Physical activity and fatigue in adults with Inflammatory Bowel Disease (IBD): a systematic review

Background: Fatigue is frequently reported in inflammatory bowel disease (IBD). IBD has been shown to have an impact on, and be impacted by, physical activity levels in IBD patients, Yet, to date, there have been no systematic reviews considering the impact of physical activity on levels of IBD fatigue.Aim: This aim of this review is to explore the current body of knowledge of what kind of physical activity interventions are available to treat IBD fatigue.Methods: Systematic database searchs (CINAHL, EMBASE, PsychInfo, PsycARTICLES, AMED, Medline) and hand searching were conducted on 03/03/2019. Searches were restricted to ‘human’, ‘adult’, ‘primary research’ and ‘English language’publications. No time limit was set. Quality appraisal and data extraction was undertaken by at least 2 reviewers.Results: searches yielded 32 publications; 2 studies were included in the review. Physical activity is inhibited by higher fatigue levels, lowering HRQoL, but also as a means of reducing fatigue, subsequently improving HRQoL.Conclusion: There was very little data eligible for inclusion in this review, and it was not of a high quality. The findings of the review suggest that physical activity may be beneficial for IBD fatigue, but this cannot be definitively stated. Evidence suggests physical activity is safe to undertake in active disease, therefore better-quality studiesare needed in this area

Systematic review: the impact of inflammatory bowel disease-related fatigue on health-related quality of life

Background: Fatigue is frequently reported in inflammatory bowel disease (IBD) and impacts on Health-Related Quality of Life (HRQoL). HRQoL has not been systematically reviewed in IBD fatigue. Aim: To investigate what impact IBD fatigue has on HRQoL in adults with IBD.Methods: Systematic searches (CINAHL, EMBASE, PsychInfo, Medline) were conducted 25.09.2018, restricted to ‘human’, ‘adult’, ‘primary research’ and ‘English language’. Search terms encompassed concepts of ‘Fatigue’, ‘IBD’ and ‘HRQoL’. A 5 year time limit (2013-2018) was set to include the most relevant publications. Publications were screened, data extracted, and quality appraised by two authors. A narrative synthesis was conducted.Results: Eleven studies were included, presenting data from 2823 participants. Fatigue experiences were significantly related to three HRQoL areas: symptom acceptance, psychosocial wellbeing, and physical activity. Patients reporting high fatigue levels had low symptom acceptance. Psychosocial factors were strongly associated with both, fatigue and HRQoL. Higher social support levels were associated with higher HRQoL. Physical activity was impaired by higher fatigue levels, lowering HRQoL, but it was also used as a means of reducing fatigue and improving HRQoL. Quality appraisal revealed methodological shortcomings in a number of studies. Notably use of multiple measures, comparison without statistical adjustment and fatigue and HRQoL assessment using the same tool

Ultrasound use to assess Crohn’s disease in the UK: a survey of British Society of Gastroenterology Inflammatory Bowel Disease Group members

BackgroundData from the METRIC trial (PMID:29914843) has shown that small bowel ultrasound has very good diagnostic accuracy for disease extent, presence and activity in Crohn’s Disease (CD), is well tolerated by patients and is cheaper when compared to MRI. However, Uptake of ultrasound in the UK is limitedMethodsWe designed and conducted an online survey to assess the current usage of ultrasound throughout the UK. The survey was undertaken by BSG IBD group members between 9 June 2021 - 25 June 2021. Responses were anonymous, respondents were able to skip questions.Results103 responses were included in the data analysis Responses came from 14 different regions of the UK, from 66 individual NHS trusts. 103 respondents reported that they currently have an MRI service for Crohn’s disease, where only 31 had an ultrasound service. Numbers of MRIs per month was reported as an average of 15, with a range of 3-75. The average number of ultrasounds undertaken was reported as 8 per month, with a range of 0-50. Average time for results to be reported for MRI scans was reported as between 4-6 weeks, with a range of 2 days to 28 weeks. The average time for an ultrasound to be reported was stated as 1-4 weeks, with a range of 0-8 weeks. 26 respondents were ‘extremely confident’ when using MRI data to make clinical decisions, 5 were ‘very confident’ were somewhat confident and 3 were not so confident. Only 6 respondents stated they would be extremely confident in using ultrasound to make clinical decisions, 17 people stated they would be very confident, 20 were somewhat confident, 15 not so confident and 15 not at all confident. Of those respondents who did not have access to an ultrasound service, 72 stated that they would be interested in developing an ultrasound service.ConclusionThere is an appetite for the uptake of ultrasound in the UK for assessment of CD, however there remains a significant number of UK centres with little or no access to an ultrasound service. There is a difference in the levels of confidence that clinicians have in using ultrasound as a diagnostic tool in the UK. Further research is necessary to understand why this is the case. Results from this survey will go on to inform our future work in developing an implementation package for ultrasound in the UK in the NH

