Exercise in cirrhosis: Translating evidence and experience to practice

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.

Review article: malnutrition/sarcopenia and frailty in patients with cirrhosis

“…Physical inactivity and frailty are highly prevalent, independent predictors of morbidity and mortality in patients with cirrhosis . Consistent with the broader chronic disease literature, the experimental and clinical evidence for a benefit of exercise in cirrhosis is promising.…”

“…Consistent with the broader chronic disease literature, the experimental and clinical evidence for a benefit of exercise in cirrhosis is promising. Several small clinical trials have demonstrated significant improvements in muscle health (mass, strength, functional capacity), quality of life, fatigue, cardiopulmonary fitness and reductions in the hepatic venous pressure gradient, without adverse events . Unfortunately, most patients (63%‐92%) included in these trials were cirrhosis CP‐A, while patients at the lower end of physical deconditioning (CP‐B/C) have not been evaluated systematically so far .…”

“…Patients with cirrhosis, whenever possible, can be encouraged to avoid hypomobility and to progressively increase physical activity to prevent and/or ameliorate sarcopenia . It is reasonable to recommend 30‐to‐60‐minute sessions of supervised moderated intensity exercise combining both aerobic and resistance training to achieve ≥150 min/wk for cirrhotic patients . Aerobic training would be particularly relevant to improve overall fitness, while resistance training would help reverse sarcopenia, improve strength and balance, and bone mineral density .…”

The Gain Is Worth the Pain: Home‐Based Exercise in Liver Transplantation

“…As with efforts to enhance muscle mass in other wasting conditions, empiric interventions to improve physical performance through exercise, nutrition, pharmacotherapy, and behavioral support have been used . Williams et al in the current issue of Liver Transplantation assess the value of a home‐based exercise program (HBEP) …”

Growing muscle against cirrhosis: In the quest for models to revealing mechanisms

“…As in many chronic diseases, sarcopaenia—the loss of muscle mass and strength—represents a major complication of chronic liver disease, being recognized in up to 30%‐70% of these patients . Regardless of such variable prevalence, sarcopaenia is now a well‐recognized predictor of poor outcomes in patients with cirrhosis, including low quality of life and increased morbidity (infections, hepatic encephalopathy) and mortality, even after liver transplantation . The coexistence of sarcopaenia and obesity, common in patients with non‐alcoholic fatty liver disease, further worsens the prognosis .…”