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PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:006 Revision: 01 Page: 1 of 17

PHYSICAL THERAPY MANAGEMENT OF HIV & AIDS PATIENTS

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Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.

Medicine: it’s a noble profession, it serves humanity

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SPEC. BY: Abdulrehman S. Mulla DATE: 03/25/2009 REVISION HISTORY REV.

DESCRIPTION

CN No.

BY

DATE

01 Initial Release PTM001 ASM 03/28/2009






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TABLE OF CONTENTS PAGE PHYSICAL THERAPY MANAGEMENT OF HIV & AIDS PATIENTS:................................................................................................... 3 1.0 PATHOPHYSIOLOCY OF HIV/AIDS: ..................................................................................................................................... 4

1.1 WHAT PT SERVICES WOULD BE BENEFICIAL TO PERSONS WITH HIV?......................................................... 6 1.1.1 PAIN MANAGEMENT / DEALING WITH NEUROPATHIES: ..................................................................... 6 1.1.2 STRENGTHENING: ................................................................................................................................... 6 1.1.3 FUNCTIONAL REHABILITATION:............................................................................................................. 6 1.1.4 WHAT TO EXPECT? ................................................................................................................................. 7

1.2 PAIN MANAGEMENT / DEALING WITH NEUROPATHIES:................................................................................... 7 1.3 STRENGTHENING: ................................................................................................................................................. 7 1.4 FUNCTIONAL REHABILITATION: ........................................................................................................................... 7 1.5 WHAT TO EXPECT?:............................................................................................................................................... 8

2.0 HIV RELATED PAIN: .............................................................................................................................................................. 9 2.1 WHAT CAUSES PAIN?............................................................................................................................................ 9 2.2 WHAT ARE THE MOST COMMON TYPES OF PAIN? ........................................................................................... 9

2.2.1 PERIPHERAL NEUROPATHY:.................................................................................................................. 9 A. ABDOMINAL PAIN:........................................................................................................................... 10 B. HEADACHE: ..................................................................................................................................... 10 C. POST-HERPETIC PAIN:................................................................................................................... 10 D. JOINT AND MUSCLE PAIN: ............................................................................................................. 10 E. OTHERS: .......................................................................................................................................... 10

3.0 ASSESSING PAIN:............................................................................................................................................................... 11 3.1 DEFINE THE SEVERITY OF THE PAIN: ............................................................................................................... 11 3.2 PAIN MEDICATION SELECTION: ......................................................................................................................... 11 3.3 DOES THE PAIN MEDICATION WORK? .............................................................................................................. 11

4.0 TREATMENT OF PAIN:........................................................................................................................................................ 11 4.1 NON-OPIOID:......................................................................................................................................................... 11 4.2 OPIOIDS / NARCOTICS ........................................................................................................................................ 12

4.2.1 WEAK OPIOIDS:...................................................................................................................................... 12 4.2.2 STRONG OPIOIDS: ................................................................................................................................. 12

4.3 ADJUVANT THERAPY:.......................................................................................................................................... 12 4.3.1 ANTI-DEPRESSANTS: ............................................................................................................................ 13 4.3.2 ANTICONVULSANTS: ............................................................................................................................. 13 4.3.3 LOCAL ANESTHETICS: .......................................................................................................................... 13

5.0 WHAT SHOULD YOU DO IF YOU HAVE PAIN? ................................................................................................................. 13 5.1 NEVER IGNORE YOUR PAIN: .............................................................................................................................. 13

5.1.1 ASSESS YOUR PAIN: ............................................................................................................................. 13 5.1.2 NOTIFY YOUR DOCTOR: ....................................................................................................................... 13 5.1.3 TAKE YOUR PAIN MEDICATIONS: ........................................................................................................ 13 5.1.4 BE RESPONSIBLE: ................................................................................................................................. 13 5.1.5 IF THEY DON’T WORK TELL YOUR DOCTOR: ..................................................................................... 14

6.0 PHYSIOTHERAPY FOR PATIENTS WITH HIV/AIDS: ......................................................................................................... 14 6.1 EXERCISE PRESCRIPTION:................................................................................................................................. 15 6.2 PATIENT LIMITATIONS TO AN EXERCISE PROGRAM: ..................................................................................... 15

6.2.1 CENTRAL NERVOUS SYSTEM: ............................................................................................................. 15 6.2.2 PERIPHERAL NERVOUS SYSTEM: ....................................................................................................... 16 6.2.3 MUSCULOSKELETAL SYSTEM: ............................................................................................................ 17






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PHYSICAL THERAPY MANAGEMENT OF HIV & AIDS PATIENTS: Physiotherapy is an essential component in the multidisciplinary care for people living with HIV/AIDS. Early

physiotherapy intervention is effective and be given in any HIV care settings and also at any physiotherapy units without any additional investment. Physiotherapy reduces hospital stay and the individual can be discharged in a functionally independent state.

