Background
Methods
Search strategy
Study selection
Data extraction
Results
Reason for exclusion | Number of articles excluded |
---|---|
No PA intervention | n=29 |
No IBD patients | n=5 |
Study protocol | n=1 |
Use of same study sample | n=2 |
Reviews / no Interventions | n=4 |
Total number of articles excluded after full text screening |
n
=41
|
Characteristics of the studies
Author | Subjects and design | Endpoints | Medication EG (CG) | Methods | Duration and frequency | Main findings | Adverse events | Level of evidence |
---|---|---|---|---|---|---|---|---|
Robinson et al., [33] | 107 patients with CD, mild to moderate disease activity; block randomization (EG: n=53, CG: n=54) | BMD | All under steroid use | Home-based; floor-based, progressive low-impact dynamic resistance training | At least twice a week, with a min. of 10 sessions per month; 1 year | Fully compliant patients (14): BMD increased at the femoral neck (n.s.), the spine (n.s.), the Ward’s triangle (n.s.) and the trochanter major ([EG-CG] (95% CI) = 4.67 (0.86-8.48), p=.02) | Not reported | 2 |
D’Inca et al., [38] | 6 CD patients in remission; 6 healthy controls | Disease activity, various gastrointestinal parameters | Not reported | Cycling exercise | Cycle ergometer exercise at 60% of max. oxygen intake; once for 1 hour | No statistically significant effects on gastrointestinal parameters; no change in disease activity | None | 3 |
Loudon et al., [39] | 12 physically inactive patients with inactive or mildly active CD, no controls | Stress Index, HrQoL, disease activity, fitness, BMI | Prednisone n=4; 5-ASA n=5; 6-MP n=6; no medication n=2 | Supervised and unsupervised walking program (indoor track) | 3 sessions a week (20-35 min); 12 weeks | Significant improvements in IBD Stress Index (mean change study outset (29.2±15.4) to completion (19.5±10.8) p<.001), IBDQ (172±27 to 189±12, p=.01), HBI (5.9±5.0 to 3.6±3.1, p=.02), VO2max (30.6±4.7 to 32.4±4.8, p<.01), BMI (24.3±5.3 to 23.9±5.3, p=0.07) | None | 4 |
Candow et al., [40] | 12 CD patients, no controls; disease activity not specified | Disease activity, muscle strength | Not reported | Supervised resistance training (12 exercises) | 3 times a week over the course of 12 weeks, 3 sets, 8-10 repetitions; 60-70% of 1RM | Significant increase in muscle strength (p<.05); no change in disease activity (HBI) | None | 4 |
Elsenbruch et al., [34] | 30 UC patients in remission or low disease activity; randomized controlled trial | Neuroendocrine and cellular immune parameters, HrQoL, disease activity | 5-ASA n=8 (7); probiotics n=1 (3); ironsulfate n=0 (1) no medication n=6 (4) | Structured and supervised mind-body therapy (includes stress management training, moderate exercise, Mediterranean diet, cognitive behavioral techniques with focus on self-care strategies) | 60-hour program over a 10-week period (i.e. 6 h on 1 day every week) | Significant improvements in HrQoL (SF-36 short: psychosocial health sum score p<.05, mean change EG=7.2±10.7; mean change CG = 0.0±8.5) and IBDQ (bowel symptoms: d=0.52, p<.01); no statistically significant group differences in lymphocyte sub-set numbers or production of TNF α and RI | Not reported | 2 |
Gupta et al., [41] | 175 patients with different chronic conditions (n=18 with gastrointestinal problems including CD, disease activity not specified) | Anxiety scores | Not specified | Lifestyle intervention | Yoga, breathing exercise, mediation, stress management and nutrition education; 5+3 days with a two day break for weekend | No statistically significant change in anxiety levels (STAI) | Not reported | 4 |
Ng et al., [30] | 32 patients in remission or with mildly active CD, matched and randomized | HrQoL, disease activity, Stress Index | 5-ASA n=6 (6); no medication n=10 (10) | Independant walking program | 60% HRmax during exercise, 3 times a week over 3 month; 30 min per session | Significant improvements in IDB Stress Index (p<.05), disease related dysfunction (IBDQ) (p<.05) and reduction in HBI (p<.01) | None | 2 |
De Souza Tajiri et al., [42] | 19 patients (CD: n=10, UC: n=9), no controls; disease activity not specified | Thigh circumference, bodyweight, quadriceps strength, HrQoL | Not reported | Progressive resistance training | Knee extension; first 4 weeks: 50% 1RM, 3 sets of 12 repetitions; last 4 weeks: weekly increase of load by 10% until 80% of max. load | Significant improvements in quadriceps strength (greater than 40%, p<.001), IBDQ (mean changes baseline 156.3±29.0 to post 180.5±24.2, p<.001). No statistically significant changes in thigh circumference and bodyweight | None | 4 |
Gerbarg et al., [36] | 25 patients with mild to moderate IBD, randomized | Psychological and physical symptoms (HrQoL), inflammatory markers | No medication n=5; all other mixed medications (biologics, immunosuppressive; corticosteroids; mesalamines) | EG: 9 hours administered Breath-Body-Mind Workshop (BBMW) (breathing, Qigong, mediation) CG: 9 hours educational seminar (ES) (information about IBD and its treatment) | EG: BBMW and 26 weeks homebased, self-administered sessions, every day for 20 min | No between group differences IBDQ (mean change EG= 12.57±15.85, mean change CG= -1.73±19.91; p=.08); Significant changes in CRP (median change EG: baseline 1026.0 to post 730.0; p=.01; median change CG: 8590.0 to 7180.0, p=.39) but not in FCP (median change EG: baseline 216.3 to post 155.9, p=.78; median change CG: 157.8 to 341.5, p=.59), | None | 2 |
