Article Text

Extended report
Self-management of fatigue in rheumatoid arthritis: a randomised controlled trial of group cognitive-behavioural therapy
  1. Sarah Hewlett1,2,
  2. Nick Ambler3,
  3. Celia Almeida1,
  4. Alena Cliss1,
  5. Alison Hammond4,
  6. Karen Kitchen2,
  7. Bev Knops3,
  8. Denise Pope2,
  9. Melissa Spears5,
  10. Annette Swinkels6,
  11. Jon Pollock7
  1. 1Department of Nursing and Midwifery, University of the West of England, Bristol, UK
  2. 2Academic Rheumatology, University Hospitals Bristol, Bristol, UK
  3. 3Pain Management Centre, Frenchay Hospital, Bristol, UK
  4. 4Centre for Health, Sport and Rehabilitation Research, University of Salford, Salford, UK
  5. 5School of Social and Community Medicine, University of Bristol, Bristol, UK
  6. 6Department of Allied Health Professions, University of the West of England, Bristol, UK
  7. 7Department of Health and Applied Social Studies, University of the West of England, Bristol, UK
  1. Correspondence to Sarah Hewlett, Academic Rheumatology Unit, Bristol Royal Infirmary, Bristol BS2 8HW, UK; Sarah.Hewlett{at}


Objectives To investigate the effect of group cognitive behavioural therapy (CBT) for fatigue self-management, compared with groups receiving fatigue information alone, on fatigue impact among people with rheumatoid arthritis (RA).

Methods Two-arm, parallel randomised controlled trial in adults with RA, fatigue ≥6/10 (Visual Analogue Scale (VAS) 0–10, high bad) and no recent change in RA medication. Group CBT for fatigue self-management comprised six (weekly) 2 h sessions, and consolidation session (week 14). Control participants received fatigue self-management information in a 1 h didactic group session. Primary outcome at 18 weeks was the impact of fatigue measured using two methods (Multi-dimensional Assessment of Fatigue (MAF) 0–50; VAS 0–10), analysed using intention-to-treat analysis of covariance with multivariable regression models.

Results Of 168 participants randomised, 41 withdrew before entry and 127 participated. There were no major baseline differences between the 65 CBT and 62 control participants. At 18 weeks CBT participants reported better scores than control participants for fatigue impact: MAF 28.99 versus 23.99 (adjusted difference −5.48, 95% CI −9.50 to −1.46, p=0.008); VAS 5.99 versus 4.26 (adjusted difference −1.95, 95% CI −2.99 to −0.90, p<0.001). Standardised effect sizes for fatigue impact were MAF 0.59 (95% CI 0.15 to 1.03) and VAS 0.77 (95% CI 0.33 to 1.21), both in favour of CBT. Secondary outcomes of perceived fatigue severity, coping, disability, depression, helplessness, self-efficacy and sleep were also better in CBT participants.

Conclusions Group CBT for fatigue self-management in RA improves fatigue impact, coping and perceived severity, and well-being.

Trial registration: ISRCTN 32195100

This paper is freely available online under the BMJ Journals unlocked scheme, see

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Supplementary materials

  • Web Only Data

    Files in this Data Supplement:


  • Funding This research was funded by Arthritis Research UK (grant 17340), which had no role in study design or conduct, the preparation of this paper or decision to submit for publication.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the North Somerset and South Bristol Research ethics committee, Reference P6/Q2006/149.

  • Provenance and peer review Not commissioned; externally peer reviewed.