EXERCISE STRATEGIES TO COPE WITH SYMPTOMS OF HIV-ASSOCIATED DEMENTIA

By Mary Jane Detroyer, MS, RD, CDN

Overview of the Nervous System

The nervous system consists of an elaborate framework of fragile nerve cells (neurons) that form the brain and spinal cord, the central nervous system (CNS), the peripheral nervous system (PNS), the extremities, and all other parts of the system. The PNS is subdivided into two systems. The somatic system provides voluntary control over skeletal muscle, while the autonomic system provides involuntary regulation of smooth muscle. All conscious awareness of the external environment and all motor activity to cope with it operate through the somatic division of the PNS. The many parts of the nervous system communicate by receiving and responding to stimuli. For example the sensory neurons originating in the PNS receive a message and bring it to the CNS. Then motor neurons that run from the CNS to skeletal muscles tell them to take an action in response to the message (you touch something hot and you pull away). The nervous system also uses sensory receptors in joints, muscles, and other parts of the body to regulate and coordinate contraction of skeletal muscle.

HIV in the Central Nervous System

Neurologists believe that HIV infection in the brain is indirectly responsible for HIV-associated dementia (HAD). HAD includes: (a) AIDS dementia complex (ADC), which involves more serious impairment of the CNS, and (b) HIV-1 minor cognitive-motor disorder (MCMD), which involves less severe symptoms that dont usually interfere with independent living.¹ Evidence reveals that neurons are indirectly killed by toxic substances produced by HIV-infected cells.² Antiretroviral therapy has had a positive impact on decreasing the incidence of new cases of HAD and partially reversing symptoms in existing cases.³⁵

Neurotoxicity has been found in different areas of the brain that exert control over cognition, motor activity, and behavior; individuals with HAD experience symptoms that effect all or some of these areas. Cognitive symptoms include forgetfulness (short-term memory loss), problems with concentration and complex thought, and difficulty completing tasks or carrying out commands. Reported motor symptoms include clumsiness, slow or unsteady gait, poor balance and coordination, leg weakness, and fatigue. Behavior changes may include social withdrawal, apathy, change in personality, loss of appetite, lack of motivation, depression, and sharp mood swings.⁶

Wiseman et al measured cerebral blood flow in HIV+ MCMD subjects, HIV+ controls, and HIV controls and found that those with HIV+ MCMD had difficulty retrieving and organizing information.⁷ Damaged neurons have been found in a part of the brain called the substantia nigra that exerts control over posture, reflexes, balance, and muscle tone; scientists feel this damage may be responsible for some of the motor disorders frequently seen in people with HAD.⁸ HIV has also been found in the subcortical area of the brain called the basal ganglia, which is also involved in control of movement.⁹ Parkinsons disease, caused by the degeneration of dopaminergic (DA) neurons that communicate with the basal ganglia, produces symptoms similar to those found in patients with HAD (weakness, tremors, rigidity of the limbs, poor balance, and difficulty initiating movements). DA neurons appear to be damaged early in HIV infection, and patients with HIV have lower levels of DA in their cerebrospinal fluid.

In Germany, movement therapy is often used to improve motor performance in individuals with Parkinsons disease. Though most experience only minor improvement in motor function, their sense of well-being and physiological function improves significantly.¹⁰ Public health nurses in Japan followed 438 patients with Parkinsons disease and found that those who performed the most physical activity lived longer.¹¹ Though neurological problems like poor balance and coordination may affect such patients, it appears that individuals with mild to moderate Parkinsons disease are capable of maintaining their aerobic capacity with regular aerobic exercise.¹²

HIV in the PNS

Peripheral neuropathy is a very common and disabling problem encountered in patients with HIV infection. A recent article in Movement Disorders reported that HIV+ patients with neuropathy complained of pain with movement of their legs and toes.¹³ Others have experienced a loss of feeling in the feet or many other uncomfortable sensations of swelling, prickling, throbbing, or burning in this area. As the disease progresses, it may travel up the leg and may eventually effect the hands. I have had clients tell me that they experience some of these feeling in other parts of their body.

Simpson and Tagliati reviewed data on the epidemiologic, clinical, pathogenic, and therapeutic aspects of neurologic symptoms associated with AIDS and concluded that early diagnosis and treatment of neurologic disorders can have a significant impact on survival and quality of life for persons living with AIDS (PLWAs).¹⁴

I found no studies that looked at exercise as therapy for neuropathy associated with HIV, but research has been done with other populations that experience neuropathies and chronic pain. Ruhland and Shields found that people with chronic peripheral neuropathies had a lower health-related quality of life (HRQL). Those who participated in a home exercise program improved their HRQL.¹⁵ One study found that patients with diabetic neuropathy who performed stretching exercises for muscular pain experienced some improvement compared with no improvement in controls.¹⁶ Traditional exercise therapies for peripheral neuropathies have focused on maintaining range of motion of the joints and exercise to improve strength and re-education of movement skills. Clients should be cautioned not to overstretch weakened muscles and to avoid exhaustive routines, substituting instead brief episodes of isometric and isotonic exercise.¹⁷

Out of the Lab and into Practice

Any of the symptoms listed above can impact your ability to participate in exercise. This does not mean you should not exercise. Rather, look for options that allow you to continue while accommodating your symptoms.

In my practice I have seen clients exhibit many of the symptoms of HAD. Whether in a group setting or one-on-one, clients who always show up for exercise improve their balance, coordination, and ability to follow commands, and no matter how much they complain before exercise they always go home feeling better. If they cannot stand up to perform the exercises, they sit in chairs and participate. They do what they can. Breathing and muscle-relaxation techniques at the end of sessions facilitate connection with the body and provide a way to cope with pain. Being part of a group provides support, and finishing a session provides a sense of control and accomplishment.

Timothy Brewi, a personal trainer and dietetic technician in Los Angeles, says the symptom he sees most often is neuropathy. When a client arrives and complains of pain, he praises him/her just for being there and emphasizes that this is when they need exercise the most. For painful feet, Tim will switch clients from standing free-weight exercises to seated weight machines. If aerobic exercise is needed to reduce symptoms of lipodystrophy, he suggests moving quickly through a circuit of exercises to keep the heart rate up and to burn calories while reducing impact on the feet.

Suggestions for safe alternatives to traditional exercise include:

" Aerobic and resistance workouts in water

" Riding an indoor bike instead of running or walking

" Tai chi or yoga to improve strength, balance, and coordination

" Pilates, Feldenkrais, or Alexander movement techniques

" Stretching or range-of-motion exercises

It is easy to exercise when you feel good. The challenge is to stick with it when youre tired, depressed, and hurting. Concentrate on what you can do today, not on what you did yesterday. The bottom line is that its always better to do something rather than nothing.

Contact Mary Jane at .

Mary Jane Detroyer is a registered dietician and exercise physiologist who has been working with clients for 14 years to improve their health through diet, exercise, and simple lifestyle changes. She has a private pratice in Manhattan specializing in HIV/AIDS, Womens Wellness, Weight Management, and Prevention.