3.3 More information on the rehabilitation interventions available for people living with HIV

Advice and exercises can be given to individuals to address challenges with speaking. These include rehabilitation to improve fluency, resonance, phonation, producing sound, intonation, variance of pitch, and voice and language, as well as aeromechanical components of respiration. Individuals may be assessed by a speech-language pathologist and work in collaboration with the multidisciplinary team to implement therapy.

The provision of assistive devices can help people with disabilities address and adapt to their environment, promoting normal lifestyle and facilitating employment and education participation. Examples of assistive devices are mobility devices, home modification devices, respiratory devices, hearing aids, and self-care equipment. Assistive devices can range from low cost to high cost and some devices can be no cost. For example, individuals experiencing memory loss may set a reminder on their phone to alert them when medication needs to be taken. Other examples of low cost devices are reaching aids that can be purchased from various retail stores. Governmental programs can provide assistance for high-cost assistive devices. For example, the province of Ontario has an assistive devices program. Non-governmental organizations can also be a valuable source of assistive devices.

For auditory impairments and assistive devices, referrals should be made to an audiologist or the local association for deaf people. Rehabilitation providers can give advice to individuals with auditory impairments, including: environmental modifications, auditory training and cued speech.

Chest physiotherapy techniques are used to treat individuals with respiratory impairments. The goals of treatment are to mobilize secretions to clear lungs, improve the work of breathing and improve oxygenation of the lungs. There are a variety of chest physiotherapy techniques including (but not limited to) deep breathing exercises, active cycle of breathing techniques (ACBT), positioning to encourage postural drainage, and manual techniques such as percussion, vibrations and shaking.

Respiratory devices such as positive expiratory pressure masks, incentive spirometers and flutter devices can be used to assist chest physiotherapy techniques.

The aim of CBR is to promote inclusion of people with disabilities, by establishing community-based programs for social integration, equalization of opportunities, and rehabilitation programs. Leadership in CBR is not dependent on professionals in healthcare, education, vocational or social services but involves community leaders, families and people with disabilities. It is a multi-sectoral strategy that empowers persons with disabilities to access and benefit from education, employment, health and social services. CBR is delivered within the community, using predominantly local resources. CBR ranges from providing assistive devices for people with disabilities to coordinating with local schools to include vocational rehabilitation for adult education as well as family support and counselling.

It is important that rehabilitation providers are aware of community organizations operating within their local areas and collaborate with these organizations, where possible. People living with HIV throughout the world have been proactive in developing and managing community-based responses related to education, food security and advocacy efforts. Examples of these organizations include Community Based HIV Organizations (CBHOs) and AIDs Service Organizations (ASOs).

Cryotherapy is the use of low temperatures such as cold water or ice to reduce pain, inflammation and spasm. In acute injuries, cryotherapy is used to promote vasoconstriction of blood vessels and reduce the effects of inflammation and cell damage. Cryotherapy is not recommended for children under three years of age or for children with severe sensory or communication disorders.

Desensitization techniques can be employed to assist people living with HIV who suffer from hypersensitivity, hyperalgesia and allodynia related to conditions such as peripheral neuropathy and polyneuropathy. These techniques include advice regarding adaptation of clothing, such as wearing seamless clothing or wearing socks inside out. Rubbing of the skin with variously textured materials (from smooth to rough) can help desensitize skin. As individuals become less sensitive, contrast bathing (the alternating use of cold and hot water bathing) can be used to treat affected areas of the body.

In addition to inferential current therapy (IFC) and transcutaneous electrical nerve stimulation (TENS), there are a variety of other electrotherapy modalities that may benefit people living with HIV, including ultrasound therapy, pulsed shortwave diathermy (PSD), laser therapy and infrared therapy.

Pacing and energy conservation techniques assist individuals to balance work, social and leisure pursuits by ensuring they have the necessary energy levels when required. Various strategies can be taught to people living with HIV by rehabilitation providers to achieve optimum energy levels. Education includes the collaborative setting of achievable goals, advice on the planning of errands to minimize fatigue, and teaching correct posture and biomechanics to ensure efficiency of activity. Adaptation of the physical environment can also assist with energy conservation, as can the prescription of assistive devices, where required. Rehabilitation and exercise sessions should be timed when individuals typically have the highest levels of energy and where necessary, to ensure the optimal effect of any medication (e.g., analgesics) that the individual may take prior to exercise.

Environmental adaptation refers to changing or restructuring the environment to meet the needs of people with impairments. The change could involve home, work, community and/or study environments e.g., adapting the environment of the home to accommodate a person using a wheelchair by clearing passages and widening doorways.

