Treatment expectations influence the outcome of multidisciplinary rehabilitation treatment in patients with CFS

https://doi.org/10.1016/j.jpsychores.2016.02.004Get rights and content

Highlights

  • Expectancy influenced the fatigue and the quality of life after multidisciplinary rehabilitation treatment for patients with CFS.

  • Credibility did not influence the outcomes in multidisciplinary rehabilitation treatment or in cognitive behavioural therapy.

  • Expectancy was significantly influenced by centre of treatment.

  • For future research it is important to study how to increase expectations in order to increase the effectiveness of treatment.

Abstract

Objective

To improve the effectiveness of treatment in patients with chronic fatigue syndrome it is worthwhile studying factors influencing outcomes. The aims of this study were (1) to assess the association of expectancy and credibility on treatment outcomes, and (2) to identify baseline variables associated with treatment expectancy and credibility.

Methods

122 patients were included in a randomized controlled trial of whom 60 received cognitive behavioural therapy (CBT) and 62 multidisciplinary rehabilitation treatment (MRT). Expectancy and credibility were measured with the credibility and expectancy questionnaire. Outcomes of treatment, fatigue, and quality of life (QoL), were measured at baseline and post-treatment. Multiple linear regressions were performed to analyse associations.

Results

In explaining fatigue and the physical component of the QoL, the effect of expectancy was significant for MRT, whereas in CBT no such associations were found. The main effect of expectancy on the mental component of QoL was not significant. For credibility, the overall effect on fatigue and the physical component of QoL was not significant. In explaining the mental component of QoL, the interaction between treatment and credibility was significant. However, the effects within each group were not significant.

In the regression model with expectancy as dependent variable, only treatment centre appeared significantly associated. In explaining credibility, treatment centre, treatment allocation and depression contributed significantly.

Conclusions

For clinical practice it seems important to check the expectations of the patient, since expectations influence the outcome after MRT.

Introduction

Chronic Fatigue Syndrome (CFS) is a condition characterised by persistent fatigue which often leads to a substantial limitation in function, activities and participation [1]. Cognitive behavioural therapy (CBT), a monodisciplinary treatment with a psychotherapeutic approach focusing on the perpetuating factors (cognitions and behaviour) of the CFS, has shown to be an effective, evidence based treatment for patients with CFS [2]. Recently, a new, innovative multidisciplinary rehabilitation treatment (MRT) has been developed and compared with CBT in a randomized controlled trial. MRT is a multidisciplinary treatment in which different interventions (for example CBT, gradual increasing activity and body awareness) can be combined to treat the patient depending on the modifiable components and personal aims of the patient [3]. Results of the randomized trial comparing MRT and CBT showed that immediately post-treatment (26 weeks after start of treatment) both treatments showed significant reduction of fatigue and increase of quality of life, however the between group differences were not significant. At 52 weeks follow-up, MRT was more effective in reducing fatigue and equally effective in improving quality of life [4]. To understand the working mechanisms of these interventions and to find out how to increase their effectiveness, it is important to study factors that influence the outcome of treatment. A factor that might influence important treatment outcomes such as fatigue and quality of life, is the expectancy of the patient. Expectations or predicted expectations are what the patient believes will occur after following treatment [5]. Heins et al. (2013) [6] were the first to investigate whether outcome expectations contribute to the reduction in fatigue during CBT for patients with CFS. Twenty-five percent of the variance in post-treatment fatigue was jointly explained by outcome expectations and agreement between therapist and patient on the content of treatment and how to achieve the patient's goals [6]. It is postulated that these factors exert their positive effect through a change in fatigue perpetuating factors. In patients with chronic low back pain, similar results were found regarding the influence of expectations on the outcome. Expectations explained 1–8% of the variance in the equation of four different outcome variables after CBT, namely: motor behaviour, pain coping and control, negative effect and QoL [7]. Whether expectations influence the outcome after MRT in patients with CFS needs to be evaluated.

Another factor, which might influence treatment outcomes is credibility. Credibility is how believable, convincing and logical the treatment seems to the patient. In patients with chronic low back pain, credibility was a significant predictor for global perceived effect in patients following a rehabilitation treatment, which combined active physical therapy with CBT [8]. In patients with CFS, the association between credibility and outcome of treatment has never been studied before. If expectancy and/or credibility influence the treatment effects, interventions could be designed to increase these concepts, which might increase effectiveness of the treatment. To influence the expectancy and/or credibility it is worthwhile studying factors that are associated with these concepts. Age, internal control over symptoms, self-efficacy, depression, duration of complaints and severity of symptoms have been proposed as factors influencing expectations before treatment [8], [9], [10]. Whether these factors influence the expectancy or credibility in patients with CFS referred for treatment needs to be studied.

The purpose of this study was two-fold: first, to assess the association of patients' treatment expectancy and credibility on the outcome of treatment (change in fatigue severity and quality of life), and whether these associations are different for MRT and CBT respectively. Second, to study the effect of age, treatment centre, type of treatment allocation, self-efficacy, symptoms of depression and duration of complaints at baseline on treatment expectancy and credibility.

Section snippets

Methods

This study is part of the FatiGo trial, a multi-centre, pragmatic two-arm randomized controlled trial (ISRCTN77567702) of which the methods and results are described previously [3], [4]. The main aim of the FatiGo trial was to analyse the difference in treatment effect between MRT and CBT for patients with CFS.

Baseline characteristics

Overall, 364 patients were referred to the participating rehabilitation centres with a major complaint of fatigue. The most common reasons for exclusion were unwillingness to participate (54 patients), not meeting the CDC-94 criteria (34 patients), and other diagnosis explaining the presence of fatigue or fatigue was not the primary complaint (34 patients). Finally, 60 patients completed the baseline assessment and were randomized to CBT and 62 to MRT. In the MRT group 57 (95%) patients

Discussion

Patients with higher expectancy at the beginning of treatment who receive MRT improve more in terms of fatigue and physical QoL than those that receive CBT. Expectations did not influence treatment response on the outcome of mental QoL.

The mechanism by which patients with higher expectations respond better to MRT than CBT is unknown and was not investigated in this study. It is possible that the rationale of MRT is more in line with what patients think will help them in achieving a positive

Competing interest statement

The authors have no competing interests to report.

Acknowledgements

We thank all the participants who took part in the FatiGo trial and all the professionals, support staff and management of the participating rehabilitation centres. The FatiGo trial was funded by the Netherlands Organisation for Health Research and Development (ZonMw) grant number 56100007, Rehabilitation Fund (the Netherlands) 2007176/sw, Foundation Nutsohra, grant number 0801-06 and the ME/CVS Stichting Nederland. The funders had no role in study design, data collection and analysis, decision

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