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NIHR Signal Group cognitive behavioural courses may reduce fatigue from rheumatoid arthritis

Published on 15 January 2020

doi: 10.3310/signal-000860

Fatigue can be one of the most difficult symptoms to cope with for people with rheumatoid arthritis and this study found that group cognitive behavioural courses may help.

This NIHR-funded study compared six weekly group sessions plus a booster session with a single brief one-to-one meeting. Both groups also received an educational booklet. It took place in seven UK hospitals and was co-delivered by pairs of trained rheumatology nurses and occupational therapists.

The group sessions caused a small reduction in the impact of fatigue which was still evident after two years. The course was well-received by participants, with more than 80% expressing satisfaction with it and saying they would recommend it to others.

Those members of the rheumatology team delivering the courses also found the additional training they had received beneficial in other areas of their practice. This is a promising intervention that could be more widely implemented to reduce the emotional and practical problems associated with fatigue.

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Why was this study needed?

Rheumatoid arthritis affects around 400,000 people in the UK. Women are affected two to four times more often than men. Rheumatoid arthritis is an autoimmune disease in which the body’s immune system attacks healthy tissue, mainly the joints, causing inflammation, pain, swelling and stiffness. A more generalised symptom of rheumatoid arthritis is fatigue.

While there is no universal definition of fatigue, there is general agreement that it comprises a lack of or decreased energy, and physical or mental exhaustion. Fatigue is a significant problem for more than 50% of people with rheumatoid arthritis and can be an enduring presence in their lives.

Group-based cognitive behavioural therapy programmes have been successful in reducing multiple sclerosis fatigue. This study explores the potential for groups run by rheumatology nurses and occupational therapists using cognitive behavioural approaches to reduce levels of rheumatoid arthritis fatigue.

What did this study do?

This randomised controlled trial took place in seven UK hospitals. It compared a group cognitive behavioural course and provision of the Arthritis Research UK fatigue booklet, against a five-minute one-to-one consultation on fatigue and provision of the booklet. The cognitive behavioural course, delivered by rheumatology nurses and occupational therapists, was provided in six weekly two-hour sessions plus a consolidation session for one hour in week 14.

The course consisted of exploratory questioning, goal-setting and peer-support towards fatigue-related behaviour, and underpinning thoughts and feelings.

The average age of the 333 participants was around 60 years old and 80% were female. They had been diagnosed with rheumatoid arthritis for an average of 10 years.

Fatigue was measured using the Bristol Rheumatoid Arthritis Fatigue Numerical Rating Scale (BRAF scale), which runs from 0 to 10, with higher scores indicating worse fatigue.

The results are likely to be relevant and reliable as this was a pragmatic trial in an NHS setting.

What did it find?

  • At week 26, fatigue impact reduced more in those attending the group sessions, with BRAF scores reducing from 7.10 to 5.74 compared with 7.23 to 6.36 for the control group (adjusted mean difference [aMD] -0.59, 95% confidence interval [CI] -1.11 to -0.06). This difference in fatigue impact scores was still apparent at two years (aMD -0.49, 95% CI -0.83 to -0.14).
  • The difference in fatigue impact BRAF scores between the groups increased over successive courses, suggesting therapist learning over time (first course cohort aMD -0.37 and last course cohort aMD -0.82).
  • Group sessions also slightly improved emotional fatigue by 26 weeks on the BRAF-Multidimensional Questionnaire (BRAF-MDQ emotional fatigue, scale 0 to 12) compared with the control group (aMD -0.91, 95% CI -1.58 to -0.23). This improvement was sustained at two years (aMD -0.90, 95% CI -1.44 to -0.37).
  • Living with fatigue also improved a little more for those who attended group sessions according to the BRAF-MDQ living score (scale 0 to 21) compared with the control group at 26 weeks (aMD -1.19, 95% CI -2.17 to -0.21) and two years (aMD -0.93, 95% CI -1.75 to -0.10).
  • There was no difference in other outcomes such as pain, disability, quality of life, anxiety, depression or valued life activities. However, group sessions were highly appreciated by participants, with 89% scoring it 8 or more out of 10 for satisfaction and 96% indicating they would recommend it to others. The staff leading the courses also felt that taking part had improved their wider clinical practice.

What does current guidance say on this issue?

The NICE 2018 guideline on managing rheumatoid arthritis in adults recommends periodic assessment of the effects of rheumatoid arthritis, including fatigue, on patients’ lives. It recommends that multidisciplinary teams help people manage their condition.

