Exercise in cirrhosis: Translating evidence and experience to practice
Author(s): ,
Margaret McNeely
Physical Therapy, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
Deborah Ann Josbeno
University of Pittsburgh, School of Health and Rehabilitation Sciences, Department of Physical Therapy, Pittsburgh, PA, USA
Mark Joseph Franklin Haykowsky
Integrated Cardiovascular Exercise Physiology and Rehabilitation (iCARE) Laboratory, College of Nursing and Health Innovation, The University of Texas Arlington, Arlington, TX, USA
Nancy Howes
London Health Sciences Centre, London, ON, Canada
Jennifer Holman
Transplant Centre, University of Alberta Hospital, Alberta Health Services, Edmonton, AB, Canada
Michael Andrew Dunn
Center for Liver Diseases, Thomas E Starzl Transplantation Institute and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
Bandar Al-Judaibi
Medicine, School of Medicine & Dentistry, University of Rochester, Rochester, NY, USA
Andres Duarte-Rojo
Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
Kenneth Riess
Physical Therapy, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
Kathleen Patricia Ismond
Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
Puneeta Tandon
Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
Corresponding author. Address: Zeidler Centre, 8540-112th Street, Edmonton, AB T6G 2X8, Canada.
EASL LiverTree™. Tandon P. 11/01/18; 234550
Dr. Puneeta Tandon
Dr. Puneeta Tandon
Journal Abstract

Physical inactivity, sarcopenia, and frailty are highly prevalent, independent predictors of morbidity and mortality in patients with cirrhosis. Across a range of chronic diseases, exercise training is a key recommendation supported by guidelines and, for some conditions, even by governmental funding of exercise programmes. Consistent with the broader chronic disease literature, the evidence for a benefit of exercise in cirrhosis is promising. Several small trials have reported significant improvements in muscle health (mass, strength, functional capacity), quality of life, fatigue, and reductions in the hepatic venous pressure gradient, without adverse events. With strong emerging evidence surrounding the substantial risks of sarcopenia/frailty and our first-hand experiences with liver pre-transplant exercise programmes, we contend that routine patient care in cirrhosis should include an exercise prescription. Some clinicians may lack the resources and necessary background to translate the existing evidence into a practicable intervention. Our team, comprised of physiotherapists, exercise physiologists, hepatologists, transplant specialists, and knowledge translation experts from six North American centres, has distilled the essential background information, tools, and practices into a set of information ready for immediate implementation into clinics ranging from a family practice setting to specialty cirrhosis clinics. Augmenting the rationale and evidence are supplementary materials including video and downloadable materials for both patients and the physician. Supporting the exercising patient is a section regarding information about nutrition, providing practical tips suitable for all patients with cirrhosis.

Physical activity, End-stage liver disease, Pre-transplant candidate, 6-min walk test, Pre-habilitation, Frailty, Sarcopenia, Nutrition
[1]. G. Moore - ACSMs exercise management for persons with chronic diseases and disabilities
[2]. N. Galie - Exercise training in pulmonary hypertension: improving performance but waiting for outcome
[3]. K.H. Schmitz - American College of Sports Medicine roundtable on exercise guidelines for cancer survivors
[4]. L. Wickerson - Physical rehabilitation for lung transplant candidates and recipients: an evidence-informed clinical approach
[5]. R.J. Thomas - Performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services
[6]. H.-W. Chen - Arresting frailty and sarcopenia in cirrhosis: future prospects
[7]. S. Mathur - Meeting report: consensus recommendations for a research agenda in exercise in solid organ transplantation
[8]. J.C. Garcia-Pagan - Physical exercise increases portal pressure in patients with cirrhosis and portal hypertension
[9]. J.C. Bandi - Effects of propranolol on the hepatic hemodynamic response to physical exercise in patients with cirrhosis
[10]. R. Brustia - Physical exercise in cirrhotic patients: towards prehabilitation on waiting list for liver transplantation. A systematic review and meta-analysis
[11]. A. Duarte-Rojo - Exercise and physical activity for patients with end-stage liver disease: Improving functional status and sarcopenia while on the transplant waiting list
[12]. J.C. Jones - Exercise capacity and muscle strength in patients with cirrhosis