An examination of resting-state functional connectivity in patients with active Crohn’s disease

Background: Alterations in resting state functional connectivity (rs-FC) in Crohn’s Disease (CD) have been documented in default mode network (DMN) and frontal parietal network (FPN) areas, visual, cerebellar, salience and attention resting-state-networks (RSNs), constituting a CD specific neural phenotype. To date, most studies are in patients in remission, with limited studies in active disease. Methods: 25 active CD cases and 25 age-, BMI- and gender-matched healthy controls (HC) were recruited to a resting-state-functional Magnetic Resonance Imaging (rs-fMRI) study. Active disease was defined as C-reactive protein>5mg/dl, faecal calprotectin>250μg/g, or through ileocolonoscopy or MRE. rs-fMRI data were analysed using independent component analysis (ICA) and dual regression. Differences in RSNs between HCs and active CD were assessed, and rs-FC was associated with disease duration and abdominal pain. Results: Increased connectivity in the FPN (fusiform gyrus, thalamus, caudate, posterior cingulate cortex, postcentral gyrus) and visual RSN (orbital frontal cortex) were observed in CD versus HC. Decreased activity was observed in the salience network (cerebellum, postcentral gyrus), DMN (parahippocampal gyrus, cerebellum), and cerebellar network (occipital fusiform gyrus, cerebellum) in CD versus HCs. Greater abdominal pain scores were associated with lower connectivity in the precuneus (visual network) and parietal operculum (salience network), and higher connectivity in the cerebellum (frontal network). Greater disease duration was associated with greater connectivity in the middle temporal gyrus and planum temporale (visual network). Conclusion: Alterations in rs-FC in active CD in RSNs implicated in cognition, attention, emotion, and pain may represent neural correlates of chronic systemic inflammation, abdominal pain, disease duration, and severity

Substantial cost savings of ultrasound-based management over magnetic resonance imaging-based management in an inflammatory bowel disease service

Background: Imaging is used to monitor disease activity in small bowel Crohn’s disease (CD). Magnetic Resonance Enterography is often employed as a first modality in the United Kingdom for assessment and monitoring; however, waiting times, cost, patient burden and limited access are significant. It is as yet uncertain if small bowel intestinal ultrasound (IUS) may be a quicker, more acceptable, and cheaper alternative for monitoring patients with CD. Methods: A clinical service evaluation of imaging pathways was undertaken at a single NHS site in England, United Kingdom. Data were collected about patients who were referred and underwent an imaging analysis for their IBD. Only patients who underwent a therapy change were included in the analysis. Data were collected from care episodes between 01 January 2021–30 March 2022. Results: A combined total of 193 patient care episodes were reviewed, 107 from the IUS pathway and 86 from the MRE pathway. Estimated costs per patient in the IUS pathway was £78.86, and £375.35 per patient in the MRE pathway. The MRE pathway had an average time from referral to treatment initiation of 91 days (SD= ±61) with patients in the IUS pathway waiting an average of 46 days (SD= ±17). Conclusions: Findings from this work indicate that IUS is a potential cost-saving option when compared to MRE when used in the management of CD. This is in addition to the cost difference of the radiological modalities. A large, multicentre, prospective study is needed to validate these initial findings

An examination of resting-state functional connectivity in patients with active Crohn’s disease

