Is Bed Rest Recommended for Rheumatoid Arthritis?

The Effect of Bed Rest on Disease Activity

Bed rest
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With the onset of rheumatoid arthritis symptoms or during an acute flare of symptoms, people just want to crawl in bed and stay there. That's both understandable and rational. It's what we do when we don't feel well, right? But, rheumatoid arthritis is a chronic disease. There is no cure. The disease must be managed for the duration. How does bed rest fit into a long-term plan to manage rheumatoid arthritis?

What is the effect of bed rest on disease activity?

Recommendations From Long Ago

Hippocrates said, "In every movement of the body, whenever one begins to endure pain, it will be relieved by rest." That's how far back we must go to find the origin of thought that bed rest is the optimal pain reliever. Interestingly, doctors held to that and have recommended bed rest for various conditions for eons. But, as researchers became more involved in evaluating studies that considered the therapeutic effect of bed rest, statistically significant results were hard to come by—and even more importantly, some findings pointed to worse results with bed rest.

In 1978, the Mayo Clinic stated that rest therapy in rheumatoid arthritis was "controversial". Evidence at the time suggested that exercise increases joint inflammation and destruction, while rest reduces inflammation. It suggested that hospitalization may improve inflammation.

It also suggested that fatigue should be used as a guideline in treating rheumatoid arthritis. Mayo Clinic concluded that enough rest to prevent fatigue in combination with appropriate physical therapy is the best treatment course.

Meta-Analysis Results

By 1999, Allen C. et al. (Lancet. Oct 8, 1999;354:1229-33) performed a meta-analysis by searching MEDLINE and the Cochrane Library for studies of the therapeutic effect of bed rest.

They identified 39 randomized controlled trials, which involved 5,700 patients being treated for 15 diseases and conditions. In 15 of the trials, bed rest was studied as the primary treatment for conditions that included low back pain, spontaneous labor, uncomplicated myocardial infarction, acute hepatitis, and rheumatoid arthritis. The authors concluded that little evidence could be found to support the use of bed rest. There was a range of outcomes for bed rest—from non-contributory to harmful. The authors quoted advice originally offered decades earlier which stated that bed rest is "a highly unphysiologic and definitely hazardous form of therapy, to be ordered for specific indications and discontinued as early as possible."

Short-Term Versus Long-Term Bed Rest

Researchers have since concluded that rest can be beneficial for locally inflamed and painful joints in the short term. Rest can reduce pain and inflammation in affected joints. But, in the long term, there are potential side effects from the inactivity, according to Johns Hopkins. The side effects include decreased range of motion, diminished strength, an altered response to joint loading, and reduced aerobic capacity. Based on study results from Mueller et al.

(Archives of Physical Medicine and Rehabilitation, 1970), patients on strict bed rest can lose 1 percent to 1.5 percent of strength per day over just a two-week period. A physical therapist once told me that what takes just weeks to lose, in terms of muscle strength, takes many months to re-gain.

While temporary or short-term bed rest may serve to reduce pain and reduce the number of tender joints or inflamed joints, it is prolonged bed rest that is most concerning. Prolonged bed rest, along with muscle atrophy, can cause decubitus ulcers, tendon shortening, and contractures. It may also be associated with thromboembolic disease (formation of blood clots) and insulin resistance.

Since there is the dilemma of doing more harm than good with prolonged bed rest, alternatives must be considered. For certain individual joints, immobilization may be possible temporarily by using splinting or by wearing a support to limit movement of the affected joint. Optimally, there should be balance between rest and activity. You simply cannot forgo exercise and physical activity in favor of prolonged rest. Exercise is necessary to avoid muscle atrophy, weakness, and joint instability. Current thinking suggests that in the long-run, exercise actually reduces pain and fatigue rather than increase it. If you are laying in bed thinking you can't exercise enough to even matter, think again. Check out your exercise regimen: 5 steps to get started.

Sources:

Brower, Roy G. Consequences of Bed Rest. Johns Hopkins University. Published in Critical Care Medicine. Vol.37 Supplement 10. October 2009.

Cush, Weinblatt, and Kavanaugh. Rest and Exercise. Page 92. Rheumatoid Arthritis: Early Diagnosis and Treatment. Professional Communications, Inc. Third edition.

Krabak, Brian MD and Minkoff, Evan DO. Johns Hopkins Arthritis Center. Rehabilitation Management for Rheumatoid Arthritis Patients. Relative Rest. Updated July  31, 2012.

Smith RD and Polley HF. Rest Therapy for Rheumatoid Arthritis. Mayo Clinic Proceedings. 1978 March;53(3):141-5.

Walling, Anne D. MD. Beware of Recommending Bed Rest for Most Illnesses. American Family Physician. 2000 Feb 15;61(4):1164.

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