[13]. M.A. Dunn - The gap between clinically assessed physical performance and objective physical activity in liver transplant candidates
[14]. M.P. Wallen - Safety, adherence and efficacy of exercise training in solid-organ transplant candidates: a systematic review
[15]. M. Ney - Patient-perceived barriers to lifestyle interventions in cirrhosis
[16]. T. Trojetto - Availability, characteristics, and barriers of rehabilitation programs in organ transplant populations across Canada
[17]. A. Biswas - Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis
[18]. W. Liu - Myostatin is a skeletal muscle target of growth hormone anabolic action
[19]. K.M. Lakshman - Measurement of myostatin concentrations in human serum: Circulating concentrations in young and older men and effects of testosterone administration
[20]. M. Merli - MuRF-1 and p-GSK3beta expression in muscle atrophy of cirrhosis
[21]. M. Sinclair - Low serum testosterone is associated with adverse outcome in men with cirrhosis independent of the model for end-stage liver disease score
[22]. V.C. Mazurak - Nutrition and the transplant candidate
[23]. J. Meza-Junco - Sarcopenia as a prognostic index of nutritional status in concurrent cirrhosis and hepatocellular carcinoma
[24]. A.J. Montano-Loza - Muscle wasting is associated with mortality in patients with cirrhosis
[25]. T. Masuda - Sarcopenia is a prognostic factor in living donor liver transplantation
[26]. J.L. van Vugt - Systematic review and meta-analysis of the impact of computed tomography-assessed skeletal muscle mass on outcome in patients awaiting or undergoing liver transplantation
[27]. E.J. Carey - A multicenter study to define sarcopenia in patients with end-stage liver disease
[28]. R.J. Cruz - Objective radiologic assessment of body composition in patients with end-stage liver disease: going beyond the BMI
[29]. A. DiMartini - Muscle mass predicts outcomes following liver transplantation
[30]. M.J. Englesbe - Sarcopenia and mortality after liver transplantation
[31]. P. Tandon - Severe muscle depletion in patients on the liver transplant wait list: its prevalence and independent prognostic value
[32]. F. Durand - Prognostic value of muscle atrophy in cirrhosis using psoas muscle thickness on computed tomography
[33]. A.J. Montano-Loza - Inclusion of sarcopenia within MELD (MELD-sarcopenia) and the prediction of mortality in patients with cirrhosis
[34]. J.L.A. van Vugt - A model including sarcopenia surpasses the MELD score in predicting waiting list mortality in cirrhotic liver transplant candidates: a competing risk analysis in a national cohort
[35]. J.L.A. van Vugt - Low skeletal muscle mass is associated with increased hospital costs in patients with cirrhosis listed for liver transplantation-a retrospective study
[36]. S. Dharancy - Impact of impaired aerobic capacity on liver transplant candidates
[37]. H.F. Alameri - Six Minute Walk Test to assess functional capacity in chronic liver disease patients
[38]. E.J. Carey - Six-minute walk distance predicts mortality in liver transplant candidates
[39]. M. Ney - Systematic review: pre- and post-operative prognostic value of cardiopulmonary exercise testing in liver transplant candidates
[40]. A. Yadav - Relationship between sarcopenia, six-minute walk distance and health-related quality of life in liver transplant candidates
[41]. D.E. Forman - Prioritizing functional capacity as a principal end point for therapies oriented to older adults with cardiovascular disease: a scientific statement for healthcare professionals from the American Heart Association
[42]. R.U. Macias-Rodriguez - Changes in hepatic venous pressure gradient induced by physical exercise in cirrhosis: results of a pilot randomized open clinical trial
[43]. A. Berzigotti - Effects of an intensive lifestyle intervention program on portal hypertension in patients with cirrhosis and obesity: The SportDiet study
[44]. C. Kruger - Home exercise training improves exercise capacity in cirrhosis patients: role of exercise adherence
[45]. A. Hiraoka - Efficacy of branched-chain amino acid supplementation and walking exercise for preventing sarcopenia in patients with liver cirrhosis
[46]. G. Borg - Physical work and effort
[47]. R. de Franchis - Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension
[48]. G. Garcia-Tsao - Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases
[49]. J. Browne - Focus on exercise: client and clinician perspectives on exercise in individuals with serious mental illness
[50]. T.M. Jones - MyMoves program: feasibility and acceptability study of a remotely delivered self-management program for increasing physical activity among adults with acquired brain injury living in the community
