physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial

© 2011 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY

nature publishing group ORIGINAL CONTRIBUTIONS 915

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INTRODUCTION Irritable bowel syndrome (IBS) is a common functional gas-

trointestinal (GI) disorder ( 1 – 3 ), characterized by abdominal

pain / discomfort related to altered bowel habits in the absence of

organic cause ( 4 ). GI disorders aff ect health-related quality of life

(HRQOL) negatively. Th is negative eff ect is more pronounced in

functional GI disorders compared with organic GI disorders ( 5 ).

Moreover, patients with IBS have a higher prevalence of migraine,

fi bromyalgia, and depression ( 6 ), and fatigue is oft en a prominent

symptom ( 7 ).

Physical activity is benefi cial to prevent or treat a number of

conditions, such as depression ( 8 ), fi bromyalgia ( 9 ), and colon

cancer ( 10,11 ). Increases in maximal cardiorespiratory fi tness and

habitual physical activity are associated with less severe depressive

symptoms and greater emotional well-being ( 12 ).

Physical activity has been shown to improve gas transit and

abdominal distension in healthy subjects, but not the perception of

bloating ( 13 ). Regular physical activity improves defecation pattern

and colonic transit time in patients complaining of chronic con-

stipation ( 14 ). On the other hand, endurance athletes have been

reported to complain of GI symptoms ( 15 ). Symptoms such as

bloating, diarrhea, fl atulence, and nausea are well documented in

these athletes ( 16 ).

In a questionnaire survey by Lustyk et al. , it was shown that

women suff ering from IBS are less physically active than are healthy

women. Women with IBS who were physically active reported less

fatigue and less feelings of incomplete evacuation. However, in this

study, it could not be determined whether IBS prevented these

women from being physically active or whether being physically

inactive worsened their symptoms ( 17 ). In educational programs

for IBS, patients are advised to be more physically active or to

exercise, although it has so far not been explored whether physical

activity is benefi cial in IBS ( 18 ).

Th erefore, the primary aim of this study was to test the hypo-

thesis that increased physical activity decreases the severity of

IBS symptoms. Th e secondary aims were to assess the impact of

Physical Activity Improves Symptoms in Irritable Bowel Syndrome: A Randomized Controlled Trial Elisabet Johannesson 1 , Magnus Simr é n 1 , Hans Strid , MD, PhD 1 , Antal Bajor , MD, PhD 1 and Riadh Sadik , MD, PhD 1

OBJECTIVES: Physical activity has been shown to be effective in the treatment of conditions, such as fi bromyalgia and depression. Although these conditions are associated with irritable bowel syndrome (IBS), no study has assessed the effect of physical activity on gastrointestinal (GI) symptoms in IBS. The aim was to study the effect of physical activity on symptoms in IBS.

METHODS: We randomized 102 patients to a physical activity group and a control group. Patients of the physical activity group were instructed by a physiotherapist to increase their physical activity, and those of the control group were instructed to maintain their lifestyle. The primary end point was to assess the change in the IBS Severity Scoring System (IBS-SSS).

RESULTS: A total of 38 (73.7 % women, median age 38.5 (19 – 65) years) patients in the control group and 37 (75.7 % women, median age 36 (18 – 65) years) patients in the physical activity group completed the study. There was a signifi cant difference in the improvement in the IBS-SSS score between the physical activity group and the control group ( − 51 ( − 130 and 49) vs. − 5 ( − 101 and 118), P = 0.003). The proportion of patients with increased IBS symptom severity during the study was signifi cantly larger in the control group than in the physical activity group.

CONCLUSIONS: Increased physical activity improves GI symptoms in IBS. Physically active patients with IBS will face less symptom deterioration compared with physically inactive patients. Physical activity should be used as a primary treatment modality in IBS.

Am J Gastroenterol 2011; 106:915–922; doi: 10.1038/ajg.2010.480; published online 4 January 2011

1 Department of Internal Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden . Correspondence: Riadh Sadik, MD, PhD , Department of Internal Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg , Gothenburg , SE 413 45 , Sweden . E-mail: [email protected] Received 3 August 2010; accepted 18 November 2010

The American Journal of GASTROENTEROLOGY VOLUME 106 | MAY 2011 www.amjgastro.com

physical activity on quality of life (QOL), psychological symptoms,

and fatigue in IBS patients and also on oroanal transit.

