neurological complications of hiv will chegwidden, senior occupational therapist & emma...

Neurological Neurological complications of HIVcomplications of HIV

Will Chegwidden, Senior Occupational Therapist & Will Chegwidden, Senior Occupational Therapist & Emma McGettigan, Senior PhysiotherapistEmma McGettigan, Senior Physiotherapist

Infection & Immunity Speciality GroupInfection & Immunity Speciality GroupBarts HospitalBarts Hospital

August 2005August 2005

Outline of sessionOutline of session

Classification of HIV impairment and HIV Classification of HIV impairment and HIV neurological impairmentneurological impairment

Neuropathogenesis of HIVNeuropathogenesis of HIV CNS involvementCNS involvement PNS involvementPNS involvement Issues for therapists and discussionIssues for therapists and discussion

Classification systemClassification system

To understand how neurological impairment To understand how neurological impairment occurs in HIV, it is helpful to use a classification occurs in HIV, it is helpful to use a classification system of how impairment occurs generally in system of how impairment occurs generally in HIV diseaseHIV disease

One way is to divide in to the following five One way is to divide in to the following five categories:categories:

1.1. Opportunistic InfectionsOpportunistic Infections2.2. MalignanciesMalignancies3.3. Auto-immune and reconstitution diseasesAuto-immune and reconstitution diseases4.4. Constitutional disease Constitutional disease 5.5. Other /multi-factorial / poorly understoodOther /multi-factorial / poorly understood

How being HIV+ leads to illness or How being HIV+ leads to illness or impairmentimpairment

1.1. OI’s: OI’s: Immunosupressed state renders individual Immunosupressed state renders individual susceptible to infections / illnesses “opportunistic susceptible to infections / illnesses “opportunistic infections” (most widely understood)infections” (most widely understood)

2.2. Autoimmune diseases and reconstitution Autoimmune diseases and reconstitution diseasesdiseases where the immune system is where the immune system is “overactive” e.g. joint disease (not fully “overactive” e.g. joint disease (not fully understood)understood)

3.3. Malignancies – Malignancies – Some malignancies much more Some malignancies much more prevalent with HIV – unsure why, some links to prevalent with HIV – unsure why, some links to other virusesother viruses

4.4. Constitutional Disease:Constitutional Disease: The action of HIV at The action of HIV at cellular level directly causing illness cellular level directly causing illness “constitutional symptoms” (not fully understood)“constitutional symptoms” (not fully understood)

Disease groupingsDisease groupings

OIs: OIs:

– Viral Infections (CMV, HSV, PML, HPV)Viral Infections (CMV, HSV, PML, HPV)

– Bacterial Infections (TB, MAI, Salmonella)Bacterial Infections (TB, MAI, Salmonella)

– Protozoal Infections (PCP, Toxoplasmosis)Protozoal Infections (PCP, Toxoplasmosis)

– Fungal Infections (Cryptococcyl Meningitis, Candida)Fungal Infections (Cryptococcyl Meningitis, Candida)

Malignancies (KS, CNS lymphoma, Burketts, MCD)Malignancies (KS, CNS lymphoma, Burketts, MCD)

Autoimmune diseases (Arthraligias, GBS) Autoimmune diseases (Arthraligias, GBS)

Constitutional Conditions (HIVE/HAD/ADC, DSPN, Constitutional Conditions (HIVE/HAD/ADC, DSPN, Wasting Syndromes)Wasting Syndromes)

NeuropathogenesisNeuropathogenesis

Neurological impairment can occur through Neurological impairment can occur through several routes:several routes:

1.1. As a result of opportunistic infectionsAs a result of opportunistic infections2.2. As a result of HIV related malignanciesAs a result of HIV related malignancies3.3. As a result of autoimmune disordersAs a result of autoimmune disorders4.4. Directly related to the action of HIV (can be Directly related to the action of HIV (can be

CNS or PNS related)CNS or PNS related)5.5. Multifactorial / drug related / not Multifactorial / drug related / not

understoodunderstood

1.1. Opportunistic infections with Opportunistic infections with CNS involvementCNS involvement

Cerebral toxoplasmosisCerebral toxoplasmosis PMLPML Meningitis (Cryptococcyl meningitis, TB Meningitis (Cryptococcyl meningitis, TB

meningitis)meningitis) Encephalitis (CMV, HSV, VZV)Encephalitis (CMV, HSV, VZV) NeurosyphilisNeurosyphilis

