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Physical Therapy for Patients with HIV/AIDS

Sonya L. Anderson, MPT Madonna Rehabilitation Hospital, Lincoln, NE

ABSTRACT Purpose: As the number of patients with HIV/AIDS increases, the demand on the health care system will increase. This demand will place greater emphasis on maximizing the patient's independence, minimizing the disability, and increasing the patient's functional status so their quality of life may improve. Summary of Key Points: Patients are surviving longer than ever before with HIV/ AIDS and with a potential for a cure, or at least drugs that slow the progression of this disease, physical therapy can play an important role in maximizing the patients' quality of life. This literature review is designed to provide the reader an overview of the pathophysiology of HIV, effects of exercise on the immune system, and the role of aerobic exercise in patients with HIV/AIDS and AIDS wasting syndrome. The role of progressive resistive exercise (PRE) in patients with HIV/AIDS, exercise prescription, and patient limitations to an exercise program will also be reviewed. Statement of Conclusion: Regular progressive resistive exercise and moderate aerobic exercise is safe and beneficial for the person with HIV infection during any stage of their illness. Through the use of exercise, the patient can play an important role in the management of their illness, while improving their quality of life. Key Words: HIV/AIDS, aerobic training, resistance training, exercise prescription INTRODUCTION Since 1981, Human Immunodeficiency Virus (HIV)/ Acquired Immunodeficiency Syndrome (AIDS) has increased to epidemic proportions. The United States, which is the most heavily affected country in the industrialized world, has approximately 1,000,000 people living with HIV.1 Despite advances, HIV incidence has not declined significantly in the United States; with approximately 40,000 new infections occurring every year.1 On a world level, there are approximately 40 million people living with HIV/AIDS, and 5 million of these infections occurred in 2001 which translates to 16,000 persons infected per day that year.1

Address correspondence to: Sonya L. Anderson, MPT, Madonna Rehabilitation Hospital, Inpatient Physical Therapy Department, 5401 South Street, Lincoln, NE 68506 ([email protected]).

PATHOPHYSIOLOGY OF HIV/AIDS Human Immunodeficiency Virus causes AIDS. Acquired Immunodeficiency Syndrome is considered a secondary, or acquired, immunodeficiency since it does not result from a genetic or developmental defect. To understand the effects of exercise on the immune system, one must understand some basic concepts of the immune system. There are 2 main components of immunity: innate and acquired. Innate immunity includes skin, cilia, and mucosal linings of the respiratory and digestive systems, gastric fluids and enzymes of the stomach, and phagocyte cells.2 The innate system also uses neutrophils and macrophages.3 Natural killer cells are also part of this innate immune system; they work to kill cells infected by some viruses and also to stimulate the acquired immune response.3 Acquired immunity includes humoral and cell-mediated responses. Humoral response depends on antibodies and B-lymphocytes, which may be effective on free-floating or cell-surface pathogens. Cell-mediated immunity, associated with T-lymphocytes, is essential for destroying pathogens responsible for opportunistic infections associated with AIDS. Macrophages complete the initial destruction, while B-cells and T-cells complete the rest of the destruction. There are at least 8 types of T-cells; however, CD-4 and CD-8 (CD=Cluster Designation) cells are the most important cells in the study of HIV/AIDS. On recognition of an antigen, CD-4 (helper) cells will activate other lymphocytes to destroy the foreign material. If there is a sufficient number of B-cells and T-cells, CD-8 (suppressor) cells will inhibit this process so noninfected cells are not destroyed.2 In patients with HIV/AIDS, there is a low CD-4 cell count while CD-8 cell counts remain the same.3 Human Immunodeficiency Virus is a retrovirus. Retroviruses carry their genetic information in the form of RNA. When the virus enters the cell, the RNA is reverse transcribed to DNA. An enzyme called reverse transcriptase (RT) reverses the normal transcription process so that a DNA copy is made of the viral RNA genome. This new copy is called a provirus and is then integrated into the cell genome when the cell replicates along with the cell's original DNA. After a period of latency, the replicated virions bud out of this lymphocyte and infect other lymphocytes.2 As many as 109 virions are released per day which continually infect and destroy additional T-lymphocytes.4 This eventually results in the death of T-cells and subsequent immunosuppression.5 This immunosuppression leaves the individual susceptible to a wide variety of unusual infections and malignancies, which are collectively called

