Physical fitness and physical activity in fatigued and non-fatigued inflammatory bowel disease patients

Unraveling the fatigue puzzle: insights into the pathogenesis and management of IBD-related fatigue including the role of the gut-brain axis

A significant percentage of patients with an inflammatory bowel disease (IBD) encounter fatigue which can profoundly diminish patients' quality of life, particularly during periods of disease remission when gastrointestinal symptoms have receded. Various contributing risk factors have been identified including active inflammation, anemia, psychological, lifestyle and drug-related factors. While addressing these risk factors has been suggested as the initial approach to managing fatigue, a considerable number of patients still experience persisting symptoms, the primary causes of which remain incompletely understood. Recent insights suggest that dysfunction of the gut-brain axis may play a pathogenic role. This review provides an overview of established risk factors for fatigue, alongside emerging perspectives on the role of the gut-brain axis, and potential treatment strategies.

Evaluation of walking activity and gait to identify physical and mental fatigue in neurodegenerative and immune disorders: preliminary insights from the IDEA-FAST feasibility study

BACKGROUND

Many individuals with neurodegenerative (NDD) and immune-mediated inflammatory disorders (IMID) experience debilitating fatigue. Currently, assessments of fatigue rely on patient reported outcomes (PROs), which are subjective and prone to recall biases. Wearable devices, however, provide objective and reliable estimates of gait, an essential component of health, and may present objective evidence of fatigue. This study explored the relationships between gait characteristics derived from an inertial measurement unit (IMU) and patient-reported fatigue in the IDEA-FAST feasibility study.

METHODS

Participants with IMIDs and NDDs (Parkinson's disease (PD), Huntington's disease (HD), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), primary Sjogren's syndrome (PSS), and inflammatory bowel disease (IBD)) wore a lower-back IMU continuously for up to 10 days at home. Concurrently, participants completed PROs (physical fatigue (PF) and mental fatigue (MF)) up to four times a day. Macro (volume, variability, pattern, and acceleration vector magnitude) and micro (pace, rhythm, variability, asymmetry, and postural control) gait characteristics were extracted from the accelerometer data. The associations of these measures with the PROs were evaluated using a generalised linear mixed-effects model (GLMM) and binary classification with machine learning.

RESULTS

Data were recorded from 72 participants: PD = 13, HD = 9, RA = 12, SLE = 9, PSS = 14, IBD = 15. For the GLMM, the variability of the non-walking bouts length (in seconds) with PF returned the highest conditional R2, 0.165, and with MF the highest marginal R2, 0.0018. For the machine learning classifiers, the highest accuracy of the current analysis was returned by the micro gait characteristics with an intrasubject cross validation method and MF as 56.90% (precision = 43.9%, recall = 51.4%). Overall, the acceleration vector magnitude, bout length variation, postural control, and gait rhythm were the most interesting characteristics for future analysis.

CONCLUSIONS

Counterintuitively, the outcomes indicate that there is a weak relationship between typical gait measures and abnormal fatigue. However, factors such as the COVID-19 pandemic may have impacted gait behaviours. Therefore, further investigations with a larger cohort are required to fully understand the relationship between gait and abnormal fatigue.

Healthy Lifestyle Is a Protective Factor from Moderate and Severe Relapses and Steroid Use in Inflammatory Bowel Disease: A Prospective Cohort Study

BACKGROUND

A healthy lifestyle, including good adherence to a Mediterranean diet (MD) and regular physical exercise, may be an important factor during the course of inflammatory bowel disease (IBD). Our aim is to determine whether adherence to MD, physical activity, and the combination of both can impact on IBD course.

METHODS

This prospective cohort study includes 693 IBD outpatients who were in remission with a median follow-up time of 27 months (interquartile range 22-29 months). Each patient completed a survey to assess their adherence to the MD and physical activity. Healthy lifestyle was considered to be a proper adherence to both MD and an active lifestyle. Relapse during follow-up, severity of relapses, need for systemic steroids, and therapy changes were recorded.

RESULTS

During the follow-up period, 188 patients (27.1%) experienced relapse, of which 56.1% were moderate or severe. Among patients with relapse, 85 (45%) required treatment with corticosteroids, and 15 (7.9%) were hospitalized. Patients with ulcerative colitis (CU) were more adherent to healthy lifestyle than patients with Crohn's disease (P = .011). Healthy lifestyle was associated with lower risk of moderate and severe relapses (adjusted Hazard ratio [aHR], 0.250; 95% confidence interval [CI], 0.093-0.670) and steroids use (aHR 0.292; 95% CI, 0.103-0.828) in IBD patients and with lower risk of moderate and severe relapses (aHR 0.270; 95% CI, 0.093-0.789) in UC patients.

CONCLUSIONS

Healthy lifestyle has a favorable influence on promoting a milder disease course, and thus should be a crucial part of clinical management of patients with IBD.

Physical Activity and IBD: State of Art and Knowledge, Patients and Healthcare Professionals Points of View, A French Multicenter Cross Sectional Study

BACKGROUND

Several studies have reported low levels of physical activity (PA) in patients with inflammatory bowel diseases (IBD), possibly related to a lack of information and support, despite the many recognized benefits such as cardiovascular prevention or quality of life (QoL) improvement.

