Universidad Pontificia de Salamanca
Published July 30, 2024 | Version v1
Journal article Open

The Association of Genetic Markers Involved in Muscle Performance Responding to Lactate Levels during Physical Exercise Therapy by Nordic Walking in Patients with Long COVID Syndrome: A Nonrandomized Controlled Pilot Study

Authors/Creators

  • 1. ROR icon Universidad Rey Juan Carlos
  • 2. ROR icon Universidad Francisco de Vitoria
  • 3. Facultad de Enfermería y Fisioterapia Salus Infirmorum. Universidad Pontificia de Salamanca

Description

Several genetic markers have shown associations with muscle performance and physical
abilities, but the response to exercise therapy is still unknown. The aim of this study was to test the
response of patients with long COVID through an aerobic physical therapy strategy by the Nordic
walking program and how several genetic polymorphisms involved in muscle performance influence
physical capabilities. Using a nonrandomized controlled pilot study, 29 patients who previously
suffered from COVID-19 (long COVID = 13, COVID-19 = 16) performed a Nordic walking exercise
therapy program for 12 sessions. The influence of the ACE (rs4646994), ACTN3 (rs1815739), AMPD1
(rs17602729), CKM (rs8111989), and MLCK (rs2849757 and rs2700352) polymorphisms, genotyped by
using single nucleotide primer extension (SNPE) in lactic acid concentration was established with
a three-way ANOVA (group × genotype × sessions). For ACE polymorphism, the main effect was
lactic acid (p = 0.019). In ACTN3 polymorphism, there were no main effects of lactic acid, group, or
genotype. However, the posthoc analysis revealed that, in comparison with nonlong COVID, long
COVID increased lactic acid concentrations in Nordic walking sessions in CT and TT genotypes
(all p < 0.05). For AMPD1 polymorphism, there were main effects of lactic acid, group, or genotype
and lactic acid × genotype or lactic acid × group × genotype interactions (all p < 0.05). The
posthoc analysis revealed that, in comparison with nonlong COVID, long COVID increased lactic
acid concentrations in Nordic walking sessions in CC and CT genotypes (all p < 0.05). Physical
therapy strategy through Nordic walking enhanced physical capabilities during aerobic exercise
in post-COVID19 patients with different genotypes in ACTN3 c.1729C>T and AMPD1 c.34C>T
polymorphisms. These findings suggest that individuals who reported long COVID who presumably
exercised less beforehand appeared to be less able to exercise, based on lactate levels, and the effect of
aerobic physical exercise enhanced physical capabilities conditioned by several genetic markers in
long COVID patients

Files

ijms-25-08305.pdf

Files (1.9 MB)

Name Size Download all
md5:e116d66e1cbcd406d0514b5218264cb4
1.9 MB Preview Download

Additional details

Software

Repository URL
https://summa.upsa.es/details.vm?q=id:0000175961
Development Status
Active