The guidelines focus on symptom control and non-pharmacological management for joint protection rather than the quality of life issues such as control and management of fatigue, for which there is no specific advice.

What are the implications?

In the absence of clinical psychologists as part of rheumatology teams, it is feasible for cognitive behavioural courses to be successfully delivered by rheumatology nurses and occupational therapists to relieve the impact of rheumatoid arthritis fatigue.

Though the impact may be modest, there is a lack of other available interventions to improve fatigue, which can be debilitating for people with rheumatoid arthritis.

Each hospital delivered four consecutive courses over two years. Results appear to have improved over time as the therapists gained experience, so the overall results may underestimate the full impact that could be achieved.

Citation and Funding

Hewlett S, Almeida C, Ambler N et al. Group cognitive behavioural programme to reduce the impact of rheumatoid arthritis fatigue: the RAFT RCT with economic and qualitative evaluations. Health Technol Assess. 2019;23(57).

Hewlett S, Almeida C, Ambler N et al. Reducing arthritis fatigue impact: two-year randomised controlled trial of cognitive behavioural approaches by rheumatology teams (RAFT). Ann Rheum Dis. 2019;78:465-72.

This project was funded by the NIHR Health Technology Assessment Programme (project number 11/112/01).

Bibliography

Arthritis Foundation. Fighting the fatigue of RA. Atlanta [GA]: Arthritis Foundation; 2017.

NHS website. Rheumatoid arthritis: overview. London: Department of Health and Social Care; updated 2019.

NICE. Rheumatoid arthritis in adults: management. NG100. London: National Institute for Health and Care Excellence; 2018.

Versus Arthritis. What is rheumatoid arthritis? Chesterfield: Versus Arthritis; 2018.

Why was this study needed?

Rheumatoid arthritis affects around 400,000 people in the UK. Women are affected two to four times more often than men. Rheumatoid arthritis is an autoimmune disease in which the body’s immune system attacks healthy tissue, mainly the joints, causing inflammation, pain, swelling and stiffness. A more generalised symptom of rheumatoid arthritis is fatigue.

While there is no universal definition of fatigue, there is general agreement that it comprises a lack of or decreased energy, and physical or mental exhaustion. Fatigue is a significant problem for more than 50% of people with rheumatoid arthritis and can be an enduring presence in their lives.

Group-based cognitive behavioural therapy programmes have been successful in reducing multiple sclerosis fatigue. This study explores the potential for groups run by rheumatology nurses and occupational therapists using cognitive behavioural approaches to reduce levels of rheumatoid arthritis fatigue.

What did this study do?

This randomised controlled trial took place in seven UK hospitals. It compared a group cognitive behavioural course and provision of the Arthritis Research UK fatigue booklet, against a five-minute one-to-one consultation on fatigue and provision of the booklet. The cognitive behavioural course, delivered by rheumatology nurses and occupational therapists, was provided in six weekly two-hour sessions plus a consolidation session for one hour in week 14.

The course consisted of exploratory questioning, goal-setting and peer-support towards fatigue-related behaviour, and underpinning thoughts and feelings.

The average age of the 333 participants was around 60 years old and 80% were female. They had been diagnosed with rheumatoid arthritis for an average of 10 years.

Fatigue was measured using the Bristol Rheumatoid Arthritis Fatigue Numerical Rating Scale (BRAF scale), which runs from 0 to 10, with higher scores indicating worse fatigue.

The results are likely to be relevant and reliable as this was a pragmatic trial in an NHS setting.

What did it find?

  • At week 26, fatigue impact reduced more in those attending the group sessions, with BRAF scores reducing from 7.10 to 5.74 compared with 7.23 to 6.36 for the control group (adjusted mean difference [aMD] -0.59, 95% confidence interval [CI] -1.11 to -0.06). This difference in fatigue impact scores was still apparent at two years (aMD -0.49, 95% CI -0.83 to -0.14).
  • The difference in fatigue impact BRAF scores between the groups increased over successive courses, suggesting therapist learning over time (first course cohort aMD -0.37 and last course cohort aMD -0.82).
  • Group sessions also slightly improved emotional fatigue by 26 weeks on the BRAF-Multidimensional Questionnaire (BRAF-MDQ emotional fatigue, scale 0 to 12) compared with the control group (aMD -0.91, 95% CI -1.58 to -0.23). This improvement was sustained at two years (aMD -0.90, 95% CI -1.44 to -0.37).
  • Living with fatigue also improved a little more for those who attended group sessions according to the BRAF-MDQ living score (scale 0 to 21) compared with the control group at 26 weeks (aMD -1.19, 95% CI -2.17 to -0.21) and two years (aMD -0.93, 95% CI -1.75 to -0.10).
  • There was no difference in other outcomes such as pain, disability, quality of life, anxiety, depression or valued life activities. However, group sessions were highly appreciated by participants, with 89% scoring it 8 or more out of 10 for satisfaction and 96% indicating they would recommend it to others. The staff leading the courses also felt that taking part had improved their wider clinical practice.

