Altered postural control and stability in cirrhotic patients with minimal hepatic encephalopathy correlate with cognitive deficits

Urios, Amparo; Mangas‐Losada, Alba; Giménez-Garzó, Carla; González‐López, Olga; Giner‐Durán, Remedios; Serra, Miguel; Noé, Enrique; Felipo, Vicente; Montoliú, Carmina

doi:10.1111/liv.13345

Cited by 32 publications

(32 citation statements)

References 44 publications

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“…The cause of the predisposition of patients with cirrhosis to falling is probably multifactorial, but cognitive dysfunction (or minimal hepatic encephalopathy) appears to play an important role. (8,26) Cognitive function improved in patients from the probiotic group, as shown by the increase in the PHES results at the end of the treatment. This finding is in agreement with studies reporting an improvement in cognitive function in patients with cirrhosis treated with the probiotic used here (16,27) as well as in studies using other probiotics.…”

Section: Discussionmentioning

confidence: 90%

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Effect of a Multistrain Probiotic on Cognitive Function and Risk of Falls in Patients With Cirrhosis: A Randomized Trial

et al. 2019

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Probiotics can modulate gut microbiota, intestinal permeability, and immune response and could therefore improve cognitive dysfunction and help avoid potential consequences, such as falls, in patients with cirrhosis. The aim of this study was to evaluate the effect of a multistrain probiotic on cognitive function, risk of falls, and inflammatory response in patients with cirrhosis. Consecutive outpatients with cirrhosis and cognitive dysfunction (defined by a Psychometric Hepatic Encephalopathy Score [PHES] < −4) and/or falls in the previous year were randomized to receive either a sachet of a high‐concentration multistrain probiotic containing 450 billion bacteria twice daily for 12 weeks or placebo. We evaluated the changes in cognitive function (PHES); risk of falls (Timed Up and Go [TUG] test, gait speed, and incidence of falls); systemic inflammatory response; neutrophil oxidative burst; intestinal barrier integrity (serum fatty acid–binding protein 6 [FABP‐6] and 2 [FABP‐2] and zonulin and urinary claudin‐3); bacterial translocation (lipopolysaccharide‐binding protein [LBP]); and fecal microbiota. Thirty‐six patients were included. Patients treated with the probiotic (n = 18) showed an improvement in the PHES ( P = 0.006), TUG time ( P = 0.015) and gait speed ( P = 0.02), and a trend toward a lower incidence of falls during follow‐up (0% compared with 22.2% in the placebo group [n = 18]; P = 0.10). In the probiotic group, we observed a decrease in C‐reactive protein ( P = 0.01), tumor necrosis factor alpha ( P = 0.01), FABP‐6 ( P = 0.009), and claudin‐3 ( P = 0.002), and an increase in poststimulation neutrophil oxidative burst ( P = 0.002). Conclusion: The multistrain probiotic improved cognitive function, risk of falls, and inflammatory response in patients with cirrhosis and cognitive dysfunction and/or previous falls.

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Section: Discussionmentioning

confidence: 90%

Section: Discussionmentioning

confidence: 97%

Effect of a Multistrain Probiotic on Cognitive Function and Risk of Falls in Patients With Cirrhosis: A Randomized Trial

et al. 2019

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“…Supplementary motor area shows a wide range of white matter connections with motor, language and limbic areas. These alterations, together with a widespread altered anatomical connectivity of white matter in the brain in MHE patients, as compared with controls or patients without MHE [12], could explain the disturbances in movement initiation involved in bradykinesia in MHE [31] and contribute to alterations in postural control in these patients [32]. Lower connectivity in this network could explain the low manual dexterity for the execution of PHES subtests assessing visuomotor coordination (SDT and LTT).…”

Section: Discussionmentioning

confidence: 99%

Reduced resting state connectivity and gray matter volume correlate with cognitive impairment in minimal hepatic encephalopathy

García‐García¹,

Cruz-Gómez²,

Mangas‐Losada³

et al. 2017

PLoS ONE

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Background and aimsMinimal hepatic encephalopathy (MHE) is associated with cognitive alterations and changes in connectivity. We assessed the relationship of the abnormalities of resting-state functional connectivity (rs-FC) and gray matter (GM) volume with different cognitive alterations and biochemical parameters associated to MHE.MethodsThirty-nine cirrhotic patients (26 without and 13 with MHE) and 24 controls were widely cognitive assessed with a battery of psychometric tests. Atrophy was determined using Voxel-Based Morphometry and rs-FC was assessed by independent component analysis. Receiver operating characteristic (ROC) curves was performed to assess the diagnostic utility of rs-FC and GM reduction for the discrimination of patients with and without MHE. Blood ammonia, cGMP, and levels of pro-inflammatory interleukins were measured.ResultsMHE patients showed significant decrease of GM volume and lesser degree of rs-FC in different networks related to attention and executive functions as compared to controls and patients without MHE. There is a progressive reduction in rs-FC in the default mode network with the progression of cognitive impairment. MHE patients showed GM reduction in the right frontal lobe, right insula and right cerebellum compared to patients without MHE. Alterations in GM volume and rs-FC correlated with the scores of different cognitive tests.ConclusionsDecreased cognitive performance is associated by reduced rs-FC and GM atrophy in MHE patients. These changes could have predictive value for detecting MHE.

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“…Falls in cirrhotic patients are strongly associated with especially high risk of morbidity and death. 56 Knowing that many factors can increase the risk of falls (e.g., covert HE, psychoactive drugs, and muscle weakness), 57 observations made during baseline patient assessment (e.g., unsteadiness, tremors, use of chair or wall for support) are indicators of fall risk. So too is a history of three or more falls in the past year, routine use of a cane or walker, and self-reported fear of falling.…”

Section: Supervised Exercisementioning

confidence: 99%

Exercise in cirrhosis: Translating evidence and experience to practice

Tandon

Riess

Duarte‐Rojo

et al. 2018

Journal of Hepatology

160

151

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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.

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Altered postural control and stability in cirrhotic patients with minimal hepatic encephalopathy correlate with cognitive deficits

Abstract: Balance patterns and limits of stability in MHE patients are impaired compared to patients without MHE and controls. This seems to contribute to a higher falls risk. Attention and motor coordination deficits could contribute to balance impairment in patients with MHE.

Cited by 32 publications

References 44 publications

Effect of a Multistrain Probiotic on Cognitive Function and Risk of Falls in Patients With Cirrhosis: A Randomized Trial

Effect of a Multistrain Probiotic on Cognitive Function and Risk of Falls in Patients With Cirrhosis: A Randomized Trial

Reduced resting state connectivity and gray matter volume correlate with cognitive impairment in minimal hepatic encephalopathy

Exercise in cirrhosis: Translating evidence and experience to practice

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