Original research| Volume 97, ISSUE 1, P26-36, January 2016

Effects of Person-Centered Physical Therapy on Fatigue-Related Variables in Persons With Rheumatoid Arthritis: A Randomized Controlled Trial

  • Caroline Feldthusen
    Corresponding author Caroline Feldthusen, PhD, Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Box 480, S-405 30 Gothenburg, Sweden.
    Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

    The University of Gothenburg Centre for Person-centred Care, Gothenburg, Sweden
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  • Elizabeth Dean
    Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada

    School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
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  • Helena Forsblad-d’Elia
    Department of Public Health and Clinical Medicine, Rheumatology, Umeå University, Umeå, Sweden
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  • Kaisa Mannerkorpi
    The University of Gothenburg Centre for Person-centred Care, Gothenburg, Sweden

    Section of Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Published:October 16, 2015DOI:



      To examine effects of person-centered physical therapy on fatigue and related variables in persons with rheumatoid arthritis (RA).


      Randomized controlled trial.


      Hospital outpatient rheumatology clinic.


      Persons with RA aged 20 to 65 years (N=70): intervention group (n=36) and reference group (n=34).


      The 12-week intervention, with 6-month follow-up, focused on partnership between participant and physical therapist and tailored health-enhancing physical activity and balancing life activities. The reference group continued with regular activities; both groups received usual health care.

      Main Outcome Measures

      Primary outcome was general fatigue (visual analog scale). Secondary outcomes included multidimensional fatigue (Bristol Rheumatoid Arthritis Fatigue Multi-Dimensional Questionnaire) and fatigue-related variables (ie, disease, health, function).


      At posttest, general fatigue improved more in the intervention group than the reference group (P=.042). Improvement in median general fatigue reached minimal clinically important differences between and within groups at posttest and follow-up. Improvement was also observed for anxiety (P=.0099), and trends toward improvements were observed for most multidimensional aspects of fatigue (P=.023–.048), leg strength/endurance (P=.024), and physical activity (P=.023). Compared with the reference group at follow-up, the intervention group improvement was observed for leg strength/endurance (P=.001), and the trends toward improvements persisted for physical (P=.041) and living-related (P=.031) aspects of fatigue, physical activity (P=.019), anxiety (P=.015), self-rated health (P=.010), and self-efficacy (P=.046).


      Person-centered physical therapy focused on health-enhancing physical activity and balancing life activities showed significant benefits on fatigue in persons with RA.


      List of abbreviations:

