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E-Module

An HIV and Rehab Resource

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  • About
    • 1 – What is this resource about and who is it for?
    • 2 – Why was this resource created?
    • 3 – How can this resource be used?
    • 4 – Can this resource be used for teaching?
    • 5 – How was this resource developed?
    • 6 – Who contributed to developing this adapted resource?
    • 7 – Who funded the development of this resource?
    • 8 – Disclaimer
  • Section 1
    • 1.1 How is “rehabilitation” defined in this resource?
    • 1.2 How can rehabilitation help people living with HIV?
    • 1.3 How can the World Health Organization’s “ICF” help us think about rehabilitation for people living with HIV?
    • 1.4 How can the Episodic Disability Model help us think about rehabilitation for people living with HIV?
    • 1.5 Who provides rehabilitation for people living with HIV?
    • 1.6 Do rehabilitation providers need special skills or training to care for people living with HIV? If so, what?
    • 1.7 What roles do rehabilitation providers have related to HIV?
    • 1.8 When is rehabilitation clinical intervention useful along the HIV care continuum?
  • Section 2
    • 2.1 What do rehabilitation professionals need to know about the stages of HIV infection?
    • 2.2 What do rehabilitation providers need to know about CD4 count and viral load?
    • 2.3 What is the impact of HIV on body systems and why does this matter for rehabilitation providers?
    • 2.4 Who might rehabilitation providers treat?
    • 2.5 What do rehabilitation providers need to know about antiretroviral therapies?
  • Section 3
    • 3.1 What are the rehabilitation interventions that address impairments common among people living with HIV?
    • 3.2 What are the rehabilitation interventions that can address the activity limitations and participation restrictions common among people living with HIV?
    • 3.3 More information on the rehabilitation interventions available for people living with HIV
    • 3.4 – What do rehabilitation providers need to know about their patients’ beliefs and use of traditional healers, spiritual leaders and alternative therapies outside the formal medical system?
  • Section 4
    • 4.1: Intersectionality Theory in the Context of Rehabilitation
    • 4.2: Children and Youth
    • 4.3: HIV and Aging
    • 4.4: Substance Use
    • 4.5: Trauma
    • 4.6: Racialized Populations
    • 4.7: Indigenous Populations
    • 4.8: HIV, Sex and Gender
    • 4.9: HIV and COVID-19
    • 4.10: Is HIV itself a disability?
  • Section 5
    • 5.1 What are outcome measures?
    • 5.2 Why is it important to use outcome measures during rehabilitation with people living with HIV?
    • 5.3 How do rehabilitation providers know if an outcome measure will be useful in practice?
    • 5.4 What are floor and ceiling effects in outcome measurement?
    • 5.5 What is the difference between generic and HIV-specific outcome measures?
    • 5.6 How should you decide which outcome measures to use?
    • 5.7 How do you access a copy of an outcome measure?
    • 5.8 What are rehabilitation-related outcome measures that can be useful for people living with HIV?
  • Case Studies
    • Case #1 – Acute Care, Cardiorespiratory and Neurological
    • Case #2 – Musculoskeletal – Knee Pain
    • Case #3 – Aging, Cognition, Community, Stroke
    • Case #4 – Complex Case – Musculoskeletal, Episodic, Cardiorespiratory
    • Case #5 – Diabetes, Neuropathy, Substance Use
    • Case #6 – Transition from Paediatric to Adult Care
    • Supplemental Case Studies without Leading Questions
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3.1 What are the rehabilitation interventions that address impairments common among people living with HIV?

This section is organized according to the categories of impairment in the World Health Organization’s International Classification of Functioning, Disability and Health1 (see Section 1.3).

  • Mental functions
  • Sensory functions and pain
  • Voice and speech functions
  • Functions of the cardiovascular, hematological, immunological and respiratory systems
  • Functions of the digestive, metabolic and endocrine systems
  • Genitourinary and reproductive functions
  • Neuromuscular and movement related structures
  • Functions of the skin and related structures

1 World Health Organization: International Classification of Functioning, Disability and Health (ICF) – Geneva. 2001. http://www.who.int/classifications/icf/en

3.1.1 Mental functions

People living with HIV commonly experience changes in mental functions. These include (but are not limited to) difficulties related to consciousness, orientation, intellect, energy and drive, sleep, attention, memory, emotion, perception, cognition and language.

These impairments may be caused by the HIV infection itself, one of the many opportunistic infections associated with HIV or side effects of various HIV-related medications. Pre-existing mental impairments may also be present which further impacts the rehabilitation of people living with HIV.

