The Roles of Complementary Structured Exercise and Physical Therapy in The Aging and Older Adult IBD Patient Care Team

Abstract

Structured exercise (SE) and physical therapy (PT) are integral components of disease management. Older adults with inflammatory bowel disease (IBD) represent a growing proportion of patients, and are at disproportionate risk of functional decline due to the combined effects of aging, chronic inflammation, malnutrition, and inactivity. Despite the well-established benefits of SE and PT, most gastroenterologists report feeling inadequately equipped to counsel and refer patients with physical function limitations, and thus these therapies remain underutilized. The purpose of this review is to synthesize the existing evidence and provide practical, actionable guidance for gastroenterologists to incorporate SE and PT into IBD care.

Recent Findings

Initial studies suggest complementary SE and PT may significantly improve IBD-related musculoskeletal extraintestinal manifestations (EIMs), such as joint pain, fatigue, sarcopenia, frailty, and improve exercise confidence as compared with standard care alone. Additionally, multimodal prehabilitation strategies may significantly reduce severe postoperative complications and shorten hospital stays in older patients undergoing IBD-related surgery.

Summary

SE and PT are low-cost, low-risk interventions with benefits spanning multiple domains of physical function and morbidity in older adults with IBD. This article highlights pertinent SE and PT literature in the aging IBD population, including underlying pathophysiology, interventions, and scope of practice. Gastroenterologists are provided evidence-based, condition-specific assessments and PT referral pathways that can be implemented in routine practice. Integrating this into the multidisciplinary IBD care team may improve patients’ physical function and quality of life.

Introduction

Inflammatory bowel disease (IBD) affects nearly 7 million people worldwide, and approximately one-third of patients with IBD are 60 years or older in Western countries.¹ Despite a growing armamentarium of medical treatment options, the musculoskeletal and functional burden of IBD remains underrecognized, leaving older adults with IBD at particular risk of sarcopenia (loss of muscle mass, strength, and/or function) and frailty (a state of decreased physiologic reserve).² The benefits of structured exercise (SE) and physical therapy (PT) as health promotion, disease mitigation, and management interventions are well-established, yet their application in IBD remains underutilized.³ This article highlights the evidence for complementary SE and PT in the aging and older adult IBD population. An evidence-based practical guide for clinical gastroenterologists is also provided.

Physical Activity, Structured Exercise and Physical Therapy Definitions

When discussing SE and PT interventions, it is important to distinguish between physical activity (PA), SE, and PT.^3,4 PA refers to any bodily movement that increases energy expenditure.⁵ SE is a structured form of PA designed to improve specific components of physical function, such as cardiovascular, endurance, or muscular strength.⁵ Examples of SE are aerobic (AE) and resistance exercise (RE).

PT provides care for patients with impairments in body structures or function that limit activity and performance. PTs are essential members of the IBD care team who apply disease-specific knowledge to evaluate, develop care plans, and prescribe and monitor individualized therapeutic exercise across training modalities, volumes, durations, and intensities.

Exercise Physiology and Healthy Aging

Preserving functional capacity is essential for maintaining independence in activities of daily living (ADLs), including walking and lifting, and functional ADLs, such as grocery shopping.^6,7 Aging adults begin to reduce lower extremity use during ADLs and decrease participation in SE, leading to declines in lower extremity strength and endurance. Conditions such as chronic inflammatory diseases and arthritis may contribute to both decreased PA and an inflammatory milieu, resulting in both muscle atrophy and contractile dysfunction (the pathological loss of muscle force without loss of muscle size).^8,9 In response to reduced physiological demand, skeletal muscle metabolic capacity and neuromuscular recruitment can decline.^6,10 These changes contribute to progressive declines in strength and mobility, which, if unaddressed, may result in sarcopenia and frailty.

