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The prevalence and meaning of fatigue in rheumatic disease

Authors:
  • National Data Bank for Rheumatic Diseases

Abstract

To determine the prevalence of fatigue in rheumatic disease; to characterize the strength of associations between demographic and clinical features and fatigue; to identify predictors of fatigue, and to determine the consequence of clinically significant fatigue. 1488 consecutive patients with rheumatic disease were assessed with the Clinical Health Assessment Questionnaire, a health status instrument with scales for fatigue, pain, global severity, sleep disturbance, gastrointestinal problems, anxiety, depression, health status, health satisfaction, and work ability. All patients underwent rheumatic disease examinations and laboratory testing. Fatigue measured by visual analog scale (VAS) was present in 88-98% of patients, but clinically important levels of fatigue (> or = 2.0 on VAS) were present in more than 41% of patients with rheumatoid arthritis (RA) or osteoarthritis (OA) and 76% of those with fibromyalgia (FM). Fatigue was related to almost all demographic and clinical variables, but in multivariate analyses the strongest independent predictors of fatigue were pain, sleep disturbance, depression, tender point count and Health Assessment Questionnaire (HAQ) disability. About 90% of the R2 of the model (all patients = 0.51, RA = 0.49, OA = 0.45, FM = 0.41) was explained by pain, sleep disturbance, and depression. In RA assessed by erythrocyte sedimentation rate, joint count and grip strength, no association of the inflammatory process with fatigue could be found in the multivariate analyses. In measuring health status, fatigue was strongly associated with work dysfunction and general measures of health (VAS of global severity, health status, and health satisfaction). Fatigue is common across all rheumatic diseases, associates with all measures of distress, and is a predictor of work dysfunction and overall health status. The correlates of fatigue are generally similar across RA, OA and FM. Fatigue assessment adds much to understanding and management of patients and diseases.
... 2]. The causes of RMD-fatigue remain unclear, but the role of inflammation has been long, and fiercely, debated [3-, 4-9]. ...
... They would also like to thank the National Rheumatoid Arthritis Society for their support with recruitment and members of the uMotif team who supported data collection. 2 ...
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Background People with rheumatic diseases experience troublesome fluctuations in fatigue. Debated causes include pain, mood and inflammation. To determine the relationships between these potential causes, serial assessments are required but are methodologically challenging. This mobile health (mHealth) study explored the viability of using a smartphone app to collect patient-reported symptoms with contemporaneous Dried Blood Spot Sampling (DBSS) for inflammation. Methods Over 30 days, thirty-eight participants (12 RA, 13 OA, and 13 FM) used uMotif, a smartphone app, to report fatigue, pain and mood, on 5-point ordinal scales, twice daily. Daily DBSS, from which C-reactive Protein (CRP) values were extracted, were completed on days 1–7, 14 and 30. Participant engagement was determined based on frequency of data entry and ability to calculate within- and between-day symptom changes. DBSS feasibility and engagement was determined based on the proportion of samples returned and usable for extraction, and the number of days between which between-day changes in CRP which could be calculated (days 1–7). Results Fatigue was reported at least once on 1085/1140 days (95.2%). Approximately 65% of within- and between-day fatigue changes could be calculated. Rates were similar for pain and mood. A total of 287/342 (83.9%) DBSS, were returned, and all samples were viable for CRP extraction. Fatigue, pain and mood varied considerably, but clinically meaningful (≥ 5 mg/L) CRP changes were uncommon. Conclusions Embedding DBSS in mHealth studies will enable researchers to obtain serial symptom assessments with matched biological samples. This provides exciting opportunities to address hitherto unanswerable questions, such as elucidating the mechanisms of fatigue fluctuations.
... Over 70% of persons with rheumatoid arthritis report having symptoms like chronic fatigue syndrome on most days [4,5]. ...
