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J Hepatol. 2018 Nov;69(5):1164-1177. doi: 10.1016/j.jhep.2018.06.017. Epub 2018 Jun 30.

Exercise in cirrhosis: Translating evidence and experience to practice.

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Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada. Electronic address:
Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada.
School of Health and Life Sciences, Northern Alberta Technical Institute, Edmonton, AB, Canada; Physical Therapy, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada.
Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
Medicine, School of Medicine & Dentistry, University of Rochester, Rochester, NY, USA.
Center for Liver Diseases, Thomas E Starzl Transplantation Institute and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA.
Transplant Centre, University of Alberta Hospital, Alberta Health Services, Edmonton, AB, Canada.
London Health Sciences Centre, London, ON, Canada.
Integrated Cardiovascular Exercise Physiology and Rehabilitation (iCARE) Laboratory, College of Nursing and Health Innovation, The University of Texas Arlington, Arlington, TX, USA.
University of Pittsburgh, School of Health and Rehabilitation Sciences, Department of Physical Therapy, Pittsburgh, PA, USA.
Physical Therapy, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada.


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.


6-min walk test; End-stage liver disease; Frailty; Nutrition; Physical activity; Pre-habilitation; Pre-transplant candidate; Sarcopenia


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