Workplace Interventions in Chronic Fatigue Management Professor Diane L Cox Director of Research, Professor of Occupational Therapy, University of Cumbria diane.cox@cumbria.ac.uk

Definitions • Fatigue

• physical or mental exhaustion due to exertion • a tiring activity or effort • Extreme tiredness resulting from mental or physical exertion

or illness

• Chronic • persisting for a long time or constantly recurring

So Chronic Fatigue is physical or mental exhaustion due to activity or effort persisting for a long time or constantly recurring

But what is Chronic Fatigue Syndrome?

Oxford Criteria 1991

Requirements for diagnosis;

• 6 months duration of fatigue;

• substantial impairment & disruption of daily activities;

• post-exertional fatigue;

• cognitive & neuropsychiatric symptoms required

Suggested Chronic Fatigue Syndrome (CFS) was best name as it is descriptive and free from unproven aetiological implications.

(Sharpe, et al 1991 J Roy Soc Med)

CDC Criteria 1994; often known as Fukuda Criteria

Defined Prolonged Fatigue as self-reported persistent fatigue lasting 1 month or longer and; Chronic Fatigue as self-reported persistent or relapsing fatigue lasting 6 or more consecutive months

(Fukuda, et al 1994 Ann Intern Med) Clinical Evaluation Requires: 1. A thorough history that covers medical and psychological circumstances at onset of fatigue 2. A mental status examination 3. A thorough physical examination 4. A minimum battery of laboratory screening tests. Tests should be directed toward confirming or excluding other aetiologic possibilities. Exclusions: Any active medical condition, current diagnosis of major depressive illness, alcohol or substance abuse within 2 years, severe obesity, any unexplained findings.

The Interface of Fatigue

People with prolonged fatigue of at least one month

Overlapping disorders; Depression; Fibromyalgia, Chronic pain etc..,

CFS/ ME

Chronic Fatigue

NICE Clinical Guidelines CG53 (2007)

• Suggested advice on symptom management should not be delayed until a diagnosis is established

• This advice should be tailored to the specific symptoms the person has and be aimed at minimising their impact on daily life and activities

• A diagnosis should be made after other possible diagnoses have been excluded and the symptoms have persisted for: • 4 months in an adult • 3 months in a child or young person; the diagnosis should

be made or confirmed by a paediatrician.

Symptoms of Chronic Fatigue Syndrome

• severe disabling fatigue; both mental and physical • impairments in concentration, speed processing and memory • sleep disturbances - initial hypersomnia then insomnia • musculo-skeletal pain • new headaches • mood disturbance; irritability • hypersensitivity; light and sound • digestive changes; IBS • temperature changes • recurrent sore throats • post-exertional malaise • tender cervical or axillary lymph nodes

How common is CFS? Persistent fatigue

• Preliminary estimates of the incidence of new cases per year of prolonged fatigue or chronic fatigue in primary care are 3%-5%

Who is at risk? • Predominately working age adults 20 – 40 years • Ratio of 2/3:1 Female to Male

Mean total cost of services and lost employment across a study sample was £3878 in a six month period. Lost employment accounted for 61%. Suggesting total economic cost associated with chronic fatigue is high, with informal care & lost productivity.

(Sabes-Figuera et al BMC Health Services Research 2010 10: 56)

What is the prevalence of CFS/ ME?

In 2002, thought to be at least 0.2% - 0.4% that is; 200–400 per 100,000 people.

CFS/ ME Working Group 2002, pg. 6 NICE (2007) supported this estimate. So as an example in the North West England 3,640 – 7,280 people could have CFS/ ME

The Issues in Chronic Fatigue Management & Work • Fatigue is a common symptom of a range of physical illnesses and

mental health conditions (Newton & Jones Occup Med 2014, 60:326-332)

• Fatigue is commonly reported in primary care settings (Sabes-Figuera et al 2010, 10: 56)

• The traditional view of general fatigue is that it caused by work

• Need to identity the factors that cause fatigue & evaluate if there is a link between fatigue & work

• The relation between fatigue and energy • Motivational control aspects of fatigue

• Varieties of fatigue; mental, physical, sleepiness

Adapted from Hockey B (2012) In: The Handbook of Operator Fatigue Eds; Matthews G, Desmond P,

Neubauer C, Hancock PA

Factors associated with Long-term sickness absence in CFS Chronic Fatigue Syndrome is associated with high levels of occupational disability.

Long-term sickness absence among patients with CFS is associated with physical fatigue, poor sleep, and cognitive and behavioural responses characterised by embarrassment over symptoms and avoidant behaviour

Factors other than symptom severity are important in predicting prognosis in CFS, suggesting that cognitive and behavioural responses have a role in management.

By addressing avoidance behaviours and cognitions regarding embarrassment in interventions for CFS, this may enhance the chance of individuals returning to work.