2. HIV related malignancies with2. HIV related malignancies withneuro involvementneuro involvement

Primary lymphoma (most common)Primary lymphoma (most common) Kaposi’s sarcoma with cerebral involvement Kaposi’s sarcoma with cerebral involvement

(rare)(rare) Multiple lymphomas with either CNS Multiple lymphomas with either CNS

(including spinal cord compression) or rarely (including spinal cord compression) or rarely PNS involvement (ie secondary CNS/PNS PNS involvement (ie secondary CNS/PNS lymphomas)lymphomas)

3. Autoimmune disorders with3. Autoimmune disorders withneuro involvementneuro involvement

Guillain-Barré Syndrome (GBS)Guillain-Barré Syndrome (GBS) Inflammatory Demyelinating Polyneuropathy Inflammatory Demyelinating Polyneuropathy

(IDP) (IDP)

4. Direct action of HIV4. Direct action of HIV

AIDS Dementia Complex (ADC) AIDS Dementia Complex (ADC) oror HIV HIV Associated Dementia (HAD)Associated Dementia (HAD)

Distal Symmetrical Polyneuropathy (DSPN)Distal Symmetrical Polyneuropathy (DSPN) Mononeuritis multiplexMononeuritis multiplex Vacuolar MyolopathyVacuolar Myolopathy ?Wasting Syndromes (although cardiac ?Wasting Syndromes (although cardiac

system now implicated more)system now implicated more)

5. Multifactorial / drug related / 5. Multifactorial / drug related / poorly understoodpoorly understood

““Neuromuscular weakness syndrome”Neuromuscular weakness syndrome” Role of drugs in peripheral neuropathyRole of drugs in peripheral neuropathy

Direct action of HIV in the Direct action of HIV in the CNSCNS

HIV can easily cross the blood brain barrierHIV can easily cross the blood brain barrier HIV thought to chiefly target phagocytic HIV thought to chiefly target phagocytic

macrophages, but also astrocytes, microglia macrophages, but also astrocytes, microglia and monocytesand monocytes

Do not affect directly affect CNS neurons or Do not affect directly affect CNS neurons or oligodendrocytesoligodendrocytes

Theories of how HIV crosses the Theories of how HIV crosses the blood brain barrier blood brain barrier

Different theories including:Different theories including: Infected monocytes and lymphocytes traffic Infected monocytes and lymphocytes traffic

across the BBB as part of their normal across the BBB as part of their normal immune surveillance roleimmune surveillance role

Blood brain barrier weakened by this Blood brain barrier weakened by this process – leading to increased traffickingprocess – leading to increased trafficking

Monocytes differentiate in to microglia and Monocytes differentiate in to microglia and macrophagesmacrophages

Theories of how HIV crosses the Theories of how HIV crosses the blood brain barrierblood brain barrier

Also theory that meningeal macrophages Also theory that meningeal macrophages infiltrate the CNS through the CSF infiltrate the CNS through the CSF compartmentcompartment

May also be a combination of these May also be a combination of these processesprocesses

Neurotoxic viral proteins released in to CNS Neurotoxic viral proteins released in to CNS by HIV infected cells resulting in neuronal by HIV infected cells resulting in neuronal injury / deathinjury / death

Direct action of HIV in the Direct action of HIV in the PNSPNS

Thought that HIV cells can lead to axonal Thought that HIV cells can lead to axonal degeneration (resulting in DSPNs)degeneration (resulting in DSPNs)

Thought that HIV can lead to inflammation / Thought that HIV can lead to inflammation / demylination (resulting in inflammatory demylination (resulting in inflammatory demyelinating neuropathies)demyelinating neuropathies)

Principles of HIV NeurologyPrinciples of HIV Neurology

Time Locking – Neurological compliocations are Time Locking – Neurological compliocations are directly related to the duration of HIV disease, directly related to the duration of HIV disease, degree of advancement of HIV diseasedegree of advancement of HIV disease

Parallel Tracking – Existence of muliple Parallel Tracking – Existence of muliple pathologies in different parts of the nervous pathologies in different parts of the nervous system (cerebral, spinal cord, peripheral nerves)system (cerebral, spinal cord, peripheral nerves)