METHODS

The purpose of our study was to identify challenges faced by patients and to evaluate IBD impact on PA and QoL by using the International Physical Activity Questionnaire short form and the 32-item Inflammatory Bowel Disease Questionnaire (IBDQ-32) questionnaire, respectively. We also assessed the expectations and knowledge of patients and healthcare professionals using the MICI-Active questionnaire that we developed.

RESULTS

We included 298 IBD patients in 4 French hospitals, with a mean age of 38 years. We found a decrease in training frequency since IBD diagnosis, regardless of age, gender, symptom intensity, or type of disease. Moreover, there was an increase in low intensity activities like walking and a decrease in competitions and sports club registrations. Intensity of symptoms has a negative impact on QoL, as evidenced by the worsening of IBDQ score. Conversely, a higher PA intensity was correlated with a higher IBDQ score, regardless of symptoms intensity. The main barrier to PA was fatigue (56%), and the main fear was diarrhea (42%). Furthermore, 75% of patients did not feel sufficiently informed, and 61% were interested in coaching. A total of 112 healthcare professionals were interviewed, 62.5% said they had already discussed of PA with their patients, but 98% felt that they lacked knowledge.

CONCLUSIONS

Inflammatory bowel disease constraints and symptoms have a strong impact on PA. Work needs to be done to better train practitioners to improve IBD patient management, who have much to gain from better PA.

Sleep Quality Drives Next Day Pain and Fatigue in Adults With Inflammatory Bowel Disease: A Short Report

BACKGROUND AND AIMS

Poor sleep is prevalent in inflammatory bowel disease [IBD] and is associated with increased symptom severity and decreased quality of life. To date, research is mostly cross-sectional, limiting the ability to examine the causal direction between sleep and IBD symptoms. This short report aims to assess the temporal associations among sleep quality, pain, fatigue, and physical activity in adults with IBD.

METHODS

Adult IBD patients [N = 18] completed a structured electronic diary two times per day [morning and evening] over 14 consecutive days. Morning diary items assessed sleep [sleep quality, wake after sleep onset, number of awakenings] and evening diary items assessed daytime IBD symptoms [abdominal pain, fatigue]. An actigraph measured daily step count [physical activity]. Generalised estimating equation models evaluated the lagged temporal associations between sleep ratings and next day pain, fatigue, and physical activity as well as reverse lagged temporal associations between daytime symptoms and physical activity and subsequent sleep ratings.

RESULTS

Poor self-reported sleep quality predicted increased next day abdominal pain and fatigue scores. Increased time awake during the night predicted decreased next day physical activity. In the reverse analyses, only the relationship between daytime abdominal pain and wake after sleep onset was significant.

CONCLUSIONS

Poor sleep appears to drive IBD-related outcomes, such as pain and fatigue. These findings are a first step in demonstrating the key role of sleep in the IBD patient experience, potentially resulting in a treatment target for intervention. Future research is needed to confirm results in a larger sample.

Fatigue-Related Changes of Daily Function: Most Promising Measures for the Digital Age

Background

Fatigue is a prominent symptom in many diseases and is strongly associated with impaired daily function. The measurement of daily function is currently almost always done with questionnaires, which are subjective and imprecise. With the recent advances of digital wearable technologies, novel approaches to evaluate daily function quantitatively and objectively in real-life conditions are increasingly possible. This also creates new possibilities to measure fatigue-related changes of daily function using such technologies.

Summary

This review examines which digitally assessable parameters in immune-mediated inflammatory and neurodegenerative diseases may have the greatest potential to reflect fatigue-related changes of daily function.

Key Messages

Results of a standardized analysis of the literature reporting about perception-, capacity-, and performance-evaluating assessment tools indicate that changes of the following parameters: physical activity, independence of daily living, social participation, working life, mental status, cognitive and aerobic capacity, and supervised and unsupervised mobility performance have the highest potential to reflect fatigue-related changes of daily function. These parameters thus hold the greatest potential for quantitatively measuring fatigue in representative diseases in real-life conditions, e.g., with digital wearable technologies. Furthermore, to the best of our knowledge, this is a new approach to analysing evidence for the design of performance-based digital assessment protocols in human research, which may stimulate further systematic research in this area.

Fatigue and Physical Activity Patterns in Children With Inflammatory Bowel Disease

OBJECTIVES

Fatigue is a common symptom in children with inflammatory bowel disease (IBD). Diagnostic tests to evaluate biological causes of fatigue commonly include markers of inflammation and hemoglobin (Hb), yet functional parameters have been inadequately studied in pediatric IBD. In this study, we compared fatigued and non-fatigued children with IBD from both a biological and functional point of view.

METHODS

A cross-sectional study of 104 pediatric IBD patients with mild to moderately active IBD was conducted. Fatigued children were defined as those with a Pediatric Quality of Life Inventory Multidimensional Fatigue Scale z score <-2.0. Non-fatigued children had a z score ≥-2.0. Disease-specific quality of life (measured with IMPACT-III score), C-reactive protein (CRP), fecal calprotectin (FC), hemoglobin z score (Hb z score), and physical activity tests including 6-minute walking distance z score (6MWD z score) and triaxial accelerometry (TA) were evaluated.

