Adult Inflammatory Bowel Disease, Physical Rehabilitation, and Structured Exercise

What aspects do we overlook in the rehabilitation of patients with inflammatory bowel disease?

In this editorial, we comment on the article by Stafie et al. Inflammatory bowel disease (IBD) constitutes a cluster of chronic and progressive inflammatory disorders affecting the digestive system. IBD can impede an individual's capacity to perform daily activities, hinder work productivity, limit physical capabilities, and negatively impact medical outcomes. Although physical activity and structured exercise programs are becoming increasingly important in many chronic inflammatory diseases, they are not being sufficiently implemented in IBD patients. Effective prevention of future disability and drug dependence in IBD patients requires timely diagnosis and treatment of musculoskeletal problems, including sarcopenia, as well as decreased muscle strength, aerobic capacity, and bone mineral density. To improve treatment outcomes for IBD patients, it is crucial to develop individualized rehabilitation programs tailored to their unique needs. Equally critical is the active participation of pertinent departments in this process. It is imperative to highlight the significance of creating a personalized rehabilitation program with a multidisciplinary approach in IBD management.

Disability, Physical Activity, and Their Correlates in Patients With Inflammatory Bowel Disease: A Portuguese Cross-Sectional Survey

Knowledge about disability and physical activity is critical for enhancing self- and clinical management of inflammatory bowel disease, but the interplay between the two is unknown. This study aimed to explore the correlates of disability and physical activity in patients with inflammatory bowel disease. A cross-sectional online survey was conducted in 2019 in Portuguese patients (n = 108) capturing disability, clinical factors including disease status and comorbidities, physical activity habits, and barriers. The magnitude of disability was moderate (mean [95% confidence interval] = 41.85 [38.39, 45.31]). Disease activity and comorbidities were the most important predictors of disability (Model 2, F(102) = 20.285, p < .001, R2 = 0.499, R2adj = 0.443). About 62% of the participants engaged in moderate (31.5%) to vigorous (30.6%) physical activities. Perceived effort to engage in physical activities was the sole predictor of total weekly physical activity (R2 = 0.070, R2adj = 0.044, p = .006). The amount of disability and physical activity were poorly associated (ρ = -0.144, p = .068). Findings encourage gastroenterology nurses and other healthcare providers involved in the comprehensive care of patients with gastrointestinal disorders to recommend regular physical activity to these patients as part of an overall health enhancement strategy. Disability and back pain should be given further attention.

The IBD-FITT study - moderate-intensity exercise for patients with inflammatory bowel disease with moderate disease activity: an open-label randomized controlled trial

BACKGROUND

Inflammatory bowel disease (IBD), Crohn's disease, and ulcerative colitis are chronic autoimmune lifelong diseases with fluctuating activity over time. The treatment includes medical therapy and surgery, however, there is no definite cure. Therefore, the quest for new and supplementary treatment options is imperative to improve patients' general health and quality of life. Physical activity and exercise have been suggested to be elements in both the prevention and supplementary treatment of IBD; however, this is based on limited underpowered trials. Thus, the role of exercise as a treatment option still has to be settled. We aim to investigate the effect of a 12-week exercise intervention in adult patients with moderately active IBD on three categories of outcomes (1) disease-specific health-related quality of life (IBDQ); (2) general health status of the patients, i.e., waist circumference, disease activity by clinical scorings systems (Harvey Bradshaw Index, Simple Clinical Colitis Activity Index), blood pressure, blood lipids, and non-disease specific quality of life (EQ5D) scores; and (3) explorative outcomes on biomarkers (C-reactive protein and fecal calprotectin) plus different biomarkers of immunology (cytokine panel).

METHODS

We will apply a superiority design in this open-label randomized clinical trial including 150 patients equally allocated to intervention and usual care. The intervention will be based on a 12-week aerobic exercise program and will include two supervised exercise sessions of 60 min per week, combined with one weekly home training session. We have defined a moderate exercise level as 60-80% of patients' maximum heart rate. The patients in the intervention group will also be offered an online video lesson of 15-25 min on lifestyle guidance, and the same online video lesson will be offered in the comparator group. Questionnaires on quality of life will be forwarded electronically both at inclusion and at the end of the study, and the patients will have blood samples, and fecal samples for calprotectin at baseline, weeks 4 and 8, as well as after 12 weeks (study end).

DISCUSSION

This will be a clinical trial investigating the effect of exercise on patients with Crohn's disease and ulcerative colitis. This trial will add to the evidence on the possible effect of exercise and might clarify whether exercise can benefit as a supplementary treatment addendum. Thus, the trial may provide a new patient-active disease management approach.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04816812. Date of first registration: March 23, 2021.

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 activity measured by accelerometry in paediatric and young adult patients with inflammatory bowel disease

OBJECTIVES

Physical activity in paediatric and young adult patients suffering from inflammatory bowel disease (IBD) may play an important role in the overall health status. However, physical activity in these patients has not been reported using objective methods. We aimed to describe accelerometry-measured physical activity levels in paediatric and young adult IBD patients with either ulcerative colitis (UC) or Crohn's disease (CD).

