Improvement of Fatigue and Quality of Life in Patients with Quiescent Inflammatory Bowel Disease Following a Personalized Exercise Program

The Potential Benefits of Exercise in Managing Inflammatory Bowel Disease: A Systematic Review

Adults with inflammatory bowel disease (IBD) experience a significant decline in quality of life due to various symptoms. Exercise has emerged as a potential therapeutic approach to improve IBD management, but its effectiveness requires further investigation. This systematic review, adhering to PRISMA 2020 guidelines, explored the effects of exercise on IBD progression and its potential as a treatment in adults. A comprehensive search strategy was conducted across three databases and two registries from May 12, 2024, to May 22, 2024. Methodological rigor and potential bias were minimized through quality assessment using the Cochrane risk-of-bias tool 2 (RoB 2) for randomized controlled trials (RCTs), the Newcastle-Ottawa Scale (NOS) for cohort studies, and the Joanna Briggs Institute (JBI) critical appraisal checklist for studies evaluating the effectiveness of non-randomized interventions. This process yielded 12 high-quality studies for analysis. The review identified positive evidence from both RCTs and observational studies. Exercise interventions demonstrated improvements in cardiorespiratory fitness, disease activity, quality of life, and mental health in adults with IBD. Studies explored various modalities, including aerobic exercise, resistance training, and mind-body interventions. However, further research is needed to optimize exercise prescription and elucidate the underlying mechanisms of action. This review strengthens the evidence for exercise as a beneficial intervention for IBD patients. Personalized exercise programs based on individual needs hold promise for improved IBD management and patient outcomes. However, limitations exist due to study design variations and the need for long-term follow-up studies.

Deficits in geriatric assessment are important in relation to fatigue in older patients with Inflammatory Bowel Disease

BACKGROUND

No previous study has investigated fatigue in older patients with Inflammatory Bowel Disease (IBD).

AIMS

To describe the prevalence of fatigue in older patients and compare it to the prevalence in younger patients with IBD, and to determine factors associated with fatigue.

METHODS

A prospective, multicenter cohort study, including older- (≥ 65 years) and younger patients with IBD (18-64 years). A geriatric assessment was performed in older patients to measure deficits in geriatric assessment (DiG). Fatigue was defined by one item from the short Inflammatory Bowel Disease Questionnaire. Active disease was defined as the presence of clinical or biochemical disease activity.

RESULTS

Fatigue prevalence in the 405 older patients varied between 45.4% (71/155) in active disease to 23.6% (60/250) in remission. Fatigue prevalence in 155 younger patients was 59.5% (47/79) and 57.4% (89/155), respectively. Female sex, clinical disease activity, use of immunomodulators and presence of DiG were associated with fatigue in older patients with IBD.

CONCLUSIONS

Fatigue prevalence is lower in older patients with IBD compared to younger patients with IBD, but increases when active disease is present. Clinicians should be aware that fatigue is a relevant symptom in older patients with IBD, as it is associated with DiG.

Relationship between depression, anxiety, stress, and health-related quality of life in adults with and without chronic diseases: A cross-sectional study