Layering – multiple complications in one part of Layering – multiple complications in one part of the nervous systemthe nervous system

Unmasking – previously compensated deficits may Unmasking – previously compensated deficits may be unmasked by occurrence of an additional insultbe unmasked by occurrence of an additional insult

PresentationsPresentations

Vary wildlyVary wildly Often multiple pathologies on different Often multiple pathologies on different

coursescourses Often hard to diagnose, especially if already Often hard to diagnose, especially if already

treated empiricallytreated empirically May not be HIV related! May not be HIV related!

ConditionsConditions

Now going to present the most commonly Now going to present the most commonly seen conditions at BLTseen conditions at BLT

Would be good to share all our experience Would be good to share all our experience on prevalence, experience of treating and on prevalence, experience of treating and progression of diseaseprogression of disease

We can collate and feed back to therapists We can collate and feed back to therapists who aren’t able to attend, especially those who aren’t able to attend, especially those outside of Londonoutside of London

HIV and HIV and CNS involvementCNS involvement

Cerebral ToxoplasmosisCerebral Toxoplasmosis

Most common CNS impairment seen in HIVMost common CNS impairment seen in HIV Is a reactivation of a latent protozoal Is a reactivation of a latent protozoal

infectioninfection Can also affect myocardium, lung skeletal Can also affect myocardium, lung skeletal

musclemuscle Generally presents as multiple enhancing Generally presents as multiple enhancing

lesions with perifocal oedema in the basal lesions with perifocal oedema in the basal ganglia and grey-white matter interface of ganglia and grey-white matter interface of the cerebral hemispheres, although can be the cerebral hemispheres, although can be in any part of brainin any part of brain

ToxoplasmosisToxoplasmosis

http://imaging.birjournals.org/content/vol14/issue1/images/large/IMJ77374-1-3.jpeg


Common signs and symptoms Common signs and symptoms – Headache, fever Headache, fever – Confusion Confusion – Lethargy Lethargy – Seizure (may be initial clinical manifestation) Seizure (may be initial clinical manifestation) – Focal neurologic signs (50%-60% of HIV-infected Focal neurologic signs (50%-60% of HIV-infected

cases)cases) Usually hemiparesis or visual field defects Usually hemiparesis or visual field defects

TreatmentTreatment– Antio-toxo drugs: Sulfadiazine, pyrimethamine, Antio-toxo drugs: Sulfadiazine, pyrimethamine,

clindamycin, pyrimethamine, folinic acidclindamycin, pyrimethamine, folinic acid


Usually responds well to treatmentUsually responds well to treatment Usually the worse the initial presentation, Usually the worse the initial presentation,

the longer the recovery; may have some the longer the recovery; may have some long term residual deficitslong term residual deficits

Can sometimes have multiple small lesions Can sometimes have multiple small lesions which present with quite specific / unusual which present with quite specific / unusual sensory / motor / cognitive symptomssensory / motor / cognitive symptoms


Therapy usually “treat what you assess” – Therapy usually “treat what you assess” – relearning gait / UL movement through normal relearning gait / UL movement through normal movement approach; cognitive rehab; use of movement approach; cognitive rehab; use of functional activity etc.functional activity etc.

Need to be aware of visual field deficitsNeed to be aware of visual field deficits Great to work with as generally will recoverGreat to work with as generally will recover ?Impact of early intervention – usually recover ?Impact of early intervention – usually recover

quickly at first – may be more important where quickly at first – may be more important where tone / positioning is an issuetone / positioning is an issue

PML: Progressive Multifocal PML: Progressive Multifocal LeukoencephalopathyLeukoencephalopathy

Used to be more common and was nearly always Used to be more common and was nearly always fatal; now not seen that oftenfatal; now not seen that often

Is a reactivation of a latent JC virus (due to Is a reactivation of a latent JC virus (due to immunosuppression) – often seen more in more immunosuppression) – often seen more in more severely immunocompromised peopleseverely immunocompromised people

Appears as patchy white matter on scans, often Appears as patchy white matter on scans, often bilateral, asymmetrical scalloped lesions in sub-bilateral, asymmetrical scalloped lesions in sub-cortical white matter, often in parietal lobecortical white matter, often in parietal lobe

