Could one common cause be assessed instead of 101 diagnoses?

Modern medical treatment is focused on diagnoses to be able to give the best available treatment. Traditionally diagnoses are used in assessing treatment, loss of work ability or disability. A sick listed patient can have any diagnoses in the ICD-10 system. Sick listing and disability are dominated by mental and musculoskeletal disorders in Norway, and common symptoms are anxiety, pain, fatigue and depression.

In 1997 Claw (96) presented a hypothesis on unexplained pain and fatigue. Genetic and environmental factors could interact to cause the development of these syndromes. He postulated that these syndromes were caused by central nervous system dysfunction and that various components of the central nervous system appeared to be involved, including the hypothalamic pituitary axes, pain-processing pathways and autonomic nervous system. He also postulated that these central nervous system changes could lead to corresponding changes in immune function.

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Svedberg (157) described that “many patients on long-term sick-leave with unclear diagnoses may suffer from unrecognized, and therefore probably untreated, medical disorders and co-morbidity.”

“Subgroups must be observed,” said Stapelfeldt (108). In our study comorbidity was common. Table 6.5 shows the distribution of side diagnoses from 216 (51.4 %) individuals registered through our clinical contact. The long-term sick leave patient group had multiple diseases in addition to the musculoskeletal and psychiatric disorders.

In several European countries, the number of patients with difficulty resuming work after long-term sick leave has increased. In a Swedish investigation, Linder et al. (2009) studied 635 long-term sick leavers from the National Insurance Office by questionnaires and examined by three board-certified specialist physicians in psychiatry, orthopaedic surgery and rehabilitation medicine (37). Of the patients 55 % had a psychiatric-somatic comorbidity. The three most frequent combinations of diagnoses in the comorbidity group were

fibromyalgia/myalgia and depressive episodes, fibromyalgia or myalgia and recurrent depression, and spinal pain and depressive episode; whereas the three most frequent in those with psychiatric diagnosis only were depressive episode, recurrent depression and phobias or anxiety. Differences in pain and difficulties with activities were found among the three

groups. By multidisciplinary assessment, 80 % needed rehabilitation. Patients with psychiatric diagnoses, or both psychiatric and somatic diagnoses, need medical/vocational rehabilitation to a greater extent than patients with somatic diagnoses only. This implies that medical rehabilitation programs ought to increasingly adapt to the needs of patients with psychiatric-somatic comorbidity.

In our study, the psychiatric diagnoses were not frequent as main diagnoses (Table 6.1 and section 8.4.1). However, as side diagnoses, psychiatric diagnoses were most frequent (39.

6 %) in the extra intervention group and must be taken into account.

Different diagnoses with varying comorbidity and the same functional loss, loss of working ability, could all be a result of some central coordinating mechanism. What is recognized as “pain” is a common factor that tends to be automated and, to some extent, out of our control. For the rehabilitation matter it is more important to control the pain responses and bring the attitudes into problem solving more than protective behaviour (46, 96).

Against this background, whether the experience of generalized pain is a “one-cause syndrome” (158) is discussed so that a reclassification of this part of the diagnostic system could have been developed further (95). RTW activity is an example of such thinking. All those on long-term sick-leave are treated in the same way regardless of diagnosis.

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The picture of symptoms is almost alike for all those suffering from musculoskeletal and minor mental disorders, but the anatomical localization differs. Bruusgaard (159, 160) discussed the possibility of a more common reason for the disorders, Natvig investigated the spread of painful areas on the body and functional level, and found a linear covariation (161), while Bruusgaard (162) studied the symptom load. As the number of painful sites increases, the ability to work decreases.

Morley et al. conducted a survey of randomized controlled trials and cognitive

behavioural therapy for chronic pain in adults excluding headaches (66). They concluded that active psychological treatments based on the principle of cognitive behavioural therapy were effective, though there are no comments on working ability. Hsu et al. demonstrated a good effect of psychodynamic intervention on persons with no response on conventional

rehabilitation actions (163, 164).

The effect of a brief intervention is not obvious, and in our investigation is difficult to acknowledge. Whether the brief intervention effect is a Hawthorne effect or not can be discussed (section 8.2.3). The Hawthorne effect can be represented by the question: Are behaviours altered when people know they are being studied? McCambridge et al. conclude in a review article about the Hawthorne effect that most studies “reported some evidence of an effect, although significant biases are judged likely because of the complexity of the

evaluation object [ . . . ] consequences of research participation for behaviours being investigated do exist” (131). The promising results of our pilot project could be due to this effect. Hence, it was difficult to distinguish the effect of the intervention from the normal process of recovering from sick leave.

Haugstad et al. (33) investigated women with pelvic pain and performed

somatocognitive therapy. Those who received somatocognitive therapy had improved scores for all motor functions and pain, as well as anxiety-insomnia-distress and GHQ-30 scores for coping (a self-rating questionnaire assessing psychological distress and general well-being).

This is an example indicating that a treatment focusing on the central understanding of pain is more effective than focusing on the anatomical and physiological location of pain.

However, Schlamann, Naglatzki and Nickel have in three different articles describes brain changes from autogenic training and bioenergetics exercises (165-167). Explanations on reduced work ability related to disturbances in one or a few functional areas in the central brain seems closer today than when presented by Clauw twenty years ago.

Results from our study and among others as is referred above should encourage more research in this field.

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