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

Abstract

ObjectiveTo 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.MethodsSystematic 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.ResultsFrom 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.ConclusionsPhysica activity or exercise and psychoeducational interventions are efficacious and safe for managing fatigue in people with I-RMDs.

A systematic review on the effects of non-pharmacological interventions for fatigue among people with upper and/or lower limb osteoarthritis

“…Also, exercises have been shown to improve fatigue in other chronic conditions such as RA, HIV, multiple sclerosis, chronic fatigue syndrome, and SLE [ 56 ]. In a recent systematic review, physical activity was found to be effective in reducing fatigue symptoms in a variety of inflammatory rheumatic and musculoskeletal diseases such as RA, SLE, spondyloarthritis, systemic sclerosis and Sjogren’s syndrome [ 19 ]. An examination of the 49 studies encompassed in the review by Hulme et al .…”

“…The impact of fatigue may worsen the pre-existing disability in individuals with upper limb and/or lower limb OA. In other rheumatic conditions including RA, SLE, there is strong evidence for the effectiveness of physical activity and psycho-educational interventions in relieving fatigue symptoms [ 19 ]. However, this finding may not be extrapolated to individuals with OA.…”

Factors influencing the outcomes of non-pharmacological interventions for managing fatigue across the lifespan of people living with musculoskeletal (MSK) conditions: a scoping review protocol

“…The European Alliance of Associations for Rheumatology (EULAR) recently funded a taskforce to examine the effectiveness of non-pharmacological interventions for fatigue in inflammatory rheumatic conditions and the resulting systematic review found strong evidence that some interventions are effective. 14 This informed the EULAR recommendations for the management of fatigue 21 and highlighted a need to better understand contextual factors and the mechanisms by which interventions are effective. 7 There is currently no comprehensive understanding of the factors which influence the success of an intervention.…”

“…A systematic review assessed the quality of evidence available to support non-pharmacological interventions to reduce fatigue in patients with inflammatory rheumatic conditions. 14 The National Institute for Health and Care Research has recently awarded funding for the project 'Effectiveness of Interventions For FatiguE in Long term conditions' (EIFFEL). 18 Study protocols have been registered on the PROSPERO database which state that the team will be conducting two systematic reviews; one to assess the effectiveness of interventions for fatigue in longterm conditions 19 and the other to explore the acceptability of interventions for fatigue.…”

“…9 10 This has been mirrored in healthcare research and recent systematic reviews have examined the strength of the evidence supporting a range of non-pharmacological interventions in different patient groups. [11][12][13][14][15] Non-pharmacological interventions are any non-chemical or biological interventions that are theoretically based and empirically…”