Role of rehabilitation in chronic stress-induced exhaustion disorder
ceived stress in healthy adults (54). We found 2 RCTs
that evaluate qigong in patients with SED. In one study
qigong was performed twice a week during 12 weeks
in combination with TAU (n = 82). The control group
received TAU. The outcome was psychological variab-
les and physical measurements. Both groups improved
significantly, but there was no difference between the
groups (55). In the other RCT, patients with burnout
were randomized to qigong only or in combination with
cognitively oriented behavioural rehabilitation (CBR)
(n = 136). Both groups significantly improved in terms
of psychological variables and sick leave rates at the
12-month follow-up. There was no difference between
the groups (56). At a 3-year follow-up there was still
no difference between the groups in terms of rates of
sick leave; however, the patients who undertook the
CBR seemed to have implemented cognitive tools
learned from the CBR and also reported lower levels
of burnout (57).
In summary, research does not support that qigong
improve psychological variables and rates of sick leave
compared with TAU.
Garden/nature. Forest environments seem to reduce
stress and can be viewed as therapeutic landscapes
in healthy people (58, 59). A review by Keniger et al.
summarizes that there is evidence that natural settings
have many beneficial effects, including physical health,
psychological well-being and cognitive benefits, at
least in healthy people (60).
A Swedish study examined in an RCT the qualitative
experiences of a forest-based rehabilitation programme
in patients (n = 19) on long-term sick leave because of
SED. The intervention was offered during 3 months be-
fore a cognitively oriented behavioural rehabilitation.
Mental peace and conditions for starting the recovery
process were the main positive effects reported. The
effect was transient and, according to the authors,
visiting a forest is a complementary treatment and
should probably be combined with CBT to improve
recovery by increasing reflection and facilitating the
coping process (61). When a forest rehabilitation group
(n = 35) was compared with a waiting list group (n = 43)
in an RCT, the recovery from SED and psychological
measures did not differ between the groups, either after
the 3-month forest rehabilitation or after the subsequent
1-year of MMR including CBI for all participants in
both groups (62).
A retrospective cohort study of the effect of a nature-
assisted rehabilitation programme in a sick-listed group
of patients with reactions to severe stress and/or mild
to moderate depression found reduced healthcare
consumption, but no effect on RTW compared with a
matched reference group from the general population
(63). In a longitudinal study from Pálsdóttir et al. (64)
337
with a mixed-method approach, symptoms of severe
stress and RTW were examined in 21 patients with
stress-related mental illness after a 12-week nature-
based rehabilitation programme. RTW was measured
after 1 year and symptoms of stress after the interven-
tion. The results showed significant changes in symp-
toms of stress and self-reported RTW (64). However,
since the study did not include a control group, it is
unclear whether the results were due to time or to the
intervention.
In summary, in the few studies retrieved, nature-
based rehabilitation may reduce symptoms of stress,
but there is only self-reported or no evidence for
reduced RTW.
Cognitive training
One RCT on SED and cognitive training was found.
Patients with SED (n = 27) treated in an MMR pro-
gramme with additional process-based cognitive train-
ing were compared with patients treated with MMR
without additional process-based cognitive training.
The outcome was an extensive cognitive test battery.
The patients in the group with additional process-based
cognitive training reported significantly improved
cognitive function and lower levels of burnout (65).
In summary, one RCT supports that cognitive
training improves cognitive function and decreases
symptoms of burnout in patients with SED.
Treatment of sleep disturbances
Patients with SED experience mental and physical
exhaustion. One reason for these symptoms might be
the sleep disruptions that many patients with chronic
stress-induced exhaustion experience. Sleep disrup-
tions predict SED, contribute to the onset of SED
and may maintain the state (9, 66). Stress might also
contribute to cognitive dysfunction by affecting sleep-
related neuronal plasticity processes (67). A systematic
review from Kärkkäinen et al. (68) exploring factors
associated with RTW in patients with burnout found
a positive association between unimpaired sleep and
RTW.
Typical sleep disruptions that patients with SED
experience are arousals, sleep fragmentation, more
wake time and lower sleep efficiency (69). In a study
investigating the role of sleep physiology, patients
(n = 23) with a burnout-related diagnosis and on more
than 3 months’ sick leave were subjected to polysom-
nographic recordings at baseline and after 6−12 months
of MMR. Patients improved significantly, with fewer
arousals, less sleep fragmentation, less sleep latency
and increased sleep efficiency; however, they never
reached the levels of healthy controls (n = 16). The
J Rehabil Med 51, 2019