RECOMMENDATIONS: Physiotherapy should be included in the HIV/AIDS care manifesto. Early

intervention should be made available. Patient education and awareness among health care fraternity about the potential benefits of physiotherapy is necessary in promoting appropriate referrals.

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.

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.

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.

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.

Hot in the news: Bone marrow transplant to offer HIV cure

2008-11-13 11:54:37 Last Updated: 2008-11-13 13:09:22

New Delhi: Researchers from Berlin’s Charite hospital were successfully able to ward off HIV virus from a patient’s body with the help of bone marrow transplantation.

According to the doctors, bone marrow transplants are generally used to fight leukemia, however, during the present study the researchers found that the procedure can also prove effective against HIV virus.

Dr. Gero Huetter conducted the research over a 42-year-old American man from Berlin who had been infected with the AIDS virus for more than a decade.

However, after the transplantation of genetically selected bone marrow, he no longer showed signs of carrying the virus, reports China Daily.

But Dr. Andrew Badley, director of the HIV and immunology research lab at the Mayo Clinic in Rochester, Minn, suggests, “ a lot more scrutiny from a lot of different biological samples would be required to say it’s not present.”

Before the transplant, the patient was asked to take powerful drugs and radiation to kill off his own infected bone marrow cells and disable his immune system. He also stopped the use of important drugs to treat AIDS, anticipating that the new, mutated cells would ward off virus on their own

Huetter revealed that some people carry a genetic mutation called Delta 32 that apparently makes them resistant to HIV infection. If the mutation is inherited from both parents, it prevents HIV from attaching itself to cells by blocking CCR5, a receptor critical for the spread of AIDS virus.

"It helps prove the concept that if somehow you can block the expression of CCR5, maybe by gene therapy, you might be able to inhibit the ability of the virus to replicate," said Fauci.






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1.0 PATHOPHYSIOLOCY OF HIV/AIDS:






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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. The innate system also uses neutrophils and macrophages. 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.

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. In patients with HIV/AIDS, there is a low CD-4 cell count while CD-8 cell counts remain the same.

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. As many as 109 virions are released per day which continually infect and destroy additional T-lymphocytes. This eventually results in the death of T-cells and subsequent immunosuppression. This immunosuppression leaves the individual susceptible to a wide variety of unusual infections and malignancies, which are collectively called opportunistic infections. 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.






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These patients all had significant decreases in the subpopulation of T- lymphocytes that carry the CD-4 marker.

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. 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. A decrease in the CD-4 cell count may adversely affect the cytotoxic effect of natural killer cells as well.

Initially, HIV disseminates to the lymphoid tissue causing a strong immune response. CD-8 T-lymphocytes regulate this process so that the viral load in the circulation stays steady, and this can continue for years. Some newly infected patients may experience mononucleosislike symptoms including fever, swollen glands, and rash. This stage may be referred to as 'HIV seroconversion illness. Otherwise, HIV commonly is broken into 3 stages: (1) Asymptomatic (CD-4 >500/mm^sup 3^), (2) Symptomatic (CD-4 at 200-500/mm^sup 3^), and (3) AIDS (CD0 -4

Viral load can reflect long-term risk of disease progression, whereas CD-4 counts are associated with the risk of developing an opportunistic infection. 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.

Kaposi's sarcoma is the most common form of cancer in patients with human immunodeficiency virus (HIV) infection. Although Kaposi sarcoma lesions may contribute to significant physical impairments, there is a lack of scientific literature detailing the role of physiotherapy in the treatment of HIV-associated Kaposi's sarcoma. 1.1 WHAT PT SERVICES WOULD BE BENEFICIAL TO PERSONS WITH HIV?