METHODS Subjects A total of 162 patients with a clinical diagnosis of IBS, based on

the ROME II criteria ( 4 ), were invited to participate in the study.

Patients were referred from gastroenterology units at community

hospitals and a university hospital in V ä stra G ö talandsregion,

Sweden. Th ey were recruited from June 2005 until March 2008,

and data collection was performed from August 2005 until

August 2008. To be included in the study, subjects had to be able

to increase their level of physical activity. Exclusion criteria were

age younger than 18 years, pregnancy, organic GI disorders, and

respiratory or cardiac disease. Patients were contacted through

telephone and given information by a physiotherapist before the

randomization visit.

All subjects gave informed consent, and the study was approved

by the ethics committee and by the radiation safety committee of

the University of G ö teborg. Th e consort guidelines were followed.

Randomization At the randomization visit, the exclusion and inclusion criteria

were reviewed by a gastroenterologist (RS) and by the physio-

therapist (EJ). Patients were then randomized to the physical

activity group or to the control group. To allocate an equal

number of patients to both groups, randomization was carried

out in blocks of four patients, in which two out of four were rando-

mized to the physical activity group by pulling a card out of an

envelope. Th e randomization and dropouts are shown in the fl ow

chart below ( Figure 1 ).

Intervention Th e physical activity group had regular telephone contact once or

twice a month with a physiotherapist who gave individual advice

regarding physical activity during 12 weeks. To encourage and

stimulate patients to increase their physical activity, they com-

pleted a training diary and performed a cycle test aft er 6 weeks.

Th e aim of this intervention was to moderately increase the level

of physical activity to an extent that would have a positive eff ect on

oxygen uptake. Th e advice followed the Swedish National Institute

of Public Health publication, Physical Activity in the Prevention and

Treatment of Disease ( 19 ), which is a guide for prescribing physi-

cal activity. Th e recommendation for increasing cardiorespiratory

fi tness is 20 – 60 min of moderate-to-vigorous intensive physical

activity 3 to 5 days per week. Th ese recommendations are based

on the review from the American College of Sports Medicine ( 20 ).

Patients were given individual advice depending on their previous

level of physical activity and experience of exercise. Th e activities

suggested could be any activity depending on individual factors,

such as time, opportunities, or costs.

Th e control group was encouraged to maintain their lifestyle.

Th ey also had a supportive telephone contact with the physio-

162 Patients were referredto the study

102 Patients included

52(40F) Randomized toControl group

7(6F)drop outsDid not attend first testControl group:4 Lack of time2 No reason1 Other diagnosis

4(4F)drop outs:Did not attend first testPhysical activity group:3 Lack of time1 No reason

60 Patients were not included:29 Did not meet inclusioncriteria (20 were already activeand could not increase theirlevel of physical activity)16 Lack of time15 No reason

9(9F)drop outs:After first testPhysical activity group:4 Lack of time2 No reason1 Family situation2 Other diagnosis

7(7F)drop outsAfter first testControl group:2 Lack of time1 No reason1 Family situation3 Other diagnosis

38(28F)Control group

completed

37(28F)Physical activity group

completed

50(41F) RandomizedPhysical activity group

Figure 1 . Inclusion and randomization in the study.

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therapist once a month. Aft er 12 weeks, controls were off ered the

same intervention as the physical activity group to increase their

physical activity level (results not reported in this article).

Questionnaires Th e IBS-SSS . Th e IBS Severity Scoring System (IBS-SSS) ( 21 ) con-

sists of visual analog scales and is divided into two subscales, name-

ly an overall IBS score and an extracolonic score. Th e IBS score con-

tains questions regarding pain severity, pain frequency, abdominal

bloating, bowel habit dissatisfaction, and life interference. Th e extra-

colonic score contains questions regarding vomiting, gas, belching,

satiety, headache, fatigue, musculoskeletal pain, heartburn, dysuria,

and urgency. Each subscale ranges from 0 to 500, with higher scores

meaning more severe symptoms. A reduction of 50 is considered to

be adequate to detect a clinical improvement ( 21 ).

