Physical activity interventions for fatigue in rheumatoid arthritis: a systematic review

Clinical effect and biological mechanism of exercise for rheumatoid arthritis: A mini review

Rheumatoid arthritis (RA) is a common systematic, chronic inflammatory, autoimmune, and polyarticular disease, causing a range of clinical manifestations, including joint swelling, redness, pain, stiffness, fatigue, decreased quality of life, progressive disability, cardiovascular problems, and other comorbidities. Strong evidence has shown that exercise is effective for RA treatment in various clinical domains. Exercise training for relatively longer periods (e.g., ≥ 12 weeks) can decrease disease activity of RA. However, the mechanism underlying the effectiveness of exercise in reducing RA disease activity remains unclear. This review first summarizes and highlights the effectiveness of exercise in RA treatment. Then, we integrate current evidence and propose biological mechanisms responsible for the potential effects of exercise on immune cells and immunity, inflammatory response, matrix metalloproteinases, oxidative stress, and epigenetic regulation. However, a large body of evidence was obtained from the non-RA populations. Future studies are needed to further examine the proposed biological mechanisms responsible for the effectiveness of exercise in decreasing disease activity in RA populations. Such knowledge will contribute to the basic science and strengthen the scientific basis of the prescription of exercise therapy for RA in the clinical routine.

Higher Fatigue Prospectively Increases the Risk of Falls in Older Men

Background and Objectives

Fatigue is a common complaint and shares many risk factors with falls, yet the independent contribution of fatigue on fall risk is unclear. This study’s primary aim was to assess the association between fatigue and prospective fall risk in 5642 men aged 64–100 enrolled in the Osteoporotic Fractures in Men Study (MrOS). The secondary aim was to examine the association between fatigue and recurrent fall risk.

Research Design and Methods

Fatigue was measured at baseline using the Medical Outcomes Study (short form) single-item question “During the past four weeks, how much of the time did you feel energetic?” Responses were then classified: higher fatigue = “none,” “a little,” or “some” of the time and lower fatigue = “a good bit,” “most,” or “all” of the time. We assessed falls using triannual questionnaires. Fall risk was examined prospectively over 3 years; recurrent falling was defined as at least 2 falls within the first year. Generalized estimating equations and multinomial logistic regression modeled prospective and recurrent fall risk as a function of baseline fatigue status, adjusted for demographics, medications, physical activity, and gait speed.

Results

Men with higher (26%) versus lower baseline fatigue were older (75.1 ± 6.2 vs 73.2 ± 5.7 years), 24% less active, and had worse physical function (gait speed = 1.09 ± 0.24 vs 1.24 ± 0.21 m/s), all p < .0001. Within 1 year, 25.4% (n = 1409) had fallen at least once, of which 47.4% (n = 668) were recurrent fallers. Men with higher versus lower fatigue had 25% increased fall risk (relative risk = 1.25, 95% CI: 1.14–1.36) over 3 years follow-up, but had 50% increased odds of recurrent falling (odds ratio = 1.50, 95% CI: 1.22–1.85) within the first year.

Discussion and Implications

Fatigue is an important risk factor of falling independent of established risk factors. Reductions in fatigue (ie, increased energy) may lessen the burden of falls in older men and provide a novel avenue for fall risk intervention.

The effect of physical exercise on rheumatoid arthritis: An overview of systematic reviews and meta-analysis

AIMS

To determine which outcomes will be improved by different exercise interventions and the evidence quality for each intervention.

DESIGN

Overview of systematic reviews and meta-analysis.

DATA SOURCES

PubMed, Cochrane, Web of Science, CINAHL, and Embase. Published from the establishment of the database to 3 September 2019.

REVIEW METHODS

AMSTAR 2 and PRISMA were used to evaluate methodological and reporting quality. Evidence quality of the effect of each intervention was assessed according to GRADE guidelines. Meta-analysis of original studies was conducted for comparison of systematic reviews and to explore the effect of different exercise interventions on the same outcome.

RESULTS

Ten systematic reviews were included in the overview. A significant improvement was seen in: aerobic exercise for aerobic capacity; strength training for erythrocyte sedimentation rate and 50-foot walking time; aerobic exercise combined with strength training for aerobic capacity, physical function, and fatigue; hand exercise for hand function.

CONCLUSIONS

For the maximum benefit of rheumatoid arthritis (RA) patients, different exercise methods should be selected according to the symptoms. For RA patients, any exercise is better than no exercise, but the intensity, frequency, and period of exercise for better results are not determined.

IMPACT

What problem did the study address is which outcomes will be improved by different exercise interventions. For maximum benefit for RA patients, different exercise methods should be selected according to symptoms. The research summarized the evidence of exercise rehabilitation of RA and will help RA patients or their caregivers choose the appropriate type of exercise, which will play a positive role on the rehabilitation of patients with RA.