Ergonomics involves the re-design of the physical environment and the use of equipment to better complement the individual living within that environment. Practical examples of applying ergonomic principles include the re-positioning of furniture in the home, school and/or workplace to decrease musculoskeletal overuse injuries, and advising regular rest intervals during sustained activities. Advice on posture and biomechanics when working or studying can also reduce undue strain and fatigue. Task analysis of an individual’s daily activities can ascertain priority areas for intervention. Knowledge of one’s country’s specific occupational and safety acts is also important to ensure that employers make the necessary adaptations for all workers, particularly those who may have physical and/or cognitive impairments. Knowledge of national, provincial and local inclusion policies can also determine adaptations to be made in schools.

Exercise is a key strategy that may be used by people living with HIV and by rehabilitation professionals to address or prevent disability and improve or sustain the health of people living with HIV. Exercise is defined as any physical activity involving bodily movement produced by skeletal muscles that requires energy expenditure including (but not limited to) aerobic, resistance, flexibility and neuromotor activity beyond activities of daily living to improve and maintain physical fitness and health.

Regular exercise is widely accepted as an important part of optimal health. In HIV, exercise has been shown to:

• Improve cardiovascular fitness
• Increase body weight
• Improve body composition
• Improve bone density
• Increase strength
• Improve balance and mobility
• Improve quality of life, improve mood and decrease stress

Aerobic (also known as cardiovascular) exercise includes activities such as walking, jogging, stepping, swimming and cycling. Aerobic exercise has been shown to be beneficial for people living with HIV conferring physical benefits as well as improving mental health and quality of life, and reducing symptoms of depression. These exercises can be done at little or no cost and can be performed with fellow patients, friends and family members. Although few studies investigate the role of aerobic exercise in children living with HIV, preliminary results suggest that it is an appropriate intervention provided the child is not acutely ill.

Neuromotor exercises include activities that work on various motor skills such as balance, coordination, gait, agility and proprioceptive training. These exercises can be easily incorporated into any exercise program and can help improve quality of life and decrease fall risk. This is particularly important since balance decreases with age and older adults living with HIV have a higher prevalence of frailty.

Pelvic floor exercises (e.g., Kegels) can be used to strengthen the muscles beneath the uterus, bladder and bowel. These exercises can be taught to men or women who have any problems with bladder or bowel incontinence. Individuals should initially be taught how to contract these muscles when the bladder and bowel are empty and then progress to building the endurance of these muscles and finally using these exercises to limit or prevent incontinence. Individuals should be encouraged to continue with these exercises even when the incontinence has resolved.

Strength (or resistance) training involves exercises that overcome either internal or external forces using body weight or a variety of equipment including free weights (dumbbells and barbells), machine weights, resistance bands/tubing and hydrotherapy. When correctly taught, these exercises can improve muscle strength, power, endurance and coordination, and also improve daily functioning and quality of life. This form of exercise has been shown to be safe and beneficial for people living with HIV. Although few studies investigate the role of strengthening exercise in children infected with HIV, preliminary results suggest that it is an appropriate intervention if the child is not acutely ill.

Passive movement is the movement of separate parts of an individual’s body by the rehabilitation provider or by another external force. Passive movements and stretching exercises can help improve flexibility and circulation, normalize muscle tone and reduce the risk of contractures and pressure sores. Family members and friends can be taught to assist with these exercises, providing both a therapeutic intervention as well as an opportunity for interaction and involvement with others. Static stretching exercises can be taught to individual patients, while proprioceptive neuromuscular facilitation (PNF) techniques should always be instructed by a trained professional.

People living with HIV report an increased level of fatigue. The exercise prescription described above should incorporate principles of task analysis, pacing of activities, efficiency of tasks and the suitable timing of therapy/exercise so as to improve levels of energy, rather than exacerbate fatigue. An assessment of the workplace and home environment, including ergonomic considerations (see above), should be conducted in order to assist the individual, where possible, to conserve energy.

Heat therapy (also called thermotherapy) is the application of heat to the body to relieve pain. Methods of application include warm water, hot packs (hydrocollator or microwave heated), ultrasound, infrared lamp, and hot cloth. In some facilities, whirlpool baths and hot thermal wraps are available. Heat is also used to reduce joint stiffness and edema, aid healing, and relieve muscle spasms. Great care should be taken when using heat therapy with young children, the elderly, or anyone with altered sensation.

HBR is a rehabilitation strategy that is usually coordinated by discharge teams at hospitals or community care organizations. It provides care for patients in their own homes. It is used for patients post-discharge from the acute healthcare setting or when patients are unable to access healthcare services. A review of HBR programs demonstrated that this model can be based on evidence-based practice, support task shifting to lay personnel, enable patient-centred care and maximize function and independence of people living with HIV.

