The role of non-pharmacological interventions in the management of rheumatoid-arthritis-related fatigue

Non-pharmacological interventions may be beneficial in the management of rheumatoid arthritis related fatigue. A narrative review was undertaken, with a focus upon research published in the past 6 years. Seven studies were identified, four focusing upon physical activity, two on psychosocial interventions and one that investigated aromatherapy and reflexology. Findings supported previous evidence that physical activity and psychosocial interventions have potential to produce small to moderate reductions in fatigue related to rheumatoid arthritis. Reflexology and aromatherapy interventions also appeared promising. Limitations to the evidence included lack of consistency in fatigue measurement, and minimal data on long-term outcomes and cost effectiveness. The wide range of physical activity interventions prevent specific recommendations. For psychosocial interventions the strongest evidence is for group-based cognitive behavioural approaches. There was lack of consideration given to fatigue mechanisms and intervention design. Due to the complexity of fatigue, future research exploring personalized approaches is warranted

Training and delivery of a novel fatigue intervention: a qualitative study of rheumatology health-care professionals’ experiences

ObjectivesSuccessful, non-pharmacological research interventions are challenging to implement in clinical practice. The aim of the study was to understand the experiences of rheumatology nurses and occupational therapists (tutors) delivering a novel fatigue intervention in a trial setting, and their views on requirements for clinical implementation. After training, tutors delivered courses of a manualized group cognitive-behavioural intervention to patients with RA in a seven-centre randomized controlled trial [Reducing Arthritis Fatigue by clinical Teams using cognitive-behavioural approaches (RAFT)], which demonstrated reduced fatigue impact at 2 years.MethodsFourteen tutors participated in interviews, and eight tutors also participated in a focus group. Data were audio-recorded, transcribed and analysed using inductive thematic analysis.ResultsThe following five main themes were identified: ‘exciting but daunting’ reflected the mixture of excitement and anxiety in intervention training and delivery; ‘skills practice and demonstrations were essential’ captured the value of learning and practising together, even though the process could be uncomfortable; ‘an individual approach to a standardized intervention’ showed how tutors negotiated adherence to the manual with delivery using their own words; ‘becoming a better practitioner’ described how participation enhanced tutors’ wider clinical practice; and ‘pragmatic and flexible’ highlighted practical adaptations to facilitate training and intervention roll out.ConclusionThese insights inform strategies for clinical implementation of an evidence-based intervention that addresses a patient priority, with implications for other successful research interventions. Tutors believed that the skills acquired during RAFT enhanced their wider clinical practice, which highlights the benefits of upskilling members of clinical teams to provide self-management support to patients

Patient perspectives of managing fatigue in ankylosing spondylitis, and views on potential interventions: a qualitative study

<p>Background: Fatigue is a major component of living with ankylosing spondylitis (AS), though it has been largely over-looked, and currently there are no specific agreed management strategies.</p> <p>Methods: This qualitative exploratory study involved participants who are members of an existing population-based ankylosing spondylitis (PAS) cohort. Participants residing in South West Wales were invited to participate in a focus group to discuss; (1) effects of fatigue, (2) self-management strategies and (3) potential future interventions. The focus groups were audio-recorded and the transcripts were analysed using thematic analysis.</p> <p>Results: Participants consisted of 3 males/4 females (group 1) and 4 males/3 females (group 2), aged between 35 and 73 years (mean age 53 years). Three main themes were identified: (1) The effects of fatigue were multi-dimensional with participants expressing feelings of being ‘drained’ (physical), ‘upset’ (emotional) and experiencing ‘low-mood’ (psychological); (2) The most commonly reported self-management strategy for fatigue was a balanced combination of activity (exercise) and rest. Medication was reluctantly taken due to side-effects and worries over dependency; (3) Participants expressed a preference for psychological therapies rather than pharmacological for managing fatigue. Information on Mindfulness-Based Stress Reduction (MBSR) was received with interest, with recommendations for delivery in a group format with the option of distance-based delivery for people who were not able to attend a group course.</p> <p>Conclusions: Patients frequently try and manage their fatigue without any formal guidance or support. Our research indicates there is a need for future research to focus on psychological interventions to address the multi-faceted aspects of fatigue in AS.</p&gt

