Purpose: Fatigue is a common and highly debilitating complaint among individuals with symptomatic osteoarthritis (OA) which can substantially affect all aspects of their daily live. Interestingly, poor physical function and physical inactivity appear associated with higher fatigue levels in people with symptomatic OA. Although various pharmaceutical and non-pharmaceutical management strategies are reported to address fatigue in different clinical populations, physical and behavioural interventions are thought to be very effective. However, evidence in this area is lacking. Therefore, this systematic review with meta-analysis aims to assess the effectiveness of exercise- and physical activity interventions for improving fatigue in individuals with symptomatic OA.
Methods: Randomized controlled trials (RCTs) that reported on individuals with symptomatic OA and that investigated the effectiveness of exercise- and physical activity interventions on any fatigue outcomes, were included. Studies with significant adjunct interventions were excluded. Risk of bias of individual studies was assessed using the Cochrane Risk of Bias tool 2 and the Grading of Recommendations, Assessment, Development and Evaluations framework was used to evaluate the quality of evidence for meta-analysis. Standardized mean differences (SMD) were used to pool the effects of primary studies utilizing a random-effects meta-analysis.
Results: We found 4027 records in the database search. After duplicate deletion as well as title, abstract and full-text screening, five RCTs met the inclusion criteria but only three studies were included in a meta-analysis comparing exercise- and physical activity interventions versus non exercise / no intervention control group. Those involved 349 participants (mean age 65 years; 75,4% female) with lower extremity OA (2 studies) and hand OA (1 study). Provided interventions were a behavioural graded activity program, a hand exercise program and chair yoga which were compared to control subjects on a waiting list or receiving information and advice respectively. Time in which the intervention was provided ranged from 8 weeks to 3 months. The primary outcomes for self-reported level of fatigue were Numerical Rating Scale (0-10) and PROMIS Fatigue-V (5-point scale) at 3 months. Pooled effect sizes (Figure 1) were statistically significant but small in favour of exercise- and physical activity interventions to decrease fatigue at short term follow up (SMD -0.22; 95% CI -0.43 to -0.01 I2=0%). Two of three studies were classed as low risk of bias and one as high risk of bias. The overall quality of evidence for this outcome was classed as moderate.
The remaining two studies compared different types of exercise- and physical activity interventions in 67 individuals with symptomatic knee OA. Fatigue was measured subjectively using a visual analogue scale (0-10) and the Short Form 36 Health Survey Questionnaire domain Vitality (energy and fatigue). Both studies were classed as having high risk of bias. One study found no difference in general fatigue between group differences of aquatic dance compared to standard aquatic exercise. The other study found no statistically significant differences between aquatic exercise and land-based exercise.
Conclusions: This meta-analysis suggests that exercise- and physical activity interventions are effective for perceived fatigue in individuals with symptomatic OA, albeit with small effects that need to be considered with caution. Firstly, effects may be impacted by the fact that all trials included subjects with only a low to moderate level of fatigue. Further, the limited available literature evaluating fatigue as outcome is surprising when compared to the large amount of research reported on physical activity and exercise in individuals with symptomatic OA. So, the current small effect sizes, low number of studies reported and selection bias on intensity of fatigue, limits comprehensive generalizability of current evidence. Finally, the content and duration of the exercise- and physical activity interventions was heterogenous and the used protocols might not have had enough impact on elements influencing fatigue such as disease specific factors (inflammatory levels, physical function) or secondary factors (physical activity level, sleep, mental health, cardiorespiratory fitness, ⋯). Large RCTs with long term follow-up and comprehensively tailored interventions are needed to investigate the effects of exercise- and physical interventions on fatigue in individuals with symptomatic OA.
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