Best-practice clinical management of flares in people with osteoarthritis: A scoping review of behavioral,lifestyle and adjunctive treatments

IntroductionTransient episodes of increased pain, stiffness or swelling are common in people with osteoarthritis (OA). Yet, evidence-based management strategies for lessening the impact of OA flares are rarely covered in clinical guidelines and have been identified as a gap by clinicians delivering OA care. We aimed to identify evidence on behavioral, lifestyle or other adjunctive flare management strategies that could be used by clinicians or consumers.Materials and methodsA literature search between 1990-2020 was performed in three databases using a scoping methodology. We included qualitative or quantitative studies, and reviews that examined OA flare management, or that reported OA flare outcomes at timepoints ≤2 weeks post-intervention. Outcomes included any physical or psychological OA outcome treatable with a therapeutic intervention.ResultsWe included 9 studies, all of which examined the relationship between therapeutic exercise/ physical activity and OA flares. All studies reported pain outcomes at the knee. Two also included the hip. Only two studies examined specific management strategies for OA flares. Both favorably reported the benefits of undertaking an exercise program modified accordingly during an episode, but the quality of the evidence was low.DiscussionThis scoping review highlights the paucity of evidence available on non-pharmacological treatments of OA flare management that could influence clinical practice. At present, there is no robust evidence to support or reject any specific therapies for OA flare management in clinical practice. Future work is needed, particularly around outcomes beyond pain, trajectories of symptom improvement, and for joints other than the knee.     

Palliative management of refractory dyspnea in COPD

COPD is a progressive illness with worldwide impact. Patients invariably reach a point at which they require palliative interventions. Dyspnea is the most distressing symptom experienced by these patients; when not relieved by traditional COPD management strategies it is termed “refractory dyspnea” and palliative approaches are required. The focus of care shifts from prolonging survival to reducing symptoms, increasing function, and improving quality of life. Numerous pharmacological and non-pharmacological interventions can achieve these goals, though evidence supporting their use is variable. This review provides a summary of the options for the management of refractory dyspnea in COPD, outlining currently available evidence and highlighting areas for further investigation. Topics include oxygen, opioids, psychotropic drugs, inhaled furosemide, Heliox, rehabilitation, nutrition, psychosocial support, breathing techniques, and breathlessness clinics.     

Importance of fatigue and its measurement in chronic liver disease

The mechanisms of fatigue in the group of people with non-alcoholic fatty liver disease and non-alcoholic steatohepatitis are protean. The liver is central in the pathogenesis of fatigue because it uniquely regulates much of the storage, release and production of substrate for energy generation. It is exquisitely sensitive to the feedback controlling the uptake and release of these energy generation substrates. Metabolic contributors to fatigue, beginning with the uptake of substrate from the gut, the passage through the portal system to hepatic storage and release of energy to target organs (muscle and brain) are central to understanding fatigue in patients with chronic liver disease. Inflammation either causing or resulting from chronic liver disease contributes to fatigue, although inflammation has not been demonstrated to be causal. It is this unique combination of factors, the nexus of metabolic abnormality and the inflammatory burden of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis that creates pathways to different types of fatigue. Many use the terms central and peripheral fatigue. Central fatigue is characterized by a lack of self-motivation and can manifest both in physical and mental activities. Peripheral fatigue is classically manifested by neuromuscular dysfunction and muscle weakness. Therefore, the distinction is often seen as a difference between intention (central fatigue) versus ability (peripheral fatigue). New approaches to measuring fatigue include the use of objective measures as well as patient reported outcomes. These measures have improved the precision with which we are able to describe fatigue. The measures of fatigue severity and its impact on usual daily routines in this population have also been improved, and they are more generally accepted as reliable and sensitive. Several approaches to evaluating fatigue and developing endpoints for treatment have relied of biosignatures associated with fatigue. These have been used singly or in combination and include: physical performance measures, cognitive performance measures, mood/behavioral measures, brain imaging and serological measures. Treatment with non-pharmacological agents have been shown to be effective in symptom reduction, whereas pharmacological agents have not been shown effective.     

