Progressive resistive exercise interventions for adults living with HIV/AIDS

Perceptions, facilitators and barriers of physical activity among people living with HIV: a qualitative study

BACKGROUND

People living with HIV (PLWH) have low levels of physical activity. Using the social ecological model to understand perceptions, facilitators and barriers of physical activity in this population is of importance for developing contextualised interventions to improve physical activity in PLWH.

METHOD

This was a qualitative sub-study conducted between august and November 2019 as part of a cohort study on diabetes and associated complications in HIV infected in Mwanza, Tanzania. Sixteen in-depth interviews and three focus groups with nine participants in each were conducted. The interviews and focus groups were audio recorded, transcribed and translated into English. The social ecological model was considered during the coding and interpretation of the results. Transcripts were discussed, coded and analyzed using deductive content analysis.

RESULTS

Forty-three PLWH aged 23-61 years participated in this study. The findings showed that most PLWH perceived physical activity as beneficial to their health. However, their perceptions of physical activity were rooted within existing gender stereotypes and roles in the community. Running and playing football were perceived as activities for men while household chores activities were for women. Further, men were perceived to do more physical activity than women. For women, household chores and income-generating activities were perceived as sufficient physical activity. Social support and engagement of family members and friends in physical activity were reported as facilitators of physical activity. Reported barriers of physical activity were lack of time, money, availability of physical activity facilities and social support groups, and poor information on physical activity from health care providers in HIV clinics. Human-immunodeficiency virus (HIV) HIV infection was not perceived by PLWH as a barrier for doing physical activity but most family members did not support them to do physical activity, fearing that it might worsen their condition.

CONCLUSION

The findings demonstrated differing perceptions, facilitators and barriers of physical activity among PLWH. Interventions addressing awareness, gender stereotypes and roles related to physical activity from individual to community level are needed. Supportive environment and infrastructures are needed to improve physical activity levels in PLWH in Tanzania.

Levels and correlates of physical activity and capacity among HIV-infected compared to HIV-uninfected individuals

INTRODUCTION

In the HIV-infected individuals, physical activity improves physical strength, quality of life and reduces the risk of developing non-communicable diseases. In Sub-Saharan Africa, HIV-infected patients report being less active compared to HIV-uninfected individuals. We assessed the levels and correlates of objectively measured physical activity and capacity among HIV-infected antiretroviral therapy (ART)-naive individuals compared to HIV-uninfected individuals in Mwanza, Tanzania.

METHOD

We conducted a cross-sectional study among newly diagnosed HIV-infected ART-naive individuals and HIV-uninfected individuals frequency-matched for age and sex. Socio-demographic data, anthropometrics, CD4 counts, haemoglobin level, and C-reactive protein (CRP) were collected. Physical activity energy expenditure (PAEE) was assessed as measure of physical activity whereas sleeping heart rate (SHR) and grip strength were assessed as measures of physical capacity. Multivariable linear regression was used to assess the correlates associated with physical activity and capacity.

RESULTS

A total of 272 HIV-infected and 119 HIV-uninfected individuals, mean age 39 years and 60% women participated in the study. Compared to HIV-uninfected individuals, HIV-infected had poorer physical activity and capacity: lower PAEE (-7.3 kj/kg/day, 95% CI: -11.2, -3.3), elevated SHR (7.7 beats/min, 95%CI: 10.1, 5.3) and reduced grip strength (-4.7 kg, 95%CI: -6.8, -2.8). In HIV-infected individuals, low body mass index, moderate-severe anaemia, low CD4 counts and high CRP were associated with lower physical activity and capacity. In HIV-uninfected individuals, abdominal obesity and moderate anaemia were associated with lower physical activity and capacity.

CONCLUSION

HIV-infected participants had lower levels of physical activity and capacity than HIV-uninfected participants. Correlates of physical activity and capacity differed by HIV status. Management of HIV and related conditions needs to be provided effectively in health care facilities. Interventions promoting physical activity in these populations will be of importance to improve their health and reduce the risk of non-communicable diseases.

Comparative effects of 6-weeks progressive resistance exercise and moderate intensity aerobic exercise on CD4 count and weights of people living with HIV/AIDS in Alex-Ekwueme Federal University Teaching Hospital Ebonyi State

INTRODUCTION

The most significant clinical challenges in people living with HIV/AIDS (PLWHA) are decline in CD4+ T helper cells and abnormal weight reduction. Consequently, PLWHA who are on Anti-Retroviral Therapy (ART) or Highly Active Anti-Retroviral Therapy (HAART) are usually predisposed to coronary artery diseases due to abnormal weight gain (lipohypertrophy), though with improved and unstable Cluster of Differentiation 4 (CD4) counts.The main aim of this study was to compare the effects of 6 weeks progressive resistance exercise (PRE) and moderate intensity aerobic exercise (MIAE) on CD4 count, and weight of PLWHA in Alex-Ekwueme Federal University Teaching Hospital Ebonyi State.

METHOD

The study adopted quasi experimental research design. The population of the study was 60 Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome patients that attended HIV clinics at Alex-Ekwueme Federal University Teaching Hospital Abakaliki (AE-FUTHA) which formed 58 sample sizes for this study.Simple random sampling technique was adopted for the study and flow cytometry, Heel Densitometer (X-rite 331C), and Omron BF 400 were the instrument used for data collection of CD4 counts and weight respectively; and they are standardized hence not validated. Mean, standard deviation and Analysis of Co-variance (ANCOVA) were used to analyze the data obtained. The reliability coefficient obtained from the pilot study was 0.848 and 0.994 for CD4 and WEIGHT respectively.

RESULTS

The major findings revealed a significant difference after 6 weeks' PRE and MIAE on CD4 and Weight of PLWHA.

CONCLUSION

Health promotion policy maker's arm of the government and Healthcare givers should integrate and enforce the use of exercises either as a single regimen or combined exercises into the management plan of PLWHA for greater boost in absolute CD4 count bearing in mind that both have positive effects. Physiotherapist should be integrated in the managements of PLWHA for appropriate prescription and education of therapeutic exercises for body weight.

Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews

BACKGROUND

Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes.

METHODS

Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised.

RESULTS

Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I2 = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I2 = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions.

CONCLUSION

There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns.

TRIAL REGISTRATION

Registered in PROSPERO ( CRD42019120295 ) on 10th January 2019.

A qualitative focus group study of perceived barriers and benefits to exercise by self-described exercise status among older adults living with HIV

OBJECTIVES

Although exercise interventions have been shown to improve health outcomes among older people with HIV (PLWH), this population remains highly sedentary. The purpose of this study was to examine the differences in perceived barriers and benefits of exercise among older PLWH by self-identified exercise status.

DESIGN

Five focus groups were formed among PLWH: two groups of exercising men, two groups of non-exercising men and one group of women (mixed exercisers and non-exercisers). Themes were analysed in relation to the social-ecological model, utilising the constant comparative approach.

SETTING

Patients were recruited from an academic medical centre, HIV clinic and community locations.

PARTICIPANTS

PLWH aged 50 or older, diagnosed with HIV for at least 2 years, with no other health conditions that would preclude exercise.

PRIMARY AND SECONDARY OUTCOME MEASURES

Determine facilitators, barriers and the ideal environment for exercise or physical activity and determine whether these differ between older PLWH who self-identify as exercisers or non-exercisers.

RESULTS

Among 25 men (11 exercisers and 14 non-exercisers) and four women (three non-exercisers and one exerciser), non-exercisers mentioned fewer benefits of exercise (n=46) than exercisers (n=75). Exercisers emphasised positive reinforcement, positive mood change and increased energy as benefits of exercise; interpersonal benefits of exercise were also discussed twice as often by exercisers than by non-exercisers. Non-exercisers emphasised barriers to exercise including lack of motivation, lack of self-efficacy and a negative perception of gym culture. Non-exercisers identified the need for age-appropriate activities as a feature of an ideal exercise environment. Both groups identified time, cost and health-related challenges as barriers to exercise.

