Non-pharmacological interventions for the management of patient-reported fatigue in rheumatoid arthritis

This summary of a Cochrane review presents what we know from research that has investigated the effects of non-pharmacological treatments for fatigue in people with rheumatoid arthritis

After searching for all relevant studies, 24 were identified for inclusion in the review with a total of 2882 people. The findings are summarised as follows.

- Physical activity has a small benefit for managing fatigue in people with rheumatoid arthritis.

- Psychosocial therapy has a small benefit for managing fatigue in people with rheumatoid arthritis.

- No other interventions showed a difference in managing fatigue in people with rheumatoid arthritis. This may have happened by chance.

The information available regarding side effects and complications of the interventions was not very informative although it is unlikely that any side effects would cause a serious problem.

What is rheumatoid arthritis and what are non-pharmacological interventions?

When you have rheumatoid arthritis, your immune system, which normally fights infection, attacks the lining of your joints. This makes your joints swollen, stiff and painful. The small joints of your hands and feet are usually affected first. There is no cure for rheumatoid arthritis at present, so the treatments aim to relieve pain and stiffness and improve your ability to move. Fatigue is also a problem for people with rheumatoid arthritis.

Non-pharmacological interventions include any treatment that is not a registered drug, such as physical activity and psychosocial interventions (talking therapies). A talking therapy could include meeting with a counsellor, alone or in a group. It might involve writing about your thoughts and feelings in a journal and talking about it, problem-solving, setting goals and getting feedback about self-management. It might also include sessions on pain management and relaxation; and coping with depression. There are other non-pharmacological treatments that have been tested for their effect upon fatigue in people with rheumatoid arthritis. These include different dietary supplements and studies on the effects of giving people access to information about their own disease status. These treatments if supported by the overall body of evidence would allow the patient to have some personal control of their fatigue.

What happens to people with rheumatoid arthritis who use non-pharmacological interventions?

- At the end of the intervention, people receiving a control had a mean score of 63 on a scale of 0 to 100 with a lower score meaning less fatigue.

- People who used physical activity rated their fatigue as 54 on a scale of 0 to 100 at the end of the intervention, that is 9 points lower than the people who received the control.

- People who participated in a psychosocial intervention rated their fatigue as 57 on a scale of 0 to 100 at the end of the intervention, that is 6 points lower than the people who received the control.

Authors' conclusions: 

This review provides some evidence that physical activity and psychosocial interventions provide benefit in relation to self-reported fatigue in adults with rheumatoid arthritis. There is currently insufficient evidence of the effectiveness of other non-pharmacological interventions.

Read the full abstract...
Background: 

Fatigue is a common and potentially distressing symptom for people with rheumatoid arthritis with no accepted evidence based management guidelines. Non-pharmacological interventions, such as physical activity and psychosocial interventions, have been shown to help people with a range of other long-term conditions to manage subjective fatigue.

Objectives: 

To evaluate the benefit and harm of non-pharmacological interventions for the management of fatigue in people with rheumatoid arthritis. This included any intervention that was not classified as pharmacological in accordance with European Union (EU) Directive 2001/83/EEC.

Search strategy: 

The following electronic databases were searched up to October 2012, Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; AMED; CINAHL; PsycINFO; Social Science Citation Index; Web of Science; Dissertation Abstracts International; Current Controlled Trials Register; The National Research Register Archive; The UKCRN Portfolio Database. In addition, reference lists of articles identified for inclusion were checked for additional studies and key authors were contacted.

Selection criteria: 

Randomised controlled trials were included if they evaluated a non-pharmacological intervention in people with rheumatoid arthritis with self-reported fatigue as an outcome measure.

Data collection and analysis: 

Two review authors selected relevant trials, assessed risk of bias and extracted data. Where appropriate, data were pooled using meta-analysis with a random-effects model.

Main results: 

Twenty-four studies met the inclusion criteria, with a total of 2882 participants with rheumatoid arthritis. Included studies investigated physical activity interventions (n = 6 studies; 388 participants), psychosocial interventions (n = 13 studies; 1579 participants), herbal medicine (n = 1 study; 58 participants), omega-3 fatty acid supplementation (n = 1 study; 81 participants), Mediterranean diet (n = 1 study; 51 participants), reflexology (n = 1 study; 11 participants) and the provision of Health Tracker information (n = 1 study; 714 participants). Physical activity was statistically significantly more effective than the control at the end of the intervention period (standardized mean difference (SMD) -0.36, 95% confidence interval (CI) -0.62 to -0.10; back translated to mean difference of 14.4 points lower, 95% CI -4.0 to -24.8 on a 100 point scale where a lower score means less fatigue; number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 4 to 26) demonstrating a small beneficial effect upon fatigue. Psychosocial intervention was statistically significantly more effective than the control at the end of the intervention period (SMD -0.24, 95% CI -0.40 to -0.07; back translated to mean difference of 9.6 points lower, 95% CI -2.8 to -16.0 on a 100 point scale, lower score means less fatigue; NNTB 10, 95% CI 6 to 33) demonstrating a small beneficial effect upon fatigue. For the remaining interventions meta-analysis was not possible and there was either no statistically significant difference between trial arms or findings were not reported. Only three studies reported any adverse events and none of these were serious, however, it is possible that the low incidence was in part due to poor reporting. The quality of the evidence ranged from moderate quality for physical activity interventions and Mediterranean diet to low quality for psychosocial interventions and all other interventions.

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