Structured Exercise and Physical Therapy Benefits in Older Adults with Chronic Diseases

SE studies in healthy aging adults as well as those with chronic diseases have demonstrated physiologic and functional declines in cardiovascular and mitochondrial function are, at least in part, reversible.¹¹ RE and concurrent AE + RE studies in healthy older adults recovering from breast and colorectal cancer surgery have reported gains in aerobic muscle strength, muscle endurance, and fatigability.^12–14 A meta-analysis of exercise studies determined moderate intensity AE or concurrent AE + RE had the greatest effect on reducing intermuscular adipose tissue in adults with chronic diseases and frailty (effect size 0.24, 95% CI 0.1–0.37).¹⁵ However, improper SE prescriptions may be counterproductive for this in frail older adults, underscoring the importance of individualized programming. PT specialists, through their ability to provide tailored education, guidance, and therapeutic exercise prescription to improve both muscle composition and functionality are well-positioned to design and supervise exercise interventions for medically complex aging populations.

Further, regular PA and moderate exercise can counter many of the functional declines associated with aging by preserving muscle mass, cardiovascular fitness, bone density, and cognitive function.¹⁶ As such, older adults participating in individualized programs that incorporate AE, RE, and balance training demonstrate improved functional capacity (including strength gains of 40–150%) and reduced fall risk (of 20–42%), particularly when combined with cognitive tasks.¹⁶ This may be driven by reductions in chronic inflammatory markers along with adaptations in mitochondrial function, cellular aging, and beneficial changes in gut microbiota composition. These physiologic benefits may be relevant in IBD, where reduced PA and chronic inflammation contribute to muscle atrophy and contractile dysfunction.^8,9 Notably, older adults with IBD have lower levels of PA compared with the general population, and more than two-thirds do not meet recommended exercise guidelines, underscoring the critical importance of prioritizing exercise interventions in this population.^17,18

Structured Exercise and Physical Therapy Benefits in Aging and Older Adults with IBD

Individuals with IBD may be at high risk for physical inactivity during periods of active disease.¹⁹ Musculoskeletal EIMs, which affect up to 46% of patients with inactive disease, further limit physical activity, mobility, and contribute to musculoskeletal deterioration, frailty, and eventual disability.¹⁹ EIMs, including pelvic floor dysfunction, joint pain, muscle loss, and bone loss may result from age and disease-related inflammation, poor nutrition, medication use, inactivity, and other environmental factors.^2,20–22 This cycle of inactivity is difficult to break without professional assistance, and longitudinal data suggest that PA and exercise in IBD populations remain largely unchanged over time without structured interventions.^23,24 While some patients with IBD report barriers to exercise, those who do initiate activity experience improvements in mood and energy following participation.²⁵

Further observational data support the benefits of exercise in IBD. Exercise and PA may be associated with reduced IBD flare frequency and severity.²⁶ Further, a longitudinal study of 5,052 older adults with IBD found a healthy lifestyle, including regular PA, was associated with reduced mortality in both UC (HR=0.61, 95% CI 0.48–0.79) and CD (HR=0.49, 95% CI 0.36–0.67).²⁷ Taken together, these findings highlight the need for a multidisciplinary approach to IBD care that incorporates PT, enabling individualized exercise programs that can improve patients’ confidence in safe activity participation.

Barriers to Exercise Interventions in IBD

The SE barriers reported by IBD populations are largely driven by 5 central themes: gaps in disease-specific knowledge, fear of disease flares, fear of extraintestinal manifestation exacerbation, fear of excessive post-exertional fatigue, and pelvic floor dysfunction-related embarrassment and shame.^25,28–32 A multinational survey of 1,997 older adults with IBD (≥60 years) found patients’ top priorities were reducing fatigue (56%), preserving/restoring good mood (43%), and decreasing diarrhea/incontinence (32%).³³

The STRIDE II update addressed IBD population priorities and barriers, emphasizing the absence of disability and the restoration of quality of life as key treatment targets.³⁴ PT can play a central role in achieving these goals, addressing barriers to activity through disease-specific education and targeted intervention strategies. PTs employ breath training, manual therapy, neuromuscular re-education, energy conservation, activity pacing strategies, pelvic floor rehabilitation and other therapeutic techniques to improve respiratory function, optimize tissue mobility and physical function, and reduce pain. PT may, thereby, facilitate safe and sustained engagement in PA, which is particularly important for older adults with IBD.

