Scandinavian Journal of Gastroenterology. 2015; Early Online, 1–11
ORIGINAL ARTICLE
Scand J Gastroenterol Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15 For personal use only.
Physical fitness and physical activity in fatigued and non-fatigued inflammatory bowel disease patients
LAURAN VOGELAAR1, RITA VAN DEN BERG-EMONS3, HANS BUSSMANN3, ROBERT ROZENBERG3, REINIER TIMMAN2 & CHRISTIEN J. VAN DER WOUDE1 1
Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands, 2Department of Psychology and Psychotherapy, Erasmus MC, Rotterdam, The Netherlands, and 3Department of Rehabilitation Medicine, Erasmus MC, Rotterdam, The Netherlands
Abstract Objective. To assess physical fitness and physical activity in inflammatory bowel disease (IBD) patients and whether fatigue is associated with impaired physical fitness and impaired physical activity. Materials and methods. Ten patients with quiescent IBD and fatigue (fatigue group [FG]) based on the Checklist Individual Strength-Fatigue score of ‡35 were matched for age (±5 years) and sex with a non-fatigue group (NFG) with IBD. Physical fitness was measured with a cyclo-ergometric-based maximal exercise test, a submaximal 6-min walk test, and a dynamometer test to quantify the isokinetic muscle strength of the knee extensors and flexors. Level of physical activity was measured with an accelerometer-based activity monitor. Results. The patients in both groups did not differ in regard to medication use, clinical characteristics, and body composition. However, medium-to-large effect sizes for impaired physical fitness (both cardiorespiratory fitness and muscle strength) and physical activity were seen between the patients in the FG and the NFG. Especially, intensity of physical activity was significantly lower in the FG patients compared with the NFG patients (effect size: 1.02; p = 0.037). Similar results were seen when outcomes of the FG and NFG were compared with reference values of the normal population. Conclusion. Fatigued IBD patients show an impaired physical fitness and physical activity compared with non-fatigued IBD patients. This gives directions for a physical component in fatigue in IBD patients. Therefore, these new insights into fatigue indicate that these patients might benefit from an exercise program to improve physical fitness and physical activity.
Key Words: fatigue, inflammatory bowel disease, physical activity, physical fitness
Introduction Despite more effective treatments for patients with inflammatory bowel disease (IBD), many patients still suffer from disabling fatigue, which is associated with decreased quality of life (QoL) [1–5]. Several factors such as disease activity, perceived stress, depressive coping, female gender, and psychological well-being contribute to fatigue in IBD patients. Moreover, we showed in a previous study that solution-focused therapy, a psychological intervention, is effective in reducing fatigue and subsequently in increasing QoL [5–13]. However, although effective in the majority,
there are still patients who suffer from invalidating fatigue. Previous studies among cancer patients and liver transplant recipients showed evidence for a relationship between fatigue, impaired physical fitness and impaired physical activity [14–16]. Cardiorespiratory fitness (VO2peak) in liver transplant recipients was related with severity of fatigue and QoL, but no indications of impaired muscle strength was observed [17]. Furthermore, the level of daily physical activity measured with an accelerometer was related with fatigue in liver transplant recipients [18]. In cancer patients the etiology of fatigue is poorly understood,
Correspondence: Lauran Vogelaar, Department of Gastroenterology and Hepatology, Erasmus MC, ‘s Gravendijkwal 230, Room HS 306, 3000 CA Rotterdam, The Netherlands. Tel: +31 6 26664056. Fax: +31 10 703 5172. E-mail: [email protected]
(Received 14 March 2015; revised 25 April 2015; accepted 26 April 2015) ISSN 0036-5521 print/ISSN 1502-7708 online 2015 Informa Healthcare DOI: 10.3109/00365521.2015.1046135
Scand J Gastroenterol Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15 For personal use only.