Health-related quality of life (HRQoL) in patients with chronic diseases is an important tool to measure patient-reported health outcomes and evaluate the usefulness of treatment, management, and rehabilitation programs. Patients with chronic diseases are more likely than those without to experience psychological problems such as depression, anxiety, and stress, all of which can affect HRQoL. This study evaluated the impact of psychological problems such as depression, anxiety, and stress on HRQoL in people with and without chronic diseases in South Korea. The study's descriptive survey included 501 participants (191 with and 310 without chronic diseases). Data were collected using structured questionnaires between April and May 2021. The general characteristics, DASS-21, and HRQOL of this study were analyzed using descriptive statistics. Differences in DASS-21 and HRQoL based on general characteristics were analyzed using t tests and ANOVA. The study analyzed the factors influencing the participants' HRQoL using stepwise multiple regression analysis with SPSS Win 27.0. HRQoL was generally lower for patients with chronic diseases than for patients without. In patients with chronic diseases, the major variables affecting HRQoL were depression (β = -0.244, t = -3.582, P < .001), exercise (β = 0.201, t = 2.927, P = .004), and economic status (β = -0.150, t = -2.184, P = .030), of which depression was the most influential. These variables explained 12.5% of the variance in the regression model for total HRQoL. These results emphasize the need to explore intervention measures that can reduce depression in patients with chronic diseases and anxiety in patients without chronic diseases to improve their HRQoL. In addition, national efforts are needed to provide economic support, as economic status is an influential factor in HRQoL regardless of the presence of chronic disease. The study's limitations include the fact that neither did it consider disease severity among chronically ill patients nor did it examine all the variables affecting HRQoL.

Scoping review on health-related physical fitness in patients with inflammatory bowel disease: Assessment, interventions, and future directions

BACKGROUND

Reaching the Selecting Therapeutic Targets in Inflammatory Bowel Disease-II (STRIDE-II) therapeutic targets for inflammatory bowel disease (IBD) requires an interdisciplinary approach. Lifestyle interventions focusing on enhancing and preserving health-related physical fitness (HRPF) may aid in improving subjective health, decreasing disability, or even controlling inflammation. However, ambiguity remains about the status and impact of HRPF (i.e. body composition, cardiorespiratory fitness, muscular strength, muscular endurance, and flexibility) in IBD patients, hindering the development of physical activity and physical exercise training guidelines.

AIM

To review HRPF components in IBD patients and the impact of physical activity and physical exercise training interventions on HRPF.

METHODS

A systematic search in multiple databases was conducted for original studies that included patients with IBD, assessed one or more HRPF components, and/or evaluated physical activity or physical exercise training interventions.

RESULTS

Sixty-eight articles were included. No study examined the complete concept of HRPF, and considerable heterogeneity existed in assessment methods, with frequent use of non-validated tests. According to studies that used gold standard tests, cardiorespiratory fitness seemed to be reduced, but findings on muscular strength and endurance were inconsistent. A limited number of studies that evaluated physical activity or physical exercise training interventions reported effects on HRPF, overall showing a positive impact.

CONCLUSION

We performed a scoping review using a systematic and iterative approach to identify and synthesize an emerging body of literature on health-related physical fitness in patients with IBD, highlighting several research gaps and opportunities for future research. Findings of this review revealed a gap in the literature regarding the accurate assessment of HRPF in patients with IBD and highlighted important methodological limitations of studies that evaluated physical activity or physical exercise training interventions. This scoping review is a step towards performing studies and systematic reviews in the future, which was not possible at present given the heterogeneity in endpoints and designs of the available studies on this topic. Future well-designed studies are required to determine the optimal training paradigm for improving HRPF in patients with IBD before guidelines can be developed and integrated into the therapeutic strategy.

Physical Training and Healthy Diet Improved Bowel Symptoms, Quality of Life, and Fatigue in Children With Inflammatory Bowel Disease

OBJECTIVES

Physical activity programs have been suggested as adjunctive therapy in adult inflammatory bowel disease (IBD) patients. We assessed the effects of a 12-week lifestyle intervention in children with IBD.

METHODS

This study was a randomized semi-crossover controlled trial, investigating a 12-week lifestyle program (3 physical training sessions per week plus personalized healthy dietary advice) in children with IBD. Endpoints were physical fitness (maximal and submaximal exercise capacity, strength, and core stability), patient-reported outcomes (quality of life, fatigue, and fears for exercise), clinical disease activity (fecal calprotectin and disease activity scores), and nutritional status (energy balance and body composition). Change in maximal exercise capacity (peak VO 2 ) was the primary endpoint; all others were secondary endpoints.

