Table 1.

Recommendations on patient education and treatments for systemic sclerosis patients with fatigue

			Level of evidence	Reference	Level of Agreement (0–10) Mean (s.d.); Median (range)
PATIENT EDUCATION
Persistent fatigue can have far-reaching consequences for activities of daily living and social participation. It is therefore essential that all patients with SSc who report symptoms of fatigue are properly informed about measures that support self-management skills.   All SSc patients who report fatigue should receive patient information about the following aspects.
	1.	Maintaining good physical condition and regular exercise	I	[35–37]	9.3 (0.8) 9 (8–10)
	2.	Principles of energy conservation and good sleep hygiene	I	[36, 38]	8.8 (1.0) 9 (7–10)
	3.	Relaxation exercises	I	[38]	7.5 (1.7) 7 (4–10)
	4.	A healthy diet	V	n/a	7.9 (1.8) 8 (2–10)
	5.	The possible link between fatigue and drug side effects	V	n/a	7.2 (2.1) 8 (2–10)
TREATMENTS
a) Treatments for SSc patients with persistent fatigue and related restrictions in whose activities of daily living and who have an imbalance between mental load and mental resilience
	6.	Psychoeducational interventions (individually or in a group) aimed at principles of goal setting, energy conservation, dealing with the social environment and relaxation should be offered to SSc patients with fatigue. These interventions can be performed by a skilled health professional, e.g. a nurse, social worker or occupational therapist.	I	[36, 38, 39]	8.7 (1.1) 9 (7–10)
	7.	CBT under the supervision of a psychologist should be offered to SSc patients with fatigue, if there are severe impediments to activities of daily living.	I	[38–40]	8.2 (1.2) 8.0 (6–10)
	8.	Participation in available online and face-to-face courses with fellow patients, provided by trained patient representatives: e.g. ReumaUitgedaagd! (self-management training for people with rheumatism) should be offered to patients with SSc with fatigue.	V	n/a	8 (1.3) 8 (5–10)
	9.	In order to maintain the ability to work, SSc patients with fatigue should be guided in adapting the work environment or switching to different work by a skilled health professional, e.g. an occupational therapist or social worker.	V	n/a	8.3 (1.2) 8.0 (5–10)
b) Treatments for SSc patients with persistent fatigue where reduced physical resilience plays a role
	10.	SSc patients with fatigue should receive support to improve exercise capacity and incorporate more physical activity into daily life with the guidance of health professionals such as physical therapists.	I	[35–38, 41–43]	9.1 (1.0) 9 (7–10)
	11.	Advice about a healthy diet and preventing malnutrition offered by e.g. a dietician should be offered to SSc patients with fatigue.	V	n/a	7.9 (1.2) 8 (6–10)
c) Multidisciplinary treatments
	12.	A multidisciplinary rehabilitation program should be offered to SSc patients with severe fatigue symptoms that lead to problems in several domains of activities of daily living.	V	n/a	8.3 (1.6) 9 (3–10)

Level of evidence (according to the standards of the Oxford Centre for Evidence Based Medicine), Level of Agreement for the recommendations, Numeric Rating Scale from 0 (total disagreement) to 10 (total agreement) reported as mean (range), n/a not applicable. CBT: cognitive behavioural therapy.