RESULTS

Fatigued children (n = 24) had a significant lower IMPACT-III score than non-fatigued children (n = 80). Hb z scores, CRP, FC, and 6MWD z scores were not significantly different between groups. TA was performed in 71 patients. Wear time validation requirements were met in only 31 patients. Fatigued patients spent significant shorter median time in moderate-to-vigorous activity than non-fatigued patients (18.3 vs 37.3 minutes per day, P = 0.008).

CONCLUSION

Biological parameters did not discriminate fatigued from non-fatigued patients. TA possibly distinguishes fatigued from non-fatigued patients; the potential association may provide a target for interventions to combat fatigue and improve quality of life.

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.

Lifestyle Can Exert a Significant Impact on the Development of Metabolic Complications and Quality Life in Patients with Inflammatory Bowel Disease

Inflammatory bowel diseases (IBDs) are associated with an increased risk of metabolic comorbidities. There is a lack of data regarding the relationship between lifestyle and metabolic diseases in IBD patients. A cross-sectional study on consecutive IBD outpatients was conducted. Adherence to the Mediterranean diet (MD) was assessed using a 14-item questionnaire from the PREDIMED study, and physical activity was evaluated using the GODIN-Leisure score. Body composition was studied based on body mass index and waist-hip ratio (WHR), while quality of life was assessed using a nine-item short questionnaire. Among the 688 evaluated IBD patients, 66% were overweight or obese, 72.7% did not lead an active lifestyle and 70.1% did not adhere to the MD. Metabolic syndrome was associated with age (OR = 1.07, p = 0.019), overweight/obesity (OR = 12.987, p < 0.001) and the inflammatory behavior of Crohn's disease (OR = 6.172, p = 0.001). Type 2 diabetes mellitus or prediabetes was associated with age (OR = 1.063 p = 0.016), overweight/obesity (OR = 3.861, p < 0.001) and the inflammatory behavior of Crohn's disease (OR = 4.716, p = 0.001). Overweight /obesity (OR = 5.494, p < 0.001), a high WHR (OR = 2.564, p = 0.005) and a non-active lifestyle (OR = 2.202, p = 0.0003) were associated with metabolic dysfunction-associated steatotic liver disease. Lifestyle, body composition and not solely systemic inflammation might exert a significant influence on the emergence of metabolic comorbidities such as MASLD, type 2 diabetes mellitus and metabolic syndrome in patients with IBD.

Nutritional Risk and Sarcopenia Features in Patients with Crohn's Disease: Relation to Body Composition, Physical Performance, Nutritional Questionnaires and Biomarkers

Patients with Crohn's disease (CD) face malnutrition risk, which, combined with inflammation, can lead to sarcopenia, associated with a worse prognosis. The purpose of the present study was to assess malnutrition and sarcopenia in patients with CD. Fifty-three patients (26 women) participated (38.1 ± 10.9 years, 79% in remission). Body composition, physical performance, nutritional questionnaires, and biomarkers were performed. Malnutrition was screened with the Mini Nutritional Assessment (MNA) and the Malnutrition Inflammation Risk Tool (MIRT) and was assessed with the Global Leadership Initiative on Malnutrition (GLIM) tool using etiologic along with three different phenotypic criteria: low Body Mass Index (BMI), low Calf Circumference (CC), and low Fat-Free Mass Index (FFMI). To find cases and evaluate sarcopenia, the Sarcopenia Questionnaire (SARC-F) and European Working Group on Sarcopenia2 (EWGSOP2) criteria were used. Malnutrition rates were 11.3% (n = 6), 7.5% (n = 4), and 5.6% (n = 3) based on low FFMI, CC, and BMI, correspondingly. Four (7%) patients had low Hand-Grip Strength (HGS), n = 8 (14.8%) had low Appendicular Lean Mass (ALM), and n = 3 (5.6%) had low gait speed. No-one had sarcopenia. A high albumin and triceps skinfold pattern, identified by principal component analysis, was related to reduced C-Reactive Protein (CRP) levels (B = -0.180, SE = 0.085, p = 0.045). In conclusion, based on the studied anthropometric, nutritional, and functional variables, CD patients were not diagnosed with sarcopenia in the present study. Body composition patterns were related to the inflammatory burden, underlying the interplay of inflammation and malnutrition, even in remission states. Further studies on older populations and during disease exacerbation are necessary to explore the potential link between CD, inflammation, and sarcopenia.

Regulatory Qualification of a Cross-Disease Digital Measure: Benefits and Challenges from the Perspective of IMI Consortium IDEA-FAST

Background

Innovative Medicines Initiative (IMI) consortium IDEA-FAST is developing novel digital measures of fatigue, sleep quality, and impact of sleep disturbances for neurodegenerative diseases and immune-mediated inflammatory diseases. In 2022, the consortium met with the European Medicines Agency (EMA) to receive advice on its plans for regulatory qualification of the measures. This viewpoint reviews the IDEA-FAST perspective on developing digital measures for multiple diseases and the advice provided by the EMA.

Summary

The EMA considered a cross-disease measure an interesting and arguably feasible concept. Developers should account for the need for a strong rationale that the clinical features to be measured are similar across diseases. In addition, they may expect increased complexity of study design, challenges when managing differences within and between disease populations, and the need for validation in both heterogeneous and homogeneous populations.