References

  • Callard, F.; Perego, E. How and why patients made Long Covid. Soc. Sci. Med. 2021, 268, 113426. [CrossRef] [PubMed] 2. Shah, W.; Hillman, T.; Playford, E.D.; Hishmeh, L. Managing the long term effects of COVID-19: Summary of NICE, SIGN, and RCGP rapid guideline. BMJ 2021, 372, n136. [CrossRef] [PubMed] 3. Burnett, D.M.; Skinner, C.E. Year in Review: Long COVID and Pulmonary Rehabilitation. Respir. Care 2023, 68, 846–851. [CrossRef] [PubMed] 4. Besnier, F.; Bérubé, B.; Malo, J.; Gagnon, C.; Grégoire, C.A.; Juneau, M.; Simard, F.; L'Allier, P.; Nigam, A.; Iglésies-Grau, J.; et al. Cardiopulmonary Rehabilitation in Long-COVID-19 Patients with Persistent Breathlessness and Fatigue: The COVID-Rehab Study. Int. J. Environ. Res. Public Health 2022, 19, 4133. [CrossRef] [PubMed] 5. Nopp, S.; Moik, F.; Klok, F.A.; Gattinger, D.; Petrovic, M.; Vonbank, K.; Koczulla, A.R.; Ay, C.; Zwick, R.H. Outpatient Pulmonary Rehabilitation in Patients with Long COVID Improves Exercise Capacity, Functional Status, Dyspnea, Fatigue, and Quality of Life. Respiration 2022, 101, 593–601. [CrossRef] [PubMed] 6. Dennis, A.; Wamil, M.; Alberts, J.; Oben, J.; Cuthbertson, D.J.; Wootton, D.; Crooks, M.; Gabbay, M.; Brady, M.; Hishmeh, L.; et al. Multiorgan impairment in low-risk individuals with post-COVID-19 syndrome: A prospective, community-based study. BMJ Open 2021, 11, e048391. [CrossRef] [PubMed] 7. Tziolos, N.R.; Ioannou, P.; Baliou, S.; Kofteridis, D.P. Long COVID-19 Pathophysiology: What Do We Know So Far? Microorganisms 2023, 11, 2458. [CrossRef] [PubMed] 8. Montes-Ibarra, M.; Oliveira, C.L.P.; Orsso, C.E.; Landi, F.; Marzetti, E.; Prado, C.M. The Impact of Long COVID-19 on Muscle Health. Clin. Geriatr. Med. 2022, 38, 545–557. [CrossRef] [PubMed] 9. Gérard, M.; Mahmutovic, M.; Malgras, A.; Michot, N.; Scheyer, N.; Jaussaud, R.; Nguyen-Thi, P.L.; Quilliot, D. Long-Term Evolution of Malnutrition and Loss of Muscle Strength after COVID-19: A Major and Neglected Component of Long COVID-19. Nutrients 2021, 13, 3964. [CrossRef] 10. Burgess, L.C.; Venugopalan, L.; Badger, J.; Street, T.; Alon, G.; Jarvis, J.C.; Wainwright, T.W.; Everington, T.; Taylor, P.; Swain, I.D. Effect of neuromuscular electrical stimulation on the recovery of people with COVID-19 admitted to the intensive care unit: A narrative review. J. Rehabil. Med. 2021, 53, jrm00164. [CrossRef] 11. Hashmi, M.D.; Alnababteh, M.; Vedantam, K.; Alunikummannil, J.; Oweis, E.S.; Shorr, A.F. Assessing the need for transfer to the intensive care unit for Coronavirus-19 disease: Epidemiology and risk factors. Respir. Med. 2020, 174, 106203. [CrossRef] [PubMed] 12. Morrow, A.; Gray, S.R.; Bayes, H.K.; Sykes, R.; McGarry, E.; Anderson, D.; Boiskin, D.; Burke, C.; Cleland, J.G.F.; Goodyear, C.; et al. Prevention and early treatment of the long-term physical effects of COVID-19 in adults: Design of a randomised controlled trial of resistance exercise-CISCO-21. Trials 2022, 23, 660. [CrossRef] 13. Jimeno-Almazán, A.; Franco-López, F.; Buendía-Romero, Á.; Martínez-Cava, A.; Sánchez-Agar, J.A.; Sánchez-Alcaraz Martínez, B.J.; Courel-Ibáñez, J.; Pallarés, J.G. Rehabilitation for post-COVID-19 condition through a supervised exercise intervention: A randomized controlled trial. Scand. J. Med. Sci. Sports 2022, 32, 1791–1801. [CrossRef] [PubMed] 14. Jimeno-Almazán, A.; Pallarés, J.G.; Buendía-Romero, Á.; Martínez-Cava, A.; Franco-López, F.; Sánchez-Alcaraz