Usually gradual onsetUsually gradual onset


Common presenting symptoms and signs Common presenting symptoms and signs – Hemiparesis Hemiparesis – Gait abnormality Gait abnormality – Speech disturbances Speech disturbances – Cognitive dysfunction Cognitive dysfunction – Dysarthria Dysarthria – Ataxia Ataxia – Sensory loss Sensory loss – Vertigo Vertigo – Visual impairment Visual impairment


No specific PML treatment; aim is to No specific PML treatment; aim is to improve immune health therefore usually improve immune health therefore usually treatment is with ARVs (although cidofovir treatment is with ARVs (although cidofovir sometimes used)sometimes used)

Still often fatal; survivors tend to have Still often fatal; survivors tend to have residual dysfunction in some or all of the residual dysfunction in some or all of the presenting deficit areaspresenting deficit areas


Therapy approach is again to treat what you Therapy approach is again to treat what you find – in more advanced disease may need find – in more advanced disease may need to look at positioning to discourage poor to look at positioning to discourage poor movement or even prevent contracture; or movement or even prevent contracture; or looking at managing advanced dementia / looking at managing advanced dementia / behaviourbehaviour

If patient does survive may require some If patient does survive may require some compensation on discharge e.g. compensation on discharge e.g. supervision, wheelchairs etc. supervision, wheelchairs etc.

Cryptococcyl meningitis, TB Cryptococcyl meningitis, TB meningitismeningitis

Both quite common presentationsBoth quite common presentations Crypto caused by fungal infectionCrypto caused by fungal infection TB may also cause focal lesions as well as TB may also cause focal lesions as well as

the menigitisthe menigitis Both may or may not have other systemic Both may or may not have other systemic

illness associated e.g. Cryptococcosis, TB illness associated e.g. Cryptococcosis, TB lung, spine, miliary TB lung, spine, miliary TB


Symptoms Symptoms – Headache (without focal signs) Headache (without focal signs) – Fever Fever – Altered mental status Altered mental status – Nausea and/or vomitingNausea and/or vomiting– May have some focal deficits, cranial nerve featuresMay have some focal deficits, cranial nerve features

Therapy input may be around focal deficits / Therapy input may be around focal deficits / cranial nerve involvement; patients also typically cranial nerve involvement; patients also typically become deconditioned and lack balance as they become deconditioned and lack balance as they recover so often benefit from general functional / recover so often benefit from general functional / activity tolerance approachactivity tolerance approach


Crypto treated with IV amphotericin / Crypto treated with IV amphotericin / fluconazolefluconazole

TB treated with standard TB therapyTB treated with standard TB therapy Both generally respond reasonably well; Both generally respond reasonably well;

crypto quite often relapses a few times crypto quite often relapses a few times before treated successfullybefore treated successfully

Either sometimes may require a shunt top Either sometimes may require a shunt top effectively manage the raised ICPeffectively manage the raised ICP

CMV Encephalitis (and others)CMV Encephalitis (and others)

CMV= cytomegalovirusCMV= cytomegalovirus Quite common; CMV encephalitis is a Quite common; CMV encephalitis is a

reactivation of latent CMV infection - reactivation of latent CMV infection - features cell death in meninges and peri-features cell death in meninges and peri-ventricular areaventricular area

Often associated with a CMV retinitisOften associated with a CMV retinitis Rapidly progressing; responds well to Rapidly progressing; responds well to

treatment if caught in time otherwise treatment if caught in time otherwise responds poorlyresponds poorly


Treatment is usually IV ganciclovir, Treatment is usually IV ganciclovir, valganciclovir, foscarnet, cidofovir – these valganciclovir, foscarnet, cidofovir – these drugs can be quite toxicdrugs can be quite toxic

Presentations vary, however usually involve Presentations vary, however usually involve confusion, headache, deliriumconfusion, headache, delirium

Can have focal neurology, cranial nerve Can have focal neurology, cranial nerve deficitsdeficits


Therapy approach again is treat what Therapy approach again is treat what presents; often complicated by permanent presents; often complicated by permanent visual field lossvisual field loss