Klare et al., [37] | 30 patients with mild to moderate IBD, randomized controlled trial | HrQoL, disease activity, BMI | Prednisolone n=4 (1); budesonide n=3 (2); mesalazine n=3 (5); ASA/5-MP n=3 (5) | Supervised outdoor running program for untrained people | Moderate intensity, equated by BMI; 3 times a week for 10 weeks | Significant improvements of IBDQ social dimension ([EG-CG] (95% CI) = 4.4 (0.6-8.2), p=.03); no changes in disease activity (CDAI: [EG-CD] (95% CI) = -3.7 (-35.8-29.3, p=.81; RI: [EG-CG] (95% CI) = -0.2 (-2,6-2.3), p=.88); BMI ([EG-CG] (95% CI) = 0.4 (0.0-0.9), p=.08) or laboratory results (Lc: [EG-CG] (95% CI) = -0.7(-2.3-0.9), p=.39; CRP: [EG-CG] (95% CI) = 0.0 (-0.3-0.2), p=.88; FCP: [EG-CG] (95% CI) = -25.3 (-433.6-383.0), p=.90 | None | 2 |
Sharma et al., [7] | 87 patients (CD: n=36, UC: n=51) in clinical remission, randomly allocated to EG or CG | Stress Index, anxiety, cardiovascular autonomic functions, immune markers | “all treated with maintenance dose of mesalamines and azathriopine” (p.103) | Supervised Yoga intervention (physical postures, pranayama, meditation) | 1 hour a day for 8 weeks | No statistically significant group differences in any outcome parameter (overall), but significant differences within the UC groups (EG and CG) in State (mean change baseline from 38.9±8.9 to post 32.8±8.2, p=.01) and Trait (mean change from 49.5±8.7 to 41.2±8.2, p=.001) anxiety levels (STAI); fewer UC patients reported arthralgia (p<.05) | Not reported | 2 |
Hassid et al., [43] | 10 patients (CD n=7, UC n=3), no controls; disease activity not specified | Disease activity | Not reported | Different types of intensive exercise: marathon (1), half-marathon (5), long bicycle ride (>45 miles) (3), triathlon (1) | Once | No statistically significant change in disease activity (HBI and SCCAI); no abnormally elevated FCP | None | 4 |
Cramer et al., [35] | 77 UC patients, randomly assigned; in remission | HrQoL, disease activity | Biologics n=4 (6); immunosuppressive n=0 (1); thiopurines n=10 (10); mesalazine n=30 (28); probiotics n=5 (1) | Supervised traditional hatha yoga intervention (EG); two self-care books - without instructions for using - providing general information on UC (CG) | 90 min weekly over a period of 12 weeks | Significant increase of HrQoL after 12 weeks (IBDQ: [EG-CG] (95% CI) = 14.7 (2.4-26.9), p=.02) and after 24 weeks ([EG-CG] (95% CI) = 16.4 (2.5-30.3), p=.02); disease activity (RI: [EG-CG] (95% CI) = -1.2 (-0.1-[-2.3]), p=.03) | None | 2 |
Findings by type of exercise intervention
Cardiovascular training
Strength training
Yoga
Lifestyle intervention – mixed methods
Discussion
Biologic rationale for benefits of PA interventions in IBDs
a) Inflammatory biomarkers
Disease activity
Health benefits of PA interventions in IBD
a) Physical effects
b) Psychological effects
Conclusion
-
Type and volume of exercise must be sufficient to stimulate anti-inflammatory effects. Research has shown, that the anti-inflammatory output of exercise depends on the FITT-Criteria [45] as well as the amount of recruited muscle mass [53]. In order to assist clinicians to advise patients better and improve the design of future exercise studies, a representation of recommended FITT criteria, has been provided in Table 3.
-
The maintenance of an active lifestyle is the main goal of all exercise interventions. Thus, future studies need to implement psychological techniques to enhance motivation, self-regulation and self-reflection, in order to enable patients implement PA for their individual disease management [83].
-
An agreement in standardized assessment instruments including the most important health outcomes in IBD would be necessary for the quantitative synthesis of future studies [28, 84]. The interventions as well as outcome assessments should be multidimensional, i.e. the combination of disease-specific clinical markers with physiological and psychological parameters.
-
Future investigations should assess quality of life as it is an important aspect of medical decision-making and a major goal of therapy.
-
Because of the cyclical nature of IBD and the individuality of the disease patterns, it is difficult to conduct standardized large-scale RCTs. To counteract this methodological obstacle the application of systematic N-of-1-trials can be helpful [85].
FITT-Criteria
|
The patient should….
|
F-requency | ...engage in moderate PA at least three times a week, even better five times a week. |
I-ntensity | ... choose an activity which increases the energy expenditure by at least a factor of three or four, as it is the case for brisk walking. For exercise control via heart rate (HR), the intensity of the exercise should be between 60 – 80% of the maximum HR. Bear in mind: moderate intensity is key in order to improve inflammation. |
T-ime | … exercise for at least 30 minutes per day (more is even better, if tolerated). |
T-ype | ... engage in an enjoyable activity, to increase the probability to maintain this behavior. Exercising in groups can increase the motivation. A mixture of endurance and resistance exercise is favorable, because it avoids unilateral training and emphasizes the use of all big muscle groups. ... increase the amount of leisure time PA. “Walk before you run”. |