Challenging management of patients with functional symptoms for the physical and rehabilitation medicine specialist: What can we learn from literature?

Abstract

Functional symptoms (FS) are symptoms for which no “organic” cause is found. They could concern a significant part of physical and rehabilitation medicine (PRM) patients, since they represent 25 to 50% of all symptoms in primary care. Their management is challenging, often generating negative emotions during medical encounter. Their prognosis usually appears to be unfavorable. Is FS treatment worthwhile if the results are so uncertain? How could we be more efficient? Is the referral to a psychiatrist imperative? This literature review attempts to answer to those questions applied to PRM. The MeSH terms «Somatoform Disorders», «Physical and Rehabilitation Medicine», «Prognosis», «Treatment» and «Health Care Costs» were used on PubMed database to find the most recent and relevant articles enlightening the FS management. FS create incongruence between patients’ symptoms and doctors’ explanatory models for biomedical diseases. The explanation is however the key aspect of the diagnostic process. Psychosocial issues relating to the symptoms can bring elements to find congruence between patients’ and practitioners’ views. FS management includes physical rehabilitation that should integrate a cognitive behavioral therapy. Antidepressants are to be considered. Referral to a psychiatrist is a second line treatment. Mindfulness-based cognitive therapy is an arising and promising method for FS. Intensive multidisciplinary treatment is adapted for chronic and severe FD. FS are associated with relevant direct and indirect costs strongly depending on symptoms severity. This burden justifies the allocation of sufficient resources. FS management is based on a positive doctor–patient relationship made of trust, partnership and support. Cognitive behavioral therapy is actually an essential ongoing process that PRM specialists should conduct. It helps patients to think about and to respond to their symptoms differently. Teaching interviewing and information-giving skills to medical students could improve their ability to deal with illnesses beyond the only goal of treating diseases. In conclusion, FS management suggests a conceptual move from curing to caring and coping. Cognitive behavioral therapy is not restricted to psychiatrists. Studies about patients with functional disability in the field of PRM are lacking and no specific recommendations are yet available.