IFC is the use of low frequency electrical stimulation created by the interference of two medium frequency currents passing through tissues simultaneously. These result in the stimulation of nerve endings. IFC is applied using 2-4 surface electrodes that are metal plate and pads with water-soaked sponges, carbon rubber electrodes with conducting gel, or suction cup electrodes. IFC is used to manage pain, elicit muscle contraction, decrease edema, increase blood flow, and stimulate soft tissue healing and repair. IFC devices are becoming more portable and practitioners are able to use them easily in community settings. IFC is not recommended for use with children.

Massage is the use of physical techniques or manipulations such as Swedish strokes, deep tissue work, myofascial release and neuromuscular techniques. It is used to relieve pain, improve circulation, reduce edema, increase mobility of connective tissue, relieve stress and improve quality of life.

Massage is also believed to have a positive effect on immune function through stress mediation and enhanced with the use of other stress modalities.

NDT therapy is typically provided by a physiotherapist, occupational therapist or speech therapist. It is used to treat children or adults with neurological disorders, and is potentially useful in treating children with HIV encephalopathy. The aim is to optimize functional abilities by improving postural tone and co- ordination. The family is very important in providing continued treatment at home.

Neurological rehabilitation interventions are designed to reduce the symptoms of people with neurological impairments and improve their functional ability. These include activities to improve mobility and gait, exercises to improve movement and strength (active, passive and proprioceptive neuromuscular facilitation and neurodevelopmental therapy), techniques to minimize disorders of muscle tone (such as Bobath or Motor Relearning techniques), assistance with activities of daily living (e.g., washing, dressing, feeding), speech therapy to assist with speaking and swallowing, and advice on assistive aids to promote independence. Involvement of family and friends in this rehabilitation and the referral to community support groups, where possible, should be central to these interventions.

Appropriate psychosocial interventions may also enhance the success of this form of rehabilitation.

Poor diet has a direct effect on the immune system. Advice on nutrition must be tailored to the individual and their circumstances. People living with HIV may suffer from weight loss or weight gain. Individuals need to eat a balanced diet with fat, carbohydrates and protein. Individuals could be advised to eat several small meals per day using what is available to supplement all food groups. Individuals may be further advised, to keep logbooks on their weight and diet, with education on warning parameters for weight loss or gain. Dietitians or nutritionists may recommend daily multivitamins. It is important however to consider possible interactions of dietary supplements and ARTs. Referral can be made to a dietitian (when available) who may conduct a nutritional assessment, counsel individuals, or assist with food provision through referral to nutrition supports. Any advice on nutrition must include information on adequate hydration level for each individual.

Up to 15% of people living with HIV may develop peripheral neuropathy characterized by distal, symmetric anesthesia and/or painful dysesthesia.Although peripheral neuropathy is present in untreated HIV infection, exposure to certain types of older ARTs place some individuals at an increased risk. Physical interventions to address peripheral neuropathy include transcutaneous electrical nerve stimulation (TENS) or interferential current (IFC) for symptomatic management, adapted footwear, night ankle splints and bed tents to keep sheets off of feet and desensitization techniques (e.g., rubbing hands and feet with varying textures of material).

Medication can assist in pain management, but this intervention should be directed by a qualified practitioner. Pharmacological interventions for pain include topical analgesics, opioids, non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids.

Research also shows there is an intrinsic psychological component of pain and the importance of chronic pain behavioural interventions that include treatment of depression and substance use. Education, thus, is vital in helping minimize the experience of pain. Furthermore, aerobic exercise can also be an effective means of reducing pain. Aerobic exercise can also be an effective means of reducing pain. Other non-pharmacological interventions for pain management include relaxation techniques, increased rest, cognitive-behavioural techniques, balance diet, acupuncture and TENS.

Advice on positioning can be provided to individuals who may suffer from a number of impairments related to HIV. Correct positioning can help with the drainage of respiratory secretions, limit postural deformities, improve the function of individuals with neurological impairments, decrease swelling and minimize secondary complications of disuse such as pressure sores and contractures. Additional devices such as pillows, splints and gel pads can further assist in positioning.

More specialized psychological rehabilitation services can be offered by specifically trained professionals, including psychiatrists, psychologists, psychotherapists and occupational therapists. However, primary prevention, in the form of exercise, adequate nutrition and maximizing quality of life falls within the scope of all rehabilitation providers. Social support structures, such as support groups, friends, family, cultural, religious and other community organizations, can also provide emotional and practical support.

