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Original research
Efficacy of non-pharmacological interventions: a systematic review informing the 2023 EULAR recommendations for the management of fatigue in people with inflammatory rheumatic and musculoskeletal diseases
  1. Eduardo José Ferreira Santos1,2,
  2. Bayram Farisogullari3,
  3. Emma Dures4,5,
  4. Rinie Geenen6 and
  5. Pedro M Machado7,8,9
  6. The EULAR taskforce on recommendations for the management of fatigue in people with inflammatory rheumatic diseases
    1. 1School of Health, Polytechnic University, Viseu, Portugal
    2. 2Health Sciences Research Unit: Nursing (UICiSA:E), Coimbra, Portugal
    3. 3Division of Rheumatology, Department of Internal Medicine, Hacettepe University, Ankara, Turkey
    4. 4Academic Rheumatology, Bristol Royal Infirmary, Bristol, UK
    5. 5School of Health and Social Wellbeing, University of the West of England, Bristol, UK
    6. 6Department of Psychology, Utrecht University, Utrecht, Netherlands
    7. 7Centre for Rheumatology & Department of Neuromuscular Diseases, University College London, London, UK
    8. 8National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
    9. 9Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
    1. Correspondence to Professor Pedro M Machado; p.machado{at}ucl.ac.uk

    Abstract

    Objective To identify the best evidence on the efficacy of non-pharmacological interventions in reducing fatigue in people with inflammatory rheumatic and musculoskeletal diseases (I-RMDs) and to summarise their safety in the identified studies to inform European Alliance of Associations for Rheumatology recommendations for the management of fatigue in people with I-RMDs.

    Methods Systematic review of randomised controlled trials (RCTs) including adults with I-RMDs conducted according to the Cochrane Handbook. Search strategy ran in Medline, Embase, Cochrane Library, CINAHL Complete, PEDro, OTseeker and PsycINFO. Assessment of risk of bias, data extraction and synthesis were performed by two reviewers independently. Data were pooled in meta-analyses.

    Results From a total of 4150 records, 454 were selected for full-text review, 82 fulfilled the inclusion criteria and 55 RCTs were included in meta-analyses. Physical activity or exercise was efficacious in reducing fatigue in rheumatoid arthritis (RA) (standardised mean differences (SMD)=−0.23, 95% CI=−0.37 to −0.1), systemic lupus erythematosus (SLE) (SMD=−0.54, 95% CI=−1.07 to −0.01) and spondyloarthritis (SMD=−0.94, 95% CI=−1.23 to −0.66); reduction of fatigue was not significant in Sjögren’s syndrome (SMD=−0.83, 95% CI=−2.13 to 0.47) and systemic sclerosis (SMD=−0.66, 95% CI=−1.33 to 0.02). Psychoeducational interventions were efficacious in reducing fatigue in RA (SMD=−0.32, 95% CI=−0.48 to −0.16), but not in SLE (SMD=−0.19, 95% CI=−0.46 to 0.09). Follow-up models in consultations (SMD=−0.05, 95% CI=−0.29 to 0.20) and multicomponent interventions (SMD=−0.20, 95% CI=−0.53 to 0.14) did not show significant reductions of fatigue in RA. The results of RCTs not included in the meta-analysis suggest that several other non-pharmacological interventions may provide a reduction of fatigue, with reassuring safety results.

    Conclusions Physical activity or exercise and psychoeducational interventions are efficacious and safe for managing fatigue in people with I-RMDs.

    • Arthritis
    • Autoimmune Diseases
    • Inflammation
    • Physical Therapy Modalities
    • Rehabilitation

    Data availability statement

    All data relevant to the study are included in the article or uploaded as online supplemental information.

    http://creativecommons.org/licenses/by-nc/4.0/

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as online supplemental information.

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    Footnotes

    • Twitter @EduardoJFSantos, @pedrommcmachado

    • EJFS and BF contributed equally.

    • Presented at This study was previously presented at EULAR 2023—Annual European Congress of Rheumatology, and its abstract published in: Santos E, Farisogullari B, Dures E, et al. OP0182-HPR Efficacy of non-pharmacological interventions: a systematic review informing the 2023 EULAR recommendations for the management of fatigue in people with inflammatory rheumatic and musculoskeletal diseases. Annals of the rheumatic diseases. 2023;82:120-120.

    • Correction notice This article has been corrected since it was first published online. Figure 3 has been updated and the reference in the sentence 'In PsA, physical activity or exercise reduced fatigue', has been updated from 101 to 74.

    • Collaborators The EULAR taskforce on Recommendations for the management of fatigue in people with inflammatory rheumatic diseases: Anna Molto (France) anna.molto@aphp.fr Bayram Farisogullari (Turkey) bayramfarisogullari@gmail.com Caroline Feldthusen (Sweden) caroline.feldthusen@gu.se Claire Harris (UK) claire.harris10@nhs.net Corinna Elling-Audersch (Germany) ellingiaudersch@aol.com Deirdre Conolly (Ireland) connoldm@tcd.ie Eduardo Santos (Portugal) ejf.santos87@gmail.com Elena Elefante (Italy) elena.elefante87@gmail.com Emma Dures (UK) emma2.dures@uwe.ac.uk Fernando Estévez-López (USA, Spain) fer@estevez-lopez.com Ilaria Bini (Italy) dottssa.ilariabini.psi@gmail.com Jette Primdahl (Denmark) jprimdahl@danskgigthospital.dk Kirsten Hoeper (Germany) hoeper.kirsten@mh-hannover.de Marie Urban (UK) urban.zing.101@hotmail.co.uk Mart van de Laar (Netherlands) m.a.f.j.vandelaar@utwente.nl Marta Redondo (Spain) mredondo@ucjc.edu Pedro Machado (UK) p.machado@ucl.ac.uk Peter Böhm (Germany) peboehm@gmx.de Raj Amarnani (UK) raj.amarnani@nhs.net Rhys Hayward (UK) rhys.hayward@nhs.net Rinie Geenen (Netherlands) r.geenen@uu.nl Simona Rednic (Romania) srednic.umfcluj@gmail.com Susanne Pettersson (Sweden) susanne.pettersson@sll.se Tanja Thomsen (Denmark) tanja.thomsen@regionh.dk Till Uhlig (Norway) tillmann.uhlig@medisin.uio.no Valentin Ritschl (Austria) valentin.ritschl@meduniwien.ac.at.

    • Contributors All authors are members of the EULAR’s task force for the development of 2023 EULAR Recommendations for the management of fatigue in people with inflammatory rheumatic diseases. EJFS and BF were the fellows. ED was the convenor. PMM was the methodologist and is responsible for the overall content as guarantor. All authors have contributed to the work, read and finally approved the manuscript for submission.

    • Funding This study was funded by the European Alliance of Associations for Rheumatology-EULAR (Project HPR052: EULAR points toconsider/recommendations for the management of fatigue in people with inflammatory rheumatic diseases).

    • Competing interests PMM has received consulting/speaker’s fees from Abbvie, BMS, Celgene, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this manuscript, and is supported by the National Institute for Health Research (NIHR), University College London Hospitals (UCLH), Biomedical Research Centre (BRC). EJFS, BF, RG and ED have no disclosures to report.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.