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HUMAN IMMUNODEFICIENCY VIRUS, Exercise Prescription, Primary Infection…
HUMAN IMMUNODEFICIENCY VIRUS
Exercise Prescription
Complications with highly active antiretroviral therapy (HAART) therapy
Hyperlipidaemia or hyperlipoproteinemia
Osteonecrosis, or avascular necrosis
Impaired glucose metabolism & Insulin resistance
Diarrhoea, nausea, and other gastrointestinal tract disorders
Lipodystrophy
Increased risk of CVD and type 2 diabetes
Goals of exercise prescription
↓ CVD risk factors (blood lipids, obesity)
Enhance musculoskeletal function (strength & mobility)
Improve body composition (↓ visceral fat deposits)
Augment metabolic function (insulin resistance)
Include Resistance and aerobic exercise
Exercise Training and Immune Function
HIV-seropositive individuals have:
– ↓ed CD4+ counts
– Impaired ability to mobilize neutrophils and NK-cells into circulation.
• Exercise training does not appear to negatively affect immune function or disease progression.
• Some evidence of direct beneficial effects on immune function or viral load in HIV-infected individuals.
Take note of:
Patients should receive medical cleara
Goals are to enhance physical functioning and QOL and reduce morbidity
Modify for the individual circumstances
Strongly consider methods to positively affect adherance
Adherence
Factors influencing exercise adherence
Infection
Treatment complications
Poverty
Nausea
Inadequate transportations
High-intensity training has been shown to cause a decrement in exercise adherence due to DOMS, the risk of injury in untrained population or both
Substance abuse
Motivators of adherence
Self-efficacy - capable of performing a course of action to attain a desired outcome
Outcome expectation (belief of specific consequences will result from specific personal actions).
HIV anxiety, depression and depressive symptoms
↑ Supervision
↓ adherence
Type of training
Resistance
Progression
Slow incremental progression
To 3 sets at > 60% of 1 RM
Frequency
2-3 days/week
Duration
1/2 sets per exercise
8-10 reps per set
6-8 exercises
Goals
Focus on major muscle group strength and endurance
Intensity
80% of 10 RM or <= 60% of 1 RM
Special considerations
Suspect bone tumors
Suspect chronic unexplained musculoskeletal pain
Suspect Osteinecrosis
Mode
Free weights
Resistance bands
Machine weights
Resistance Exercise & Osteonecrosis
Joint capsule compromised
Resistance exercise contraindicated
Resistance Exercise & Peripheral Neuropathy
May affect coordination
Caution with all weight-bearing exercise
Range of Motion
Duration
Hold 10-30 sec
2-4 reps of each
Progression
Stretch should always be relaxed without significant discomfort
Frequency
2-3 days/week
Special considerations
Mild progression advised because of deconditioning
Intensity
Relaxed, comfortable stretch (tightness/discomfort)
Don't stretch to muscle spindle activation
Goals
Increase ROM
Mode
Yoga
Static or PNF stretching of major muscle groups
Aerobic
Duration
Begin with 10min
Progress to 40-59% of VO2R or HRR
Progression
Slow incremental pogression
40-59% of VO2R or HRR
Frequency
3-5 days/weel
Goals
Increase CRF
Intensity
Begin 30-39% of VO2R or HRR
Special considerations
Consider osteopenia risk
Mode
Cycling
Jogging
Walking
Swimming
CD4+ Count & Exercise Prescription
Alterations in values of immune function and viral load can be used to inform decisions regarding exercise prescription
Additionally, pharmacological treatments might influence exercise prescription.
The combination of viral effects, lifestyle choices (e.g., physical inactivity), and pharmacologic treatment renders management of HIV complex and multidimensional.
Primary Infection Syndrome
• Moderate to severe case of influenza
• Symptoms:
• Fever
• Sore throat
• Fatigue
• Lymphadenopathy
• Rash
• Myalgia
• Malaise
• Oral / esophageal sores or both
• Seroconversion phase
• Time of unchecked viremia before the development of antibodies)
• May last from a few days to several weeks
• Rapid replication leads to massive increase in HIV viral load
• Accompanied by decline in CD4+ cell count (which is usually reversible).
Clinical Considerations
Goals of exercise
Primary
• ↓ Morbidity & Mortality
• ↑ Quality of life
Secondary
• ↑ Cardiorespiratory fitness
• ↓ in Cardiovascular disease
• Improvement in body composition
• Improvement in metabolic functioning
• Improvement of musculoskeletal function
These modalities improve people’s capacity for activities of daily living as well as enhancing their ability to remain as physically and mentally active to the extent their illness allows.
Benefits of exercise training in the HIV-infected patient
↑ functionality
↑ endurance
↑ strength
↑ body composition
↓ incidence of comorbid chronic disease
↑ lipid profiles
↑ immune indices
↑ aerobic fitness
↑ Quality of Life
↑ resting heart rate
↑ mood
Inverses nervous system disorders
Signs & Symptoms
HIV-infected patient may present from completely
asymptomatic (stage 1) to critically ill (stage 3).