Rehabilitation interventions for these mental impairments include specific psychosocial techniques as well as general exercise and education. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.

Table 3.1.1: Clinical Aspects of Mental Function Impairments

Table 3.1.1: Clinical Aspects of Mental Function Impairments

Impairments

Possible Etiologies

Rehabilitation Interventions

(for details, see Section 3.3)

HIV Cognitive-Motor Complex (also known as AIDS Dementia Complex or HIV Dementia)

HIV (the virus itself)

Opportunistic infections

Exercise prescription – aerobic

Exercise prescription – strength

Energy conservation

Fatigue management

Psychosocial rehabilitation

Relaxation techniques

Cognitive impairment (including memory loss)

Hypoxia

Cryptococcal meningitis

TB meningitis

Syphilis

Neurovascular disease (stroke)

Focal cerebral disease

Vitamin deficiency (e.g., B12, B6)

Electrolyte abnormalities

Pain-related

Exercise prescription – aerobic

Exercise prescription – strength

Fatigue management

Psychosocial rehabilitation

Relaxation techniques

Psychological disorders (including depression, mood disorders, anxiety and delirium)

Related to cognitive impairment

Side effects of medication

Psychosocial factors (e.g., stigma)

Premorbid psychiatric disorders

Post-traumatic stress disorder Pain-related

Exercise prescription – aerobic

Exercise prescription – strength

Fatigue management

Psychosocial rehabilitation

Relaxation techniques

Substance-related disorders

Prescription medications (e.g., narcotics)

Over-the-counter medications

Street drugs: premorbid or current

Alcohol: premorbid or current

Psychosocial rehabilitation

Referral to drug or alcohol treatment

Harm reduction approach

Legend: TB – tuberculosis

3.1.2 Sensory functions and pain

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”1 Pain can be classified temporarily as acute (i.e., pain < 3 months in duration) or chronic (i.e., pain > 3 months in duration). Pain can also be classified through a mechanistic perspective (i.e., nociceptive, neuropathic or nociplastic). In certain circumstances, chronic pain can now be considered a health condition in its own right.2 Pain is commonly experienced by people living with HIV at all stages of the disease process. Pain prevalence in people living with HIV ranges from 54% to 83%. This pain is often of moderate to severe intensity, which has a negative impact on physical functioning and overall quality of life.3

Rehabilitation techniques for pain management can include exercise prescription, self-management support, and pain education as well as electrotherapy modalities, cryotherapy, heat, and massage. Rehabilitation techniques used may vary depending whether pain is acute or chronic in addition to the mechanism of pain. Other sensory impairments, including difficulties related to sight, hearing and vestibular control are also experienced by people living with HIV. These may be managed by environmental modifications, provision of assistive devices and education.

These impairments may be caused by the HIV infection itself, one of the many opportunistic infections associated with HIV, or toxicity or side effects of various HIV-related medications. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.

1 Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020 Sep 1;161(9):1976-1982. doi: 10.1097/j.pain.0000000000001939. PMID: 32694387

2 Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain. 2019 Jan;160(1):19-27. doi: 10.1097/j.pain.0000000000001384. PMID: 30586067.

3 Parker R, Stein DJ, Jelsma J. Pain in people living with HIV/AIDS: a systematic review. J Int AIDS Soc. 2014 Feb 18;17(1):18719. doi: 10.7448/IAS.17.1.18719. PMID: 24560338

Table 3.1.2: Clinical Aspects of Sensory Impairment

Table 3.1.2: Clinical Aspects of Sensory Impairment
Impairments Possible Etiologies Rehabilitation Interventions

Visual loss

(including retinitis, retinal detachment, retinal vascular disease and blindness)

Viral (e.g., CMV, HSV, VSV)

Parasitic (e.g., Toxoplasmosis)

Fungal (e.g., PCP)

Bacterial (e.g., Cryptococcus)

Malignancy (e.g., Kaposi’s sarcoma, Burkitt’s lymphoma)

Ischemia

Cranial nerve involvement

Diabetes-related

Side effects from medication

Pre-existing (e.g., cataracts)

Assistive devices

Environmental adaptation

Psychosocial rehabilitation

Visual Loss – meal preparation, shopping and medication

Auditory impairments (including hearing loss, tinnitus and otalgia)

HIV (the virus itself)

Opportunistic infections

Lesions in the central nervous system

Medication-related

Pre-existing

Assistive devices

Auditory training

Education on managing conversations and communication, cued speech, use of visual clues, learning strategies

Environmental adaptation

Vestibular impairments (including dizziness and poor balance)

Otitis media

Side effects of medication

Visual impairment

Environmental adaptation

Vestibular rehabilitation

Pain (acute and chronic)

Musculoskeletal pain (inflammatory or non- inflammatory)

Secondary processes, inactivity or deconditioning

Joint pain caused by bacterial infections, arthritis and medication

Central nervous system lesions (parasitic, fungal, bacterial, fungal or malignant)

Peripheral neuropathy (HIV or medication-related)

Myelopathy (e.g., secondary to CMV)

Systemic pain (e.g. malignancies, pleurisy, esophagitis, myocarditis, colitis)

Exacerbation of pain by lack of sleep, anxiety or depression

Impact of life situation (stress, finances, etc.)