METHODS

We recruited Danish patients with IBD aged 10-20 years in clinical remission and with a faecal calprotectin below 200 µg/mg. Physical activity was assessed using tri-axial wrist accelerometry over seven days and quantified using the activity-related acceleration derived as the conventional Euclidian Norm Minus One (ENMO) metric expressed in milli-gravity units (mg). Time spent in Moderate-to-Vigorous Physical Activity (MVPA) was classified as ENMO > 210 mg in 5 s epoch resolution (unbouted).

RESULTS

We included 61 patients with a median age of 17 years [Inter Quartile Range, IQR 14-19]. The total volume of activity expressed as average acceleration (ENMO) per day was 31.5 mg (95% CI 29.1-33.9). Time spent in unbouted MVPA was 32 min per day (95% CI 26-37). There was no significant difference in activity volume between patients with UC to patients with CD, the adjusted linear regression coefficient was - 1.7 mg (95% CI -6.2-2.7). Activity volume was higher for males (36.2 mg, 95% CI 31.9-40.5) than for females (27.8 mg, 95% CI 25.6-30.0), and younger patients were more active than older patients; Activity volume in 10-13 year olds was 37.2 mg (95% CI 28.6-45.7), whereas it was 28.5 mg (95% CI 25.2-31.7) for those aged 18-20 years.

CONCLUSIONS

We collected tri-axial accelerometry in young patients with IBD in clinical remission, and described their level of physical activity by the conventional ENMO measure. We found no statistically significant difference in patients with UC compared to patients with CD. The volume of physical activity was higher in males compared to females, and inversely associated with age.

The Influence of Aerobic Type Exercise on Active Crohn’s Disease Patients: The Incidence of an Elite Athlete

A lifestyle factor which contributes to the remission of Crohn’s disease (CD) is physical activity. The effect seems to positively impact the disease’s symptoms, improving the quality of life, especially on patients in remission. Due to the lack of clinical studies about the effects of physical activity on active CD patients, the purpose of the present case study was to record the influence of swimming training (aerobic type of exercise) on an athlete with active CD. In this study participated a 22-year-old male, who is an elite swimmer and who was diagnosed in 2019 with CD. The research was conducted over the last three years (2019–2022). Both the athlete and doctor consented to the clinical examinations by the author. According to the present study, immediate medical examination and the prescription of anti-TNF-α therapy is probably the most appropriate solution for someone who is diagnosed with CD symptoms. Moreover, patient participation in any sport activity is discouraged because of the potential danger of exacerbation of the symptoms. Therefore, for the sake of patient safety, physical activity should only be encouraged when the disease is in remission.

The Combination of Intestinal Alkaline Phosphatase Treatment with Moderate Physical Activity Alleviates the Severity of Experimental Colitis in Obese Mice via Modulation of Gut Microbiota, Attenuation of Proinflammatory Cytokines, Oxidative Stress Biomarkers and DNA Oxidative Damage in Colonic Mucosa

Inflammatory bowel diseases (IBD) are commonly considered as Crohn's disease and ulcerative colitis, but the possibility that the alterations in gut microbiota and oxidative stress may affect the course of experimental colitis in obese physically exercising mice treated with the intestinal alkaline phosphatase (IAP) has been little elucidated. Mice fed a high-fat-diet (HFD) or normal diet (ND) for 14 weeks were randomly assigned to exercise on spinning wheels (SW) for 7 weeks and treated with IAP followed by intrarectal administration of TNBS. The disease activity index (DAI), grip muscle strength test, oxidative stress biomarkers (MDA, SOD, GSH), DNA damage (8-OHdG), the plasma levels of cytokines IL-2, IL-6, IL-10, IL-12p70, IL-17a, TNF-α, MCP-1 and leptin were assessed, and the stool composition of the intestinal microbiota was determined by next generation sequencing (NGS). The TNBS-induced colitis was worsened in obese sedentary mice as manifested by severe colonic damage, an increase in DAI, oxidative stress biomarkers, DNA damage and decreased muscle strength. The longer running distance and weight loss was observed in mice given IAP or subjected to IAP + SW compared to sedentary ones. Less heterogeneous microbial composition was noticed in sedentary obese colitis mice and this effect disappeared in IAP + SW mice. Absence of Alistipes, lower proportion of Turicibacter, Proteobacteria and Faecalibacterium, an increase in Firmicutes and Clostridium, a decrease in oxidative stress biomarkers, 8-OHdG content and proinflammatory cytokines were observed in IAP + SW mice. IAP supplementation in combination with moderate physical activity attenuates the severity of murine colitis complicated by obesity through a mechanism involving the downregulation of the intestinal cytokine/chemokine network and oxidative stress, the modulation of the gut microbiota and an improvement of muscle strength.