Fatigue in chronic liver disease: New insights and therapeutic approaches

The management of fatigue associated with chronic liver disease is a complex and major clinical challenge. Although fatigue can complicate many chronic diseases, it is particularly common in diseases with an inflammatory component. Fatigue can have both peripheral (i.e., neuromuscular) and central (i.e., resulting from changes in neurotransmission within the brain) causes. However, fatigue in chronic liver disease has strong social/contextual components and is often associated with behavioural alterations including depression and anxiety. Given the increasing awareness of patient‐reported outcomes as important components of treatment outcomes and clinical research, there is a growing need to better understand and manage this poorly understood yet debilitating symptom. Although several pathophysiological mechanisms for explaining the development of fatigue have been generated, our understanding of fatigue in patients with chronic liver disease remains incomplete. A better understanding of the pathways and neurotransmitter systems involved may provide specific directed therapies. Currently, the management of fatigue in chronic liver disease can involve a combined use of methods to beneficially alter behavioural components and pharmacological interventions, of which several treatments have potential for the improved management of fatigue in chronic liver disease. However, evidence and consensus are lacking on the best approach and the most appropriate biochemical target(s) whilst clinical trials to address this issue have been few and limited by small sample size. In this review, we outline current understanding of the impact of fatigue and related symptoms in chronic liver disease, discuss theories of pathogenesis, and examine current and emerging approaches to its treatment.     

Cardiovascular Considerations in the Management of People With Suspected Long COVID

Approximately 15% of adult Canadians with SARS-CoV-2 infection develop lingering symptoms beyond 12 weeks after acute infection, known as post-COVID condition or long COVID. Some of the commonly reported long COVID cardiovascular symptoms include fatigue, shortness of breath, chest pain, and palpitations. Suspected long-term cardiovascular complications of SARS-CoV-2 infection might present as a constellation of symptoms that can be challenging for clinicians to diagnose and treat. When assessing patients with these symptoms, clinicians need to keep in mind myalgic encephalomyelitis/chronic fatigue syndrome, postexertional malaise and postexertional symptom exacerbation, dysautonomia with cardiac manifestations such as inappropriate sinus tachycardia, and postural orthostatic tachycardia syndrome, and occasionally mast cell activation syndrome. In this review we summarize the globally evolving evidence around management of cardiac sequelae of long COVID. In addition, we include a Canadian perspective, consisting of a panel of expert opinions from people with lived experience and experienced clinicians across Canada who have been involved in management of long COVID. The objective of this review is to offer some practical guidance to cardiologists and generalist clinicians regarding diagnostic and treatment approaches for adult patients with suspected long COVID who continue to experience unexplained cardiac symptoms.     

Exercise in myositis: What is important,the prescription or the person?

Our aim for this narrative review was to undertake a search of studies into exercise for people living with Idiopathic Inflammatory myopathies (IIM). We explored the strength of existing evidence with a particular consideration for the implications for people living with IIM and what is important to them. The search strategy from the 2021 Cochrane Physical Activity review in neuromuscular disease was used, and we selected articles that included people with IIM, including Dermatomyositis (DM), Inclusion Body Myositis (IBM), Immune Mediated Necrotising Myopathy (IMNM) [also known as necrotizing autoimmune myopathy (NAM)], and Polymyositis (PM). 2967 records were screened and 16 were included in this review. Safety of exercise was demonstrated in nine articles, using a range of measures of disease activity, serum creatine kinase, indicators of inflammation, pain, or fatigue. Two studies that took muscle biopsies showed no evidence of increased inflammation. Aerobic exercise protocols were used in 8 studies across conditions and demonstrated improvements in cardiorespiratory fitness or exercise capacity. Six studies of strength training observed improvements in muscle function, with two studies reporting muscle biopsy results of amplified immune response and up regulation of genes related to recycling of damaged proteins. Nine of 13 studies that measures functional outcomes showed significant improvements, and evidence for behaviour change was observed in a study of a self-management intervention. The evidence of safety and effect of training is reassuring and welcome, and we now need to explore how we support people to incorporate exercise and physical activity longer term into active lifestyles.     

