Review for 10.1186/s12876-025-03881-4 (2025)

Title: Mapping of rehabilitation interventions and assessment methods for patients with liver
cirrhosis: A scoping review
Version: 1 Date: 05 Mar 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-While the review aims to map intervention content based on FITT principles, there seems to be
limited detail on the specific types of exercise used in rehabilitation programs (e.g., resistance
training, and aerobic exercise). Further clarification or categorization of the interventions based
on specific exercise modalities, their frequency, intensity, and duration would help in making
more specific recommendations for clinical practice.
-While the review is rigorous in its methodology, it does not evaluate the quality of the evidence
included in the studies. Assessing the risk of bias or methodological quality of the included
studies could provide a clearer picture of the robustness of the conclusions drawn from the data.
-The review includes a wide array of outcome measures, but there is no standardized approach
to evaluating or synthesizing the results of these assessments across studies. Given the diversity
of outcome measures, it would be useful to conduct a more detailed analysis of the effectiveness
of interventions across different outcome measures to identify which interventions are most
beneficial for specific outcomes (e.g., muscle mass vs. QOL).
-Although excluding non-English articles ensures easier readability and accessibility for the
review, it may limit the breadth of evidence considered. This exclusion could result in a bias,
particularly for research conducted in non-English-speaking countries where liver cirrhosis
prevalence and rehabilitation practices may differ.
-The review primarily focuses on immediate or short-term outcomes such as muscle mass
and oxygen uptake. It would be beneficial to explore the long-term effects of rehabilitation
interventions, especially liver function, survival rates, and long-term QOL improvements. This
would help assess whether exercise therapy offers sustainable benefits for patients with liver
cirrhosis.
-While the review includes clinical outcomes, there could be a stronger emphasis on patient-
centered perspectives, such as patient preferences, barriers to exercise adherence, and the
feasibility of implementing exercise interventions in diverse clinical settings. Addressing these
factors would provide a more comprehensive view of the rehabilitation process.
-While the review highlights the potential benefits of resistance training, it also notes that there
is a lack of consensus regarding the appropriate intensity settings for cirrhosis patients. Despite
referencing previous studies and offering recommendations based on sarcopenia guidelines, it
could be beneficial to expand the discussion by proposing specific resistance training intensity
ranges based on the reviewed studies or other evidence from similar chronic conditions.
-The discussion acknowledges that patients with lower hepatic reserve (Child-Pugh C) are
underrepresented in exercise therapy studies, and while this is valuable insight, there could be
further emphasis on the importance of developing tailored exercise interventions for these more
vulnerable patients.
-While the discussion mentions that exercise therapy does not appear to worsen liver function, it
also highlights a lack of conclusive evidence regarding the effects of exercise on liver function
itself. This ambiguity could be further explored to determine whether exercise may improve
liver function, or at least preserve it over time, and to emphasize the need for further research
on this topic.
-The discussion effectively mentions the challenges of compliance with unmonitored home-
based exercises, but it could further explore strategies for improving adherence. For example,
exploring motivational interviewing, technology-assisted monitoring (e.g., apps or wearables),
or community-based interventions could provide solutions to enhance exercise adherence among
liver cirrhosis patients.