CONCLUSIONS

Unique exercise barriers and benefits by self-identified exercise status provide important insights into the design of future interventions to initiate and maintain exercise.

TRIAL REGISTRATION NUMBER

NCT02404792; Results.

A six week contextualised physical activity intervention for women living with HIV and AIDS of low socioeconomic status: a pilot study

Research has consistently shown the benefits of regular physical activity (PA) for women living with HIV and AIDS (WLWHA). This study is a pilot, randomised controlled crossover trial, reporting the effects of a contextualised PA intervention amongst a sample of 21 HIV positive Xhosa-speaking women of low socioeconomic status (SES). The study determined total moderate-to-vigorous PA (TMVPA) as measured subjectively by the Global Physical Activity Questionnaire (GPAQ), total weekly steps (TWS) as measured by a pedometer, and self-efficacy for PA as measured by the Physical Exercise Self-efficacy scale (PESES). Multivariate analysis of covariance (MANCOVA) was used to compute the impact of the intervention on TMVPA, TWS, and self-efficacy for PA from baseline to six weeks, and baseline to 12 weeks post-intervention controlling for pre-test differences in TMVPA. Results showed that participants exposed to the intervention had significant increases in PA as measured by TMVPA (p = .027), TWS (p = .032), as well as exercise self-efficacy (p = .000) from pre-test to 6 weeks. Insignificant findings were reported for all three variables when measured from baseline to 12 weeks. In conclusion, the findings of the pilot study suggest that the intervention was effective in producing significant increases in PA in a sample of PLWHA of low SES over six weeks. Careful consideration of behavioural constructs, such as self-efficacy, can help WLWHA of low SES to adopt regular PA as a complementary therapy for managing their health.

Evaluating the Effectiveness of Physical Exercise Interventions in Persons Living With HIV: Overview of Systematic Reviews

Physical exercise (PE) has not been well studied in persons living with HIV (PLHIV). We conducted an overview of systematic reviews to assess the effectiveness of PE and to determine the most appropriate PE regimen for PLHIV. We used the CDC's Prevention Research Synthesis Project's database and manual searches to identify systematic reviews published between 1996 and 2013. We qualitatively synthesized the findings from five reviews to assess the effectiveness of PE and conducted meta-analyses on CD4 counts to identify the best PE regimen. PE is associated with reduced adiposity and depression, but was not associated with a decrease in HIV viral load. CD4 counts were improved by interventions with interval aerobic or 41-50 minutes of exercise three times per week compared with other modes and duration of exercise. PE appears to benefit PLHIV, but more research is needed to help develop appropriate PE strategies specifically for PLHIV.

Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews

BACKGROUND

Chronic pain is defined as pain lasting beyond normal tissue healing time, generally taken to be 12 weeks. It contributes to disability, anxiety, depression, sleep disturbances, poor quality of life, and healthcare costs. Chronic pain has a weighted mean prevalence in adults of 20%.For many years, the treatment choice for chronic pain included recommendations for rest and inactivity. However, exercise may have specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, and physical functioning.Physical activity and exercise programmes are increasingly being promoted and offered in various healthcare systems, and for a variety of chronic pain conditions. It is therefore important at this stage to establish the efficacy and safety of these programmes, and furthermore to address the critical factors that determine their success or failure.

OBJECTIVES

To provide an overview of Cochrane Reviews of adults with chronic pain to determine (1) the effectiveness of different physical activity and exercise interventions in reducing pain severity and its impact on function, quality of life, and healthcare use; and (2) the evidence for any adverse effects or harm associated with physical activity and exercise interventions.

METHODS

We searched theCochrane Database of Systematic Reviews (CDSR) on the Cochrane Library (CDSR 2016, Issue 1) for systematic reviews of randomised controlled trials (RCTs), after which we tracked any included reviews for updates, and tracked protocols in case of full review publication until an arbitrary cut-off date of 21 March 2016 (CDSR 2016, Issue 3). We assessed the methodological quality of the reviews using the AMSTAR tool, and also planned to analyse data for each painful condition based on quality of the evidence.We extracted data for (1) self-reported pain severity, (2) physical function (objectively or subjectively measured), (3) psychological function, (4) quality of life, (5) adherence to the prescribed intervention, (6) healthcare use/attendance, (7) adverse events, and (8) death.Due to the limited data available, we were unable to directly compare and analyse interventions, and have instead reported the evidence qualitatively.

MAIN RESULTS

We included 21 reviews with 381 included studies and 37,143 participants. Of these, 264 studies (19,642 participants) examined exercise versus no exercise/minimal intervention in adults with chronic pain and were used in the qualitative analysis.Pain conditions included rheumatoid arthritis, osteoarthritis, fibromyalgia, low back pain, intermittent claudication, dysmenorrhoea, mechanical neck disorder, spinal cord injury, postpolio syndrome, and patellofemoral pain. None of the reviews assessed 'chronic pain' or 'chronic widespread pain' as a general term or specific condition. Interventions included aerobic, strength, flexibility, range of motion, and core or balance training programmes, as well as yoga, Pilates, and tai chi.Reviews were well performed and reported (based on AMSTAR), and included studies had acceptable risk of bias (with inadequate reporting of attrition and reporting biases). However the quality of evidence was low due to participant numbers (most included studies had fewer than 50 participants in total), length of intervention and follow-up (rarely assessed beyond three to six months). We pooled the results from relevant reviews where appropriate, though results should be interpreted with caution due to the low quality evidence. Pain severity: several reviews noted favourable results from exercise: only three reviews that reported pain severity found no statistically significant changes in usual or mean pain from any intervention. However, results were inconsistent across interventions and follow-up, as exercise did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point. Physical function: was the most commonly reported outcome measure. Physical function was significantly improved as a result of the intervention in 14 reviews, though even these statistically significant results had only small-to-moderate effect sizes (only one review reported large effect sizes). Psychological function and quality of life: had variable results: results were either favourable to exercise (generally small and moderate effect size, with two reviews reporting significant, large effect sizes for quality of life), or showed no difference between groups. There were no negative effects. Adherence to the prescribed intervention: could not be assessed in any review. However, risk of withdrawal/dropout was slightly higher in the exercising group (82.8/1000 participants versus 81/1000 participants), though the group difference was non-significant. Healthcare use/attendance: was not reported in any review. Adverse events, potential harm, and death: only 25% of included studies (across 18 reviews) actively reported adverse events. Based on the available evidence, most adverse events were increased soreness or muscle pain, which reportedly subsided after a few weeks of the intervention. Only one review reported death separately to other adverse events: the intervention was protective against death (based on the available evidence), though did not reach statistical significance.

AUTHORS' CONCLUSIONS

The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews.There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life.The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life. However, further research is required and should focus on increasing participant numbers, including participants with a broader spectrum of pain severity, and lengthening both the intervention itself, and the follow-up period.

WITHDRAWN: Interventions for fatigue and weight loss in adults with advanced progressive illness

BACKGROUND

Fatigue and unintentional weight loss are two of the commonest symptoms experienced by people with advanced progressive illness. Appropriate interventions may bring considerable improvements in function and quality of life to seriously ill people and their families, reducing physical, psychological and spiritual distress.

OBJECTIVES

To conduct an overview of the evidence available on the efficacy of interventions used in the management of fatigue and/or unintentional weight loss in adults with advanced progressive illness by reviewing the evidence contained within Cochrane reviews.

METHODS

We searched the Cochrane Database of Systematic Reviews (CDSR) for all systematic reviews evaluating any interventions for the management of fatigue and/or unintentional weight loss in adults with advanced progressive illness (The Cochrane Library 2010, Issue 8). We reviewed titles of interest by abstract. Where the relevance of a review remained unclear we reached a consensus regarding the relevance of the participant group and the outcome measures to the overview. Two overview authors extracted the data independently using a data extraction form. We used the measurement tool AMSTAR (Assessment of Multiple SysTemAtic Reviews) to assess the methodological quality of each systematic review.