Other encephalitis presentations include Other encephalitis presentations include HSV (Herpes Simplex Virus) and VZV HSV (Herpes Simplex Virus) and VZV (Varicellar Zoster Virus)(Varicellar Zoster Virus)

Primary CNS LymphomaPrimary CNS Lymphoma

1000-4000 times more common in HIV+ 1000-4000 times more common in HIV+ population than in immunocompetent population than in immunocompetent populationpopulation

Doesn’t correlate with low CD4 countsDoesn’t correlate with low CD4 counts Pathogenesis not fully understood but Pathogenesis not fully understood but

known to be linked to the Epstein-Barr Virusknown to be linked to the Epstein-Barr Virus Thought that long term low level immune Thought that long term low level immune

system damage may be contributing factorsystem damage may be contributing factor


Is generally non-Hodgkin’s B-cell type with high Is generally non-Hodgkin’s B-cell type with high mitotic rate; tumours usually double in size in 14 mitotic rate; tumours usually double in size in 14 days. (can also be a Burkitt or more rarely a days. (can also be a Burkitt or more rarely a Primary Effusion Lymphoma)Primary Effusion Lymphoma)

Can be multifocal (50%) and appear in uncommon Can be multifocal (50%) and appear in uncommon locations with greater frequency than in non-HIV locations with greater frequency than in non-HIV populationpopulation

Studies have average survival rates from Studies have average survival rates from diagnosis between 3 and 24 monthsdiagnosis between 3 and 24 months

May be treated actively or palliatively with May be treated actively or palliatively with radiotherapy (usually palliative) or high dose radiotherapy (usually palliative) or high dose methotrexate (chemo)methotrexate (chemo)


Disagreement between researchers whether Disagreement between researchers whether discontinuing or continuing ARVs throughout discontinuing or continuing ARVs throughout treatment is most beneficialtreatment is most beneficial

Therapy input is usually initially around Therapy input is usually initially around advice / treatment to help maintain function / advice / treatment to help maintain function / independence and planning for deterioration independence and planning for deterioration / palliative approach/ palliative approach

HIV EncephalopathyHIV EncephalopathyHIVE / ADC / HADHIVE / ADC / HAD

Number of terms used overlappingly to Number of terms used overlappingly to describe poorly understood syndromes of describe poorly understood syndromes of long term infiltration of HIV into the CNSlong term infiltration of HIV into the CNS

Names include:Names include:– HIV-1-associated dementia complex (HAD)HIV-1-associated dementia complex (HAD)– AIDS Dementia Complex (ADC)AIDS Dementia Complex (ADC)– HIV encephalitis / HIV Encephalopathy (HIVE)HIV encephalitis / HIV Encephalopathy (HIVE)– multinucleated giant-cell encephalitis multinucleated giant-cell encephalitis


Can be seen in early disease but more common laterCan be seen in early disease but more common later Severe form less common since the introduction of Severe form less common since the introduction of

HAARTHAART Many long term diagnosed however do report mild Many long term diagnosed however do report mild

cognitive problems e.g. memory problems, and show cognitive problems e.g. memory problems, and show some general brain atrophy on scanssome general brain atrophy on scans

On scans often higher concentrations changes in the On scans often higher concentrations changes in the basal ganglia - ?due to numbers of microglia in the basal ganglia - ?due to numbers of microglia in the brain – thought to be why high rates of extra-pyramidal brain – thought to be why high rates of extra-pyramidal signs / symptoms seensigns / symptoms seen


Symptoms generally develop over weeks to Symptoms generally develop over weeks to months in the following domains:months in the following domains:

Cognition Cognition – Decreased concentration Decreased concentration – Forgetfulness, particularly daily or recent events Forgetfulness, particularly daily or recent events – Slowing of thought processes Slowing of thought processes – Global dementia Global dementia – Psychomotor slowing: verbal responses delayed, near Psychomotor slowing: verbal responses delayed, near

or absolute mutism, vacant stare or absolute mutism, vacant stare – Unawareness of illness, disinhibition Unawareness of illness, disinhibition – Confusion, disorientation Confusion, disorientation – Organic psychosis Organic psychosis

Motor function Motor function – Unsteady gait Unsteady gait – Clumsiness Clumsiness – Tremor Tremor – Leg weakness (legs more than arms) Leg weakness (legs more than arms) – Loss of coordination, impaired handwriting Loss of coordination, impaired handwriting