IBS-QOL . Th e IBS-QOL is a disease-specifi c instrument measur-

ing HRQOL. It consists of 30 items, which measures 9 dimensions

of emotional functioning, mental health, sleep, energy, physical

functioning, diet, social role, physical role, and sexual relations.

For each subscale, the scores are transformed to range from 0 to

100, 100 representing the best possible HRQOL ( 22,23 ).

Short Form-36 . Short Form-36 was used to assess the general

HRQOL. It includes 36 items, which are divided into 8 subscales,

namely physical functioning, physical role, body pain, general

health perceptions, vitality, social functioning, emotional role,

and mental health. For each subscale, the raw scores are trans-

formed into a scale from 0 to 100, where 100 represents the best

possible HRQOL ( 24, 25 ).

Th e HADS . Th e HADS (Hospital Anxiety and Depression Scale)

was developed for medical outpatients ( 26 ) and consists of 14

items, each using a 4-graded Likert ’ s scale (0 – 3). Th e scale is divi-

ded into two subscales, anxiety and depression. Each subscale rang-

es from 0 to 21, where high score means more severe symptoms.

Th e Fatigue Impact Scale . Th is scale was initially developed for

patients with chronic fatigue syndrome ( 27 ) and has previously

been used in studies in IBS patients ( 7 ). Th e scale consists of 40

questions divided into 3 subscales, physical functioning (10 items),

cognitive functioning (10 items), and psychosocial functioning

(20 items). Subjects are asked to rate to which extent fatigue has

caused problems for them during the previous month. Each item

consists of a statement and the subject should rate 0 to 4, where 0

means “ no problem ” and 4 means “ extreme problem. ”

Measurements Th e following measurements were performed at the time of

inclusion and 12 weeks later:

Weight : Weight was measured to the nearest 0.1 kg.

Oxygen uptake : Oxygen uptake was calculated from a sub-

maximal cycle (Monark Ergomedic 839, Monark Exercise

AB, Kroons v ä g 1, Vansbro, Sweden ). Th e ergometer test was

conducted according to the study by Astrand and Ryhming ( 28 ).

Oroanal transit time : To measure oroanal transit time ( 29 ),

patients ingested 10 radiopaque markers for 6 days. On the

seventh day, the markers were counted using fl uoroscopy. Th e

oroanal transit time was calculated in days by dividing the number

of retained radiopaque markers by 10, i.e., the daily dose.

Bristol Stool Form Scale : Patients recorded their bowel move-

ments during the week before the visits to the laboratory. Th ey

recorded all bowel movements and its consistency according to the

Bristol Stool Form Scale ( 30 ).

Training diary : Th e training diary is a non-validated form fi lled

out by the physical activity group every day during the 12-week

period. Patients reported performed activity, duration, and esti-

mated intensity. Th e diary was used only to stimulate patients to

be physically active and to know the type of physical activity they

were performing.

Data analysis and statistics Th e primary end point was between-group diff erences in the

change in IBS-SSS scores from the 12-week follow-up visit rela-

tive to baseline. Th e secondary end points were to assess whether

changes in the other questionnaires assessing QOL, anxiety,

depression, and fatigue diff ered between the groups. Other sec-

ondary end points were changes in weight, oxygen uptake, oro-

anal transit, and Bristol Stool Form Scale.

Within-group comparison were also performed for exploratory

reasons. A per-protocol analysis of data obtained from patients

completing the study was performed. We also performed an inten-

tion-to-treat analysis that is reported separately in the results. Th e

results are presented as median, and percentile 10 and 90. Anal-

yses used on the data with normal distribution were paired and

unpaired t -tests. Th e t -test was used only for oxygen uptake. Th e

results from the questionnaires were considered as ordinal data,

and therefore, analyses were performed using Wilcoxon ’ s signed

rank test and Mann – Whitney U -test. McNemar ’ s exact test was

used to assess the diff erence between the physical activity group

and the control group regarding the proportion of patients with

decreased or increased IBS symptoms. Signifi cance was accepted

at the 5 % level ( < 0.05). For statistical analyses, we used SPSS

version 14.0 (SPSS, IBM Corporation, NY ). Th e study has not been

registered on a regulatory agency.