Exercise and Physical Therapy Applications in Older Adults with IBD

Multidisciplinary Perioperative Care

Despite major advances in medical management, surgical intervention remains a necessary treatment for many individuals with IBD. Almost 30% of patients undergoing major abdominal surgery experience postoperative complications.³⁵ Patients with IBD are particularly vulnerable to post-surgical functional decline. A study of CD patients found postoperative exercise capacity was inversely proportional to the amount of small bowel resected.³⁶ A study of UC and CD patients demonstrated that postoperative functional capacity was significantly reduced compared to healthy reference data.³⁷ As poor muscle quality and frailty are major determinants of postoperative trajectory, there is growing consensus that postoperative rehabilitation alone cannot fully address this need. The European Crohn’s and Colitis Organization recommends considering ≥4-weeks of individualized prehabilitation and postoperative rehabilitation for patients scheduled for surgery.³⁸ Guidelines from The American Society of Colon and Rectal Surgeons recommend multimodal prehabilitation for patients with multiple comorbidities or deconditioning (Grade 2B), with stronger recommendations specifically for frail older adults (Grade 1B).^39,40 The goals of perioperative rehabilitation are twofold: to optimize physical conditioning prior to surgery, and to improve functional capacity during recovery.

Perioperative rehabilitation has been well-studied in other abdominal surgery populations. The PREHAB trial, a multicenter, supervised, 4-week, progressive multimodal randomized controlled trial (RCT) combining PT, nutritional, and psychological counseling for 251 patients awaiting colorectal cancer surgery (median age 69 years) found that individualized prehabilitation improved postoperative functional outcomes and reduced severe and medical complications compared to standard care alone.⁴¹ However, these findings may not be directly generalizable to patients with IBD, where the chronic inflammatory environment may persist.

Perioperative IBD rehabilitation represents an important yet understudied research domain. A randomized home-based prehabilitation trial in colorectal surgery patients (mean age 60 years, 15% IBD) found that both a structured cycling and strengthening program and a simpler walking and breathing regimen improved VO₂ max during the prehabilitation period.¹⁴ Furthermore, patients with improved functional capacity during prehabilitation were more likely to recover baseline walking capacity postoperatively.⁴² Early data from two perioperative, multidisciplinary studies have also shown complementary, individualized PT prior to surgery reduces complications, opioid use, readmission rates, and re-operation rates in IBD.^43,44

The initial evidence suggests referral for complementary, multidisciplinary, prehabilitation, including PT, and ongoing postoperative rehabilitation may reduce complications and accelerate recovery, although further IBD-specific data are needed.

IBD and Pelvic Floor Dysfunction

Patients with IBD commonly report abdominopelvic symptoms or persistent pelvic floor dysfunction, despite the resolution of chronic inflammation and the absence of infection.^45,46 Persistent pelvic symptoms including fecal incontinence, urgency, frequent defecation, constipation, abdominopelvic pain, and sexual dysfunction are associated with significant impairment of ADLs, PA, social participation, and sexual health as well as psychosocial burden.^47,48 Poor coordination between the pelvic floor and abdominal musculature, or dyssynergic defecation, affects 45–97% of IBD patients and is a common cause of persistent pelvic dysfunction, though estimates vary due to heterogeneous diagnostic criteria and under-reporting due to patient embarrassment and lack of knowledge regarding treatment options.^45,46 Pelvic dysfunction in IBD may result from or be exacerbated by sensorimotor function disturbances due to prolonged inflammation and/or surgery.^45,46 These challenges are compounded in older adults, who may have reduced pelvic floor muscle tone, weakened sphincter function, and decreased connective tissue resilience.^49–51