Relaxation techniques (including stress reduction techniques, visualization and imagery, progressive muscle relaxation, and the use of music) can improve name and face recall, short-term memory and incidental learning, reduce anxiety and depression, and strengthen immune function. Where possible, family members, friends and caregivers should also be taught these techniques, as they have been shown to increase caregivers’ self-efficacy.

These strategies are similar to those discussed in Return to Work and/or Activities Strategies. The rehabilitation provider can work together with the child, family and educators to prepare a child for return to school. This is particularly important after long absences, when the child has been extremely ill, or is returning with a new disability. The peers of the returning child should be prepared and given strategies to support their friend.

Return to work strategies are aimed at rehabilitating people with impairments to facilitate their return to work. It prepares both the employer and employee for what is involved in their return so optimal function is resumed. The employer and employee work together to tailor the work to suit the needs of the employee. The vocational rehabilitation provider, employee and employer work hand in hand to develop and implement strategies for return to work. All employees should be trained to prevent injury and provide an environment that is supportive toward people living with disabilities.

For some individuals, the focus will be a on a return to regular activities which may include non-paid work, non-recognized work, volunteerism, leisure activities, etc.

Some medication can increase the risk of skin sensitivity and sun damage, making prevention even more important. Protective clothing (sunglasses, long sleeved shirts and pants that block the sun, broad brimmed hats) protect skin. Dermatologically tested sun care products with a Sun Protection Factor (SPF) that is tailored to suit individual needs should be used to protect the skin from sun damage.

Swallowing studies and trial feeding as directed by a speech-language pathologist in collaboration with the wider healthcare team, are typically used to ensure a nutritionally adequate diet for people living with HIV based on texture and consistency. They can also assist in evaluating an individuals’ ability to safely ingest oral food.

TENS is a battery-operated electrical device that is used to relieve pain. It has surface electrodes (2 or more) that transfer electrical current to the surface of the skin and cause nerve stimulation. A TENS unit modulates pulse width, frequency and intensity.

Vestibular rehabilitation (VR) can be effective in improving symptoms such as vertigo, dizziness, visual disturbance and imbalance. It is a research-based approach involving exercises and individualized techniques to help the brain compensate for problems in the vestibular system or treat mechanical dysfunction in the vestibular portion of the inner ear. Post-graduate training is required for VR and is usually implemented by a physiotherapist. Vestibular involvement is common in people living with HIV, however the prevalence and nature of vestibular involvement is still largely unknown and merits more research.

Individuals with visual impairments and visual loss can be assisted with advice and education on meal preparation such as organizing work space and materials, adequately labeling dials and controls on appliances and, with the assistance of occupational therapists, on the safe use of assistive devices with kitchen utensils.

Similarly, shopping can be made easier by organizing lists according to store layout, asking store personnel for assistance, contacting caregivers to assist with shopping, getting items delivered, and using magnifiers or penlights for reading labels.

Individuals can be educated about administration of medication by organizing them by time of day, identifying containers by shape and size, or using elastic bands, magnetic tape, coloured tape, or marked contrasts in labels. The local pharmacy can also assist with alternative packaging (e.g., bubble packs).

For visual loss and assistive devices, referrals can be made to the specific country’s association for blind/visually impaired people (e.g., the Canadian National Institute for the Blind). Rehabilitation providers can give advice to individuals with visual impairments, including: ensuring the physical environment is free from obstacles, ergonomic advice, organizing clothing according to texture, and advice on food storage and meal preparation. Support should be provided for visually impaired children returning to school.

Individuals suffering from acute digestive and endocrine-related impairments should be referred for appropriate medical care. There are rehabilitation interventions that can assist individuals who want to put on weight, including: exercise (particularly strength training to build muscle mass), nutrition, rehydration and supplementation. Referral to community food programs may be necessary in instances where individuals cannot afford adequate nutrition. Psychosocial rehabilitation or referral may be necessary when excessive weight loss is primarily related to psychological causes.

Individuals suffering from acute digestive and endocrine-related impairments should be referred for appropriate medical care. There are rehabilitation interventions that can assist individuals who want to lose weight, including: exercise and nutritional advice. Referrals to community food programs may be required for individuals who cannot afford alternatives to low-cost, high-caloric foods.

Characteristic features of protease inhibitor-associated lipodystrophy include increases in abdominal visceral adipose tissue, loss of facial fat, development of dorsocervical and supraclavicular fat pads and enlargement around the breasts in women. Adipose cells are not lost but are redistributed to areas around the viscera and within blood vessels. This redistribution, in addition to elevated triglycerides, increases the risk of developing cardiovascular disease and its complications. A combination of aerobic and strength exercise has proven beneficial in reducing the effects of body fat redistribution and improving the quality of lives of people living with HIV and this condition.