RESULTS

Fifteen patients (median age 15 [IQR: 12-16]) completed the program. At baseline, peak VO 2 was reduced (median 73.3% [58.8-100.9] of predicted). After the 12-week program, compared to the control period, peak VO 2 did not change significantly; exercise capacity measured by 6-minute walking test and core-stability did. While medical treatment remained unchanged, Pediatric Crohn's Disease Activity Index decreased significantly versus the control period (15 [3-25] vs 2.5 [0-5], P = 0.012), and fecal calprotectin also decreased significantly but not versus the control period. Quality of life (IMPACT-III) improved on 4 out of 6 domains and total score (+13 points) versus the control period. Parents-reported quality of life on the child health questionnaire and total fatigue score (PedsQoL Multidimensional Fatigue Scale) also improved significantly versus the control period.

CONCLUSIONS

A 12-week lifestyle intervention improved bowel symptoms, quality of life, and fatigue in pediatric IBD patients.

A systematic review of the effect of structured exercise on inflammation and body composition in inflammatory bowel disease

PURPOSE

Given the substantial risk of treatment failure in inflammatory bowel disease (IBD), adjuvant therapies may play a role in disease management. We aim to carry out a systematic review to examine the effects of structured exercise on the inflammatory response in patients with IBD. Our secondary aim is to examine the effect of structured exercise programmes on body composition given both an increase in visceral obesity and the presence of sarcopenia have deleterious effects on outcomes in IBD.

METHODS

A systematic review was carried out following the Methodological Expectations of Cochrane Intervention Reviews (MECIR) manual and the Cochrane Handbook for Systematic Reviews of Interventions. Title/Abstract and MeSH Terms were used to search for relevant studies.

RESULTS

In total, 1516 records were screened for eligibility, and 148 records were reviewed for eligibility, of which 16 were included and a further 7 studies were identified from hand searching references. Four studies included body composition outcomes, and 14 studies reviewed the inflammatory response to exercise.

CONCLUSION

Further studies of adequate duration are required to include patients with more active disease to demonstrate an inflammatory response to exercise. Body composition measurements including muscle mass and visceral adiposity may play a key role in response to medical therapy in IBD and should be included as exploratory outcomes in future studies. A meta-analysis was not carried out due to the significant heterogeneity amongst studies.

The Effect of Biological Treatment on Fatigue in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis

BACKGROUND

Fatigue is a frequent complaint in patients with inflammatory bowel disease. Biological drugs have demonstrated beneficial effects on some extraintestinal manifestations, but the effect on fatigue is not clear.

OBJECTIVE

This study investigated the effects of biological and small molecule drugs approved for inflammatory bowel disease on fatigue.

METHODS

We performed a systematic review and meta-analysis of randomized, placebo-controlled trials reporting Federal Drug Agency (FDA)-approved biological and small molecule drugs for use in ulcerative colitis and Crohn's disease in which measures of fatigue were recorded before and after treatment. Only induction studies were included. Maintenance studies were excluded. We searched Embase (Ovid), Medline (Ovid), PsycINFO (Ovid), Cinahl (EBSCOhost), Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov in May 2022. Risk of bias was analyzed using the Cochrane risk-of-bias tool. Standardized mean difference was used to measure the treatment effect.

RESULTS

A total of seven randomized controlled trials composed of 3835 patients were included in the meta-analysis. All of the studies included patients with moderately to severely active ulcerative colitis or Crohn's disease. The studies used three different generic fatigue instruments: the Functional Assessment of Chronic Illness Therapy-Fatigue and the Short Form 36 Health Survey Vitality Subscale versions 1 and 2. Overall treatment with biological or small molecule agents showed a beneficial effect compared with placebo, with a standardized mean difference of 0.25 (95% confidence interval 0.15-0.34, p < 0.001). The effect was independent of type of drug or subtype of inflammatory bowel disease.