Martínez, B.J.; Bernal-Morel, E.; Courel-Ibáñez, J. Post-COVID-19 Syndrome and the Potential Benefits of Exercise. Int. J. Environ. Res. Public Health 2021, 18, 5329. [CrossRef] [PubMed] 15. Cano-de-la-Cuerda, R.; Jiménez-Antona, C.; Melián-Ortiz, A.; Molero-Sánchez, A.; Gil-de Miguel, Á.; Lizcano-Álvarez, Á.; Hernández-Barrera, V.; Varillas-Delgado, D.; Laguarta-Val, S. Construct Validity and Test-Retest Reliability of a Free Mobile Application to Evaluate Aerobic Capacity and Endurance in Post-COVID-19 Syndrome Patients—A Pilot Study. J. Clin. Med. 2022, 12, 131. [CrossRef] [PubMed] 16. Kalil-Filho, R.; Saretta, R.; Franci, A.; Baracioli, L.M.; Galas, F.; Gil, J.S.; Ferino, A.; Giacovone, C.; Oliveira, I.; Souza, J.; et al. Post-COVID-19 Cardiopulmonary Symptoms: Predictors and Imaging Features in Patients after Hospital Discharge. Arq. Bras. Cardiol. 2023, 120, e20220642. [CrossRef] [PubMed]; Piotrowicz, K.; G ˛asowski, J.; Michel, J.P.; Veronese, N. Post-COVID-19 acute sarcopenia: Physiopathology and management. Aging Clin. Exp. Res. 2021, 33, 2887–2898. [CrossRef] [PubMed] 18. Dotan, A.; David, P.; Arnheim, D.; Shoenfeld, Y. The autonomic aspects of the post-COVID19 syndrome. Autoimmun. Rev. 2022, 21, 103071. [CrossRef] [PubMed] 19. Colas, C.; Le Berre, Y.; Fanget, M.; Savall, A.; Killian, M.; Goujon, I.; Labeix, P.; Bayle, M.; Féasson, L.; Roche, F.; et al. Physical Activity in Long COVID: A Comparative Study of Exercise Rehabilitation Benefits in Patients with Long COVID, Coronary Artery Disease and Fibromyalgia. Int. J. Environ. Res. Public Health 2023, 20, 6513. [CrossRef] 20. Varillas-Delgado, D.; Morencos, E.; Gutiérrez-Hellín, J.; Aguilar-Navarro, M.; Muñoz, A.; Mendoza Láiz, N.; Perucho, T.; Maestro, A.; Tellería-Orriols, J.J. Genetic profiles to identify talents in elite endurance athletes and professional football players. PLoS ONE 2022, 17, e0274880. [CrossRef] 21. Hughes, D.C.; Day, S.H.; Ahmetov, I.I.; Williams, A.G. Genetics of muscle strength and power: Polygenic profile similarity limits skeletal muscle performance. J. Sports Sci. 2011, 29, 1425–1434. [CrossRef] [PubMed] 22. Maestro, A.; Del Coso, J.; Aguilar-Navarro, M.; Gutiérrez-Hellín, J.; Morencos, E.; Revuelta, G.; Ruiz Casares, E.; Perucho, T.; Varillas-Delgado, D. Genetic profile in genes associated with muscle injuries and injury etiology in professional soccer players. Front. Genet. 2022, 13, 1035899. [CrossRef] [PubMed] 23. Varillas Delgado, D.; Tellería Orriols, J.J.; Monge Martín, D.; Del Coso, J. Genotype scores in energy and iron-metabolising genes are higher in elite endurance athletes than in nonathlete controls. Appl. Physiol. Nutr. Metab. 2020, 45, 1225–1231. [CrossRef] [PubMed] 24. Varillas Delgado, D.; Telleria Orriols, J.J.; Martin Saborido, C. Liver-Metabolizing Genes and Their Relationship to the Performance of Elite Spanish Male Endurance Athletes; a Prospective Transversal Study. Sports Med. Open 2019, 5, 50. [CrossRef] [PubMed] 25. Vasudeva, K.; Balyan, R.; Munshi, A. ACE-Triggered Hypertension Incites Stroke: Genetic, Molecular, and Therapeutic Aspects. Neuromol. Med. 2020, 22, 194–209. [CrossRef] [PubMed] 26. Zhang, X.; Wang, C.; Dai, H.; Lin, Y.; Zhang, J. Association between angiotensin-converting enzyme gene polymorphisms and exercise performance in patients with COPD. Respirology 2008, 13, 683–688. [CrossRef] [PubMed] 