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Meta-Analysis
. 2013 Aug 23;2013(8):CD008322.
doi: 10.1002/14651858.CD008322.pub2.

Non-pharmacological interventions for fatigue in rheumatoid arthritis

Fiona Cramp  1 , Sarah Hewlett, Celia Almeida, John R Kirwan, Ernest H S Choy, Trudie Chalder, Jon Pollock, Robin Christensen
Affiliations
Meta-Analysis

Non-pharmacological interventions for fatigue in rheumatoid arthritis

Fiona Cramp et al. Cochrane Database Syst Rev. .

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 methods: 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.

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.

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Conflict of interest statement

The authors do not have any conflicts of interest.

At the time of protocol development Sarah Hewlett was in receipt of a small unrestricted educational grant from GlaxoSmithKline to partially fund a PhD studentship on fatigue measurement in RA. She was also undertaking an RCT of cognitive behavioural therapy for the self‐management of RA fatigue, funded by the Arthritis Research Campaign. During the full review process Sarah Hewlett also received a small consultancy fee from UCB Pharmaceuticals to advise on the translatation of the Bristol RA Fatigue Scales. These associations reflect our large programme of research in fatigue into RA but do not constitute a conflict of interests.

Professor Ernest Choy has received research grants, and served as member of advisory boards and speaker bureaus of Abbott Laboratories, Allergan, AstraZeneca, Boehringer Ingelheim, Chelsea Therapeutics, Chugai Pharma, Daiichi Sankyo, Eli Lilly, Ferring Pharmacuetical, GSK, ISIS, Jazz Pharmaceuticals, MedImmune, Merrimack Pharmaceutical, MSD, Novartis, Pfizer, Pierre Fabre Medicament, Roche, Schering Plough, Synovate, and UCB. These activities do not constitute a conflict of interest.

Professor Robin Christensen has received grant support and/or provided expert advice and/or presentations for Abbott/AbbVie, Axellus, Bayer HealthCare Pharmaceuticals, Biogen Idec, Bristol‐Myers Squibb, Cambridge Weight Plan, Ipsen, Laboratoires Expanscience, MSD, Mundipharma, Norpharma, Pfizer, Roche, and Wyeth. He reports being involved in health‐care initiatives and research that could benefit from wide uptake of comparative effectiveness research (including Cochrane Collaboration, OMERACT, and the GRADE Working Group) but these do not constitute a conflict of interest.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Funnel plot of comparison: 1 Physical activity versus control, outcome: 1.1 Fatigue.
5
5
Funnel plot of comparison: 2 Psychosocial versus control, outcome: 2.1 Fatigue.
1.1
1.1. Analysis
Comparison 1 Physical activity versus control, Outcome 1 Fatigue.
2.1
2.1. Analysis
Comparison 2 Psychosocial versus control, Outcome 1 Fatigue.
3.1
3.1. Analysis
Comparison 3 Mediterranean diet versus control, Outcome 1 Fatigue.
4.1
4.1. Analysis
Comparison 4 Andrographis paniculata versus control, Outcome 1 Fatigue.
5.1
5.1. Analysis
Comparison 5 Omega‐3 fatty acid versus control, Outcome 1 Fatigue.
6.1
6.1. Analysis
Comparison 6 Data tracker versus control, Outcome 1 Fatigue.
7.1
7.1. Analysis
Comparison 7 Reflexology versus control, Outcome 1 Fatigue.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD008322

References

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