Pelvic floor rehabilitation (PFR) is a complementary, low-cost approach to pelvic dysfunction management with demonstrated efficacy in non-IBD populations. Treatment includes patient education, breathwork, manual therapy, myofascial release, soft tissue manipulation, therapeutic exercise, neuromuscular re-education, feedback techniques, and/or home programs.⁴⁵ Biofeedback is one such therapy, providing real-time visual and/or auditory reinforcement to improve awareness of pelvic floor muscular contraction and relaxation. One RCT demonstrated a five-fold higher odds of improvement for adults with fecal incontinence who received pelvic floor muscle training and biofeedback, compared with those who received conservative treatment alone for 16 weeks.⁵²

PFR studies in IBD are limited, though several small-scale studies are encouraging. Systematic reviews have found that pelvic floor muscle training in quiescent IBD, with or without biofeedback, improved symptoms in 68% of patients with evacuation difficulty and 80% of patients with fecal incontinence, with pooled biofeedback response rates of 70% in patients without ileal pouch-anal anastomosis (IPAA) and 86% in those with IPAA.^45,46 Beyond bowel symptoms, a prospective cohort study by Khera et al. examined the effectiveness of an individualized behavioral treatment program (comprising pelvic floor muscle training, biofeedback, neuromuscular re-education, breathing exercises, and a home program) delivered over up to six monthly sessions in IBD patients in remission with persistent fecal incontinence, urgency, or constipation.⁵³ Among completers, 72% reported moderate or substantial symptom improvement, with improvements in fecal incontinence severity, constipation scores, IBD-specific quality of life, bodily pain, social functioning, and illness perception.⁵³

Recommendations for pelvic floor rehabilitation in IBD are largely extrapolated from the general population, highlighting an important gap for future research. Despite these limitations, PFR is a low-risk intervention that significantly reduces bowel symptoms and healthcare utilization and improves quality of life. PFR should be considered for patients with persistent pelvic floor dysfunction.

IBD-Related Arthropathies and Joint Pain

IBD-associated spondyloarthritis (SpA) includes axial and peripheral arthritis. Peripheral spondyloarthritis (pSpA) includes peripheral arthritis, affecting synovial joints, and enthesitis, where tendons, ligaments, and fascia are inflamed at their bony insertion points.⁵⁴ A study of 635 IBD patients (mean age 46 years) found quality of life in patients with joint symptoms were significantly impacted compared to those without joint complaints.⁵⁵ Accordingly, the 2022 American College of Rheumatology guidelines provide a strong recommendation for regular exercise in patients with rheumatoid arthritis to improve physical function and pain, representing the only strong recommendation among integrative interventions.⁵⁶

Broad evidence supports the benefits of PA in axial SpA. Multi-society guidelines for ankylosing spondylitis and non-radiographic axial SpA strongly recommend PT over no PT.⁵⁷ These guidelines also favor active interventions, such as supervised exercise, over passive modalities, and land-based over aquatic programs.⁵⁷ Further, while home-based programs have been shown to improve quality of life, fatigue, pain, mobility, and disease activity, supervised exercise has demonstrated greater efficacy.^58–61 The findings of several small studies highlight the potential role of supervised, PT-guided exercise programs in improving joint range of motion and physical function and reducing pain and disability among older adults with IBD.^62–65

IBD-Related Excessive Fatigue

Excessive exertional fatigue, or disproportionate fatigue in response to energy expended, is common among individuals with IBD, affecting >80% of patients with active disease and 40–60% of those with inactive or mild disease.⁶⁶ In one survey, while 66% of IBD patients reported fatigue as a daily concern, only 36% of physicians recognized its impact.⁶⁷ Physiologic factors contributing to excessive fatigue may include increased skeletal muscle fatigability, reduced working capacity, and micronutrient deficiencies, and may disproportionately affect older adults.^36,68 Recent literature also suggests that fatigue perception in quiescent Crohn’s disease and other chronic inflammatory conditions may reflect changes in cerebral and peripheral muscle mechanisms, rather than differences in body composition or muscle strength.

