THE ROLE OF PHYSIOTHERAPY IN PEOPLE LIVING WITH HIV/AIDS

Physiotherapy plays a role in caring and treatment of people suffering from conditions related to
HIV/Aids worldwide. It helps in optimization of life in these patients. Human immunodeficiency virus
(HIV) is the lentivirus that can lead to development of AIDS. This is a condition in which the human
defense mechanism starts to fail and the body progressively deteriorates. It can affect any human being
regardless of age or gender. It’s usually transmitted through shared blood, vaginal fluid, semen and
breast milk. In the past, concern of disability due HIV was excluded from major HIV reports until
2009.Uptodate the role of Physiotherapy in HIV patients is over looked and that’s why there are not
included in most multi disciplined teams caring for HIV patients at hospital or even at provincial level.
Most of people living with HIV live in sub Saharan Africa. It has been noted especially in sub Saharan
Africa that most HIV/AIDS patient have lengthened period of stay in hospital due to multisystem
pathology of the diseases. This brings up complications such as contractures, muscle wastage, stiff joints,
bedsores and respiratory. Disability can be due to HIV as a disease, secondary side effects and the side
effects of treatment. This establishes the need for physiotherapeutic care. UN recognized HIV and
disability has one of the major problems facing the populations in Africa

Physiotherapy in acute stage

Physiotherapists are experts in body movements and exercises that’s why they take a primary role in
treatment of HIV/Aids patients both during acute and rehabilitation phases. In acute stage
Physiotherapists are involved in the following ways depending on the presentation of the patient:

• Maintaining clear the pulmonary system by clearing chest secretions and expanding lung tissue if there
is a collapse

• Maintaining the normal joint ranges and increasing circulation to dependant limbs by doing passive
mobilization.

• Postural correction to prevent any deformities.

Physiotherapy in Chronic Stage/Rehabilitation Stage

Physiotherapists work with all health providers as a team viz Doctors, Nurses, Occupational therapists,
and Social workers only to mention a few. The advances in the treatment of HIV have resulted in
increased life expectance in people living with HIV as long as they have access to the new treatment
regime. But due to the medicinal or disease effects, the chances of these people developing disability
are very high. A wide range of problems are likely arising from neurological, musculoskeletal and painful
syndromes. All these problems can be alleviated through Physiotherapy interventions by applying the
following depending on the presentation of the patient;

• Maintaining the normal joint ranges and increasing circulation to dependant limbs by doing passive
mobilization.

• Stretching exercises as a prevention of painful contractures

• Restoration of body image due to weight loss by strengthening wasted muscles

• Pain management by using electrotherapy

• Active mobilization through to independent walking

• Provision of assistive device i.e. Crutches, walking sticks etc

• Health promotion advice

• Postural correction to prevent any deformities

Definition/Description

The Centers for Disease Control and Prevention (CDC) revised the definition of AIDS in 1992 to include
those who have HIV-1 and a CD4 count below 200/mL (the normal CD4 lymphocyte count is 600 to
1200/mL) or 14% of the total lymphocyte count, even if the person has no other signs or symptoms of
infection. 
Three distinct points identify this continuum:
(1) asymptomatic HIV seropositive, 
(2) early symptomatic HIV, and 
(3) HIV advanced disease (AIDS). [1]

AIDS, acquired immunodeficiency syndrome, is a contagious, chronic and life-threatening condition

caused by the human immunodeficiency virus (HIV). Acquired means the disease is not inherited or
genetic in nature but develops as a result of a virus. Immuno refers to the immune system, and
deficiency means the immune system is underperforming or hypoactive. By damaging your immune
system, HIV interferes with your body's ability to fight off viruses, bacteria, and fungi that cause
disease and other invasive pathologies. HIV makes you more susceptible to certain types of cancers
and infections your body would normally resist. The cytopathogenic virus and the infection itself are
known as HIV. "Acquired immunodeficiency syndrome (AIDS)" is the name given to the later and
more serious stages of an HIV infection.  [2]

