Home Exercise Training Improves Exercise Capacity in Cirrhosis Patients: Role of Exercise Adherence
Calvin Kruger, Margaret L McNeely, Robert J Bailey, Milad Yavari, Juan G Abraldes, Michelle Carbonneau, Kim Newnham, Vanessa DenHeyer, Mang Ma, Richard Thompson, Ian Paterson, Mark J Haykowsky, Puneeta Tandon, Calvin Kruger, Margaret L McNeely, Robert J Bailey, Milad Yavari, Juan G Abraldes, Michelle Carbonneau, Kim Newnham, Vanessa DenHeyer, Mang Ma, Richard Thompson, Ian Paterson, Mark J Haykowsky, Puneeta Tandon
Abstract
Cirrhosis patients have reduced peak aerobic power (peak VO2) that is associated with reduced survival. Supervised exercise training increases exercise tolerance. The effect of home-based exercise training (HET) in cirrhosis is unknown. The objective was to evaluate the safety and efficacy of 8 weeks of HET on peak VO2, 6-minute walk distance (6MWD), muscle mass, and quality of life in cirrhosis. Random assignment to 8 weeks of HET (moderate to high intensity cycling exercise, 3 days/week) or usual care. Exercise adherence defined as completing ≥80% training sessions. Paired t-tests and analysis of covariance used for comparisons. Forty patients enrolled: 58% male, mean age 57 y, 70% Child Pugh-A. Between group increases in peak VO2 (1.7, 95% CI: -0.33 to 3.7 ml/kg/min, p = 0.09) and 6MWD (33.7, 95% CI: 5.1 to 62.4 m, p = 0.02) were greater after HET versus usual care. Improvements even more marked in adherent subjects for peak VO2 (2.8, 95% CI: 0.5-5.2 mL/kg/min, p = 0.02) and 6MWD (46.4, 95% CI: 12.4-80.5 m, p = 0.009). No adverse events occurred during testing or HET. Eight weeks of HET is a safe and effective intervention to improve exercise capacity in cirrhosis, with maximal benefits occurring in those who complete ≥80% of the program.
Conflict of interest statement
The authors declare that they have no competing interests.
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References
- D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis. A systematic review of 118 studies. J Hepatol. 2006;44:217–231. doi: 10.1016/j.jhep.2005.10.013.
- Tandon, P. et al. A Rapid Bedside Screen to Predict Unplanned Hospitalization and Death in Outpatients With Cirrhosis: A Prospective Evaluation of the Clinical Frailty Scale. Am J Gastroenterol, 10.1038/ajg.2016.303 (2016).
- Lai JC, et al. Frailty predicts waitlist mortality in liver transplant candidates. American journal of transplantation: official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2014;14:1870–1879. doi: 10.1111/ajt.12762.
- Montano-Loza AJ, et al. Muscle Wasting Is Associated With Mortality in Patients With Cirrhosis. Clin.Gastroenterol.Hepatol. 2012;10:166–173. doi: 10.1016/j.cgh.2011.08.028.
- Tandon P, et al. Severe muscle depletion in patients on the liver transplant wait list - its prevalence and independent prognostic value. Liver Transpl. 2012;18:1209–1216. doi: 10.1002/lt.23495.
- Nathan J, Fuld J. Skeletal muscle dysfunction: a ubiquitous outcome in chronic disease? Thorax. 2010;65:97–98. doi: 10.1136/thx.2009.120824.
- Montano-Loza AJ. Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation. Liver Transpl. 2014;20:1424. doi: 10.1002/lt.23978.
- Lemyze, M., Dharancy, S. & Wallaert, B. Response to exercise in patients with liver cirrhosis: Implications for liver transplantation. Dig Liver Dis, 10.1016/j.dld.2012.09.022 (2012).
- Neviere RE, et al. Implications of Preoperative Aerobic Capacity and Exercise Oscillatory Ventilation AfterLiver Transplantation. Am J Transplantation. 2013;14:88–95. doi: 10.1111/ajt.12502.
- Bernal W, et al. Aerobic capacity at cardio-pulmonary exercise testing and survival with and without liver transplantation in patients with chronic liver disease. Liver Transpl. 2013;20:54–62. doi: 10.1002/lt.23766.
- Ney M, et al. Systematic review: pre- and post-operative prognostic value of cardiopulmonary exercise testing in liver transplant candidates. Aliment Pharmacol Ther. 2016;44:796–806. doi: 10.1111/apt.13771.
- Myers J, et al. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med. 2002;346:793–801. doi: 10.1056/NEJMoa011858.
- Jones JC, Coombes JS, Macdonald GA. Exercise capacity and muscle strength in patients with cirrhosis. Liver Transpl. 2012;18:146–151. doi: 10.1002/lt.22472.