(Knudsen et al Brit J Psych 2011 199:430-431)

Predictors of work status in fatigued employees

CFS is a strong predictor of an inactive work status and full work incapacity in the long term There is a need for early interventions that restore or preserve the ability to work, especially for workers who meet the criteria for CFS

(Huibers et al Occup Environ Med 2006; 63: 570-572)

Sustainability of Work with Chronic Health Conditions Need to; • Apply & adapt theories • Test workplace interventions that might prevent disability & disengagement

A symposium in October 2012 and subsequent publications in June 2013 Journal of Occupational Rehabilitation 23:2 suggested the need to;

• Address social, not just physical, aspects of the workplace, • To include individual-level and organisational interventions • To integrate employer perspectives & operational models • Focus on appropriate choice of outcome measurement • Symptom self-management at work • Job accommodations • Prognostic factors for disability escalation • Perceived needs of affected workers

Issues in Return to Work

• Perceived work attitude • Self efficacy • Perceived social support • The time to Return to Work

(Brouwer et al J Occup Rehabil 20:104-112)

As well as; • Uncertainty • The time to Diagnosis

The Issues for Practitioners

• Clarity in diagnosis & theory • Dynamic & Regulatory perspectives • The important of measurement

• Subjective • Objective

• The case for complexity • The case for simplicity • Multidisciplinarity in research and practice

Employment status in CFS

Suggested that; • Exercise testing should only form part of the assessment

of employment status in people with CFS

and that • The American Medical Association scale of impairment

should not be used as the sole criterion for the assessment of employment status in people with CFS

As the association between either exercise testing or self reported disability were too weak to predict employment status

(Nijs J, et al (2005) Clinical Rehabilitation 19: 895-899)

NICE (2007) clinical guideline 53: CFS/ME States a key priority for implementation is;

Healthcare professionals should proactively advise about fitness for work and education, and recommend flexible adjustments or adaptations to work or studies to help people with CFS/ME to return to them when they are ready and fit enough

Through, liaison with employers, education providers and support services, such as:

• occupational health services • disability services through Jobcentre Plus • schools, home education services and local education

authorities • disability advisers in universities and colleges.

http://guidance.nice.org.uk/CG053

Current Evidence-based interventions for Chronic Fatigue Management • Cognitive Behaviour Therapy (CBT)

• CBT for CFS/ME involves a more rehabilitative approach where balanced levels of activity and rest are established, unhelpful thoughts and beliefs about CFS/ ME that may impair recovery are addressed and, specific lifestyle changes are encouraged.

• Graded Exercise Therapy (GET) • GET for CFS/ ME is based on the illness model of de-conditioning.

The approach involves a physical assessment of the person with CFS/ME, mutually negotiated goal setting and education.

• Activity/ Lifestyle Management (GAT, AM) • Activity management is a person-centred approach to managing a

person’s symptoms by using activity with the aim to increase function by introducing a balance of activity, rest and sleep throughout the day and week.

Cox DL (2012) Chronic Fatigue Syndrome In: The Handbook of Operator Fatigue Eds; Matthews G, Desmond P, Neubauer C, Hancock PA http://guidance.nice.org.uk/CG053

Workplace Interventions for other Chronic Conditions & General Fatigue • Strength training can prevent deterioration in those with musclo-skeletal

disorders exposed to highly repetitive and forceful job tasks (Sundstrup et al 2014 Scan J Work Environ Health, Online-first-article)

• A study is currently underway trialling tailored advice (exposure to daylight, sleep, physical activity & nutrition) through a smart phone application for fatigue management in airline pilots (van Drongelen et al BMC Public Health 2013 13:776)

• A study of acute & chronic job stressors among ambulance personal found the main risk factors were to do with social aspects of the work environment, in particular lack of support from supervisor as well as colleagues and, poor communication (van der Ploeg & Kleber 2003 Occup Environ Med 60(Suppl 1):i40-i46)

• Employees with chronic diseases prefer work accommodations that offer them more flexibility in the organization of work tasks and allow them to work fewer hours (Varekamp & van Diik Occupational Medicine 2010; 60:287-293)

• A group empowerment programme aimed at job retention was perceived to be effective (Varekamp et al Int Arch Occup Environ Health 2011; 84:35-43)

Workplace interventions in fatigued workers Experience Before VR; • Symptoms of prolonged fatigue • Personal limitations • Interpersonal factors • Activities & conditions at work • Life/work imbalance

After VR; • Improved personal factors; awareness, coping skills, taking breaks, using

relaxation techniques, more efficient work strategy • Improved activities during work; increase in mental & physical functioning • Gradual return to work plan; individually tailored, in collaboration with

employee, supervisor, & treatment caregiver; customised work tasks, work demands and working hours with gradual increase

• Work adaptation; fewer contractual hours, extra manpower, career change

(Joosen et al Disability & Rehabilitation 2011; 33(23-24): 2166-2178)

Employers Leaflets NHS Plus 2006

People with Chronic Fatigue are likely to fall under the remit of the Equality Act 2010 Chapter 4 & Schedule 8-Work: reasonable adjustments, where there is a requirement to make reasonable workplace adjustments. These may include measures such as:

− changing locations of work − working from home − modifying work hours − reducing workloads − reducing physical tasks.