Cryotherapy

Desensitization techniques

Electrotherapy Modalities (e.g., TENS1, IFC)

Environmental adaptations

Exercise prescription – aerobic

Exercise prescription – strength

Exercise prescription – stretching and passive movement

Progressive goal setting

Graded physical activity2

Mind-body interventions (e.g., yoga)3

Heat therapy

Massage therapy

Psychosocial rehabilitation

Relaxation techniques (e.g., progressive muscle relaxation)

Splinting and joint support

Sleep hygiene techniques

Cognitive behavioural therapies and insight-oriented focus counselling

Return to work and/or activities strategies

Self-management support4

Pain education5

Sensation changes (including numbness, burning or tingling)

HIV

Peripheral neuropathy

Desensitization

Exercise prescription – aerobic

Exercise prescription – strength

Exercise prescription – stretching and passive movement

Legend: CMV – Cytomegalovirus; HSV – Herpes Simplex Virus; IFT – Interferential Therapy; PCP – Pneumocystis Carinii Pneumonia; TENS – Transcutaneous Electrical Nerve Stimulation; VSV – Varicella-Zoster Virus

1 Dailey DL, Vance CGT, Rakel BA, Zimmerman MB, Embree J, et al. Transcutaneous Electrical Nerve Stimulation Reduces Movement-Evoked Pain and Fatigue: A Randomized, Controlled Trial. Arthritis Rheumatol. 2020 May;72(5):824-836. doi: 10.1002/art.41170. Epub 2020 Mar 18. PMID: 31738014

2 Moseley GL. A pain neuromatrix approach to patients with chronic pain. Man Ther. 2003 Aug;8(3):130-40. doi: 10.1016/s1356-689x(03)00051-1. PMID: 12909433.

3 Morone NE, Greco CM. Mind-body interventions for chronic pain in older adults: a structured review. Pain Med. 2007 May-Jun;8(4):359-75. doi: 10.1111/j.1526-4637.2007.00312.x. PMID: 17610459.

4 Nkhoma K, Norton C, Sabin C, Winston A, Merlin J, Harding R. Self-management Interventions for Pain and Physical Symptoms Among People Living With HIV: A Systematic Review of the Evidence. J Acquir Immune Defic Syndr. 2018 Oct 1;79(2):206-225. doi: 10.1097/QAI.0000000000001785. PMID: 30212435.

5 Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2016 Jul;32(5):332-55. doi: 10.1080/09593985.2016.1194646. PMID: 27351541.

3.1.3 Voice and speech functions

People living with HIV experience impairments relating to voice and speech function caused by infection by viral pathogens or secondary sarcomas, and bacterial or fungal infections. In some cases, voice and speech impairments are associated with neurological impairments.

Rehabilitation interventions for voice and speech functions include exercise related to articulation, fluency, resonance, language as well as adaptation of the communication environment. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.

Table 3.1.3: Clinical Aspects of Voice and Speech Impairments

Table 3.1.3: Clinical Aspects of Voice and Speech Impairments
Impairments Possible Etiologies Rehabilitation Interventions

Dysphagia

Kaposi’s sarcoma of mouth, pharynx, larynx

Viral, bacterial or fungal infection

Articulation, fluency, resonance, language advice and exercises

Swallowing studies and trial feeding

Alternative feeding options e.g. percutaneous gastronomy tubes

Phonatory dysfunction

Kaposi’s sarcoma of mouth, pharynx, larynx

Viral, bacterial or fungal infection

Articulation, fluency, resonance, language advice and exercises

Sound amplification devices

Dysarthria

Viral pathogen

Neurogenic anomalies of viral infection

Articulation, fluency, resonance, language advice and exercises

Psychosocial rehabilitation

Augmentative communication devices e.g., text-to-voice output device

3.1.4 Functions of the cardiovascular, hematological, immunological and respiratory systems

People living with HIV experience impairments related to the heart, blood pressure, hematological system (blood), immune system (including allergies, hypersensitivities) and respiration (breathing).

