lack of implementation of current research). The potential for litigation in the United States makes it almost impossible for obstetricians not to utilize bed rest. Who wants to be responsible for the death of a baby or mother? If a pregnant woman has a complication and an obstetrician doesn't put her on bed rest and she has an adverse outcome (or worse yet, she, her baby or both die), it can be career ending. Yet, our statistics show that bed rest is not improving outcomes nor making any dent whatsoever in maternal or infant mortality. Everyday I read articles and studies showing 'promising' new treatments and yet these potentially lifesaving treatments and procedures are years away because of the need to provide evidence of efficacy and then for them to go through the approval process of the US FDA and then final adoption by ACOG. Yes we want safety and efficacy of treatments, but with all this bureaucracy, are we providing protection for mothers and babies or for those who treat them? It's heartening to see so many new treatments available such as Fetal Fibronectin tests and the broadening use of Progesterone therapies. But we still need more.

Should bed rest be completely eliminated as a treatment for high risk pregnancy? It can't be because when a pregnant woman presents with acute vaginal bleeding or with uncontrolled hypertension, or preterm labor, she needs to be stabilized and immediate bed rest needs to be part of that stabilization. But once she is stabilized, it becomes unclear whether further confinement is necessary or beneficial. This is where more research, new treatments and new information are essential.

Bed rest has been around for a long time. Organizations like Sidelines and Better Bedrest have been in operation supporting high risk pregnant women since 1991 and 1995 respectively. I first came to know bed rest when it was suggested for me in 2002 when I was pregnant with my daughter. It is amazing to me that here we are in 2012 and we are still prescribing bed rest for high risk pregnancy. Bypasses have been changed and are more streamlined and less invasive. Prostate surgeries and hysterectomies are facilitated by robotics. Most disciplines have moved away from bed rest, but in obstetrics, still the same old prescription. Why am I so 'anti' bed rest? I have a daughter who is 9. I imagine that in roughly 20 years, she'll be considering starting a family of her own. I don't know if my reproductive problems will be passed on to her or not, but it is my sincerest hope that if my daughter becomes pregnant with a high risk pregnancy (circa 2032), we'll have something more effective and beneficial to offer her than the same bed rest prescription offered to her mother almost 30 years prior.

References
Allen C, Glasziou P, Del Mar C. 'Bed rest: a potentially harmful treatment needing more careful evaluation'. Lancet 1999: 354:1229-33.
Judith Maloni, PhD, RN, FAAN. 'Antepartum Bed Rest for Pregnancy Complications: Efficacy and Safety for Preventing Preterm Birth'. Biological Research for Nursing: 12(2) 106-124

ª The Author(s) 2010
Reprints and permission:
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DOI: 10.1177/1099800410375978
http://brn.sagepub.com

Wikipedia Encyclopedia
http://en.wikipedia.org/wiki/Bed_rest
http://en.wikipedia.org/wiki/Silas_Weir_Mitchell
http://en.wikipedia.org/wiki/Charlotte_Perkins_Gilman

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