Remotely Delivered Cognitive-Behavioral, Exercise Care Benefits Rheumatic Fatigue

Neil Basu, MD, PhD

Cognitive-behavioral approaches and personalized exercise programs delivered via telephone provided statistically significant reductions in symptoms including fatigue among patients with inflammatory rheumatic disease (IRD), according to a first-of-its-kind study.

The trial, presented at the American College of Rheumatology (ACR) 2021 Convergence this week, supports the strategy of rheumatic care team-delivered remote interventions—at a time when COVID-19 outbreaks have necessitated global embraces of telemedicine health care, particularly for at-need patients with chronic diseases.

Led by Neil Basu, MD, PhD, of the University of Glasgow, the investigators found that benefits of telephone-delivered wellness care can last for up to 6 months in patients with a litany of rheumatic diseases who are working with a rheumatology multidisciplinary team. It’s the first trial to assess remote cognitive-behavioral approaches and personalized exercise programs for such a patient population.

Basu and colleagues conducted the study to observe strategies that would overcome a trio of barriers hindering the greater use of cognitive-behavioral and exercise-based approaches in patients with IRD: the lack of standardization and testing of such interventions in patients with IRD managed by rheumatologists; the infrequent access to requisite expertise in conducting such interventions among rheumatology teams; and the lack of patient interest in-person care among patients during COVID-19.

As they noted, IRD-related fatigue is “pervasive and disabling, even in otherwise stable disease.”

They conducted a 3-arm, randomized, controlled trial comparing usual care plus telephone-delivered cognitive-behavioral approaches or personalized exercise programs, versus lone usual care. In this case, usual care was comprised of a fatigue self-management education booklet made available for patients with IRD.

Patients were deemed eligible if they had been diagnosed with significant IRD (≥6 on the 10-item numerical rating scale) treated with unaltered immunomodulatory therapy for ≥3 months, and fatigue persisting for ≥3 months.

Members of the rheumatology multidisciplinary team were provided specialist-based training on both remote methods of care, then delivered the care to patients with IRD through ≤7 sessions across 14 weeks, plus a “booster session” at 6 months. Basu and colleagues sought a primary outcome of improvement in fatigue severity per Chalder Fatigue Scale (CFS) and impact per Fatigue Severity Scale (FSS) at 12 months.

They also sought secondary outcomes including patient depression per Hospital Anxiety and Depression Scale, pain, sleep disturbance, and Work Productivity and Activity Impairment (WPA-I) at 12 months.

The trial’s cohort included 368 patients with IRD—of whom 55% had rheumatoid arthritis, 21% had connective tissue disease, 19% had spondyloarthritis, and 5% had another IRD. Post-randomization baseline characteristics were fairly similar across the 3 treatment arms.

Primary outcome data was available for three-fourths (77%) of all patients; 73% of patients completed personalized exercise programs and 85% completed cognitive-behavioral approaches; both were associated with significantly improved fatigue severity (-2.9 [95% CI, 4.6 to -1.2; P = .001] and -2.5 [95% CI, -4.01 to -0.8; P = .003], respectively) versus usual care.

Fatigue impact was also improved by a mean 0.6 decrease for both personalized exercise programs (95% CI, -0.9 to -0.3; P <.001) and completed cognitive-behavioral approaches (95% CI, -0.8 to -0.3; P <.001) versus usual care.

Investigators additionally observed improvements in sleep with both remotely delivered methods, while personalized exercise programs were associated with further improved depression and overall work impairment among patients with IRD.

Basu and colleagues concluded the benefit of the remotely-delivered programs provided clinically significant reductions in the severity and impact of fatigue in patients stably treated for IRD.

“The benefit was maintained for 6 months following treatment completion and was successfully delivered by members of the rheumatology multidisciplinary team after specialist training,” they wrote.

The study, “Remotely Delivered Cognitive Behavioural and Personalised Exercise Interventions Reduce Fatigue Severity and Impact in Inflammatory Rheumatic Diseases: Results from a Multi-centre Randomised Controlled Parallel Group Trial,” was presented at ACR 2021.