What helps occupational rehabilitation when the doctor cannot explain the symptoms?
Peter White
Agenda Symptom defined illnesses (SDIs) The example of chronic fatigue syndrome Biopsychosocial management is best Prevention is even better
10 8
Symptoms Organic Cause
3-Year 6 Incidence 4 (%) 2
0
ss ain tigue iness ache dema Pain hagia mnia in e p n t b k sp nso l Pa E es Fa Dizz Head c m a h u I y B C N D ina m o Abd Kroenke, et. al., AJM, 1989
Prevalence of unexplained symptoms in hospital clinics Clinic
Prevalence %
Chest Cardiology Gastroenterology Rheumatology Neurology Dental Gynaecology
59 56 60 58 55 49 57
Total
56
Symptom defined illnesses Tension headaches, Atypical facial and chest pains Fibromyalgia (chronic widespread pain) Other chronic pain disorders Irritable bowel syndrome Multiple chemical sensitivity Chronic (postviral) fatigue syndrome (ME)
How common is CFS? 0.2 - 2.6 % population or primary care
Risk (OR) of depressive illness with chronic physical disorders CFS
7.2
Fibromyalgia
3.4
Peptic ulcers COPD Migraine Back pain Cancer MS
2.8 2.7 2.6 2.3 2.3 2.3
UK costs of CFS 118,000 on incapacity benefit 19,000 on disability living allowance + Cost of medical and social care + Loss of employment
Outcome is poor without treatment Systematic review of longitudinal studies 5 % (range 0 - 31) recovered by follow up 39 % (range 8 - 63) some improvement Cairns R, Hotopf M, Occup Med 2005
Use the biopsychosocial model The biopsychosocial model “takes into account the patient, the social content in which he lives and ... the physician role and the health care system.� George Engel, 1977
Management is biopsychosocial • Biological e.g. medication, physical rehabilitation • Psychological e.g. CBT
Social Remove the barriers to recovery Relationships .. at work or home Iatrogenic .. bad healthcare advice Benefit gap .. financial incentives
The lost art of rehabilitation We have forgotten not only how to rehabilitate patients, but that we need to do so for the patient to make a full recovery.
Graded exercise therapy for CFS Exercise = “an activity requiring physical effort”
Percentage improved with GET 70 60 50 GET Control
40 30 20 10 0 UK
UK
UK
NZ
Austral
Percentage improved with CBT 80 70 60 50 CBT Control Control
40 30 20 10 0 UK
UK
NL
NL
UK
But do these treatments help patients return to work? “Only cognitive behavior therapy, rehabilitation, and exercise therapy interventions were associated with restoring the ability to work.� - Even without occupation as the aim. Systematic review: SD Ross et al, Arch Intern Med 2004
Predictions of non-response to GET • High psychological distress • Membership of a self-help group • Sickness benefit R Bentall et al, 2002
Social risks “If you have to prove you are ill, you can’t get well.” (N Hadler, 1996) “ME is an incurable disease.” (UK doctor, 2008)
Does the BPS approach work? • • • • • •
CFS Low back pain IBS Depressive illness (Cardiac disease) (DM)
Preventing SDIs Patients with infectious mononucleosis – Brief rehabilitation, with graded return to activities – Compared to leaflet
By 6 months, 26% had abnormal fatigue after rehab, compared to 50% of controls. B Candy et al, 2004