Home-based EXercise and motivAtional Program Before and After Liver Transplantation

The primary outcome measure for this trial is the PCS from the SF-36v2 health-related QoL questionnaire at 24 weeks post LT. The SF-36v2 questionnaire includes 36 questions composed of eight multi-item scales, which reflect the impact of health problems on both the physical and mental condition of the patient.(A higher score reflects better quality of life. Two summary sub-scores can be calculated which are weighted combinations of the 8 scales, one to reflect the impact on physical function (PCS) and one to reflect the impact on psychological function, known as the mental component score (MCS).Scoring of the SF-36v2 questionnaire will based on the instructions provided in the SF-36v2 user's manual.

The CCI is a well validated, reproducible tool in surgery and LT, which provides a 0-100 index (0=no complications, 100=death) using the frequency and grade (CTCAE grade) of surgical-related complications (i.e. wound dehiscence, bile leak, abdominal collections, bleeding, hepatic artery thrombosis etc).

The SF-36v2 questionnaire is a practical, reliable, and valid measure of physical and mental health that can be completed in 5 to 10 minutes. Scoring of the (MCS) SF-36v2 questionnaire is as described above for PCS SF-36v2 questionnaire.

The LFI is a composite metric of three performance-based measures: hand grip strength (HGS), time to do 5 chair stands (seconds) and time holding 3 balance positions (feet side by side, semi-tandem and tandem) to objectively assess physical frailty in ambulatory patients with end-stage liver disease. The LFI score can be calculated using an on-line calculator (available at: http://liverfrailtyindex.ucsf.edu) with patient physical frailty categorised as robust, pre-frail and frail according to their index (index ≤ 3.2 (robust), 3.2-4.5 (pre-frail), >4.5 (frail)).

The DASI is a 12 item self-reported assessment of functional capacity that requires minimal time to complete. It provides prognostic information in a variety of chronic diseases and can be used as an index of disease progression over time .

The date and cause (based on death certificate) of death will be recorded.

UKELD: a scoring system (using a patient's international normalized ratio (INR), serum bilirubin, creatinine and sodium) used to predict the prognosis of patients with end-stage liver disease.

MELD-Na Score: is a scoring system created in 2008, based on the original MELD score, but with the addition of serum sodium. The MELD-Na, largely used for prioritisation in the United States, is a better predictor of mortality than the MELD score. Patients on oral anti-coagulants (including warfarin and the new oral anti-coagulants; predicted to be <2%) will be excluded from the analysis, as their UKELD/MELD-Na will be artificially high.

Unscheduled hospital admissions: The frequency and duration (days) of non-elective hospital admissions .

Length of ICU stay (hours)

length of hospital stay (days)

Re-listing for transplant will be recorded (date, reason) .

The date and cause (based on death certificate) of death will be recorded.

Habitual (daily) levels of physical activity engagement (light, moderate and vigorous intensity) which may occur during the course of the trial will be measured using a 'blinded' wrist worn accelerometer (Actigraph GT9X). These will be worn for 14 days (24 hours/day):

• Baseline (visit 1, week 0) to 14 days
• 14 days before visit 2 (6 weeks), visit 3 (12 weeks) and visit 4 (24 weeks) pre-LT
• 14 days before visit 7 (6 weeks post-LT), visit 8 (12 weeks post-LT) and visit 9 (24 weeks post-LT, end of intervention) Data captured during the 14-day periods will be analysed to quantify daily time (min/day) spent in; (1) light physical activity (1.6 - 2.9 metabolic equivalents (METS), (2) moderate physical activity (≥ 3 - 5.9 METS), (3) vigorous physical activity (≥6 METS), and sedentary time (≤1.5 METS).

Data will be analysed from the 'blinded' wrist worn accelerometer (Actigraph GT9X) to understand the intensity and duration of the exercises completed during the 14 day periods.

Adherence to the HBEP will be measured using the 'blinded' wrist-worn accelerometer worn in the 14 day periods (described above). In addition, the participant will fill a self-reported exercise diary throughout the trial, which will be reviewed by the physiotherapist at each face-to-face trial visit until visit 9 (24 weeks post-LT, end of intervention). Using the diary, the physiotherapist will document how many structured HBEP sessions the participant has completed per week (maximum 5 per week).

This will be measured using the Health Care Climate Questionnaire (HCCQ). The HCCQ comprises 15 items/statements which represent the patient's perceptions of the degree to which they feel their interactions with their physiotherapist (health care climate) empower them to engage in exercise (e.g. "I feel that my physiotherapist has provided me choices and options"). Patients are asked to respond to each item, indicating the extent to which they agree with each statement, on a Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).

This will be measured using the Basic Psychological Need Satisfaction in Exercise Scale (PNSE): The PNSE will be used to examine participants basic psychological need satisfaction, in relation to their exercise engagement. The PNSE comprises 18 items, capturing the three basic psychological needs of autonomy (6 items, e.g. "I feel free to exercise in my own way"), competence (6 items, e.g. "feel that I am able to complete exercises that are personally challenging") and relatedness (6 items, e.g. I feel connected to the people who I interact with while I exercise"). Participants are asked to respond to each item, indicating the degree with which they agree with each statement, on a Likert scale from 1 (false) to 6 (true).

This will be measured using the Behavioural Regulation in Exercise Questionaire-2 (BREQ-2). The BREQ-2 will measure participant's degree of self-determined motivation to engage in exercise, by assessing their external, introjected, identified and intrinsic regulations, as well as motivation. Following the stem, "I take part in exercise" participants will be asked to respond to 19 items assessing intrinsic regulation (4 items; e.g., "because I enjoy doing this"), identified regulation (4 items; e.g., "because I value the benefits of doing this"), introjected regulation (3 items; e.g., "because I feel guilty when I am not doing this"), external regulation (4 items; e.g., "because my friends and family say I should") and motivation (4 items; e.g., "but I think doing this is a waste of time"). Participants were asked to rate their agreement with each statement on a 5-point Likert scale from 0 (not true for me) to 4 (very true for me).