Emerging evidence demonstrates the benefits of SE and PT on IBD-related excessive exertional fatigue outcomes. A longitudinal survey study of patients with Crohn’s disease found that initiation of routine SE was independently associated with improved physical fatigue.⁶⁹ Further, Van Erp et al. conducted a PT supervised, 12-week, 60-min, 3x/week, AE + RE program in 22 IBD patients with severe fatigue. Participants in the individualized, moderate-intensity training protocol demonstrated significant improvements in heart rate recovery, body fat percentage, and fatigue scores on a validated questionnaire.⁷⁰ Even brief interventions may be beneficial. In a randomized controlled, double-blind trial, a 4-week, 15-min, 6x/week, home-based core-based exercise video program significantly improved fatigue in patients with mild-to-moderate IBD compared with general range-of-motion and bodyweight exercises.⁷¹

IBD-Associated Sarcopenia, Frailty, Bone Health

Sarcopenia and frailty are highly prevalent among aging and older adults with IBD, occurring at roughly twice the rate of age-matched controls.^72,73 Sarcopenia affects approximately 40% of adults with IBD, and has been shown to be a predictor of adverse postoperative outcomes.⁷⁴ Compared to healthy controls, individuals with IBD demonstrate significantly reduced quadricep strength, handgrip strength, gait speed, and sit-to-stand performance.^7,75,76

Available evidence suggests SE and PT may prevent and mitigate the effects of sarcopenia and frailty in IBD. A 16-week, 60 minute, 2x/week uncontrolled trial for IBD patients without musculoskeletal EIMs (mean age 50 years) showed that participants significantly improved muscle mass, lower body strength and coordination, speed, and endurance after their individually tailored progressive program.⁷⁷ Similarly, an 8-week, RE + whey protein versus RE + placebo RCT among IBD patients with sarcopenia demonstrated significant improvements in appendicular skeletal muscle mass and nutritional markers, though functional measures including handgrip strength, sit-to-stand, and walk test did not improve.⁷⁸ These findings are consistent with broader evidence in sarcopenia supporting resistance and balance training combined with protein supplementation as the most effective strategy for improving muscle mass, gait speed, and physical function.⁷⁹ This latter finding reflects the importance of understanding exercise specificity and underscores the need for skilled exercise professional inclusion in SE research design and execution.

Reductions in muscle mass and bone mineral density (BMD) may occur simultaneously.⁸⁰ Low BMD affects 14–42% of IBD patients.⁸¹ Two RCTs in patients with CD suggest RE may assist in preventing clinical BMD loss in IBD patients without osteopenia. A 52-week, 2x/week progressive, low-impact RE home RCT in 107 CD patients (mean age 41 years) without bone loss found that fully adherent participants achieved significant BMD gains, including a 7.7% improvement at the greater trochanter.⁸² BMD gains were positively associated with session volume, independent of corticosteroid use, diet, and body weight.⁸² A second 24-week, 60-min, 3x/week RE + impact RCT in 47 CD patients (mean age 49 years) demonstrated a significant median improvement in lumbar spine BMD (3.8%) compared to controls.⁸³ Notably, these exercise-induced improvements appear comparable to those observed with oral bisphosphonates, suggesting that combining exercise and pharmacologic interventions may offer compounding benefits.⁸⁴ Larger studies, particularly in older adults with IBD and low BMD are needed.

Practical Considerations for the Practicing Gastroenterologist

Despite a majority of adults with IBD reporting that IBD limits their PA and nearly 70% expressing motivation to change their activity habits, 98% of IBD healthcare professionals reported feeling insufficiently informed on PA, exercise, and PT.^18,29,85 Guideline recommendations support SE and PT for their demonstrated benefits across perioperative outcomes, persistent pelvic floor dysfunction, arthropathies, fatigue, sarcopenia, and bone loss, as summarized in Table 1. Addressing this gap through focused screening, thoughtful interview, and appropriate referral to PT with individualized exercise programs and ongoing patient monitoring (Figure 1) may improve patient exercise ability and exercise consistency, thereby preventing functional decline before it occurs.