27. Kang, S.W.; Kim, S.K.; Chung, J.H.; Jung, H.J.; Kim, K.I.; Kim, J.; Ban, J.Y. Genetic Polymorphism of Angiotensin-Converting Enzyme and Chronic Obstructive Pulmonary Disease Risk: An Updated Meta-Analysis. BioMed Res. Int. 2016, 2016, 7636123. [CrossRef] 28. Uh, S.T.; Kim, T.H.; Shim, E.Y.; Jang, A.S.; Park, S.W.; Park, J.S.; Park, B.L.; Choi, B.W.; Shin, H.D.; Kim, D.S.; et al. Angiotensin- converting enzyme (ACE) gene polymorphisms are associated with idiopathic pulmonary fibrosis. Lung 2013, 191, 345–351. [CrossRef] [PubMed] 29. Deschamps, C.L.; Connors, K.E.; Klein, M.S.; Johnsen, V.L.; Shearer, J.; Vogel, H.J.; Devaney, J.M.; Gordish-Dressman, H.; Many, G.M.; Barfield, W.; et al. The ACTN3 R577X Polymorphism Is Associated with Cardiometabolic Fitness in Healthy Young Adults. PLoS ONE 2015, 10, e0130644. [CrossRef] 30. Norman, B.; Esbjörnsson, M.; Rundqvist, H.; Österlund, T.; Glenmark, B.; Jansson, E. ACTN3 genotype and modulation of skeletal muscle response to exercise in human subjects. J. Appl. Physiol. 2014, 116, 1197–1203. [CrossRef] 31. Yang, N.; MacArthur, D.G.; Gulbin, J.P.; Hahn, A.G.; Beggs, A.H.; Easteal, S.; North, K. ACTN3 genotype is associated with human elite athletic performance. Am. J. Hum. Genet. 2003, 73, 627–631. [CrossRef] [PubMed] 32. Binkley, P.F.; Auseon, A.; Cooke, G. A polymorphism of the gene encoding AMPD1: Clinical impact and proposed mechanisms in congestive heart failure. Congest. Heart Fail. 2004, 10, 274–278. [CrossRef] [PubMed] 33. Maltese, P.E.; Venturini, L.; Poplavskaya, E.; Bertelli, M.; Cecchin, S.; Granato, M.; Nikulina, S.Y.; Salmina, A.; Aksyutina, N.; Capelli, E.; et al. Genetic evaluation of AMPD1, CPT2, and PGYM metabolic enzymes in patients with chronic fatigue syndrome. Genet. Mol. Res. 2016, 15, gmr.15038717. [CrossRef] [PubMed] 34. Chen, C.; Sun, Y.; Liang, H.; Yu, D.; Hu, S. A meta-analysis of the association of CKM gene rs8111989 polymorphism with sport performance. Biol. Sport 2017, 34, 323–330. [CrossRef] [PubMed] 35. Clarkson, P.M.; Hoffman, E.P.; Zambraski, E.; Gordish-Dressman, H.; Kearns, A.; Hubal, M.; Harmon, B.; Devaney, J.M. ACTN3 and MLCK genotype associations with exertional muscle damage. J. Appl. Physiol. 2005, 99, 564–569. [CrossRef] [PubMed] 36. Yates, A.D.; Achuthan, P.; Akanni, W.; Allen, J.; Alvarez-Jarreta, J.; Amode, M.R.; Armean, I.M.; Azov, A.G.; Bennett, R.; Bhai, J.; et al. Ensembl 2020. Nucleic Acids Res. 2020, 48, D682–D688. [CrossRef] [PubMed] 37. Fiuza-Luces, C.; Ruiz, J.R.; Rodríguez-Romo, G.; Santiago, C.; Gómez-Gallego, F.; Cano-Nieto, A.; Garatachea, N.; Rodríguez-Moreno, I.; Morán, M.; Lucia, A. Is the ACE I/D polymorphism associated with extreme longevity? A study on a Spanish cohort. J. Renin Angiotensin Aldosterone Syst. 2011, 12, 202–207. [CrossRef] 38. Fernández-Lázaro, D.; Santamaría, G.; Sánchez-Serrano, N.; Lantarón Caeiro, E.; Seco-Calvo, J. Efficacy of Therapeutic Exercise in Reversing Decreased Strength, Impaired Respiratory Function, Decreased Physical Fitness, and Decreased Quality of Life Caused by the Post-COVID-19 Syndrome. Viruses 2022, 14, 2797. [CrossRef] 39. Rooney, S.; Webster, A.; Paul, L. Systematic Review of Changes and Recovery in Physical Function and Fitness After Severe Acute Respiratory Syndrome-Related Coronavirus Infection: Implications for COVID-19 Rehabilitation. Phys. Ther. 2020, 100, 1717–1729. [CrossRef] Int. J. Mol. Sci. 2024, 25, 8305 