1.1.1 PAIN MANAGEMENT / DEALING WITH NEUROPATHIES:

Physical Therapists help to educate patients about effective pain management strategies, and use stretching or strengthening exercises, joint mobilization, and physical agents, such as electrical stimulation to improve function and decrease pain.

1.1.2 STRENGTHENING:

Potential effects of long term infection and some treatment regimens include loss of muscle strength and bulk.

In recent studies, exercise with weights has been shown effective in increasing strength in patients with HIV.

Physical therapists work with clients to set up appropriate programs, modify and adjust the programs based on the response and the client’s medical status.

1.1.3 FUNCTIONAL REHABILITATION:

Many individuals encounter increasing challenges in daily activities because of neuropathy, weakness, fatigue, etc.

Physical therapists identify strategies that address causes of the functional problem; for example, strengthening to improve walking or running abilities, and bracing and other techniques for a person with neuropathy who cannot move well.






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1.1.4 WHAT TO EXPECT?

Individual assessment Therapist working individually with you to develop a treatment plan that works in

your life Follow-up to modify and adjust the plan and to monitor response Coordination and communication with your physician and other health care

providers 1.2 PAIN MANAGEMENT / DEALING WITH NEUROPATHIES:

Physical Therapists help to educate patients about effective pain management Strategies, and use stretching or strengthening exercises, joint mobilization, and physical agents, such as electrical stimulation to improve function and decrease pain.

1.3 STRENGTHENING: Potential effects of long term infection and some treatment regimens include loss of muscle

strength and bulk. In recent studies, exercise with weights has been shown effective in increasing strength in patients

with HIV. Physical therapists work with clients to set up appropriate programs, modify and adjust the

programs based on the response and the client’s medical status.

1.4 FUNCTIONAL REHABILITATION: Many individuals encounter increasing challenges in daily activities because of neuropathy,

weakness, fatigue, etc.






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Physical therapists identify strategies that address causes of the functional problem; for example, strengthening to improve walking or running abilities, and bracing and other techniques for a person with neuropathy who cannot move well.

1.5 WHAT TO EXPECT?: Individual assessment Therapist working individually with you to develop a treatment plan that works in your life Follow-up to modify and adjust the plan and to monitor response Coordination and communication with your physician and other health care providers






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2.0 HIV RELATED PAIN:

Unfortunately, pain is a common companion of HIV. Pain can occur at all stages of the disease; each individual is different. As HIV progresses so does the incidence and strength of pain. A study of HIV patients found that over 50 percent of HIV+ people had pain. 2.1 WHAT CAUSES PAIN?

Pain occurs for many reasons: A symptom of HIV A symptom of other illness or infections A side effect of HIV drugs Regardless of the reason, pain must be identified, assessed, and then treated in order to maintain quality of life.

2.2 WHAT ARE THE MOST COMMON TYPES OF PAIN? The first step in pain management is identifying the type of pain. The most common types of pain include the following:

2.2.1 PERIPHERAL NEUROPATHY:

Pain as a result of sensory nerve damage, mostly in the feet, hands and face. It is described as numbness, tingling, or burning sensations. The nerve damage can be a result of HIV drugs or other medical conditions such as diabetes.






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A. ABDOMINAL PAIN:

There are many reasons an HIV+ person would experience abdominal pain. A side effect of some HIV drugs. Inflammation of the pancreas (pancreatitis) caused by some medicines HIV-related abdominal infections caused by bacteria or parasites Bladder and urinary tract infections (especially in women) Menstruation or conditions of the uterus, cervix or ovaries Diseases of the intestinal tract such as irritable bowels

B. HEADACHE:

This pain can be mild to intense. Causes of mild headaches include muscle tension, stress, HIV drug side effects, and sometimes viral illness. Moderate headaches can be caused by sinus or tooth infections. Severe headaches can be caused by brain tumors, bleeding in the brain, or infection.

C. POST-HERPETIC PAIN:

Herpes is a family of viral infections common to HIV+ people. Once infected, herpes stays for life. Post herpetic pain is present even after the herpes sores have healed. There are several types of Herpes: Chickenpox: which causes open, itching sores on the body Herpes Simplex (HSV-2, or genital herpes): which causes painful sores in the genital

area Herpes zoster (HSV-1 or “cold sores”): causes painful sores near the lips Shingles: which is similar to chickenpox but causes painful sores along nerve pathways

D. JOINT AND MUSCLE PAIN:

This pain can be mild to severe and related to conditions such as arthritis, any kind of injury, lack of exercise, or just aging. It can also be a side effect of some HIV drugs and high cholesterol medications.