According the AIDS.gov, 35.3 million people are currently living with HIV/AIDS worldwide. Though the
spread of the virus has slowed in some countries, it has escalated or remained unchanged in others.
The best hope for stemming the spread of HIV lies in prevention, treatment and education.  [3]

For a visual illustration of how HIV and AIDs progresses, please visit the
following: http://aids.gov/hiv-aids-basics/hiv-aids-101/what-is-hiv-aids/

Prevalence

Prevalence is defined as the number of people living with HIV infection at the end of a given year.
According to the CDC, at the end of 2010, about 1.1 million people in the United States were living
with HIV/AIDS. Of those people, about 16% do not know they are infected. The prevalence of HIV is
increased in African American males, male to male sexual relations, and age 25-34. The prevalence is
5 times greater in incarcerated populations than the general population at large. The high HIV
transmission rates among inmates maybe related to homosexual encounters and potentially tattooing.
Ethnicity is not directly related to AIDS risk, but it is associated with other determinants of health
status such as poverty, illegal drug use, access to health care, and living in communities with a high
prevalence of AIDS.   [4]

Incidence is the number of new HIV infections that occur during a given year. HIV infection is the 5th
leading cause of death for people who are between the ages of 25-44 years old in the United States.
In 2010, the CDC estimated that approximately 47,500 people were newly infected with HIV. There
are four transmission categories of HIV: male to male sexual relations, heterosexual relations,
injection drug users, and homosexual relations combined with injection drug users. Male to male sex
accounted for 78% of new HIV infections among men and 63% of all new infections in 2010.
Furthermore, black men represented 31% of all new HIV infections, in the United States, in 2010.
Black/African American men and women were also strongly affected and were estimated to have an
incidence rate that was 7 times as high as the incidence rate among whites. African-American's
represent about 14% of the total United States population, but make up almost half of the people
known that are suffering from AIDS. AIDS is the leading cause of death for African-American men
between the ages of 35-44 years old in the United States. It is thought that approximately 5 million
new HIV cases occur each year worldwide.  [4]

For complete HIV/AIDS prevalence and incidence statistics, please

visit http://www.cdc.gov/nchhstp/newsroom/docs/2012/HIV-Infections-2007-2010.pdf or visit the
HIV/AIDS page on the CDC website at http://www.cdc.gov/hiv/default.html. 

Characteristics/Clinical Presentation

The clinical presentation of HIV and AIDS vary depending on which stage of infection the person is in.

Early infection:

When a person first becomes infected with HIV, many people will experience flu-like symptoms often
described as "the worst flu ever." These symptoms usually occure within 2-4 weeks of becoming
infected with HIV. Early signs and symptoms may include: fever, headache, sore throat, swollen
lymph vessels, fatigue, muscle and joint aches and pain, and rash. GI complaints include change in
bowel and bladder function, especially diarrhea. Cutaneous complaints are common and include: dry
skin, new skin rashes, and nail bed changes. Because these are very common and present in a
number of other diseases, a combination of complaints is more suggestive of HIV infection than any
one sign/symptom. In addition, many people with HIV present with back pain, but the underlying
cause may differ from person to person. Back pain may be due to: muscle weakness and atrophy that
occurs as a result of the disease process. Back muscle weakness and atrophy can alter the person's
normal postural alignment and may cause subsuquent backpain as well as a person's response to their
medications may contribute to back pain as well. It has been reported that back pain is more likely to
occur when the bodies T-cell count drops. Eventhough, the person may or may not exhibit symptoms
they can still transmit the virus to others. Once, the virsus enters the person's body, the person's
immune system comes under attack. The virus then starts to multiply in the person's lymph nodes and
slowly degins to eradicate the helper T- cells, the white blood cells that help the immune system.     
[3] [4] [2]

Later infection:

A person may remain symptom free for as long as 8-9 years, but as the virus continues to multiply
and destroy immune cells, the person may begin to develop chronic symptoms and/or acquire mild
infections. Chronic symptoms seen in this stage are but not limited to the following: swollen lympth
nodes-which is often one of the first signs of HIV infection, diarrhea, weight loss, fever, cough and
shortness of breath. [3]