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Introduction: Rheumatoid arthritis (RA) is a common autoimmune illness that manifests mostly as chronic, symmetric, and progressive polyarthritis with a global frequency of 0.3–1.0%. RA is a disease that affects people all over the world. In India, the prevalence is estimated to be 0.7%, with around 10 million persons suffering from RA. Most people with rheumatoid arthritis experience fatigue on most days, with over 70% experiencing symptoms similar to chronic fatigue syndrome. Patients rate fatigue as a top priority and believe this unmanageable symptom is ignored by clinicians; a systematic review shows the biological agents for RA inflammation have only a small effect on fatigue. Fatigue predicts and reduces the quality of life, and it is as difficult to cope with as pain. Physicians have traditionally concentrated on the inflammatory aspects of the illness (e.g., synovitis), whereas RA patients have prioritized pain, exhaustion, sleep difficulties, and other quality-of-life issues. Aims and Objectives: The basic aim of the study was to access the incidence of fatigue in rheumatoid arthritis and evaluate its impact on the quality of life in these patients using the MAF scale (multidimensional assessment of fatigue) after prior permission for the first time in an Asian population. Results: A total of 140 subjects and 100 controls were included in the study. Age was closely matched between the study subjects and controls. Among study subjects with the disease, 94 (67%) had a disease duration ≤ 5 years, 26 (19%) had a disease duration between 6–10 years, 10 (7%) had a duration of 11–15 years and 10 (7%) had >10 years disease duration. Among the sample, 31 (25%) study subjects had a DAS score ≤ 4.0, 63 (50%) study subjects had a DAS score (disease activity score) between 4.01 and 6.0, and in the remaining 31 (25%) study subjects, the DAS score was >6.0. The mean DAS score among study subjects was 4.96, and the study subjects had a mean activity of daily living (ADL) score of 11.64; controls had a mean score of 2.42 with a statistically significant p-value. The global fatigue index was higher in study subjects, with a mean of 33.16 in contrast with a mean of 14.41 in the controls with a significant p-value. Conclusion: Our study fatigue was a persistent problem, despite treatment. The median level of fatigue experienced by study subjects with RA was high. Therefore, as persistent fatigue is associated with functional loss, fatigue in RA remains an ‘unmet need’ and continues to be ignored by clinicians.
... Over 70% of persons with rheumatoid arthritis report having symptoms like chronic fatigue syndrome on most days [4,5]. ...
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Introduction: Rheumatoid arthritis (RA) is a common autoimmune illness that manifests mostly as chronic, symmetric, and progressive polyarthritis with a global frequency of 0.3-1.0%. RA is a disease that affects people all over the world. In India, the prevalence is estimated to be 0.7%, with around 10 million persons suffering from RA. Most people with rheumatoid arthritis experience fatigue on most days, with over 70% experiencing symptoms similar to chronic fatigue syndrome. Patients rate fatigue as a top priority and believe this unmanageable symptom is ignored by clinicians; a systematic review shows the biological agents for RA inflammation have only a small effect on fatigue. Fatigue predicts and reduces the quality of life, and it is as difficult to cope with as pain. Physicians have traditionally concentrated on the inflammatory aspects of the illness (e.g., synovitis), whereas RA patients have prioritized pain, exhaustion, sleep difficulties, and other quality-of-life issues. Aims and objectives: The basic aim of the study was to access the incidence of fatigue in rheumatoid arthritis and evaluate its impact on the quality of life in these patients using the MAF scale (multidimensional assessment of fatigue) after prior permission for the first time in an Asian population. Results: A total of 140 subjects and 100 controls were included in the study. Age was closely matched between the study subjects and controls. Among study subjects with the disease, 94 (67%) had a disease duration ≤ 5 years, 26 (19%) had a disease duration between 6-10 years, 10 (7%) had a duration of 11-15 years and 10 (7%) had >10 years disease duration. Among the sample, 31 (25%) study subjects had a DAS score ≤ 4.0, 63 (50%) study subjects had a DAS score (disease activity score) between 4.01 and 6.0, and in the remaining 31 (25%) study subjects, the DAS score was >6.0. The mean DAS score among study subjects was 4.96, and the study subjects had a mean activity of daily living (ADL) score of 11.64; controls had a mean score of 2.42 with a statistically significant p-value. The global fatigue index was higher in study subjects, with a mean of 33.16 in contrast with a mean of 14.41 in the controls with a significant p-value. Conclusion: Our study fatigue was a persistent problem, despite treatment. The median level of fatigue experienced by study subjects with RA was high. Therefore, as persistent fatigue is associated with functional loss, fatigue in RA remains an 'unmet need' and continues to be ignored by clinicians.
... To assess the impact of FM symptoms, the Revised Fibromyalgia Impact Questionnaire (FIQR), a validated outcome measure to evaluate FM, was used [28]. As fatigue is a significant symptom that people affected by FM find burdensom [29,30] the Chalder Fatigue Scale (CFS) Questionnaire was used [31], which has previously been used in the FM population [32]. To monitor changes to QoL, the SF-36 was used and has been validated for use in Primary Care [33]. ...