[51]. V. van der Wardt - Adherence support strategies for exercise interventions in people with mild cognitive impairment and dementia: a systematic review
[52]. K. Ibanez - Safety and feasibility of rehabilitation interventions in children undergoing hematopoietic stem cell transplant with thrombocytopenia
[53]. L.S. Pescatello - Highlights from the functional single nucleotide polymorphisms associated with human muscle size and strength or FAMuSS study
[54]. D. Riebe - Updating ACSM’s recommendations for exercise preparticipation health screening
[55]. S.R. Colberg - Physical activity/exercise and diabetes: a position statement of the american diabetes association
[56]. G. Ezaz - Increased morbidity and mortality associated with falls among patients with cirrhosis
[57]. A. Urios - Altered postural control and stability in cirrhotic patients with minimal hepatic encephalopathy correlate with cognitive deficits
[58]. M.C. Nevitt - Risk factors for recurrent nonsyncopal falls. A prospective study
[59]. M. Speechley - Falls and injuries in frail and vigorous community elderly persons
[60]. M.M. Lusardi - Determining risk of falls in community dwelling older adults: a systematic review and meta-analysis using posttest probability
[61]. F. El-Khoury - The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials
[62]. L.D. Gillespie - Interventions for preventing falls in older people living in the community
[63]. V. Weerdesteyn - A five-week exercise program can reduce falls and improve obstacle avoidance in the elderly
[64]. E. Roman - Effects of an exercise programme on functional capacity, body composition and risk of falls in patients with cirrhosis: a randomized clinical trial
[65]. J.C. Lai - Development of a novel frailty index to predict mortality in patients with end-stage liver disease
[66]. J.C. Lai - The liver frailty index improves mortality prediction of the subjective clinician assessment in patients with cirrhosis
[67]. P. Tandon - A rapid bedside screen to predict unplanned hospitalization and death in outpatients with cirrhosis: a prospective evaluation of the clinical frailty scale
[68]. M. Sinclair - Frailty is independently associated with increased hospitalisation days in patients on the liver transplant waitlist
[69]. E.B. Tapper - Standard assessments of frailty are validated predictors of mortality in hospitalized patients with cirrhosis
[70]. L.A. Fleisher - 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
[71]. J. Alonso - Measuring functional status of chronic coronary patients. Reliability, validity and responsiveness to clinical change of the reduced version of the Duke Activity Status Index (DASI)
[72]. R. Arena - Using the Duke Activity Status Index in heart failure
[73]. R. Carter - Criterion validity of the Duke Activity Status Index for assessing functional capacity in patients with chronic obstructive pulmonary disease
[74]. P. Ravani - The Duke Activity Status Index in patients with chronic kidney disease: a reliability study
[75]. R.A. Gary - Combined aerobic and resistance exercise program improves task performance in patients with heart failure
[76]. S. Volpato - Predictive value of the Short Physical Performance Battery following hospitalization in older patients
[77]. J. Verghese - Quantitative gait markers and incident fall risk in older adults
[78]. L.J. Viccaro - Is timed up and go better than gait speed in predicting health, function, and falls in older adults?
[79]. M.A. Dunn - Frailty as tested by gait speed is an independent risk factor for cirrhosis complications that require hospitalization
[80]. G. Abellan van Kan - Gait speed at usual pace as a predictor of adverse outcomes in community-dwelling older people an International Academy on Nutrition and Aging (IANA) Task Force
[81]. P. Tandon - A practical approach to nutritional screening and assessment in cirrhosis
[82]. B.H. Goodpaster - The loss of skeletal muscle strength, mass, and quality in older adults: the health, aging and body composition study
[83]. C.W. Wang - A comparison of muscle function, mass, and quality in liver transplant candidates: results from the functional assessment in liver transplantation study
[84]. A.J. Montano-Loza - Sarcopenic obesity and myosteatosis are associated with higher mortality in patients with cirrhosis
[85]. S. Dasarathy - Sarcopenia from mechanism to diagnosis and treatment in liver disease
[86]. F.M. Malini - Prevalence of fear of falling in older adults, and its associations with clinical, functional and psychosocial factors: the Frailty in Brazilian Older People-Rio de Janeiro study
[87]. S. Rochat - What is the relationship between fear of falling and gait in well-functioning older persons aged 65 to 70 years?
