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The ACR/ARHP Annual Meeting provided a research update on surrounding issues and strategies for helping patients.
Although multiple reviews, meta-analyses, and professional society guidelines recommend exercise and physical activity for treating chronic pain and fatigue, patients who live with rheumatologic diseases often face many barriers to developing successful exercise routines.
A research update on the issues surrounding fitness with fatigue and persistent pain was provided by Dr Daniel Clauw, Director of the Chronic Pain and Fatigue Research Center at the University of Michigan, in a presentation at the ACR/ARHP Annual Meeting in San Diego.
Strategies for rheumatologists to help enable their clients to improve their level of fitness were offered by Dr David Williams, Associate Director at the same research center.
The impact of fatigue
Dr Clauw explained that fatigue is quite common in patients who have rheumatologic diseases and that residual fatigue is possible even after successful treatment with a biologic medication. But while fatigue is often as functionally limiting as pain, Dr Clauw cited a study (Wolfe F, Pincus T. Arthritis Rheum. 1999) showing that only about 10% of rheumatologists even evaluate fatigue in their care of patients with rheumatoid arthritis.
Rheumatologists may ignore fatigue more often than they should because it can be difficult to determine exactly why it is happening, he noted. The myriad potential contributors to fatigue include psychological/psychiatric issues, sleep/chronobiology issues, inflammation, neurotransmitter imbalance, diet, endocrine, anemia, drugs, cardiovascular, muscular, obesity, and current level of fitness.
Dr Clauw emphasized that comorbid fibromyalgia can present additional challenges for some patients. In addition, managing fatigue can be difficult because the word “fatigue” doesn’t necessarily mean the same thing to every patient.
The role of exercise in treating fatigue
Other than properly treating underlying disease, Dr Clauw stressed that exercise is likely the most effective treatment for fatigue. Exercise is also the most effective treatment for fibromyalgia, coming out as the highest level recommendation in all treatment guidelines aimed at that condition.
Dr Clauw concluded that the types of exercise programs recommended to treat fatigue tend to have very few adverse effects and that the benefits generally exceed the risks.
Dr Williams continued that treatment guidelines across many disciplines offer a lot of evidence for addressing fatigue with exercise.
Patient-centric conversations about exercise
In spite of existing evidence on the benefits of exercise, patients often face a number of barriers to actually increasing their level of activity, Dr Williams noted, and without addressing these barriers, a recommendation to exercise more can be frustrating for both the patient and the clinician.
Thus, he emphasized the importance of initiating a patient-centric conversation that not only focuses on the merits of exercise but also engages in problem solving to address the particular barriers each individual patient faces. This discussion also needs to include practical advice about motivation, rewards, and how to get started.
Dr Williams recognized that an in-depth conversation about exercise can be quite challenging during short clinical visits. He thus recommended asking about exercise often and with the same enthusiasm and regularity as discussing medications, which can help the patient understand the value of exercise as part of their treatment regimen.
The F.I.T.T. principle
He also endorsed the F.I.T.T. principle in guiding the discussion: Frequency (number of days per week), Intensity (how hard the activity feels), Time (the total time of physical activity), and Type (the kind of physician activity).
E-Health techniques, or giving patients access to additional educational resources online that can be accessed at home, may also aid with the issue of limited time. As an example, Dr Williams recommended FibroGuide, an online symptom management program developed by the “Living Well with Fibromyalgia” program.
Strategies for patients who are resistant
Several strategies were discussed for assisting patients who may be resistant to starting a formal exercise program. Using a step counter (such as a pedometer or Fitbit) can be a helpful way for patients to get feedback on their current level of activity and feel like they are accomplishing something.
Clinicians can also suggest simple ways to fit additional physical activities into daily routine, such as taking the stairs instead of the elevator or parking slightly farther away.
For patients who are really struggling, pleasant activity scheduling can encourage patients to alter their schedule with something that feels doable, making it more likely they can find time for additional activity in the future.
Avoid overprescribing of exercise routines
Although evidence supports exercise and physical activity for improving pain and fatigue, Dr Williams cautioned that clinicians should avoid the temptation to prescribe exactly what type of exercise routine the patient ought to do. Instead, he argued that it’s easier to actually get patients to exercise by having early patient-centric conversations where the patient determines what is realistically possible and the clinician engages in problem solving to help overcome barriers.
Williams DA, Kuper D, Segar M, et al. “Internet-enhanced management of fibromyalgia: a randomized controlled trial.” Pain. 2010;151:694-702. doi: 10.1016/j.pain.2010.08.034. Epub 2010 Sep 19.