Research abstract & comment by Tom Kindlon:

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 prior to, immediately after, and 4 months following each workshop. 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 4 months after the workshops. 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.

Evaluating interactive fatigue management workshops for Occupational Health professionals in the United Kingdom, by Sheila Ali, Trudie Chalder, and Ira Madan in Saf Health Work. Dec 2014; 5(4): 191–197  [Published online Jul 27, 2014]

Tom Kindlon comments on the content of the workshops assessed in the research 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 weak.

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 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

(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

(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.

(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.

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