E. OTHERS:

Painful skin rashes, chest pain caused by lung infections such as TB, bacterial pneumonia and PCP pneumonia (Pneumocystis pneumonia).

Mouth pain can be caused by mouth ulcers (“canker sores”) or severe fungal infections (thrush).

POST-HERPETIC PAIN

skin rashes






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3.0 ASSESSING PAIN: Once the type of pain is identified the next step is to assess its characteristics. There are three primary goals of pain assessment: 3.1 DEFINE THE SEVERITY OF THE PAIN:

This can be accomplished in several ways. Your healthcare provider will ask you to assign a number to your pain, one being very little pain to

ten, being the worst. Pictures can describe pain. A smiling face represents little or no pain, while a crying face represents

severe pain. There may come a time when you are having pain but do not want to complain. You may feel

reporting your pain will in some way inconvenience your provider. In that case your medical provider watches your body language, facial expressions, and your vital signs.

3.2 PAIN MEDICATION SELECTION:

All pain cannot be treated the same way. The severity, cause and type of pain, and projected duration of pain, and any history of substance abuse all play a role in selecting medication.

3.3 DOES THE PAIN MEDICATION WORK?

Frequent pain assessment is necessary to see if pain medications are working. People can become resistant to pain medications.

4.0 TREATMENT OF PAIN: Once the type and characteristics of pain are identified, treatment must be selected. There are many options for pain relief: Non-medicinal: Meaning pain relief without medicines. Heat and cold therapy Massage Relaxation techniques Physical therapy Hypnosis Mental imagery (focusing on a pleasing mental picture, also known as visualization) While these may be enough to relieve pain, they are usually used along with pain medications. 4.1 NON-OPIOID:

Meaning pain relief by medicines that do not contain narcotics (opiates). Tylenol (acetaminophen) Non-steroidal anti-inflammatories (NSAIDs); examples include Advil and Motrin (ibuprofen) Steroids – examples include prednisone and hydrocortisone COX-2 inhibitors – these drugs block body chemicals that send pain messages to the brain. An

example is Celebrex (celecoxib) These pain medications are effective in relieving mild pain related to inflammation or swelling. They can also cause some side effects: Stomach upset (especially NSAIDs) Altered blood clotting Cardiac complications (especially with COX-2 inhibitors) Liver toxicity (especially acetaminophen)






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Stomach bleeding and ulcers (especially NSAIDs) Non-opioids are available over-the-counter or by prescription.

4.2 OPIOIDS / NARCOTICS Opioids are the strongest pain relievers, available only by prescription. They treat moderate to severe pain, including acute (recent and sudden) and chronic (long-term) pain. Opioids are classified according to speed of action and duration of pain relief. Immediate release opioids - act rapidly but don’t relieve pain for very long Sustained-released opioids - take longer to act but pain relief is sustained over longer

periods The type used depends on pain characteristics. Chronic pain requires sustained release drugs while acute pain requires rapid, shorter acting opioids. Opioids are also classified by strength.

4.2.1 WEAK OPIOIDS:

Relieve mild to moderate pain (less than a severity of 7 on a 1 to 10 pain scale). These are usually mixed with non-opioids to improve their action. Hydrocodone Codeine Tylenol with codeine (acetaminophen and codeine) (Hydrocodone and acetaminophen)

4.2.2 STRONG OPIOIDS:

Relieve severe pain (pain with a designation of greater than 7). Morphine Fentanyl Methadone Oxycodone

4.3 ADJUVANT THERAPY:

These are medicines indicated for purposes other than pain relief but have pain-relieving properties.






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4.3.1 ANTI-DEPRESSANTS:

Relieve pain related to the nervous system (neuropathic) such as peripheral neuropathy. A prescription is needed for these drugs. An example is Cymbalta ® (dulozetine).

4.3.2 ANTICONVULSANTS:

Used to treat seizures, these drugs are effective in relieving the pain of peripheral neuropathy. An example is Neurontin (gabapentin).

4.3.3 LOCAL ANESTHETICS:

These drugs are topical (applied directly to the area of pain) or injectable (in the blood stream or spinal canal). They are effective in relieving tingling or burning type pain. An example would be Xylocaine (Lidocaine).