What does current guidance say on this issue?

The NICE 2018 guideline on managing rheumatoid arthritis in adults recommends periodic assessment of the effects of rheumatoid arthritis, including fatigue, on patients’ lives. It recommends that multidisciplinary teams help people manage their condition.

The guidelines focus on symptom control and non-pharmacological management for joint protection rather than the quality of life issues such as control and management of fatigue, for which there is no specific advice.

What are the implications?

In the absence of clinical psychologists as part of rheumatology teams, it is feasible for cognitive behavioural courses to be successfully delivered by rheumatology nurses and occupational therapists to relieve the impact of rheumatoid arthritis fatigue.

Though the impact may be modest, there is a lack of other available interventions to improve fatigue, which can be debilitating for people with rheumatoid arthritis.

Each hospital delivered four consecutive courses over two years. Results appear to have improved over time as the therapists gained experience, so the overall results may underestimate the full impact that could be achieved.

Citation and Funding

Hewlett S, Almeida C, Ambler N et al. Group cognitive behavioural programme to reduce the impact of rheumatoid arthritis fatigue: the RAFT RCT with economic and qualitative evaluations. Health Technol Assess. 2019;23(57).

Hewlett S, Almeida C, Ambler N et al. Reducing arthritis fatigue impact: two-year randomised controlled trial of cognitive behavioural approaches by rheumatology teams (RAFT). Ann Rheum Dis. 2019;78:465-72.

This project was funded by the NIHR Health Technology Assessment Programme (project number 11/112/01).

Bibliography

Arthritis Foundation. Fighting the fatigue of RA. Atlanta [GA]: Arthritis Foundation; 2017.

NHS website. Rheumatoid arthritis: overview. London: Department of Health and Social Care; updated 2019.

NICE. Rheumatoid arthritis in adults: management. NG100. London: National Institute for Health and Care Excellence; 2018.

Versus Arthritis. What is rheumatoid arthritis? Chesterfield: Versus Arthritis; 2018.

Group cognitive behavioural programme to reduce the impact of rheumatoid arthritis fatigue: the RAFT RCT with economic and qualitative evaluations

Published on 11 October 2019

Hewlett S, Almeida C, Ambler N, Blair P S, Choy E, Dures E, Hammond A, Hollingworth W, Kadir B, Kirwan J, Plummer Z, Rooke C, Thorn J, Turner N & Pollock J.

