Impact of physical activity and selected relaxation techniques on the quality of life of female patients with irritable bowel syndrome

Introduction

Gastrointestinal disorders significantly impair the quality of life, often causing distress to patients and their families. The lack of effective pharmacological methods, at a time of great advances in medicine and pharmacotherapy, to alleviate patients’ complaints prompts the search for alternative methods of treating patients. Irritable bowel syndrome (IBS), which affects about 20% of the world’s population, two thirds of whom are women, is characterised by abdominal pain, bloating and faecal disturbances. Patients often have mental disorders and even depressive symptoms [1, 2].

The difficulty in treating or merely alleviating symptoms prompts the search for unconventional methods on the basis of cooperation between doctors, psychologists and coaches.

One of the discussed and researched ways to alleviate the symptoms of the disease is appropriately selected physical exercise. In this study, an original training programme was used, which was conducted for 8 weeks at a frequency of twice a week in 5 subgroups. It was considered that only systematic and specialist-led training would guarantee the desired results. The training followed the same pattern each time to enable the subjects to remember it in order to continue it on their own in the future.

In order to increase the effectiveness of the training, the exercises were combined with selected relaxation techniques, which have been shown to help reduce stress levels. In the diagnostic and therapeutic recommendations of the Polish Society of Gastroenterology, after interviewing the patient with IBS and before starting medication, it is recommended to avoid situations that exacerbate symptoms. Here, the need for lifestyle modification is emphasised, which, in addition to diet, includes physical activity and methods of coping with stress [3]. With regard to physical activity, training and yoga are mentioned in the recommendations. As for methods of stress management, the authors of the guidelines suggest visiting a psychologist, who will incorporate the appropriate therapy depending on the severity of the complaints. Particular care should be taken to ensure that the type of physical activity is selected by a specialist, as an inappropriate form of physical activity can result in an exacerbation of IBS symptoms.

Aim

The aim of this study was to evaluate the impact of exercise on the quality of life (QOL) of patients with IBS.

Material and methods

Forty-one women diagnosed with IBS were enrolled in 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 a questionnaire containing inclusion criteria, which was filled in during the recruitment meeting. The questionnaire asked about, among other things, 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 were also the ones who decided whether the inclusion criteria for the study were met.

In order to facilitate the possibility of taking part in the research programme, the clients were divided into five subgroups in a training schedule with a total of 10 dates in three different locations. The choice of venues and proposed times made it easier for women to participate in the training cycle, especially those who worked shifts.

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 insurance of the study and how personal data were collected and processed. Participation in the study was voluntary and each subject signed an informed consent form.

A validated IBS-QOL (Irritable Bowel Syndrome–Quality of Life) questionnaire was used to assess the effectiveness of the method used. Participants completed it at the beginning of the first and at the end of the last training session. Permission to use the questionnaire was granted by the official distributor Mapi Research Trust, based in Lyon, France.

The IBS-QOL is a disease-specific instrument that measures health-related quality of life. Developed by Patrick and Drossman, the scale consists of 34 items that assess the dimensions of QOL: dysphoria, activity interference, body image, health worries, diet (food avoidance), social responsiveness, sexuality, social relationships and an overall dimension. Responses relate to the last 30 days and are given on a five-point Likert scale. Female respondents selected one of the following options: not at all, to a small extent, moderately, to a large extent, or to a very large extent [4].

The study used a proprietary training programme based on the basic steps used in a fitness class, yoga postures to improve bowel motility and relaxation training: autogenic Schultz and Jacobson. 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 made use of postures from hatha yoga, such as upward dog, downward dog, horse saddle, cat’s back, McKenzie standing and lying stretches, standing, sitting and kneeling trunk twists, child’s pose, lying backwards, etc. All the postures (asanas) were demonstrated in a relaxed manner. 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.

Results and discussion

Forty-one women were eligible for the study. Thirty-eight women started the study and 29 completed it. Reasons for dropping out included colds, sprained ankle, and change of working hours. Three people dropped out of the study without giving a reason. The obtained responses from the IBS-QOL questionnaire regarding the impact of physical activity and relaxation techniques on the QOL of IBS patients were statistically analysed.