Key Messages

EMA highlighted the challenges teams may encounter when developing a cross-disease measure, though benefits potentially include reduced resources for the technology developer and health authority, faster access to innovation across different therapeutic fields, and feasibility of cross-disease comparisons. The insights included here can be used by project teams to guide them in the development of cross-disease digital measures intended for regulatory qualification.

Physical fitness in children and adolescents with inflammatory bowel disease: protocol for a case-control study

INTRODUCTION

Inflammatory bowel disease (IBD) is a chronic disorder of the gastrointestinal tract, associated with adverse health consequences that may adversely influence physical activity and body composition in youth. These effects may lead to changes in physical fitness, which is positively associated with health-related outcomes. The aim is to assess health-related physical fitness levels in paediatric patients with IBD and to compare these levels with those in healthy matched controls.

METHODS AND ANALYSIS

This trial is a bicentric case-control study. Fifty paediatric patients with IBD and 50 matched healthy controls will be recruited (1:1), and physical fitness levels (cardiorespiratory fitness, muscular strength, speed/agility and flexibility) will be assessed. The primary outcome is cardiorespiratory fitness, which will be compared between children and adolescents with IBD and healthy controls matched for age, sex and body mass index class. We will assess whether the two groups differ with respect to other physical fitness components and cardiovascular risk in adulthood according to sex-specific cut-offs for a healthy cardiorespiratory fitness level in adolescents. We will identify relationships between physical fitness and characteristics of IBD, quality of life and daily physical activity.

ETHICS AND DISSEMINATION

This study was approved by the Research Ethics Committee (Comité de Protection des Personnes, Centre-Ouest I, Tours, France; No 2019-A02651-56) and was declared to the Commission Nationale de l'Informatique et des Libertés. All procedures will be performed according to the ethical standards of the 1975 Declaration of Helsinki, as revised in 2008, and the European Union's Guidelines for Good Clinical Practice. Written informed consent will be obtained from the youths and their parents. Research findings will be disseminated in peer-reviewed journals and scientific meetings, as well as in social media and IBD family support groups.

TRIAL REGISTRATION NUMBER

NCT04647578.

Pathogenesis of Musculoskeletal Deficits in Children and Adults with Inflammatory Bowel Disease

Musculoskeletal deficits are among the most commonly reported extra-intestinal manifestations and complications of inflammatory bowel disease (IBD), especially in those with Crohn’s disease. The adverse effects of IBD on bone and muscle are multifactorial, including the direct effects of underlying inflammatory disease processes, nutritional deficits, and therapeutic effects. These factors also indirectly impact bone and muscle by interfering with regulatory pathways. Resultantly, individuals with IBD are at increased risk of osteoporosis and sarcopenia and associated musculoskeletal morbidity. In paediatric IBD, these factors may contribute to suboptimal bone and muscle accrual. This review evaluates the main pathogenic factors associated with musculoskeletal deficits in children and adults with IBD and summarises the current literature and understanding of the musculoskeletal phenotype in these patients.

Review article: The aetiology of fatigue in inflammatory bowel disease and potential therapeutic management strategies

BACKGROUND

Fatigue is the inability to achieve or maintain an expected work output resulting from central or peripheral mechanisms. The prevalence of inflammatory bowel disease (IBD) fatigue can reach 86% in active disease, persisting in 50%-52% of patients with mild to inactive disease. Fatigue is the commonest reason for work absence in IBD, and patients often report fatigue burden to be greater than that of primary disease symptoms. Relatively few evidence-based treatment options exist, and the aetiology is poorly understood.

AIM

To review the available data and suggest a possible aetiology of IBD fatigue and to consider the efficacy of existing management strategies and highlight potential future interventions.

METHODS

We reviewed fatigue-related literature in IBD using PubMed database.

RESULTS

Disease related factors such as inflammation and pharmacological treatments negatively impact skeletal muscle and brain physiology, likely contributing to fatigue symptoms. Secondary factors such as malnutrition, anaemia, sleep disturbance and psychological comorbidity are potential determinants. Immune profile, faecal microbiota composition and physical fitness differ significantly between fatigued and non-fatigued patients, suggesting these may be aetiological factors. Solution-focused therapy, high-dosage thiamine supplementation and biological therapy may reduce fatigue perception in IBD. The effect of physical activity interventions is inconclusive.

CONCLUSIONS

A multimodal approach is likely required to treat IBD fatigue. Established reversible factors like anaemia, micronutrient deficiencies and active disease should initially be resolved. Psychosocial intervention shows potential efficacy in reducing fatigue perception in quiescent disease. Restoring physical deconditioning by exercise training intervention may further improve fatigue burden.

Physical Activity in Patients with Inflammatory Bowel Disease: A Cross-Sectional Study

Introduction and Objective

Despite the known benefits of physical activity in the management of chronic diseases, the use of exercise as a treatment is relatively underemployed, with many patients reporting their disease to be a barrier. This study aimed to assess physical activity levels, attitudes, and barriers towards exercise in a cohort of patients with inflammatory bowel disease (IBD). In addition, this study aimed to assess possible relationships between physical well-being, psychological well-being, and sociodemographic factors.

Methods

306 patients >18 years with diagnosed IBD in Dunedin, New Zealand, were approached to participate in this study. Participants who consented completed questionnaires regarding exercise preferences and attitudes, physical activity levels, and psychological well-being.

