# Exercise as it relates to Disease/Beneficial effects of exercise for individuals suffering Crohn's disease
## Background
### What is Crohn's Disease?

Crohn’s disease (CD), categorized under a broader group of illnesses known as inflammatory bowel disease (IBD), is a chronic inflammatory disease of the gastrointestinal system. Evidence suggests that CD is a large cause of morbidity within Australia, and it is estimated that 50 people per 100,000 are suffering this chronic disease. CD commonly effects people within their 20s and 60s and may also affect any portion of the alimentary tract, from the mouth to the anus, most commonly:
* Ileum and Cecum - 40% of CD cases
* Small Intestine - 30% of CD cases
* Colon - 25% of CD cases

### Signs/Symptoms

* Cramps/Abdominal pain
* Diarrhea
* Weight loss
* Fatigue
* Muscle weakness

### Causes of Crohn's Disease

The main cause of Crohn’s disease is unclear although a number of possible causes have been suggested including:
* Genetics - pro-inflammatory and anti-inflammatory markers
* Microbial infection - microbial balance disrupted
* Immunology - abnormalities of the immune system
* Environment - smoking etc.
* Diet
* Vasculature
* Psychological factors
A number of these possible causes of CD could be preventable, including:
| Preventable Factors | Non-Preventable Factors |
| * Poor diet * Smoking. | * Age * Race and gender * Family History/Genetics |

### Comorbidities

A number of comorbidity’s are associated with Crohn’s disease, mainly caused by medications, malabsorption, cell changes, lesions and intestinal blockages These include:
* Osteoporosis and osteopenia
* Depression
* Reduced skeletal muscle mass and strength and
* Cancer
Patients who suffer comorbidities have a decreased quality of life, but prevention is possible.

## Common Treatments

There are a number of treatments currently used to manage the symptoms associated with CD, including:
* Medication - which is dependent on: the stage of the disease (active or remissive) and the level of severity (mild to severe)
* Surgery: surgery is used to rectify problems including stricture, obstruction, fistulae
* Complementary and Alternative Treatments: including probiotics, prebiotics and acupuncture.
* Diet and lifestyle changes: quit smoking etc.
* Exercise: Aerobic and Resistance training

### Exercise

Recent research suggests that physical activity is now being recommended to a large number of people suffering from chronic illnesses, including CD. The positive effects associated with physical activity have the potential to improve an individual’s physical condition and quality of life. The table below illustrates some of the potential benefits physical activity possesses for individuals with Crohn’s disease.
| Symptoms | Type of Exercise | Exercise Effects |
| Pain – cramps located in the abdominal region produced by inflammation of the intestines. | Stretching exercises and Extended swimming exercise. | Induced analgesia – pain suppression. |
| Bone Mineral Loss – due to calcium and vitamin D malabsorption, malnutrition and medications, | Aerobic, Muscular training and Balance exercises. | Counteract bone mineral loss and reduce falls/fractures. |
| Fatigue – due to lack of physical exercise (decreased aerobic fitness and muscle strength). | More research is needed to know which type of physical activity would obtain the best results. | Physical activity has a direct effect on a person’s feeling of energy, exercise could attenuate perceived fatigue. |
| Intestinal Problems – diarrhea and constipation. | Light to moderate exercise. . | Beneficial effects are mainly due to decreased gastrointestinal blood flow, neuroimmuno-endocrine alterations, increased gastrointestinal motility and mechanical bouncing whilst exercising. |
| Body Composition – weight loss and malnutrition. | Resistance training. | Increases total body weight and improves body composition, by increasing skeletal muscle mass. |
| Sleep Disturbances - poor sleep patterns e.g. feeling hot and cold, abdominal pain, bad dreams and breathing problems. | Aerobic exercise. | Evidence suggest that aerobic exercises help people with sleeping problems, therefore CD patients may benefit. |
| Anaemia | Aerobic exercise. | Reduce or prevent declines in erythrocyte levels. |
| Depression and Anxiety | Social/Team exercises. | Anti-depressant effects e.g. hormonal changes. |

## Recommendations

To determine physical activity for individuals suffering from CD including the type, frequency, intensity and duration, more research is needed to understand the exact benefits provided. However, recent evidence suggests there appears to be two main types of exercise that are beneficial for individuals with CD: aerobic activity and muscular resistance training. The following recommendations refer to the ideal training for maximum efficiency at reducing the signs and symptoms of Crohn’s Disease.
Aerobic Exercise:
* 2–3 days per week for 20–30 minutes at low intensity
* Exercises can include walking, cycling, swimming and low impact aerobics
* Progression: increase to most days of the week when comfortable
Resistance Exercise:
* 2–3 days per week completing 2-3 sets, 8-12 repetitions
* Exercises that utilize the major muscle groups of the trunk and legs
* Exercises completed at 50% 1RM (moderate intensity)
* Exercises can include the use of elastic bands and free weights
* Progression: increase repetitions performed at 60% 1RM

## Limitations and Considerations

It is important to note that exercise programs should be individualised and when planning an exercise routine, it is also essential to consider the physical limitations a CD patient may be suffering including:
* Dehydration - due to the high rate of diarrhea, fluid intake is essential (1-2 L per day).
* Age - important factor that influences physical ability.
* Severity of disease - the severe cases of CD experience a number of symptoms which make exercise difficult.
* Medications - side effects may inhibit a patient from exercising comfortably.
* Lack of Motivation - due to depression and negative self-image.
* Comorbidities - several comorbidities are associated with CD and may inhibit exercise further.
* Improving compliance - it is suggested that Crohn's patients participate within supervised exercise sessions or group activities.

## Further reading

Research suggests that there is a positive link between exercise and its role in preventing or managing the burden of Crohn's disease, however the clinical recommendations and knowledge for exercise prescription are limited. Future studies into standardising an exercise regime for CD sufferers would be extremely beneficial in both prevention and treatment.
Crohn's Disease - Colorectal Surgeons Sydney
How exercise benefits Crohn's Disease
Information regarding CD

## References

* 1 2 Ruthruff, B., 2007, Clinical review of Crohn’s disease, Journal of American Academy of Nurse Practitioners
* ↑ Colorectal Surgeons Sydney, Crohn’s Disease, http://colorectalsurgeonssydney.com.au/?page_id=397
* 1 2 3 4 Wick, J.Y., 2010, Crohn’s Disease: Managing a Complex and Chronic Condition, Pharmacy Times
* ↑ Chen, Y., &Noble, E.G., 2008, is exercise beneficial to the inflammatory bowel diseases? An implication of heat shock proteins, School of Kinesiology, Faculty of Health Sciences, University of Western Ontario, London
* 1 2 Mazal, J., 2014, Crohn Disease: Pathophysiology, Diagnosis, and Treatment, Radiologic Technology, vol 85, No. 3
* ↑ Langenberg, V., Della Gatta, P., Hill, B., Zacharewicz, E., Gibson, P.R., & Russell A.P., 2013, Delving into disability in Crohn’s disease: Dysregulation of molecular pathways may explain skeletal muscle loss in Crohn’s disease, Department of Gastroenterology & Hepatology, Monash University, Box Hill, Victoria, Australia
* 1 2 3 Perez, C. A., 2009, Prescription of physical exercise in Crohn’s disease, Faculty of Education and Sport Science, University of Vigo, Spain
* ↑ Ng, V., Millard, W., Lebrun, C., & Howard, J., 2006, Exercise and Crohn’s disease: Speculations of potential benefits, Can J Gastroenterol Vol 20, No. 10