A biopsychosocial network model of fatigue in rheumatoid arthritis: a systematic review

Fatigue in RA is prevalent, intrusive and disabling. We propose a network model of fatigue encompassing multiple and mutually interacting biological, psychological and social factors. Guided by this model, we reviewed the literature to offer a comprehensive overview of factors that have been associated with fatigue in RA. Six categories of variables were found: physical functioning, psychological functioning, medical status, comorbidities and symptoms, biographical variables and miscellaneous variables. We then systematically reviewed associations between fatigue and factors commonly addressed by rheumatology health professionals. Correlations of fatigue with physical disability, poor mental well-being, pain, sleep disturbance and depression and anxiety were ∼0.50. Mostly these correlations remained significant in multivariate analyses, suggesting partly independent influences on fatigue and differences between individuals. These findings indicate the importance of research into individual-specific networks of biopsychosocial factors that maintain fatigue and tailored interventions that target the influencing factors most relevant to that person.

Associations of fatigue and sleep disturbance with nine common mental disorders

OBJECTIVE

To investigate the contribution of nine mental/substance use disorders to fatigue and sleep disturbance.

METHODS

3620 Australians aged 18 years or older recruited from the general community via Facebook during January-February 2016 completed an online survey assessing demographic characteristics, diagnosed medical conditions and nine mental disorders. Outcome measures were Patient Reported Outcomes Measurement Information System (PROMIS®) fatigue and PROMIS sleep disturbance.

RESULTS

Overall, 56% of the sample met criteria for at least one mental disorder. Linear regression models of sleep disturbance revealed all mental disorders except obsessive compulsive disorder (β = 0.038) had independent associations with sleep disturbance, with generalised anxiety disorder (GAD) (β = 0.173), major depressive disorder (MDD) (β = 0.117) and post-traumatic stress disorder (PTSD) (β = 0.111) making the greatest contribution. Inclusion of fatigue in the model attenuated the effects of panic disorder, MDD and attention-deficit hyperactive disorder (ADHD) to non-significance. For the outcome of fatigue, GAD (β = 0.223), MDD (β = 0.176) and PTSD (β = 0.147) made the greatest contributions, although all disorders had significant independent relationships. After adjusting for sleep disturbance, all mental disorders continued to make a significant contribution except for alcohol use disorder and substance use disorder.

CONCLUSION

Sleep disturbance and fatigue have independent associations with many mental disorders after correcting for comorbidity and known confounds. The disorders providing the greatest contribution to sleep disturbance and fatigue were GAD and MDD. Sleep disturbance and fatigue may be appropriate transdiagnostic targets for improving symptoms and global functioning for people with mental disorders.

Developing a group intervention to manage fatigue in rheumatoid arthritis through modifying physical activity

Background

Fatigue is a major symptom of rheumatoid arthritis (RA). There is some evidence that physical activity (PA) may be effective in reducing RA fatigue. However, few PA interventions have been designed to manage fatigue and there is limited evidence of end-user input into intervention development. The aim of this research was to co-design an intervention to support self-management of RA fatigue through modifying PA.

Methods

A series of studies used mixed methodological approaches to co-design a fatigue management intervention focused on modifying PA based on UK Medical Research Council guidance, and informed by the Behaviour Change Wheel theoretical framework. Development was based on existing evidence, preferences of RA patients and rheumatology healthcare professionals, and practical issues regarding intervention format, content and implementation.

Results

The resulting group-based intervention consists of seven sessions delivered by a physiotherapist over 12 weeks. Each session includes an education and discussion session followed by supervised PA chosen by the participant. The intervention is designed to support modification and maintenance of PA as a means of managing fatigue. This is underpinned by evidence-based behaviour change techniques that might support changes in PA behaviour. Intervention delivery is interactive and aims to enhance capability, opportunity and motivation for PA.

Conclusion

This study outlines stages in the systematic development of a theory-based intervention designed through consultation with RA patients and healthcare professionals to reduce the impact of RA fatigue. The feasibility of future evaluation of the intervention should now be determined.

Physical Activity Intensity is Associated with Symptom Distress in the CNICS Cohort

Symptom distress remains a challenging aspect of living with HIV. Physical activity is a promising symptom management strategy, but its effect on symptom distress has not been examined in a large, longitudinal HIV-infected cohort. We hypothesized that higher physical activity intensity would be associated with reduced symptom distress. We included 5370 people living with HIV (PLHIV) who completed patient-reported assessments of symptom distress, physical activity, alcohol and substance use, and HIV medication adherence between 2005 and 2016. The most frequent and burdensome symptoms were fatigue (reported by 56%), insomnia (50%), pain (46%), sadness (45%), and anxiety (45%), with women experiencing more symptoms and more burdensome symptoms than men. After adjusting for age, sex, race, time, HIV medication adherence, alcohol and substance use, site, and HIV RNA, greater physical activity intensity was associated with lower symptom intensity. Although individual symptoms may be a barrier to physical activity (e.g. pain), the consistent association between symptoms with physical activity suggests that more intense physical activity could mitigate symptoms experienced by PLHIV.