MAIN RESULTS

We included 27 systematic reviews (302 studies with 31,833 participants) in the overview. None of the included systematic reviews reported quantitative data on the efficacy of interventions to manage fatigue or weight loss specific to people with advanced progressive illness. All of the included reviews apart from one were deemed of high methodological quality. For the remaining review we were unable to ascertain the methodological quality of the research strategy as it was described. None of the systematic reviews adequately described whether conflict of interests were present within the included studies. Management of fatigueAmyotrophic lateral sclerosis/motor neuron disease (ALS/MND) - we identified one systematic review (two studies and 52 participants); the intervention was exercise.Cancer - we identified five systematic reviews (116 studies with 17,342 participants); the pharmacological interventions were eicosapentaenoic acid (EPA) and any drug therapy for the management of cancer-related fatigue and the non pharmacological interventions were exercise, interventions by breast care nurses and psychosocial interventions.Chronic obstructive pulmonary disease (COPD) - we identified three systematic reviews (59 studies and 4048 participants); the interventions were self management education programmes, nutritional support and pulmonary rehabilitation.Cystic fibrosis - we identified one systematic review (nine studies and 833 participants); the intervention was physical training.Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) - we identified two systematic reviews (21 studies and 748 participants); the interventions were progressive resistive exercise and aerobic exercise.Multiple sclerosis (MS) - we identified five systematic reviews (23 studies and 1502 participants); the pharmacological interventions were amantadine and carnitine. The non pharmacological interventions were diet, exercise and occupational therapy.Mixed conditions in advanced stages of illness - we identified one systematic review (five studies and 453 participants); the intervention was medically assisted hydration. Management of weight lossALS/MND - we identified one systematic review but no studies met the inclusion criteria for the systematic review; the intervention was enteral tube feeding.Cancer - we identified three systematic reviews with a fourth systematic review also containing extractable data on cancer (66 studies and 5601 participants); the pharmacological interventions were megestrol acetate and eicosapentaenoic acid (EPA) (this systematic review is also included in the cancer fatigue section above). The non pharmacological interventions were enteral tube feeding and non invasive interventions for patients with lung cancer.COPD - we identified one systematic review (59 studies and 4048 participants); the intervention was nutritional support. This systematic review is also included in the COPD fatigue section.Cystic fibrosis - we identified two systematic reviews (three studies and 131 participants); the interventions were enteral tube feeding and oral calorie supplements.HIV/AIDS - we identified four systematic reviews (42 studies and 2071 participants); the pharmacological intervention was anabolic steroids. The non pharmacological interventions were nutritional interventions, progressive resistive exercise and aerobic exercise. Both of the systematic reviews on exercise interventions were also included in the HIV/AIDS fatigue section.MS - we found no systematic reviews which considered interventions to manage unintentional weight loss for people with a clinical diagnosis of multiple sclerosis at any stage of illness.Mixed conditions in advanced stages of illness - we identified two systematic reviews (32 studies and 4826 participants); the interventions were megestrol acetate and medically assisted nutrition.

AUTHORS' CONCLUSIONS

There is a lack of robust evidence for interventions to manage fatigue and/or unintentional weight loss in the advanced stage of progressive illnesses such as advanced cancer, heart failure, lung failure, cystic fibrosis, multiple sclerosis, motor neuron disease, Parkinson's disease, dementia and AIDS. The evidence contained within this overview provides some insight into interventions which may prove of benefit within this population such as exercise, some pharmacological treatments and support for self management.Researchers could improve the methodological quality of future studies by blinding of outcome assessors. Adopting uniform reporting mechanisms for fatigue and weight loss outcome measures would also allow the opportunity for meta-analysis of small studies.Researchers could also improve the applicability of recommendations for interventions to manage fatigue and unintentional weight loss in advanced progressive illness by including subgroup analysis of this population within systematic reviews of applicable interventions.More research is required to ascertain the best interventions to manage fatigue and/or weight loss in advanced illness. There is a need for standardised reporting of these symptoms and agreement amongst researchers of the minimum duration of studies and minimum percentage change in symptom experience that proves the benefits of an intervention. There are, however, challenges in providing meaningful outcome measurements against a background of deteriorating health through disease progression. Interventions to manage these symptoms must also be mindful of the impact on quality of life and should be focused on patient-orientated rather than purely disease-orientated experiences for patients. Systematic reviews and primary intervention studies should include the impact of the interventions on standardised validated quality of life measures.

Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews

BACKGROUND

Chronic pain is defined as pain lasting beyond normal tissue healing time, generally taken to be 12 weeks. It contributes to disability, anxiety, depression, sleep disturbances, poor quality of life, and healthcare costs. Chronic pain has a weighted mean prevalence in adults of 20%.For many years, the treatment choice for chronic pain included recommendations for rest and inactivity. However, exercise may have specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, and physical functioning.Physical activity and exercise programmes are increasingly being promoted and offered in various healthcare systems, and for a variety of chronic pain conditions. It is therefore important at this stage to establish the efficacy and safety of these programmes, and furthermore to address the critical factors that determine their success or failure.

OBJECTIVES

To provide an overview of Cochrane Reviews of adults with chronic pain to determine (1) the effectiveness of different physical activity and exercise interventions in reducing pain severity and its impact on function, quality of life, and healthcare use; and (2) the evidence for any adverse effects or harm associated with physical activity and exercise interventions.

METHODS

We searched theCochrane Database of Systematic Reviews (CDSR) on the Cochrane Library (CDSR 2016, Issue 1) for systematic reviews of randomised controlled trials (RCTs), after which we tracked any included reviews for updates, and tracked protocols in case of full review publication until an arbitrary cut-off date of 21 March 2016 (CDSR 2016, Issue 3). We assessed the methodological quality of the reviews using the AMSTAR tool, and also planned to analyse data for each painful condition based on quality of the evidence.We extracted data for (1) self-reported pain severity, (2) physical function (objectively or subjectively measured), (3) psychological function, (4) quality of life, (5) adherence to the prescribed intervention, (6) healthcare use/attendance, (7) adverse events, and (8) death.Due to the limited data available, we were unable to directly compare and analyse interventions, and have instead reported the evidence qualitatively.

MAIN RESULTS

We included 21 reviews with 381 included studies and 37,143 participants. Of these, 264 studies (19,642 participants) examined exercise versus no exercise/minimal intervention in adults with chronic pain and were used in the qualitative analysis.Pain conditions included rheumatoid arthritis, osteoarthritis, fibromyalgia, low back pain, intermittent claudication, dysmenorrhoea, mechanical neck disorder, spinal cord injury, postpolio syndrome, and patellofemoral pain. None of the reviews assessed 'chronic pain' or 'chronic widespread pain' as a general term or specific condition. Interventions included aerobic, strength, flexibility, range of motion, and core or balance training programmes, as well as yoga, Pilates, and tai chi.Reviews were well performed and reported (based on AMSTAR), and included studies had acceptable risk of bias (with inadequate reporting of attrition and reporting biases). However the quality of evidence was low due to participant numbers (most included studies had fewer than 50 participants in total), length of intervention and follow-up (rarely assessed beyond three to six months). We pooled the results from relevant reviews where appropriate, though results should be interpreted with caution due to the low quality evidence. Pain severity: several reviews noted favourable results from exercise: only three reviews that reported pain severity found no statistically significant changes in usual or mean pain from any intervention. However, results were inconsistent across interventions and follow-up, as exercise did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point. Physical function: was the most commonly reported outcome measure. Physical function was significantly improved as a result of the intervention in 14 reviews, though even these statistically significant results had only small-to-moderate effect sizes (only one review reported large effect sizes). Psychological function and quality of life: had variable results: results were either favourable to exercise (generally small and moderate effect size, with two reviews reporting significant, large effect sizes for quality of life), or showed no difference between groups. There were no negative effects. Adherence to the prescribed intervention: could not be assessed in any review. However, risk of withdrawal/dropout was slightly higher in the exercising group (82.8/1000 participants versus 81/1000 participants), though the group difference was non-significant. Healthcare use/attendance: was not reported in any review. Adverse events, potential harm, and death: only 25% of included studies (across 18 reviews) actively reported adverse events. Based on the available evidence, most adverse events were increased soreness or muscle pain, which reportedly subsided after a few weeks of the intervention. Only one review reported death separately to other adverse events: the intervention was protective against death (based on the available evidence), though did not reach statistical significance.