BackgroundAlterations in resting state functional connectivity (rs-FC) in Crohn’s Disease (CD) have been documented in default mode network (DMN) and frontal parietal network (FPN) areas, visual, cerebellar, salience and attention resting-state-networks (RSNs), constituting a CD specific neural phenotype. To date, most studies are in patients in remission, with limited studies in active disease.MethodsTwenty five active CD cases and 25 age-, BMI- and gender-matched healthy controls (HC) were recruited to a resting-state-functional Magnetic Resonance Imaging (rs-fMRI) study. Active disease was defined as C-reactive protein>5 mg/dL, faecal calprotectin>250 μg/g, or through ileocolonoscopy or MRE. rs-fMRI data were analysed using independent component analysis (ICA) and dual regression. Differences in RSNs between HCs and active CD were assessed, and rs-FC was associated with disease duration and abdominal pain.ResultsIncreased connectivity in the FPN (fusiform gyrus, thalamus, caudate, posterior cingulate cortex, postcentral gyrus) and visual RSN (orbital frontal cortex) were observed in CD versus HC. Decreased activity was observed in the salience network (cerebellum, postcentral gyrus), DMN (parahippocampal gyrus, cerebellum), and cerebellar network (occipital fusiform gyrus, cerebellum) in CD versus HCs. Greater abdominal pain scores were associated with lower connectivity in the precuneus (visual network) and parietal operculum (salience network), and higher connectivity in the cerebellum (frontal network). Greater disease duration was associated with greater connectivity in the middle temporal gyrus and planum temporale (visual network).ConclusionAlterations in rs-FC in active CD in RSNs implicated in cognition, attention, emotion, and pain may represent neural correlates of chronic systemic inflammation, abdominal pain, disease duration, and severity

The impact of Inflammatory Bowel Disease related fatigue on Health-Related Quality of Life: A qualitative semi-structured interview study

Background: Fatigue is a frequently reported symptom of inflammatory bowel disease (IBD), having a negative impact on Health-Related Quality of Life (HRQoL). Patients’ experiences of this have not been researched in IBD. Methods: Semi-structured interviews were conducted with adults with Crohn’s Disease from out-patient clinics in the United Kingdom. Interviews were audio-recorded and transcribed verbatim, then analysed using thematic analysis.Results: Fourteen participant interviews were conducted. Three key themes were identified: 1) ’The new normal’ established through adaptation and acceptance; 2) ’Energy as a resource’ describing attempts to better manage fatigue through planning and prioritising tasks; 3) ‘Keeping healthy’ encompasses participants beliefs that ‘good health’ allows better management of fatigue.Conclusion: Participants establish a ‘new’ normality, through maintaining the same or similar level of employment/education activities. However, this is often at the expense of social activities. Further research is required to explore patient led self-management interventions in IBD fatigue

Review article: The aetiology of fatigue in inflammatory bowel disease and potential therapeutic management strategies

Background: Fatigue is the inability to achieve or maintain an expected work output resulting from central or peripheral mechanisms. The prevalence of inflammatory bowel disease (IBD) fatigue can reach 86% in active disease, persisting in 50%-52% of patients with mild to inactive disease. Fatigue is the commonest reason for work absence in IBD, and patients often report fatigue burden to be greater than that of primary disease symptoms. Relatively few evidence-based treatment options exist, and the aetiology is poorly understood. Aim: To review the available data and suggest a possible aetiology of IBD fatigue and to consider the efficacy of existing management strategies and highlight potential future interventions. Methods: We reviewed fatigue-related literature in IBD using PubMed database. Results: Disease related factors such as inflammation and pharmacological treatments negatively impact skeletal muscle and brain physiology, likely contributing to fatigue symptoms. Secondary factors such as malnutrition, anaemia, sleep disturbance and psychological comorbidity are potential determinants. Immune profile, faecal microbiota composition and physical fitness differ significantly between fatigued and non-fatigued patients, suggesting these may be aetiological factors. Solution-focused therapy, high-dosage thiamine supplementation and biological therapy may reduce fatigue perception in IBD. The effect of physical activity interventions is inconclusive. Conclusions: A multimodal approach is likely required to treat IBD fatigue. Established reversible factors like anaemia, micronutrient deficiencies and active disease should initially be resolved. Psychosocial intervention shows potential efficacy in reducing fatigue perception in quiescent disease. Restoring physical deconditioning by exercise training intervention may further improve fatigue burden