Chronic fatigue has its own set of defining criteria, and each must be dealt with in an appropriate way when organising rehabilitation, say Tristan Mellin and Anne Harriss.
Chronic fatigue syndrome (CFS) is a severe, disabling physical and mental fatigue lasting for at least six months and unexplained by a conventional medical diagnosis (Centre for Disease Control, 2006).
Estimates for the prevalence of CFS range from 0.007% to 2.8% in the adult population (Afari and Buchwald, 2003) and from 0.006% to 3% in primary care (Reeves et al, 2007). Early reports suggested that CFS affected primarily young, white, successful women (Lloyd et al, 1990).
Most patients diagnosed with CFS are 30 to 40 years of age, and at a time of life when occupational issues are likely to be important (Afari and Buchwald, 2003). Health care workers, shift workers and airline pilots seem to have higher levels of fatigue (Ranjith, 2005).
Jason et al (1998) suggest that shift work, work-related stressors and viruses encountered through work, contribute to the higher prevalence in these occupational groups. CFS represents a considerable public health burden with estimated national costs of £6.4 billion a year (Thomas, 2006), which includes sickness absence, ill-health retirement (NHS Plus, 2006) and the need for informal care (Sabes-Figuera et al, 2010).
Causes of chronic fatigue syndrome
The causes of CFS remain poorly understood (NHS Plus, 2006). Occupational health nurses (OHNs) possess knowledge of factors associated with a successful return to work (RTW) following sickness absences; much can be done to improve the outcome for clients with CFS. One of the most important being the embedding of sickness absence policies within the organisational culture, especially elements relating to early RTW interventions and rehabilitation. If this can be achieved OHNs can be proactive in recommending interventions before chronicity is established, thus promoting the RTW recovery programmes at a time when they can achieve the greatest benefit.
This article examines the impact of CFS on work detailing how a framework can be used in assessing fitness to RTW. Symptoms – including extreme fatigue, musculoskeletal pain, poor memory and concentration – significantly impact on the activities of daily living and thus work performance. These can be explored using a “biopsychosocial” model (Sharpe, 1996; Mountstephen et al, 1997).
Many authors propose that viral infections including glandular fever (herpes virus/Epstein-Barr virus (EBV)) (White et al, 1997), hepatitis (Berelowitz et al, 1995) and viral meningitis (Hotopf et al, 1996) explain the persistence of the symptoms of CFS. Others suggest the virus may act as a stressor (Cleare et al, 1996). Conversely, one prospective study found no association between self-reported viral infections and subsequent CFS (Wessely, et al 1995). Indeed, some patients have no clinical or laboratory evidence of viral infection; and antiviral agents such as acyclovir or interferon have not been beneficial in the treatment of CFS (Wilson et al, 1994).
This perspective has, in turn, been questioned by a follow-up study that identified approximately 10% of individuals infected with Epstein-Barr virus in adulthood go on to develop CFS (White et al, 1995). In summary, it is improbable that a single infectious agent causes CFS; rather there may be a heterogeneous group of infections that may trigger or perpetuate the symptoms of chronic fatigue.
Musculoskeletal pain is one of the symptoms of CFS. Mowbray et al (1991) suggest a possible cause being fragments of incomplete infectious virus particles in muscle cells released on cell death. This is endorsed by a study of polymer chain resonance of muscle biopsies indicating that 56% of patients with CFS were positive for incomplete enteroviruses compared with only 15% controls (Muir and Archard 1996). This was replicated in a small research study of eight CFS patients (Galbraith 1997) which found they were positive for enteroviral elements.
Another possible explanation is the release of interferons by infected cells commonly giving rise to flu-like symptoms and gastrointestinal disorders similar to those experienced by patients with CFS (Martin et al, 2000).
Komaroff (1994) has identified cognitive problems as some of the most disruptive and disabling symptoms of CFS. Although as many as 85% of patients complain of impairments in attention, concentration and memory abilities, formal neuropsychological studies have not yielded consistent results (Altay et al, 1990; DeLuca et al, 1995).
However, the review of Michiels (et al, 2001) confirmed a modest but significant deficit in information processing, impaired working memory and poor learning in the test group.
The guidelines on CFS of both the National Institute of Health and Clinical Excellence (NICE) (2005) and NHS Plus (2006) identify no clear treatment pathway. Studies have shown promising results for both cognitive behavioural therapy (CBT) (Malouff et al, 2008) and graded exercise therapy (GET) (Edmonds et al, 2004) in managing the symptoms of CFS as gaining symptom control is associated with recovery (Glozier, 2005).
Many people living with CFS withdraw from activities and rest in an attempt at symptom control. While there is no direct evidence of harmful effects of prolonged rest, this avoidance of activity may cause physical de-conditioning and further disability (NHS Plus, 2006).
Cope (et al, 1996) suggests interpersonal factors including perceived lack of social support or unhelpful reaction from colleagues contributes to the persistence of fatigue. This concurs with the assertion of Prins et al (2004) that more negative social interaction at baseline is associated with greater fatigue at eight months.
Other authors suggest that individuals who previously set themselves high standards may become frustrated at their reduced performance (Michiels et al, 2001) resulting in a loss of confidence with regard to RTW. A proactive approach by the OH nurse to assessing fitness to work and recommending early interventions before chronicity is established aims to achieve the greatest benefit for employee and their employer.