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opportunistic infections.6 In 1981, the first group of patients in the United States that were identified with AIDS were experiencing infections such as Pneumocystis carinii pneumonia (PCP) and Kaposi's sarcoma, both common opportunistic infections in this population. 4 These patients all had significant decreases in the subpopulation of T- lymphocytes that carry the CD-4 marker.4 The HIV infects T-lymphocytes that carry the CD-4 antigen on their surface. Some strains of HIV will attack monocytes, B cells, or any type of cell carrying the CD-4 antigen on its surface. There is a high affinity between a coat-protein of HIV (glycoprotein 120) and CD-4 antigen cell surface.4 The destruction of the CD-4 cell decreases the normal function of the immune system and its ability to produce an effective immune response to pathogens; in fact, the CD-4 cell can be considered the `turn-on' mechanism for the immune response.6 A decrease in the CD-4 cell count may adversely affect the cytotoxic effect of natural killer cells as well.7 Initially, HIV disseminates to the lymphoid tissue causing a strong immune response.2 CD-8 T-lymphocytes regulate this process so that the viral load in the circulation stays steady, and this can continue for years.4 Some newly infected patients may experience mononucleosislike symptoms including fever, swollen glands, and rash. This stage may be referred to as `HIV seroconversion illness.'3 Otherwise, HIV commonly is broken into 3 stages: (1) Asymptomatic (CD-4 >500/mm3), (2) Symptomatic (CD-4 at 200-500/mm3), and (3) AIDS (CD-4<200/mm3). A normal CD-4 count is 1000/mm3.2 Diagnosis of AIDS must include presence of the antibodies for HIV along with CD-4 counts below 200 cells/mm3, occurrence of opportunistic infections, and impaired or delayed hypersensitivity reactions to antigens in which they would normally react.4 Often patients live approximately 15 years in stage 1, 3 to 4 years in stage 2, and 3 to 4 more years in stage 3.6 Viral load can reflect long-term risk of disease progression, whereas CD-4 counts are associated with the risk of developing an opportunistic infection.3 Ideally, a patient would possess a low viral load and a high CD-4 T cell level.4 Moreover, both the viral load and CD-4 counts should be examined when determining disease progression.5 EFFECTS OF EXERCISE ON THE IMMUNE SYSTEM AND THE ROLE OF AEROBIC EXERCISE WITH PATIENTS WITH HIV/AIDS Although there seems to be controversy regarding the immune response with exercise, a review of the literature reveals exercise does not decrease CD-4 levels at any stage of the disease; in fact, there is a trend toward an increase in CD-4 levels.2 Exercise, especially when introduced early in the infection in those with HIV, can help stave off opportunistic infections.2 Long-term survivors of HIV/AIDS have attributed their longevity to regular physical exercise.6 LaPierriere et al6 reviewed the available literature in regard to aerobic exercise across all 3 stages of patients with