Table 1:

Physician’s Reference Guide: SE and PT in Older Adults with IBD

IBD-Associated Condition / Physical Function Deficit	Guideline Source (If Applicable)	Recommendation for Aging and Older Adults with IBD	Sample of Physical Function Screening Tools
General Physical Function	IOIBD: STRIDE II34	Long-term treatment targets should include the absence of disability and normalized health-related quality of life	Patient interview IBD Questionnaire (IBDQ) IBD-Disability Index *Baecke Physical Activity Questionnaire6 **60-Second Sit-to-Stand Test76
	GETECCU92	A systematic, comprehensive assessment to detect functional deficits is recommended for IBD patients of advanced age and those with suspected frailty Specific interventions for functional rehabilitation are recommended for IBD patients with functional deficits
Perioperative Functional Deficits	ECCO: Roadmap to Optimal Perioperative Care in IBD38	Recommend ≥4 weeks individualized, multimodal prehabilitation (PT, RD, psychosocial support) and postoperative rehabilitation for IBD patients with physical function limitations (Low Evidence)	General Physical Function Screening Arthropathy and Joint Pain Screening Sarcopenia Screening Frailty Screening
	ASCRS39,40	Recommend ≥4 weeks PT, RD, psychosocial prehabilitation for patients with frailty (Grade 1B) Recommend prehabilitation for patients with multiple comorbidities or deconditioning (Grade 2B)
Pelvic Floor Dysfunction		Persistent pelvic floor dysfunction in the absence of active inflammation, infection, or abscess may be referred to PT specialists with pelvic rehabilitation certification45,46,53	Anorectal Manometry St. Mark’s Fecal Incontinence Score Patient Assessment of Constipation Symptoms Pain Visual Analog Scale
Arthropathies and Joint Pain	ACR/SAA57	Strongly recommend PT over no PT for IBD patients with active ankylosing spondylitis	†IBIS-Q DETAIL questionnaire Quiero axial and peripheral questionnaires STR II TASQ-IBD93 Refer to PT in consultation with rheumatology
	NICE Guidance On Spondyloarthritis94	Recommend axial SpA referral to PT specialistRecommend SpA referral to PT/OT specialists for functional impairments, ADL difficulties, or work-related limitations, including: Exercise, stretching, joint protection Pain and fatigue management
	CDC Clinical Practice Guideline for Prescribing Opioids for Chronic Pain95	PT can improve pain and function without risk of serious harm for back pain, fibromyalgia, and arthritis (Category A, Evidence Type 2)	Consider complementary PT referral in consultation with specialists to assist in tapering opioid medication dosage
Excessive Fatigue			IBD-Fatigue Questionnaire96 Fatigue Short Form 7a97 Checklist Individual Strength – Fatigue (CIS-F)76 **60-Second Sit-to-Stand Test76
Muscle Loss (Sarcopenia)	ICFSR: Older Adults with Sarcopenia87	Strongly recommend resistance-based activity for older adults with sarcopenia (Strong Recommendation, High Evidence)	DEXA: Lean Mass + Fat-Free Mass Evaluation ***Walking Speed **60-Second Sit-to-Stand Test76
Bone Loss (Osteoporosis)	AACE/ACCE Guidelines for Diagnosis and Treatment of Postmenopausal Osteoporosis98	Consider referring women with postmenopausal osteoporosis to PT: may reduce discomfort, prevent falls, and improve quality of life (Grade A)	DEXA Bone Mineral Density Testing
	APTA: Physical Therapist Management of Patients with Suspected or Confirmed Osteoporosis	Recommend premenopausal women participate in: Progressive RE + Impact Training Recommend postmenopausal women and those with confirmed osteoporosis at the hip/femoral neck participate in: Progressive RE alone, or add Impact Training if safe Recommend postmenopausal women with osteoporosis at the lumbar spine participate in: Progressive RE, Tai Chi (Grade B, Moderate Evidence)
	NOGG Clinical Guideline for Prevention and Treatment of Osteoporosis99	Recommend postmenopausal women and men ≥50 years with osteoporosis or at risk of fragility fracture participate in regular weight-bearing and muscle-strengthening exercise, tailored to individual needs and ability (Strong Recommendation) Recommend falls assessment in all patients with osteoporosis and fragility fractures; those at risk should be offered balance exercise programs and/or combined exercise protocols (Strong Recommendation)
Frailty	ICFSR International Clinical Practice Guidelines for Identification and Management of Frailty87	Strongly recommend pre-frail older adults are referred to activity programs with progressive resistance training Strongly recommend frail older adults are referred to multicomponent progressive training with resistance training (Strong Recommendation, Moderate Evidence)	Clinical Frailty Score ≥492 Fried Frailty Index ≥2/5100 FRAIL Scale101

