# Exercise as it relates to Disease/The effects of walking on the lives of Crohn's disease sufferers

This page is an analysis of an original research article "Low-Intensity Exercise Improves Quality of Life in Patients With Crohn's Disease" by Ng et al (2007)

## What is the background to this research?

Inflammatory Bowel Disease (Crohn's disease and Ulcerative Colitis) affects one in 250 people aged 5–40 in Australia. Currently 75,000 people in Australian suffer from Crohn's Disease (CD) with this number expected to increase to 100,000 by 2022. Economically, Inflammatory Bowel Disease (IBD) is estimated to cost $2.7 billion dollars per annum in health system costs. Currently there is no known cure for CD and treatment is mostly focused around symptom management with pharmaceuticals. Concerns of patients and clinicians is that exercise may increase bowel motility, however previous studies investigating this have reported varying results. While physical activity is currently used as a complementary treatment for other chronic conditions such as depression and heart disease, little is known about the impacts of exercise on disease activity and inflammation in those with CD

## Where is the research from?

This research was conducted at the University of Western Ontario, London by the following departments:
* Fowler Kennedy Sport Medicine Clinic
* Department of Paediatrics
* Schulich School of Medicine

## What kind of research was this?

This research was a parallel, two group, randomised control study. Both intervention and control groups were given the same outcome measurements, discussed below. Outcome measures were based on self reported, standardised surveys which provides consistency in the field however is not immune to inaccuracy of self reported data.

## What did the research involve?

This study consisted of an exercise and a control group with mean age, BMI, gender and medication status described in Table 1. Participants had to meet an inclusion criteria consisting of the following:
* mildly active disease or disease in remission
* habitual vigorous activity of less than 2 times per week
* not anticipating a change in medication for CD
* no history of cardiovascular disease
Table 1: Description of Research Participants :
| | Exercise (n=16) | Control (n=16) |
| Age Body Mass Index Gender (M/F) 5-Aminosalicylate users at study entry Not taking any medication | 40.6 ± 11.7 25.7 ± 4.8 7/9 6 10 | 37.0 ± 12.7 23.0 ± 3.0 7/9 6 10 |
Exercise group:
* independent walking for 30 minutes, 3 times per week for three months.
* maintain target heart rate of 60% max, monitored with an issued heart rate monitor
* steps recorded using an issued pedometer
* significant physical activity was recorded, including type, intensity and duration
Control group:
* required to maintain current habitual physical activity level of less than 2 times per week
* no equipment issued
Both groups completed surveys summarised in Table 2 which were conducted at the beginning of the study, at 1 month, 2 months and upon completion to provide outcome measures.
Table 2: Categories each survey uses to assess overall well being of CD patients :
| International Physical Activity Long Questionnaire | IBD Stress Index | IBD Questionnaire | Harvey-Bradshaw Simple Index of CD |
| Habitual activity levels | overall life satisfaction worry about health relationships school & employment recreational activities sexuality psychosomatic symptomatology (disease made worse by mental factors) body image | symptoms directly related to primary bowel disturbance systemic symptoms emotional function social function | general well being abdominal pain number of liquid stools per day abdominal mass complications |

## What were the basic results?

* Exercise group showed a significant change (P<0.05) in pre-study and post-study scores for both IBD Stress Test and IBD Questionnaire
* In both exercise and control groups, the Harvey-Bradshaw Simple index of CD severity showed significant changes when comparing pre and post-test scores. The control groups symptoms significantly worsened (P=0.04) and the exercise group showed a significant reduction in symptoms (P<0.01)
* No detrimental effects of low-intensity walking in terms of disease activity
Researchers interpreted these results to mean that low intensity exercise can improve quality of life in patients with CD.

## What conclusions can we take from this research?

This research is an important contribution towards understanding how physical activity can impact quality of life in those with mildly active or in remission for CD. It builds on previous work done by Loudon et al (1999) that demonstrated an improvement in quality of life in CD patients after participating in a group walking exercise program. By implementing an independent walking program they removed the effects of positive social interactions associated with group exercise programs and therefore can more accurately attribute their results with the intervention. However, Ng et al did not implement a controlled, supervised exercise program and therefore cannot account for variables such as terrain, duration, environment and compliance which can significantly impact the results. There is also the possibility that the control group increased their habitual physical activity as they knew their counterparts were participating in an exercise intervention. Additionally, Ng et al conducted surveys at one month intervals and did not require participants to keep a daily log of disease activity. By asking participants to remember what their symptoms and disease stress index was like over a month period may provide inaccurate data. As the subjects of this study were either in remission or were only experiencing mild disease state, it would be beneficial to look at the effects of exercise in patients with more severe disease states to be able to apply the findings to a larger population group. A later study conducted by Klare et al (2015) looked at a running intervention of thrice weekly for 10 weeks on patients with moderately active IBD and found that subjects were able to perform symptom-free regular exercise. Further research which combines qualitative analysis of questionnaires in composite with quantitive data such as biomarkers looking at inflammation responses to exercise and disease exacerbation would be advantageous.

## Practical advice

With studies like this we can begin to understand the role of physical activity in improving quality of life for patients with CD. Clinicians can use this research to encourage patients to slowly increase their physical activity for multifaceted approach to health care in this population group. It is important to note that this research was done on patients with mildly active disease states or in remission and therefore it's advised to consult a health care provider before increasing physical activity levels.

## Further information/resources

Crohns and Colitis Australia Gastroenterology Society of Australia

## References

* 1 2 3 4 5 6 Ng, V. Millard, W. Lebrun, C. Howard, J, 2007. Low-Intensity Exercise Improves Quality of Life in Patients With Crohn's Disease. Clinical Journal of Sports Medicine, 17, Number 5, 384-388.
* ↑ Crohns and Colitis Australia. 2013. Improving Inflammatory Bowel Disease Care Across Australia. [ONLINE] Available at: https://www.crohnsandcolitis.com.au/research/studies-reports/. [Accessed 18 September 2016].
* 1 2 3 Klare, P. Nigg, J. Nold, J. Haller, B. Krug, A. Mair, S. Fhoeringer, C. Christle, J. Schmid, R. Halle, M. Huber, W. 2015. The Impact of a Ten-Week Physical Exercise Program on Health-Related Quality of Life in Patients with Inflammatory Bowel Disease: A Prospective Randomised Controlled Trial. Digestion, [Online]. 91, 239-247. Available at: https://www.researchgate.net/publication/274317505 [Accessed 20 August 2016].
* ↑ Science for all Brainwaves. 2012. The dangers of self-report. [ONLINE] Available at: http://www.sciencebrainwaves.com/the-dangers-of-self-report/. [Accessed 18 September 2016].
* ↑ Patterson, E. 2012. The International Physical Activity Questionnaire. [ONLINE] Available at: https://sites.google.com/site/theipaq/questionnaire_links. [Accessed 14 September 2016].
* 1 2 Crohns and Colitis Foundation of America. 2016. IBD Surveys/Questionnaires for Clinical Practice. [ONLINE] Available at: http://www.ccfa.org/science-and-professionals/programs-materials/ibd-nurses/best-practices/ibd-questions.pdf. [Accessed 29 August 2016].
* ↑ Harvey RF, Bradshaw JM. A simple index of Crohn’s-disease activity. Lancet. 1980;315(8167):514.
* ↑ Loudon, CP, 1999. The effects of physical exercise on patients with CD. The American journal of gastroenterology, [Online]. 94/3, 697-703. Available at: https://www-ncbi-nlm-nih-gov.ezproxy.canberra.edu.au/pubmed/10086654 [Accessed 26 September 2016]