[88]. Z.A. Puthucheary - Acute skeletal muscle wasting in critical illness
[89]. L. Zenith - Eight weeks of exercise training increases aerobic capacity and muscle mass and reduces fatigue in patients with cirrhosis
[90]. M.K. Bean - Motivational interviewing targeting diet and physical activity improves adherence to pediatric obesity treatment: results from the MI Values randomized controlled trial
[91]. C. Bouchard - The response to exercise with constant energy intake in identical twins
[92]. P.A. Villablanca - Nonexercise activity thermogenesis in obesity management
[93]. R.N. Butler - Physical fitness: benefits of exercise for the older patient
[94]. P. Tandon - The nutrition in cirrhosis guide
[95]. P. Amodio - The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus
[96]. S.M. Robinson - Does nutrition play a role in the prevention and management of sarcopenia?
[97]. M. Ney - Insufficient protein intake is associated with increased mortality in 630 patients with cirrhosis awaiting liver transplantation
[98]. D.K. Houston - Dietary protein intake is associated with lean mass change in older, community-dwelling adults: the Health, Aging, and Body Composition (Health ABC) Study
[99]. R.R. McLean - Dietary protein intake is protective against loss of grip strength among older adults in the Framingham offspring cohort
[100]. G. Marchesini - Nutritional supplementation with branched-chain amino acids in advanced cirrhosis
[101]. Y. Muto - Effects of oral branched-chain amino acid granules on event-free survival in patients with liver cirrhosis
[102]. T. Kawaguchi - Branched-chain amino acids as pharmacological nutrients in chronic liver disease
[103]. M. Plauth - ESPEN guidelines on enteral nutrition: liver disease
[104]. O.E. Owen - Hepatic, gut, and renal substrate flux rates in patients with hepatic cirrhosis
[105]. L.D. Plank - Nocturnal nutritional supplementation improves total body protein status of patients with liver cirrhosis: a randomized 12-month trial
[106]. C.D. Tsien - Late evening snack: exploiting a period of anabolic opportunity in cirrhosis
[107]. C.M. Kerksick - International society of sports nutrition position stand: nutrient timing
[108]. R. Jager - International Society of Sports Nutrition Position Stand: protein and exercise
[109]. R. Dalle Grave - Cognitive-behavioral strategies to increase the adherence to exercise in the management of obesity
[110]. K. Shaw - Psychological interventions for overweight or obesity
[111]. L.L. Gluud - Branched-chain amino acids for people with hepatic encephalopathy
[112]. M. Holecek - Branched-chain amino acid supplementation in treatment of liver cirrhosis: updated views on how to attenuate their harmful effects on cataplerosis and ammonia formation
[113]. A.R. Rinnov - Impaired follistatin secretion in cirrhosis
[114]. S. Dasarathy - Sarcopenia associated with portosystemic shunting is reversed by follistatin
[115]. J.R. Mendell - Follistatin gene therapy for sporadic inclusion body myositis improves functional outcomes
[116]. M. Sinclair - Testosterone therapy increases muscle mass in men with cirrhosis and low testosterone: a randomised controlled trial
[117]. A. Ticinesi - Aging gut microbiota at the cross-road between nutrition, physical frailty, and sarcopenia: is there a gut-muscle axis?
[118]. C. de Labra - Effects of physical exercise interventions in frail older adults: a systematic review of randomized controlled trials
[119]. E. Dent - The Asia-Pacific clinical practice guidelines for the management of frailty
[120]. M. Pahor - Effect of structured physical activity on prevention of major mobility disability in older adults: the LIFE study randomized clinical trial
[121]. M. Hoffman - Effects of pulmonary rehabilitation in lung transplant candidates: a systematic review
[122]. E.M. Minnella - Multimodal prehabilitation improves functional capacity before and after colorectal surgery for cancer: a five-year research experience
[123]. E. Roman - Randomized pilot study: effects of an exercise programme and leucine supplementation in patients with cirrhosis
[124]. M. Debette-Gratien - Personalized adapted physical activity before liver transplantation: acceptability and results
[125]. M.N. Sawka - American College of Sports Medicine position stand. Exercise and fluid replacement
[126]. V. DiLillo - Incorporating motivational interviewing into behavioral obesity treatment

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