16 of 17 40. Szarvas, Z.; Fekete, M.; Horvath, R.; Shimizu, M.; Tsuhiya, F.; Choi, H.E.; Kup, K.; Fazekas-Pongor, V.; Pete, K.N.; Cserjesi, R.; et al. Cardiopulmonary rehabilitation programme improves physical health and quality of life in post-COVID syndrome. Ann. Palliat. Med. 2023, 12, 548–560. [CrossRef] 41. Volckaerts, T.; Vissers, D.; Burtin, C.; Van Meerbeeck, X.; de Soomer, K.; Oostveen, E.; Claes, K.; Roelant, E.; Verhaegen, I.; Thomeer, M.; et al. Randomised, controlled, open-label pragmatic trial evaluating changes in functional exercise capacity after primary care PUlmonary REhabilitation in patients with long COVID: Protocol of the PuRe-COVID trial in Belgium. BMJ Open 2023, 13, e071098. [CrossRef] [PubMed] 42. Araújo, B.T.S.; Barros, A.; Nunes, D.T.X.; Remígio de Aguiar, M.I.; Mastroianni, V.W.; de Souza, J.A.F.; Fernades, J.; Campos, S.L.; Brandão, D.C.; Dornelas de Andrade, A. Effects of continuous aerobic training associated with resistance training on maximal and submaximal exercise tolerance, fatigue, and quality of life of patients post-COVID-19. Physiother. Res. Int. 2023, 28, e1972. [CrossRef] [PubMed] 43. Binetti, J.; Real, M.; Renzulli, M.; Bertran, L.; Riesco, D.; Perpiñan, C.; Mohedano, A.; Segundo, R.S.; Ortiz, M.; Porras, J.A.; et al. Clinical and Biomarker Profile Responses to Rehabilitation Treatment in Patients with Long COVID Characterized by Chronic Fatigue. Viruses 2023, 15, 1452. [CrossRef] [PubMed] 44. Omar, A.; Ferreira, A.S.; Hegazy, F.A.; Alaparthi, G.K. Cardiorespiratory Response to Six-Minute Step Test in Post COVID-19 Patients—A Cross Sectional Study. Healthcare 2023, 11, 1386. [CrossRef] [PubMed] 45. Eksombatchai, D.; Wongsinin, T.; Phongnarudech, T.; Thammavaranucupt, K.; Amornputtisathaporn, N.; Sungkanuparph, S. Pulmonary function and six-minute-walk test in patients after recovery from COVID-19: A prospective cohort study. PLoS ONE 2021, 16, e0257040. [CrossRef] [PubMed] 46. Bullo, V.; Gobbo, S.; Vendramin, B.; Duregon, F.; Cugusi, L.; Di Blasio, A.; Bocalini, D.S.; Zaccaria, M.; Bergamin, M.; Ermolao, A. Nordic Walking Can Be Incorporated in the Exercise Prescription to Increase Aerobic Capacity, Strength, and Quality of Life for Elderly: A Systematic Review and Meta-Analysis. Rejuvenation Res. 2018, 21, 141–161. [CrossRef] [PubMed] 47. Kettinen, J.; Tikkanen, H.; Venojärvi, M. Comparative effectiveness of playing golf to Nordic walking and walking on acute physiological effects on cardiometabolic markers in healthy older adults: A randomised cross-over study. BMJ Open Sport. Exerc. Med. 2023, 9, e001474. [CrossRef] [PubMed] 48. Reed, J.L.; Terada, T.; Cotie, L.M.; Tulloch, H.E.; Leenen, F.H.; Mistura, M.; Hans, H.; Wang, H.W.; Vidal-Almela, S.; Reid, R.D.; et al. The effects of high-intensity interval training, Nordic walking and moderate-to-vigorous intensity continuous training on functional capacity, depression and quality of life in patients with coronary artery disease enrolled in cardiac rehabilitation: A randomized controlled trial (CRX study). Prog. Cardiovasc. Dis. 2022, 70, 73–83. [CrossRef] [PubMed] 49. Cokorilo, N.; Ruiz-Montero, P.J.; González-Fernández, F.T.; Martín-Moya, R. An Intervention of 12 Weeks of Nordic Walking and Recreational Walking to Improve Cardiorespiratory Capacity and Fitness in Older Adult Women. J. Clin. Med. 2022, 11, 2900. [CrossRef] 