Cancer-related fatigue and its psychosocial burden

Cancer-related fatigue (CRF) is a highly prevalent and the most distressing symptom during and after treatment for cancer. It is characterized by feelings of physical and mental tiredness, weakness, and lack of energy and is not influenced by rest or sleep. Approximately 40% of patients suffer from CRF at diagnosis and nearly all patients experience fatigue during the course of cancer therapy. The impact of CRF on daily living and patient quality of life (QoL) is substantial. It profoundly affects patient quality of life and limits personal, social and occupational roles. The fatigue is also associated with significant levels of distress and it imposes a financial burden by limiting the ability to work. The underlying causes of CRF are poorly understood as are the relationship between fatigue and psychosocial distress, depression or anxiety. This paper seeks to give an overview of cancer-related fatigue and its psychosocial burden.     

Tumorbedingte Fatigue und ihre psychosozialen Belastungen

Cancer-related fatigue (CRF) is a highly prevalent and the most distressing symptom during and after treatment for cancer. It is characterized by feelings of physical and mental tiredness, weakness, and lack of energy and is not influenced by rest or sleep. Approximately 40% of patients suffer from CRF at diagnosis and nearly all patients experience fatigue during the course of cancer therapy. The impact of CRF on daily living and patient quality of life (QoL) is substantial. It profoundly affects patient quality of life and limits personal, social and occupational roles. The fatigue is also associated with significant levels of distress and it imposes a financial burden by limiting the ability to work. The underlying causes of CRF are poorly understood as are the relationship between fatigue and psychosocial distress, depression or anxiety. This paper seeks to give an overview of cancer-related fatigue and its psychosocial burden.     

Practical guidelines for the acute emergency sedation of the severely agitated older patient

The vulnerability of older people to serious underlying medical illness and adverse effects of psychotropics means that the safe and effective treatment of severe agitation can be lifesaving, the primary management goals being to create a safe environment for the patient and others, and to facilitate assessment and treatment. We review the literature on acute sedation and provide practical guidelines for the management of this problem addressing a range of issues, including aetiology, assessment, pharmacological and non-pharmacological strategies, restraint and consent. The assessment of the agitated older patient must include concurrent assessment of the likely aetiology of, the risks posed by, and the risks/benefits of management options for, the agitation. A range of environmental modifications and non-pharmacological strategies might be implemented to maximize the safety of the patient and others. Physical restraints should only be considered after appropriate assessment and trial of alternative management and if the risk of restraint is less than the risk of the behaviour. Limited evidence supports a range of pharmacological options from traditional antipsychotics to atypical antipsychotics and benzodiazepines. It is advised to start low and go slow, using small increments of dose increase. Medical staff are frequently called to sedate agitated older patients in hospital settings, often after hours, with limited access to relevant medical information and history. Safe and effective management necessitates adequate assessment of the aetiology of the agitation, exhausting all non-pharmacological strategies, and resorting to pharmacological and/or physical restraint only when necessary, judiciously and for a short-term period, with frequent review and the obtaining of consent as soon as possible.     