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HIV/AIDS. The review reported an increase in CD-4 levels with asymptomatic patients (increased by 115 cells/mm3) and early symptomatic patients (increased by 80 cells/ mm3), while the CD-4 counts were maintained in patients with AIDS. The asymptomatic and early symptomatic patients exercised at 70% to 80% of predicted maximum HR for 45 minutes/day, 3 days/week x 10 weeks (asymptomatic group) or 12 weeks (early symptomatic group). The patients with AIDS exercised at either high intensity (70-85% of VO2max) or low intensity (50-60% of VO2max) 60 minutes/day, 3 days/week x 24 weeks. This review further supported the theory that the increased CD-4 count increase is a `normalization' of CD-4 cells returning to their normal level. In fact, if healthy individuals participate in an aerobic exercise program, they do not have an increase in CD-4 cell levels since their CD-4 levels are already at a normal level. This normalization of CD-4 levels in asymptomatic patients was accompanied by a decrease in antibody titers to the Epstein-Barr virus (virus responsible for mononucleosis) thus suggesting an improved immune response to pathogens. Terry et al8 performed a randomized clinical trial on 21 individuals with HIV with CD-4 cell count greater than 200 cells/mm3. The subjects completed 60 minutes of aerobic activity 3x/week x 12 weeks. One group exercised at 60 ± 4% of their maximal heart rate which was considered moderate exercise. The second group exercised at 84 ± 4% of their maximal heart rate which was considered heavy exercise. There were no differences in the immunologic markers (CD-4, CD-8, CD-4/CD-8 ratio), anthropometric, or depression scores between the 2 groups. Both groups significantly increased their exercise capacity as determined by an increase time on the treadmill. The authors concluded, in contrast to other studies, there was no increase in CD-4 levels with moderate intensities, and high intensity exercise did not produce negative results in regard to immune function.8 Perna et al9 performed a randomized clinical trial where 28 people with HIV finished the trial. Exercise included interval cycling 45 minutes/day, 3x/week x 12 weeks. The control group refrained from exercise. The intervention group with aerobic exercise had a statistically significant increase in BMI, leg power, and cardiopulmonary functioning as measured through VO2 peak compared to the control group. Moreover, compliant exercisers increased their CD-4 levels by 13%, noncompliant exercisers decreased their CD-4 levels by 18%, and the control group decreased their CD-4 levels by 10%. Patients that were noncompliant were typically obese and smokers, and did not claim their noncompliance was due to exercise-associated illness. So why are health care providers cautious to prescribe exercise to this patient population? Researchers argue that heavy exercise (defined by ACSM as 70-85% of maximum heart rate or 55-70% of VO2max)10 or exercise for long periods of time (90 minutes) in healthy individuals cause a temporary depletion of T-cells.11 Healthy bodies normally return to immunologic baseline after an acute bout of

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exercise, but it could take anywhere from 3 to 72 hours, leaving a vulnerable period for infection even in healthy people.11 In fact, researchers found an increase in upper respiratory infections the week after a marathon with runners compared with a group of runners that did not participate in the marathon.12 Furthermore, these effects have been shown to occur after both endurance and resistance exercise, with the degree of post-exercise immune suppression proportional to the intensity of the exercise.13 Thus, heavy/exhaustive exercise or exercise for 90 minutes should be avoided in individuals with HIV due to immunosuppressive effects. 11 Because HIV replication occurs with CD-4 T-lymphocyte proliferation, there has been concern that beginning an exercise program with patients who have HIV might result in increased HIV replication and extension of the disease through the infection of additional lymphocytes.13 To answer this question, Roubenoff et al14 sought to determine if a single bout of exercise, similar to what people experience when starting an intense exercise program (aerobic or resistive), has a detrimental effect on HIV viral load levels. Twenty-five patients with HIV infection performed one 15-minute bout of acute exercise that consisted of step aerobics on a 60 cm step at a cadence of 1 step per second. Following the exercise, there was an increase in neutrophil counts, serum creatine phosphokinase, and urinary 3-methylhistidine indicating a mild acute-phase response with muscle proteolysis. However, mean HIV RNA levels did not increase throughout the week after the single bout of exercise. The authors concluded the lack of increased viral loads in response to acute exercise suggests that the initiation of exercise training is safe in people with HIV infection. However, the authors warn that the results from a 15 minute bout of exercise should not be generalized to activities such as long-duration running. Ullum et al15 examined the difference in the immune response to acute exercise between a group of 8 healthy (seronegative) subjects and a group of 8 patients with HIV infection (seropositive), matched in age and gender. All subjects exercised on a bicycle ergometer for 1 hour at 75% of maximal oxygen uptake. The post-exercise increases in neutrophils, natural killer (NK) cells, IL-2 stimulated NK cells, and lymphokine-activated killer (LAK) cells were less pronounced in the HIV-seropositive group compared to the control subjects. The results suggest that in response to physical stress, patients with HIV have an impaired ability to mobilize neutrophils, NK, and LAK cells to the blood, which may increase vulnerability to opportunistic infections in very intense bouts of exercise. Both groups had a comparable transient increase in their CD-4 levels during exercise. Although there was a doubling of CD-4 cell levels, the percentage of CD-4 percentage relative to other T-cells did not change. Ullum et al15 concluded that HIV infection can suppress features of the immune response to acute exercise, and patients starting an exercise program may start with high-intensity exercise, but certainly not exhausting exercise.