Possible causes of these impairments include primary HIV infection or secondary bacterial and fungal infections such as cytomegalovirus, Pneumocystis Jirovecii Pneumonia (PJP) or Tuberculosis (TB).

Malignancy such as Kaposi’s sarcoma and Non-Hodgkin’s Lymphoma are also secondary complications which affect the cardiovascular, hematological, immunological and respiratory systems. These impairments can also be caused by side effects of medications.

Rehabilitation interventions include chest physiotherapy, aerobic and strength exercise, pain management and adaptation of environment. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.

Table 3.1.4: Clinical Aspects of Cardiovascular, Hematological, Immunological and Respiratory Impairments

Table 3.1.4: Clinical Aspects of Cardiovascular, Hematological, Immunological and Respiratory Impairments
Impairments Possible Etiologies Rehabilitation Interventions

Impairments related to cardiac dysfunction

(e.g., angina pain, anxiety, decreased endurance)

Myocarditis or endocarditis (e.g., from bacterial or fungal infection)

Cardiomyopathy (e.g., from viral pathogens or side effects of medication)

Pericarditis or pericardial effusion (e.g., resulting from infections from multiple pathogens)

Coronary artery disease (e.g., resulting from side effects of medication)

Peripheral vascular disease (e.g., resulting from viral pathogens)

Exercise prescription – aerobic

Exercise prescription – strength

Nutritional advice

Pain management

Psychosocial rehabilitation

Relaxation techniques

Return to work and/or activities strategies

Formal referral for cardiac rehabilitation

Shortness of breath and other respiratory impairments

Acute lung disease (e.g., pneumonia)

Malignancies (e.g., Kaposi’s sarcoma, Non-Hodgkins Lymphoma)

Assistive devices

Chest physiotherapy techniques

Exercise prescription – aerobic

Exercise prescription – strength

Nutritional advice

Pain management

Psychosocial rehabilitation

3.1.5 Functions of the digestive, metabolic and endocrine systems

People living with HIV may have impairments related to digestion, endocrine function and weight maintenance (both excessive weight loss and weight gain). These impairments may be caused by the HIV infection itself, one of the many opportunistic infections associated with HIV, or side effects of various HIV-related medications.

Dietary advice and exercise prescription can be utilized as methods to assist people living with HIV with both weight gain and weight loss. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.

Table 3.1.5: Clinical Aspects of Digestive, Metabolic and Endocrine Impairments

Table 3.1.5: Clinical Aspects of Digestive, Metabolic and Endocrine Impairments
Impairments Possible Etiologies Rehabilitation Interventions

Digestive dysfunction

HIV enteropathy

Secondary infections (e.g., MAC, cryptosporidium)

Obstruction (e.g., tumour)

Food intolerances

Medication-related

Exercise prescription – aerobic

Nutritional advice

Endocrine dysfunction

Malignancy

Adrenal insufficiency

Hypogonadism

Hypothyroidism

Medication-related

Food intolerances

Nutritional advice

Pain management

Weight loss

Anorexia secondary to physiological (e.g., esophagitis, candida) or psychological causes

Dysphagia (e.g., due to candida, KS or CMV)

Malnutrition Malabsorption

Malignancy

Infection and fever-related

Side effects of medication

Exercise prescription – aerobic

Exercise prescription – strength

Nutritional advice

Psychosocial rehabilitation

Weight loss interventions

Weight gain

Inactivity and deconditioning

Constipation

Side effects of medication

Exercise prescription – aerobic

Exercise prescription – strength

Exercise prescription – stretching and passive movement

Nutritional advice

Psychosocial rehabilitation

Weight gain interventions

Weight redistribution

HIV-infection

Side effects of medication

Lipodystrophy

Exercise prescription – aerobic

Exercise prescription – strength

Nutritional advice

Psychosocial rehabilitation

Legend: CMV – Cytomegalovirus; KS – Kaposi’s Sarcoma; MAC – Mycobacterium Avium Complex

3.1.6 Genitourinary and reproductive functions

People living with HIV can experience impairments of genitourinary and reproductive functions. These impairments are related to urination functions and sexual functions and may be directly caused by the viral pathogen or secondary bacterial and fungal infection. Side effects of medications also have an effect on urinary and sexual functions. Sexual impairments can also result from psychosocial etiologies.

Rehabilitation interventions include psychosocial rehabilitation, electrotherapy modalities and exercise. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.

