What is the background to this study?
People with inflammatory arthritis (such as rheumatoid arthritis) say that the fatigue they experience as part of their condition has a large impact on what they are able to do. When these people are asked to identify possible research priorities, they rank understanding how to improve fatigue highly. Epidemiological studies also confirm this – fatigue has been shown to be associated with poor quality of life amongst patients with inflammatory arthritis, and can be an important influence on being able to continue to work.
We already know that management focussed on lowering overall disease activity in inflammatory arthritis can improve fatigue, but this is not enough. We also need to identify therapies which are specifically targeted to improve fatigue itself. There is some evidence that a combination of a cognitive behaviour approach (sometimes called “talking therapy”) along with exercise programmes can be effective, as both have been demonstrated to be important for managing pain, which is a symptom that often co-occurs with fatigue. However, very few rheumatology departments currently provide management specifically for fatigue.
What did we want to find out?
We wanted to know whether a cognitive behaviour approach or a personalised exercise programme improved fatigue more than the standard care provided currently. We were interested in two aspects of fatigue: its impact and severity. There were two novel aspects to this study – we studied people with a range of inflammatory arthritis conditions, rather than study just one condition, and the intervention was delivered remotely to make it more accessible for patients to receive it.
What did we do?
Patients with any inflammatory arthritis condition in six participating hospitals in Scotland and England, whose condition was stable, and who reported significant and persistent fatigue were eligible to take part. Participants’ treatment was determined by random allocation. All participants received standard care, and were split into three subgroups – those who received a cognitive behaviour approach, those who received a personalised exercise programme, and those who received no additional intervention. The cognitive behaviour approach and personal exercise programme were delivered remotely over 6 months by members of the rheumatology care team.
What did we find?
A total of 367 people took part and approximately a third were allocated to each type of management. Three quarters of participants were women and their average age was 58 years. Approximately half of participants had rheumatoid arthritis, while connective tissue diseases and axial spondyloarthritis were also common diagnoses amongst participants.
Compared to the group who received standard care only, both the group who got the cognitive behaviour approach and the group who got the personalised exercise programme reported that both the severity and impact of their fatigue had lessened. Moreover, the size of the improvement was significant, and meant we were confident that the observation showed a real effect rather than it having occurred by chance. The beneficial effects were noted while the treatments were underway but also at six and twelve months after they had finished. We also noted a particularly strong beneficial effect of the interventions on work ability.
Why does this matter?
A personalised exercise programmer and a cognitive behaviour approach to management are effective in improving fatigue in patients with inflammatory rheumatic diseases and we believe that they should now be recommended in routine clinical practice. The fact that they were delivered by existing members of rheumatology teams should mean that they are also practicable to implement. Because they can also be delivered remotely this can make them more accessible for patients and more efficient for care teams to deliver.
The study highlights the urgent need for developing a model of care for fibromyalgia. Such a model can ensure that people are diagnosed as soon as possible, have access to evidence-based treatments and receive long-term support. To improve outcomes for all, it is important to be aware about the condition in men and focus on the wider, individual needs of people (such as wanting to continue to work).
Who authored this study?
This study was co-authored by a large team of investigators, including Eva-Maria Bachmair, Neil Basu and Gary J Macfarlane from the Epidemiology Group.
Who funded this work?
This study was funded by Versus Arthritis. The costs of the interventions were met by the NHS boards which took part in the study.
Where can I read more?
To view the full scientific paper, click here.
You can also read the press release which accompanies the publication of the scientific paper here.