Unstimulated cortisol secretory activity in everyday life and its relationship with fatigue and chronic fatigue syndrome : a systematic review and subset meta-analysis

Copyright © 2013 The Authors. Published by Elsevier Ltd.. All rights reserved.Peer reviewedPublisher PD

A multi-centre study of interactional style in nurse specialist- and physician-led Rheumatology clinics in the UK

Background: Nurse-led care is well established in Rheumatology in the UK and provides follow-up care to people with inflammatory arthritis including treatment, monitoring, patient education and psychosocial support. Aim: The aim of this study is to compare and contrast interactional style with patients in physician-led and nurse-led Rheumatology clinics. Design: A multi-centre mixed methods approach was adopted. Settings: Nine UK Rheumatology out-patient clinics were observed and audio-recorded May 2009-April 2010. Participants: Eighteen practitioners agreed to participate in clinic audio-recordings, researcher observations, and note-taking. Of 9 nurse specialists, 8 were female and 5 of 9 physicians were female. Eight practitioners in each group took part in audio-recorded post-clinic interviews. All patients on the clinic list for those practitioners were invited to participate and 107 were consented and observed. In the nurse specialist cohort 46% were female 71% had a diagnosis of Rheumatoid Arthritis (RA). The physician cohort comprised 31% female 40% with RA and 16% unconfirmed diagnosis. Nineteen (18%) of the patients observed were approached for an audio-recorded telephone interview and 15 participated (4 male, 11 female). Methods: Forty-four nurse specialist and 63 physician consultations with patients were recorded. Roter's Interactional Analysis System (RIAS) was used to code this data. Thirty-one semi-structured interviews were conducted (16 practitioner, 15 patients) within 24 h of observed consultations and were analyzed using thematic analysis. Results: RIAS results illuminated differences between practitioners that can be classified as 'socio-emotional' versus 'task-focussed'. Specifically, nurse specialists and their patients engaged significantly more in the socio-emotional activity of 'building a relationship'. Across practitioners, the greatest proportion of 'patient initiations' were in 'giving medical information' and reflected what patients wanted the practitioner to know rather than giving insight into what patients wanted to know from practitioners. Interviews revealed that continuity of practitioner was highly valued by patients as offering the benefits of an established relationship and of emotional support beyond that of the clinical encounter. This fostered familiarity not only with their particular medical history, but also their individual personal circumstances, and this encouraged patient participation. In contrast, practitioners (mis)perceived waiting times to have a greater impact on patient satisfaction. However, practitioner interviews also revealed that clinic structure is often outside of the practitioner control and can undermine the possibility of maintaining patient-practitioner continuity. Conclusions: This research enhances understanding of nurse specialist consultation styles in Rheumatology, specifically the value of their socio-emotional communication skills to enhance patient participation

Relations between self-reported daily-life fatigue, hearing status and pupil dilation during a speech perception in noise task

Objective: people with hearing impairment are likely to experience higher levels of fatigue due to effortful listening in daily communication. This hearing-related fatigue might not only constrain their work performance, but also result in withdrawal from major social roles. Therefore, it is important to understand the relationships between fatigue, listening effort, and hearing impairment, by examining the evidence from both subjective and objective measurements. The aim of the present study was to investigate these relationships by assessing subjectively measured daily-life fatigue (self-report questionnaires) and objectively measured listening effort (pupillometry) in both normally-hearing and hearing-impaired participants. Design: twenty-seven normally-hearing and 19 age-matched participants with hearing impairment were included in this study. Two self-report fatigue questionnaires: Need For Recovery and Checklist Individual Strength were given to the participants before the test session to evaluate the subjectively measured daily fatigue. Participants were asked to perform a speech reception threshold test with single-talker masker targeting a 50% correct response criterion. The pupil diameter was recorded during the speech processing, and we used peak pupil dilation as the main outcome measure of the pupillometry. Results: No correlation was found between subjectively measured fatigue and hearing acuity, nor was a group difference found between the normally-hearing and the hearing-impaired participants on the fatigue scores. A significant negative correlation was found between self-reported fatigue and peak pupil dilation. A similar correlation was also found between Speech Intelligibility Index required for 50% correct and peak pupil dilation. Multiple regression analysis showed that factors representing 'hearing acuity' and 'self-reported fatigue' had equal and independent associations with the peak pupil dilation during the speech in noise test. Less fatigue and better hearing acuity were associated with a larger pupil dilation. Conclusions: To the best of our knowledge, this is the first study to investigate the relationship between a subjective measure of daily-life fatigue and an objective measure of pupil dilation, as an indicator of listening effort. These findings help to provide an empirical link between pupil responses, as observed in the laboratory, and daily life fatigue

