Abdominally Targeted Management Exercises for Crohn's Disease Patients (TAME-CD)

Inflammatory bowel diseases (IBD) are chronic relapsing diseases that carry considerable impact on patients' quality of life (QoL) including objective measures such as increased bowel movements and more subjective measures such as fatigue, stress and depression. While the pathogenesis of IBD is thought to result from a deregulated immune response towards microbial antigens in a genetically predisposed person, various associations of environmental factors and disease activity have been described. These include, but are not limited to diet, stress, physical activity, and microbial composition and function.

Mild to moderate physical activity, which by itself can be beneficial for patients who suffer from chronic disabling diseases such as IBD, is thought to have positive effects on health, general well-being and stress. The positive effects of physical activity can be mediated directly and/ or secondarily through its impact on other modifying factors such as sleep quality, bowel circadian rhythm, and perceived stress. In this regard, by reducing stress through physical activity, one can not only improve patients' QoL and reported outcomes (PROMs) such as sleep quality and stress reduction, which are an important measure by themselves; but also to improve subjective measures of the disease severity. Additionally, physical activity can impact the enteric microbiome, which can be beneficial in IBD patients.

It is currently not clear whether routine physical activity, performed by IBD patients, improves their symptoms, disease activity and quality of lives and if yes, which activity is mostly recommended.

In this study, the investigator intends to further examine whether these disease-specifically designed exercise sets can improve patients' perceived QoL and positively influence clinical and biological responses.

The hypothesize anticipates performing sets of special physical exercises designed for IBD patients, compared to a control set of exercises, can result in an improved QoL, in CD patients suffering from mild to moderate disease activity.

The effect of each set of exercises on patients' QoL, clinical and biological responses through symptoms severity, inflammatory biomarkers, intestinal ultrasound, change in microbiome and gut permeability, will be evaluated.

For this aim, CD patients suffering from mild to moderate disease will be randomized to undergo either a set of specific physical exercises for CD or a control set of unrelated exercises. Patients will be randomized to either group by a computer randomization program according to disease activity (5<HBI≤7 or 7<HBI≤15) and biomarker status (Fecal calprotectin below or above 350ugr/gr). Patients will receive an email with the link to an internet site where they will be able to watch the exercise program.

Videos sets of exercises will be available online and patients will be able to watch and follow these videos at their home. Each video will include explicit instructions and examples for each of the exercises.

Compliance will be documented by the study coordinator (by mail or phone call) every week during the first 2 weeks and then every 2 weeks until the end of the study. This will be verified through the software itself, which documents whenever a patient activates the video.

All patients should remain on consistent dietary regimen throughout the study period.

Patients will attend research visits at weeks 0, 4, and 8. During visits patients will answer questionnaires for QoL (IBDQ), and PROMs (PROMIS-29); and will be monitored for disease activity. At these time points, patients will give biologic samples:

• Serum- 20 ml of blood will be drawn for serum analysis of CRP concentration and for LPS binding protein (LBP). Serum will also be frozen for future metabolome analysis.
• Stool - analyzed for inflammatory marker calprotectin, as well as microbial composition and function.

Data collection will include basic medical and demographic information, including gender, age, weight, height, smoking and exercise habits. Medical data will include age at diagnosis, disease duration, CD Montreal classification, HBI (Harvey-Bradshaw Index), lab results (CRP, LBP and calprotectin), comorbidities, medications history and previous intestinal surgery.

Inclusion criteria

• Patients with no treatment or on constant medicinal therapy, expected to remain constant: mesalamine for at least 6 weeks, steroids at least 2 weeks (≤20mg prednisone or budesonide ≤6mg), immunomodulatory at least 12 weeks or biologics/ small molecules for at least 12 weeks therapy. Patients who initiate the study on steroids will remain on a constant dose throughout the study.
• If patients stopped therapy prior to the study then they should be at least 2 weeks from stopping steroids or 5ASA, or 4 weeks from stopping small molecules, 8 weeks from stopping biologics, or 12 weeks from stopping thiopurines.
• CD patients will be included if their symptoms score >4 and ≤15 on the HBI score
• Fecal calprotectin>150ug/gr or evidence of an active disease per IUS defined as increased blood flow (modified Limberg score>0) or thickness of bowel wall>3mm

Exclusion criteria

• Inability to commit for performing at least 10-15 minutes of exercise, 6 times a week.
• Lack of availability or capability to use a computer/ internet.
• Any proven current infection such as, fever, active abscess, Clostridioides difficile infection, positive stool culture, or parasite in patients with chronic diarrhea.
• Inability to sign informed consent and/ or complete the study protocol.
• Incompetent individuals who are unable to provide informed consent.
• Planed pregnancy or pregnancy- up to 3 months post labor.
• Subjects with chronic conditions such as active arthritis, cancer (within the previous 5 years, not including BCC, SCC), organ transplant subjects, advanced kidney or liver disease, or systemic inflammatory conditions other than IBD.
• Patients who underwent surgery in the previous 3 months, had more than 1 surgery of intestinal resection, patients with ileostomy, pouch or patients with short bowel (small intestine<1.5 meter).
• Patients with a significant abdominal wall hernia, unless received a written confirmation from a treating surgeon.
• Active peri-anal disease (fistula, abscess, fissure), stricturing or penetrating disease
• Active extra-intestinal manifestations (not excluded are- oral aphthae and peripheral arthralgia without arthritis)
• Patients on total parenteral nutrition (TPN) or on exclusive enteral nutrition (EEN).
• Probiotics or antibiotics in the 15 days prior to enrollment or during the study period.