AUTHORS' CONCLUSIONS

The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews.There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life.The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life. However, further research is required and should focus on increasing participant numbers, including participants with a broader spectrum of pain severity, and lengthening both the intervention itself, and the follow-up period.

Evaluation of a physiotherapy-led group rehabilitation intervention for adults living with HIV: referrals, adherence and outcomes

HIV is characterised by episodes of disability. We report a novel, hospital outpatient rehabilitation intervention, combining physiotherapy-led group exercise and education for people living with HIV (PLWH). This observational study evaluated routine delivery of the 10-week intervention in terms of referral patterns, rehabilitation goals, intervention adherence and change in patient outcomes. Measurements at baseline & 10 weeks included locomotor performance (6 minute walk test; 6MWT), flexibility, upper and lower limb strength and health related quality of life (HRQOL). Adherence was defined as attending ≥8/20 sessions, with reasons for non-adherence identified in retrospective telephone interviews. Goal Attainment Scale measured progression to individual goals. Total 92 referrals were mostly for musculoskeletal (25.0%), oncological (19.6%) or cardio-metabolic (18.5%) reasons, and mostly male (81.5%), Caucasian (70.7%) and older (mean 51.5 years). Common themed rehabilitation goals included improving body image, participation, mobility, health/fitness and function. Adherence was achieved by 42 (46%) patients, with open access utilised by 34 patients, returning (n = 19) or restarting when non-adherent (n = 15). Post-intervention measurements collected for 37 (40%) patients demonstrated improvements in 6MWT distance (p < .001), flexibility (p < .001), strength in triceps (p < .001), biceps (p < .001), Lattisimus Dorsi (p < .001), shoulder-press (p < .001), chest-press (p < 0.001), and leg-press (p < 0.001). HRQOL improved in total score (p < .001), physical (p < .001), emotional (p < .001) and functional (p = .065) subscales. Extent of goal achievement demonstrated 83% of goals was "expected" (n = 57), "somewhat more" (n = 31) or "much more" (n = 14). Reasons for non-adherence from 21 telephone interviews identified physical health challenges, individual factors and time or location issues. This novel rehabilitation approach for PLWH improved function, HRQOL and goal attainment among those completing the intervention. Sub-optimal adherence likely relates to episodic disability.

Social-Ecological, Motivational and Volitional Factors for Initiating and Maintaining Physical Activity in the Context of HIV

Sport and exercise can have several health benefits for people living with HIV. These benefits can be achieved through different types of physical activity, adapting to disease progression, motivation and social-ecological options. However, physical activity levels and adherence to exercise are generally low in people living with HIV. At the same time, high drop-out rates in intervention studies are prevalent; even though they often entail more favourable conditions than interventions in the natural settings. Thus, in the framework of an intervention study, the present study aims to explore social-ecological, motivational and volitional correlates of South African women living with HIV with regard to physical activity and participation in a sport and exercise health promotion programme. The qualitative data was produced in the framework of a non-randomised pre-post intervention study that evaluated structure, processes and outcomes of a 10-week sport and exercise programme. All 25 participants of the programme were included in this analysis, independent of compliance. Data was produced through questionnaires, participatory group discussions, body image pictures, research diaries and individual semi-structured interviews. All participants lived in a low socioeconomic, disadvantaged setting. Hence, the psychological correlates are contextualised and social-ecological influences on perception and behaviour are discussed. The results show the importance of considering social-cultural and environmental influences on individual motives, perceptions and expectancies, the fear of disclosure and stigmatisation, sport and exercise-specific group dynamics and self-supporting processes. Opportunities and strategies to augment physical activity and participation in sport and exercise programmes in the context of HIV are discussed.

Effects of Combined Aerobic and Resistance Exercise on Exercise Capacity, Muscle Strength and Quality of Life in HIV-Infected Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Many HIV-infected patients demonstrate disability and lower aerobic capacity. The inclusion of resistance training combined with aerobic exercise in a single program is known as combined aerobic and resistance exercise (CARE) and seems to be an effective strategy to improve muscle weakness, as well as aerobic capacity in HIV-infected patients. We performed a meta-analysis to investigate the effects of CARE in HIV-infected patients.

METHODS

We searched MEDLINE, Cochrane Controlled Trials Register, EMBASE, CINAHL (from the earliest date available to august 2014) for controlled trials that evaluated the effects of CARE in HIV-infected patients. Weighted mean differences (WMD) and 95% confidence intervals (CIs) were calculated, and heterogeneity was assessed using the I2 test.

RESULTS

Seven studies met the study criteria. CARE resulted in improvement in Peak VO2 WMD (4.48 mL·kg-1·min-1 95% CI: 2.95 to 6.0), muscle strength of the knee extensors WMD (25.06 Kg 95% CI: 10.46 to 39.66) and elbow flexors WMD (4.44 Kg 95% CI: 1.22 to 7.67) compared with no exercise group. The meta-analyses also showed significant improvement in Health status, Energy/Vitality and physical function domains of quality of life for participants in the CARE group compared with no exercise group. A nonsignificant improvement in social function domain of quality of life was found for participants in the CARE group compared with no exercise group.

CONCLUSIONS

Combined aerobic and resistance exercise may improve peak VO2, muscle strength and health status, energy and physical function domains of quality of life and should be considered as a component of care of HIV-infected individuals.

Informing the development of an online self-management program for men living with HIV: a needs assessment

Background

The aim of this mixed methods study was to conduct a multifaceted needs assessment to inform the development of an online self-management program for men living with HIV. The objectives were to describe the health-related quality of life for men living with HIV, the impact of living with HIV, and the perceived problem areas and service and support needs of these men. The needs assessment was conducted in accordance with the PRECEDE model for health promotion program planning.

Methods

A survey assessing the quality of life of men living with HIV (n = 72) was conducted and results were compared to Australian normative data. Focus groups were also undertaken with men living with HIV (n = 11) and a multidisciplinary team of service providers working in the area of HIV (n = 11). Focus groups enabled an in-depth description of the impact of HIV on quality of life and perceived problem areas in daily life.

Results

HIV-positive men experience significantly lower quality of life when compared with Australian normative data, particularly in those domains concerned with social and emotional aspects of quality of life. Qualitative focus groups yielded an overarching theme ‘The psychosocial impact of HIV’ which contained three sub-themes; (1) Life before and after HIV – a changed identity and its repercussions; (2) Resilience and the importance of social support; (3) Negotiating the practicalities – intimate relationships and disclosure.

Conclusions

The findings from this needs assessment highlight the need to target socio-emotional contexts of HIV positive men’s daily lives to improve quality of life and well-being. Intervention priorities for the proposed online self-management program include: (1) managing the emotional impact of HIV; (2) disclosing HIV status to family and friends; (3) maintaining social connectedness; (4) managing HIV within intimate relationships; and (5) disclosure of HIV status to intimate partners.

A guide to exercise prescription

Exercise is a fundamental component of good health. The American College of Sports Medicine and "Exercise is Medicine" recommend treating exercise as a vital sign, and assessing and prescribing physical activity at every medical visit. Meeting the recommended goals of physical activity results in a significant reduction in all-cause mortality. Physicians can improve health by prescribing exercise.

