Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.


Sustained Reduction in Fatigue Impact in Rheumatoid Arthritis: RCT of Cognitive Behavioural Therapy.

Hewlett5,  Sarah E., Ambler2,  Nicholas, Knops2,  Bev, Cliss1,  Alena, Almeida6,  Celia, Pope3,  Denise, Hammond4,  Alison

Frenchay Hospital, Bristol UK
Frenchay Hospital, Bristol, UK
University Hospitals Bristol, UK
University of Salford, Matlock Derbyshire, United Kingdom
University of the West of England, Bristol, United Kingdom
University of the West of England, Bristol UK

Aim:

Up to 90% of RA patients experience distressing, unmanageable fatigue that impacts profoundly on life. In other long-term conditions, fatigue self-management programmes of cognitive behavioural techniques (CBT) show benefit. This randomized controlled trial tested CBT for RA fatigue.

Methods:

CBT was delivered by a clinical psychologist and specialist occupational therapist in 6 × 2hr weekly group sessions (1hr booster at wk 14), addressing thoughts, feelings and behaviours, underpinned by goal-setting. Included were activity pacing, self-monitoring diaries for energy management, achieving balance (prioritizing), stress, communication, assertiveness, sleep, and managing setbacks. The information-only control arm comprised a 1hr group session based on the Arthritis Research UK fatigue leaflet. Entry criteria were fatigue VAS >=6/10 and no change in major medication in previous 16 wks (steroids 6 wks). Assessments: VAS 0–10 for fatigue impact, severity and coping, Multi-dimensional Assessment of Fatigue (MAF 0–50), quality of life (RAQoL 0–30), sleep (good/poor), anxiety and depression (HADS 0–21), helplessness (AHI 5–35).

Results:

Of 168 patients randomized, 41 withdrew before entry, 51 did not complete all datasets, 76 completed to wk 18 (no significant baseline differences for age, gender, disease duration). At baseline, the 76 patients (38 CBT, 38 Control) comprised 55F, 21M, mean age 60.4 yrs (95% CI 57.8–62.9), disease duration 11 yrs (10–15). All data were tested for normality and outcomes transformed where necessary. Analysis was adjusted for group and for baseline scores. At baseline, CBT and Control patients only differed by better RAQoL in CBT arm: 13.7 (11.8–15.6) vs 17.3 (14.8–19.9).

At the end of the programme (6 wks) the CBT group had significantly better scores than the Control group for every fatigue and every well-being outcome, which were maintained at 18 wks, except for RAQoL (see Table). More CBT than Control patients reported better sleep quality (6 wks 22/38 vs 19/38, p=0.024; 18 wks 30/38 vs 20/38, p=0.012).

 Week 6Week 18
 CBT n=38 mean (95% CI)Control n=38 mean (95% CI)CBT n=38 mean (95% CI)Control n=38 mean (95% CI)
Fatigue:    
Impact4.2 (3.4–5.1)6.0 (5.1–6.9)4.2 (3.3–5.1)6.0 (5.1–6.9)
Severity4.7 (3.8–5.5)6.3 (5.5–7.1)4.8 (4.0–5.6)6.2 (5.2–7.1)
Coping (high good)7.3 (6.6–8.0)5.3 (4.4–6.1)7.2 (6.6–7.9)5.8 (4.9–6.6)
MAF24.7 (21.3–28.0)30.7 (27.2–34.4)24.0 (20.2–27.7)28.8 (24.9–32.7)
Well-being:    
RAQoL10.8 (8.7–12.8)16.8 (14.1–19.5)10.9 (8.8–13.1)14.8 (11.5–18.2)*
Anxiety5.7 (4.3–7.1)8.6 (6.8–10.4)5.2 (3.6–6.7)7.8 (6.2–9.4)
Depression4.7 (3.7–5.8)7.5 (6.0–9.0)4.75 (3.5–6.0)7.2 (6.2–9.3)
Helplessness13.4 (11.9–14.9)18.7 (17.0–20.3)13.6 (12.3–15.0)18.0 (16.3–19.8)
High scores are worse, except for Coping
All p=0.001 to 0.045
*p=0.480

Interim assessment at 10 wks showed the CBT group was still significantly better than the Control group in all except 3 outcomes that just failed to reach statistical significance (Anxiety p=0.057, Fatigue Coping p=0.066, Fatigue Severity p=0.064). The planned booster session was delivered at 14 wks. At 18 wks these outcomes were all significantly different again (Table).

Conclusion:

CBT for fatigue self-management in RA significantly improves fatigue and well-being, maintained at 3 months. The loss of significance in three variables before the booster session and subsequent improvement afterwards may indicate the value of 'top-up' sessions in clinical practice. As clinical psychology provision is often limited, the efficacy and cost of a lower-intensity CBT approach provided by the clinical team (with training and support) should be explored.

To cite this abstract, please use the following information:
Hewlett, Sarah E., Ambler, Nicholas, Knops, Bev, Cliss, Alena, Almeida, Celia, Pope, Denise, et al; Sustained Reduction in Fatigue Impact in Rheumatoid Arthritis: RCT of Cognitive Behavioural Therapy. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :1325
DOI: 10.1002/art.29091

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