After reviewing 10 randomized clinical trials, the Cochrane review of 2005 concluded that constant aerobic exercise for at least 20 minutes/day, 3 x/week x 4 weeks appears to be safe and may improve cardiopulmonary fitness in patients with HIV/AIDS.16 This review did not discuss intensity of exercise. Also, aerobic exercise in combination with progressive resistive exercise (PRE) appears to be a safe combination.16 WASTING SYNDROME AND THE ROLE OF PROGRESSIVE RESISTIVE EXERCISE WITH PATIENTS WITH HIV/ AIDS The Center for Disease Control (CDC) defines AIDS wasting syndrome (also HIV wasting syndrome or AIDS cachexia) as unexplained weight loss of more than 10% and accompanied by fever or diarrhea. Approximately 18% of patients with AIDS experience the wasting syndrome.2 This malnutrition contributes to further immunosuppression, and aggressive measures need to be taken to stop such depletion. Just a 5% weight loss in patients with HIV infection is associated with an increased risk of developing an opportunistic infection.17 Moreover, there is a linear relationship between the extent of body cell mass depletion and timing of death.13 When health care providers can identify this `wasting' early in the disease progression, treatment can improve functional status along with survival. When a person has the wasting syndrome, mobilization of fat is accompanied by a loss of somatic and visceral proteins resulting in protein energy malnutrition.17 AIDS wasting syndrome includes starvation, a decrease in caloric intake or malabsorption, along with cachexia. Cachexia is associated with the acute-phase immune response induced by inflammatory and neoplastic conditions.13 Cachexia describes the loss of lean mass, specifically body cell mass.12 Controversy exists in regard to whether starvation or cachexia best characterizes AIDS wasting syndrome. Regardless, the causative factors for these 2 etiologies for the AIDS wasting syndrome are reduced nutritional intake, malabsorption, altered metabolism, and decreased physical activity.13 In early HIV infection, cell mass declines while extracellular water often rises, so that overall, there is little or no loss of weight. Weight is often maintained until an opportunistic infection presents itself. If weight is recovered after this opportunistic infection, then it is normally fat or water weight, not lean muscle. Muscle, followed by viscera and then the immune system, is lost at the greatest rate in cachexia. The loss of muscle is serious because it is not only a determinant of strength, but also the primary reservoir of amino acids for gluconeogenesis and protein synthesis. The only nonpharmacologic anabolic treatment that can improve lean body mass, strength, and function is PRE.12 It is well established that PRE results in compensatory muscle hypertrophy and improved muscle function in diseased and healthy persons. Progressive resistive exercise can prevent weight loss, maintain a desirable adipose/lean

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tissue ratio, and restore body weight and muscle mass to a normal or desirable level after a period of weight loss.18 Building up lean tissue mass might forestall the AIDS wasting syndrome. Progressive resistive exercise can provide an alternative to pharmacologic anabolic treatment. Spence et al19 performed a randomized control trial on 24 male outpatient volunteers with HIV. The experimental group engaged in PRE consisting of a hydraulic isokinetic resistance training machine to train the knee, shoulders, and chest muscles in extension and flexion 3x/week x 6 weeks. There were significant improvements of approximately 20% in power and torque production in the knee and shoulder muscles with training, compared with moderate deteriorations of approximately 10% in the control group. In addition, there was a mean weight loss of 1.9 kg in the control group compared with a gain of 1.7 kg in the training group (p < 0.0001), and a significant improvement in combined mid-arm and mid-thigh circumference in the training group compared with a decline in the control group (p <.003).19 Roubenoff et al20 determined the effects of PRE on increasing strength and lean body mass. The study was conducted with an ethnically mixed group of 25 men and a woman with HIV. Six of these 25 patients had the AIDS wasting syndrome. This 16-week longitudinal study was conducted without a control group. Strengthening exercises included double leg press, leg extension, seated chest press, and seated row machine exercised on Keiser pneumatic resistance machines. Patients performed 3 sets of 8 repetitions at 80% of their one repetition maximum (1RM) by the third session. There was a significant increase in lean body mass (1.75 ± 1.94 kg), strength improved by 30% to 50% as determined by 1RM and body fat significantly decreased by 0.92 ± 2.22 kg. There was no change in CD-4 count, viral load, or bone density during the study. This study promotes the efficacy of PRE for lean body mass repletion in patients with existing AIDS wasting syndrome as well as preventative treatment for those without wasting.20 In a subsequent study, Roubenoff et al21 considered the effect of PRE on functional status in patients with HIV. Their purpose was to assess whether PRE improves functional status, measured using a validated Physical Function Scale (MOS SF-36). The Physical Function Scale included items such as lifting and carrying groceries, climbing stairs, bending, kneeling, stooping, walking, bathing, and dressing. There was a significant 6 point increase in the MOS SF-36 score in the subjects with wasting syndrome, but not in the subjects with HIV without the wasting syndrome. Both the increase in lean body mass and strength were significantly and independently associated with an increase in physical function. The authors concluded that PRE does increase functional status in patients with HIV wasting, both by increasing lean body mass and strength.21 A Cochrane review of 2004 reviewed 7 randomized clinical trials concluding that PRE for at least 3 x/week x 4 weeks appears to be safe in patients with HIV/AIDS, and

