Protocol for a randomised controlled trial for Reducing Arthritis Fatigue by clinical Teams (RAFT) using cognitive-behavioural approaches.

INTRODUCTION: Rheumatoid arthritis (RA) fatigue is distressing, leading to unmanageable physical and cognitive exhaustion impacting on health, leisure and work. Group cognitive-behavioural (CB) therapy delivered by a clinical psychologist demonstrated large improvements in fatigue impact. However, few rheumatology teams include a clinical psychologist, therefore, this study aims to examine whether conventional rheumatology teams can reproduce similar results, potentially widening intervention availability. METHODS AND ANALYSIS: This is a multicentre, randomised, controlled trial of a group CB intervention for RA fatigue self-management, delivered by local rheumatology clinical teams. 7 centres will each recruit 4 consecutive cohorts of 10-16 patients with RA (fatigue severity ≥ 6/10). After consenting, patients will have baseline assessments, then usual care (fatigue self-management booklet, discussed for 5-6 min), then be randomised into control (no action) or intervention arms. The intervention, Reducing Arthritis Fatigue by clinical Teams (RAFT) will be cofacilitated by two local rheumatology clinicians (eg, nurse/occupational therapist), who will have had brief training in CB approaches, a RAFT manual and materials, and delivered an observed practice course. Groups of 5-8 patients will attend 6 × 2 h sessions (weeks 1-6) and a 1 hr consolidation session (week 14) addressing different self-management topics and behaviours. The primary outcome is fatigue impact (26 weeks); secondary outcomes are fatigue severity, coping and multidimensional impact, quality of life, clinical and mood status (to week 104). Statistical and health economic analyses will follow a predetermined plan to establish whether the intervention is clinically and cost-effective. Effects of teaching CB skills to clinicians will be evaluated qualitatively. ETHICS AND DISSEMINATION: Approval was given by an NHS Research Ethics Committee, and participants will provide written informed consent. The copyrighted RAFT package will be freely available. Findings will be submitted to the National Institute for Health and Care Excellence, Clinical Commissioning Groups and all UK rheumatology departments. ISRCTN: 52709998; Protocol v3 09.02.2015.

"They didn't tell us, they made us work it out ourselves": patient perspectives of a cognitive-behavioral program for rheumatoid arthritis fatigue.

OBJECTIVE: Fatigue is an overwhelming rheumatoid arthritis (RA) symptom caused by interacting clinical and psychosocial factors. Cognitive-behavioral therapy (CBT) addresses links between thoughts, feelings, and behaviors and uses cognitive restructuring to facilitate behavior changes. In a randomized controlled trial, a group CBT program for RA fatigue improved fatigue impact, severity, and perceived coping, as well as mood and quality of life. The aim of this study was to explore the patient perspective of the program and the impact of behavior changes. METHODS: Ten exit focus groups were held (38 patients). Transcripts were analyzed by an independent researcher using a hybrid thematic approach, with a subset analyzed by a team member and patient partner. RESULTS: Three overarching themes were identified. In "they made us work it out ourselves" (program factors facilitating changes), patients spontaneously identified elements of group CBT as pivotal, including guided discovery, the impact of metaphors, and working as a group. In "feeling much better about yourself and coping much better" (the nature of changes), patients described cognitive changes, including enhanced self-efficacy and problem solving, and emotional changes, including being less volatile and fearful of fatigue. In "my life has changed so much it's unbelievable" (benefits beyond fatigue), patients reengaged in previously abandoned activities, were more active, and enjoyed greater social participation. CONCLUSION: Patients highlighted that CBT elements were key to making behavior changes and that these had far-reaching impacts on their lives. This suggests it could be beneficial in clinical practice to incorporate cognitive-behavioral approaches into patient education programs that aim to enhance self-management.

Sexual difficulties of chronic pain patients.

OBJECTIVE: Description of the specific physical and psychological problems associated with sexual activity in patients with chronic pain. DESIGN: Self-completion questionnaire on extent and nature of sexual difficulties related to pain; data on psychological and physical function in respondents; personal and medical data for respondents and nonrespondents. PATIENTS: Three hundred twenty-seven patients with chronic pain in inpatient and outpatient pain programs; 237 (72%) completed the questionnaire. MEASURES: Extent of general and specific sexual problems; anxiety and depression (Hospital Anxiety and Depression Scale [HAD]); pain self-efficacy; pain-related disability (Sickness Impact Profile); drug use. RESULTS: Respondents were younger and had less depressed mood than nonrespondents, but there were no other major differences. Seventy-three percent of respondents had pain-related difficulty with sexual activity; most had several, in various combinations of problems with arousal, position, exacerbating pain, low confidence, performance worries, and relationship problems. All except position difficulties were associated with less frequent sexual activity. There were few differences between men and women, and only weak relations emerged between specific problems and mood and disability. CONCLUSIONS: There is a high prevalence of sexual difficulties in patients with chronic pain attending treatment, nearly double that of a general UK survey. These difficulties are not simply related to mood or disability. The range of problems and patients' expressed preferences for help suggest that multidisciplinary intervention is required.