Results

Seventy-seven patients participated in the study (77/308 = 25%). Sixty-six percent of participants met physical activity guidelines and the median metabolic equivalent minutes/week of 1,027.5 (505.5-2,339.5). Walking was the most preferred activity (30%) followed by water-based exercise (20%). Two-thirds of participants reported their disease limited the amount of physical activity undertaken. Common barriers to participating in physical activity included fatigue (34%) and abdominal pain (20%). Patients with active disease reported higher levels of barriers than those in remission (80 vs. 54%, p = 0.018). Higher physical activity levels were correlated with lower levels of fatigue (p = 0.022-0.046).

Conclusions

While patients with IBD in Dunedin, New Zealand, are physically active, reducing real and perceived barriers is crucial to further increase physical activity in patients with IBD who are in remission or with active disease.

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

BACKGROUND AND AIMS

Fatigue significantly impacts the quality of life of patients with inflammatory bowel disease (IBD). This study aimed to assess the effect of a personalized, intensive exercise program on fatigue, health-related quality of life (HRQoL), and cardiorespiratory fitness in patients with quiescent IBD and severe fatigue.

METHODS

A pilot study was performed including IBD patients in remission with severe fatigue. The 12-week exercise program consisted of three times per week 1-h sessions, including aerobic- and progressive-resistance training at personalized intensity based on a cardiopulmonary exercise test (CPET) and one-repetition maximum. CPET was repeated after 12 weeks. Fatigue and HRQoL were assessed using the checklist individual strength and 32-item IBD questionnaire.

RESULTS

Twenty-five IBD patients with mean age of 45 (± 2.6) years were included of which 22 (88%) completed the exercise program. Fatigue significantly improved from 105 (± 17) points on the checklist individual strength before, to 66 (± 20) after completion of exercise program (p < 0.001). Patients' HRQoL significantly improved from 156 (± 21) to 176 (± 19) (p < 0.001). When looking at the subdomains of HRQoL, significant improvement was seen in emotional (58 ± 12 vs. 69 ± 9.1, p = 0.003), systemic (19 ± 3.9 vs. 24 ± 4.7, p < 0.001), and social function (25 ± 5.4 vs. 30 ± 3.9, p < 0.001). Bowel symptoms did not change (53 ± 7.7 vs. 55 ± 7.3, p = 0.208). Repeat CPET showed a significant improvement in maximum power patients were able to deliver (2.4 ± 0.5 vs. 2.7 ± 0.5 W/kg, p = 0.002).

CONCLUSIONS

A personalized, intensive exercise program can lead to significant improvement of fatigue, HRQoL, and cardiorespiratory fitness in patients with quiescent IBD and severe fatigue.

Randomised clinical trial: combined impact and resistance training in adults with stable Crohn's disease

BACKGROUND

Crohn's disease (CD) is a predisposing factor for bone loss and muscle dysfunction, which could lead to osteoporotic fractures and physical disability, respectively.

AIM

To assess the effect of 6 months of combined impact and resistance training on bone mineral density (BMD) and muscle function in adults with CD.

METHODS

In this randomised controlled trial, 47 adults with stable CD were assigned to exercise (n = 23) or control (n = 24) groups and followed up for 6 months. The exercise group received usual care plus a 6-month combined impact and resistance training programme, involving three, 60-minute sessions per week and a gradual tapering of supervision to self-management. The control group received usual care alone. The primary outcomes were BMD (via dual energy X-ray absorptiometry) and muscle function (measures of upper and lower limb strength and endurance) at 6 months.

RESULTS

At 6 months, BMD values were superior in the exercise group with statistical significance at lumbar spine (adjusted mean difference 0.036 g/cm², 95% CI 0.024-0.048; P < 0.001), but not at femoral neck (0.018 g/cm², 0.001-0.035; P = 0.059) or greater trochanter (0.013 g/cm², -0.019 to 0.045; P = 0.415) after correcting for multiple outcomes. The exercise group also had superior values for all muscle function outcomes (P < 0.001; unadjusted mean differences ranging 22.6‒48.2%), and lower fatigue severity (P = 0.005). Three exercise-related adverse events were recorded: two instances of light-headedness and one of nausea.

CONCLUSIONS

The intervention improved BMD and muscle function in adults with CD and appears as a suitable model of exercise for reducing future risk of osteoporotic fractures and disability.

TRIAL REGISTRATION

ISRCTN11470370.

Non-pharmacological interventions to manage fatigue in adults with inflammatory bowel disease: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

The prevalence of fatigue is higher in adults with inflammatory bowel disease (IBD). There is limited information on the effectiveness of non-pharmacological interventions to manage fatigue. The purposes of this review is to evaluate the effectiveness of these interventions to manage fatigue in adults with IBD.

MATERIALS AND METHODS

A systematic review was conducted based on the PRISMA guidelines. Comprehensive Meta-Analysis software was used to compute metaanalysis.

RESULTS

Eleven studies were included in the review. The interventions to manage fatigue included problem-solving therapy, solution-focused therapy, cognitive behavioral therapy, psychoeducational intervention, exercise advice with omega-3 supplements, electro-acupuncture, and AndoSan. The pooled evidence from the metaanalysis demonstrated that non-pharmacological interventions could decrease IBDFatigue (SMD = 0.33, 95% CI [0.10, 0.55], p = 0.005).