RESULTS Subjects A total of 162 patients were assessed for participation in the study.

In all, 60 (89 % women, median age 33 (17 – 67) years) patients

were not included because of the reasons shown in the fl ow

chart ( Figure 1 ). Overall, 20 patients could not increase their

level of physical activity, as they were already physically active

( Figure 1 ). More than half of this group claimed that physical

activity helped them to handle their IBS symptoms. All in all, 102

(79 % women, median age 38.5 (18 – 77) years) patients fulfi lled the

inclusion criteria and were included in the study. Th ere were 13

dropouts in the physical activity group. Four of these dropouts did

not attend the fi rst test and could not be included in the intention-

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to-treat analysis. Th erefore, 46 patients in the physical activity

group could be included in the intention-to-treat analysis. In the

control group, there were 14 dropouts ( Figure 1 ). Seven of these

dropouts did not attend the fi rst test and could not be included

in the intention-to-treat analysis. Overall, 45 patients in the con-

trol group could be included in the intention-to-treat analysis

( Figure 1 ). In both groups, the main reason for dropout was lack

of time: 6 (42.8 % ) subjects in the control group and 7 (53.8 % )

subjects in the physical activity group.

A total of 75 patients (75 % women, median age 38 (18 – 65)

years) completed the study and could be included in the per-pro-

tocol analysis. In all, 22 were classifi ed as diarrhea-predominant

IBS, 20 as constipation-predominant IBS, and 33 as the alternat-

ing-type IBS.

A total of 38 (73.7 % women, median age 38.5 (19 – 65) years)

patients in the control group and 37 (75.7 % women, median age

36 (18 – 65) years) patients in the physical activity group completed

the study.

Th e details of randomization are shown in the ( Figure 1 ).

Table 1 shows the demographic data for the 75 patients complet-

ing the study.

Per-protocol analysis . Th e IBS-SSS : Th ere was a signifi cant dif-

ference in the improvement in the overall IBS score between the

physical activity group and the control group ( − 51 ( − 130 and

49) vs. − 5 ( − 101 and 118), P = 0.003). Th ere was no signifi cant

diff erence between the groups in the improvement in the extraco-

lonic score ( − 36 ( − 99 and 52) vs. − 19 ( − 70 and 113), P = NS).

As shown in Figures 2 and 3 , the physical activity group improved

signifi cantly in both subscales of the IBS-SSS, which was not the

case in the control group.

Table 2 shows the proportion of patients in each group with

a clinically signifi cant change of the IBS-SSS of > 50 points.

Th e table shows that the proportion of patients with increased

IBS symptom severity is signifi cantly larger in the control group

than in the physical activity group. Moreover, the proportion

of patients showing improvement in the overall IBS score tend-

ed to be larger in the physical activity group than in the control

group.

Other measurements and questionnaires : Th ere was a signifi cant

diff erence between the groups in the improvement in disease-

specifi c QOL dimensions of physical functioning and physical

role at the 12-week visit relative to baseline ( Table 3) with greater

improvement in the physical activity group.

Table 1 . Demographic data

Control group

( n =38) Physical activity group ( n =37)

Marital status

Cohabitant / single 25 / 13 26 / 11

Educational level

Primary school 7 5

High school 22 19

University studies 9 13

Physically demanding work

Yes / no 17 / 21 20 / 17

Employment

Employed 27 31

Unemployed 4

Student 3 6

Retired 4

500

400

300

200

100

0

Control group Physical activity group

P= 0.001

Start 12 Weeks

Figure 2 . IBS-Severity Scoring System, IBS score.

500

400

300

200

100

0

Control group Physical activity group

P= 0.013

Start 12 Weeks

Figure 3 . IBS-Severity Scoring System, extracolonic score.

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As shown in Table 4 , in the physical activity group, the disease-

specifi c QOL (IBS-QOL) improved signifi cantly in dimensions of

emotion, sleep, energy, physical functioning, social, and physical

role, whereas mental health, diet, and sexual relations were not

aff ected.

Th e control group demonstrated improvements in dimensions

of emotion, diet, and social role, but the dimensions of mental

health, sleep, energy, physical function, physical role, and sexual

relations were not aff ected ( Table 4 ).

