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      The impact of fatigue in rheumatoid arthritis and the challenges of its assessment

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          Abstract

          Fatigue is one of the most important symptoms for patients with RA, and imposes a great burden on patients’ lives, being associated with significantly reduced health-related quality of life. Although being recognized by the rheumatology community as a major gap in the current management of the disease, fatigue has not been easy to measure and conceptualize. Part of the problem seems to reside in the multidimensional causality of this phenomenon, which may warrant dedicated measures and interventions. Although there are several instruments available to measure it, no consensus has yet been reached to recommend a ‘gold-standard’. This review aims at synthesizing the role of fatigue in the global impact of RA; describing validated instruments and their psychometric properties as measures of fatigue among patients with RA; and finally proposing a clinically meaningful, valid and feasible process to measure fatigue in clinical practice.

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          Most cited references44

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          Dimensional assessment of chronic fatigue syndrome.

          The absence of laboratory tests and clear criteria to identify homogeneous (sub)groups in patients presenting with unexplained fatigue, and to assess clinical status and disability in these patients, calls for further assessment methods. In the present study, a multi-dimensional approach to the assessment of chronic fatigue syndrome (CFS) is evaluated. Two-hundred and ninety-eight patients with CFS completed a set of postal questionnaires that assessed the behavioural, emotional, social, and cognitive aspects of CFS. By means of statistical analyses nine relatively independent dimensions of CFS were identified along which CFS-assessment and CFS-research can be directed. These dimensions were named: psychological well-being, functional impairment in daily life, sleep disturbances, avoidance of physical activity, neuropsychological impairment, causal attributions related to the complaints, social functioning, self-efficacy expectations, and subjective experience of the personal situation. A description of the study sample on these dimensions is presented.
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            Propriedades psicométricas na avaliação de instrumentos: avaliação da confiabilidade e da validade

            Resumo Instrumentos de medida desempenham um importante papel na pesquisa, na prática clínica e na avaliação de saúde. Estudos sobre a qualidade desses instrumentos fornecem evidências de como as propriedades de medida foram avaliadas, auxiliando o pesquisador na escolha da melhor ferramenta para utilização. A confiabilidade e a validade são consideradas as principais propriedades de medida de tais instrumentos. Confiabilidade é a capacidade em reproduzir um resultado de forma consistente, no tempo e no espaço. Validade refere-se à propriedade de um instrumento medir exatamente o que se propõe. Neste artigo são apresentados, discutidos e exemplificados os principais critérios e testes estatísticos empregados na avaliação da confiabilidade (estabilidade, consistência interna e equivalência) e validade (conteúdo, critério e construto) de instrumentos. A avaliação das propriedades de medida de instrumentos é útil para subsidiar a seleção de instrumentos válidos e confiáveis, de modo a assegurar a qualidade dos resultados dos estudos.
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              Fatigue in rheumatoid arthritis reflects pain, not disease activity.

              We determined the amount of fatigue experienced by patients with RA, and its relationship to synovitis, pain and other common clinical features. We also examined to what extent RA fatigue is improved by disease-modifying antirheumatic drugs (DMARDs) and anti-tumour necrosis factor (TNF) therapy. We studied two cohorts of 238 and 274 RA patients cross-sectionally and examined treatment responses in 30 RA patients starting anti-TNF and 54 starting DMARDs followed for 3 and 6 months. We measured fatigue using visual analogue scores (VAS) and Medical Outcomes Study Short Form 36 (SF-36) vitality scores. We recorded the disease activity score for 28 joints and its components (tender/swollen joint counts, patient global assessment, ESR), morning stiffness, health assessment questionnaire, physician global assessment, erosive disease, nodules, rheumatoid factor, concomitant medications and illnesses, and the SF-36 questionnaire. Fatigue was common in RA patients; over 80% had clinically relevant fatigue (VAS > or =20 mm), over 50% had high levels (VAS > or =50 mm). It was associated with pain and changes in mental health, particularly depression. In each of the two cross-sectional cohorts, this relationship was similar whichever measures of fatigue and mental health were used. Fatigue fell with DMARDs and anti-TNF: before treatment, 87% of patients had high fatigue, after treatment this fell to 50%. These treatment effects were mainly linked to improvements in pain. High fatigue levels characterize RA and are mainly linked to pain and depression. The association with disease activity is secondary. Fatigue falls with DMARD and anti-TNF therapy. The balance of evidence suggests that fatigue is centrally mediated in established RA.
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                Author and article information

                Journal
                Rheumatology (Oxford)
                Rheumatology (Oxford)
                brheum
                Rheumatology (Oxford, England)
                Oxford University Press
                1462-0324
                1462-0332
                November 2019
                04 November 2019
                04 November 2019
                : 58
                : Suppl 5 , Fatigue in Rheumatic Arthritis
                : v3-v9
                Affiliations
                [1 ] Rheumatology Department, Centro Hospitalar e Universitário de Coimbra , Coimbra
                [2 ] Abel Salazar Institute of Biomedical Sciences, University of Porto , Porto
                [3 ] Health Sciences Research Unit: Nursing, Nursing School of Coimbra, University of Coimbra , Coimbra, Portugal
                [4 ] Coimbra Institute for Clinical and Biomedical Research (iCBR) - Faculty of Medicine, University of Coimbra , Coimbra, Portugal
                Author notes
                Correspondence to: Ricardo J. O. Ferreira, Serviço de Reumatologia, Consulta Externa, Piso 7, Centro Hospitalar e Universitário de Coimbra, EPE, Avenida Dr. Bissaya Barreto, 3000-075 Coimbra, Portugal. E-mail: rferreira@ 123456reumahuc.org
                Author information
                http://orcid.org/0000-0003-0557-2377
                https://orcid.org/0000-0001-9327-6935
                http://orcid.org/0000-0002-2782-6780
                http://orcid.org/0000-0002-2517-0247
                Article
                kez351
                10.1093/rheumatology/kez351
                6827262
                31435662
                b44ab557-4c49-4541-9de2-78215529fc1d
                © The Author(s) 2019. Published by Oxford University Press on behalf of the British Society for Rheumatology.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                History
                : 6 March 2019
                : 16 July 2019
                Page count
                Pages: 7
                Funding
                Funded by: Gilead Sciences, Inc
                Categories
                Reviews

                Rheumatology
                arthritis,rheumatoid,fatigue,psychometrics,outcome assessment (health care)
                Rheumatology
                arthritis, rheumatoid, fatigue, psychometrics, outcome assessment (health care)

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