Impact of psychological stress on irritable bowel syndrome

Psychological stress is an important factor for the development of irritable bowel syndrome (IBS). More and more clinical and experimental evidence showed that IBS is a combination of irritable bowel and irritable brain. In the present review we discuss the potential role of psychological stress in the pathogenesis of IBS and provide comprehensive approaches in clinical treatment. Evidence from clinical and experimental studies showed that psychological stresses have marked impact on intestinal sensitivity, motility, secretion and permeability, and the underlying mechanism has a close correlation with mucosal immune activation, alterations in central nervous system, peripheral neurons and gastrointestinal microbiota. Stress-induced alterations in neuro-endocrine-immune pathways acts on the gut-brain axis and microbiota-gut-brain axis, and cause symptom flare-ups or exaggeration in IBS. IBS is a stress-sensitive disorder, therefore, the treatment of IBS should focus on managing stress and stress-induced responses. Now, non-pharmacological approaches and pharmacological strategies that target on stress-related alterations, such as antidepressants, antipsychotics, miscellaneous agents, 5-HT synthesis inhibitors, selective 5-HT reuptake inhibitors, and specific 5-HT receptor antagonists or agonists have shown a critical role in IBS management. A integrative approach for IBS management is a necessary.     

Non-pharmacological intervention for rehabilitation of post-stroke spasticity: A protocol for systematic review and network meta-analysis

Background:Post-stroke spasticity (PSS) is a major worldwide health problem, and timely and effective rehabilitation is associated with the risk of diabetes development; there are a variety of non-pharmacological interventions applied to the rehabilitation of PSS in these treatments; however, the relative efficacy and safety of different therapies remain uncertain, and we will conduct a systematic review and network meta-analysis to evaluate different non-pharmacological interventions. The relative efficacy and safety of intervention in PSS rehabilitation, thus providing evidence to support the optimization of the PSS rehabilitation program.Methods:We searched the following databases electronically, including four English literature databases (i.e., PubMed, Medline, Embase, and Cochrane Library) and two Chinese literature databases (i.e., China National Knowledge Infrastructure and VIP). We will also search for randomized controlled trials on non-pharmacological interventions for post-stroke spasticity, and the search time limit is from its establishment to May 2020. Two reviewers working independently will screen the titles, abstracts, and full papers. Data extraction will be completed by two independent authors. The primary outcome was the motor function. The secondary outcome was the assessment of daily living ability. We will use RevMan V.5.3 software to compute the data synthesis carefully when a meta-analysis is allowed. We will conduct Bayesian network meta-analysis using the Markov Chain Monte Carlo random effects model in Aggregate Data Drug Information System version 1.16.8 (Drugis, Groningen, NL).Results:This study provides a high-quality synthesis to assess the effectiveness and safety of non-pharmacological interventions for patients with PSS.Conclusion:The results of this study will provide evidence to judge whether non-pharmacological interventions are effective interventions for patients with post-stroke spasticity.Ethics and dissemination:The results of this meta-analysis and meta-regression will be disseminated through publication in a peer-reviewed journal and presented at a relevant conference. The data used in the network meta-analysis did not contain individual patient data. Therefore, ethical approval was not required.INPLASY registration number:INPLASY202140059     

Chronic fatigue syndrome in cancer patients. Diagnostic and treatment options

Fatigue is the most frequent symptom accompanying a cancer disease and its treatment according to the visual analogue scale. Fatigue is reported by as many as 100% of patients in the course of cancer treatment and still by 40 to 70% of patients one year after the treatment has finished. This symptom has become known under the designation of "cancer-related fatigue" in the English language literature on the subject. The knowledge of the causes and mechanisms of fatigue is relatively limited. Based on practical guidelines, an algorithm has been used to detect, evaluate and influence by treatment the syndrome of fatigue caused by a cancer disease. Research in the field has been focused on both pharmacological and non-pharmacological approach. The highest efficiency in the treatment of fatigue syndrome has been recorded for the treatment of anaemia with erythropoietin, while aerobic exercise programmes have proven to be most efficient among the behavioural measures. In spite of a dramatically growing interest in the above problem in the past decade, a number of issues continue unresolved with respect to chronic fatigue syndrome related to a cancer disease or to its treatment. Based on their own experience and on the relevant literature, the authors deal with issues of chronic fatigue syndrome and the options for its diagnosing and treatment in patients undergoing cancer treatment.     