- Roman E, et al. Randomized pilot study: effects of an exercise programme and leucine supplementation in patients with cirrhosis. Dig Dis Sci. 2014;59:1966–1975. doi: 10.1007/s10620-014-3086-6.
- Berzigotti, A. et al. Effects of an intensive lifestyle intervention program on portal hypertension in patients with cirrhosis and obesity: The sportdiet study. Hepatology, 10.1002/hep.28992 (2016).
- Zenith, L. et al. Eight weeks of exercise training increases aerobic capacity and muscle mass and reduces fatigue in patients with cirrhosis. Clin Gastroenterol Hepatol12, 1920-1926 e1922, 10.1016/j.cgh.2014.04.016 (2014).
- Doolan-Noble F, Broad J, Riddell T, North D. Cardiac rehabilitation services in New Zealand: access and utilisation. N Z Med J. 2004;117:U955.
- Jones M, et al. ‘DNA’ may not mean ‘did not participate’: a qualitative study of reasons for non-adherence at home- and centre-based cardiac rehabilitation. Fam Pract. 2007;24:343–357. doi: 10.1093/fampra/cmm021.
- Hwang R, Marwick T. Efficacy of home-based exercise programmes for people with chronic heart failure: a meta-analysis. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology. 2009;16:527–535. doi: 10.1097/HJR.0b013e32832e097f.
- Fokkenrood HJ, et al. Supervised exercise therapy versus non-supervised exercise therapy for intermittent claudication. Cochrane Database Syst Rev. 2013;8:CD005263.
- Ashworth NL, Chad KE, Harrison EL, Reeder BA, Marshall SC. Home versus center based physical activity programs in older adults. Cochrane Database Syst Rev, CD004017. 2005
- Wilson TM, Tanaka H. Meta-analysis of the age-associated decline in maximal aerobic capacity in men: relation to training status. American journal of physiology. Heart and circulatory physiology. 2000;278:H829–834. doi: 10.1152/ajpheart.2000.278.3.H829.
- Fitzgerald MD, Tanaka H, Tran ZV, Seals DR. Age-related declines in maximal aerobic capacity in regularly exercising vs. sedentary women: a meta-analysis. Journal of applied physiology. 1997;83:160–165. doi: 10.1152/jappl.1997.83.1.160.
- Carey EJ, et al. Six-Minute Walk Distance Predicts Mortality in Liver Transplant Candidates. Liver Transpl. 2010;16:1373–1378. doi: 10.1002/lt.22167.
- O’Connor CM, et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301:1439–1450. doi: 10.1001/jama.2009.454.
- Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. Journal of the American Geriatrics Society. 2006;54:743–749. doi: 10.1111/j.1532-5415.2006.00701.x.
- Brooks D, Solway S, Gibbons WJ. ATS statement on six-minute walk test. Am J Respir Crit Care Med. 2003;167:1287. doi: 10.1164/ajrccm.167.9.950.
- Wolfel EE. Exercise testing with concurrent beta-blocker usage: is it useful? What do we learn? Current heart failure reports. 2006;3:81–88. doi: 10.1007/s11897-006-0006-x.
- Ney M, et al. Patient-perceived barriers to lifestyle interventions in cirrhosis. Saudi J Gastroenterol. 2017;23:97–104.
- Jones WK. Understanding barriers to physical activity is a first step in removing them. American journal of preventive medicine. 2003;25:2–4. doi: 10.1016/S0749-3797(03)00171-5.
- White JL, Ransdell LB, Vener J, Flohr JA. Factors related to physical activity adherence in women: review and suggestions for future research. Women Health. 2005;41:123–148. doi: 10.1300/J013v41n04_07.
- Babatunde FO, MacDermid JC, MacIntyre N. A therapist-focused knowledge translation intervention for improving patient adherence in musculoskeletal physiotherapy practice. Archives of Physiotherapy. 2017;7:1–16. doi: 10.1186/s40945-016-0029-x.
- Lee HH, Emerson JA, Williams DM. The Exercise-Affect-Adherence Pathway: An Evolutionary Perspective. Front Psychol. 2016;7:1285.
- Sharif S, et al. Resistance exercise reduces skeletal muscle cachexia and improves muscle function in rheumatoid arthritis. Case Rep Med. 2011;2011:205691. doi: 10.1155/2011/205691.
- Keilani, M. et al. Effects of resistance exercise in prostate cancer patients: a meta-analysis. Supportive care in cancer: official journal of the Multinational Association of Supportive Care in Cancer, 10.1007/s00520-017-3771-z (2017).