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Background Fibromyalgia is a condition associated with widespread musculoskeletal pain, fatigue and sleep problems. Fibromyalgia treatment guidelines recommend non-pharmacological interventions and the development of self-management skills. An example of a programme that fits these guidelines is the Fibromyalgia Self-management Programme (FSMP) which consists of one 2.5-hour weekly session over six successive weeks and includes education about fibromyalgia, goal setting, pacing, sleep hygiene and nutritional advice. The FSMP is currently provided in a secondary care hospital setting and co-delivered by a multidisciplinary team. Delivery in a primary care setting has the potential to improve the accessibility of the programme to people with fibromyalgia. Therefore, this feasibility study aimed to determine the practicality and acceptability of conducting a future definitive randomised controlled trial of the FSMP in a community setting. Method An exploratory, parallel-arm, one-to-one, randomised controlled trial. Participants were recruited from general practices across South West England, and the FSMP was co-delivered by physiotherapists and occupational therapists across two community sites. To determine the outcome measures for a future definitive trial several were tested. The Revised Fibromyalgia Impact Questionnaire, Arthritis Self-Efficacy Scale-8, Chalder Fatigue Scale, Short form 36, 5-Level EQ-5D version and Jenkins Sleep Scale were collected at baseline, 6 weeks and 6 months. Semi-structured interviews were conducted with patient participants, occupational therapists and physiotherapists to explore the acceptability and feasibility of delivering the FSMP in a community setting. Results A total of 74 participants were randomised to the FSMP intervention ( n = 38) or control arm ( n = 36). Attrition from the trial was 42% (31/74) at 6 months. A large proportion of those randomised to the intervention arm (34%, 13/38) failed to attend any sessions with six of the 13 withdrawing before the intervention commenced. The proportion of missing values was small for each of the outcome measures. Three overarching themes were derived from the interview data; (1) barriers and facilitators to attending the FSMP; (2) FSMP content, delivery and supporting documentation; and (3) trial processes. Conclusion It is feasible to recruit people with fibromyalgia from Primary Care to participate in a randomised controlled trial testing the FSMP in a community setting. However, improvement in trial attrition and engagement with the intervention is needed. Trial registration The trial is registered with ISRCTN registry and was assigned on 29/04/2019. The registration number is ISRCTN10824225.
... It is more highly correlated with the number of chronic diseases experienced rather than the severity of chronic disease [63,64]. The majority of our TKA cohort evidenced multimorbidity, yet few studies have explored fatigue in the TKA population, despite relatively high prevalence in people with osteoarthritis [64,65]. Hodges and colleagues found higher fatigue levels were associated with reduced physical activity and poorer patient-reported outcomes in the medium term after TKA [41,66]. ...
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Background: Resilience, or the ability to bounce back from stress, is a key psychological factor that is associated with ongoing functional independence and higher quality of life in older adults in the context of chronic health conditions. Emerging research has explored resilience and patient-reported outcomes after TKA. Our primary aim was to explore the relationship between resilience and acute hospital length of stay after total knee arthroplasty (TKA). Methods: A prospective observational study recruited 75 participants one month before total knee arthroplasty from two Australian hospitals. Two preoperative psychological measures were used: the Brief Resilience Scale, and for comparison, the Depression, Anxiety and Stress Scale-21 (DASS-21). We collected sociodemographic, medical and surgical details, patient-reported pain, function, fatigue and quality of life one month before TKA. Health service data describing acute hospital length of stay, inpatient rehabilitation use, and physiotherapy occasions of service were collected after TKA. Non-parametric analysis was used to determine any differences in length of stay between those with low or high resilience and DASS-21 scores. Secondary regression analysis explored the preoperative factors affecting acute hospital length of stay. Results: No significant difference was detected in length of stay between those with a low or a high resilience score before TKA. However, the group reporting psychological symptoms as measured by the DASS-21 before TKA had a significantly longer acute hospital length of stay after TKA compared to those with no psychological symptoms [median length of stay 6 (IQR 2.5) days vs. 5 (IQR 2) days, respectively (Mann-Whitney U = 495.5, P=0.03)]. Multivariate regression analysis showed that anesthetic risk score and fatigue were significant predictors of length of stay, with the overall model demonstrating significance (χ2=12.426, df = 4, P=0.014). Conclusions: No association was detected between the brief resilience score before TKA and acute hospital length of stay after TKA, however, symptoms on the DASS-21 were associated with longer acute hospital length of stay. Preoperative screening for psychological symptoms using the DASS-21 is useful for health services to identify those at higher risk of longer acute hospital length of stay after TKA.
... There are around 690,000 RA patients in UK, 80% of whom report suffering from relevant fatigue [1]. This symptom is described as a principal burden of the disease [2], with an impact over the quality of life even greater than pain [3]. Consequences of fatigue include an impact upon daily activities, general health, mental health, work and relationships among others [3]. ...
