The potential use of physical activity to help manage fatigue in rheumatoid arthritis: Lessons from other long-term conditions

Background: Fatigue is a major symptom of RA and the need for effective interventions is evident. Programmes based upon physical activity (PA) have been shown to improve patient reported fatigue in other long term conditions (LTCs). To inform the development of PA programmes for RA we aimed to identify PA components of existing fatigue management programmes for LTCs, and to explore expert opinion regarding their deliverability and acceptability.Methods: A purposive sample of 9 health professionals (HPs) delivering PA for fatigue management in LTCs participated in semistructured interviews. Transcripts were analysed using hybrid thematic analysis with a subset analysed independently.Results: 5 physiotherapists, 2 occupational therapists, 1 clinical nurse specialist, 1 exercise physiologist were interviewed; age range 33-53 years; time since qualification 11-32 years; time delivering programme 7 months to 8 years. Fatigue management programmes targeted cancer-related fatigue (n=4) and chronic fatigue syndrome (n=5). Six main themes were identified: Format: Between 6 and 14 group or individual sessions delivered initially every 1-2 weeks over 6-52 weeks. Individual sessions tended to be shorter (45-50 minutes) than group sessions (60-120 minutes). Delivery: In a hospital setting by a multi-disciplinary team following referral from a HP. Key challenges to delivery included location and timing of sessions. HPs recommended that good administrative support and a flexible, holistic approach are crucial. Theoretical approach: Although cognitive behavioural therapy was mentioned by some HPs as the basis for their programme, application in practice was not clearly described. One participant mentioned use of a self-efficacy outcome measure. Other HPs were unaware of the theoretical basis of the programme. Methods of behaviour change: A range of techniques were used including instruction on performing PA, graded tasks, goals and planning, and self-monitoring. HPs reported that psychosocial and motivation issues need to be addressed to improve engagement with PA, and are integral to success. Content: PA and psychosocial content were described. Graded exposure to exercise without exacerbating fatigue was important. HPs emphasized that activity management, sleep management and relaxation should be included to optimize the benefits. Patient support materials included programme booklets, record charts, and relaxation CDs. Advice about long term PA was provided, including suggestions for local exercise groups. Outcome: HPs believed that PA and fatigue levels improve following PA interventions, although evaluation was inconsistent.Conclusion: There are a variety of approaches to providing PA programmes for LTCs. Consistent findings included use of graded exercise therapy, the need for organizational flexibility and to address psychosocial and motivation issues. Although this might best be achieved using cognitive behavioural approaches, these were not firmly embedded within current programmes. These should be incorporated in the development of PA interventions for RA fatigue