Specialist nurse counsellor interventions at the time of diagnosis of breast cancer: comparing 'advocacy' with a conventional approach.

Over recent years, specialist breast care nurses have become increasingly recognized as core members of any breast care team within the UK. Part of the role is to support patients at the highly stressful stage of receiving a diagnosis. This paper describes an 'advocacy' style of nurse counsellor intervention which aims to improve patients' preparation for, and involvement in, the diagnostic consultation and provides a framework for future counselling support. One hundred and three women undergoing surgery following diagnosis of breast cancer or a benign breast lump were supported using either this advocacy intervention or a more conventional model of care. The aim was to identify the most effective and appropriate method of intervening at this important stage. Assessment took place before surgery, with 2-week and 6-month follow-ups, and included the Hospital Anxiety and Depression Scale, Rotterdam Symptom Check List and semi-structured interviews addressing perceived quality of care, involvement in decision-making and psycho-social functioning. Whilst the results of many measures were similar for women in the two intervention groups, qualitative data support the implementation of the advocacy method by the breast care nurse.

Outpatient pulmonary rehabilitation in severe chronic obstructive pulmonary disease.

BACKGROUND: This is a study of an outpatient programme for rehabilitation of patients with severe ventilatory impairment due to chronic obstructive pulmonary disease (COPD). Its main purpose was to assess the feasibility of such a programme and so no control group was included. METHODS: The study included 44 patients (28 men) of mean age 66 years with COPD. They all had severe ventilatory impairment as defined by a forced expiratory volume in 1 second (FEV1) less than 40% of predicted. Initial assessment included a shuttle walking test, the Chronic Respiratory Disease Questionnaire (CRDQ), the Hospital Anxiety and Depression scale (HAD) and the Sickness Impact Profile (SIP). The patients then entered a 6-week outpatient programme during which they attended twice weekly for a 2 1/2 hour session. Assessment was repeated on completion of the study (the 3 1/2 month assessment) and at 6 months. RESULTS: The shuttle walking distance improved significantly and was maintained at the improved level for 6 months. The improvement in all four dimensions of the CRDQ was statistically significant and reached clinical significance for fatigue and for mastery. On entry, a notable level of depression was found in 32% of patients, and of anxiety in 40%. There was significant reduction in both of these which was maintained at 6 months. There was no improvement in the SIP at 3 months, but significant improvement was found at 6 months. CONCLUSIONS: This study shows that a successful outpatient programme can be conducted in patients with severe ventilatory impairment, and that apparent benefit in physical ability and in health-related quality of life can be achieved. The improvements were maintained at 6 months.

A randomized controlled trial of a stroke rehabilitation ward.

In S.E. Kent, during 1978 and 1979, 225 patients, representing 228 occurrences of hemiplegia, were referred to a new 20-bed stroke rehabilitation ward. These patients were randomly allocated to treatment in the special ward (group A 112 strokes) or to remain in conventional treatment locations (group C 116 strokes); the two groups were closely similar, except for the initial level of consciousness. Survivors were observed at four-month intervals to one year. There are indications of benefit for patients in group A by comparison with Group C in terms of treatment received (number treated by remedial therapists, the extent of treatment, and the arrangements for after-care), and in outcome (survival and the proportion returned to the community). The direction of the trend of advantage is consistent with another recent controlled trial, although not all modes of improvement are identical in the two trials. It is suggested that every health district should develop a comprehensive policy of stroke management.

The incidence and survival of stroke patients in a defined community.

A register of strokes in South East Kent was compiled over a period of 30 months. In a population of 248 000 the register of 1267 strokes indicated a crude annual incidence of 2.04/1000, and an annual incidence adjusted to the population structure of England and Wales of 1.66/1000. For the purposes of a comparative study of stroke management in 1978 and 1979 a register of patients with hemiplegia surviving 24 hours totalled 855 cases, of which 655 (77%) were admitted to hospital and 200 remained in the care of general practitioners. Follow-up was completed in 811 hemiplegic cases; 517 (63%) survived two weeks; and 271 (33%) survived one year. Comparisons are made with five recently published stroke registers in Europe. A higher incidence among males than females over age 54 is commonly observed. Survival of one-third of hemiplegic patients to one year from onset is lower than in other reported registers.