As shown in Table 5 , the parameters body weight, oroanal

transit time, self-reported bowel movements, and stool consist-

ency showed no signifi cant changes between or within the groups.

As shown in Tables 6 – 8 , Short Form-36, HADS, and the Fatigue

Impact Scale showed no signifi cant changes between or within the

groups.

Oxygen uptake and training diary : Th ere was no signifi cant

change in oxygen uptake between the groups. Oxygen uptake

increased signifi cantly in the physical activity group, from 2.36

(1.51 and 3.23) to 2.47 (1.80 and 3.28) liter per minute ( P = 0.02),

whereas there was no signifi cant change in the control group,

from 2.24 (1.41 and 3.20) to 2.20 (1.65 and 3.22) liter per minute .

Th e fi ve most common activities reported in the training diaries

were walking, cycling, swimming, running / jogging, and Nordic

walking.

Intention-to-treat analysis . A total of 46 patients in the physical

activity group and 45 in the control group were included in this

analysis. Th e signifi cant changes found in the per-protocol analy-

sis are also found in the intention-to-treat analysis.

Table 2 . Proportion of patients with a clinically signifi cant decrease or increase in symptoms

Physical activity

group, N ( % ) Control group,

N ( % ) P value

IBS score

Decrease > 50 points 16 (43 % ) 10 (26 % ) 0.07

Increase > 50 points 3 (8 % ) 9 (23 % ) < 0.01

Extracolonic score

Decrease > 50 points 10 (26 % ) 10 (26 % ) NS

Increase > 50 points 4 (11 % ) 8 (21 % ) < 0.01

IBS, irritable bowel syndrome; NS, not signifi cant. Clinically signifi cant changes in the IBS Severity Scoring System (IBS-SSS).

Table 3 . Changes in IBS Quality of Life at start compared with after 12 weeks

Dimension Control group Physical activity group

Emotional 6 ( − 18 and 28) 12 ( − 11 and 33)

Mental health 5 ( − 25 and 25) 5 ( − 18 and 23)

Sleep 0 ( − 16 and 25) 8 ( − 25 and 30)

Energy 0 ( − 41 and 25) 12 ( − 16 and 37)

Physical function 0 ( − 27 and 30) 16 ( − 2 and 35), P =0.015

Diet 0 ( − 8 and 26) 3 ( − 20 and 20)

Social role 6 ( − 12 and 18) 12 ( − 8 and 33)

Physical role 0 ( − 39 and 31) 6 ( − 14 and 50), P =0.032

Sexual relations 0 ( − 18 and 26) 0 ( − 16 and 20)

IBS, irritable bowel syndrome. P values refer to comparisons between the groups.

Table 4 . IBS Quality of Life at baseline and after 12 weeks

Dimension Control group Physical activity group

Emotional 47 (25 – 76) – 56 (31 – 88), P =0.021

56 (31 – 90) – 66 (40 – 100), P =0.002

Mental health 72 (49 – 90) – 80 (45 – 96) 82 (50 – 100) – 85 (60 – 100)

Sleep 62 (25 – 92) – 71 (33 – 94) 75 (31 – 100) – 79 (39 – 100), P =0.031

Energy 50 (12 – 78) – 56 (9 – 88) 50 (25 – 90) – 75 (25 – 100), P =0.006

Physical function

58 (32 – 92) – 58 (22 – 100) 67 (40 – 100) – 92 (50 – 100), P =0.001

Diet 60 (46 – 87) – 67 (38 – 93), P =0.028

60 (39 – 87) – 60 (40 – 100)

Social role 62 (30 – 94) – 69 (38 – 100), P =0.01

69 (31 – 89) – 88 (42 – 100), P =0.001

Physical role 59 (25 – 100) – 66 (9 – 100) 69 (24 – 100) – 84 (36 – 100), P =0.008

Sexual relations 50 (17 – 80) – 60 (33 – 80) 67 (33 – 80) – 70 (40 – 80)

IBS, irritable bowel syndrome. P values refer to within-group comparisons between scores at baseline vs. those at 12 weeks.