Abbreviations

AACE: American Association of Clinical Endocrinologists; ACCE: American College of Clinical Endocrinology; ACR: American College of Rheumatology; ADL: Activities of Daily Living; APTA: American Physical Therapy Association; ASCRS: American Society of Colon and Rectal Surgeons; CDC: Centers for Disease Control and Prevention; CIS-F: Checklist Individual Strength – Fatigue subscale; DETAIL: DETection of Arthritis in Inflammatory boweL diseases; DEXA: Dual-Energy X-ray Absorptiometry; ECCO: European Crohn’s and Colitis Organization; GETECCU: Spanish Group for Working on Crohn’s Disease and Ulcerative Colitis; IBDQ: IBD Questionnaire; IBIS-Q: IBD Identification of Spondyloarthritis Questionnaire; ICFSR: International Conference on Frailty and Sarcopenia Research; IOIBD: International Organization for the Study of IBD; NICE: National Institute for Health and Care Excellence (UK); NOGG: National Osteoporosis Guideline Group (UK); OT: Occupational Therapy; PT: Physical Therapy / Physical Therapist; RD: Registered Dietitian; RE: Resistance Exercise; SAA: Spondylitis Association of America; SE: Structured Exercise; SpA: Spondyloarthritis; STR II: Screening Tool for Rheumatologic Investigation in Inflammatory Bowel Disease; STRIDE: Selecting Therapeutic Targets in IBD; TASQ-IBD: Toronto Axial Spondyloarthritis Questionnaire on IBD

Notes

^*Baecke Physical Activity Questionnaire: accurate in IBD patients with inactive or mild-to-moderate disease compared to accelerometry data

^**60-Second Sit-to-Stand Test: validated in small IBD cohort compared to VO₂peak and lower extremity strength dynamometry testing

^***Gait speed: ≥0.8 m/s is considered safe community ambulation; ≥0.4 m/s is safe household ambulation

^†IBIS-Q, DETAIL, Quiero axial and peripheral questionnaires, STR II, and TASQ-IBD: direct comparison between arthropathy screening tools is limited by methodological heterogeneity; the IBIS-Q has the most evidence in IBD populations⁹³

Figure 1. Physician Screening and Referral Algorithm for Older Adults with IBD.

*Safe activities: low-to-moderate intensity AE, gradually increase duration and intensity to tolerance, avoid high-intensity exercise during active disease, and consider behavioral health referral if ongoing activity avoidance.

Abbreviations

AE: Aerobic Exercise; PACC: Pelvic floor Advanced Competency Certification; PRPC: Pelvic Rehabilitation Practitioner Certification; PT: Physical Therapy / Physical Therapist; RD: Registered Dietitian; RE: Resistance Exercise; WCS: Women’s Clinical Specialist

Assessment of physical function deficits, including muscular function and pre-clinical and clinical frailty screening tools can identify patients who would benefit from PT evaluation. Though optimal frailty measures for individuals with IBD are still being determined through ongoing research, the American Academy of Family Physicians recommends screening patients over 60 years and those with risk factors including social isolation, low socioeconomic status, or comorbidities such as diabetes, chronic obstructive pulmonary disease, stroke, osteoarthritis, or connective tissue disorders. In both academic and stand-alone practices, pre-visit patient questionnaires administered via patient portal or by paper form can capture functional limitations and exercise barriers prior to the visit. Physical function screening tests such as the grip strength test and 60-second sit-to-stand may also be performed by trained ancillary staff during intake, as resources allow. Patients identified as pre-frail or frail should then be referred to multi-component, progressive, supervised PT training which includes RE and, ideally, nutritional optimization.^86,87