Physiotherapy intervention as a complementary treatment for people living with HIV/AIDS

Background

The advent of highly active antiretroviral therapy has dramatically extended the life expectancy of people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome. Despite this increased longevity, HIV disease and its pharmacological treatment can cause long-term and acute health complications, many of which can be treated successfully by physiotherapy. The purpose of this paper is to report the effect of a 12-week rehabilitation program on several health-related markers in a 43-year-old woman living with HIV.

Methods

This case study examined the effect of a 12-week exercise and manual therapy intervention on morphology, pain, cardiopulmonary fitness, strength, neurological balance, immune markers (CD4 cell count), and quality of life in a 43-year-old woman living with HIV.

Results

The results showed complete elimination of pain and shortness of breath on exertion. There was also a reduction in resting heart rate, waist circumference, exercise duration, muscle strength, and endurance. The patient showed an increase in peak expiratory flow rate, maximal heart rate attained, upper arm, forearm, and thigh circumference, and CD4+ cell count. The patient also showed improvements in the quality of life domains of general health, pain, energy/fatigue, social and physical functioning, and emotional well-being.

Conclusion

Physiotherapy interventions consisting of exercise and manual therapy appear beneficial in several areas as an adjunct therapy in HIV management.

Pain in people living with HIV/AIDS: a systematic review

INTRODUCTION

Pain is one of the most commonly reported symptoms in people living with HIV/AIDS (PLWHA). However, wide ranges of pain prevalence have been reported, making it difficult to determine the relative impact of pain in PLWHA. A systematic review of the literature was conducted to establish the prevalence and characteristics of pain and to explore pain management in PLWHA.

METHODS

Studies that included cross-sectional data were included in the search, which was conducted in April 2012. Databases searched using a time limit of March 1982 to March 2012 included PubMed, Scopus, Africa-wide: NIPAD, CINAHL, PsychARTICLES, PSYCINFO, PSYCHIATRYONLINE, ScienceDirect and Web of Science. Search terms selected were "pain" and "HIV" or "acquired immune deficiency syndrome." Two reviewers independently screened all citation abstracts for inclusion. Methodological quality was evaluated using a standardized 11-item critical appraisal tool.

RESULTS

After full text review, 61 studies fulfilled the inclusion criteria. Prevalence of pain ranged from a point prevalence of 54% (95%CI 51.14-56.09) to 83% (95%CI 76-88) using a three-month recall period. The reported pain was of moderate-to-severe intensity, and pain was reported in one to two and a half different anatomical sites. Moderate levels of pain interference with function were reported. All nine studies reporting on the adequacy of pain management recorded marked under-treatment of pain.

DISCUSSION

The studies reviewed reported that pain commonly presents at multiple pain sites with a range of severity suggesting that there are several differing pathological processes contributing to pain at one time. The interplay of variables associated with pain suggests that the biopsychosocial model of pain is an appropriate paradigm from which to view pain in PLWHA and from which to approach the problem, explore causes and establish effective treatment.

CONCLUSIONS

The results highlight that pain is common in PLWHA at all stages of the disease. The prevalence rates for pain in PLWHA do not appear to have diminished over the 30 years spanning the studies reviewed. The body of work available in the literature thus far, while emphasizing the problem of pain, has not had an impact on its management.

The positive outlook study- a randomised controlled trial evaluating the effectiveness of an online self-management program targeting psychosocial issues for men living with HIV: a study protocol

Background

The emergence of HIV as a chronic condition means that people living with HIV are required to take more responsibility for the self-management of their condition, including making physical, emotional and social adjustments. This paper describes the design and evaluation of Positive Outlook, an online program aiming to enhance the self-management skills of gay men living with HIV.

Methods/design

This study is designed as a randomised controlled trial in which men living with HIV in Australia will be assigned to either an intervention group or usual care control group. The intervention group will participate in the online group program ‘Positive Outlook’. The program is based on self-efficacy theory and uses a self-management approach to enhance skills, confidence and abilities to manage the psychosocial issues associated with HIV in daily life. Participants will access the program for a minimum of 90 minutes per week over seven weeks. Primary outcomes are domain specific self-efficacy, HIV related quality of life, and outcomes of health education. Secondary outcomes include: depression, anxiety and stress; general health and quality of life; adjustment to HIV; and social support. Data collection will take place at baseline, completion of the intervention (or eight weeks post randomisation) and at 12 week follow-up.

Discussion

Results of the Positive Outlook study will provide information regarding the effectiveness of online group programs improving health related outcomes for men living with HIV.

Trial registration

ACTRN12612000642886.

Pilot study of pioglitazone and exercise training effects on basal myocardial substrate metabolism and left ventricular function in HIV-positive individuals with metabolic complications

BACKGROUND

Individuals with HIV infection and peripheral metabolic complications have impaired basal myocardial insulin sensitivity that is related to left ventricular (LV) diastolic dysfunction. It is unknown whether interventions shown to be effective in improving peripheral insulin sensitivity can improve basal myocardial insulin sensitivity and diastolic function in people with HIV and peripheral metabolic complications.

OBJECTIVE

In a pilot study, we evaluated whether the peroxisome proliferator-activated receptor-gamma (PPAR-γ) agonist pioglitazone or combined endurance and resistance exercise training improves basal myocardial insulin sensitivity and diastolic function in HIV+ adults with peripheral metabolic complications.

DESIGN

Twenty-four HIV+ adults with metabolic complications including peripheral insulin resistance were randomly assigned to 4 months of pioglitazone (PIO; 30 mg/d) or supervised, progressive endurance and resistance exercise training (EXS; 90-120 min/d, 3 d/wk). Basal myocardial substrate metabolism was quantified by radioisotope tracer methodology and positron emission tomography (PET) imaging, and LV function was measured by echocardiography.

RESULTS

Twenty participants completed the study. Neither PIO nor EXS resulted in a detectable improvement in basal myocardial insulin sensitivity or diastolic function. Post hoc analyses revealed sample sizes of more than 100 participants are needed to detect significant effects of these interventions on basal myocardial insulin sensitivity and function.

CONCLUSIONS

PIO or EXS alone did not significantly increase basal myocardial insulin sensitivity or LV diastolic function in HIV+ individuals with peripheral metabolic complications.

Human immunodeficiency virus-associated obstructive lung diseases

In the era of effective antiretroviral therapy (ART), epidemiologic studies have found that persons infected with human immunodeficiency virus (HIV) have a higher prevalence and incidence of chronic obstructive pulmonary disease than HIV-uninfected persons. In comparison with HIV-uninfected persons and those with well-controlled HIV disease, HIV-infected persons with poor viral control or lower CD4 cell count have more airflow obstruction, a greater decline in lung function, and possibly more severe diffusing impairment. This article reviews the evidence linking HIV infection to obstructive lung disease, and discusses management issues related to the treatment of obstructive lung disease in HIV-infected patients.

Counselling, case management and health promotion for people living with HIV/AIDS: an overview of systematic reviews

Our objective was to identify all existing systematic reviews related to counselling, case management and health promotion for people living with HIV/AIDS. For the reviews identified, we assessed the quality and local applicability to support evidence-informed policy and practice. We searched 12 electronic databases and two reviewers independently assessed the 5,398 references retrieved from our searches and included 18 systematic reviews. Each review was categorized according to the topic(s) addressed, quality appraised and summarized by extracting key messages, the year searches were last completed and the countries in which included studies were conducted. Twelve reviews address topics related to counselling and case management (mean quality score of 6.5/11). Eight reviews (mean quality score of 6/11) address topics related to health promotion (two address both domains). The findings from this overview of systematic reviews provide a useful resource for supporting the development and delivery of evidence-informed support services in community settings.

A systematic review of effects of concurrent strength and endurance training on the health-related quality of life and cardiopulmonary status in patients with HIV/AIDS

PURPOSE

To determine the effects of concurrent strength and endurance training (concurrent training) on the Health-Related Quality of Life (HRQOL) and cardiopulmonary status among HIV-infected patients, using a systematic search strategy of randomized, controlled trials (RCTs).