Table 5 . Changes in weight, oroanal transit time, bowel movements, and stool consistency

Measurements Control group Physical activity group

Body weight (kg) 65.9 (53.1 and 95.6) – 66.7 (52.4 and 94.6),

P =NS

69.0 (53.6 and 91.5) – 69.3 (53.6 and 89.60)

P =NS

Oroanal transit time (days)

1.1 (0.4 and 3.5) – 1.2 (0.2 and 2.8), P =NS

1.1 (0.6 and 3.7) – 1.2 (0.3 and 3.3), P =NS

Bowel movements per week

12 (5 and 26) – 12 (6 and 24), P =NS

10 (4 and 21) – 9 (3 and 20), P =NS

Stool consistency 4 (2 and 6) – 5 (2 and 6), P =NS

4 (2 and 6) – 5 (3 and 6), P =NS

NS, not signifi cant. No signifi cant differences were observed between the groups. P values refer to within-group comparisons between values at baseline vs. those at 12 weeks.

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P = 0.014). Th ere was no signifi cant diff erence between the groups

in the improvement in the extracolonic score ( − 13 ( − 97 and 59)

vs. − 14 ( − 67 and 90), P = NS).

IBS score : Th e physical activity group changed from 292 (133 and

371) to 246.0 (104 and 371) ( P = 0.001).

Th e control group changed from 270 (151 and 362) to 255 (134

and 373) ( P = NS).

Extracolonic score : Th e physical activity group changed from 194

(97 and 304) to 173 (56 and 294) ( P = 0.013).

Th e control group changed from 187 (72 and 295) to 176 (75

and 316) ( P = NS).

IBS-QOL : Th ere was a signifi cant diff erence between the groups

in the improvement in the disease-specifi c QOL dimensions of

physical function (0 ( − 37 and 20) vs. 8 ( − 3 and 28), P = 0.01) and

physical role (0 ( − 40 and 31) vs. 0 ( − 14 and 50), P = 0.03) at the

12 week-visit relative to baseline, with greater improvement in the

physical activity group.

Th e oxygen uptake : Th ere was no signifi cant change in oxygen

uptake between the groups. Th e physical activity group changed

from 2.35 (1.56 and 3.35) to 2.44 (1.74 and 3.34) liter per minute

( P = 0.02). Th e control group changed from 2.22 (1.48 and 3.35) to

2.16 (1.66 and 3.22) liter per minute ( P = NS).

DISCUSSION Th is prospective, randomized, controlled, open-label study shows

that increased physical activity decreases the severity of IBS symp-

toms and improves some dimensions of QOL in IBS patients. More-

over, increasing the severity of IBS symptoms was signifi cantly less

prevalent in the physically active group than in the control group.

Th is study presents the fi rst application of physical activity as

a treatment modality for IBS. Moreover, the presented results are

clinically applicable without requiring costly resources or very

high eff orts.

Th is study supports the advice to increase physical activity in

IBS. In several publications ( 18,31,32 ), it has been suggested that

advice on physical activity may be given to IBS patients. How-

ever, it has not been previously shown that physical activity has

a positive eff ect on the symptoms in IBS. Moreover, the current

study shows that the risk of symptom deterioration is signifi cantly

higher in physically inactive IBS patients. Th is is also an important

message to patients that their symptoms may increase if they are

physically inactive.

Th e fi ndings of the positive eff ect of physical activity on GI symp-

toms in the current study supports previous results indicating a

protective eff ect of physical activity on GI symptoms ( 13,14,17,33 ).

Levy et al. ( 33 ) stated the hypotheses that GI symptoms could

be inversely related to behaviors that reduce obesity risk, such as

high exercise, low fat intake, and high fruit / vegetable intake. Th eir

main fi nding was that a higher level of physical activity was protec-

tive against GI symptoms in obese individuals. Lustyk et al. ( 17 )

