Durable Improvement in Rheumatic Pain, Health Seen With Brief Lifestyle Program

A comprehensive lifestyle-improvement program — delivered entirely online — helped patients with inflammatory arthritis (IA), osteoarthritis (OA), and fibromyalgia enjoy better overall health and less pain and fatigue long after the formal intervention ended, Dutch researchers said.

Focusing on nutrition, physical activity, sleep quality, and relaxation, the primary program lasted 3 months and participants were followed for an additional 21 months, during which they could seek additional advice. Almost all patient-reported outcome measures showed at least numerical improvements at the end of the full 2 years, according to Kim van Slingerland, MSc, RN, of Erasmus Medical Center in Rotterdam, the Netherlands, and colleagues.

In many cases, the group reported in Rheumatology, the gains were statistically and clinically significant as well, if relatively modest.

For example, at 24 months, mean pain ratings on a 100-point scale had decreased 8 points from baseline in IA patients, 3 points in those with OA, and 10 points in the fibromyalgia patients. These were statistically significant in the IA and fibromyalgia groups.

Patients in all three groups saw mean weight loss of 4.2-4.3 kg after 3 months, all P<0.001. Some regain occurred during the “aftercare” period, but remained numerically below baseline (significantly so in IA patients). The same pattern was seen for body mass index and waist circumference.

Other highlights included:

• In all three disease categories, morning stiffness improved by 1 point from baseline on a 10-point scale after 3 and 24 months
• Fatigue showed small but persistent improvements across disease types
• OA and fibromyalgia patients reported significantly less stress, by 2.8 and 2.4 points, respectively, on a 40-point scale
• Mean sleep disturbance ratings declined by roughly 4-6 points out of 100, but these fell short of statistical significance in the OA and fibromyalgia patients
• Patients were generally satisfied with the overall program and its individual components, awarding ratings of 6.0-7.6 on an 11-point scale

Notably, though, van Slingerland and colleagues characterized the study as a pilot and did not include control groups. Also, attrition was high: dropout rates after 1 year were 28%, 33%, and 51% for the IA, OA, and fibromyalgia patients, respectively, although most of those still retained at that point stayed through the final year.

Some outcomes showed little change, notably for overall health status as evaluated with the Health Assessment Questionnaire and for life impacts from their disease.

Study Details

The program was designed by Voeding Leeft, a foundation based in the Netherlands, and was dubbed “Leef! met reuma” (“Live! with rheumatism”). Participants were encouraged to eat a healthy Mediterranean-type diet and to avoid processed foods, alcohol, and between-meal snacking. Techniques for relaxation and proper sleep were taught, too, as were exercises appropriate for their health conditions. All of these were geared toward “sustainable behavioral change,” the researchers explained.

Participants attended three 5-hour plenary meetings in groups of about 100 and also got six coaching sessions in smaller groups — all via the Zoom platform. “Patients also had access to a secure online platform during the 24-month program where they could find more background information, ask questions (to the program coordinator, nutritionist, lifestyle coach, or peers) and/or share their experiences,” van Slingerland and colleagues wrote.

A total of 264 patients enrolled: 88 with IA, 105 with OA, and 71 with fibromyalgia. Women comprised 90% or more of each disease group. Mean age was 59 for IA, 50 for OA, and 47 for fibromyalgia. About two-thirds of the IA and OA groups were considered to have low education, as were half of the fibromyalgia patients. Body mass index values averaged 28 among the IA and fibromyalgia patients, and 26 in the OA group.

Pain scores at baseline averaged about 35-50 on the 100-point scale among the three disease groups; fatigue, also rated up to 100, averaged 50-65. Mean ratings of sleep disturbance were in the range of 35-50 at baseline.

All outcomes were patient-reported, a study strength but also a limitation, insofar as standard disease-specific assessments such as DAS28 for rheumatoid arthritis or WOMAC scores for OA that include objective measures were not reported either at baseline or during follow-up.

Besides the lack of control groups, other limitations to the study included the relatively small number of patients, which precluded analyses stratified by IA subtypes, and the predominance of women in the sample.