Beyond frailty, the presence of specific deficits or pain should prompt formal PT referral rather than general physical activity counseling (Figure 1). It is important not only to conduct a thorough review of symptoms, but also to specifically ask older adults about sexual dysfunction and fatigue, both of which may respond to dedicated PT intervention. Additionally, inquiring about barriers to exercise is essential, as addressing IBD-related exercise fears and improving exercise knowledge via PT referral can improve exercise consistency, outcomes, quality of life and health-span. Physicians should also recognize that grief over lost physical capacity may underlie resistance to activity recommendations, and behavioral health referral may complement PT in those cases.⁸⁸ For patients who may not warrant or may not be interested in PT, safe PA counseling and symptom monitoring for new or worsening symptoms should still be provided. Patients new to exercise or returning to exercise after a long illness may also benefit from PT counseling, prescription, and exercise monitoring.

Physicians should be aware that cost may represent a barrier to PT access, though PT is covered by the majority of U.S. insurance plans with an allotted number of visits per year. Following referral, PT practices manage prior authorizations independently based on documented medical necessity. For patients with limited coverage, clear documentation of functional limitations supports necessity determinations and appeals for additional visits. Group PT classes and community-based programs may serve as lower-cost alternatives.

Depending upon their functional impairment, patients who are not interested in PT may be encouraged to participate in AE and RE on nonconsecutive days, gradually increasing the duration, number of exercises, and intensity to tolerance. Exceptions include cases in which participation would be unsafe, such as exercising with balance deficits in the absence of appropriate supervision or beginning a resistance program with joint or muscle pain without specialist evaluation. Older adults with chronic diseases, including IBD, have been found to benefit from as little as 2 days/week, 30min, of moderate-intensity AE and RE. For example, 5–10 min of walking along with basic body-weight chair stands, wall push-ups, and bridge exercises are an excellent start. If any new or worsening musculoskeletal pain is experienced, patients should stop and contact their physician for guidance. For patients who are successfully exercising independently, a brief reminder to incorporate RE 2 days/week for muscle and bone health may be appropriate.

Conclusion

Aging and older adults with IBD experience a disproportionate burden of physical symptoms due to the combined effects of chronic disease and age-related inflammation. SE and PT have demonstrated benefit across multiple domains including persistent pelvic floor dysfunction, joint pain, fatigue, muscle loss, bone loss, functional capacity, frailty, and disability. While IBD-specific data remain limited, findings are promising. Importantly, these deficits are not exclusive to older adults, as addressing developing functional impairments earlier in life may slow the trajectory towards frailty and improve long-term outcomes in patients with IBD. Gastroenterologists are uniquely positioned to identify functional impairments early through routine functional screening, with targeted PT referrals representing a practical and impactful intervention. As the IBD population continues to age, and the field advances beyond pharmacologic innovation alone, PTs (like registered dietitians and mental health professionals) must be recognized as essential members of the IBD care team, with accessible referral pathways to facilitate timely intervention. Larger, multidisciplinary, prospective trials of SE and PT-based interventions are urgently needed in the growing older adult IBD population to establish evidence-based care standards.

Key Points.

• Older adults with IBD are at disproportionate risk of functional decline due to chronic inflammation, malnutrition, and EIMs, which can accelerate frailty in this population.

• Structured exercise and physical therapy are low-cost and low-risk interventions that meaningfully improve function, symptoms, and quality of life in older adults with IBD, yet remain underused in routine care.

• Evidence supports the use of structured exercise and physical therapy across multiple domains including fatigue, arthropathy, pelvic floor dysfunction, bone loss, and perioperative outcomes.

• Gastroenterologists can implement condition-specific screening to trigger targeted PT referral pathways, particularly for older adults with identified functional deficits or frailty.

• Intervening before overt frailty or disability across the IBD lifespan may alter trajectory and improve long-term outcomes.