Reliability and sensitivity to change of the bristol rheumatoid arthritis fatigue scales

Objective. To examine the reliability (stability) and sensitivity of the Bristol Rheumatoid Arthritis Fatigue scales (BRAFs) and patient-reported outcome measures (PROMs) developed to capture the fatigue experience. The Multi-Dimensional Questionnaire (BRAF-MDQ) has a global score and four subscales (Physical Fatigue, Living with Fatigue, Cognitive Fatigue and Emotional Fatigue), while three numerical rating scales (BRAF-NRS) measure fatigue Severity, Effect and Coping. Methods. RA patients completed the BRAFs plus comparator PROMs. Reliability (study 1): 50 patients completed questionnaires twice. A same-day test-retest interval (minimum 60 min) ensured both time points related to the same 7 days, minimizing the capture of fatigue fluctuations. Reliability (study 2): 50 patients completed the same procedure with a re-worded BRAF-NRS Coping. Sensitivity to change (study 3): 42 patients being given clinically a single high dose of i.m. glucocorticoids completed questionnaires at weeks 0 and 2.Results. The BRAF-MDQ, its subscales and the BRAF-NRS showed very strong reliability (r = 0.82-0.95). BRAF-NRS Coping had lower moderate reliability in both wording formats (r = 0.62, 0.60). The BRAF-MDQ, its subscales and the BRAF-NRS Severity and Effect were sensitive to change, with effect sizes (ESs) of 0.33-0.56. As hypothesized, the BRF-NRS Coping was not responsive to the pharmaceutical intervention (ES 0.05). Preliminary exploration suggests a minimum clinically important difference of 17.5% for improvement and 6.1% for fatigue worsening. Conclusion. The BRAF scales show good reliability and sensitivity to change. The lack of BRAF-NRS Coping responsiveness to medication supports the theory that coping with fatigue is a concept distinct from severity and effect that is worth measuring separately. © The Author 2013. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved

Protocol for a randomised controlled trial for Reducing Arthritis Fatigue by clinical Teams (RAFT) using cognitive-behavioural approaches

Introduction: Rheumatoid arthritis (RA) fatigue is distressing, leading to unmanageable physical and cognitive exhaustion impacting on health, leisure and work. Group cognitive-behavioural (CB) therapy delivered by a clinical psychologist demonstrated large improvements in fatigue impact. However, few rheumatology teams include a clinical psychologist, therefore, this study aims to examine whether conventional rheumatology teams can reproduce similar results, potentially widening intervention availability. Methods and analysis: This is a multicentre, randomised, controlled trial of a group CB intervention for RA fatigue self-management, delivered by local rheumatology clinical teams. 7 centres will each recruit 4 consecutive cohorts of 10-16 patients with RA (fatigue severity ≥6/10). After consenting, patients will have baseline assessments, then usual care (fatigue self-management booklet, discussed for 5-6 min), then be randomised into control (no action) or intervention arms. The intervention, Reducing Arthritis Fatigue by clinical Teams (RAFT) will be cofacilitated by two local rheumatology clinicians (eg, nurse/occupational therapist), who will have had brief training in CB approaches, a RAFT manual and materials, and delivered an observed practice course. Groups of 5-8 patients will attend 6×2 h sessions (weeks 1-6) and a 1 hr consolidation session (week 14) addressing different self-management topics and behaviours. The primary outcome is fatigue impact (26 weeks); secondary outcomes are fatigue severity, coping and multidimensional impact, quality of life, clinical and mood status (to week 104). Statistical and health economic analyses will follow a predetermined plan to establish whether the intervention is clinically and costeffective. Effects of teaching CB skills to clinicians will be evaluated qualitatively. Ethics and dissemination: Approval was given by an NHS Research Ethics Committee, and participants will provide written informed consent. The copyrighted RAFT package will be freely available. Findings will be submitted to the National Institute for Health and Care Excellence, Clinical Commissioning Groups and all UK rheumatology departments