A Comparison of Pain,Fatigue, Dyspnea and their Impact on Quality of Life in Pulmonary Rehabilitation Participants with Chronic Obstructive Pulmonary Disease

In addition to dyspnea and fatigue, pain is a prevalent symptom in chronic obstructive pulmonary disease (COPD). Understanding the relative prevalence, magnitude, and interference with aspects of daily living of these symptoms can improve COPD management. Therefore, the purposes of this study were to: (1) compare the prevalence and magnitude of dyspnea, fatigue, and pain and how each limits aspects of daily living; (2) determine the association between pain and the other two symptoms; and (3) assess the impact of these symptoms on quality of life in COPD. Participants were recruited from pulmonary rehabilitation programs. Pain, dyspnea, and fatigue were measured using the Brief Pain Inventory (BPI), Brief Fatigue Inventory (BFI), and Dyspnea Inventory (DI), respectively. Quality of life was measured using the Clinical COPD Questionnaire (CCQ). The prevalence of dyspnea, fatigue, and pain were 93%, 77%, and 74%, respectively. Individuals with COPD reported similar severity scores of the three symptoms. Dyspnea interfered with general activity more than pain (F_1.7,79.9 = 3.1, p < 0.05), whilst pain interfered with mood (F_{1.8, 82.7} = 3.6, p < 0.05) and sleep (F_1,46 = 7.4, p < 0.01) more than dyspnea and fatigue. These three symptoms were moderately-to-highly correlated with each other (ρ = 0.49–0.78, p < 0.01) and all individually impacted quality of life. In summary, pain is a common symptom in addition to dyspnea and fatigue in COPD; all three interfere similarly among aspects of daily living with some exceptions. Accordingly, management of COPD should include a multifaceted approach that addresses pain as well as dyspnea and fatigue.     

Managing treatment complexity in cystic fibrosis: challenges and opportunities

Cystic fibrosis (CF) is a complex, chronic, multisystem disease for which there is currently no cure. Nonetheless, advances in management have led to dramatic improvements in patient survival. With this development, new issues have arisen for CF patients and their care providers, including an increased symptom burden and increased frequency of co-morbidities as patients reach older ages, leading to the need for a highly complicated and time-consuming regimen of treatments. Such high symptom and treatment burden often leads to non-adherence and low levels of competence with administration of therapy, both of which may have detrimental impacts on CF outcomes. Optimal management is also hindered by other patient-related factors, including inadequacies in disease education which may lead to issues with self-management. This is particularly important during the transition from parent-directed therapy to independent self-management that occurs during adolescence and early adulthood. Clinicians are also faced with a considerable challenge when selecting interventions for individual patients; although the paradigm of aggressive care necessitates a wide range of therapies, there is a limited evidence base with which to compare available therapeutic regimens. Novel pharmacological agents are being developed to target the underlying cause of CF, while non-pharmacological interventions aim to improve competence and maximize adherence and health outcomes. Comparative effectiveness research is needed to simplify management and facilitate the implementation of appropriate treatment strategies.     

Recent Developments in Diagnosis and Assessment of Morphea

Pain is a complex phenomenon affected by biological, psychological, and social factors. Treatment of pain is most effective when using a multidisciplinary approach consisting of a careful selection of pharmacological and non-pharmacological interventions based upon disease factors, pain characteristics, psychological coping abilities, and lifestyle factors. In this review we focus on research-based evidence for non-pharmacological intervention including psychological intervention, physical exercise, patient education, and complementary approaches for pain management for patients with rheumatic diseases and common musculoskeletal pain conditions, such as low back pain. The vast majority of research studies on chronic pain conditions are focused on adults but pediatric studies are also reviewed wherever possible, to give the reader a more inclusive view of non-pharmacological approaches for pain management across the lifespan.     