DISCUSSION

The risk of bias was considered to be low for all domains except for missing outcome data. Even though the included studies were of high methodological quality, the review is limited by the small number of studies included and that the available studies were not designed to evaluate fatigue specifically.

CONCLUSION

Biological and small molecule drugs used in inflammatory bowel disease have a consistent, though small, beneficial effect on fatigue.

ESPEN guideline on Clinical Nutrition in inflammatory bowel disease

The present guideline is an update and extension of the ESPEN scientific guideline on Clinical Nutrition in Inflammatory Bowel Disease published first in 2017. The guideline has been rearranged according to the ESPEN practical guideline on Clinical Nutrition in Inflammatory Bowel Disease published in 2020. All recommendations have been checked and, if needed, revised based on new literature, before they underwent the ESPEN consensus procedure. Moreover, a new chapter on microbiota modulation as a new option in IBD treatment has been added. The number of recommendations has been increased to 71 recommendations in the guideline update. The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. General aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.

An Irish Multi-Centre Study of Behaviours, Attitudes and Barriers to Exercise in Inflammatory Bowel Disease, a Survey from the Patient’s Perspective

Background: Physical activity (PA) in inflammatory bowel disease (IBD) has many potential favourable outcomes including anti-inflammatory effects, improvement in quality of life and improvements in patient body composition. It is recognised that patients with IBD have a significantly decreased exercise tolerance. Aim: 1. To assess physical activity levels, behaviours and barriers to PA in IBD. 2. To assess the likelihood of patients with IBD to engage in a community-based exercise programme. 3. To examine the presence of body image concerns in IBD. Method: Patient surveys were distributed in Beaumont and Connolly Hospitals between October and December 2021. Descriptive statistics, Chi-squared testing and Pearson’s correlations were completed using Minitab. p < 0.05 denoted statistical significance. Results: Data were recorded for a total of 203 patients. Out of all patients, 62% (n = 126) had Crohn’s disease (CD). Over half of the cohort were male (n = 115). Mean weight among females was 75 kg and 83 kg among males. Exercise behaviours: Out of all patients, 71% exercise regularly, on average for 59 min, 3.2 days/week. Walking was the most common form of PA (74%). A post-diagnosis change in exercise behaviour was found in 66% with three-quarters exercising less. The primary barrier to exercise was fatigue (54%). Female gender (p = 0.007) and age < 45 years (p = 0.02) were associated with body image dissatisfaction reported in 62% of patients. Conclusion: These data demonstrate the patient-reported impact of IBD on patient participation in PA. Concerns regarding body image were common and associated with gender and age. A feasibility study of a physician-derived exercise programme in patients with active IBD is underway in Beaumont Hospital to determine the effect on patient response to therapy, inflammation and body composition outcomes (NCT05174754).

Effects of structured exercise programmes on physiological and psychological outcomes in adults with inflammatory bowel disease (IBD): A systematic review and meta-analysis

BACKGROUND

Exercise has been suggested to counteract specific complications of inflammatory bowel disease (IBD). However, its role as a therapeutic option remains poorly understood. Therefore, we conducted a systematic review and meta-analysis on the effects of exercise in IBD.

METHODS

Five databases (MEDLINE, Embase, CINAHL, CENTRAL and SPORTDiscus) and three registers (Clinicaltrials.gov, WHO ICTRP and ISRCTN) were searched from inception to September 2022, for studies assessing the effects of structured exercise of at least 4 weeks duration on physiological and/or psychological outcomes in adults with IBD. Two independent reviewers screened records, assessed risk of bias using the Cochrane Risk of Bias (RoB 2.0) and ROBINS-I tools, and evaluated the certainty of evidence using the GRADE method. Data were meta-analysed using a random-effects model.