may improve body weight and composition.22 Also, PRE in combination with aerobic exercise appears to be safe. 22 EXERCISE PRESCRIPTION When considering an exercise program for any population, it is warranted to have a complete medical/physical examination to ensure the person is a candidate for this regimen, and the population with HIV/AIDS is no different. Additionally, a disease specific assessment is required to help in the determination of the exercise prescription. A treadmill or cycle ergometer cardiopulmonary exercise test should be performed to obtain baseline cardiovascular values, such as VO2max, along with careful monitoring of vital signs.10 Also, the patient needs to be educated on the importance of maintaining a high-calorie diet during the exercise program. It would be beneficial to obtain baseline values for weight, lean body mass values, and lab values including CD-4 count and viral load prior to starting an exercise program. Side effects of medication must be considered in exercise prescription.10 The use of protease inhibitor-based highly active anti-retroviral therapy (HAART) has substantially reduced the high rate of morbidity and mortality associated with HIV infection and may even decrease the viral load to undetectable levels in the blood.4 HAART is normally started when CD-4 levels are between 200-500/ mm3.2 However, side effects of protease inhibitors include nausea, diarrhea, headache, fat redistribution (central adiposity), glucose intolerance, increased cholesterol, increased triglycerides, abdominal pain, weakness, prickling sensation in skin, blurred vision, and dizziness.4 The exercise program should promote an individual and balanced program designed to increase aerobic capacity, muscle function, flexibility, and functional ability.11 It is important to remember that every patient is unique medically, physically, emotionally, and motivated by different goals. The physical therapist must emphasize and educate the patient on the importance of consistent and moderate exercise. Ideally, individuals with HIV should begin exercising while asymptomatic and adopt strategies to help them maintain an exercise program throughout the course of their illness. See Table 1 for exercise recommendations for patients with HIV/AIDS. Moderate aerobic exercise can be defined as 60% to 70% of maximum heart rate (220-age) or 45% to 55% of VO2max for 20 to 30 minutes (excludes warm-up and cool-down) 3 to 5 days per week.10 Heavy aerobic exercise can be defined as 70% to 85% of maximum heart rate or 55% to 70% of VO2max.10 The greatest improvement in VO2max occurs when exercise involves the use of large muscle groups over prolonged periods in activities that are rhythmic and aerobic in nature (ie, walking, swimming, cycling, or endurance games).10 PATIENT LIMITATIONS TO AN EXERCISE PROGRAM Exercise training is contraindicated during rapid weight loss associated with an acute illness or an active oppor-

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Table 1. Exercise Recommendations for Patients with HIV/AIDS Stage 1 Asymptomatic CD-4>500/ mm3 Start exercise regimen as early as possible. Promote consistency. No limitations for most individuals. *Moderate aerobic exercise and **PRE combined. 16 Stage 2 Symptomatic CD-4=200-500/mm3 Possibly reduced exercise capacity due to a decreased VO2max, O2 pulse max, elevated heart rate, elevated breathing, and reduced vital capacity.2 *Moderate aerobic exercise and **PRE combined. 16 Stage 3 AIDS CD-4 < 200/mm3 Even further reduced exercise capacity due to a decreased VO2max, O2 pulse max, elevated heart rate, elevated breathing, and reduced vital capacity.2 Individuals should still remain physically active, but continue exercise on a symptom limited basis, *moderate aerobic exercise and **PRE combined, as tolerated. 16 ***Heavy aerobic exercise should be avoided. Individuals should stop exercising during acute illness or rapid weight loss.