A meta-analysis to determine the effect of pharmacological and non-pharmacological treatments on fibromyalgia symptoms comprising OMERACT-10 response criteria

Fibromyalgia is characterized by widespread pain, sleep problems, fatigue, functional impairment, psychological distress, and cognitive dysfunction. The objective of this meta-analysis is to synthesize the available data on the effectiveness of pharmacological and non-pharmacological interventions across all domains included in the Outcome Measures in Rheumatology Clinical Trials (OMERACT-10) fibromyalgia response definitions, and to examine response based on these definitions. We searched Cochrane, PubMed, Scopus, and the reference lists of articles for randomized controlled trials of any drug formulation or non-pharmacological intervention used for fibromyalgia treatment. We extracted efficacy data regarding pain, sleep, physical function, fatigue, anxiety, depression, and cognition. The available data were insufficient to draw definite conclusions regarding response. Indirect evidence indicates that it may be expected with the use of serotonin noradrenaline reuptake inhibitors (SNRIs), noradrenaline reuptake inhibitors (NRIs), and multidisciplinary treatment.     

“Worn out”: Coping strategies for managing antiretroviral treatment fatigue among urban people of color living with HIV who were recently disengaged from outpatient HIV care

Abstract

Antiretroviral-related treatment fatigue is inconsistently defined in the literature on barriers to ART adherence. Research suggests that treatment fatigue is a salient challenge for people struggling with antiretroviral therapy adherence, but little is known about how people living with HIV attempt to manage this fatigue. Twenty-seven semi-structured interviews were conducted with low-income people of color living with HIV in NYC that were currently, or recently, disengaged from HIV care. The findings from this exploratory study suggest that treatment fatigue was common and that participants devised personal strategies to overcome it. These strategies included using reminder programs, requesting weekly rather than monthly pill quantities, and taking “pill holidays”. The varied nature- and varying levels of effectiveness- of these strategies highlight the need for specific programing to provide tailored support. Future research should examine treatment fatigue as a specific subtype of adherence challenge, and aim to define pill fatigue clearly.     

Reducing the impact of rheumatic diseases in childhood

Reducing the impact of rheumatic diseases in childhood is the fundamental objective of every member of the multi-disciplinary team involved in the care of affected children and families. The means by which this objective may be achieved are broad and include the implementation of a range of non-pharmacological therapies to address the effects of rheumatic diseases on the physical development of the child. In addition, the treating team must be aware of the psychosocial impact that these diseases may have and the ways in which this may be minimized. This chapter is devoted to an examination of some of the non-pharmacological issues that arise in the management of the commonest rheumatic disease found in children, juvenile idiopathic arthritis (JIA). Aspects of physical rehabilitation, schooling, medication compliance, pain management and family dynamics are discussed, as are interventions to reduce the impact of this disease and its sequelae, utilizing, where possible, evidence-based principles from the literature. Although specific issues applicable to children with arthritis will be discussed, the broad principles of much of what follows applies to all of the rheumatic diseases in childhood.     

The role of digital health technologies in management of pain in older people: An integrative review

Pain is one of the most distressing and debilitating health issues faced by older people. The burden of unrelieved pain experienced by older people and its associated high symptom and economic costs demands consideration of new strategies to better this condition. As the global uptake of digital technology increases, exploring its potential to impact positively on older peoples’ pain self-management practices warrants investigation. This integrative review aimed to evaluate the use of digital health technology for management of older people’s pain across care-settings. Searches were conducted to identify relevant English language studies published in CINHAL, Medline, Academic Search Complete, EMBASE, Cochrane library databases, and Google and Google Scholar websites. A total of 1003 papers were identified, 9 met the inclusion criteria. The highest level of evidence (Level II) was generated by three Phase II randomized controlled trials. These trials demonstrated the feasibility of computer based interactive or instructive video interventions however there was limited evidence to support their use for reduction of pain intensity and interference. Qualitative evidence demonstrated older people’s willingness to use mobile technologies (iPhone or digital pen) to help manage their pain, however, the need of device-use training and connectedness with clinicians were highlighted.In conclusion, there is some evidence that integrating digital health technology into older peoples’ pain self-management plan is feasible and acceptable. However, the provision of high-quality technological interventions informed by a thorough understanding of older people’s digital technology pain management needs is required to ensure greater integration of this technology in clinical practice.