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and literature on fatigue and objective physical components is scarce. However, literature suggests associations between impaired muscle strength, impaired physical activity and fatigue [15,19]. Moreover, most research on fatigue in cancer patients focused on exercise interventions and showed reduction of fatigue by these interventions [16,20–25]. Therefore, we hypothesize that fatigue in IBD patients might be partly related to impaired physical fitness and impaired physical activity. However, data on the association between physical activity and physical fitness and fatigue in IBD patients is lacking. For the development of an exercise intervention to reduce fatigue, more objective knowledge of these associations is necessary. The aim of this study was to assess the level of physical fitness (cardiorespiratory fitness and muscle strength) and daily physical activity in IBD patients and whether fatigue is associated with impaired physical fitness and impaired physical activity. Methods Study design We performed a matched cross-sectional study in fatigued and non-fatigued IBD patients. This study was conducted in accordance with the protocol International Conference on Harmonization Guidelines for Good Clinical Practice, the Declaration of Helsinki, and local national regulations governing clinical study conduct. The protocol was approved by the medical ethics committee of the Erasmus Medical Center (Erasmus MC, registration number: MEC-2010-249; NL33396.078.10). The study was not designed for an interim analysis and no Data Safety Monitoring Board was assigned. All patients gave written informed consent. Patients were enrolled at the Erasmus MC in The Netherlands from November 2010 to October 2011. Patients were randomly selected from the IBD outpatient population. Sample size. For the sample size calculation, we applied data from the study of van den Berg-Emonset al. [18]. They reported correlation between 0.81 and 0.84 between severity of fatigue and daily physical activity within a group of liver transplant recipients. Applying a two-sided a-level of 0.05, power 0.80, nine cases are needed for a correlation of 0.80. In a study of van Ginneken et al. correlations between 0.50 and 0.61 were reported between cardiorespiratory fitness and severity of fatigue within a group of liver transplant recipients [17]. Again applying a two-sided a-level of 0.05, power 0.80,
28 cases are needed for a correlation of 0.50, and 18 cases for a correlation of 0.60. Combining these results we felt confident in applying a sample size of 20. Therefore we decided to include 10 patients in the fatigue group (FG) and 10 patients in the non-fatigue group (NFG). Patients were matched for sex and age (maximal difference: ±5 years). Patients and fatigue measurement Men and women aged ‡18 years, diagnosed with IBD which was radiologically or endoscopically/ histologically confirmed, were included. Patients had to be in remission of the disease, defined as Harvey Bradshaw Index score of
ORIGINAL ARTICLE
Scand J Gastroenterol Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15 For personal use only.
Physical fitness and physical activity in fatigued and non-fatigued inflammatory bowel disease patients
LAURAN VOGELAAR1, RITA VAN DEN BERG-EMONS3, HANS BUSSMANN3, ROBERT ROZENBERG3, REINIER TIMMAN2 & CHRISTIEN J. VAN DER WOUDE1 1
Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands, 2Department of Psychology and Psychotherapy, Erasmus MC, Rotterdam, The Netherlands, and 3Department of Rehabilitation Medicine, Erasmus MC, Rotterdam, The Netherlands
Abstract Objective. To assess physical fitness and physical activity in inflammatory bowel disease (IBD) patients and whether fatigue is associated with impaired physical fitness and impaired physical activity. Materials and methods. Ten patients with quiescent IBD and fatigue (fatigue group [FG]) based on the Checklist Individual Strength-Fatigue score of ‡35 were matched for age (±5 years) and sex with a non-fatigue group (NFG) with IBD. Physical fitness was measured with a cyclo-ergometric-based maximal exercise test, a submaximal 6-min walk test, and a dynamometer test to quantify the isokinetic muscle strength of the knee extensors and flexors. Level of physical activity was measured with an accelerometer-based activity monitor. Results. The patients in both groups did not differ in regard to medication use, clinical characteristics, and body composition. However, medium-to-large effect sizes for impaired physical fitness (both cardiorespiratory fitness and muscle strength) and physical activity were seen between the patients in the FG and the NFG. Especially, intensity of physical activity was significantly lower in the FG patients compared with the NFG patients (effect size: 1.02; p = 0.037). Similar results were seen when outcomes of the FG and NFG were compared with reference values of the normal population. Conclusion. Fatigued IBD patients show an impaired physical fitness and physical activity compared with non-fatigued IBD patients. This gives directions for a physical component in fatigue in IBD patients. Therefore, these new insights into fatigue indicate that these patients might benefit from an exercise program to improve physical fitness and physical activity.