50. Morat, T.; Krueger, J.; Gaedtke, A.; Preuss, M.; Latsch, J.; Predel, H.G. Effects of 12 weeks of Nordic Walking and XCO Walking training on the endurance capacity of older adults. Eur. Rev. Aging Phys. Act. 2017, 14, 16. [CrossRef] 51. Ochman, M.; Maruszewski, M.; Latos, M.; Jastrz˛ebski, D.; Wojarski, J.; Karolak, W.; Przybyłowski, P.; Zeglen, S. Nordic Walking in Pulmonary Rehabilitation of Patients Referred for Lung Transplantation. Transplant. Proc. 2018, 50, 2059–2063. [CrossRef] [PubMed] 52. Brooks, G.A. Lactate as a fulcrum of metabolism. Redox Biol. 2020, 35, 101454. [CrossRef] [PubMed] 53. Gupta, G.S. The Lactate and the Lactate Dehydrogenase in Inflammatory Diseases and Major Risk Factors in COVID-19 Patients. Inflammation 2022, 45, 2091–2123. [CrossRef] 54. Bouchard, C.; Rankinen, T.; Timmons, J.A. Genomics and genetics in the biology of adaptation to exercise. Compr. Physiol. 2011, 1, 1603–1648. [CrossRef] [PubMed] 55. Bouchard, C. Genomic predictors of trainability. Exp. Physiol. 2012, 97, 347–352. [CrossRef] [PubMed] 56. Varillas-Delgado, D.; Del Coso, J.; Gutiérrez-Hellín, J.; Aguilar-Navarro, M.; Muñoz, A.; Maestro, A.; Morencos, E. Genetics and sports performance: The present and future in the identification of talent for sports based on DNA testing. Eur. J. Appl. Physiol. 2022, 122, 1811–1830. [CrossRef] [PubMed] 57. Puthucheary, Z.; Skipworth, J.R.; Rawal, J.; Loosemore, M.; Van Someren, K.; Montgomery, H.E. The ACE gene and human performance: 12 years on. Sports Med. 2011, 41, 433–448. [CrossRef] [PubMed] 58. Yang, N.; Garton, F.; North, K. alpha-actinin-3 and performance. Med. Sport. Sci. 2009, 54, 88–101. [CrossRef] [PubMed] 59. Guth, L.M.; Roth, S.M. Genetic influence on athletic performance. Curr. Opin. Pediatr. 2013, 25, 653–658. [CrossRef] 60. Fedotovskaya, O.N.; Danilova, A.A.; Akhmetov, I.I. Effect of AMPD1 gene polymorphism on muscle activity in humans. Bull. Exp. Biol. Med. 2013, 154, 489–491. [CrossRef] 61. Norweg, A.; Yao, L.; Barbuto, S.; Nordvig, A.S.; Tarpey, T.; Collins, E.; Whiteson, J.; Sweeney, G.; Haas, F.; Leddy, J. Exercise intolerance associated with impaired oxygen extraction in patients with long COVID. Respir. Physiol. Neurobiol. 2023, 313, 104062. [CrossRef] [PubMed] 62. Varillas-Delgado, D.; Jimenez-Antona, C.; Lizcano-Alvarez, A.; Cano-de-la-Cuerda, R.; Molero-Sanchez, A.; Laguarta-Val, S. Predictive Factors and ACE-2 Gene Polymorphisms in Susceptibility to Long COVID-19 Syndrome. Int. J. Mol. Sci. 2023, 24, 16717. [CrossRef] [PubMed] Int. J. Mol. Sci. 2024, 25, 8305 17 of 17 63. Demirbu ˘ga, A.; Hançerli Törün, S.; Kaba, Ö.; Dede, E.; Mete Atasever, N.; Eryılmaz, C.C.; Okay, N.S.; Somer, A. Long COVID in Children: A Pediatric Center Experience. Mikrobiyol. Bul. 2023, 57, 60–70. [CrossRef] [PubMed] 64. López-Sampalo, A.; Bernal-López, M.R.; Gómez-Huelgas, R. Persistent COVID-19 syndrome. A narrative review. Rev. Clin. Esp. 2022, 222, 241–250. [CrossRef] [PubMed] 65. Yong, S.J. Long COVID or post-COVID-19 syndrome: Putative pathophysiology, risk factors, and treatments. Infect. Dis. 2021, 53, 737–754. [CrossRef] [PubMed] 66. Liu, Y.; Xie, W.; Li, J.; Ossowski, Z. Effects of aerobic exercise on metabolic indicators and physical performance in adult NAFLD patients: A systematic review and network meta-analysis. Medicine 2023, 102, e33147. [CrossRef] 67. Weir, B.S.; Hill, W.G. Estimating F-statistics. Annu. Rev. Genet. 2002, 36, 721–750. [CrossRef