CONCLUSION

The pooled data indicate that non-pharmacological interventions are helpful in managing IBD-Fatigue. Additionally, the non-pharmacological interventions reviewed could be utilized to promote self-management in IBD.

Fatigue in inflammatory bowel disease: a problematic ailment

PURPOSE OF REVIEW

Fatigue, a protean complaint encompassing both physical, mental exhaustion but also demotivation, has shown to effect quality of life in patients with inflammatory bowel disease (IBD). Here we present a review of the literature as it relates to IBD-associated fatigue. Moreover, we present the common causes attributed to fatigue and present an algorithmic approach to the assessment of fatigue. Finally, we report data regarding potential management strategies for IBD-associated fatigue.

RECENT FINDINGS

Unfortunately, owing to its multidimensional nature and multifactorial causes, patients with IBD may continue to report fatigue despite optimization of disease management, replenishment of nutritional deficiencies, or management of coexistent disorders. Management likely requires a multidisciplinary approach.

SUMMARY

The majority of patients with IBD report fatigue symptoms both in setting of active disease but also during the course of remission. Fatigue is a multidimensional complaints, and management likely requires a multidisciplinary approach. Herein, we present a framework for the management and assessment of fatigue in IBD.

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.

Structured physical activity interventions as a complementary therapy for patients with inflammatory bowel disease - a scoping review and practical implications

BACKGROUND

Patients with Inflammatory Bowel Disease (IBD) also suffer from a wide range of additional disorders, which may be caused by the disease, the side effect of the medication, or a lack of physical activity (PA). This results in reduced physical and psychological wellbeing. However, as known from other chronic diseases exercise could be utilized as supportive therapy for IBD patients. Main goals of this article are (a) collecting data of the effects structured physical activity interventions have on validated clinical parameters of IBD and health related symptoms, (b) developing activity recommendations for this clientele.

METHODS

A scoping review was conducted, searching for relevant articles published until May 2018, which investigated the effects of structured exercise interventions in IBD patients. The heterogeneity of the outcomes and the interventions did not support a quantitative synthesis thus, a qualitative discussion of the studies is provided.

RESULTS

After reviewing 353 records, 13 eligible articles were identified. Five studies investigated aerobic exercise, three studies resistance exercise, three studies mind-body therapies and two studies yoga. The quality of the studies is mixed, and the duration is rather short for exercise interventions. Only few studies assessed validated IBD activity markers or inflammatory biomarkers. Nevertheless, the patients showed an increase in fitness, bone mineral density (BMD), quality of life and a decrease of IBD induced stress and anxiety. No severe adversial events were reported.

CONCLUSION

Even though the evidence is limited the application of exercise interventions in IBD patients can be assumed to be safe and beneficial for the patients' overall-health, and IBD specific physical and psychosocial symptoms. But there is still a high demand for more thoroughly conducted studies, focussing on important clinical outcome parameters.

European Crohn's and Colitis Organisation Topical Review on Complementary Medicine and Psychotherapy in Inflammatory Bowel Disease

Patients with inflammatory bowel disease [IBD] increasingly use alternative and complementary therapies, for which appropriate evidence is often lacking. It is estimated that up to half of all patients with IBD use various forms of complementary and alternative medicine during some point in their disease course. Considering the frequent use of such therapies, it is crucial that physicians and patients are informed about their efficacy and safety in order to provide guidance and evidence-based advice. Additionally, increasing evidence suggests that some psychotherapies and mind-body interventions may be beneficial in the management of IBD, but their best use remains a matter of research. Herein, we provide a comprehensive review of some of the most commonly used complementary, alternative and psychotherapy interventions in IBD.

Fatigue in IBD: epidemiology, pathophysiology and management

Fatigue is an important clinical problem in patients with IBD, affecting nearly 50% of patients in clinical remission and > 80% of those with active disease. The resulting decrease in quality of life and impaired work productivity and functioning contribute markedly to the societal costs of fatigue. However, despite the burden and effects of fatigue, little is known about its aetiology and pathophysiology, which impairs our ability to effectively treat this symptom. Here, we review the theories behind the development of fatigue in IBD and the role of contributing factors, including nutritional deficiency, inflammation and altered metabolism. We also explore the potential role of the gut microbiome in mediating fatigue and other psychological symptoms through the gut-brain axis. We discuss the efficacy of nutrient repletion and various psychological and pharmacological interventions on relieving fatigue in patients with IBD and expand the discussion to non-IBD-related fatigue when evidence exists. Finally, we present a therapeutic strategy for the management of fatigue in IBD and call for further mechanistic and clinical research into this poorly studied symptom.