Latest phase of infection:

Usually, after a person has been infected with HIV for 10 years or more the last phase of HIV
conmenses. More serious symptoms of the virus start to appear and the infection may then meet the
offical definition of AIDS. Some of the signs/symptoms of later infection are: Kaposi's sarcoma,
multiple purple blotches and bumps on skin, HTN (pulmonary and or cardiac), dyspnea, syncope,
chest pain, non-productive cough, easy bruising, thrush, muscle atrophy and weakness, back pain,
poor wound healing, HIV related dementia (memory loss, confusion, behavioral change, imparired
gait), and distal symmetric polyneuropathy (pain, numbness, tingling, burning, weakness, and
atrophy).    By the time AIDS develops, the person's immune system has been severly damaged,
making the person susceptible to many opportunistic infections such as TB, Pneumocystsis carinii,
pneumonia, lymphoma, thrush, herpes 1 and 2, toxoplasmosis and cansisiasis. They are called
"opportunistic" infections or diseases because they take advantage of the compromised immune
system to infect and destroy the person's body. Under normal conditions, a person would not be
affected to the degree of severity they are under the presence of these infections with normal immune
function.  The signs and symptoms of some of these infections may include but not limited to the
following: soaking night sweats, shaking chills or fever higher than 100 degrees F (38 C) for several
weeks, dry cough and shortness of breath, chronic diarrhea, persistant white spots or unusual lesions
on the person's tongue or in thier mouth, headeaches, blurred and distorted vision, weight loss. 
[2]

In 1993, the CDC redefined AIDS to mean the presence of HIV infection as shown by a positive HIV
antibody test with the presense of at least one of the following: 
[3]

1. If an individual has HIV and one or more of certain OIs defined by the CDC no matter what that
person's CD4 count is. The CDC lists more than 20 OIs that are considered AIDS-defining conditions.
These are: 

 Candidiasis of bronchi, trachea, esophagus, or lungs

 Invasive cervical cancer
 Coccidioidomycosis
 Cryptococcosis
 Cryptosporidiosis, chronic intestinal (greater than 1 month's duration)
 Cytomegalovirus disease (particularly CMV retinitis)
 Encephalopathy, HIV-related
 Herpes simplex: chronic ulcer(s) (greater than 1 month's duration); or bronchitis,
pneumonitis, or esophagitis
 Histoplasmosis
 Isosporiasis, chronic intestinal (greater than 1 month's duration)
 Kaposi's sarcomav
 Lymphoma, multiple forms
 Mycobacterium avium complex
 Tuberculosis
 Pneumocystis carinii pneumonia
 Pneumonia, recurrent
 Progressive multifocal leukoencephalopathy
 Salmonella septicemia, recurrent
 Toxoplasmosis of brain
 Wasting syndrome due to HIV

2. A CD4 lymphocyte, helper T cell count of 200 or less. According to AIDS.gov recent research has
shown that it may be easier to mainatin higher CD4 counts if you start treatment before your count
drops below 350. Normal count ranges from 500 to 1,000.

3. Certain Cancers such as: Lymphoma, CNS Lymphoma, Kaposi's Sarcoma, Anal Cancer, and
Invasive Cervical Cancer.

Associated Co-morbidities

AIDS is an unique disease in that no other known infectious disease attacks the immune system
directly in the same manner. Because the immune system is greatly affected many patient's suffering
from AIDS may present with the folllowing co-morbidities among others: [5][6]
  Cancer (especially with the apperance of the highly unsual Kaposi's Sarcoma)
 Non-Hodgkin's Lymphoma
 AIDS-related primary central nervous system lymphoma
 Hepatocellular carcinoma
 Tuberculosis (pulmonary and extrapulmonary TB)
 HIV neurologic disease
 AIDS dementia complex/HIV encephalopathy
 Progressive multifocal leukoencephalopathy
 Vacuolar myelopathy (most common in the Thoracic spine)
 inflammatory polyneuropathies
 sensory neuropathies
 mononeuropathies
 inflammatory demylinating polyneuropathy (similar to Guillain-Barre syndrome)
 Cytomegalovirus
 hypersensitivity disorders
 A twofold increase in risk of MI[7]

