Effects of physical activity on symptoms of irritable bowel syndrome

Introduction

Functional gastrointestinal disorders are among the most common diseases of the gastrointestinal tract and account for approximately 50% of people presenting for specialist treatment. Irritable bowel syndrome (IBS) affects approximately 10–20% of adults, two thirds of whom are women. In Poland, IBS is estimated to affect around 13% of the population. The disease usually begins between the ages of 30 and 40, i.e. in the third decade of life [1].

Complex aetiopathogenetic factors and the lack of good and simple diagnostic tools mean that patients often search on their own for the causes of their complaints and treatments, often among unconventional methods [2].

Irritable bowel syndrome is characterised by recurrent abdominal pain that has occurred on average at least 1 day per week for the past 3 months. Abdominal pain in IBS must meet 2 of 3 criteria: association with bowel movements, with a change in the frequency of bowel movements or with a change in the formation and appearance of stools.

Evidence is emerging in the literature on the effectiveness of physical activity and relaxation training in the treatment of IBS symptoms. It confirms that physical exercise at a moderate level, combined with postures derived from yoga, may provide an alternative way to alleviate IBS symptoms.

The latest version of the recommendations developed by a working group set up by the General Board of the Polish Society of Gastroenterology in 2018 emphasises the role of physical activity, relaxation techniques and yoga [3].

An attempt was made to confirm the beneficial effect of physical activity on the symptoms of irritable bowel syndrome. To this end, an exercise regimen based on classical aerobics combined with hatha yoga and Schultz-Jacobson relaxation training was created to assess the effect of increasing physical activity levels in patients with irritable bowel syndrome on the severity of symptoms associated with the disease.

Material and methods

Forty-one women diagnosed with irritable bowel syndrome were enrolled in the study (29 completed the study). The mean age of the women in the study was 44.6 years. The composition of the study group was determined by analysing data from a questionnaire containing inclusion criteria, which was completed at the recruitment meeting. The questionnaire asked about age, current body weight, education, occupational activity, gastrointestinal complaints and their duration, chronic diseases, past pregnancies, and surgical procedures. Patients with significant chronic diseases, especially cardiovascular diseases, were not eligible for the study.

Verification of the history and clinical data giving rise to the diagnosis of IBS was performed by specialist gastroenterologists. They also made the decision on meeting the inclusion criteria for the study. To facilitate the possibility of taking part in the research programme, a schedule was established, with 10 dates proposed in three different locations and at different times of day. The choice of venues and proposed times made it easier for respondents to participate in the training cycle, especially those who worked shifts. The study used a proprietary training programme based on the basic steps used in a fitness class, yoga positions to improve bowel motility and relaxation training: the autogenic Schultz technique and Jacobson’s technique. The basic steps in the warm-up were: step touch, heel back, step out (side to side), march, knee up, etc., combined with upper limb work in all main planes (transverse, frontal and sagittal). The main part involved trunk bending in the aforementioned planes combined with upper and lower track breathing. The main focus was on abdominal (diaphragmatic) breathing to relax the abdominal muscles and internal organs. The training used positions taken from hatha yoga, such as head-up dog, head-down dog, horse saddle, cat’s back, McKenzie standing and lying stretches, trunk twists in standing, sitting and kneeling positions, child’s position, lying backwards, etc. All positions (asanas) were shown and discussed by the trainer, and attention was paid to the breath (pranayama) for each position. The third part of the training was relaxation using the common Jacobson and Schultz relaxation techniques. A total of 29 women completed the entire training cycle, in line with the objectives of the study.

The study women were informed about the purpose of the study, how it was conducted, and the risks and benefits of participating in the study. Information was also provided on the study’s insurance coverage and how personal data were collected and processed. Participation in the study was voluntary and each subject signed an informed consent form. The study was conducted with the approval of the Bioethics Committee of the Piastów Śląskich University of Medical Sciences in Wrocław, based on resolution no. KB - 809/2018 of 3 January 2019.

A validated IBS-SSS (Irritable Bowel Syndrome Severity Scoring System) questionnaire was used to assess the effectiveness of the method used, which was completed by the participants at the beginning of the first training session and at the end of the last training session. Approval for the use of the questionnaire was granted by its official distributor, Mapi Research Trust, based in Lyon, France.

