AIDS: the physical therapist's role in rehabilitation.

Intervention

The quality of life for people with human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) can be improved and expanded through physical therapy intervention. With more than 13 million people throughout the world infected with HIV, it is imperative that rehabilitation professionals be prepared to access and utilize all possible modes of effective treatment (PT Bulletin, 1992).

People with AIDS have needs that may involve the services of virtually every member of the rehabilitation team. The physical therapist is an important member of this multidisciplinary team, whose services include those that address the psychological, spiritual, vocational, and physical health of the individual. An understanding of the role of physical therapist can facilitate the rehabilitation specialist's ability to make the best use of these professionals.

While AIDS is still regarded as a terminal illness, (Pamarola-Sune, Navia, Cordon-Cardo, Cho, & Price, 1986) survival rates have increased to the point where rehabilitation is a predictable and necessary part of the person's plan of care. Rehabilitation needs are usually the result of disabilities caused as a primary or secondary result of the HIV infection or disabilities or injuries that result from etiologies unrelated to HIV (O'Dell & Dillon, 1992; Galantino, 1992). In either case, physical therapy intervention may be divided into four major categories of goal-based activities. These are:

* Management of Pain

* Maintenance of Strength and Endurance

* Independence in Self-Care

* Education

Management of Pain

Pain experienced by people with AIDS may come from any number of sources, ranging from those seen across the population in general to those more specifically associated with the sequelae of severe immune deficiencies (Wells, Frampton, & Bowsher, 1988). The key factor in pain as it relates to the role of the physical therapist is its effect on function. Pain may be the primary cause of a reduction in function (Goodman, 1990; O'Dell & Dillon, 1992). This can lead to a rapid loss of independence and increased reliance on caregivers. The physical therapist may use a combination of modalities and techniques for reducing pain. These include ultrasound, transcutaneous nerve stimulation (TENS), laser, and counter-irritation. Manual therapy may be particularly successful in virus related myelitis. Reports of success in using techniques called myofacial release and craniosacral therapy also have been published (O'Dell & Dillon, 1992; Galantino, 1992).

Maintenance of Strength and Endurance

Since one of the hallmarks of AIDS is that it is a multisystem disease with a characteristically uneven clinical course, the maintenance of strength and endurance is critically important. In all cases, an individualized exercise program is designed after careful and thorough physical therapy assessment.

The intensity of exercises designed for the AIDS client range from light resistive exercises--similar to those used for chronically ill persons--to assistive exercises, which are effective when strength to complete the appropriate motion on an independent basis is lacking. Whenever possible, the individual should be encouraged to participate in physical activities to his level of tolerance (Levinson & O'Connell, 1991). Galantino and Pizzi (1991) report that they have found no data that support very aggressive exercise protocols. In fact, exercises that take the client to a point of fatigue may have negative consequences, including an increased feeling of a lack of control as well as general exhaustion. Based on the present body of literature, exercises should be limited to comfortable ranges that avoid fatigue (Spence, Galantino, Mossberg, & Zimmerman, 1990).

Self-Care

Self-care includes those activities relating to dressing, washing, feeding, taking medications, wound dressing, and exercise that are routinely employed by the client (Galantino, 1992; Spence, Galantino, Mossberg, & Zimmerman, 1990; Levinson & O'Connell, 1991). Of particular importance to the physical therapist is the individual's ability to apply any necessary splints, braces, or other assistive devices necessary for maintaining function and independence. Techniques of energy conservation are also taught to enable the chronically ill person to achieve the maximum amount of self-care with the least amount of unnecessary effort.

Education

Education for the caregiver as well as the person with AIDS is of critical importance. In addition to developing, evaluating, and modifying the plan of care for the patient, the physical therapist must be knowledgeable of and able to teach infection control to the client. Both the client and the caregiver must be carefully educated in methods to ensure that the activities of daily living are accomplished and that quality of life is maximized.

As the disease progresses, caregivers will become a more important part of the client's world. If they are to be effective, caregivers must be taught safe transfers from bed to chair as well as other important activities of daily living. Education to protect the health and safety of the caregiver is as important as that which pertains only to the individual with AIDS. (Levinson & O'Connell, 1991; Galantino & Pizzi, 1991; Galantino, 1992).

In all cases, AIDS education must include an in-depth coverage of Universal Precautions as defined by the Centers for Disease Control. Although sexual abstinence is the only real safe practice, those who remain sexually active should be educated in the safest procedures (Levinson & O'Connell, 1991).

In summary, the physical therapist's role in the treatment of AIDS related symptoms is an important one, and may include methods to reduce pain, increase strength and endurance, and maintain independence through self-care activities. Education that addresses all aspects of the client's life serves as the framework upon which safe, rational decisions can be made. AIDS is progressively becoming treatable. Effective and efficient treatment modalities can be selected only when the rehabilitation professional understands the scope of possibilities. Including the physical therapist in this process can greatly augment the productivity and quality of life for people with AIDS.

Dr. Stanton is Associate Professor and Chairman, Department of Physical Therapy, University of Texas, San Antonio.

Bibliography

1. Aids Watch (1992). PT Bulletin, 7 (32).

2. Centers for Disease Control (1992). Revised classification system for HIV infection and expanded surveilance case definition for AIDS among adolescents and adults. Morbity and Mortality Weekly Report 41, 1-13.

3. Galantino, M.L. (1992). Clinical assessment and treatment of HIV: Rehabilitation of a chronic illness. Thorofare, NJ: Slack.

4. Galantino, M.L., and Pizzi, M. (1991). Occupational and physical therapy for persons with HIV disease and their caregivers. Journal of Home Health Care Practitioners, 3 (3), 46-57.

5. Goodman, C.C. (1990). Differential diagnosis in physical therapy: Musculoskeletal and systemic conditions. Philadelphia: W. B. Saunders.

6. Levinson, S.E, and O'Connell, P.G. (1991). Rehabilitation dimensions of AIDS: a review. Arch of Physical Rehabilitation, 72, 690-696.

7. O'Dell, M.W., and Dillon, M.E. (1992). Rehabilitation in adults with human immunodeficiency virus-related diseases. American Journal of Physical Medicine and Rehabilitation, 71 (3), 183-188.

8. Pamarola-Sune, T., Navia, B.A., Cordon-Cardo, C., Cho, E.S., and Price, R.W. (1986). HIV antigen in the brains of patients with the AIDS dementia complex. Annals of Neurology, 21 (5), 490-496.

9. Spence, D.W., Galantino, M.L., Mossberg, K.A., and Zimmerman, S.O. (1990). Progressive resistance exercise: effect on muscle function and anthropometry of a select AIDS population. Archives of Physical Medicine and Rehabilitation, 71,644-648.

10. Wells, P.E., Frampton, V., and Bowsher, D. (1988). Pain management in physical therapy. Norwalk, CT: Appleton and Lange.