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Evaluating interactive fatigue management workshops for occupational health professionals in the UK

Tom Kindlon

Senior Member
(Not a recommendation)

Free full text: http://www.sciencedirect.com/science/article/pii/S209379111400050X

Safety and Health at Work
Available online 27 July 2014

In Press, Accepted Manuscript

Original article

Evaluating interactive fatigue management workshops for occupational health professionals in the UK


Disabling fatigue is common in the working age population. It is essential that occupational health (OH) professionals are up-to-date with the management of fatigue in order to reduce the impact of fatigue on workplace productivity. Our aim was to evaluate the impact of one-day workshops on OH professionals' knowledge of fatigue and chronic fatigue syndrome (CFS), and their confidence in diagnosing and managing these in a working population.

Five interactive problem-based workshops were held in the United Kingdom. These workshops were developed and delivered by experts in the field. Questionnaires were self-administered immediately before (T1), immediately after (T2) and four months following each workshop (T3). Questionnaires included measures of satisfaction, knowledge of fatigue and CFS, and confidence in diagnosing and managing fatigue. Open-ended questions were used to elicit feedback about the workshops.

General knowledge of fatigue increased significantly after training (with a 25% increase in the median score). Participants showed significantly higher levels of confidence in diagnosing and managing CFS (with a 62.5% increase in the median score), and high scores were maintained at T3. OH physicians scored higher on knowledge and confidence than nurses. Similarly, thematic analysis revealed that participants had increased knowledge and confidence after attending the workshops.

Fatigue can lead to severe functional impairment with adverse workplace outcomes. One-day workshops can be effective in training OH professionals in how to diagnose and manage fatigue and CFS. Training may increase general knowledge of fatigue and confidence in fatigue management in an OH setting.
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Tom Kindlon

Senior Member
Frustrating/annoying article, unless you're a fan of the CBT/GET school of thought regarding ME/CFS.

One can get an idea of what was taught in Tables 1 & 3, and the qualitative analysis section of the results.


Senior Member
General knowledge of fatigue increased significantly after training (with a 25% increase in the median score).

How did they verify the general knowledge of fatigue? With self rated questionnaire like in the PACE trial??

Participants showed significantly higher levels of confidence in diagnosing and managing CFS (with a 62.5% increase in the median score), and high scores were maintained at T3.

Translation: Participants showed significantly higher levels of confidence in misdiagnosing and illtreating ME/CFS

High scores were maintained at T3: they are evaluating everything like CBT trial!!!

And by the way, what exactly is an occupational Health professional?
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Tom Kindlon

Senior Member
Article is not up on PubMed yet. When it does go up, I intend to post the following as a PubMed Commons comment:

The evidence is not there to recommend CBT and GET to improve employment outcomes in CFS

For over a decade now, some individual patients with Chronic Fatigue Syndrome (CFS)* in Great Britain and Ireland (and probably elsewhere) have been pressurised by insurance companies and occupational health professionals into undertaking graded exercise therapy (GET) and the form of cognitive behaviour therapy (CBT) that is based on scheduling increases in activity. This seems to have been largely due to hype around the efficacy of GET and CBT and extrapolations from subjective measures, as the evidence that such interventions are efficacious in restoring the ability to work is week.

Based on the information in Tables 1, 3 and the qualitative results from this paper, CBT and GET have again been recommended to occupational professionals in these workshops.

A lot of the evidence regarding CBT and GET and their effect on occupational outcomes in CFS has been summarised in a review (1). For some reason this is quoted sometimes as justifying claims it is evidence-based to say that GET and CBT have been shown to restore the ability to work in CFS. However the data is far less impressive. It is summarised in table 6 of that paper. The accompanying text says: "Among the 14 interventional trials with work or impairment results after intervention, there were too few of any single intervention with any specific impairment domain to allow any assessment of association."

The PACE Trial is by far the biggest trial of these therapies in the field. It shows neither CBT nor GET led to an improved rate of days of lost employment [Means (sds): APT: 148.6 (109.2); CBT: 151.0 (108.2); GET: 144.5 (109.4); SMC (alone): 141.7 (107.5)] (Table 2) (2). Neither CBT nor GET led to improvements in numbers receiving welfare benefits or other financial payments (Table 4). These results are in contrast to the self-reported improvements in fatigue, physical functioning and some other measures (3).

