What exercise regimen is recommended for patients with inflammatory bowel disease (Crohn’s disease and ulcerative colitis) during remission, mild‑to‑moderate flares, severe disease activity, and postoperative recovery?

Exercise Recommendations for IBD Patients

All patients with inflammatory bowel disease should engage in regular endurance training, and those with decreased muscle mass or strength should add resistance training 2-3 times weekly, regardless of disease activity status, with intensity modifications based on symptom severity. 1

Exercise During Remission

Patients in remission should perform moderate-intensity aerobic exercise combined with progressive resistance training as the foundation of their exercise regimen. 1

• Endurance training should be encouraged universally in all IBD patients during remission, as it improves quality of life by 19% compared to 8% in non-exercising controls 1
• Supervised moderate-intensity running three times weekly for 10 weeks significantly improves health-related quality of life, particularly social functioning (p = 0.023) 1
• Resistance training (weight-bearing exercises) is specifically recommended for patients with sarcopenia or features of sarcopenia, which affects 28% of Crohn's disease patients and 13% of ulcerative colitis patients 1
• An 8-week program of moderate-intensity aerobic and resistance exercise produces favorable body composition changes, with median 2.1% body fat decrease and 1.59 kg lean tissue mass increase 1
• High-intensity interval training (HIIT) and moderate-intensity continuous training are both feasible and acceptable in Crohn's disease patients during remission, with HIIT achieving greater oxygen uptake improvements 1

Exercise During Mild-to-Moderate Disease Activity

Patients with mild-to-moderate IBD activity should continue moderate-intensity exercise, as it is safe and improves quality of life without exacerbating disease. 1

• Moderate-intensity exercise programs are safe in patients with mild to moderate IBD and improve physical fitness without worsening inflammatory markers 1
• Exercise at 60-80% of maximum heart rate for 60 minutes twice weekly under supervision, combined with one home session weekly, is currently being investigated as a treatment modality for moderately active disease 2
• While 72% of IBD patients report feeling better with exercise, clinicians should counsel that 80% may need to temporarily stop during symptom exacerbations 1

Critical caveat: Intense or strenuous exercise can induce transient mild systemic inflammation and increase circulating cytokines, potentially exacerbating IBD symptoms 1. Therefore, during active disease, intensity should be moderated to avoid prolonged strenuous efforts.

Exercise During Severe Disease Activity

During severe disease flares, patients should reduce exercise intensity to light activities and avoid strenuous exercise until inflammation is controlled. 1, 3

• Strenuous exercise can evoke transient systemic inflammation and enhance pro-inflammatory cytokine release, potentially worsening gastrointestinal symptoms during active disease 3
• Light walking and gentle stretching can be maintained for psychological benefit and to prevent deconditioning 1
• Resistance training should be temporarily reduced in intensity or paused during severe flares to avoid catabolic stress 1

Postoperative Exercise Recovery

Peri-operative physical rehabilitation should be multidimensional with early mobilization, and exercise programs must be adapted to the extent of bowel resection and baseline sarcopenia status. 1

• Pre-operative exercise therapy improves physical fitness and facilitates postoperative recovery, with 8 weeks of moderate-intensity aerobic and resistance training producing significant body composition improvements 1
• Sarcopenia is present in 59% of Crohn's disease and 27% of ulcerative colitis patients pre-operatively and increases postoperative complication risk 6-fold (OR = 6.1) 1
• Maximal exercise capacity is reduced by 9% after <10 cm resection, 22% after 15-30% small bowel resection, and 40% after >50% small bowel resection, requiring graded return to activity 1
• Early mobilization as part of Enhanced Recovery After Surgery (ERAS) protocols expedites recovery and should begin immediately postoperatively 1
• Approximately 50% of young UC patients return to athletic activities after colectomy, while others face limitations from soiling, leakage, urgency, and joint pain that must be addressed 1

Specific Exercise Prescription for Sarcopenia

IBD patients with sarcopenia require resistance training as the reference treatment, combined with protein intake of 1.2-1.5 g/kg/day. 1, 4, 5

• Progressive resistance training targeting all major muscle groups 2-3 times weekly is non-negotiable for sarcopenic patients 4, 5
• Resistance training should be supervised initially to ensure proper form and prevent injury 4
• Twelve weeks of progressive resistance training produces approximately 1.5 kg gain in muscle mass in older adults with sarcopenia 5
• Protein intake must be distributed across meals at 20-30g per meal rather than loading one meal, emphasizing branched-chain amino acid sources 4, 5

Weight Management Considerations

Obese IBD patients should only attempt weight reduction during stable remission, with endurance training as the first-line approach rather than restrictive diets. 1

• Low-calorie diets are contraindicated during active disease due to high prevalence of micronutrient deficiencies and risk of sarcopenic obesity 1
• Obesity increases postoperative wound complications (OR 1.35), infections (OR 1.16), and pulmonary complications (OR 1.21) in IBD patients undergoing surgery 1
• Weight loss should be limited to <1 kg per week maximum, emphasizing high protein intake and resistance training to preserve muscle mass 4

Common Pitfalls to Avoid

• Avoiding exercise entirely during remission: This accelerates sarcopenia and bone loss, worsening long-term outcomes 1
• Performing strenuous exercise during active flares: This can transiently increase systemic inflammation and worsen symptoms 1, 3
• Neglecting resistance training in sarcopenic patients: Endurance training alone does not adequately address muscle mass loss 1, 4
• Attempting weight loss during active disease: This accelerates muscle loss and micronutrient deficiencies 1
• Inadequate protein intake during exercise programs: Without 1.2-1.5 g/kg/day protein, exercise benefits are diminished 4, 5