Useful Resources http://www.nhshealthatwork.co.uk/chronic-fatigue.asp

Workplace Interventions: Focus of planning Person-based

• Skills • Educational achievements • Physical abilities • Fitness for work • Emotional & cognitive

needs • Assessments

Environment-based

• Living areas • Local community • Transport systems • Work environment • Physical Adaptations

Function-based • Work-type activities • Shift systems & work

scheduling • Job rotation • Demands • Tolerance & load • Task & activity analysis

Adapted from; COT (2007) Work Matters London: COT;

Matthews et al Eds (2012) The Handbook of Operator Fatigue

Common content in Multi-component Vocational Rehabilitation (VR) for fatigue • Bio-psycho-social approach • Physical training, grading • Relaxation techniques; stress reduction • Breathing exercises • Counselling • Cognitive therapy; coping strategies • Education; knowledge, awareness, goal setting, partner

sessions • Energy engineering/ management • Return to work; preparation, experience, discussion • Evaluation

(Joosen et al Int J Behav Med 2011 18:160-171)

Issues of Workplace Interventions • Shift work can be obstacle for consultations • Economic developments creating job insecurity • Anxiety • Collaboration between health staff, working population and

administration (Aelfers et al BMC Public Health 2013: 13:129)

• Use of appropriate measures for fatigue and work evaluation; • Goal setting • Work & Social Adjustment Scale (Cella et al J Psychosom Res

2011; 71: 124-128, Marks 1986) • 11-item Chalder Fatigue Scale (Chalder et al 1993) • 14-item Hospital Anxiety & Depression Scale (HADs, Snaith

2003) • SF-36 short form health survey (Ware & Sherbourne 1992)

Challenges to Functional Capacity Evaluation (FCE) It has been suggested that FCE often fails to link the unremitting fatigue of chronic fatigue syndrome (CFS) to the ability to work. and that; Scientific studies are lacking to support the reliability and validity of the FCE in this population.

(Ciccolella, M. E., & Davenport, T. E. (2013). Scientific and legal challenges to the functional capacity evaluation in chronic fatigue syndrome. Fatigue:

Biomedicine, Health & Behavior, 1(4), 243-255)

Occupational therapists add value to vocational rehabilitation by bringing specialist knowledge and skills relating to the activities that people perform in their daily lives within their life–world contexts.

Some of the specific benefits that occupational therapy brings to

vocational rehabilitation are: • Objective, comprehensive assessment of a person’s functional capacity

and limitations, the work environment, the demands of the job and any barriers to work.

• Ability to match the capacity of the individual to the demands of the job.

• Involvement of clients when choosing, planning, implementing and monitoring their individual pathways to work.

• Designing, planning, implementation and monitoring of individualised programmes to suit the needs of the employee and the workplace.

Work Experience Measurement Scale (WEMS)

The WEMS presents a multidimensional picture of the concept of work experience Factors include;

• Management • Reorganisation • Internal work experience • Pressure of Time • Autonomy • Supportive working conditions

(Nilsson P, Bringsen A, Ingemar Andersson H, Ejlertsson G (2010) Development and quality analysis of the Work Experience Measurement Scale (WEMS) Work 35:

153-161)

Work Environmental Impact Scale (WEIS)

• Semi structured interview designed to identify how clients perceive their work environment

• Information gained about client’s work performance, satisfaction and well-being

• The theoretical basis of the WEIS is the Model of Human Occupation (MOHO)

• The WEIS contains 17 items rated on a 4 point scale; 1 = strongly interferes, 4 = strongly supports

• The WEIS has been tested for validity & reliability and translated into other languages such as Swedish

(Ekbladh E, Thorell LH, Haglund L (2010a) Perceptions of the work environment among people with experience of long tem sick leave Work 35: 125-136)

WEIS 17 items; 1. Time demands 2. Task demands 3. Appeal of work tasks 4. Work Schedule 5. Co-worker interaction 6. Work group membership 7. Supervisor interaction 8. Work role standards 9. Work role style 10. Interaction with others 11. Rewards 12. Sensory Qualities 13. Physical arrangement 14. Social atmosphere 15. Properties of objects 16. Physical amenities 17. Meaning of work

The WEIS seems useful in providing information about how alterations and accommodations in the work environment could support individual workers

The Worker Role Interview (WRI)

WRI can predict return to work and therefore could be a useful tool in vocational rehabilitation for identifying individual rehabilitation needs. “Expectation of job success” which concerns the person’s beliefs in abilities in relation to return to work emerged as an important predictive factor for return to work.

(Ekbladh E, Thorell LH, Haglund L (2010b) Return to Work: The predictive value of the Worker Role Interview (WRI) over two years Work 35: 163-172)

• Relatively short periods of occupational therapy can be cost effective and can achieve successful outcomes.

• Sweetland et al (2009) found that occupational therapy-based interventions help people with multiple sclerosis to remain in work.

• They also demonstrated that the costs, based on an average annual salary of £24,000, would be recouped within two weeks of work. Sweetland J, Cano SJ, Heaney D, Wills S, Gordon A, Playford ED (2009) Vocational interventions, outcomes and costs: a prospective cohort study of people with MS.

Journal of Neurology, Neurosurgery and Psychiatry

Resources

Questions