Assessment of fitness to work
The primary purpose of a fitness to work (FTW) assessment is to identify if the person is fit to perform their job tasks, without risk to the health and safety of themselves and others (Cox et al, 2007). As a result of this assessment, the OHN is in a position to advise on suitable modifications in compliance with the requirements of the Disability Discrimination Act 2005.
Murugiah et al (2002) in their FTW model emphasise that recognising the legal requirements of employment will benefit both employer and employee and they describe a framework integrating the many variables to be considered when assessing fitness to work of an employee with a health deficit.
The client assessment must consider the psychological, physical, sociological and intellectual aspects of health. As there seems to be a relationship between workplace stressors and CFS (Jason et al, 1998) there may have been workplace difficulties prior to symptom onset. This may become a significant obstacle to an effective RTW strategy.
The client may have unhelpful thoughts and behaviours relating to work including a fear of losing their job, and a perceived lack of understanding from managers and colleagues. They may have concerns about their physical abilities and consequently discontinue leisure activities worried that pushing themselves too hard will result in delay to recovery.
The FTW framework enables client, employer and OH professional to arrive at the best possible compromise, taking into account the intricate positions of client and employer (Murugiah et al, 2002). As Battigelli (1994) suggests, this is often inadequately documented, resulting in a mismatch between worker and their ability to perform work tasks. The physical and psychological demands of their role must be established. The assessment matches the client’s attributes with the working environment and specific work requirements.
Legal aspect and assessment
The OHN must be cognisant of legislative requirements, particularly the Disability Discrimination Act 1995 (DDA). The DDA requires the employer to make “reasonable adjustments” ensuring the client is not disadvantaged by employment arrangements or any physical feature of the workplace.
CFS was one of the first conditions tested under the DDA (1995). The employment tribunal established the employer must ensure that an effective assessment of FTW is undertaken before deciding on the employment status of the now “disabled” client (O’Neil v Symm & Co Ltd, 1998). Employers have a duty to undertake risk and other assessments under a raft of legislation including: the Health and Safety at Work Act 1974 (Great Britain, 1974); the Management of Health and Safety at Work Regulations 1999 (HSE, 1999); and Workplace (Health Safety and Welfare) 1992 (HSE, 1992).
The role of the OH nurse in client assessment and associated recommendations has an ethical component. Beauchamp and Childress (2001) describe the need “to do good, do no harm” and this is fundamental to the Nursing and Midwifery Council (NMC) Code of Conduct (NMC 2008) which highlights that “the people you care for must trust you and you must provide a high standard of care at all times”.
The use of the FTW framework ensures transparency, provides consistency of decision-making and commences with an explanation of medical confidentiality and a request for consent to inform managers of the outcome of discussions. Informed consent, in compliance with the Access to Medical Reports Act 1988, must be obtained before seeking medical reports.
This evidence would enable the likely DDA (2005) status to be determined and support RTW decisions. To ensure functional safety, a risk assessment of the work area and work processes is required and is dependant on the needs of the client but generally this should take account of the demands of the job including manual dexterity, walking, climbing stairs.
A planned and supervised programme of workplace rehabilitation should be discussed in detail with both client and management. Clearly, the client’s beliefs and wishes have a powerful effect upon acceptance of any such programme. An RTW recovery plan initially usually includes reduced workload. This must be regularly reviewed with work activities progressively increased in response to progress over a defined and limited period, perhaps four to six weeks in the first instance.
Weekly line manager and monthly OH reviews should be factored into this programme. It may be appropriate to integrate the CBT treatment into the RTW programme. This hinges on the commitment of the organisation.
Rehabilitation has benefits (Cunningham and James, 2000; Nice and Thornton, 2004) and is confirmed by the Confederation of British Industry survey (CBI, 2009), which rated flexible RTW as an effective absence management tool. Undoubtedly, rehabilitation programmes can cause operational issues, however. Short-term expenditure of effort by all concerned is preferable to protracted sickness absence resulting in ill-health retirement or termination of employment.
Early referrals are essential. The review of Dame Carol Black: Working for a Healthier Tomorrow (Black, 2008) and the research of Bevan et al (2009) on musculoskeletal disorders, highlight the importance of early detection and intervention in musculoskeletal disorders in improved sickness absence rates and a reduction in the burden on the Government’s health and disability budgets.
Key to the success of RTW recovery strategies is embedding the sickness absence policy within the culture of the organisation especially with regard to early interventions before chronicity is established and when they can achieve the greatest benefit. To support this, research is required to consider aspects of rehabilitation work, who it is for and who should offer it, and to demonstrate the clinical effectiveness and ultimately, financial benefits of health interventions. The evidence could form a CFS protocol identifying good practice in CFS management.
Effective intervention in chronic fatigue syndrome
Despite continuing controversy about the status, aetiology and optimum management of CFS, there is increasing evidence that effective intervention is possible. This can be achieved through the application of a “biosocial model” and an FTW framework. Together, they provide consistency of decision-making and documentation by integrating personal aspect, work characteristics, environment and legal aspects.
Success results from identifying the predictive factors for RTW using early intervention and collaborative working with client, medical practitioners and management. Policies embracing early intervention and recovery initiatives embedded into the organisational culture are integral to the success of assisting RTW.
The challenge for OH nurses is ensuring that the need for interventions is recognised at a time when they can best benefit both client and employer.
Tristan Mellin is a final year BSc (Hons) Specialist Community Public Health Nursing (Occupational Health) student at London South Bank University. Anne Harriss is reader in educational development and course director London South Bank University.
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