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 cure an illness.^[1] 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.^[2]

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^[3] despite the growing volume of data showing it to be dangerous, causing some experts to call its use "unethical".^[4][5][6]

Indications

While some studies claim that bed rest has not been proven to have beneficial effects for any condition,^[2] 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 cases 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 varies and opinions differ.^[7] As a treatment for low back pain, bed rest should not be used for more than 48 hours.^[8]
• Women who are pregnant and are experiencing early labor, vaginal bleeding and cervix complications. One out of every 500 women who are pregnant will be prescribed bed rest. Bed rest is prescribed for some maternal or fetal complications of pregnancy, such as preterm labor, high blood pressure, incompetent cervix,(where the opening of the uterus opens early),^[9] short cervix, fetal growth restriction, preterm premature rupture of membranes (PPROM), placenta previa or placental abruption.^[10] Regarding the effectiveness of bed rest in preventing preterm birth a Cochrane review found no evidence one way or the other.^[11]
• 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.^[12]

It makes sense that by resting and keeping the uterus horizontal, you can help to decrease contractions and give the sources of bleeding a chance to heal. It has been shown that females with uterine problems benefit from this procedure if it is not done in excess of 3 days.^[13]

• Heart diseases
• Bed rest is an important measure in the cases of chorea. In the mild cases it may suffice for treatment.^[14]
• Acute gout, as early ambulation may precipitate a recurrence.^[15]

Inclined bed rest is a common practice for people suffering from some forms of Gastroesophageal reflux disease^[16][17] and heart disease ^[18] and for patients who are on a ventilator.^[19] Despite its prevalence, several studies exploring the effects of tilting the head of a bed have found no support for beneficial health claims.^[20][21]

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.^[22] 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. Additionally, prolonged bed rest can lead to the formation of ulcers.^[23] Even physical exercise in bed fails to address certain adverse effects.^[24]

Phlebothrombosis is marked by the formation of a clot within a vein without prior inflammation of the wall of the vein; it is associated with prolonged bed rest, surgery, pregnancy, and other conditions in which blood flow becomes sluggish or the blood coagulates more quickly than normal. The affected area, usually the leg, may become swollen and tender. The danger is that the clot may become dislodged and travels to the lungs (a pulmonary embolism).^[25]

Technique

This man in 1945 England has been prescribed complete bed rest, and accepts assistance so as not to sit up to drink. He was prescribed a bed rest cure after being diagnosed with postpartum depression.

Complete bed rest refers to discouraging the person in treatment from sitting up for any reason, including daily activities like drinking water.^[26]

Placing the head of a bed lower than the foot is sometimes used as a means of simulating the physiology of spaceflight.^[27]

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.^[28] 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."^[29] 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."^[30]

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.^[31] The short story became a symbol of feminism in the 1970s at the time of its rediscovery.^[32]

The author Virginia Woolf was also prescribed the rest cure, which she parodied in her novel Mrs Dalloway (1925) with the description: "you invoke proportion; order rest in bed; rest in solitude; silence and rest; rest without friends, without books, without messages; six months rest; until a man who went in weighing seven stone six comes out weighing twelve".^[33]

Some negative effects of bed rest were historically attributed to drugs taken in bed rest.^[34]

References