***Heavy aerobic exercise should be avoided. Individuals should stop exercising during acute illness or rapid weight loss.

***Heavy aerobic exercise should be avoided. Individuals should stop exercising during acute illness or rapid weight loss.

*Moderate aerobic exercise is 60-70% of maximum heart rate (220-age) or 45-55% of VO2max for 20-30 minutes (excludes warm-up and cool-down) three to five days per week.10 **Progressive resistive exercise (PRE) defined as 3x/week 22 while starting with 1 set of 8-12 reps for all major muscle groups, increasing to 2 sets, and adding weight as needed to reach repetition maximum at 8-12 reps.11 ***Heavy aerobic exercise should be avoided at all three stages, and can be defined as 70-85% of maximum heart rate or 55-70% of VO2max.10

tunistic infection.18 Although there are many possible opportunistic infections, pneumocystis carinii pneumonia (PCP) is the most common opportunistic infection, and scarring from PCP can affect cardiopulmonary status.11 Tuberculosis (TB) is another opportunistic infection affecting cardiopulmonary status.2 Upper respiratory infections, anemia, fatigue, and diarrhea are common and should be monitored as well.11 Some patients may not be able to participate in prescribed activity due to advanced disease (CD-4 levels < 100/mm3).7 Central nervous system, peripheral nervous system, and musculoskeletal complications can also limit the patient's ability to participate in exercise programs, and may need to be treated concomitantly. HIV-1 penetrates the nervous system within hours of infection, but complications may present at anytime during the progression of the illness.23 Central Nervous System Primary complications include an encephalopathy often referred to as AIDS dementia complex and myelopathy (involves cortico-spinal tracts and dorsal columns).23 Common secondary HIV-associated neurologic complications caused by opportunistic infections include cryptococcal meningitis, toxoplasma encephalitis, cytomegalovirus (CMV) encephalitis/radiculomyelopathy, progressive multifocal leukoencephalopathy, and primary CNS lymphoma.23 Also, patients can suffer strokes that are embolic, throm-

botic, hemorrhagic, or vasculitic in nature; typically, these patients present with hemiplegia.24 Peripheral Nervous System Demyelination and inflammation have been observed in peripheral nerve specimens of individuals with HIV.19 Some of the most common peripheral nervous system disorders that patients with HIV present with include distal symmetric polyneuropathy (DSP), with stocking and glove-type sensory loss and pain, demyelinating polyradiculoneuropathy or Guillain-Barré Syndrome, chronic inflammatory demyelinating polyneuropathy (CIDP), a mononeuropathy multiplex in which multiple different major nerves are affected, and nerve root syndromes. 25 Distal symmetric polyneuropathy affects as many as 40% to 60% of patients with HIV-1, and patients complain of numbness, tingling, and paresthesias in the feet. This may cause gait disturbances along with contact hypersensitivity.25 It is important the patient is educated about proper foot care, including the use of supportive shoes when performing weight-bearing activities.2 Musculoskeletal System Muscle biopsies of patients with HIV have shown the presence of retrovirus particles, which could attribute to muscle weakness and atrophy.19 Patients may present with osseous and soft tissue infections, polymyositis, arthritis,

