Role of rehabilitation in chronic stress-induced exhaustion disorder
analysis by Miller et al., showing that stress gives an
initial activation of the HPA axis, but, with time, the
activity diminishes (27).
than SED are discussed in this narrative review if a general
effect of an intervention was of interest, or if persons with SED
were likely to be included in the population, but categorized
in another way. These studies contribute to the overall know-
ledge of rehabilitation of SED, but do not fulfil the predefined
inclusion criteria of the structured search. The studies from the
structured and unstructured searches are presented both in the
text and Tables, divided into 2 main groups: (i) psychological
and stress-reducing interventions; and (ii) workplace-oriented
interventions. However, the order of the studies within these
groups is presented slightly differently, since the Tables show
chronological order, which was not always feasible in the text.
Table III shows only those studies in which the outcome RTW
was included.
Rehabilitation of patients with chronic stress-
induced exhaustion
The aim of rehabilitation is to achieve and maintain
optimum functioning in individuals who experience or
are likely to experience disability (28). Patients with
SED demonstrate physiological and neurobiological
perturbations that may contribute to prolonged cognitive
problems and exhaustion. Rehabilitation of patients with
SED is therefore challenging. In addition, patients with
SED need to evaluate stress factors in their everyday
lives and often learn stress management skills in order
to prevent relapse. Many different interventions for
rehabilitation of these patients have been tried.
This narrative review aims to summarize the eviden-
ce for different interventions for SED, with symptoms
and return to work (RTW) as primary outcomes. RTW
is a particularly stringent test of a positive outcome,
since the condition is often induced by work stress.
PSYCHOLOGICAL AND STRESS-REDUCING
INTERVENTIONS
Multimodal and cognitive interventions
Cognitive behavioural interventions (CBI) and multi
modal interventions (MMI) seem to be the most ef-
fective stress management interventions, at least for
symptom reduction (29, 30). CBI work by changing
attitudes and behaviour by focusing on thoughts, ima-
ges, beliefs and attitudes. CBI can be used, individually
or in a group setting, as one of several treatment mo-
dalities in multimodal rehabilitation (MMR) of SED.
A meta-analysis by van der Klink et al. in 2001 (30)
included 48 studies designed to prevent or reduce psy-
chological complaints related to occupational stress in
a working population with imminent or manifest stress-
related psychological problems. The meta-analysis
found a moderate effect for CBI and MMI, and a small
effect for relaxation techniques, in reducing psycholo-
gical complaints. Only 4 studies measured absenteeism,
in which no effect was seen for interventions with a
cognitive approach or relaxation techniques. Interes-
tingly, CBI showed an inverse correlation between the
number of sessions and effect size, indicating that shorter
programmes might be more effective (30).
A systematic review by Richardson & Rothstein
in 2008 (29), aimed to update the meta-analysis by
METHODS
Knowledge sources
Both structured and unstructured searches of research studies
and reports were used in order to find knowledge sources for this
review. The structured search, performed in April 2017, had 2
predefined inclusion criteria: (i) chronic stress-induced exhaus-
tion/clinical burnout/severe burnout/stress-induced exhaustion;
and (ii) rehabilitation with improvement in symptoms and/
or RTW as outcomes. The search was performed in PubMed,
PsycINFO, Web of Science and Clinical Trials, searching for
“clinical burnout” or “severe burnout” or “stress induced” and
“exhaustion”. A total of 441 articles were found. After excluding
studies that did not test interventions, studies that were not in
human beings, studies without a control group, and studies that
were duplicates, only 3 studies met the 2 predefined inclusion
criteria. These studies are shown in Table II.
The unstructured search was based on the authors’ knowledge
as active researchers and clinicians in the field. Some meta-
analyses, RCTs and cohort studies including populations other
Table II. Studies from the structured search fulfilling the inclusion and exclusion criteria
Studies found by
structured search
Diagnosis
Study design
Population,
n
1. Karlson et al. 2010 Clinical burnout Prospective controlled study,
74
(78) and Karlson et
controls were patients not interested
al. 2014 (79)
in participating in the intervention,
receiving TAU (n = 122)
2. Gavelin et al. 2015 SED
RCT
59
(65)
3. Eskilsson et al.
333
2017 (40)
SED
RCT
88
Interventions Results
Workplace-oriented intervention
including job-person match
through patient-supervisor
communication
12-week process-based
cognitive training added to an
MMR programme
12-week aerobic training
programme performed at a
moderate-vigorous intensity and
added to a MMR programme Significantly increased RTW at 1.5
years follow-up, which remained
only in subjects younger than 46
years at 2.5 years follow-up
Significant improvement of
cognitive functions and levels of
burnout
Significant improvement in
episodic memory performance,
but not in levels of burnout,
depression and anxiety
TAU: treatment as usual; RTW: return to work; SED: chronic stress-induced exhaustion or exhaustion disorder; RCT: randomized controlled study; MMR:
multimodal rehabilitation.
J Rehabil Med 51, 2019