METHODS

A systematic review was performed by two independent reviewers using Cochrane Collaboration protocol. The sources used in this review were Cochrane Library, EMBASE, LILACS, MEDLINE, PEDro and Web of Science from 1950 to August 2012. The PEDro score was used to evaluate methodological quality.

RESULT

Individual studies suggested that concurrent training contributed to improved HRQOL and cardiovascular status. Concurrent training appears to be safe and may be beneficial for medically stable adults living with HIV. The rates of nonadherence were of 16%.

CONCLUSION

Concurrent training improves the HRQOL and cardiopulmonary status. It may be an important intervention in the care and treatment of adults living with HIV. Further research is needed to determine the minimal and optimal duration, frequency, and intensity of exercise needed to produce beneficial changes in the HIV-infected population subgroups.

A systematic review of the effects of different types of therapeutic exercise on physiologic and functional measurements in patients with HIV/AIDS

Several studies have reported the benefits of exercise training for adults with HIV, although there is no consensus regarding the most efficient modalities. The aim of this study was to determine the effects of different types of exercise on physiologic and functional measurements in patients with HIV using a systematic strategy for searching randomized controlled trials. The sources used in this review were the Cochrane Library, EMBASE, MEDLINE, and PEDro from 1950 to August 2012. We selected randomized controlled trials examining the effects of exercise on body composition, muscle strength, aerobic capacity, and/or quality of life in adults with HIV. Two independent reviewers screened the abstracts using the Cochrane Collaboration's protocol. The PEDro score was used to evaluate methodological quality. In total, 29 studies fulfilled the inclusion criteria. Individual studies suggested that exercise training contributed to improvement of physiologic and functional parameters, but that the gains were specific to the type of exercise performed. Resistance exercise training improved outcomes related to body composition and muscle strength, with little impact on quality of life. Aerobic exercise training improved body composition and aerobic capacity. Concurrent training produced significant gains in all outcomes evaluated, although moderate intensity and a long duration were necessary. We concluded that exercise training was shown to be a safe and beneficial intervention in the treatment of patients with HIV.

Interventions for fatigue and weight loss in adults with advanced progressive illness

BACKGROUND

Fatigue and unintentional weight loss are two of the commonest symptoms experienced by people with advanced progressive illness. Appropriate interventions may bring considerable improvements in function and quality of life to seriously ill people and their families, reducing physical, psychological and spiritual distress.

OBJECTIVES

To conduct an overview of the evidence available on the efficacy of interventions used in the management of fatigue and/or unintentional weight loss in adults with advanced progressive illness by reviewing the evidence contained within Cochrane reviews.

METHODS

We searched the Cochrane Database of Systematic Reviews (CDSR) for all systematic reviews evaluating any interventions for the management of fatigue and/or unintentional weight loss in adults with advanced progressive illness (The Cochrane Library 2010, Issue 8). We reviewed titles of interest by abstract. Where the relevance of a review remained unclear we reached a consensus regarding the relevance of the participant group and the outcome measures to the overview. Two overview authors extracted the data independently using a data extraction form. We used the measurement tool AMSTAR (Assessment of Multiple SysTemAtic Reviews) to assess the methodological quality of each systematic review.

MAIN RESULTS

We included 27 systematic reviews (302 studies with 31,833 participants) in the overview. None of the included systematic reviews reported quantitative data on the efficacy of interventions to manage fatigue or weight loss specific to people with advanced progressive illness. All of the included reviews apart from one were deemed of high methodological quality. For the remaining review we were unable to ascertain the methodological quality of the research strategy as it was described. None of the systematic reviews adequately described whether conflict of interests were present within the included studies.Management of fatigue Amyotrophic lateral sclerosis/motor neuron disease (ALS/MND) - we identified one systematic review (two studies and 52 participants); the intervention was exercise.Cancer - we identified five systematic reviews (116 studies with 17,342 participants); the pharmacological interventions were eicosapentaenoic acid (EPA) and any drug therapy for the management of cancer-related fatigue and the non pharmacological interventions were exercise, interventions by breast care nurses and psychosocial interventions.Chronic obstructive pulmonary disease (COPD) - we identified three systematic reviews (59 studies and 4048 participants); the interventions were self management education programmes, nutritional support and pulmonary rehabilitation.Cystic fibrosis - we identified one systematic review (nine studies and 833 participants); the intervention was physical training.Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) - we identified two systematic reviews (21 studies and 748 participants); the interventions were progressive resistive exercise and aerobic exercise.Multiple sclerosis (MS) - we identified five systematic reviews (23 studies and 1502 participants); the pharmacological interventions were amantadine and carnitine. The non pharmacological interventions were diet, exercise and occupational therapy.Mixed conditions in advanced stages of illness - we identified one systematic review (five studies and 453 participants); the intervention was medically assisted hydration.Management of weight loss ALS/MND - we identified one systematic review but no studies met the inclusion criteria for the systematic review; the intervention was enteral tube feeding.Cancer - we identified three systematic reviews with a fourth systematic review also containing extractable data on cancer (66 studies and 5601 participants); the pharmacological interventions were megestrol acetate and eicosapentaenoic acid (EPA) (this systematic review is also included in the cancer fatigue section above). The non pharmacological interventions were enteral tube feeding and non invasive interventions for patients with lung cancer.COPD - we identified one systematic review (59 studies and 4048 participants); the intervention was nutritional support. This systematic review is also included in the COPD fatigue section.Cystic fibrosis - we identified two systematic reviews (three studies and 131 participants); the interventions were enteral tube feeding and oral calorie supplements.HIV/AIDS - we identified four systematic reviews (42 studies and 2071 participants); the pharmacological intervention was anabolic steroids. The non pharmacological interventions were nutritional interventions, progressive resistive exercise and aerobic exercise. Both of the systematic reviews on exercise interventions were also included in the HIV/AIDS fatigue section.MS - we found no systematic reviews which considered interventions to manage unintentional weight loss for people with a clinical diagnosis of multiple sclerosis at any stage of illness.Mixed conditions in advanced stages of illness - we identified two systematic reviews (32 studies and 4826 participants); the interventions were megestrol acetate and medically assisted nutrition.

AUTHORS' CONCLUSIONS

There is a lack of robust evidence for interventions to manage fatigue and/or unintentional weight loss in the advanced stage of progressive illnesses such as advanced cancer, heart failure, lung failure, cystic fibrosis, multiple sclerosis, motor neuron disease, Parkinson's disease, dementia and AIDS. The evidence contained within this overview provides some insight into interventions which may prove of benefit within this population such as exercise, some pharmacological treatments and support for self management.Researchers could improve the methodological quality of future studies by blinding of outcome assessors. Adopting uniform reporting mechanisms for fatigue and weight loss outcome measures would also allow the opportunity for meta-analysis of small studies.Researchers could also improve the applicability of recommendations for interventions to manage fatigue and unintentional weight loss in advanced progressive illness by including subgroup analysis of this population within systematic reviews of applicable interventions.More research is required to ascertain the best interventions to manage fatigue and/or weight loss in advanced illness. There is a need for standardised reporting of these symptoms and agreement amongst researchers of the minimum duration of studies and minimum percentage change in symptom experience that proves the benefits of an intervention. There are, however, challenges in providing meaningful outcome measurements against a background of deteriorating health through disease progression. Interventions to manage these symptoms must also be mindful of the impact on quality of life and should be focused on patient-orientated rather than purely disease-orientated experiences for patients. Systematic reviews and primary intervention studies should include the impact of the interventions on standardised validated quality of life measures.