Behaviour Behaviour – Social withdrawal Social withdrawal – Apathy Apathy – Personality change Personality change – Agitation Agitation – Hallucinations Hallucinations

Other Other – Headaches Headaches – Generalized seizures Generalized seizures – Ataxia Ataxia


Treatment is via reducing viral load and viral Treatment is via reducing viral load and viral activity in the CNS, therefore treatment is activity in the CNS, therefore treatment is primarily HAARTprimarily HAART

Need to consider ARVs with best CNS Need to consider ARVs with best CNS penetration e.g. zidovudine (AZT), abacavir, penetration e.g. zidovudine (AZT), abacavir, nevirapinenevirapine

Difficult to measure drug levels as not Difficult to measure drug levels as not known whether CSF drug levels always known whether CSF drug levels always correlate with cerebral levels; (not practical correlate with cerebral levels; (not practical to brain biopsy!)to brain biopsy!)


Therapy input more akin to treating Therapy input more akin to treating someone with dementia; early treatment someone with dementia; early treatment may be looking at memory strategies; later may be looking at memory strategies; later stages may require behavioural stages may require behavioural management and reality orientation / management and reality orientation / validationvalidation

Severe HIVE may require 24 hour Severe HIVE may require 24 hour supervisionsupervision

Vacuolar MyopathyVacuolar Myopathy

““Holes” in spinal cordHoles” in spinal cord Clinical Features – onset over weeks-months of:Clinical Features – onset over weeks-months of:

– Bilateral lower extremity stiffness and weakness with variable Bilateral lower extremity stiffness and weakness with variable sensory disturbances sensory disturbances

– Gait unsteadiness Gait unsteadiness – Bladder and erectile dysfunction Bladder and erectile dysfunction – Hyperreflexia and Babinski signs Hyperreflexia and Babinski signs – Spastic paraparesis with no definite sensory involvement Spastic paraparesis with no definite sensory involvement – Loss of proprioception and vibration senseLoss of proprioception and vibration sense

Thought to be secondary to overactive immune system Thought to be secondary to overactive immune system producing excessive cytokines, or some poorly understood producing excessive cytokines, or some poorly understood metabolic imbalance; may be related to HTLV-I and HTLV-metabolic imbalance; may be related to HTLV-I and HTLV-II II

HIV and PNS InvolvementHIV and PNS Involvement

DSPN: Distal Symmetrical DSPN: Distal Symmetrical Sensory PolyneuropathySensory Polyneuropathy

Occurs in many HIV+ patients with varying Occurs in many HIV+ patients with varying severityseverity

Poorly understood aetiology but could be Poorly understood aetiology but could be related to malnutrition and resultant wasting related to malnutrition and resultant wasting of peripheral nerves, or could be neurotoxic of peripheral nerves, or could be neurotoxic effect of cytokineseffect of cytokines

Can also be secondary to NRTI use e.g. Can also be secondary to NRTI use e.g. AZTAZT

DSPNDSPN

Often occurs in a glove and stocking distribution Often occurs in a glove and stocking distribution but there is great variance in self reportbut there is great variance in self report

Can range from mild parasthesia / numbness / Can range from mild parasthesia / numbness / pins and needles through to severe pins and needles through to severe hypersensitivities, or dysesthesias (burning, hypersensitivities, or dysesthesias (burning, stabbing pain)stabbing pain)

Can lead to poor upper limb coordination or mildly Can lead to poor upper limb coordination or mildly impaired mobility / clumsiness, attributable to impaired mobility / clumsiness, attributable to reduced sensory feedbackreduced sensory feedback

DSPNDSPN

Can progress to actual muscle weakness, Can progress to actual muscle weakness, particularly foot intrinsics (result of long term particularly foot intrinsics (result of long term de-inervation)de-inervation)

Sometimes use EMG studies to diagnoseSometimes use EMG studies to diagnose Often treated with quite high dose Often treated with quite high dose

analgesics which can interact with other analgesics which can interact with other medications or have lifestyle implicationsmedications or have lifestyle implications

Can be very disablingCan be very disabling

DSPNDSPN

Therapy input can be looking atTherapy input can be looking at– Psychogenic management of pain e.g. Psychogenic management of pain e.g.