Results

Prior to the survey, abdominal pain was present in 80% of the women surveyed. After the study, abdominal pain was reported by 50% of subjects. The difference was statistically significant (Table I).

A 0–100 analogue scale was used to assess the severity of pain. It was found that the change in abdominal pain severity after the 2-month training cycle was statistically significant. Before the study, the mean abdominal pain intensity was 34%. After the 2-month training cycle conducted, the average pain intensity was 14%. After the exercise series, the mean number of days with abdominal pain for the last 10 days was statistically significantly lower (p = 0.005243). The number of days with abdominal pain decreased by 1.4.

97% of the women surveyed confirmed that they had troublesome abdominal bloating at the time of joining the study. After completing the exercise cycle, the incidence of bloating decreased by 40%. Its severity was assessed using a scale of 1–100, where 100 meant very severe bloating. Before the study, the average bloating severity was 50%, which meant that the majority of women had quite severe bloating. After the survey, the intensity of bloating decreased and the difference was statistically significant (30%).

A further analysis looked at so-called bowel satisfaction. The resulting difference between before and after training was statistically significant. Before the study, bowel dissatisfaction was 52%, and after the study it was 29%.

Assessing the quality of life, the subjects with IBS showed a statistically significant difference in this assessment before and after the study (25%). Before the study, a problem related to bowel function, in the female subjects, interfered with quality of life at a level of 58%, while after the study it was 33%. After the survey, the quality of life of the women surveyed improved by 25%.

Discussion

Gastrointestinal disorders significantly impair quality of life, often causing distress to patients and their families. For this reason, patients themselves seek alternative methods of treatment, whose effectiveness is not always confirmed by scientific studies. It appears that one beneficial way of alleviating the symptoms of the disease is appropriately selected physical exercise.

Johannesson et al. conducted a study in which 39 patients self-increased physical activity by changing their current lifestyle. The most common activities were walking, aerobics and cycling. In patients with IBS, increasing physical activity has been shown to have a positive long-term effect on symptoms of the disease, as well as on various aspects of quality of life such as fatigue, depression and anxiety [5].

In the study conducted, the participants chose not to increase their physical activity on their own, due to a lack of control over it. It was considered that only systematic and professionally led training would guarantee the desired results. Using a proprietary training programme, conducted over an 8-week period at a frequency of twice a week, the women in the study were also given the opportunity to continue the exercise regimen on their own in the future.

Demska has written about the effectiveness of cognitive behavioural therapy, which includes increasing physical activity and introducing relaxation exercises. In her study, the author demonstrated the positive effects of physical activity as a treatment option for IBS [6].

To increase the effectiveness of the workouts, they were combined with selected relaxation techniques, which have been shown to help reduce stress levels. The 2018 diagnostic and therapeutic recommendations recommend, after discussion with the patient and before the inclusion of medication, avoiding situations that exacerbate the symptoms of the disease through lifestyle modification, which includes, in addition to diet, physical activity and the use of stress management methods [3]. In terms of physical activity, training and yoga are mentioned in the recommendations.

The effectiveness of physical activity and relaxation techniques in alleviating the severity of IBS symptoms was confirmed in this study. Systematic training not only had significant effects in alleviating the symptoms of the disease, but also translated into an improved quality of life. A subjective improvement in the gastrointestinal function and well-being of the female participants was observed after only a few training sessions.

Promising results also included a significant reduction in the severity of IBS symptoms such as abdominal pain and bloating. The training cycle resulted in a reduction in the occurrence of pain in the subjects from 80% to 52%, and the intensity of pain decreased by 20%. These were statistically significant differences. There was also a reduction in the number of days the women in the study experienced pain by an average of 1.4. Similar results were obtained by Johannesson, who reported that increased physical activity was closely associated with a reduction in gastrointestinal symptoms in IBS and should be recommended for the treatment of this condition [7].

The study also confirmed that the exercise intervention carried out reduced the frequency (by 38%) and severity (by 30%) of bloating, and the differences were statistically significant. This was also confirmed by the study of Villoria et al., who found that mild physical activity increased gas clearance and reduced bloating in IBS patients, and in healthy subjects it improved gas transit [8, 9].