Physical therapy in palliative care: from symptom control to quality of life: a critical review

Physiotherapy is concerned with identifying and maximizing movement potential, within the spheres of promotion, prevention, treatment and rehabilitation. Physical therapists practice in a broad range of inpatient, outpatient, and community-based settings such as hospice and palliative care centers where as part of a multidisciplinary team of care, they address the physical and functional dimensions of the patients’ suffering. Physiotherapy treatment methods like therapeutic exercise, electrical modalities, thermal modalities, actinotherapy, mechanical modalities, manual physical therapy and assistive devices are useful for a range of life-threatening and life-limiting conditions like cancer and cancer-associated conditions; HIV; neurodegenerative disorders like amyotrophic lateral sclerosis, multiple sclerosis; respiratory disorders like idiopathic pulmonary fibrosis; and altered mental states. The professional armamentarium is still expanding with inclusion of other miscellaneous techniques which were also proven to be effective in improving quality of life in these patients. Considering the scope of physiotherapy in India, and in palliative care, professionals in a multidisciplinary palliative care team need to understand and mutually involve toward policy changes to successfully implement physical therapeutic palliative care delivery.

Complementary and alternative therapy (CAT) use and highly active antiretroviral therapy (HAART): current evidence in the literature, 2000-2009

AIM AND OBJECTIVE

To determine current evidence about the use of complementary and alternative medicine in the context of highly active antiretroviral therapy. The following objectives included identifying the risks and benefits of using complementary and alternative medicine when living with the human immunodeficiency virus (HIV) and taking such medications.

BACKGROUND

In Canada and the USA, HIV/AIDS service organisations recognise that people affected or infected by HIV are increasingly choosing to use complementary and alternative medicine to cope with this disease. These same organisations advocate for increased access to complementary and alternative medicine and more information about the safe use of complementary and alternative medicine to make informed decisions. Based on the increased integral use of complementary and alternative medicine and conventional medicine in Canada and the USA, the literature review was limited to these two countries.

DESIGN

Systematic review.

METHOD

Available full-text abstracts published in English from 2000-2009 were retrieved by electronic searches of selected databases, including the websites of Health Canada and American National Center for Complementary and Alternate Medicine (NCCAM). Forty studies were examined and were categorised by referring to the NCCAM (2007) four types of complementary and alternative medicine.

RESULTS

Insufficient evidence exists to support the use of a particular complementary and alternate therapy to enhance the management of HIV disease.

CONCLUSION

Decisions about using complementary and alternative medicine in conjunction with highly active antiretroviral therapy are often poorly informed. Safety risks and potential drug interactions are frequently ignored as people who use highly active antiretroviral therapy prefer to focus on the physical and mental benefits of using selected complementary and alternate therapies to promote their quality of life.

RELEVANCE TO CLINICAL PRACTICE

As life expectancy increases, from the use of highly active antiretroviral therapy, it is important for health professionals like nurses to be knowledgeable about the prevention, assessment and treatment of HIV symptoms and treatment side effects. Given the increased trend of using complementary and alternative medicine by the general population, it is also important to understand the appropriate use of complementary and alternative medicine for symptom management in HIV/AIDS care.

Outcomes of highly active antiretroviral therapy in the context of universal access to healthcare: the U.S. Military HIV Natural History Study

Background

To examine the outcomes of highly-active antiretroviral therapy (HAART) for individuals with free access to healthcare, we evaluated 2327 patients in a cohort study composed of military personnel and beneficiaries with HIV infection who initiated HAART from 1996 to the end of 2007.

Methods

Outcomes analyzed were virologic suppression (VS) and failure (VF), CD4 count changes, AIDS and death. VF was defined as never suppressing or having at least one rebound event. Multivariate (MV) analyses stratified by the HAART initiation year (before or after 2000) were performed to identify risk factors associated with these outcomes.

Results

Among patients who started HAART after 2000, 81% had VS at 1 year (N = 1,759), 85% at 5 years (N = 1,061), and 82% at 8 years (N = 735). Five years post-HAART, the median CD4 increase was 247 cells/ml and 34% experienced VF. AIDS and mortality rates at 5 years were 2% and 0.3%, respectively. In a MV model adjusted for known risk factors associated with treatment response, being on active duty (versus retired) at HAART initiation was associated with a decreased risk of AIDS (HR = 0.6, 95% CI 0.4-1.0) and mortality (0.6, 0.3-0.9), an increased probability of CD4 increase ≥ 50% (1.2, 1.0-1.4), but was not significant for VF.

Conclusions

In this observational cohort, VS rates approach those described in clinical trials. Initiating HAART on active duty was associated with even better outcomes. These findings support the notion that free access to healthcare likely improves the response to HAART thereby reducing HIV-related morbidity and mortality.

HIV/AIDS e Treinamento Concorrente: a Revisão Sistemática

O uso da terapia anti-retroviral combinada (TARV) aumentou a expectativa de vida dos portadores do vírus da imunodeficiência humana (HIV) e, como conseqüência, torna-se constante o estudo do processo fisiopatológico da infecção e das estratégias de intervenção que possam melhorar a qualidade de vida destes indivíduos. O treinamento concorrente, definido como a associação dos componentes aeróbios e força na mesma sessão de exercícios pode ser inserido neste contexto. O objetivo deste artigo é revisar os aspectos centrais da infecção pelo HIV e as evidências existentes sobre o treinamento concorrente com séries múltiplas e simples nos parâmetros imunológico, virológico, cardiorrespiratório e neuromuscular de pessoas infectadas pelo HIV. O método utilizado foi uma revisão sistemática, com artigos publicados entre 2000-2007, nas bases de dados scielo e pubmed e também em dissertações e teses da biblioteca digital da educação física, esporte e saúde. As evidências científicas encontradas nos 8 estudos analisados indicam que o treinamento concorrente, tanto com séries múltiplas quanto séries simples, melhora os parâmetros cardiorrespiratório e neuromuscular; no entanto, os resultados dos parâmetros imunológico e virológico ainda não estão completamente esclarecidos, principalmente sobre os protocolos com séries simples. Considerando o número restrito de trabalhos apresentados, sugere-se o desenvolvimento de estudos com treinamento concorrente em vários desfechos clínicos para pessoas infectadas pelo HIV.

Massage therapy for people with HIV/AIDS

BACKGROUND

Infection with human immunodeficency virus (HIV) and acquired immunodeficency syndrome (AIDS) is a pandemic that has affected millions of people globally. Although major research and clinical initiatives are addressing prevention and cure strategies, issues of quality of life for survivors have received less attention. Massage therapy is proposed to have a positive effect on quality of life and may also have a positive effect on immune function through stress mediation.

OBJECTIVES

The objective of this systematic review was to examine the safety and effectiveness of massage therapy on quality of life, pain and immune system parameters in people living with HIV/AIDS.

SEARCH STRATEGY

A comprehensive search strategy was devised incorporating appropriate terms for HIV/AIDS, randomised controlled trials (RCTs), massage therapy and the pertinent measures of benefit. All electronic databases identified were searched in November 2008, including Cochrane Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, SCIENCE CITATION INDEX, AIDSLINE, AIDSearch, CINAHL, HEALTHSTAR, PsycLIT, AMED, Current Contents, AMI, NLM GATEWAY, LILACS, IndMed, SOCIOFILE, SCI, SSCI, ERIC and DAI. We also reviewed relevant published and unpublished conference abstracts and proceedings and scrutinised reference lists from pertinent journals. There were no language or date restrictions.

SELECTION CRITERIA

Studies were identified by two reviewers based on trial design (RCTs) and participants (ie, people of any age with HIV/AIDS, at any stage of the disease) who had undergone an intervention that included massage therapy for the identified aims of improving quality of life and activity and participation levels, improving immune function, reducing pain and improving other physiological or psychological impairments.

DATA COLLECTION AND ANALYSIS

Two reviewers independently identified included studies and extracted relevant data. Two other reviewers independently reviewed the included studies for risk of bias. All data and risk of bias judgements were entered into Revman (v5) and meta-analyses were conducted where appropriate.