• Symptoms:
• Fever
• Sore throat
• Fatigue
• Lymphadenopathy
• Rash
• Myalgia
• Malaise
• Oral / esophageal sores or both
General Low CR-fitness
Latency may last from 2 weeks to 2 decades
HAART
History and Physical Examinations
Indications of metabolic disorders (lipodystrophy)
Motor abnormalities (hyperreflexia, loss of equilibrioception)
Changes in body weight (wasting)
CV disease (arrhythmias, edema)
General physical examination
Peripheral neuropathy (common issue with those on HAART therapy)
Behavioral/psychological symptoms: Fatigue, malaise, depression anxiety, isolation, lower QOL
Diagnostic testing
At-home tests
Measures: Antibodies
Standard Point-care
Measures: Antibodies
`Rapid point-of-care
Measures: Antigens & antibodies
Nucleic Acid Test
Measures: HIV RNA
Client Clinician
Interaction
Hands should be washed before and after examining or testing each patient
Use appropriate barrier precautions to prevent skin and mucous membrane exposure when there is potential for contact with blood or other body fluids
Face shields or goggles and surgical masks should be used for blood sampling
Saliva - Not implicated in transmission of HIV. However, mouth-to-mount resuscitation, mouthpieces or other ventilation devices should be available when need for resuscitation is anticipated
AIDS
• CD4+ T lymphocytes drop below 200 cells/μL
• T-lymphocyte percentage of total lymphocytes below 14%
• Without treatment, life expectancy is significantly shortened.
• Susceptible to opportunistic infections
• Patients develops AIDS-defining condition
Exercise Testing
Cardiorespiratory Testing
Cycle ergometry = better for patients who exhibit poor balance or coordination secondary to fatigue or neuromuscular pathologies.
VO 2peak = 24-44% below age-predicted norms
Some however, suffer from peripheral neuropathy = increased risk for autonomic neuropathy and abnormal responses to testing (attenuated heart rate)
HAART regimens = diminished ability to extract and use oxygen (mitochondrial effect of ARV
therapy rather than true HIV).
Most HIV
cardiorespiratory values in response to a graded exercise test.
↓ CRF results of increased sedentary living and lack of PA and exercise rather than disease progression or its treatment
Conditions that may contraindicate exercise
Orthopaedic complications
• Osteonecrosis
• Chronic & debilitating joint pain
•Bone tumors
• Rheumatic manifestations
Wasting
Not itself contraindication
HAART associated symptoms
Nausea
Metabolic complications
Cardiomyopath
• Most patients present with normal ECGS
• Pulmonary hypertension (HAART)
• Left atrial enlargement (HAART)
• Cardiovascular risk factors
Acute Illness
• Chills
• Fever
•Extreme fatigue
Assessment of functional status - Disease status
Symptomatic and suffering from acute exercise. May not exercise
Recovering from a medical or disease-related event. Significantly reduced VO2peak. Increased HR at submaximal work. Probability of abnormal neuroendocrine response
Asymptomatic, medically stable and physically inactive. Decreased exercise capacity due to sedentary lifestyle
Asymptomatic, medically stable and physically active. May not differ from age-adjusted norms
Test Type
Resistance
1 RM, 3 RM or 10 RM can be used
Consider repeated chair stands as a measure of physical function
Grip Strength
Range of motion
Sit-and-reach
Or any ROM assessment
Cardiorespiratory
Postpone testing in anyone with an active infection
Maximal testing is appropriate for individuals with stable disease
Patients commonly have significant lower peak VO2 vs age and sex matched healthy populations
Also have increased risk of CV impairment
Musculoskeletal
3 RM or 10 RM may be more appropriate due to general untrained status
Assess on multiple occasions as some individuals demonstrate substantial improvements during early stages of exercise training
Assessing musculoskeletal strength and ROM should not differ from non-infected individuals
Considered safe.
Use to evaluate CVD risk, especially those at high risk
Assess for HAART-related orthopaedic complications
Assess. functional status
Avoid testing if acutely ill
Long clinical asymptomatic phase
Pathophysiology
HIV infection results from the transfer of infected bodily fluids
Penetrative sexual contact
Contaminated blood transfusions & organ transplants
Perinatal exposure (in utero, during labour, while breastfeeding
Intravenous (IV) drug use
Before HAART treatment, opportunistic infections were the primary cause of mortality in AIDS patients - Pneumocystic jiroveci pneumonia (50%) & Kaposi sarcoma (25%)
Wasting
• Unintentional > 5% weight loss
• Typically late in disease process
• Affects < 10% of patients receiving appropriate treatment.
• Induces loss of function and weakness via a decrement in protein stores (e.g., lean body mass).
• Resistance training can ameliorate the catabolic effects of AIDS-induced wasting and lead to improvements in strength, protein stores (e.g., muscle mass), and physical functioning
Lipodystrophy
Visceral fat accumulation
May be a result of mitochondrial dysfunction or impaired physical fitness
Loss of subcutaneous fat deposits in arms, legs, and face
Cardiac dysfunction & HIV
Due to aging, antiretroviral therapy, chronic inflammation, and several other factors.
HIV infection reduces HDL cholesterol, raises triglycerides, total cholesterol and vascular inflammation.
Higher prevalence of left ventricular diastolic dysfunction, cardiomyopathy, myocarditis, pulmonary arterial hypertension, vasculitis, pericardial effusion,
premature atherosclerosis, MI, and arrhythmias (Torsades des Pointes)
Dietary modifications and exercise can reduce metabolic and cardiovascular risk in HIV patients.
• Patient unaware of infection and
asymptomatic
• 10yr in untreated individuals
• Over many years, decline in CD4 cell count typically occurs
• Results from
• Direct infection and apoptosis (programmed cell death) of the CD4+ cells by the virus
• Or from Cytotoxic immune response to viral infection (e.g., CD8+ mediated cell destruction)
Definition
Novel retrovirus
Lentivirus
Retroviridae family