Table 3.1.6: Clinical Aspects of Genitourinary and Reproductive Impairments

Table 3.1.6: Clinical Aspects of Genitourinary and Reproductive Impairments
Impairments Possible Etiologies Rehabilitation Interventions

Urination dysfunction

Urinary tract infection

Viral pathogen affecting the nervous system

Side effects of medication

Opportunistic infections

Other fungal or bacterial infections

Exercise prescription – pelvic floor

Nutritional advice

Sexual impairments including loss of libido, pain during sex and male erectile problems

Viral pathogen

Emotional issues (e.g., anxiety, stress, grief and depression)

Smoking

Side effect of medication

Alcohol use

Recreational drug use

Hormone dysfunction (e.g., testosterone deficiency and thyroid dysfunction in men and women, early menopause in women with HIV)

Autonomic and/or peripheral neuropathy

Sexually transmitted infections

Exercise prescription – aerobic

Exercise prescription – strength

Psychosocial rehabilitation

Referral to sex therapy

3.1.7 Neuromuscular and movement related structures

People living with HIV commonly experience neuromuscular and movement-related impairments. These impairments include (but are not limited to) difficulties related to joint mobility, muscle power and involuntary movements.

These impairments may be caused by pathology in the central nervous system, spinal cord or peripheral nervous system. Neuromuscular rehabilitation techniques include massage therapy, passive movements, proprioceptive neuromuscular facilitation (PNF) and Bobath techniques, and exercise prescription. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.

Table 3.1.7: Clinical Aspects of Neuromuscular and Movement Related Impairments

Table 3.1.7: Clinical Aspects of Neuromuscular and Movement Related Impairments
Impairments Possible Etiologies Rehabilitation Interventions

Reduced joint mobility

Disuse Inflammation

Fluid retention

Assistive devices

Electrotherapy Modalities

Exercise prescription – aerobic

Exercise prescription – strength

Exercise prescription – stretching and passive movement

Heat therapy

Massage therapy

Pain management

Muscle tone

(increased or decreased tone including flaccidity, spasticity and rigidity)

Deconditioning

Central nervous system lesions (including stroke, malignancy or infection)

Spinal cord pathology (including myelitis, TB)

Lower motor neuron lesions

Exercise prescription – aerobic

Exercise prescription – strength

Exercise prescription – stretching and passive movement

Neurological rehabilitation

Psychosocial rehabilitation

Functional electrical stimulation

Casting/tone-inhibiting orthoses via static splinting

Reduced muscle strength, power and endurance

Inactivity or deconditioning due to prolonged bed rest or illness

Central nervous system lesions (including stroke, malignancy or infection)

Spinal cord pathology (including myelitis, TB spine)

Acute inflammatory demyelinating polyneuropathy

Inadequate nutritional intake

Anemia

Electrolyte abnormalities

Exercise prescription – aerobic

Exercise prescription – strength

Neurological rehabilitation

Psychosocial rehabilitation

Involuntary movements (including dystonia and ataxia)

Central nervous system lesions

Side effects of medication

Electrolyte abnormalities

Neurological rehabilitation

Psychosocial rehabilitation

Decreased bone density (including osteoporosis and osteopenia)

Inactivity or deconditioning

Severe weight loss

Malnutrition

Hormonal imbalances

Exercise prescription – aerobic

Exercise prescription – strength

Nutritional advice

Postural re-education

Environmental assessment for fall injury risk reduction

Osteonecrosis (avascular necrosis)

Etiology unknown but associated with HIV infection

Exercise prescription – aerobic

Exercise prescription – strength

Assistive devices – walking stick, cane

Legend: TB – tuberculosis

3.1.8 Functions of the skin and related structures

People living with HIV may experience impairments related to the skin and related structures. Impairments may be caused by viral, fungal or bacterial infections. Kaposi’s sarcoma commonly affects the skin.

Rehabilitation interventions include psychosocial rehabilitation, advice on skin care and exercises. Potential causes of these impairments and rehabilitation interventions are shown in the table below. Note: Choice of rehabilitation interventions will depend on patient assessment and available resources.

Table 3.1.8: Clinical Aspects of Skin Impairments

Table 3.1.8: Clinical Aspects of Skin Impairments
Impairment Possible Etiologies Rehabilitation Interventions

Skin lesions (including cold sores, rashes, and warts)

Herpes simplex and other viral infections

Kaposi’s sarcoma

Psychosocial rehabilitation

Skin care, clothing and environmental advice

Skin infections

Molluscum contagiosum, folliculitis, seborrheic dermatitis, psoriasis and tinea, caused by viral, bacterial and fungal infections

Psychosocial rehabilitation

Skin care, clothing and environmental advice

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