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fibromyalgia, and myasthenia gravis.2,25 They may also have secondary complications from gait pathology due to peripheral neuropathies.2 Quadriceps weakness and proximal muscle weakness is common with myopathy.24 Muscle weakness may limit perfusion of the exercising limbs, with resulting lactacidosis, fatigue, and breathlessness.7 SUGGESTIONS FOR FUTURE RESEARCH Further research is warranted in all areas of physical therapy regarding HIV/AIDS patients. Randomized clinical trials including control groups and large numbers of homogenous samples of patients with HIV in their respective stages (asymptomatic, symptomatic, and AIDS) are warranted. In futures studies, males and females should have equal representation. Also, it would be beneficial to study patients who have HIV/AIDS from the time of infection until death to determine the role of exercise in longevity and quality of life. Future studies should standardize the immune indices under study--some studies measure CD-4 levels, while others examine CD-4/CD-8 ratio or only viral loads. Parameters for exercise need to be standardized; some studies include stretching and strengthening exercise along with walking, while others use stationary bicycles. Exercise intervention times also need to be standardized since studies vary from 15 minutes to 60 minutes of aerobic exercise. Finally, it would be important to determine if an optimal frequency session and session duration existed for different stages of the disease. CONCLUSION A review of the most current literature promotes moderate exercise as safe and beneficial for the person with HIV infection during any stage of their illness. Undoubtedly, regular PRE and moderate aerobic exercise is advantageous to patients with HIV/AIDS. The importance of consistent and moderate intensity exercise throughout the entire illness should be emphasized. The literature indicates that exhaustive exercise should be avoided. Although several studies report that heavy exercise may not be contraindicated, only moderate exercise can be considered safe across all 3 stages of HIV/AIDS. Aerobic exercise does not decrease CD-4 levels or increase viral load levels and may even increase CD-4 levels. These changes in CD-4 level and viral loads may correlate with the ability of the immune system to fight opportunistic infections. Progressive resistance exercise increases lean body mass which is imperative in preventing AIDS wasting syndrome and ultimately death. Through the use of exercise, the patient can play an important role in the management of their illness, while improving their quality of life. ACKNOWLEDGEMENTS The author sincerely thanks Jim Youdas, PT, Assistant Professor of Physical Therapy at Mayo Clinic College of Medicine, Program in Physical Therapy and Brian Crum, MD, Neurologist at Mayo Clinic for their feedback and support for this literature review.

REFERENCES 1. DeCock KM, Janssen RS. An unequal epidemic in an unequal world. JAMA. 2002;288:236-243. 2. Galantino ML. Human immunodeficiency virus (HIV) infection: living with a chronic illness. In: Umphred DA, ed. Neurological Rehabilitation. 4th ed. St. Louis, Mo: Mosby; 2001:553-575. 3. Nairn R, Helbert M. Basic concepts. Immune system in health and disease/HIV infection. In: Immunology for Medical Students. New York, NY: Mosby; 2002:916, 277-282. 4. Goldsby RA, Kindt TJ, Osborne BA. AIDS and other immunoindices. In: Kuby Immunology. 4th ed. New York, NY: WH Freeman; 2000:467-494. 5. Stringer WW. HIV and aerobic exercise: current recommendations. Sports Med. 1999;28:389-395. 6. LaPerriere A, Klimas N, Fletcher MA, et al. Change in CD4+ cell enumeration following aerobic exercise training in HIV-1 disease: possible mechanisms and practical applications. Int J Sports Med. 1997;18:S56S61. 7. Shepard RJ. Exercise, immune function, and HIV infection. J Sports Med Phys Fitness. 1998;38:101107. 8. Terry L, Sprinz E, Ribeiro JP. Moderate and high intensity exercise training in HIV seropositive individuals: a randomized trial. Int J Sports Med. 1999;20:142146. 9. Perna FM, LaPerriere A, Klimas N, et al. Cardiopulmonary and CD4 cell changes in response to exercise training in early symptomatic HIV infection. Med Sci Sports Exerc. 1999;31:973-979. 10. Franklin BA, Whaley MH, Howley ET, eds. General principles of exercise prescription. In: American Col lege of Sport Medicine's Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2000:137-164. 11. Perry AC, LaPerriere A, Klimas N. Acquired immune deficiency syndrome (AIDS). In: Durstine JL, Moore GE, eds. American College of Sports Medicine's Exer cise Management for Persons with Chronic Diseases and Disabilities. 2nd ed. Champaign, Ill: Human Kinetics; 2003:173-179. 12. Evans WJ, Roubenoff R, Shevitz A. Exercise and the treatment of wasting: aging and human immunodeficiency virus infection. Semin Oncol. 1998;25(suppl 6):112-122. 13. Arey BD, Beal MW. The role of exercise in the prevention and treatment of wasting in acquired immune deficiency syndrome. J Assoc Nurses AIDS Care. 2002;13:29-49. 14. Roubenoff R, Skolnik PR, Sheritz A, et al. Effect of a single bout of acute exercise on plasma human immunodeficiency virus RNA levels. J Appl Physiol. 1999;86:1197-1201. 15. Ullum H, Palmo J, Halkjaer-Kristensen J. The effect of acute exercise on lymphocyte subsets, natural killer

