Key message: There is some evidence that physical activity and talking treatments can help people with rheumatoid arthritis manage fatigue. We don’t have enough evidence to say which elements of these types of interventions are most effective, nor whether other non-drug approaches are also helpful.
Rheumatoid arthritis (RA) is an autoimmune disease that causes inflammation of the joints. It’s the second most common type of arthritis in the UK population. Key symptoms are painful, swollen joints, but fatigue (extreme mental and/or physical tiredness) is also a problem for many people who have RA. There’s currently no cure for RA and no accepted evidence-based guidelines on how best to manage this condition. Non-pharmacological interventions, that’s alternatives to prescribed drugs such as exercise and psychotherapies or ‘talking treatments’, have been found to help people with a range of long-term conditions manage fatigue and now a new review from the Cochrane Musculoskeletal Group has looked at whether this is so for adults with RA.
Twenty-four randomised controlled trials (RCTs) with almost 3000 people were included, investigating a range of therapies. Six explored physical activity (including strength training, yoga and exercise in a pool), 13 investigated psychosocial interventions and the other five looked at a herbal medicine, Mediterranean diet, omega-3 fatty acid supplementation, reflexology and giving health tracker information. The primary outcomes of interest for this review were self-reported fatigue scores, using validated measures, and adverse events – harms associated with the interventions.
What did they find?
- Physical activity had a small beneficial effect
- Psychosocial interventions had a small beneficial effect
- No side effects were reported and only 3 RCTs reported adverse events, which were not serious, with no apparent difference between intervention and control groups
- For the other interventions, there was either no difference between intervention and control groups or findings were not reported
How good was the evidence?
The quality of the evidence ranged from low to moderate, with the evidence for physical activity graded as moderate quality and for psychosocial interventions low quality. Data were combined where possible. Poor reporting in most of the studies hampered the reviewers in determining whether quality criteria had been met and made it unclear whether the absence of adverse events in 21 RCTs was due to poor reporting or if there were genuinely none. Only one RCT was specifically powered to detect changes in fatigue though the reviewers say it’s likely that others were big enough to enable this too. A range of fatigue measures were used and the reviewers urge that future RA research uses standardised fatigue measures.
Researchers: here’s a large hole in the evidence!
This review has great value, as does any good quality systematic review, in bringing together the available evidence and showing up both what is known and what the gaps are. There is a huge gap here, actually. The main purpose of the interventions in most of these studies was not to reduce fatigue and the interventions were not designed with this aim in mind. This is surely an important gap. One consequence of fatigue not being the main focus in these studies is that the effectiveness of the interventions may have been underestimated. Fatigue may not have been a problem for many of the people taking part, which rather reduces the potential for improvement! So it looks like we need research into interventions which have reducing fatigue as their aim and are tried out by people with RA for whom fatigue is a problem.
For now, this doesn’t move things on very much for people living with this condition. Of course the reality is that people try things out and see what works for them, but the funders and policy-makers need hard evidence. Let’s hope some of the gaps and shortcomings flagged up in this review will be addressed.
Links:
Cramp F, Hewlett S, Almeida C, Kirwan JR, Choy EHS, Chalder T, Pollock J, Christensen R. Non-pharmacological interventions for fatigue in rheumatoid arthritis. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD008322. DOI: 10.1002/14651858.CD008322.pub2.
Cochrane summary http://summaries.cochrane.org/CD008322/non-pharmacological-interventions-for-the-management-of-patient-reported-fatigue-in-rheumatoid-arthritis
Evidently Cochrane 
A common problem with RCTs for ‘fatigue’ is that they assume fatigue questionnaires can reliably measure changes in ‘fatigue’ resulting from an intervention. There is no good evidence that fatigue questionnaires accurately measure the aspects of fatigue which patients find most troubling. Indeed, something like the Chalder Fatigue Scale seems to primarily measure expectations of fatigue. An intervention which encourages patients to see ‘fatigue’ as normal will lead to improvements in scores, without having done anything to improve a patients ability to actually do more stuff.
There is a real danger that exercise interventions for fatigue are really just signals to patients that medical authorities believe that they should do more, that their fatigue is their problem and a reflection of their failure to do more, and that medical authorities have put their time and effort into trying to help with symptoms, and so this leads to patients reporting lower levels of fatigue.
More effort should be put into measuring the amount that patients are able to actually do, as I think that most patients are troubled by fatigue because it means that they can do less, rather than because it means they have worse fatigue questionnaire scores.
Thank you for posting this thoughtful and thought-provoking response. You make some really good points and I hope others will read this and comment. Always so important to keep coming back to what actually matters to patients. I think this review highlights that people with RA and fatigue are poorly served by the research to date; very disappointing that fatigue wasn’t the focus of these studies nor of the interventions they were exploring.
Sarah
Thanks. I certainly agree that it is important to focus on outcomes that are actually important to patients.
I’m not sure that focussing research on ‘fatigue’, at a time when a generation of ‘fatigue experts’ have conflated the questionnaires they developed with the symptom patients complain of would necessarily have helped much. This recent article on post-cancer fatigue shows how effective CBT is for altering questionnaire scores, even though it has no impact on patient’s objectively measured levels of activity: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3360858/
In this unblinded trial with only waiting list control they reported: “Gradual increase of physical activity is an important part of the treatment protocol”. It’s interesting to read their attempts to explain their results, without acknowledging the danger of response bias or the possibility that their questionnaires are not a reliable measure of fatigue. The only mention of possible bias is when they consider the possibility that they had somehow (?) failed to measure the activity of those patients who were able to do significantly more after treatment.
They conclude: “However, even without an increase in physical activity, CBT was highly effective in reducing post-cancer fatigue.” I’m not so sure that patients would consider a treatment for fatigue to be highly effective if it did not allow them to increase their activity levels.
The whole area of fatigue research would benefit from a serious critical analysis from Cochrane, or another outside group without ties to current fatigue research, looking at what we really know, what we have good measures of, and what needs to be done for research to more effectively account for response bias, confounding factors, etc. It seems to me that we know far less than many researchers in this area try to claim.
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