5.0 WHAT SHOULD YOU DO IF YOU HAVE PAIN?

When you have pain, you need to know how to get immediate, safe pain relief.

5.1 NEVER IGNORE YOUR PAIN: Pain is the body’s way to say there’s a problem. Ignoring pain usually makes matters worse and can cause more damage in the long run.

5.1.1 ASSESS YOUR PAIN:

When pain occurs ask yourself: How long have I had the pain? Did it emerge gradually or sudden? Is the pain sharp or dull? What makes the pain worse? Does anything ease the pain? Is the pain localized or does it radiate to other areas? Are there other symptoms (e.g., numbness, cough, fever)?

5.1.2 NOTIFY YOUR DOCTOR:

Pain should be reported to your doctor. Sharing your pain assessment with the doctor will help identify the cause and how best to treat it.

5.1.3 TAKE YOUR PAIN MEDICATIONS:

If pain medications are needed, make sure you take them exactly as prescribed. Pain medications work best if they are taken at the first hint of pain. Breaking the cycle of pain means taking medications before your pain is at its worst.

5.1.4 BE RESPONSIBLE:

Pain medications are very effective when they are taken as prescribed. Taking them incorrectly or venturing away from what’s prescribed can be dangerous. Opioids are addictive, meaning a physical and emotional dependence of the drug can occur. Opioids can adversely affect breathing, level of consciousness and judgment. In extreme cases abuse of opioids can be fatal.






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5.1.5 IF THEY DON’T WORK TELL YOUR DOCTOR:

If your pain medicine is not relieving your pain, talk to your doctor. It is possible you may have become resistant to the drugs. A dose or pain medication change may be needed.

Pain is a fact of life for those who are HIV+. However it must be and can be managed for you to maintain your quality of life. If you are having pain, talk to your doctor. He or she can work with you to find the cause, treat the pain, and help you get back to living.

6.0 PHYSIOTHERAPY FOR PATIENTS WITH HIV/AIDS:






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6.1 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 ergo meter cardiopulmonary exercise test should be performed to obtain baseline cardiovascular values, such as VO^sub 2max^, along with careful monitoring of vital signs. 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. 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. HAART is normally started when CD-4 levels are between 200-500/ mm^sup 3^. However, side effects of protease inhibitors include nausea, diarrhoea, headache, fat redistribution (central adiposity), glucose intolerance, increased cholesterol, increased triglycerides, abdominal pain, weakness, prickling sensation in skin, blurred vision, and dizziness.

The exercise program should promote an individual and balanced program designed to increase aerobic capacity, muscle function, flexibility, and functional ability." 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.

6.2 PATIENT LIMITATIONS TO AN EXERCISE PROGRAM:

Exercise training is contraindicated during rapid weight loss associated with an acute illness or an active opportunistic infection. 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.

Tuberculosis (TB) is another opportunistic infection affecting cardiopulmonary status. Upper respiratory infections, anemia, fatigue, and diarrhea are common and should be monitored as well.

Some patients may not be able to participate in prescribed activity due to advanced disease (CD-4 levels 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.

6.2.1 CENTRAL NERVOUS SYSTEM:

Primary complications include an encephalopathy often referred to as AIDS dementia complex and myelopathy (involves cortico-spinal tracts and dorsal columns). 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. Also, patients can suffer strokes that are embolie, thrombotic, hemorrhagic, or vasculitic in nature; typically, these patients present with hemiplegia.






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6.2.2 PERIPHERAL NERVOUS SYSTEM:

Demyelination and inflammation have been observed in peripheral nerve specimens of individuals with HIV. 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. 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. It is important the patient is educated about proper foot care, including the use of supportive shoes when performing weight-bearing activities.






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6.2.3 MUSCULOSKELETAL SYSTEM:

Muscle biopsies of patients with HIV have shown the presence of retrovirus particles, which could attribute to muscle weakness and atrophy. Patients may present with osseous and soft tissue infections, polymyositis, arthritis, fibromyalgia, and myasthenia gravis. They may also have secondary complications from gait pathology due to peripheral neuropathies. Quadriceps weakness and proximal muscle weakness is common with myopathy. Muscle weakness may limit perfusion of the exercising limbs, with resulting lactacidosis, fatigue, and breathlessness.

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