Suja P. Davis, Patricia B. Crane, Linda P. Bolin, and Lee Ann Johnson
Key Points
- The potential health benefits of physical activity for people with IBD include improved mental health, sleep quality and gastrointestinal symptoms.
- Evidence suggests that exercise can lower the risk of developing IBD as well as lowering the chances of a flare-up.
- Symptoms of IBD like fatigue, joint pain, abdominal pain, bowel urgency, active disease and depression can get in the way of exercising.
Introduction
Inflammatory bowel disease (IBD) is a chronic illness comprised of 2 forms of disorders: Crohn’s disease (CD) and ulcerative colitis (UC). The incidence rate of IBD is increasing worldwide, including developing countries where IBD was previously considered a rare disorder. Adults with IBD present with many disturbing gastrointestinal (GI) symptoms, such as diarrhea, abdominal pain, bowel urgency, rectal bleeding, and extraintestinal manifestations. Additionally, systemic symptoms, such as anxiety, depression, fatigue, sleep disturbances, and pain, are also common in adults with IBD. The quality of life (QOL) of those with IBD is lowered due to the GI and systemic symptoms, as well as due to the extraintestinal manifestations. Although, many advanced medical and surgical therapies are available to manage IBD, adults with IBD may look for other adjuvant options to manage their symptoms and improve their QOL. Physical activity (PA) is one such alternative intervention. Exercise is an equivalent term used in the literature for PA, however it refers to more structured and repetitive activities.
Alterations in the intestinal immune system act as a trigger for IBD inflammation. The anti-inflammatory benefits of exercise are well documented and are related to the control of pro-inflammatory cytokines in the intestinal system. In healthy individuals, the immune system of the intestine is in a state of equilibrium between pro- and anti-inflammatory mechanisms. However, disturbances in this equilibrium lead to the activation of the intestinal immune system and subsequent inflammation in IBD. Animal model studies show that moderate exercise downregulates cytokines, such as interleukin-1 (IL-1) and tumor necrosis factor (TNF)-α, which reduce inflammation, suggesting a beneficial influence of exercise on IBD inflammation. Additionally, the anti-inflammatory effects of exercise are related to the release of myokines from the muscles, such as IL-6, IL-10, and IL-1ra. These myokines inhibit TNF-α production, which reduces intestinal inflammation.
While reviews have been published on the benefits of PA for adults with IBD, reviews had mixed results and many reviews included older studies. Furthermore, many studies did not include barriers to engaging in PA/exercise among adults with IBD. Therefore, the aim of this review was to synthesize the literature on PA in adults with IBD with a focus on health outcomes of PA in adults with IBD as well as to identify the barriers to engage in PA by those with IBD.
Discussion
As evident in the literature, PA can help many chronic GI illnesses, including irritable bowel syndrome, diverticular diseases, and constipation, as well as reduce the risk of colon cancer. In alignment with these studies, the reviewed research supported the benefits of PA for IBD which is a chronic illness with a disease trajectory of remission and relapse. The reviewed studies highlighted the positive effects of PA on QOL; the improvement of mental, physical, and IBD symptoms; the reduction of the risk of IBD; and the protective role of PA in maintaining remission. Overall, the reviewed studies favored low-to moderate-intensity physical activities for adults with IBD.
There are mixed opinions in published literature regarding the type and intensity of PA for adults with IBD, especially related to high-intensity exercises. In a mouse model of colitis, worsened inflammation and increased mortality were observed with forced treadmill exercise. Conversely, reduced inflammatory responses in the distal colon and reduced diarrheal episodes were noted after 30 days of voluntary wheel training. Intense exercise increased systemic inflammation and the level of cytokines, resulting in worsened GI symptoms.
However, in a qualitative analysis, participants had different views about PA. Some participants were actively engaged in exercise, and they reported having more energy. Conversely, others reported a vicious circle between fatigue and exercise, where low energy prohibited them from engaging in exercise, which led to a more sedentary life. Therefore, a dose-effect approach should be considered with PA/exercise in adults with IBD when considering the type of exercise, the intensity, and the duration. Additionally, disease activity can be a confounding factor and patients with mild form of disease activity may engage in exercise more frequently resulting in improved IBD outcomes. Although a number of reviewed studies included participants with active IBD, all these studies failed to establish a positive link between PA and active disease. A number of factors can influence PA engagement during active disease including bowel urgency, toilette access and the commencement of corticosteroids and biologics. Those with mild form of disease activity may engage in exercise more frequently resulting in improved IBD outcomes. Conversely, those with moderate or severe disease activity may have decreased frequency of PA due to pain or cramping. Further research is needed to determine PA and IBD outcomes by disease levels: mild, moderate, and severe.
None of the reviewed studies offered any specific guidelines for PA in adults with IBD. Participants of the majority of the reviewed studies engaged in walking and running as the aerobic form of PA. Although resistance training and combined aerobic exercise or resistance training were reported safe for adults with IBD, data are limited on these types of PA. Only a few studies evaluated the effects of resistance training and combined aerobic exercise or resistance training in adults with IBD. However, limitations were noted in these studies including small sample sizes, and, study participants had mild disease activity or were in remission. Because participants reported that they determined the duration of exercise based on their energy levels and recommended the same strategy to others with IBD, we recommend individually tailored PA for adults with IBD to maximize participation and resulting PA benefits. The same notion along with the dose-effect approach need to be considered while providing PA advice to adults with IBD. However, the study participants reported a lack of discussion about the health benefits of exercise from their providers. The same concern was raised in another study where 46.1% of the participants (n = 158) confirmed a lack of discussion regarding exercise by their health care professionals.
Similar to the reviewed studies, published literature lack guidelines on PA specific for adults with IBD. A recent publication addressed this concern and made some recommendations based on FITT (frequency, intensity, time and type) criteria which are: taking part in moderate PA three to five times a week for at least 30 minutes (can increase the time depending on the tolerance); selecting an activity that intensifies the energy expenditure to moderate intensity is pivotal to manage inflammation; participating in both aerobic and resistance training; engaging in group PA to maximize group support and to sustain the behavior. Lastly, the authors recommended future N-of -1-trials with PA due to the varying disease course of IBD with a focus on physical and psychological outcomes. However, the authors solely made these recommendations based on their scoping review on PA in adults with IBD without evidence-based studies. Therefore, the applications of these recommendations are not tested. Future studies focusing the FIIT criteria and N-of -1-trials are needed to validate these recommendations in adults with IBD.
Conclusion
In general, the reviewed studies supported moderate-intensity PA for adults with IBD. The reviewed studies highlighted many positive health benefits of PA, such as improvements in QOL and IBD symptoms, mental health benefits, and reduced risk of development of IBD. The results of the studies also indicated many barriers to performing PA for adults with IBD. Therefore, a dose-effect approach is recommended for PA engagement among adults with IBD.
Original source: An integrative review of physical activity in adults with inflammatory bowel disease