Kuttner et al., in a randomised controlled clinical trial including 25 adolescent patients, observed that yoga practised once a week for 4 weeks reduced anxiety and other gastrointestinal symptoms, including pain [10].

Kashyap et al. found that patients reporting medically unexplained clinical symptoms (MUS) visited various specialists in search of the cause of their symptoms, resulting in increasing dissatisfaction and increasing health burden. Yoga as an adjunctive therapy has been shown to be effective in treating disorders associated with MUS, such as gastrointestinal functional symptoms, depression and anxiety.

Similarly, the effects of yoga on IBS symptoms, quality of life, mood, stress management and overall patient safety were assessed by Schumann et al. In a review of 6 randomised trials involving 273 patients, the beneficial effects of yoga compared with conventional treatment in IBS were demonstrated. A significant reduction in the frequency and severity of bowel symptoms and accompanying anxiety was observed. Thus, the results of the study support the efficacy of yoga in supporting the treatment of IBS, although it is not recommended as a routine treatment [11]. A study by Schumann et al. suggests that repeated practice of yoga may be as effective in alleviating gastrointestinal complaints in irritable bowel syndrome as adherence to a low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diet as recommended [12].

Daley et al. documented a significant improvement in quality of life and a reduction in the severity of constipation as a result of increased physical activity. According to these authors, the beneficial effect of exercise persists after an average of 5 years and is mainly related to quality of life and selected intestinal and extraintestinal symptoms of IBS.

Forty-two studies were included in one of the meta-analyses conducted, and the results analysed included those from laboratory studies. It was found that yoga exercise had a beneficial effect on the diurnal cortisol profile, blood pressure values, heart rate, blood sugar, and lipid profile. The authors of the meta-analysis believe that yoga asanas have a positive effect on the regulation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal system [13, 14]. This was also confirmed by Kavuri et al., who used the IBS-SSS and IBS-QOL questionnaires in their study. The authors emphasise the simplicity of the recommended exercises, which patients are able to perform at any time, including after the study [15].

In contrast, Evans et al. tested the effectiveness of yoga among adolescents aged 14-17 years with IBS symptoms who followed a 6-week Iyengar yoga intervention. Half of the boys studied responded successfully to the yoga practice [16].

In addition to physical activity using body postures derived from yoga, techniques that make it possible to deal skilfully with stress and its consequences are worthy of note, which is possible, among other things, through the use of learned relaxation methods and techniques.

Siek reported that relaxation training has a regenerative effect on the body and mental apparatus and that systematic practice of relaxation training improves memory and attention functioning, relieves mental tension states, stabilises emotional reactions, and improves self-esteem [17].

Among the most popular relaxation training techniques are Schultz’s autosuggestion and Jacobson’s progressive muscle relaxation. This study linked physical activity to relaxation training, and the results confirmed their beneficial effects on the quality of life of IBS patients. The body’s response to stress in IBS patients is hypersensitivity of the intestinal muscles, their increased contractility and pain. Such reactions are observed in 40–69% of patients [18]. In a meta-analysis involving 8 randomised controlled clinical trials involving 360 patients with irritable bowel syndrome, it was found that regular performance of relaxation training can contribute to improved disease management [19].

All the studies cited above refer to light to moderate exertion, which is feasible regardless of body capacity, fitness or age. In the case of yoga, simple postures (asanas) that do not require specific motor coordination are effective in relieving symptoms. It is important to emphasise that during each meeting, all exercises were thoroughly discussed and presented, and the women participating in the study were continuously corrected. The repetition of the exercises and constant monitoring made it possible to improve them and correct errors.

The study confirms the measurable benefits of the proposed unconventional methods of symptom relief in the form of regular yoga-based exercises combined with relaxation training in patients diagnosed with IBS.

Conclusions

On the basis of the survey and the analyses carried out, the following conclusions were drawn: the relationship between physical activity and the severity of irritable bowel syndrome symptoms has been confirmed. Regular physical activity has been shown to reduce the severity of symptoms of the disease. The beneficial effect of regular exercise on the quality of life of the women studied was confirmed.