Frailty is a significant problem in patients undergoing liver transplant and is associated with poor outcomes and survival. Hence, optimizing physical fitness and counteracting frailty is important. However, many interventions are very resource intensive and therefore not feasible.

In this study, the investigators aim to test the effectiveness of a newly designed intervention to improve frailty in liver transplant candidates. The "LIver FrailTy" intervention (LIFT) will consist of an evaluation by a physical therapist, an individualized home exercise prescription (HEP), exercise tracking using a smart phone application, daily text reminders to exercise and recurrent telephone check-ins.

Frailty is defined as a biologic syndrome of decreased physiologic reserve and increased vulnerability to health stressors. The concept of frailty has recently emerged as a critical determinant in the field of cirrhosis and liver transplantation. Frailty impacts pre- and post-transplant clinical outcomes, including waitlist mortality, post-transplant mortality, frequency of hospitalizations and duration of hospital admissions. Although the impact of frailty in liver transplantation has been established in the literature, there is a lack of data supporting effective interventions to decrease frailty prior to liver transplantation. Moreover, the studies that have tested interventions to improve physical function have relied on frequent supervised physical therapy (PT) sessions and access to exercise equipment that it is not financially or logistically feasible for the majority of patients. Patient engagement in PT also remains a critical barrier to overcome to decrease frailty in preparation for liver transplantation. Developing a practical and effective intervention to consistently engage patients in physical activity and decrease frailty is essential to improving clinical outcomes in the pre- and post-liver transplant setting.

The investigators goal is to pilot test a novel PT intervention to decrease frailty in pre-transplant patients. The investigators have designed a prototype "LIver FrailTy" intervention (LIFT) that includes: PT evaluation, an individualized home exercise prescription (HEP), daily text message reminders to exercise and weekly telephone check-ins with team members.

The central hypothesis is that the LIFT intervention will 1) improve adherence to recommended levels of exercise in end-stage liver disease 2) reduce pre-transplant frailty and 3) will improve pre- and post-transplant clinical outcomes.

Inclusion Criteria:

• Patients with a diagnosis of liver cirrhosis being evaluated for liver transplantation in hepatology/transplant evaluation clinic
• English-speaking
• Patients with access to a smart phone (with videoconference capabilities)
• Vulnerable populations: We will include patients who are cognitively impaired due to hepatic encephalopathy and unable to consent for themselves.

Exclusion Criteria:

• Patients < 18 years of age
• Patients who require outpatient physical therapy.
• Patients without the ability to consent for themselves or through a medical power of attorney.

Through study completion, the mean follow-up time was 259 (SD ± 190) days. Follow-up time was defined from enrollment to end event with censoring at loss to follow-up. Possible end events: 1) the physical therapist recommended supervised outpatient PT at a future clinic visit; 2) the patient experienced a significant adverse event directly related to exercise; 3) the patient was deemed not to be a transplant candidate for any reason; 4) the patient was transplanted or 5) the patient died.

Potential adverse events related to exercise or LFI measurement were assessed during biweekly telephone calls, clinic visits and remote LFI measurements. Patients were advised to notify the research team of any adverse events immediately. Potential adverse events of interest included physical injuries such as muscle strains, falls or new complications of portal hypertension (i.e., variceal gastro-intestinal bleeding).

This study originally proposed another arm/intervention ("Realistic Effort Action Planning" (REAP), which is a form of personality-informed motivational interviewing) in a subset of patients to determine if this enhances the LIFT intervention. The study team did not have the resources, funding, or time during patient encounters to employ this intervention, and thus focused only on the LIFT intervention.