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 A trial in which a group (the ‘intervention group’) is given a intervention being tested (for example a drug, surgery, or exercise) is compared with a group which does not receive the intervention (the ‘control group’). (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 are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise). In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary 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 A treatment, procedure or programme of health care that has the potential to change the course of events of a healthcare condition. Examples include a drug, surgery, exercise or counselling. and control groups
- For the other interventions, there was either no difference between A treatment, procedure or programme of health care that has the potential to change the course of events of a healthcare condition. Examples include a drug, surgery, exercise or counselling. and control groups or findings were not reported
How good was the evidence?
The The certainty (or quality) of evidence is the extent to which we can be confident that what the research tells us about a particular treatment effect is likely to be accurate. Concerns about factors such as bias can reduce the certainty of the evidence. Evidence may be of high certainty; moderate certainty; low certainty or very-low certainty. Cochrane has adopted the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) for assessing certainty (or quality) of evidence. Find out more here: https://training.cochrane.org/grade-approach ranged from low to moderate, with the evidence for physical activity graded as moderate quality and for psychosocial interventions low quality. Data is the information collected through research. 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 The power of a trial is the chance that it will correctly detect a real effect of an intervention being tested (for example a drug, surgery, or exercise). Studies with more participants will have greater power. 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 In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research., 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 The ability of an intervention (for example a drug, surgery, or exercise) to produce a desired effect, such as reduce symptoms. 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.
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 In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. 2013, Issue 8. Art. No.: CD008322. DOI: 10.1002/14651858.CD008322.pub2.