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Background Fatigue is a common and burdensome symptom in Rheumatoid Arthritis (RA), yet is poorly understood. Currently, clinicians rely solely on fatigue questionnaires, which are inherently subjective measures. For the effective development of future therapies and stratification, it is of vital importance to identify biomarkers of fatigue. In this study, we identify brain differences between RA patients who improved and did not improve their levels of fatigue based on Chalder Fatigue Scale variation (ΔCFS≥ 2), and we compared the performance of different classifiers to distinguish between these samples at baseline. Methods Fifty-four fatigued RA patients underwent a magnetic resonance (MR) scan at baseline and 6 months later. At 6 months we identified those whose fatigue levels improved and those for whom it did not. More than 900 brain features across three data sets were assessed as potential predictors of fatigue improvement. These data sets included clinical, structural MRI (sMRI) and diffusion tensor imaging (DTI) data. A genetic algorithm was used for feature selection. Three classifiers were employed in the discrimination of improvers and non-improvers of fatigue: a Least Square Linear Discriminant (LSLD), a linear Support Vector Machine (SVM) and a SVM with Radial Basis Function kernel. Results The highest accuracy (67.9%) was achieved with the sMRI set, followed by the DTI set (63.8%), whereas classification performance using clinical features was at the chance level. The mean curvature of the left superior temporal sulcus was most strongly selected during the feature selection step, followed by the surface are of the right frontal pole and the surface area of the left banks of the superior temporal sulcus. Conclusions The results presented evidence a superiority of brain metrics over clinical metrics in predicting fatigue changes. Further exploration of these methods may support clinicians to triage patients towards the most appropriate fatigue alleviating therapies.
... and loss in quality of life [2][3][4][5][6][7]. Knee osteoarthritis (KOA) is the most prevalent form of OA [8]; the lifetime risk for developing symptomatic KOA being 44.7% [9]. ...
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Background Quality indicators (QIs) are used to monitor quality of care and adherence to osteoarthritis (OA) standards of care. Patient reported QIs can identify the most important gaps in quality of care and the most vulnerable patient groups. The aim of this study was to capture the perspective of people with knee OA (KOA) in the Netherlands on the quality of care received, and explore determinants related to lower achievement rates. Methods We sent an online survey to all members of The Dutch Knee Panel ( n = 622) of the Sint Maartenskliniek Nijmegen, the Netherlands between September and October 2019. The survey consisted of a slightly adapted version of the “OsteoArthritis Quality Indicator” (OA-QI) questionnaire (18 items; yes, no, N/A); a rating of quality of KOA care on a 10-point scale; a question on whether or not one wanted to see change in the care for KOA; and an open-ended question asking recommendations for improvement of OA care. Furthermore, sociodemographic and disease related characteristics were collected. Pass rates for separate QIs and pass rates on patient level were calculated by dividing the number of times the indicator was achieved by the number of eligible persons for that particular indicator. Results A total of 434 participants (70%) completed the survey. The mean (SD) pass rate (those answering “Yes”) for separate QIs was 49% (20%); ranging from 15% for receiving referral for weight reduction to 75% for patient education on how to manage knee OA. The mean (SD) pass rate on patient level was 52% (23%). Presence of OA in other joints, comorbidities, and having a knee replacement were associated with higher pass rates. On average, a score of 6.5 (1.6) was given for the quality of care received, and the majority of respondents (59%) wanted change in the care for KOA. Of 231 recommendations made, most often mentioned were the need for tailoring of care (14%), more education (13%), and more empathy and support from healthcare providers (12%). Conclusion This study found patients are only moderately satisfied with the OA care received, and showed substantial gaps between perceived quality of care for OA and internationally accepted standards. Future research should focus on the underlying reasons and provide strategies to bridge these gaps.
... These results are in accordance with previous studies that describe more fatigue in patients with celiac disease, compared with healthy control subjects 37,38 . The fatigue prevalence rates are similar to data reported in other chronic inflammatory conditions such as inflammatory bowel disease, primary Sjögren's syndrome, and psoriasis 3,5,36,39 . This supports the hypothesis that fatigue represents a common mechanism across different conditions, and is triggered by chronic inflammation and immunological danger signals. ...