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16.

17. 18. 19.

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cells, proliferative responses, and cytokines in HIVseropositive persons. J Acquir Immune Defic Syndr. 1994;7:1122-1133. Nixon S, O'Brien K, Glazier RH, Tynan AM. Aerobic exercise interventions for adults living with HIV/AIDS. Cochrane Database Syst Rev. 2005, Issue 2. Art. No: CD001796. DOI: 10.1002/14651858.CD001796. pub2. Willimans B, Walters D, Parker K. Evaluation and treatment of weight loss in adults with HIV disease. Am Fam Physician. 1999;60:843-861. Yarasheski KE, Roubenoff R. Exercise treatment for HIV-associated metabolic and anthropomorphic complications. Exerc Sport Sci Rev. 2001;29:170-174. Spence DW, Galantino MLA, Mossberg KA, Zimmerman SO. Progressive resistance exercise: effect on muscle function and anthropometry of a select AIDS population. Arch Phys Med Rehabil. 1990;71:644648. Roubenoff R, McDermett A, Weiss L, et al. Short-term progressive resistance training increases strength and lean body mass in adults infected with human immunodeficiency virus. AIDS. 1999;13:231-329.

21. Roubenoff R, Wilson IB. Effect of resistance training on self-reported physical functioning in HIV Infection. Med Sci Sports Exerc. 2001;33:1811-1817. 22. O'Brien K, Nixon S, Glazier RH, Tynan AM. Progressive resistive exercise interventions for adults living with HIV/AIDS. Cochrane Database Syst Rev. 2004, Issue 4. Art. No: CD004248. DOI: 10.1002/14651858.CD004248.pub2. 23. Clifford DB. Neurologic complications of human immunodeficiency virus infection. Neurologist. 1998;4:54-65. 24. Galantino ML, Jermyn RT, Tursi FJ, Eke-Okoro S. Physical therapy management for the patient with HIV: lower extremity challenges. Clin Podiatr Med Surg. 1998;15:329-346. 25. Schmahmann JD. Neurological manifestation of late stage AIDS: Part 1. Resid Staff Physician. 1997;43:2029.

Cardiovascular & Pulmonary Section Research Grant for $2,000

Call for Proposals

To stimulate well-defined research studies, the Cardiovascular and Pulmonary Section will provide a research grant award to support a study relevant to cardiovascular and pulmonary practice. For the year 2006, the Section will be able to fund one proposal for up to $2,000. To be eligible, you must be a Cardiovascular and Pulmonary Section member, and the research must be directly related to cardiovascular and pulmonary physical therapy. Graduate student members may apply and use the funding to defray the costs associated with thesis or dissertation research. The funding may be used to assist with travel to present research findings. The award will not include overhead or indirect costs. Grant recipients must submit an interim progress report by February 1 of the funding year. In addition, upon completion of the study, a manuscript/report must be submitted for publication in Physical Therapy or the Cardiopulmonary Physical Therapy Journal. The research proposal should include a title page, specific aims, summary of relevant literature, and proposed methodology including design, description of subjects, instrumentation, procedures and proposed analysis. To apply, submit your proposal (not to exceed 5 pages), abbreviated curriculum vitae/resume (not to exceed 2 pages) and proposed budget electronically as a Word or Adobe Acrobat file to: Christine R. Wilson, PhD, PT Chair, Research Committee Physical Therapy Department University of the Pacific 3601 Pacific Avenue Stockton, CA 95211 [email protected] For further information, contact Dr. Wilson at 209-946-2397 or [email protected] Deadline for submission is May 1, 2007

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