 Chronic Kidney Failure  [7]

 Osteoporosis  [7]

Physical Therapist's Guide to HIV Disease and AIDS

Today, due to advances in medications, people with HIV (human immunodeficiency virus) disease
are living longer and leading more active lives than people who had the disease 30 years ago.
Antiretroviral drugs allow many people with HIV disease to live out their natural lifespan, but some of
the drugs have side effects. In addition, as people live longer with the disease, they may develop
other health conditions, too. Physical therapists:

 Tailor treatments that take HIV disease into account

 Provide customized exercise and pain management programs

 Help people with advanced HIV disease prevent, reduce, or delay movement and function
problems  

What is HIV Disease and AIDS?

HIV disease develops when the HIV retrovirus invades the body. HIV is most commonly passed from
person-to-person through:

 Sexual relations

 Exposure to contaminated blood

 Hypodermic needle-sharing or accidental punctures

 Mother-to-child transmission during pregnancy, childbirth, or breastfeeding

AIDS is the advanced stage of HIV infection, and is marked by the onset of serious, life-threatening
“opportunistic” infections that can occur because a person’s immune system is failing.
These infections, as well as the current medical treatment for HIV called antiretroviral therapy (ART),
can cause muscle, joint, nerve, or soft-tissue conditions that can interfere with normal movement
and endurance.

Signs and Symptoms

HIV infection and AIDS can cause a number of medical symptoms that are described on the Centers
for Disease Control and Prevention website. The symptoms listed there are not treated with physical
therapy, but by a physician.

HIV-related problems that can be treated by physical therapists are:   

 Chronic pain

 Burning sensations

 Numbness

 Tingling

 Cramps

 Spasms

 Muscle weakness

 Muscle or joint stiffness

 Balance problems

 Dizziness

 Fatigue

 Difficulty walking or using stairs

 Difficulty performing work, sports, or recreational activities

 Nerve damage that results in pain, burning sensations, numbness or tingling in the arms,
legs, or feet (known as “peripheral neuropathy”)

 Muscle aches and pains (myalgia)

Signs and Symptoms

Following acute infection with HIV, you might develop flu-like symptoms (fever, headache, sore
throat, swollen glands, rash) for a period of days or weeks—or you may have no symptoms at all.
After about 3 weeks, an HIV antibody test will show that you are HIV positive. Even when you’re HIV
positive, you might remain completely symptom free for years. If untreated, however, the disease will
progress, and you will begin to have such symptoms as:

 Swollen lymph nodes

  Diarrhea

 Weight loss

 Fever

 Night sweats

 Cough or shortness of breath

If untreated, advanced disease, or AIDS, usually develops within 10 years. Advanced disease
makes you more prone to get opportunistic infections. Symptoms may include:

 Night sweats

 Chills

 Cough

 Chronic diarrhea

 White spots or lesions on the tongue or in the mouth

 Skin rashes

 Headaches

 Fatigue

 Weight loss

 Cognitive changes, such as confusion or forgetfulness

 Blurred and distorted vision

Advanced disease also can lead to chronic pain and reduced ability to do work or recreational
activities, and this is where your physical therapist can help most.

People who are successfully treated with antiretroviral drugs do not usually get opportunistic
infections, but sometimes the side effects of some of the drugs—or simply having HIV disease for a
long time--can lead to health problems. For instance, you might develop:

 Peripheral neuropathy, which is nerve damage that results in pain, burning sensations, and
numbness or tingling in your arms or legs

 Muscle ache and pain (myalgia)

 High blood pressure (hypertension)

 High blood sugar (hyperglycemia)

A diagnosis of HIV disease might complicate your treatment for other health conditions. Common
conditions, injuries, or other problems related to aging might affect long-term survival, especially in
cases of advanced HIV disease.

How Is It Diagnosed?
HIV infection can only be diagnosed by a physician.