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Fatigue is increasingly recognized as a major complaint in patients with chronic inflammatory and autoimmune diseases. Although fatigue is assumed to represent a significant problem in celiac disease, existing knowledge is scarce, and opinions are conflicting. This study aimed to investigate the prevalence and severity of fatigue in patients with newly diagnosed celiac disease and compare it with healthy control subjects. Ninety patients with newly diagnosed celiac disease were compared with 90 age- and sex-matched healthy subjects. The primary endpoints were fatigue severity as measured by: the fatigue Visual Analog Scale (fVAS), the Fatigue Severity Scale (FSS), and the inverted Vitality subscale of the MOS36 (SF-36vs). Higher scores indicate more severe fatigue. Clinically relevant fatigue was determined using predefined cut-off values. Secondary endpoints were the associations between fatigue, and sex, age, depression, pain, and selected biochemical variables. The median (IQR) fVAS-scores were 43.0 (18.0–64.5) in patients, and 9.0 (2.0–16.0) in the control group ( p < 0.001); and the FSS scores 3.8 (2.0–4.8) in patients, and 1.4 (1.0–1.9) in control subjects ( p < 0.001). Inverted SF-36vs scores had a mean (SD) value of 58.8 (23.6) in patients, and 29.7 (14.3) in healthy subjects ( p < 0.001). The presence of clinically relevant fatigue ranged from 41 to 50% in patients. Increased fatigue severity was associated with female sex, younger age, and elevated pain and depression scores, but not with levels of selected biochemical variables, including hemoglobin. Fatigue is a severe and frequent phenomenon in patients with untreated celiac disease.
... However, it has been a major finding in white populations; a British population study found 41% of patients with RA to have fatigue. 22 The findings of this study indicate that patients with RA in our setting have severe disease. We found that more than half (65.3%) of our study participants had severe disease based on the DAS28. ...
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Background: Rheumatoid arthritis (RA) is a chronic, debilitating disease that leads to joint destruction and disability if left untreated. Few studies on RA have been conducted in Uganda, and there is limited information on disease severity and associated factors. This study sought to characterize the clinical presentation and to determine disease severity and the factors associated with disease severity among participants with RA in Uganda. Methods: Between August 2018 and February 2019, patients presenting to the rheumatology outpatient clinic in Mulago National Referral Hospital were enrolled into the study using a cross-sectional design. Participants' demographics and clinical characteristics were collected using a study questionnaire, and laboratory results were extracted from their charts. The patients' functionality was assessed using the Modified Health Assessment Questionnaire and their disease severity was assessed using the RA Disease Activity Score based on 28-joint count (DAS28). Results: A total of 170 participants were enrolled, of whom 81.2% were female. Nearly two-thirds (111/170) were classified as having severe disease. Having a functional status score of >0.5 (adjusted odds ratio 1.7, 95% confidence interval 1.4-2.2, p<0.001) was significantly associated with severe disease. Conclusion: In this population, the majority of the patients seen at the rheumatology outpatient clinic had severe disease, suggesting that patients may be presenting late, with limited early detection of the disease. Impaired functional status was associated with increased disease severity and may be used by clinicians to highlight disease severity when it is not possible to assess the RA DAS28.
Article
Objective Fatigue is common in rheumatoid arthritis (RA). We aimed to explore its longitudinal course, predictors and association with disease activity in early RA. Methods Data came from the 2-year treat-to-target trial CareRA (Care in early RA) and its 3-year extension. Fatigue was measured on Visual Analogue Scale, Multidimensional Fatigue Inventory and Short Form-36 (SF-36) vitality. Longitudinal fatigue trajectories were identified with multivariate growth mixture modelling. Early predictors of fatigue and the association of fatigue and its trajectories with disease activity and clinical/psychosocial outcomes were studied with linear mixed models and multilevel mediation. Results We included 356 and 244 patients in the 2-year and 5-year analyses, respectively. Four fatigue trajectories were identified: rapid, gradual, transient improvement and early deterioration, including 10%, 14%, 56% and 20% of patients. Worse pain, mental health and emotional functioning were seen in the early deterioration group. Higher pain, patient global assessment (PGA) and disability (Health Assessment Questionnaire), lower SF-36 mental components, and fewer swollen joints at baseline predicted higher fatigue over 5 years, while early disease remission strongly improved 5-year fatigue. The association between Simple Disease Activity Index and fatigue was mediated by PGA, pain, mental health and sleep quality. Conclusions Although fatigue evolves dynamically over time in early RA, most patients do not achieve sustained fatigue improvement despite intensive disease-modifying antirheumatic drug therapy. Higher 5-year fatigue levels were seen in patients with more perceived disease impact and fewer swollen joints at baseline. Conversely, early inflammatory disease control strongly improved long-term fatigue, pointing towards an early window of opportunity to prevent persistent fatigue.