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psychosocial elements that address the chronic nature of reduced functioning and the factors that reinforce it. Evidence-based criteria for these programs have yet to be applied.

Usually, psychosocial and medical care is combined with a highly structured and generally supervised physical activation or exercise plan. These programs view disability as a behavior amenable to modification regardless of its biomedical etiology. Engel and colleagues (1998) have described such a program for Gulf War veterans with MUPS. The intervention, called the Specialized Care Program (SCP), is a three-week intensive outpatient program modeled directly after the University of Washington's Multidisciplinary Pain Center (Loeser and Egan 1989). Preliminary data suggest that treated patients make mild-to-moderate gains in multiple domains, including functional status and health-related quality of life, psychosocial distress, physical symptoms, and physical health concerns (Engel et al. 2000).

Bonica at the University of Washington was among the first to apply a multidisciplinary approach to the treatment of chronic pain patients in the late 1950s (Loeser and Egan 1989). Since then, the approach has gained relatively wide acceptance for work-impaired chronic pain patients, especially those with back pain and fibromyalgia. A recent meta-analysis of 65 controlled studies of multidisciplinary interventions for chronic pain patients noted improvements in return-to-work rates, pain, mood, and health care utilization (Flor-H. et al. 1992). The authors were cautious in their conclusions, noting that the level of methodological rigor for most studies was low.

Recommendations

Given the lack of efficacy and effectiveness studies focused on treatments for patients with MUPS, the committee is unable to recommend specific treatments. However, research conducted to date and described above has demonstrated that there are approaches to treating MUPS that show promise and should be further researched.

Therefore, for Gulf War veterans with unexplained symptoms, the committee recommends that:

  • for the purposes of treatment efficacy and effectiveness studies, explicit criteria for medically unexplained physical symptoms (apart from chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) be developed and used uniformly in treatment studies and

  • treatment studies of antidepressant medications, cognitive-behavioral therapy, and a stepped intensity-of-care program be implemented for MUPS.



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