MedpageToday

Exercise Doesn’t Exacerbate Fatigue in Rheumatoid Arthritis

– Some patients see less fatigue with exercise, none see more


This Reading Room is a collaboration between MedPage Today® and:

Medpage Today

Expert Critique

FROM THE ASCO Reading Room
Anny Wu, D.O.
Anny Wu, D.O. Rheumatologist Adventist Health
Full Critique

New research reinforces the benefits of exercise for rheumatoid arthritis patients. Even more importantly, it gives clinicians a new potential tool to encourage patients to exercise more frequently.

A meta-analysis published in April in the journal Arthritis Care and Research analyzed five randomized controlled trials, with up to 298 participants per study. Seeking the minimal important difference in study data, researchers found that aerobic, land-based exercise resulted in statistically significant reductions in self‐reported fatigue (minimal important difference effect size, ‐0.34, 95% CI, -0.58 to -0.10, P=0.006). Findings were similar when effect sizes were collapsed so that only one effect size represented each study (minimal important difference effect size, ‐0.39, 95% CI, ‐0.76 to ‐0.03, P=0.04).

Although the analysis revealed significant reductions, they were small enough that only a relatively few patients with rheumatoid arthritis will actually see their fatigue reduced because of exercise.

"Land‐based aerobic exercise is associated with statistically significant reductions in fatigue," wrote study co-author and biostatistician George Kelley of West Virginia University and colleagues. "However, it may be unlikely that a substantial number of participants with RA could obtain clinically relevant reductions in fatigue."

Fatigue because of exercise is obviously inevitable regardless of health status. The key finding from the study, Kelley said, is that fatigue related specifically to rheumatoid arthritis does not appear to be exacerbated by exercise, even if it is not reduced.

"If we work out, we get tired," Kelley said. "That's one type of fatigue. This is how you feel all day with rheumatoid arthritis. What's happening with rheumatoid arthritis is the rheumatoid arthritis fatigue, and there you won't see that increase [in fatigue]."

Even though exercise will not reduce overall fatigue in most patients, it is still likely enough that that benefit will accrue for some people.

"When we look at how much change is clinically important, it would directly benefit a few people if not many," said Guy Eakin, PhD, senior vice president of scientific strategy with the Arthritis Foundation, who was not involved in the study. Exercise is not going to increase your fatigue, but for some people it's going to reduce fatigue, but it may not be you."

Clinical Applications

The new data could be a valuable tool for physicians and their communication with rheumatoid arthritis patients. Although rheumatoid arthritis can limit physical activity for several reasons besides fatigue, including pain and stiffness, patients specifically concerned about unnecessary fatigue may be reassured to learn that land-based exercises like walking, jogging, and cycling do not appear to increase fatigue and could in some cases decrease it.

"Physicians often hear the same thing: 'I can't exercise because I'm already tired and I'll just get more tired,'" Kelley said. "But now a clinician can say 'you know what, you won't be so fatigued, plus here are all of these other benefits.'"

Most if not all clinicians are acutely aware of the many benefits of moderate exercise for all patients, including those with rheumatoid arthritis. The Centers for Disease Control and Prevention recommends 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity (or some combination) each week for rheumatoid arthritis patients.

At the same time, sedentary lifestyles and obesity rates persist across the board, and that is particularly noticeable among rheumatoid arthritis patients, who tend to avoid exercise because of their symptoms or fears it could worsen symptoms. Information from the National Health Interview Survey revealed that the age-adjusted prevalence of sedentary lifestyles is 51.2% among people with arthritis compared with 27.2% in the general population. What's more, approximately 44% of American adults with arthritis report no physical activity during their leisure time compared with 36% for adults without arthritis.

Clinicians are uniquely positioned to improve these statistics. Studies show that as few as three minutes of doctor-patient counseling during a visit can increase physical activity among patients. Although patients are sometimes viewed as reluctant to engage in diet and exercise conversations, 80% of physicians surveyed reported patients were "receptive" or "very receptive" to the counseling, with more than half of clinicians reporting patients increased physical activity afterward.

The new meta-analysis could provide a new talking point for physicians who are attempting to expand conversations around physical activity and improve exercise rates in the rheumatoid arthritis population.

"It could help set expectations for patients," Eakin said. "Somebody could always say exercise makes them really tired, and now we have a large meta-analysis that says that exercise is probably not going to increase fatigue."

Future Areas of Study

Fatigue is an important factor in rheumatoid arthritis, but it does not happen in a vacuum. Because fatigue typically appears in rheumatoid arthritis patients alongside other familiar symptoms like pain, stiffness, and swelling, Eakin suggested future analyses of this kind account for the effects of other symptoms.

"It didn't test for pain and other barriers," Eakin said, "and those are always going to be important parts of the equation."

Kelley and colleagues acknowledged their meta-analysis focused solely on studies and patients with lower levels of fatigue. Kelley called for future studies that also examined the effects of exercise on rheumatoid arthritis patients with higher levels of fatigue.

"The levels of fatigue weren't that high, so more studies with higher levels of fatigue" are needed Kelley said.