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Reducing the Impact of Rheumatoid Arthritis Fatigue: A Randomized Controlled Trial of Cognitive Behavioural Therapy

Hewlett, Sarah; Ambler, Nick; Knops, Bev; Cliss, Alena; Almeida, Celia; Pope, Denise; Hammond, Alison; Swinkels, Annette; Kitchen, Karen; Pollock, Jon


Sarah Hewlett

Nick Ambler

Bev Knops

Alena Cliss

Celia Almeida

Denise Pope

Annette Swinkels

Karen Kitchen

Jon Pollock


Background: Up to 90% of people with Rheumatoid Arthritis experience distressing and unmanageable fatigue that impacts profoundly on life. Biological therapies can lessen fatigue but are not always appropriate. In other long-term conditions, fatigue self-management programmes using cognitive behavioural techniques (CBT) have shown benefit. This randomized controlled trial aimed to test CBT in RA fatigue.
Methods: CBT was delivered by a clinical psychologist and an occupational therapist in 6 x 2 h weekly group sessions, addressing thoughts, feelings and behaviours and utilized goal setting. Topics included activity cycling (pacing), daily energy expenditure diaries, achieving a balance (prioritizing), stress, communication and assertiveness, sleep and coping with setbacks. The standard information arm (control) comprised a 1 h group session based on the arc fatigue leaflet. Entry criteria were diagnosed RA with a fatigue VAS of ≥ 6/10 and no change in major medication for 4 months (steroids 6 weeks). Assessments: VAS 0-10 for fatigue impact, severity and coping, Multi-dimensional Assessment of Fatigue (MAF 0-50), quality of life (RAQoL 0-30), a sleep quality question (1-4), anxiety and depression (HADS 0-21).
Results: 168 patients were randomized. The 127 patients who entered the trial did not differ significantly from the 41 who withdrew before giving baseline data: mean age 59.7 yrs (S.D. 11.3) vs withdrew 56.9 yrs (S.D. 11.7), disease duration 14.5 yrs (S.D. 11.1) vs 14.8 yrs (S.D. 10.4). Of the 41 who withdrew (23 CBT arm, 18 control), slightly more were female (85.4% vs 73.2%). Data were square root transformed where appropriate to achieve normality. Intention-to-treat regression analysis adjusted for baseline scores and group.
At baseline, patients in the CBT arm (n = 65) did not differ significantly from controls (n = 62) in any variable. However, at 6 weeks the CBT arm had significantly better scores in every fatigue outcome: fatigue impact in CBT arm mean 5.0 (95% CI 4.2-5.7) vs 6.4 (5.7-7.1), fatigue severity 5.5 (4.8-6.2) vs 6.6 (6.0-7.2), fatigue coping 7.0 (6.3-7.6) vs 5.5 (4.9-6.1) and MAF 27.9 (24.9-30.8) vs 31.4 (28.7-33.9) (all P < 0.001). In addition, all other measures of well-being were significantly better in the CBT group: anxiety CBT 5.5 (4.4-6.9) vs 7.5 (6.1-9.0, p = 0.021), depression 4.7 (3.8-5.7) vs 6.3 (5.3-7.5, P < 0.001), RAQoL 12.9 (11.1-14.7) vs 16.6 (14.6-18.5, P = 0.027) and sleep improvement (41.4% CBT patients vs 21.4%, X2 = 8.1, P = 0.004). Adjustment for age, disease duration or gender had no significant effect on the results.
Conclusions: CBT for the self-management of fatigue in RA appears to give substantial short-term benefit to patients for severity and impact of fatigue and perceived ability to cope with fatigue, as well as anxiety, depression and quality of life, compared with provision of self-management information alone. These data suggest an important new avenue of support for people with RA.


Hewlett, S., Ambler, N., Knops, B., Cliss, A., Almeida, C., Pope, D., …Pollock, J. (2010). Reducing the Impact of Rheumatoid Arthritis Fatigue: A Randomized Controlled Trial of Cognitive Behavioural Therapy. Rheumatology, 49,

Journal Article Type Article
Publication Date 2010-04
Deposit Date Oct 24, 2023
Journal Rheumatology
Print ISSN 1462-0324
Publisher Oxford University Press
Peer Reviewed Peer Reviewed
Volume 49