The IBS-QOL questionnaire is recognised as reliable, and its usefulness for assessing the QOL of IBS patients has been tested in numerous clinical studies [5–7]. In a study by Bijkerk et al. comparing 5 QOL scales used to assess the QOL of patients diagnosed with IBS, the IBS-QOL questionnaire scored best [8].

The questionnaire contained questions grouped into 9 dimensions: dysphoria, activity interference, body image, health preoccupation, food avoidance, social response, sexuality, relationships and overall. Statistically significant improvements were found in all 9 QOL dimensions examined (Table I). The first dimension is related to dysphoria, which is a problem directly related to mood and emotion. The patient suffers from a dysphoric state, with a markedly lowered mood. Lowered mood is a problem that also occurs in depression, but in dysphoria the predominant disorder is not sadness, a lack of feeling joy or a sense of inner emptiness. Dysphoria is primarily associated with significant irritability. In addition to it, there may be: a sense of frustration, exaggeration of a trivial matter, and embitterment. In the study, there was a statistically significant difference in the level of experiencing dysphoric mood before and after the 2-month training cycle. The average level decreased by 15.7%. It was 39% before the study and 23% after the study. Another dimension studied was activity disruption related to feeling anxious about the amount of time spent in the toilet, less activity due to bowel disruption, the need to avoid stressful situations that exacerbate IBS symptoms, the need to avoid strenuous exercise and to give up long-distance travel. Analysis of the results showed a statistically significant improvement of 8.5%. Before the start of the 2-month training cycle in the female participants, IBS interfered with activity in 34%, after participation in the study in 26%. The third QOL dimension analysed was body image. It included questions on feelings about body weight, body hygiene, sluggishness due to bowel problems and restrictions on choice of clothing worn. Analysis of the results showed a 17% improvement. Before the start of the 2-month training cycle, body image in the women with IBS surveyed was 48%; after participation in the study it was 31%. This difference was statistically significant. The fourth dimension of QOL was related to feelings of susceptibility to other illnesses, worry about the possibility of bowel deterioration and concern about constipation. Analysis of the results showed a statistically significant improvement of 17.8%. Before the start of the 2-month training cycle, health worry was 46% in the women with IBS, and 28% after participation in the study. Another dimension measured in the IBS-QOL concerns nutrition related to avoidance of products or foods that worsen symptoms in IBS. Before the study, 55% of the women surveyed paid attention to what they were eating to alleviate IBS symptoms, while 46% did so after the study. The difference was found to be statistically significant. The QOL-social response dimension addressed the lack of understanding of the problems faced by IBS patients by those around them. Feelings of shame related to the odour associated with bowel problems and disease-related limitations were present in 31% before the study. They improved after the study, to less than 20%. This difference was statistically significant. Another dimension of QOL was related to assessing the impact of the study on improving sexuality among the women studied. The impact of bowel problems on sexual desire and activity was assessed. The median was considered for this variable, the study of which does not have a normal distribution. A significant difference was found. The women studied had fewer problems with sexuality after participating in the training cycle.

I feel uncomfortable when I talk about my bowel problems; because of my bowel problems, I find it difficult to be with people I don’t know well; my bowel problems affect my closest relationships – these are statements that were included in the eighth QOL dimension studied. After the study, there was a statistically significant decrease in the impact of the aforementioned problems accompanying IBS in social relationships. Before the study, IBS symptoms interfered with social relationships in 26%, while after the study they interfered in 17%.

The last QOL dimension measured concerned the overall assessment of the impact of IBS symptom severity on the QOL of the women studied. A guided two-month training cycle was shown to improve QOL by 12.5%, and this difference was statistically significant.

Conclusions

The results of the study confirmed that there was a 12.5% relationship between physical activity and QOL in IBS patients. Of the QOL dimensions analysed, the largest differences were found in the areas of sexuality, health preoccupation, body image and dysphoria, and the smallest in the activity interference dimension.