A major audit of Belgian CFS rehabilitation (CBT & GET) centres also gives real-world data on the issue (4). The sample size was large, with over 600 patients with a confirmed diagnosis of CFS (using the Fukuda et al. criteria
(5)) taking part. It "comprised on average per patient 41 to 62 hours of rehabilitation" It found that "physical capacity did not change; employment status decreased at the end of the therapy." Again improvements were found in some self-reported measures.

It should be noted that a large assortment of abnormalities have been found in terms of the exercise response in CFS, with high rates of adverse reactions have been reported in patient surveys from CBT and GET, particularly with the latter, again putting in to question any recommendations of CBT and GET for CFS (6,7).

All in all, I question suggestions that occupational health professionals should be recommending CBT and GET to individuals with CFS.

* I'll use the term for consistency.


(1) Ross SD, Estok RP, Frame D, Stone LR, Ludensky V, Levine CB. Disability and chronic fatigue syndrome: a focus on function. Arch Intern Med. 2004 May 24;164(10):1098-107. http://archinte.ama-assn.org/cgi/content/full/164/10/1098 or http://archinte.ama-assn.org/cgi/reprint/164/10/1098

(2) McCrone P, Sharpe M, Chalder T, Knapp M, Johnson AL, et al. (2012) Adaptive Pacing, Cognitive Behaviour Therapy, Graded Exercise, and Specialist Medical Care for Chronic Fatigue Syndrome: A Cost-Effectiveness Analysis. PLoS ONE 7(8): e40808. doi:10.1371/journal.pone.0040808

(3) White PD, Goldsmith KA, Johnson AL, Potts L, Walwyn R, et al. (2011) Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome
(PACE): a randomised trial. Lancet 377: 823-836.

(4) [Fatigue Syndrome: diagnosis, treatment and organisation of care] KCE Reports 88. (with summary in English). Accessed: 6th August, 2012.

(5) Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A. The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group. Ann Intern Med. 1994 Dec 15;121(12):953-9.

(6) Twisk FN, Maes M. A review on cognitive behavorial therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS. Neuro Endocrinol Lett. 2009;30(3):284-99. Review.

(7) Kindlon T. Reporting of Harms Associated with Graded Exercise Therapy and Cognitive Behavioural Therapy in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Bulletin of the IACFS/ME. 2011;19(2):59-111.
I'd just bumped this thread in response to this article (or the abstract - not read the whole thing): http://forums.phoenixrising.me/inde...rom-pace-in-2011-still-not.23157/#post-490524

It's on a pro-CBT occupational guidelines report.

Review Date: 2011
Key findings of the review:
• Cognitive behavioural therapy and graded exercise therapy have been shown to be effective in restoring the ability to work in those who are currently absent from work
A large multicentre RCT, PACE is currently under way in the UK, comparing standardised specialist medical care with CBT, GET and pacing. PACE will include work outcomes.​
I'd have thought they'd be keen to disseminate the data from PACE showing that the addition of CBT and GET to SMC did not lead to improvements in work related outcomes. Otherwise there's a danger that they could promote an exaggerated view of the efficacy of these treatments - oh-oh! From what I remember the only evidence they ever had to argue for the value of CBT and GET in returning ability to work was really tenuous, and from a spun meta-analysis of a couple of poorly done studies.

Still not been reviewed and updated with the PACE data.
Some of the unsubstantiated and scientifically contradicted statements used to brainwash the participants:
It is important to advise patients with CFS to rest in response to their symptoms. (FALSE)
A good outcome of fatigue is predicted by a belief that the consequences of the fatigue are minor. (TRUE)
Adaptive pacing therapy is the treatment of choice for CFS. (FALSE)

In addition to the ones above needing to be corrected, I think they should've added a few:
GET and CBT lead to objective improvements in CFS patients. (FALSE)
CFS patients often improve when active chronic infections are detected and treated. (TRUE)
The 2-day CPET is a reliable indicator that reduced functioning in CFS patients is not due to deconditioning. (TRUE)

And so on :p



That tells us all we need to know about their workshops. More abuse and neglect for those with the neurological illness myalgic encephalomyelitis.