Published 23 April 2010, doi:10.1136/bmj.c1799
Cite this as: BMJ 2010;340:c1799

Editorials

Pragmatic rehabilitation for chronic fatigue syndrome

Has a short term benefit, but supportive listening does not

Each full time general practitioner in the United Kingdom has as many as 10 patients with chronic fatigue syndrome (CFS/ME) on their list.¹ Many feel they have little to offer with regard to treatment.² Patients in turn are often left feeling misunderstood and poorly cared for.

Currently, the only evidence based treatments for this condition reviewed in the Cochrane Library and recommended by the National Institute for Health and Clinical Excellence are cognitive behavioural therapy and graded exercise therapy, with cognitive behavioural therapy in specialist care having the larger evidence base.^{3 4 5} A primary care trial of brief cognitive behavioural therapy for CFS/ME offered by general practitioners who had received simplified training in the subject was unsuccessful.⁶ Few patients with CFS/ME receive specialist services, partly as a result of limited access, but also because many feel that psychological treatments delegitimise their condition.² Thus, a treatment that includes aspects of the successful treatments, but in a more pragmatic fashion with less emphasis on psychology, is an attractive proposition. But does it work?

The linked randomised controlled trial by Wearden and colleagues (doi:10.1136/bmj.c1777), assesses pragmatic rehabilitation for CFS/ME offered in primary care.⁷ The rehabilitation consists of providing patients with detailed explanations for their symptoms combined with a carefully graded exercise programme, delivered by supervised general nurses after training. Patients randomised to this treatment became significantly less fatigued and depressed, and they slept better than patients who received usual care. However, one year later no significant difference was seen between the groups.

This suggests that pragmatic rehabilitation works, but only in the short term. Why then did an earlier randomised controlled trial of pragmatic rehabilitation with a single skilled therapist show large changes in fatigue and disability at one year of follow-up?⁸ Wearden and colleagues explain that their patients had more comorbidity and disability than patients in the earlier trial,^{7 8} and indeed most other trials. Increased disability is a recognised predictor of poor outcome of cognitive behavioural therapy in this condition.^{9 10} This may be even more relevant for a minimal intervention from less experienced practitioners. A recent trial found that guided self instruction cognitive behavioural therapy, accompanied by minimal support from a therapist, reduced fatigue and disability in patients with less severe rather than more severe CFS/ME.¹⁰ Therefore the best approach may be stepped care, in which patients with less disability are offered minimal intervention, whereas more severely affected patients are offered intensive specialist input. Alternatively, having more sessions of pragmatic rehabilitation for longer may build on initial improvements. In Wearden and colleagues’ trial, patients received fewer sessions (eight hours in total) than most successful trials of cognitive behavioural therapy and graded exercise therapy.

A further question is whether generalists are as successful as specialists in offering behavioural interventions. A large Dutch trial showed that 16 hours of cognitive behavioural therapy delivered by a range of recently trained health professionals was effective for at least a year, although the improvements were less than those obtained for highly skilled therapists.¹¹ The effectiveness of these treatments may be a product of therapists’ skill and the number of sessions, with less experienced therapists needing more sessions. To understand these interactions further, trials comparing short and longer term treatments with skilled and unskilled therapists are needed. These should also examine the cost effectiveness of different levels of therapeutic skill. The economic and personal burden of CFS/ME is large, yet data on cost effectiveness are scarce.

Wearden and colleagues’ trial also investigated supportive listening therapy for CFS/ME. This approach is often used by counsellors and is more accessible to general practice than cognitive behavioural therapy or exercise therapy. Importantly, this treatment was ineffective—patients receiving supportive listening had significantly more disability at the end of treatment than those receiving usual general practitioner treatment. This may be because supportive listening did not include a graded activity component. Cognitive behavioural therapy protocols without this component seem to be no more effective than usual care for CFS/ME.⁴ The large UK based PACE trial should soon provide answers in this regard.¹² PACE compared cognitive behavioural therapy and graded exercise therapy, which focus on increasing activity, with adaptive pacing therapy, which matches activity levels to the amount of energy available to patients.

Pragmatic rehabilitation as a treatment in primary care for CFS/ME has short term benefit, but supportive listening does not. Before it can be recommended, more work is needed to determine for whom pragmatic rehabilitation works best, the optimum number of sessions needed, and the required skill of the therapists. Some of these questions may be answered by further analysis of the current trial. For instance, moderator analysis, examining interactions between patient or therapist characteristics and treatment outcome, could investigate whether less disabled patients responded better to treatment than those with greater disability. Similarly, it might be useful to study the effect of therapists’ competence on outcome. Finally, pragmatic rehabilitation has the real advantage of being an acceptable treatment. Few patients dropped out of treatment, and it may be less stigmatising for some people than cognitive behavioural therapy. This last point is crucial, and if the successful elements of pragmatic rehabilitation can be identified, it may provide an additional option to the currently limited list of possibilities.

Cite this as: BMJ 2010;340:c1799

¹ School of Psychology, University of Southampton, Southampton SO17 1BJ , ² Primary Health Care, University of Bristol, Bristol BS8 2AA

Research, doi:10.1136/bmj.c1777

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Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that: (1) They have no specified support for the submitted work; (2) RM-M has had no relationships that might have an interest in the submitted work in the previous three years; WH is a part time insurance medical officer for three companies offering income protection insurance and board member of one; his payments are fixed hourly rates and wholly unconnected to the acceptance or declinature of claims; (3) WH’s wife is also a part time insurance medical officer for one company, with a similar payment scheme; and (4) AJW, first author of the FINE trial, has chaired a trial steering committee for a study on cognitive behavioural therapy for adjusting to multiple sclerosis where RM-M was the principal investigator. WH has no non-financial interests that may be relevant to the submitted work.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

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10. Knoop H, van der Meer, JWM., Bleijenberg, G. Guided self-instructions for people with chronic fatigue syndrome: randomised controlled trial. Br J Psychiatry 2008;193:340-1.[Abstract/Free Full Text]
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12. White PD, Sharpe MC, Chalder T, DeCesare JC, Walwyn R. Protocol for the PACE trial: a randomised controlled trial of adaptive pacing, cognitive behaviour therapy, and graded exercise as supplements to standardised specialist medical care versus standardised specialist medical care alone for patients with the chronic fatigue syndrome/myalgic encephalomyelitis or encephalopathy. BMC Neurol 2007;7:6.[CrossRef][Medline]

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