RESULTS

From 4,123 citations, 15 studies (9 RCTs) were included, comprising of 637 participants (36% male). Pooled evidence from six RCTs indicated that exercise improved disease activity (SMD = -0.44; 95% CI [-0.82 to -0.07]; p = 0.02), but not disease-specific quality of life (QOL) (IBDQ total score; MD = 3.52; -2.00 to 9.04; p = 0.21) when compared to controls. Although meta-analysis could not be performed for other outcomes, benefits were identified in fatigue, muscular function, body composition, cardiorespiratory fitness, bone mineral density and psychological well-being. Fourteen exercise-related non-serious adverse events occurred. The overall certainty of evidence was low for disease activity and very low for HRQOL as a result of downgrading for risk of bias and imprecision.

CONCLUSIONS

Structured exercise programmes improve disease activity, but not disease-specific QOL. Defining an optimal exercise prescription and synthesis of evidence in other outcomes, was limited by insufficient well-designed studies to ascertain the true effect of exercise training. This warrants further large-scale randomised trials employing standard exercise prescription to verify this effect to enable the implementation into clinical practice.

REGISTRATION

This systematic review was prospectively registered in an international database of systematic reviews in health-related research (CRD42017077992; https://www.crd.york.ac.uk/prospero/).

Physical Activity in Patients With Inflammatory Bowel Disease: A Narrative Review

BACKGROUND

Despite advancement in the treatment of inflammatory bowel disease (IBD), induction and maintenance of remission remain challenging to achieve in many patients and a significant proportion of patients with IBD experience mental health conditions, including anxiety, depression, and fatigue, which impair their quality of life (QoL). We aim to describe the available evidence regarding the effects of physical activity (PA) on the onset of IBD, its disease course, and important patient-reported outcome measures (PROMs), such as QoL, fatigue, and mental health.

METHODS

A literature search was performed using electronic databases to identify original articles that assessed the effects of PA in patients with IBD using PROMs.

RESULTS

Prospective cohort and case-control studies demonstrate inverse relationships between PA and new-onset IBD in Crohn's disease but not in ulcerative colitis; however, they have small sample sizes and caution must be taken in considering associations versus causation. Small randomized controlled trials suggest promise for PA and beneficial outcomes, such as maintenance of clinical remission and improvement in QoL, fatigue, depression, and anxiety. However, these studies were small and underpowered, and limited by outcome measurements and durations of follow-up.

CONCLUSIONS

Physicians may consider discussing PA interventions with their patients on an individual basis, especially if they report impaired QoL, fatigue, depression, or anxiety, until disease-specific guidelines are available. Including PA as part of a primary prevention strategy in high-risk patients could be considered.

Prehabilitation prior to intestinal resection in Crohn’s disease patients: An opinion review

Patients with Crohn’s disease (CD) are at a considerable risk for intestinal surgery. Approximately 25% of patients with CD will undergo an intestinal resection within 10 years of diagnosis. Postoperative complications after CD surgery have been reported in 20%-47% of the patients. Both general and CD-related risk factors are associated with postoperative complications, and comprise non-modifiable (e.g., age) and potentially modifiable risk factors (e.g., malnutrition). Prehabilitation focuses on the preoperative period with strategies designed to optimize modifiable risk factors concerning the physical and mental condition of the individual patient. The aim of prehabilitation is to enhance postoperative recovery and return to or even improve preoperative functional capacity. Preoperative improvement of nutritional status, physical fitness, cessation of smoking, psychological support, and critical revision of preoperative use of CD medication are important strategies. Studies of the effect on postoperative outcome in CD patients are scarce, and guidelines lack recommendations on tailored management. In this opinion review, we review the current evidence on the impact of screening and management of nutritional status, physical fitness, CD medication and laboratory values on the postoperative course following an intestinal resection in CD patients. In addition, we aim to provide guidance for individualized multimodal prehabilitation in clinical practice concerning these modifiable factors.