Physical therapists can evaluate people for symptoms occurring as a result of a diagnosed HIV
infection, or due to the side effects of treatment with antiretroviral therapy. They design
individualized programs of care and recovery for each person’s specific problems and goals.

How Can a Physical Therapist Help?

Although physical therapists do not treat HIV disease directly (that treatment is provided by an
infectious disease specialist), they play an important role in treating movement and daily function
problems. People with HIV disease also can experience sprains, strains, or age-related conditions,
such as arthritis, that can be treated by a physical therapist. Your physical therapist's overall goal is
to improve your quality of life and to help you remain active at home, at work, and in your
community.

Your physical therapist will conduct a thorough evaluation of your body to identify the causes of any
pain or difficulty with movement and physical activity. Your physical therapist will select from a
variety of treatments to address your specific needs. Treatments can help relieve pain and improve
heart health, balance, and the ability to perform daily activities.

Your physical therapist will work with you to improve:

Pain levels. HIV infection and medication can cause pain, burning sensations, numbness, tingling,
cramps, spasms, and weakness. Your physical therapist may apply hands-on techniques (manual
therapy) or technologies like electrical stimulation to help decrease your pain. Your physical therapist
may teach you gentle exercises or techniques to perform at home to reduce your pain. All of these
options may reduce or eliminate the need for opioid pain medication.

Motion. Your physical therapist will choose specific activities and treatments to help restore normal
movement to any joints and muscles that are stiff. These might begin with “passive” motions that the
physical therapist performs for you to gently move your joints and muscles, and progress to “active”
exercises and stretches that you perform yourself.

Recovery. Your physical therapist will teach you exercises to perform at home, designed for your
specific needs, to help speed your recovery from specific symptoms and problems.

Performance of daily activities. Your physical therapist will discuss your daily activity challenges
and goals with you and help you set your work, home life, and sports recovery goals. Your physical
therapist will teach you exercises, work retraining activities, and sport-specific techniques and drills
to help you reach your goals in the safest, fastest, and most effective way possible.

Heart health. People with advanced HIV disease may have a decreased ability to process oxygen
(aerobic capacity), causing fatigue. Research shows that aerobic exercise, such as walking on a
treadmill for at least 20 minutes, 3 times per week, may help improve aerobic capacity and maintain
the body’s ability to fight HIV disease. Your physical therapist can assess your aerobic capacity and
determine the best activities for you.
Walking. Your physical therapist will help improve your ability to walk using techniques such as
strengthening exercises, walking training, and balance activities. If you have nerve damage
(neuropathy), your physical therapist may provide bracing and other techniques to make it easier or
safer for you to walk. Your therapist also may recommend using an assistive device, such as a
walker or a cane.

Strength. Long-term HIV infection and ART can result in the loss of muscle strength and muscle
bulk (myopathy). Research shows that exercise using weights is effective in increasing strength in
people with HIV. Your physical therapist will work with you to set up an exercise program customized
just for you, adjusting it over time to address any changes in your medical condition. Certain
exercises will aid healing at each stage of recovery; your physical therapist will choose and teach
you the correct exercises and equipment to use.

Flexibility. Your physical therapist will determine if any of your muscles are tight, begin to gently
stretch them, and teach you how to stretch them. For extreme tightness, your physical therapist may
apply certain treatments prior to stretching, such as hot packs, to help relax and loosen the muscles.

Coordination. Your physical therapist will help you improve and regain your coordination and agility,
so you can perform household, community, and sports activities with greater ease.

Endurance. Your physical therapist will teach you exercises to improve endurance, so you can
return to your normal activities. Cardio-exercise equipment may be used, such as treadmills or
stationary bicycles.

Balance. Your physical therapist will examine your balance, and choose specific exercises you can
perform in the clinic and at home to improve your balance and prevent falls. Your physical therapist
also may teach you how to use a cane or walker to help maintain your balance when walking and
standing.

Body weight. By creating an exercise and physical activity program tailored just for you, your
physical therapist will help you maintain a healthy body weight, which can improve your energy
levels and boost your immune system.