Th e IBS-SSS : Th ere was a signifi cant diff erence in the improve-

ment in the overall IBS score between the physical activity group

and the control group ( − 37 ( − 142 and 37) vs. 0 ( − 97 and 109),

Table 6 . Changes in Health-Related Quality of Life, SF-36

Subscale Control group Physical activity group

Physical function 85 (60 and 100) – 90 (63 and 100), P =NS

95 (64 and 100) – 95 (57 and 100), P =NS

Physical role 50 (0 and 100) – 75 (0 and 100), P =NS

75 (0 and 100) – 75 (0 and 100), P =NS

Body pain 51 (22 and 75) – 47 (12 and 74), P =NS

51 (22 and 84) – 51 (22 and 73), P =NS

General health perceptions

47 (25 and 77) – 49 (29 and 88), P =NS

56 (29 and 87) – 57 (27 and 87), P =NS

Vitality 38 (15 and 71) – 40 (15 and 80), P =NS

40 (14 and 80) – 45 (14 and 77), P =NS

Social function 63 (38 and 100) – 75 (49 and 100), P =NS

75 (38 and 100) – 75 (38 and 100), P =NS

Emotional role 67 (0 and 100) – 67 (0 and 100), P =NS

100 (27 and 100) – 100 (0 and 100), P =NS

Mental health 62 (39 and 88) – 66 (39 and 88), P =NS

72 (43 and 92) – 68 (40 and 93) P =NS


Table 7 . Changes in the Hospital Anxiety and Depression Scale


Depression 6 (2 and 12) – 6 (1 and 9), P =NS

4 (1and 10) – 4 (1 and 9), P =NS

Anxiety 9 (3 and 14) – 9 (2 and 14), P =NS

8 (2 and 12) – 6 (2 and 12), P =NS


Table 8 . Changes in the Fatigue Impact Scale


Physical functioning 1.5 (0.3 and 2.8) – 1.4 (0.3 and 2.6), P =NS

1.4 (0.2 and 3.1) – 1.6 (0.0 and 3.0), P =NS

Cognitive functioning 1.7 (0.4 and 3.0) – 1.4 (0.5 and 3.1), P =NS

1.8 (0.3 and 3.6) – 1.4 (0.2 and 3.1), P =NS

Psychosocial functioning

1.1 (0.3 and 2.8) – 1.1 (0.4 and 2.6), P =NS

1.3 (0.2 and 2.8) – 1.3 (0.1 and 2.7), P =NS


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discussed whether it was IBS that stopped the women from

being physically active or if being inactive worsened the

symptoms. Our results support the theory that being inactive

worsens IBS symptoms.

Th e main reason for not being included in our study was the

inability to increase physical activity as shown in the fl ow chart

( Figure 1 ). When contacting these patients to evaluate the possi-

bility to include them in the study, more than half of them reported

that they were physically active and that activity improved their

symptoms. Only 2 out of the 102 included patients had a negative

experience of physical activity because of their IBS and those 2 still

wanted to participate in the study. Perhaps it is more important

to fi nd another type of activity instead of stopping the training if

the patient had a bad experience. Patients included in our study

were those who could increase their level of physical activity. We

have not studied patients who already practiced a very high level

of physical activity. Long-distance runners, cyclists, and triathletes

oft en report GI symptoms during exercise ( 16 ). Th erefore, it is

important to carefully analyze the history of IBS patients to assess

the level of their physical activity before giving them advice on

increased physical activity.

Th e mechanisms behind the improvement in the physical

activity group are unknown. We may speculate that some of the

improvement can probably be explained by the fact that stress

induces exaggeration of the neuroendocrine response and visceral

perceptual alterations ( 34 ), whereas physical activity counteracts

the eff ects of stress ( 35 ). Physical activity can favorably infl uence

brain plasticity by facilitating neurogenerative, neuroadaptive, and

neuroprotective processes ( 35 ). Th is infl uence on the central nerv-

ous system may have a positive eff ect on the brain – gut axes that

is involved in IBS. Villoria et al. ( 36 ) showed that mild physical

activity enhances intestinal gas clearance and reduces symptoms

in patients complaining of abdominal bloating. Th e same group

showed earlier that physical activity improves gas transit and

abdominal distension in healthy subjects, but not the perception of

bloating ( 13 ). Th is may also explain the improvement in symptoms

shown in this study. Th e improvement in constipation-predomi-

nant IBS can be due to the positive eff ects of physical activity on

symptoms of constipation ( 14 ).

Th e improvements we observed in the physical activity group

in disease-specifi c QOL were in the dimensions of physical func-

tion and physical role. Th is is not surprising as the physical activity

group was more physically active.