      BRAF-MDQ (Bristol Rheumatoid Arthritis Fatigue Multi-Dimensional Questionnaire), DAS-28 (disease activity score), HADS (Hospital Anxiety and Depression Scale), RA (rheumatoid arthritis), VAS (visual analog scale)
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        • Wolfe F.
        • Hawley D.J.
        • Wilson K.
        The prevalence and meaning of fatigue in rheumatic disease.
        J Rheumatol. 1996; 23: 1407-1417
        • Belza B.L.
        Comparison of self-reported fatigue in rheumatoid arthritis and controls.
        J Rheumatol. 1995; 22: 639-643
        • Repping-Wuts H.
        • Uitterhoeve R.
        • van Riel P.
        • van Achterberg T.
        Fatigue as experienced by patients with rheumatoid arthritis (RA): a qualitative study.
        Int J Nurs Stud. 2008; 45: 995-1002
        • Scott D.L.
        • Wolfe F.
        • Huizinga T.W.
        Rheumatoid arthritis.
        Lancet. 2010; 376: 1094-1108
        • Pollard L.C.
        • Choy E.H.
        • Gonzalez J.
        • Khoshaba B.
        • Scott D.L.
        Fatigue in rheumatoid arthritis reflects pain, not disease activity.
        Rheumatology (Oxford). 2006; 45: 885-889
        • Repping-Wuts H.
        • Fransen J.
        • van Achterberg T.
        • Bleijenberg G.
        • van Riel P.
        Persistent severe fatigue in patients with rheumatoid arthritis.
        J Clin Nurs. 2007; 16: 377-383
        • Kirwan J.R.
        • Minnock P.
        • Adebajo A.
        • et al.
        Patient perspective: fatigue as a recommended patient centered outcome measure in rheumatoid arthritis.
        J Rheumatol. 2007; 34: 1174-1177
        • Hewlett S.
        • Cockshott Z.
        • Byron M.
        • et al.
        Patients' perceptions of fatigue in rheumatoid arthritis: overwhelming, uncontrollable, ignored.
        Arthritis Rheum. 2005; 53: 697-702
        • Feldthusen C.
        • Bjork M.
        • Forsblad-d'Elia H.
        • Mannerkorpi K.
        Perception, consequences, communication, and strategies for handling fatigue in persons with rheumatoid arthritis of working age-a focus group study.
        Clin Rheumatol. 2013; 32: 557-566
        • Rupp I.
        • Boshuizen H.C.
        • Jacobi C.E.
        • Dinant H.J.
        • van den Bos G.A.
        Impact of fatigue on health-related quality of life in rheumatoid arthritis.
        Arthritis Rheum. 2004; 51: 578-585
        • Nikolaus S.
        • Bode C.
        • Taal E.
        • van de Laar M.A.
        Fatigue and factors related to fatigue in rheumatoid arthritis: a systematic review.
        Arthritis Care Res (Hoboken). 2013; 65: 1128-1146
        • Cramp F.
        • Hewlett S.
        • Almeida C.
        • et al.
        Non-pharmacological interventions for fatigue in rheumatoid arthritis.
        Cochrane Database Syst Rev. 2013; 8: CD008322
        • Repping-Wuts H.
        • van Riel P.
        • van Achterberg T.
        Fatigue in patients with rheumatoid arthritis: what is known and what is needed.
        Rheumatology (Oxford). 2009; 48: 207-209
        • Durcan L.
        • Wilson F.
        • Cunnane G.
        The effect of exercise on sleep and fatigue in rheumatoid arthritis: a randomized controlled study.
        J Rheumatol. 2014; 41: 1966-1973
        • Sokka T.
        • Hakkinen A.
        • Kautiainen H.
        • et al.
        Physical inactivity in patients with rheumatoid arthritis: data from twenty-one countries in a cross-sectional, international study.
        Arthritis Rheum. 2008; 59: 42-50
        • Evers A.W.
        • Kraaimaat F.W.
        • van Riel P.L.
        • de Jong A.J.
        Tailored cognitive-behavioral therapy in early rheumatoid arthritis for patients at risk: a randomized controlled trial.
        Pain. 2002; 100: 141-153
        • Hewlett S.
        • Ambler N.
        • Almeida C.
        • et al.
        Self-management of fatigue in rheumatoid arthritis: a randomised controlled trial of group cognitive-behavioural therapy.
        Ann Rheum Dis. 2011; 70: 1060-1067
        • Henchoz Y.
        • Bastardot F.
        • Guessous I.
        • et al.
        Physical activity and energy expenditure in rheumatoid arthritis patients and matched controls.
        Rheumatology (Oxford). 2012; 51: 1500-1507
        • Munsterman T.
        • Takken T.
        • Wittink H.
        Are persons with rheumatoid arthritis deconditioned? A review of physical activity and aerobic capacity.
        BMC Musculoskelet Disord. 2012; 13: 202
        • Ekman I.
        • Swedberg K.
        • Taft C.
        • et al.
        Person-centered care–ready for prime time.
        Eur J Cardiovasc Nurs. 2011; 10: 248-251
        • Leplege A.
        • Gzil F.
        • Cammelli M.
        • Lefeve C.