MAIN RESULTS

Twelve papers were identified, from which four were included. The remaining eight papers were excluded predominantly due to inappropriate methodology. The four included studies were highly clinically heterogenous, investigating a range of age groups (ie, children, adolescents and adults) across the disease spectrum from early HIV through late-stage AIDS. The settings were either community or palliative care, and the outcome measures were a combination of quality of life and immunological function. The trials were judged to be at moderate risk of bias mostly because of incomplete reporting. For quality of life measures, the studies reported that massage therapy in combination with other modalities, such as meditation and stress reduction, are superior to massage therapy alone or to the other modalities alone. The quality of life domains with significant effect sizes included self-reported reduced use of health care resources, improvement in self-perceived spiritual quality of life and improvement in total quality of life scores. One study also reported positive changes in immune function, in particular CD4+ cell count and natural killer cell counts, due to massage therapy, and one study reported no difference between people given massage therapy and controls in immune parameters. Adverse or harmful effects were not well reported.

AUTHORS' CONCLUSIONS

There is some evidence to support the use of massage therapy to improve quality of life for people living with HIV/AIDS (PLWHA), particularly in combination with other stress-management modalities, and that massage therapy may have a positive effect on immunological function. The trials are small, however, and at moderate risk of bias. Further studies are needed using larger sample sizes and rigorous design/reporting before massage therapy can be strongly recommended for PLWHA.

Use of Diet, Nutritional Supplements and Exercise in HIV-Infected Patients Receiving Combination Antiretroviral Therapies: A Systematic Review

Background

The use of combination antiretroviral therapy (cART) has improved the prognosis of HIV infection, but it has also been linked to a spectrum of body composition changes and metabolic alterations known as the lipodystrophy syndrome. Nutritional status could influence body composition changes.

Methods

We performed a systematic search of published peer-reviewed data on the effects of diet, nutrition support and exercise on body composition and metabolic complications in patients receiving cART.

Results

Few controlled studies, most of them with small sample size, were found. Oral nutritional support increases protein and energy intake, and results in body weight and fat mass gains. Resistance exercise, with or without an aerobic component, increases lean mass and can improve insulin resistance. Low-fat diets or exercise can result in loss of fat mass, and they should be used with caution in subjects with lipoatrophy.

Conclusions

Nutritional support and exercise result in small but significant body composition changes and can be used as complementary interventions. There is a need for further research on nutritional interventions in HIV-infected patients receiving cART.

Chronic obstructive pulmonary disease in patients who have HIV infection

An increased prevalence of chronic obstructive pulmonary disease (COPD) among persons who have HIV infection has raised the possibility that HIV may predispose to the development or progression of COPD. This article reviews the evidence that supports an association between HIV infection and COPD-namely emphysema and chronic bronchitis-and studies that suggest an association between HIV infection and small airways abnormalities and nonspecific airway hyper-responsiveness. Risk factors for COPD and potential reasons for an increased risk for COPD in HIV-positive patients are discussed. In addition, issues in the management of COPD in HIV-positive patients are reviewed.

O estresse oxidativo e o exercício físico em indivíduos HIV positivo

A infecção pelo vírus da imunodeficiência humana (HIV) é acompanhada por alterações estruturais e funcionais relacionadas ao sistema imunológico. Além disso, o aumento do estresse oxidativo (EO) nos portadores do HIV, caracterizado por diminuição nos níveis de glutationa (GSH), aumentos na glutationa oxidada (GSSG), na razão GSSG/GSH e lipoperoxidação, bem como redução da atividade de enzimas antioxidantes - catalase, superóxido dismutase (SOD) e glutationa peroxidase (GPx) - é uma conseqüência da evolução dos pacientes infectados com HIV. As células do sistema imunológico necessitam de altas concentrações de antioxidantes para manter o balanço redox e preservar a sua integridade e função. Quando ocorre a depleção dos antioxidantes, há diminuição da resposta imunológica e aumento na replicação do HIV. O uso da terapia anti-retroviral combinada (TARV) melhorou significativamente a evolução clínica dos pacientes, porém, mesmo assim, alguns continuam apresentando EO aumentado e outros efeitos da TARV, como alterações no metabolismo lipídico e muscular. O treinamento físico é utilizado como intervenção não farmacológica nos pacientes infectados pelo HIV para proporcionar melhoria nos parâmetros antropométricos, aeróbios, musculares e psicológicos, porém, há carência de estudos sobre a sua utilização em relação ao estresse oxidativo. Nesta revisão, foram analisados os tópicos referentes ao estresse oxidativo nos pacientes HIV positivos e os possíveis benefícios do exercício físico na capacidade antioxidante. O treinamento físico é uma estratégia auxiliar para os pacientes, com ou sem uso da TARV, uma vez que melhora os aspectos cardiorrespiratórios, musculares, antropométricos e psicológicos sem induzir a imunossupressão. Referindo-se ao estresse oxidativo, infere-se, a partir dos dados em indivíduos HIV negativos, que o treinamento físico pode gerar adaptações que minimizam os efeitos deletérios provocados pelo EO através de melhorias nos níveis das defesas antioxidantes enzimáticas e não enzimáticas.

Therapeutic exercise in physiotherapy practice is beneficial: a summary of systematic reviews 2002-2005

QUESTION

Is therapeutic exercise of benefit?

DESIGN

A summary of systematic reviews on therapeutic exercise published from 2002 to September 2005.

PARTICIPANTS

People with neurological, musculoskeletal, cardiopulmonary, and other conditions who would be expected to consult a physiotherapist.

INTERVENTION

Therapeutic exercise was defined as the prescription of a physical activity program that involves the client undertaking voluntary muscle contraction and/or body movement with the aim of relieving symptoms, improving function or improving, retaining or slowing deterioration of health.

OUTCOME MEASURES

Effect of therapeutic exercise in terms of impairment, activity limitations, or participation restriction.

RESULTS

The search yielded 38 systematic reviews of reasonable or good quality. The results provided high level evidence that therapeutic exercise was beneficial for patients across broad areas of physiotherapy practice, including people with conditions such as multiple sclerosis, osteoarthritis of the knee, chronic low back pain, coronary heart disease, chronic heart failure, and chronic obstructive pulmonary disease. Therapeutic exercise was more likely to be effective if it was relatively intense and there were indications that more targeted and individualised exercise programs might be more beneficial than standardised programs. There were few adverse events reported. However, in many areas of practice there was no evidence that one type of exercise was more beneficial than another.

CONCLUSION

Therapeutic exercise was beneficial for patients across broad areas of physiotherapy practice. Further high quality research is required to determine the effectiveness of therapeutic exercise in emerging areas of practice.

A six-month, supervised, aerobic and resistance exercise program improves self-efficacy in people with human immunodeficiency virus: A randomised controlled trial

QUESTION

What is the effect of a six-month, supervised, aerobic and resistance exercise program on self-efficacy in men living with human immunodeficiency virus (HIV)?

DESIGN

Randomised, controlled trial.

PARTICIPANTS

40 (5 dropouts) men living with HIV, aged 18 years or older.

INTERVENTION

The experimental group participated in a twice-weekly supervised aerobic and resistance exercise program for six months and the control group participated in a twice-weekly unsupervised walking program and attended a monthly group forum.

OUTCOME MEASURES

The primary outcome measure was self-efficacy using the General Self-Efficacy Scale. Secondary outcome measures were cardiovascular fitness using the Kasch Pulse Recovery test, and health-related quality of life using the Medical Outcomes Study HIV Health Survey. Measures were taken by an assessor blinded to group allocation.

RESULTS

By six months, the experimental group had improved their self-efficacy by 6.8 points (95% CI 3.9 to 9.7, p < 0.001) and improved their cardiovascular fitness by reducing their heart rate by 20.2 bpm (95% CI -25.8 to -14.6, p < 0.001) more than the control group. Health-related quality of life improved in only two out of the eleven dimensions: the experimental group improved their overall health by 20.8 points (95% CI 2.0 to 39.7, p = 0.03) and their cognitive function by 14 points (95% CI 0.7 to 27.3, p = 0.04) more than the control group.

CONCLUSION

The findings of this study add to the known benefits of exercise for the HIV-infected population.