Key Words: fatigue, inflammatory bowel disease, physical activity, physical fitness
Introduction Despite more effective treatments for patients with inflammatory bowel disease (IBD), many patients still suffer from disabling fatigue, which is associated with decreased quality of life (QoL) [1–5]. Several factors such as disease activity, perceived stress, depressive coping, female gender, and psychological well-being contribute to fatigue in IBD patients. Moreover, we showed in a previous study that solution-focused therapy, a psychological intervention, is effective in reducing fatigue and subsequently in increasing QoL [5–13]. However, although effective in the majority,
there are still patients who suffer from invalidating fatigue. Previous studies among cancer patients and liver transplant recipients showed evidence for a relationship between fatigue, impaired physical fitness and impaired physical activity [14–16]. Cardiorespiratory fitness (VO2peak) in liver transplant recipients was related with severity of fatigue and QoL, but no indications of impaired muscle strength was observed [17]. Furthermore, the level of daily physical activity measured with an accelerometer was related with fatigue in liver transplant recipients [18]. In cancer patients the etiology of fatigue is poorly understood,
Correspondence: Lauran Vogelaar, Department of Gastroenterology and Hepatology, Erasmus MC, ‘s Gravendijkwal 230, Room HS 306, 3000 CA Rotterdam, The Netherlands. Tel: +31 6 26664056. Fax: +31 10 703 5172. E-mail: [email protected]
(Received 14 March 2015; revised 25 April 2015; accepted 26 April 2015) ISSN 0036-5521 print/ISSN 1502-7708 online 2015 Informa Healthcare DOI: 10.3109/00365521.2015.1046135
Scand J Gastroenterol Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15 For personal use only.
2
L. Vogelaar et al.
and literature on fatigue and objective physical components is scarce. However, literature suggests associations between impaired muscle strength, impaired physical activity and fatigue [15,19]. Moreover, most research on fatigue in cancer patients focused on exercise interventions and showed reduction of fatigue by these interventions [16,20–25]. Therefore, we hypothesize that fatigue in IBD patients might be partly related to impaired physical fitness and impaired physical activity. However, data on the association between physical activity and physical fitness and fatigue in IBD patients is lacking. For the development of an exercise intervention to reduce fatigue, more objective knowledge of these associations is necessary. The aim of this study was to assess the level of physical fitness (cardiorespiratory fitness and muscle strength) and daily physical activity in IBD patients and whether fatigue is associated with impaired physical fitness and impaired physical activity. Methods Study design We performed a matched cross-sectional study in fatigued and non-fatigued IBD patients. This study was conducted in accordance with the protocol International Conference on Harmonization Guidelines for Good Clinical Practice, the Declaration of Helsinki, and local national regulations governing clinical study conduct. The protocol was approved by the medical ethics committee of the Erasmus Medical Center (Erasmus MC, registration number: MEC-2010-249; NL33396.078.10). The study was not designed for an interim analysis and no Data Safety Monitoring Board was assigned. All patients gave written informed consent. Patients were enrolled at the Erasmus MC in The Netherlands from November 2010 to October 2011. Patients were randomly selected from the IBD outpatient population. Sample size. For the sample size calculation, we applied data from the study of van den Berg-Emonset al. [18]. They reported correlation between 0.81 and 0.84 between severity of fatigue and daily physical activity within a group of liver transplant recipients. Applying a two-sided a-level of 0.05, power 0.80, nine cases are needed for a correlation of 0.80. In a study of van Ginneken et al. correlations between 0.50 and 0.61 were reported between cardiorespiratory fitness and severity of fatigue within a group of liver transplant recipients [17]. Again applying a two-sided a-level of 0.05, power 0.80,
28 cases are needed for a correlation of 0.50, and 18 cases for a correlation of 0.60. Combining these results we felt confident in applying a sample size of 20. Therefore we decided to include 10 patients in the fatigue group (FG) and 10 patients in the non-fatigue group (NFG). Patients were matched for sex and age (maximal difference: ±5 years). Patients and fatigue measurement Men and women aged ‡18 years, diagnosed with IBD which was radiologically or endoscopically/ histologically confirmed, were included. Patients had to be in remission of the disease, defined as Harvey Bradshaw Index score of