- Kogure GS, et al. Resistance Exercise Impacts Lean Muscle Mass in Women with Polycystic Ovary Syndrome. Medicine and science in sports and exercise. 2016;48:589–598. doi: 10.1249/MSS.0000000000000822.
- McNeely ML, Campbell KL, Courneya KS, Mackey JR. Effect of acute exercise on upper-limb volume in breast cancer survivors: a pilot study. Physiother Can. 2009;61:244–251. doi: 10.3138/physio.61.4.244.
- Gould DW, Lahart I, Carmichael AR, Koutedakis Y, Metsios GS. Cancer cachexia prevention via physical exercise: molecular mechanisms. J Cachexia Sarcopenia Muscle. 2013;4:111–124. doi: 10.1007/s13539-012-0096-0.
- Galiano-Castillo N, et al. Telehealth system (e-CUIDATE) to improve quality of life in breast cancer survivors: rationale and study protocol for a randomized clinical trial. Trials. 2013;14:187. doi: 10.1186/1745-6215-14-187.
- Kairy D, Lehoux P, Vincent C, Visintin M. A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation. Disabil Rehabil. 2009;31:427–447. doi: 10.1080/09638280802062553.
- Dlugonski D, Motl RW, McAuley E. Increasing physical activity in multiple sclerosis: replicating Internet intervention effects using objective and self-report outcomes. J Rehabil Res Dev. 2011;48:1129–1136. doi: 10.1682/JRRD.2010.09.0192.
- Lovo Grona, S. et al. Use of videoconferencing for physical therapy in people with musculoskeletal conditions: a systematic review. J Telemed Telecare, 1357633X17700781, 10.1177/1357633X17700781 (2017).
- Dolansky MA, Stepanczuk B, Charvat JM, Moore SM. Women’s and men’s exercise adherence after a cardiac event. Res Gerontol Nurs. 2010;3:30–38. doi: 10.3928/19404921-20090706-03.
- Stiggelbout M, Hopman-Rock M, Crone M, Lechner L, van Mechelen W. Predicting older adults’ maintenance in exercise participation using an integrated social psychological model. Health Educ Res. 2006;21:1–14. doi: 10.1093/her/cyh037.
- Bautista-Castano I, Molina-Cabrillana J, Montoya-Alonso JA, Serra-Majem L. Variables predictive of adherence to diet and physical activity recommendations in the treatment of obesity and overweight, in a group of Spanish subjects. Int J Obes Relat Metab Disord. 2004;28:697–705. doi: 10.1038/sj.ijo.0802602.
- Kampshoff CS, et al. Determinants of exercise adherence and maintenance among cancer survivors: a systematic review. Int J Behav Nutr Phys Act. 2014;11:80. doi: 10.1186/1479-5868-11-80.
- Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46:922–938. doi: 10.1002/hep.21907.
- Haykowsky M, Taylor D, Kim D, Tymchak W. Exercise training improves aerobic capacity and skeletal muscle function in heart transplant recipients. American journal of transplantation: official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2009;9:734–739. doi: 10.1111/j.1600-6143.2008.02531.x.
- Tandon, P. et al. A Model to Identify Sarcopenia in Patients With Cirrhosis. Clin Gastroenterol Hepatol, 10.1016/j.cgh.2016.04.040 (2016).
- Younossi Z, Guyatt G, Kiwi M, King D, Boparai N. Development of a disease-specific health-related quality of life index for chronic liver disease. Gut. 1999;44:1–6. doi: 10.1136/gut.44.1.1.
- Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol Group. Annals of medicine. 2001;33:337–343. doi: 10.3109/07853890109002087.
- Schulz KH, Kroencke S, Ewers H, Schulz H, Younossi ZM. The factorial structure of the Chronic Liver Disease Questionnaire (CLDQ) Quality of life research: an international journal of quality of life aspects of treatment, care and rehabilitation. 2008;17:575–584. doi: 10.1007/s11136-008-9332-7.
- Mandic S, et al. Effects of aerobic or aerobic and resistance training on cardiorespiratory and skeletal muscle function in heart failure: a randomized controlled pilot trial. Clinical rehabilitation. 2009;23:207–216. doi: 10.1177/0269215508095362.
- Plauth M, et al. ESPEN Guidelines on Enteral Nutrition: Liver disease. Clin.Nutr. 2006;25:285–294. doi: 10.1016/j.clnu.2006.01.018.
- Amodio P, et al. The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. Hepatology. 2013;58:325–336. doi: 10.1002/hep.26370.
- Vickers AJ, Altman DG. Statistics notes: Analysing controlled trials with baseline and follow up measurements. BMJ. 2001;323:1123–1124. doi: 10.1136/bmj.323.7321.1123.
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