Editorials

Putting the rest cure to restagain

Rest has no place in treating chronic fatigue 

"Go home and rest" is still the advice given to many patients who complain of chronic fatigue. The refrain is echoed in self help books and magazines and adopted by many patients. What are the origins of rest as a treatment, does it work, and what evidence is there on which to base our advice to patients?

Chronic fatigue syndromes are not new.¹ Victorian physicians diagnosed them as neurasthenia and routinely prescribed rest. This approach was typified by Silas Weir Mitchell's "rest cure,"² which was so popular as to be described as "the greatest advance of which practical medicine can boast in the last quarter of the century."³ Despite such accolades, the popularity of the rest cure was short lived. By the turn of the century the same private clinics that once provided it were changing to more active treatments and to the newer psychotherapies.¹ The years that followed saw the end of the rest cure; Karl Menninger poured scorn on the lack of psychological sophistication shown by its proponents,⁴ while Richard Asher drew attention to the "the dangers of going to bed."⁵

Despite Asher's warnings, rest, as a treatment for chronic fatigue, resurfaced recently in conjunction with the rise in popularity of the diagnosis of myalgic encephalomyelitis, now called chronic fatigue syndrome.¹ Few articles or books on this subject have failed to emphasise the key role of rest in its treatment: Weir Mitchell himself would no doubt have concurred with the suggestions that "aggressive rest therapy" was what many patients needed. While a few dissenters drew attention to the hazards of excessive inactivity,⁶ books, magazines, and some doctors continued to emphasise the virtues of rest and the need to avoid exercise.

The scientific evidence, however, tells us that Asher's warnings against bed rest were well founded. Studies of the effects of prolonged inactivity in healthy volunteers conducted for the American space programme have confirmed that the adverse physiological effects are both profound and prolonged. Furthermore, they include many of the symptoms considered typical of chronic fatigue syndrome, such as loss of strength, poor sleep, postural hypotension, and fatigue.⁷ Not only have the known dangers of inactivity and its potential role as perpetuator of chronic fatigue been ignored, but the hazards of exercise have been overstated: the evidence indicates that patients with chronic fatigue syndrome can exercise under controlled conditions without risk of damage or relapse.⁸

If excessive rest is harmful, does exercise help? Evidence from a recent randomised trial suggests that it does. This study showed clearly the superiority of graded aerobic exercise over a low activity stretching programme in improving both functional capacity and fatigue.⁸ Interestingly, the clinical improvement observed was independent of improved muscle strength and aerobic capacity, suggesting that the benefits were not simply due to overcoming physiological deconditioning. That psychological effects such as improved confidence and reduced fears of the consequences of exercise are also important is suggested by the similar improvements found in controlled trials of cognitive behaviour therapy. ^{9 10} Cognitive behaviour therapy does not involve aerobic exercise but instead emphasises consistency in activity management and the gradual attainment of behavioural targets. Taken together this evidence suggests that it is important to differentiate between the needs of the patient with acute fatigue and the patient with a chronic fatigue state; rest may be indicated for the former, but a gradual increase in activity should be at the heart of the treatment plans for the latter.

In making these suggestions we are certainly not advocating the opposite extreme to rest. Aggressive exercise therapy may be as unhelpful as aggressive rest therapy. Menninger also drew attention to the abuse of forced exercise, which he suggested was based more on its appeal to "hard boiled industrialists and misguided army officers whose conception of neurotic illness is that its victims are lazy liars or yellow dogs feigning disability to avoid duty" than on scientific evidence of its efficacy.⁴ We find no reason to alter his verdict today. Rather we suggest a middle way of gradual, individually tailored activity, planned collaboratively with the patient, starting at an easily tolerable level and increased only at a manageable pace. Rest is not denied but included in a way that is planned and predictable and not solely as a response to symptoms. The Victorians gradually turned their backs on the rest cure. We should too. Today's patients also deserve better treatment than simply being told to "go home and rest."