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Department
of Veterans Affairs
Veterans Health Administration Office of Quality & Performance |
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MEDICALLY
UNEXPLAINED SYMPTOMS: CHRONIC PAIN AND FATIGUE
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| Citation | Medically
Unexplained Symptoms: Chronic Fatigue and Pain. Washington, DC: VA/DoD
Clinical Practice Guideline Working Group, Veterans Health Administration,
Department of Veterans Affairs , and Health Affairs, Department of
Defense, August 2002. Office of Quality and Performance publication
10Q-CPG/CF&P-01 |
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| Completion Date: | July 2001 | |||||||||||||||||||||||||||||||
| Release Date: | August
2002 |
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| Source(s): | The Medically
Unexplained Symptoms: Chronic Pain and Fatigue Guideline was developed
by and written by clinical experts from the DoD, VHA, academia, a
team of guideline development specialists, and an experienced moderator
who facilitated the multidisciplinary work group. The Work Group included
rheumatologists, internists, nurses, family practitioners, psychologists,
psychiatrists, specialists in infectious disease, epidemiology, immunology,
and occupational health, as well as consultants in the field of guideline
and algorithm development. Policy makers and civilian practitioners
joined this group of experts from the VHA and DoD. |
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| Adaptation: | A
systematic and reproducible search of the literature was conducted.
It focused on the best available evidence to address each key question,
and ensured maximum coverage of studies at the top of the hierarchy
of study types: evidence-based guidelines, meta analyses, and systematic
reviews (Cochrane, EBM, EPC reports). The search continued using well-known
and widely available databases that were appropriate for the clinical
subject. Limits on language (English), time (1997 through June 2000) and type of research (Randomized Controlled Trials (RCT)) were applied. The search included Medline and additional specialty databases, depending on the topic. The search strategy did not cast a wide net. Once definitive clinical studies that provided valid relevant answers to the question were identified, the search stopped. It was extended to studies/reports of lower quality (observational studies) only if there were no high quality studies. |
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| Guideline Status: | This is the current release of the guideline. An update is targeted for 2003. | |||||||||||||||||||||||||||||||
| Developer(s): | Veterans
Health Administration (VHA), Department of Veterans Affairs (VA) -
Federal Government Agency [U.S.] Department of Defense (DoD) - Federal
Government Agency [U.S.] |
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| Funding Source: | United
States Government |
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| Committee: | Medically
Unexplained Symptoms: Chronic Pain and Fatigue Work Group |
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| Group Composition: | List
of Contributors |
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| Disease Condition: | Medically
Unexplained Symptoms: Chronic Pain and Fatigue |
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| Category: | Assessment;
Diagnosis; Treatment: Non Pharmacologic & Pharmacologic; Treatment
of Co-Morbid Conditions; Follow Up. |
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| Intended Users: | Designed
for use by primary care providers. The guideline can also be used
to coordinate, and standardize care and as teaching tools for students
and house staff. |
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| Target Population: | Persons
eligible for care in the VA or DoD healthcare delivery system. |
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| VHA Contact Person(s): |
VHA : DoD: |
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GOALS/OBJECTIVES
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| INTERVENTIONS
AND PRACTICES The
guidelines are meant to assist clinicians in primary care settings
in all aspects of patient care related to medically unexplained
symptoms: chronic pain and fatigue.
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| OUTCOMES
CONSIDERED Goals
for individuals with post-deployment health concerns is to focus
care at the primary care level, both to enhance the continuity of
care and foster the establishment of ongoing therapeutic relationships.
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| MAJOR
RECOMMENDATIONS The
guideline is presented in an algorithmic format and is intended
to provide a systematic approach to the evaluation and management
of patients with medically unexplained symptoms: chronic pain and
fatigue.
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CLINICAL ALGORITHMS |
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| TYPE
OF EVIDENCE The
development process for the Guideline was evidence-based whenever
possible. Evidence-based practice integrates clinical expertise
with the best available clinical evidence derived from systematic
research. Where evidence is ambiguous or conflicting, or scientific
data are lacking, the clinical experience within the multidisciplinary
group guided the development of consensus-based recommendations.
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| DESCRIPTION
OF METHODS TO COLLECT EVIDENCE There
are very limited published guidelines for this topic. Several published
articles focus on a single episode (symptom) of care or a single
situation (e.g., management of low back pain). The guideline was
designed to cover a broad spectrum of symptoms, and thereby provides
an overview of treatment options, as well as discussion about general
clinical approaches to patients with MUS.
This
document will complement other existing evidence-based clinical
based guidelines (CPGs) that address stress-related conditions
such as depression, anxiety, tension headache, and musculoskeletal
disorders. |
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| METHODS
TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE The
literature was critically analyzed with evidence grading. The
rating scale used for this document was based on the evidence
rating used by U.S. Preventative Services Task Force Guide to
Clinical Preventive Services, Second Edition (U.S. PSTF, 1996):
Quality of Evidence Rating Scheme (U.S. PSTF, 1996)
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REVIEW
METHODS
Peer Review
Clinical practice guidelines, which are increasingly being used in health care, are seen by many as a potential solution to inefficiency and inappropriate variations in care. Guidelines should be evidenced-based as well as based upon explicit criteria to ensure consensus regarding their internal validity. However, it must be remembered that the use of guidelines must always be in the context of a health care provider's clinical judgment in the care of a particular patient. For that reason, the guidelines may be viewed as an educational tool analogous to textbooks and journals, but in a more user-friendly tone.