Physical Exercise and Immune System: Perspectives on the COVID-19 pandemic

Physical exercise training (PET) has been considered an excellent non-pharmacological strategy to prevent and treat several diseases. There are various benefits offered by PET, especially on the immune system, promoting changes in the morphology and function of cells, inducing changes in the expression pattern of pro and anti-inflammatory cytokines. However, these changes depend on the type, volume and intensity of PET and whether it is being evaluated acutely or chronically. In this context, PET can be a tool to improve the immune system and fight various infections. However, the current COVID-19 pandemic, caused by SARS-CoV-2, which produces cytokine storm, inducing inflammation in several organs, with high infection rates in both sedentary and physically active individuals, the role of PET on immune cells has not yet been elucidated. Thus, this review focused on the role of PET on immune system cells and the possible effects of PET-induced adaptive responses on SARS-CoV-2 infection and COVID-19.

Effect of resistance exercise training on Crohn's disease patients

Crohn’s disease (CD) is observed with increased levels of cytokines which cause inflammation in many parts of the digestive tract. Aerobic exercise contributes to the reduction of the intestine’s inflammation and increases the quality of life. Another type of exercise that shows research interest about its effects on CD symptoms is the resistance exercise (RE). The aim of the study was to review the influence of RE on CD patients. The study’s literature was collected from PubMed and Scholar databases. According to the results, the main phase of a RE training program must have a gradual increase of intensity (60%–80%) and resting periods of 15–30 seconds after each exercise, and 2–3 minutes between exercises. Also, CD patients who were in remission improved the muscle strength and quality of life via their participation in RE training program. However, the secretion of interleukin-6 in both CD and RE contributes in various physiological mechanisms setting a contradictory role in the effectiveness of RE at the disease’s inflammatory situation. So, the use of RE training in CD patients needs more research for safer participation.

Impact of pediatric inflammatory bowel disease diagnosis on exercise and sports participation: Patient and parent perspectives

BACKGROUND

Inflammatory bowel disease (IBD) may limit physical activity due to intestinal or extraintestinal manifestations, fatigue, or exercise perception. We sought to evaluate the influence of IBD diagnosis on exercise and sports participation in a pediatric population. We compared patient-reported and parent-reported perspectives.

AIM

To evaluate the influence of IBD diagnosis on exercise and sports participation in a pediatric population.

METHODS

Consecutive IBD outpatients (aged 10-18 years) and their parents completed parallel voluntary surveys. A validated, patient-reported functional activity scale, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) was used to assess children’s activity levels.

RESULTS

There were 149 completed surveys (75% response rate) with mean participant age of 16.5 years [standard deviation (SD) = 4.0] and mean age at IBD diagnosis of 11.8 years (SD = 3.4). Most patients (77%) were diagnosed within 12 mo of symptom onset. Current athletic participation was reported in 65% across 65 sports. Participation was greatest before (40%) rather than after (32%) IBD diagnosis, with no reported change in 28%. IBD negatively impacted play/performance in 45% but did not change play/performance in 44%. IBD treatment improved patients’ desire to exercise (70%) and subjective capacity for aerobic exercise (72%). Patients and parents agreed that IBD subjects demonstrate normal capacity for aerobic exercise (0.40, 95%CI: 0.22-0.58) and that treatment improved both participatory desire (0.33, 95%CI: 0.12-0.54) and capacity for aerobic exercise (0.52, 95%CI: 0.31-0.71). Almost all (99%) viewed exercise as healthy, and most encouraged its practice. IBD patients demonstrated normal mean HSS Pedi-FABS scores.

CONCLUSION

After pediatric IBD diagnosis, most patients continue exercise and sports, with mean activity levels comparable to American youth. Treatment positively impacts participatory desire and aerobic capacity. Patients favor the role of exercise in IBD.

Moderate-intensity aerobic and resistance exercise is safe and favorably influences body composition in patients with quiescent Inflammatory Bowel Disease: a randomized controlled cross-over trial

BACKGROUND

Overweight and metabolic problems now add to the burden of illness in patients with Inflammatory Bowel Disease. We aimed to determine if a program of aerobic and resistance exercise could safely achieve body composition changes in patients with Inflammatory Bowel Disease.

METHODS

A randomized, cross-over trial of eight weeks combined aerobic and resistance training on body composition assessed by Dual Energy X-ray Absorptiometry was performed. Patients in clinical remission and physically inactive with a mean age of 25 ± 6.5 years and Body Mass Index of 28.9 ± 3.8 were recruited from a dedicated Inflammatory Bowel Disease clinic. Serum cytokines were quantified, and microbiota assessed using metagenomic sequencing.

RESULTS

Improved physical fitness was demonstrated in the exercise group by increases in median estimated VO_2max (Baseline: 43.41mls/kg/min; post-intervention: 46.01mls/kg/min; p = 0.03). Improvement in body composition was achieved by the intervention group (n = 13) with a median decrease of 2.1% body fat compared with a non-exercising group (n = 7) (0.1% increase; p = 0.022). Lean tissue mass increased by a median of 1.59 kg and fat mass decreased by a median of 1.52 kg in the exercising group. No patients experienced a deterioration in disease activity scores during the exercise intervention. No clinically significant alterations in the α- and β-diversity of gut microbiota and associated metabolic pathways were evident.

CONCLUSIONS

Moderate-intensity combined aerobic and resistance training is safe in physically unfit patients with quiescent Inflammatory Bowel Disease and can quickly achieve favourable body compositional changes without adverse effects.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov; Trial number: NCT02463916 .