        • Pachoud B.
        • Ville I.
        Person-centredness: conceptual and historical perspectives.
        Disabil Rehabil. 2007; 29: 1555-1565
        • McCormack B.
        • Karlsson B.
        • Dewing J.
        • Lerdal A.
        Exploring person-centredness: a qualitative meta-synthesis of four studies.
        Scand J Caring Sci. 2010; 24: 620-634
        • Olsson L.E.
        • Ung E.J.
        • Swedberg K.
        • Ekman I.
        Efficacy of person-centred care as an intervention in controlled trials - a systematic review.
        J Clin Nurs. 2013; 22: 456-465
        • Smith C.
        What is a person?: rethinking humanity, social life, and the moral good from the person up.
        Univ of Chicago Pr, Chicago2010
        • Jones L.E.
        • Roberts L.C.
        • Little P.S.
        • Mullee M.A.
        • Cleland J.A.
        • Cooper C.
        Shared decision-making in back pain consultations: an illusion or reality?.
        Eur Spine J. 2014; 23: S13-S19
        • Arnett F.C.
        • Edworthy S.M.
        • Bloch D.A.
        • et al.
        The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis.
        Arthritis Rheum. 1988; 31: 315-324
        • Feldthusen C.
        • Grimby-Ekman A.
        • Forsblad-d'Elia H.
        • Jacobsson L.
        • Mannerkorpi K.
        Variations of fatigue in persons with Rheumatoid Arthritis- a 1 year longitudinal study. Proceedings of the Eular 2014.
        Ann Rheum Dis, Paris (France)2014
        • Grilo R.M.
        • Treves R.
        • Preux P.M.
        • Vergne-Salle P.
        • Bertin P.
        Clinically relevant VAS pain score change in patients with acute rheumatic conditions.
        Joint Bone Spine. 2007; 74: 358-361
        • Fries J.F.
        • Spitz P.
        • Kraines R.G.
        • Holman H.R.
        Measurement of patient outcome in arthritis.
        Arthritis Rheum. 1980; 23: 137-145
        • Krishnan E.
        • Tugwell P.
        • Fries J.F.
        Percentile benchmarks in patients with rheumatoid arthritis: Health Assessment Questionnaire as a quality indicator (QI).
        Arthritis Res Ther. 2004; 6: R505-R513
        • Hewlett S.
        • Dures E.
        • Almeida C.
        Measures of fatigue: Bristol Rheumatoid Arthritis Fatigue Multi-Dimensional Questionnaire (BRAF MDQ), Bristol Rheumatoid Arthritis Fatigue Numerical Rating Scales (BRAF NRS) for severity, effect, and coping, Chalder Fatigue Questionnaire (CFQ), Checklist Individual Strength (CIS20R and CIS8R), Fatigue Severity Scale (FSS), Functional Assessment Chronic Illness Therapy (Fatigue) (FACIT-F), Multi-Dimensional Assessment of Fatigue (MAF), Multi-Dimensional Fatigue Inventory (MFI), Pediatric Quality Of Life (PedsQL) Multi-Dimensional Fatigue Scale, Profile of Fatigue (ProF), Short Form 36 Vitality Subscale (SF-36 VT), and Visual Analog Scales (VAS).
        Arthritis Care Res (Hoboken). 2011; 63: S263-S286
        • Hewlett S.
        • Hehir M.
        • Kirwan J.R.
        Measuring fatigue in rheumatoid arthritis: a systematic review of scales in use.
        Arthritis Rheum. 2007; 57: 429-439
        • Price D.D.
        • McGrath P.A.
        • Rafii A.
        • Buckingham B.
        The validation of visual analogue scales as ratio scale measures for chronic and experimental pain.
        Pain. 1983; 17: 45-56
        • Nicklin J.
        • Cramp F.
        • Kirwan J.
        • Greenwood R.
        • Urban M.
        • Hewlett S.
        Measuring fatigue in rheumatoid arthritis: a cross-sectional study to evaluate the Bristol Rheumatoid Arthritis Fatigue Multi-Dimensional questionnaire, visual analog scales, and numerical rating scales.
        Arthritis Care Res (Hoboken). 2010; 62: 1559-1568
        • Dures E.K.
        • Hewlett S.E.
        • Cramp F.A.
        • et al.
        Reliability and sensitivity to change of the Bristol Rheumatoid Arthritis Fatigue scales.
        Rheumatology (Oxford). 2013; 52: 1832-1839
        • Fuchs H.A.
        The use of the disease activity score in the analysis of clinical trials in rheumatoid arthritis.
        J Rheumatol. 1993; 20: 1863-1866
        • Prevoo M.L.
        • van 't Hof M.A.
        • Kuper H.H.
        • van Leeuwen M.A.
        • van de Putte L.B.
        • van Riel P.L.
        Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis.
        Arthritis Rheum. 1995; 38: 44-48
        • van der Heijde D.M.
        • van't Hof M.A.
        • van Riel P.L.
        • van Leeuwen M.A.
        • van Rijswijk M.H.
        • van de Putte L.B.
        Validity of single variables and composite indices for measuring disease activity in rheumatoid arthritis.
        Ann Rheum Dis. 1992; 51: 177-181
        • Bohannon R.W.
        Sit-to-stand test for measuring performance of lower extremity muscles.