Health Technology Assessment Volume 23 Issue 57 , 2019

Background Fatigue is a major problem in rheumatoid arthritis (RA). There is evidence for the clinical effectiveness of cognitive–behavioural therapy (CBT) delivered by clinical psychologists, but few rheumatology units have psychologists. Objectives To compare the clinical effectiveness and cost-effectiveness of a group CBT programme for RA fatigue [named RAFT, i.e. Reducing Arthritis Fatigue by clinical Teams using cognitive–behavioural (CB) approaches], delivered by the rheumatology team in addition to usual care (intervention), with usual care alone (control); and to evaluate tutors’ experiences of the RAFT programme. Design A randomised controlled trial. Central trials unit computerised randomisation in four consecutive cohorts within each of the seven centres. A nested qualitative evaluation was undertaken. Setting Seven hospital rheumatology units in England and Wales. Participants Adults with RA and fatigue severity of ≥ 6 [out of 10, as measured by the Bristol Rheumatoid Arthritis Fatigue Numerical Rating Scale (BRAF-NRS)] who had no recent changes in major RA medication/glucocorticoids. Interventions RAFT – group CBT programme delivered by rheumatology tutor pairs (nurses/occupational therapists). Usual care – brief discussion of a RA fatigue self-management booklet with the research nurse. Main outcome measures Primary – fatigue impact (as measured by the BRAF-NRS) at 26 weeks. Secondary – fatigue severity/coping (as measured by the BRAF-NRS); broader fatigue impact [as measured by the Bristol Rheumatoid Arthritis Fatigue Multidimensional Questionnaire (BRAF-MDQ)]; self-reported clinical status; quality of life; mood; self-efficacy; and satisfaction. All data were collected at weeks 0, 6, 26, 52, 78 and 104. In addition, fatigue data were collected at weeks 10 and 18. The intention-to-treat analysis conducted was blind to treatment allocation, and adjusted for baseline scores and centre. Cost-effectiveness was explored through the intervention and RA-related health and social care costs, allowing the calculation of quality-adjusted life-years (QALYs) with the EuroQol-5 Dimensions, five-level version (EQ-5D-5L). Tutor and focus group interviews were analysed using inductive thematic analysis. Results A total of 308 out of 333 patients completed 26 weeks (RAFT, n/N = 156/175; control, n/N = 152/158). At 26 weeks, the mean BRAF-NRS impact was reduced for the RAFT programme (–1.36 units; p < 0.001) and the control interventions (–0.88 units; p < 0.004). Regression analysis showed a difference between treatment arms in favour of the RAFT programme [adjusted mean difference –0.59 units, 95% confidence interval (CI) –1.11 to –0.06 units; p = 0.03, effect size 0.36], and this was sustained over 2 years (–0.49 units, 95% CI –0.83 to –0.14 units; p = 0.01). At 26 weeks, further fatigue differences favoured the RAFT programme (BRAF-MDQ fatigue impact: adjusted mean difference –3.42 units, 95% CI –6.44 to – 0.39 units, p = 0.03; living with fatigue: adjusted mean difference –1.19 units, 95% CI –2.17 to –0.21 units, p = 0.02; and emotional fatigue: adjusted mean difference –0.91 units, 95% CI –1.58 to –0.23 units, p = 0.01), and these fatigue differences were sustained over 2 years. Self-efficacy favoured the RAFT programme at 26 weeks (Rheumatoid Arthritis Self-Efficacy Scale: adjusted mean difference 3.05 units, 95% CI 0.43 to 5.6 units; p = 0.02), as did BRAF-NRS coping over 2 years (adjusted mean difference 0.42 units, 95% CI 0.08 to 0.77 units; p = 0.02). Fatigue severity and other clinical outcomes were not different between trial arms and no harms were reported. Satisfaction with the RAFT programme was high, with 89% of patients scoring ≥ 8 out of 10, compared with 54% of patients in the control arm rating the booklet (p < 0.0001); and 96% of patients and 68% of patients recommending the RAFT programme and the booklet, respectively, to others (p < 0.001). There was no significant difference between arms for total societal costs including the RAFT programme training and delivery (mean difference £434, 95% CI –£389 to £1258), nor QALYs gained (mean difference 0.008, 95% CI –0.008 to 0.023). The probability of the RAFT programme being cost-effective was 28–35% at the National Institute for Health and Care Excellence’s thresholds of £20,000–30,000 per QALY. Tutors felt that the RAFT programme’s CB approaches challenged their usual problem-solving style, helped patients make life changes and improved tutors’ wider clinical practice. Limitations Primary outcome data were missing for 25 patients; the EQ-5D-5L might not capture fatigue change; and 30% of the 2-year economic data were missing. Conclusions The RAFT programme improves RA fatigue impact beyond usual care alone; this was sustained for 2 years with high patient satisfaction, enhanced team skills and no harms. The RAFT programme is < 50% likely to be cost-effective; however, NHS costs were similar between treatment arms.

Expert commentary

Managing fatigue is a major challenge for people with rheumatoid arthritis. Current provision to address fatigue is poor.

This research has shown that a group cognitive behavioural therapy programme can make a positive difference in managing the impact of fatigue.

This provides healthcare providers with a low cost and effective treatment option for managing fatigue. It also shows that fatigue can be addressed and managed within the rheumatology team.

Sarah Ryan, Professor of Rheumatology Nursing, Midlands Partnership NHS Foundation Trust

The commentator declares no conflicting interests

Author commentary

Patients with rheumatoid arthritis have reported that fatigue is one of the most difficult symptoms of their condition and that they receive little help to deal with it. At the same time, health professionals have said that they do not know how they can best provide support.

These findings show that patients can benefit from taking part in a six-week group fatigue programme. This programme can be run by health professionals using a manual after training.

Including this programme in clinical practice could provide health professionals with the tools to support patients to cope with the challenge of fatigue.

Emma Dures, Associate Professor in Rheumatology and Self-Management, Centre for Health and Clinical Research, University of the West of England, Bristol