Unmet Needs in IBD: the Case of Fatigue

Fatigue is a highly prevalent but relatively ignored problem in IBD patients. It is one of the most burdensome symptoms to the patient with an important impact on the quality of life. Therefore, fatigue is a highly relevant patient-reported outcome that should be included not only in disease activity measurement but also in the endpoints of clinical trials in IBD. However, most of the currently available scoring systems to quantify fatigue are not specifically designed for patients with IBD and none of them has undergone a complete validation process for IBD-related fatigue. Fatigue is more prevalent in patients with active disease and may improve or disappear when remission is reached. Far more complex is the persistence or onset of fatigue in quiescent IBD which presents in up to 40% of the patients. In this subgroup of patients, fatigue can be related to smoldering systemic inflammation, a poor sleep quality, anemia, nutritional deficiencies, or comorbidities. In most cases, however, no direct cause can be identified. The lack of knowledge on the mechanisms that drive fatigue in IBD hamper the development of specific drugs to treat the condition and only psychological support can be offered to the patient. Rodent models are indispensable to increase our understanding of the molecular pathways that lead to fatigue in chronic intestinal inflammation, and to develop novel therapies.

Non-pharmacological therapies for inflammatory bowel disease: Recommendations for self-care and physician guidance

We performed a scoping review on sought-after complementary therapies for patients with inflammatory bowel disease (IBD), specifically diet, physical activity and exercise (PA/E), and psychotherapy. We aim to update patients with IBD on therapies for self-care and provide physicians with guidance on how to direct their patients for the management of IBD. A search of MEDLINE, EMBASE, and PUBMED was completed in Sept 2016. Studies on diet, PA/E, or psychotherapy in patients with IBD were included. Medical Subject Heading terms and Boolean operators were used. The search was limited to full-text English articles describing an adult population. This review included 67 studies: Diet (n = 19); PA/E (n = 19); and psychotherapy (n = 29). We have made the following recommendations: (1) Diet: Consumption of diets rich in vegetables, fruit and soluble fiber may be beneficial in IBD. A trial of a low FODMAP diet can be considered in those patients with functional gastrointestinal symptoms. Restrictive diets are lacking in evidence and should be avoided; (2) PA/E: Regular low-moderate intensity activity, including cardiovascular and resistance exercise, has been shown to improve quality of life (QOL) and may improve inflammation; and (3) psychotherapy: Therapies such as cognitive-behavioural interventions, mindfulness, hypnosis, and stress management have been shown to improve QOL, but evidence is limited on their impact on anxiety, depression, and disease activity. Overall, these complementary therapies are promising and should be used to treat patients with IBD from a more holistic perspective.

An Examination of Appetite and Disordered Eating in Active Crohn's Disease

BACKGROUND

Crohn's disease [CD] patients suffer from nutritional deficiencies when in active disease. We aim to examine calorific intake, macronutrient choice, and disordered eating behaviour in patients with active CD.

METHODS

CD patients with matched healthy volunteers [HV] were recruited. Active disease was defined by faecal calprotectin >250 µg/g, C-reactive protein 83.8 ± 47.1 mg/dL, or active disease seen on endoscopy or imaging. Symptoms were quantified by Harvey‑Bradshaw Index [HBI]. Calorific intake was assessed by 24-h dietary recall. Disordered eating was assessed using validated questionnaires: Binge Eating Scale [BES]; Power of Food Scale [PFS]; Control of Eating Questionnaire [CoEQ]; Dutch Eating Behaviour Questionnaire [DEBQ]; and Three Factor Eating Questionnaire [TFEQ].

RESULTS

Totals of 30 CD (18 male[M]:12 female [F], age 32.3 ± 2.19 years, body mass index [BMI] 24.9 ± 0.8) and 31 matched HV [19 M:12 F, age 32.8 ± 2.0 years, BMI 24.7 ± 0.5] were recruited. Mean faecal calprotectin was 1032.5 ± 176 µg/g, C-reactive protein 8.38 ± 4.71 mg/dL, and HBI 4.8 ± 1. There were no significant differences in calorific intake between groups. Protein intake was lower in the CD cohort [p = 0.03]. Hospital Anxiety and Depression score was higher [p = 0.01] and CoEQ-Positive Mood [p = 0.001] lower in CD. CD patients were characterised by higher BES [p = 0.01] and lower CoEQ Craving Control [p = 0.027], with greater craving for Sweet [p = 0.043] and Savoury [p = 0.021] foods. PFS food Present [p = 0.005], DEBQ Emotional [p =< 0.001], and External Eating [p = 0.022] were significantly higher than among HV.

CONCLUSIONS

Reduced protein consumption and more prevalent disordered eating behaviour traits were present in CD. Greater binge eating and decreased control of cravings may be attributed to lower mood and higher anxiety observed. Patients may benefit from stronger psychological support with firm dietetic advice for healthy eating.

Cognitive behavioural therapy for the management of inflammatory bowel disease-fatigue with a nested qualitative element: study protocol for a randomised controlled trial

BACKGROUND

Fatigue is one of the most prevalent and burdensome symptoms for patients with inflammatory bowel disease (IBD). Although fatigue increases during periods of inflammation, for some patients it persists when disease is in remission. Compared to other long-term conditions where fatigue has been extensively researched, optimal management of fatigue in patients with IBD is unknown and fatigue has rarely been the primary outcome in intervention studies. To date, interventions for the management of IBD-fatigue are sparse, have short-term effects and have not been implemented within the existing health system. There is a need to integrate current best evidence across different conditions, patient experience and clinical expertise in order to develop interventions for IBD-fatigue management that are feasible and effective. Modifying an existing intervention for patients with multiple sclerosis, this study aims to assess the feasibility and initial estimates of efficacy of a cognitive behavioural therapy (CBT) intervention for the management of fatigue in patients with IBD.