In the current study, we did not see an improvement in

overall HRQOL, which might be due to the relatively short time

of follow-up. It has been shown that long-term physical activ-

ity patterns are an important determinant of HRQOL in women

( 37 ). Our data may indicate that the improvement in GI symptoms

may occur faster and before the eventual improvement in HRQOL

as we were unable to show an improvement in overall HRQOL

aft er 12 weeks. Longer future studies may be able to show such improve-

ments in HRQOL or even in other parameters, such as fatigue.

Th e improvement in cardiorespiratory fi tness in the training

group was refl ected in the increase in oxygen uptake. Th is increase

was signifi cant but not high. Th e reason for that is that the increase

in physical activity was light to moderate and that not all physi-

cal activities improve cardiorespiratory fi tness. Th e improvement

in symptoms in this group implies that even a light-to-moderate

increase in physical activity is useful and should be recommended

according to our data. Although patients were encouraged to

perform more vigorous activities, the most common activity was

walking which in most cases was used as a complement to other

physical activities.

It is possible that the amount of attention and support the

patients received in our study was not high enough to increase oxy-

gen uptake more than we have shown. Home-based training and

advice on increased physical activity is cheap, and we designed the

study so that the results can be easily applied in clinical practice.

Blumenthal et al. designed a study of major depression in which

there were four groups, one which received medical intervention,

one placebo group, and two physical activity groups. One of the

active groups received supervised physical activity and the other

one had home-based physical activity. Both active groups and the

medication group achieved higher remission of depression than

did the placebo group ( 8 ). Th ese data support the appropriateness

of our study design.

One general feature of IBS treatment studies is that there is a

placebo eff ect of the treatment. Physical activity cannot be given in

a blinded manner. In our study, the control group was also receiving

regular support through telephone calls. However, the placebo eff ect

is probably involved in the eff ect of physical activity and all other

treatments given for this patient group. Similar positive results were

observed in the per-protocol analysis and in the intention-to-treat

analysis. Light-to-moderate physical activity is cheap and also has

general positive health eff ects. Physical activity should therefore be

recommended as a primary treatment for these patients.

Th e potential weakness of this study is the number of dropouts.

However, the number of dropouts in the two groups was compa-

rable. Moreover, the number of patients in each IBS bowel habit

subgroup was not suffi cient to perform a subgroup analysis. Th is

should be addressed in future studies. Th e exercise program was

not strictly supervised, but this is in fact what happens in the real

world. Th e data may therefore be applicable for the daily clinical

practice. Th e mechanisms behind symptom improvement cannot

be assessed from this study. Further studies are required to address

these mechanisms.

In conclusion, increased physical activity improves GI symp-

toms and some aspects of disease-specifi c HRQOL in IBS. Physi-

cally active IBS patients have a lower risk of experiencing symptom

deterioration than do physically inactive patients. Physical activity

should be used as a primary treatment modality in IBS. However,

there is a need for future studies on physical activity in IBS. We

need to expand our knowledge about the type, frequency, dura-

tion, and intensity of physical activity, which gives the best eff ect.

Th e eff ect of physical activity on diff erent subtypes of IBS also

deserves further studies.

ACKNOWLEDGMENTS We thank the registered physiotherapist Emma Hellstr ö m for help

with the data collection.

Johannesson et al.


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CONFLICT OF INTEREST Guarantor of the article: Riadh Sadik, MD, PhD.

Specifi c author contributions: All the authors were involved in

the planning and conduct of this study. All authors were involved

in the writing of this manuscript and have discussed, changed, and

accepted the fi nal version.

Financial support: Th is study was supported by the Health and

Medical Care Executive Board of the V ä stra G ö taland Region and by

the Research and Development Council in S ö dra Ä lvsborg, Sweden.

Potential competing interests: None.

Study Highlights

WHAT IS CURRENT KNOWLEDGE

3 Many studies have shown that physical activity is effective in the treatment and prevention of different diseases.

3 No previous studies have assessed the effect of physical activity on irritable bowel syndrome (IBS) symptoms.

WHAT IS NEW HERE

3 This randomized controlled trial shows that increased physical activity leads to symptom improvement.

3 The study also shows that physically active IBS patients will face less symptom deterioration compared with physically inactive patients.

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physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial

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