# Exercise as it relates to Disease/Effect of physical activity on quality of life of inflammatory bowel disease patients

This is a critique of the article: The Impact of a Ten-Week Physical Exercise Program on Health-Related Quality of Life in Patients with Inflammatory Bowel Disease: A Prospective Randomized Controlled Trial (2014) by Peter Klare et. al

## What is the background to this research?

Inflammatory bowel disease (IBD) groups together two chronic diseases that inflame the gastrointestinal tract, Crohn's disease and Ulcerative colitis. Most research suggests the main factors leading to contracting IBD are environmental and genetic, IBD can't be cured and has a relapsing course. Most studies involving exercise and IBD focus on whether disease activity can be changed by physical activity, research suggests that it can't. This paper fills a gap in the research as it is geared towards the psychological side of living with IBD. There is a high prevalence of depression in IBD patients, increasing the importance of this study.

## Where is the research from?

The study was conducted by German researchers from multiple universities based out of a Munich medical clinic. The study was supported by the German institutes of immunology and clinical medical statistics, suggesting no bias and strong credibility. It is clear throughout the paper that there is no agenda, they are only looking for ways to improve quality of life for sufferers of this chronic disease.
Peter Klare led the study, he is a highly respected gastroenterologist who specialises in endoscopy and internal medicine. He is experienced and highly respected in the field of bowel disease further adding to the credibility of the paper.

## What kind of research was this?

The study is a randomized controlled trial (RCT) that took place over 10 weeks, with a baseline data set and post intervention data set collected. RCT's are considered the gold standard for clinical research as the data sets display the effectiveness of a treatment or method against a control group. This type of research is credible due to it's propensity to eliminate biases and variables. In this paper it allows the researchers to look for a clear cause-effect relationship.

## What did the research involve?

The study took place over 10 weeks and 30 subjects were included, at random 15 were prescribed moderate intensity running 3 times a week, the other 15 were the control group. The subjects were recruited over two months from the Munich university hospital of gastroenterology and Crohn's and Colitis association meetings. Subjects were given Health related quality of life (HRQOL) questionnaires at baseline and after the intervention, blood tests for disease activity were also conducted, although the article was more concerned with HRQOL.

### Study strengths

The strengths of the study come through the research done by the authors. The authors have found a clear gap in previous research and directly attempted to fill that with credible and useful data. For a study of this nature the authors also did a good job of removing as many variables as possible.

### Study limitations

In the article it is acknowledged that this study has many limitations however this is understandable as it is one of the earliest studies on this concept. Although RCT's are the gold standard for clinical research the main outcome measures in this paper were secondary, this means bias can impact results. The sample population had some limitations and may not be representative of IBD patients worldwide. Only patients who had mild scores on the Crohn's disease activity index and Rachmilewitz index were included, patients who already exercised regularly were excluded from the study. The population in the study was 73% female which is not a true representation of the statistics, these factors make it important that the results are interpreted circumspectly.

## What were the basic results?

The results showed a 19% increase in HRQOL for the intervention group and 8% increase for control. There was no significant change in disease activity measures. These results are encouraging for IBD patients but the authors were cautious when interpreting these findings due to the previously listed limitations. This does appear to be an encouraging start to this area of research but the results must be kept in perspective. Another encouraging result was that out of 89 reported missed exercise sessions only one was IBD related.

## What conclusions can we take from this research?

Even with the study limitations it's fair to assume that regular exercise will improve HRQOL in IBD patients. Although there are many limitations to the methodology the resultant increase in the intervention groups results is hard to ignore. Crucial to this is previous research indicating the same effect of exercise on people with other diseases or even healthy subjects. Further research on this topic would help to build on this and create clear path to avoiding depression for IBD patients.
The article shows IBD sufferers that exercise helps deal with the mental side of having a chronic disease. It also helps erase the stigma that IBD is a contraindication or excuse to avoid exercise. None of the subjects were partaking in regular exercise and all 15 managed to complete the ten week program of moderate intensity running. There were no adverse events and only one missed session due to IBD related reasons.
Patients with IBD are not encouraged to avoid exercise however there is a lack of guidelines and recommendations for the amount or type of exercise they should be doing. This results in patients believing it is a barrier and often self limiting physical activity, which results in some alarming physical inactivity statistics, with IBD sufferers 5% more likely to be inactive than a healthy person. Unfortunately in the six years after this article was published not much more evidence has come out on this topic, this could be due to the relatively low profile of IBD as a chronic disease.

## Practical advice

* The evidence provided in this paper and other research suggests that IBD patients should aim to meet the Australian government's physical activity guidelines of 150-300 minutes of moderate physical activity a week.
* Only moderate intensity running was prescribed in the study, however it is important to find exercise types that you personally enjoy to increase the chances of performing exercise regularly.
* Patients who are struggling with the physical effects or are finding IBD as a barrier to exercise should consult their doctor or gastroenterologist for further advice.

## Further information/resources

The following links provide information about IBD and offer support to patients:
* https://www.crohnsandcolitis.com.au/
* http://crohnsandcolitishub.com.au/
* https://guts4life.com.my/en/
* https://www.crohnscolitisfoundation.org/
The following article discusses the relationship of IBD and depression:
* Considering the Bidirectional Pathways Between Depression and IBD: Recommendations for Comprehensive IBD Care

## References

* ↑ Ananthakrishnan, A. (2015) Epidemiology and risk factors for IBD. Nature Reviews Gastroenterology and Hepatology vol 12, p205–217.
* ↑ N Narula, RN Fedorak. (2008) Exercise and inflammatory bowel disease. Canadian Journal of Gastroenterology 2008, p497-504
* ↑ Keefer L, Kane SV. (2017) Considering the Bidirectional Pathways Between Depression and IBD: Recommendations for Comprehensive IBD Care. Gastroenterology Hepatology (N Y). p164-169.
* ↑ Management & Krakenhaus. (2019) Krankenhaus Agatharied: Endoskopie-Spezialist neuer Chefarzt für Gastroenterologie.
* ↑ Shah, S C, Khalili, H et. al. (2018) Sex-Based Differences in Incidence of Inflammatory Bowel Diseases—Pooled Analysis of Population-Based Studies From Western Countries. Gastroenterology Vol. 155, No. 4, p1079-1089
* ↑ Nathan, I et.al (2012) Exercise in Individuals With Inflammatory Bowel Disease. 2013 Society of Gastroenterology Nurses and Associates vol 36,p437-441
* ↑ Eckert, K.G., Abbasi-Neureither, I., Köppel, M. et al. (2019) Structured physical activity interventions as a complementary therapy for patients with inflammatory bowel disease – a scoping review and practical implications. BMC Gastroenterology vol 19, p115.
* ↑ Australian government department of health. (2014) Australia's Physical Activity and Sedentary Behaviour Guidelines and the Australian 24-Hour Movement Guidelines.