METHODS

The study will be a two-arm pilot randomised controlled trial. Patients will be recruited from one outpatient IBD clinic and randomised individually to either: Group 1 (CBT manual for the management of fatigue, one 60-min session and seven 30-min telephone/Skype sessions with a therapist over an eight-week period); or Group 2 (fatigue information sheet to use without therapist help). Self-reported IBD-fatigue (Inflammatory Bowel Disease-Fatigue Scale) and IBD-quality of life (United Kingdom Inflammatory Bowel Disease Questionnaire) and self-reported disease activity will be collected at baseline, three, six and 12 months post randomisation. Illness perceptions, daytime sleepiness, anxiety and depression explanatory variables will be collected only at three months post randomisation. Clinical and sociodemographic data will be retrieved from the patients' medical notes. A nested qualitative study will evaluate patient and therapist experience, and healthcare professionals' perceptions of the intervention.

DISCUSSION

The study will provide evidence of the feasibility and initial estimates of efficacy of a CBT intervention for the management of fatigue in patients with IBD. Quantitative and qualitative findings from the study will contribute to the development and implementation of a large-scale randomised controlled trial assessing the efficacy of CBT interventions for IBD-fatigue.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN17917944 . Registered on 2 September 2016.

Targets for Health Interventions for Inflammatory Bowel Disease-fatigue

BACKGROUND AND AIMS

Fatigue is a complex, multifactorial, and multidimensional phenomenon. Recognition of modifiable correlates of fatigue can provide a further understanding of this phenomenon in patients with inflammatory bowel disease [IBD] and aid in the development of interventions tailored towards fatigue with potential for efficacy. Our aims were to systematically search and synthesise available evidence on potentially modifiable factors contributing to IBD-fatigue and what advances in the management of fatigue in individuals with IBD have been made.

METHODS

The process of selection of citations was based on an earlier review by Czuber-Dochan et al. [2013] and was undertaken in two phases: i] searching for new studies published since August 2012, using seven electronic databases; ii] re-selection of papers included in previous review according to the aims of the current review.

RESULTS

A total of 43 studies met the inclusion criteria. IBD-fatigue was consistently associated with disease activity, depression, anxiety, and sleep difficulties. However, most studies were cross-sectional; thus the direction of causation remains unknown. The relationship between biochemical factors, such as anaemia and inflammation, and fatigue was inconsistent. Solution-focused therapy, thiamine, and exercise showed promising effects on IBD-fatigue. Interventions continue to be sparse, with methodological limitations and only short-term effects reported.

CONCLUSIONS

The review identified a number of psychosocial and physical factors which could potentially be modified through targeted health interventions and improve fatigue in IBD. Research utilising prospective observational studies and randomized control trial [RCT] design is required to develop and test interventions to reduce fatigue, most likely within a biopsychosocial model of care.

Can exercise affect the course of inflammatory bowel disease? Experimental and clinical evidence

The inflammatory bowel disease (IBD) consisting of Crohn's disease (CD) and ulcerative colitis (UC) are defined as idiopathic, chronic and relapsing intestinal disorders occurring in genetically predisposed individuals exposed to environmental risk factors such as diet and microbiome changes. Since conventional drug therapy is expensive and not fully efficient, there is a need for alternative remedies that can improve the outcome in patients suffering from IBD. Whether exercise, which has been proposed as adjunct therapy in IBD, can be beneficial in patients with IBD remains an intriguing question. In this review, we provide an overview of the effects of exercise on human IBD and experimental colitis in animal models that mimic human disease, although the information on exercise in human IBD are sparse and poorly understood. Moderate exercise can exert a beneficial ameliorating effect on IBD and improve the healing of experimental animal colitis due to the activity of protective myokines such as irisin released from working skeletal muscles. CD patients with higher levels of exercise were significantly less likely to develop active disease at six months. Moreover, voluntary exercise has been shown to exert a positive effect on IBD patients' mood, weight maintenance and osteoporosis. On the other hand, depending on its intensity and duration, exercise can evoke transient mild systemic inflammation and enhances pro-inflammatory cytokine release, thereby exacerbating the gastrointestinal symptoms. We discuss recent advances in the mechanism of voluntary and strenuous exercise affecting the outcome of IBD in patients and experimental animal models.

Practical Guideline for Fatigue Management in Inflammatory Bowel Disease

During active inflammatory bowel disease (IBD) fatigue is a common symptom, which seems related to active gut inflammation. However, even in remission many patients suffer from fatigue that negatively affects quality of life and work productivity. Currently, robust knowledge on the pathogenesis and treatment of IBD-related fatigue is lacking. In order to alleviate the burden of IBD-related fatigue, a systematic approach is mandatory. We propose a fatigue attention cycle to enhance identification, evaluation and management of fatigued IBD patients. The benefits of the cycle are twofold. Firstly, it allows the systematic and uniform identification of patients with severe fatigue, in turn allowing tailored non-pharmacological and pharmacological interventions. Secondly, uniform identification of such patients creates a well-defined patient base to investigate the underlying pathogenesis of fatigue, resulting in a greater understanding of this debilitating phenomenon and possibly resulting in the discovery of predictive factors and new treatment interventions.