        Percept Mot Skills. 1995; 80: 163-166
        • Mannerkorpi K.
        • Svantesson U.
        • Carlsson J.
        • Ekdahl C.
        Tests of functional limitations in fibromyalgia syndrome: a reliability study.
        Arthritis Care Res. 1999; 12: 193-199
        • Mannerkorpi K.
        • Hernelid C.
        Leisure Time Physical Activity Instrument and Physical Activity at Home and Work Instrument. Development, face validity, construct validity and test-retest reliability for subjects with fibromyalgia.
        Disabil Rehabil. 2005; 27: 695-701
        • Englbrecht M.
        • Tarner I.H.
        • van der Heijde D.M.
        • Manger B.
        • Bombardier C.
        • Muller-Ladner U.
        Measuring pain and efficacy of pain treatment in inflammatory arthritis: a systematic literature review.
        J Rheumatol Suppl. 2012; 90: 3-10
        • Herrmann C.
        International experiences with the Hospital Anxiety and Depression Scale–a review of validation data and clinical results.
        J Psychosom Res. 1997; 42: 17-41
        • EuroQol Group
        EuroQol–a new facility for the measurement of health-related quality of life.
        Health Policy. 1990; 16: 199-208
        • Hurst N.P.
        • Jobanputra P.
        • Hunter M.
        • Lambert M.
        • Lochhead A.
        • Brown H.
        Validity of Euroqol–a generic health status instrument–in patients with rheumatoid arthritis. Economic and Health Outcomes Research Group.
        Br J Rheumatol. 1994; 33: 655-662
        • Hurst N.P.
        • Kind P.
        • Ruta D.
        • Hunter M.
        • Stubbings A.
        Measuring health-related quality of life in rheumatoid arthritis: validity, responsiveness and reliability of EuroQol (EQ-5D).
        Br J Rheumatol. 1997; 36: 551-559
        • Lorig K.
        • Chastain R.L.
        • Ung E.
        • Shoor S.
        • Holman H.R.
        Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis.
        Arthritis Rheum. 1989; 32: 37-44
        • Lomi C.
        • Burckhardt C.
        • Nordholm L.
        • Bjelle A.
        • Ekdahl C.
        Evaluation of a Swedish version of the arthritis self-efficacy scale in people with fibromyalgia.
        Scand J Rheumatol. 1995; 24: 282-287
        • Haskell W.L.
        • Lee I.M.
        • Pate R.R.
        • et al.
        Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association.
        Med Sci Sports Exerc. 2007; 39: 1423-1434
        • Gronblom-Lundstrom L.
        Health as a measure of rehabilitation: outcome for patients with low back pain.
        Physiother Theory Pract. 1992; 8: 67-77
        • Fayers P.
        • Machin D.
        Quality of life: the assessment, analysis and interpretation of patient-reported outcomes.
        John Wiley & Sons, Chichester2007
        • Khanna D.
        • Pope J.E.
        • Khanna P.P.
        • et al.
        The minimally important difference for the fatigue visual analog scale in patients with rheumatoid arthritis followed in an academic clinical practice.
        J Rheumatol. 2008; 35: 2339-2343
        • Wells G.
        • Li T.
        • Maxwell L.
        • MacLean R.
        • Tugwell P.
        Determining the minimal clinically important differences in activity, fatigue, and sleep quality in patients with rheumatoid arthritis.
        J Rheumatol. 2007; 34: 280-289
        • Chauffier K.
        • Salliot C.
        • Berenbaum F.
        • Sellam J.
        Effect of biotherapies on fatigue in rheumatoid arthritis: a systematic review of the literature and meta-analysis.
        Rheumatology (Oxford). 2012; 51: 60-68
        • Hewlett S.
        • Chalder T.
        • Choy E.
        • et al.
        Fatigue in rheumatoid arthritis: time for a conceptual model.
        Rheumatology (Oxford). 2011; 50: 1004-1006
        • Nikolaus S.
        • Bode C.
        • Taal E.
        • van de Laar M.A.
        Four different patterns of fatigue in rheumatoid arthritis patients: results of a Q-sort study.
        Rheumatology (Oxford). 2010; 49: 2191-2199
        • Oude Voshaar M.A.
        • Ten Klooster P.M.
        • Bode C.
        • et al.
        Assessment of fatigue in rheumatoid arthritis: a psychometric comparison of single-item, multiitem, and multidimensional measures.
        J Rheumatol. 2015; 42: 413-420
        • Nikolaus S.
        • Bode C.
        • Taal E.
        • van de Laar M.A.
        Which dimensions of fatigue should be measured in patients with rheumatoid arthritis? A Delphi study.
        Musculoskeletal Care. 2012; 10: 13-17
        • Ericsson A.
        • Bremell T.
        • Mannerkorpi K.
        Usefulness of multiple dimensions of fatigue in fibromyalgia.
        J Rehabil Med. 2013; 45: 685-693