Physical activity in inflammatory bowel disease: benefits, challenges and perspectives

PURPOSE OF THE REVIEW

Physical activity is gaining significative interest in the field of inflammatory bowel disease (IBD). In the light of the most recent publications, the present review aims to describe the level of physical activity in adult patients with IBD; describe the current body of evidence on the benefits of physical activity and discuss the challenges and perspectives related to physical activity in this population.

RECENT FINDINGS

Recent studies showed that IBD patients tend to be less active than healthy people. There is growing evidence of a positive impact of physical activity on mortality, quality of life, fatigue, body composition, strength and physical performance. The direct benefits of physical activity on clinical remission and disease activity have recently been observed only in Crohn's disease. Limitations to physical activity related to the disease, such as gastrointestinal and psychological symptoms, need to be considered in this population. Finally, no guidelines are available and there is no evidence regarding the effects of combined physical activity and nutritional support.

SUMMARY

Although physical activity seems beneficial and safe for IBD patients, future studies are needed to clearly define recommendations in this population.

Prevalence and Risk Factors for Fatigue in Adults With Inflammatory Bowel Disease: A Systematic Review With Meta-Analysis

BACKGROUND AND AIMS

Inflammatory bowel disease (IBD) is a chronic relapsing and remitting disease with high morbidity, substantial health care costs, and increasing incidence. Fatigue is one of the most common symptoms that impacts quality of life and is a leading concern for patients with IBD. The aim of this study was to determine the global prevalence, risk factors, and impact of fatigue in adults with IBD.

METHODS

A systematic review and meta-analysis was conducted. Data were retrieved from Medline, Embase, CINAHL, and PsycINFO from database inception to October 2019. A pooled prevalence of fatigue was calculated using a random-effects model. Stratified meta-analyses explored sources of between-study heterogeneity. Study quality was assessed using an adapted checklist from Downs and Black.

RESULTS

The search yielded 4524 studies, of which 20 studies were included in the systematic review and meta-analysis. Overall, the studies were of good quality. The pooled prevalence of fatigue was 47% (95% confidence interval, 41%-54%), though between-study heterogeneity was high (I² = 98%). Fatigue prevalence varied significantly by the definition of fatigue (chronic: 28%; high: 48%; P < .01) and disease status (active disease: 72%; remission: 47%; P < .01). Sleep disturbance, anxiety, depression, and anemia were the most commonly reported fatigue-related risk factors.

CONCLUSIONS

The prevalence of fatigue in adults with IBD is high, emphasizing the importance of additional efforts to manage fatigue to improve the care and quality of life for patients with IBD.

Moderate endurance and muscle training is beneficial and safe in patients with quiescent or mildly active Crohn's disease

BACKGROUND AND AIMS

Physical activity is beneficial in several chronic disorders including Crohn's disease, but the preferred type of exercise is unknown. Our study aimed to examine and compare the safety, feasibility and potential beneficial effects of individual moderate endurance and moderate muscle training in patients with Crohn's disease.

METHODS

Quiescent or mildly active (Crohn's disease activity index <220) patients with Crohn's disease were randomly allocated to either a control, endurance, or muscle training group. Participants exercised individually for 3 months three times per week. Endpoints included dropout rate, disease activity, inflammatory parameters including faecal calprotectin, anthropometric data, quality of life, physical activity and strength.

RESULTS

A total of 45 patients with Crohn's disease were randomly allocated. In the endurance group (n = 17), the dropout rate was significantly higher (47% vs. 13%) compared with the muscle group (n = 15). In both groups the maximal and average strength in the upper and lower extremities increased significantly (all P < 0.04). In the endurance group emotional function was significantly improved (P = 0.03). Statistically significant changes of disease activity and other outcome parameters were not observed in this pilot cohort.

CONCLUSION

Both individual moderate endurance and muscle training can be safely performed in patients with mild or quiescent Crohn's disease. Muscle training appears more feasible and may be favoured. Both forms of exercise have beneficial effects on strength. Quality of life increased in both intervention groups, although statistical significance was only reached in one subgroup.