relaxationrelaxation– Task planning – how to avoid parts of tasks that Task planning – how to avoid parts of tasks that

elicit painelicit pain– Safety aspects e.g. temperature sensation, Safety aspects e.g. temperature sensation,

retraining to be aware of feet catching on stairsretraining to be aware of feet catching on stairs– Padded / built up equipment to reduce / alter Padded / built up equipment to reduce / alter

sensory input to help mange pain, or provide sensory input to help mange pain, or provide more gross proprioceptive feedbackmore gross proprioceptive feedback

Inflammatory Demyelinating Inflammatory Demyelinating Polyneuropathy (IDP)Polyneuropathy (IDP)

IDP, and it’s more severe cousin Gullain- IDP, and it’s more severe cousin Gullain- Barre Syndrome sometimes occur acutely in Barre Syndrome sometimes occur acutely in otherwise well HIV+ patients, or in HIV+ otherwise well HIV+ patients, or in HIV+ patients with advanced disease. patients with advanced disease.

Seems to be some sort of auto-immune Seems to be some sort of auto-immune response that attacks the myelins sheath – response that attacks the myelins sheath – mechanism is poorly understoodmechanism is poorly understood

Treated with IVIgTreated with IVIg

(Ascending) Neuromuscular (Ascending) Neuromuscular Weakness Syndrome Weakness Syndrome

Presents as rapidly progressing Presents as rapidly progressing sensorimotor neuropathy, can lead to sensorimotor neuropathy, can lead to respiratory failurerespiratory failure

Thought to be related to NRTI useThought to be related to NRTI use

Mononeuritis Multiplex Mononeuritis Multiplex

Can present as multifocal sensory and/or Can present as multifocal sensory and/or motor abnormalities and is due to motor abnormalities and is due to asymmetrical involvement of individual asymmetrical involvement of individual peripheral and cranial nerves; may be a peripheral and cranial nerves; may be a mixed neuropathy (motor, sensory, mixed neuropathy (motor, sensory, autonomic)autonomic)

Thought to be diectly related to action of HIVThought to be diectly related to action of HIV Poorly understood Poorly understood

Issues for therapistsIssues for therapists

Deciding on treatment approaches Deciding on treatment approaches and techniquesand techniques

Not knowing what you are treatingNot knowing what you are treating Unsure prognosesUnsure prognoses Multiple pathologies in one patient with Multiple pathologies in one patient with

differing coursesdiffering courses Rehab versus compensationRehab versus compensation Evidence baseEvidence base Consent for treatmentConsent for treatment FlexibilityFlexibility

Related issues that impactRelated issues that impact

Stigma and confidentialityStigma and confidentiality Impact of asylum and immigrationImpact of asylum and immigration Co-morbid drug use and other social issuesCo-morbid drug use and other social issues Referring on to other facilitiesReferring on to other facilities Placing young physically or cognitively Placing young physically or cognitively

impaired adults ?care in the communityimpaired adults ?care in the community Infection controlInfection control

Solutions existingSolutions existing

Strong MDTStrong MDT Therapists input to diagnosis vitalTherapists input to diagnosis vital Close working with partner agencies, e.g. Close working with partner agencies, e.g.

community neurorehab teams, Queen’s Square, community neurorehab teams, Queen’s Square, RNRU’sRNRU’s

HRBI Unit at MildmayHRBI Unit at Mildmay PT and OT HIV special interest groupsPT and OT HIV special interest groups Huge research opportunitiesHuge research opportunities Working with African and emerging populationsWorking with African and emerging populations The internetThe internet

Brainstorm timeBrainstorm time

What other experiences have people to What other experiences have people to share?share?

What are the biggest challenges?What are the biggest challenges? What ideas for inpatient rehabilitation What ideas for inpatient rehabilitation

facilities and community rehabilitation do facilities and community rehabilitation do people have?people have?

Would people be interested in research?Would people be interested in research?

References / resourcesReferences / resources

The National AIDS Manual – information on The National AIDS Manual – information on presentations, illnesses and treatmentspresentations, illnesses and treatments

www.hivinsite.comwww.hivinsite.com www.clinicaloptions.comwww.clinicaloptions.com www.nam.org.ukwww.nam.org.uk www.i-base.org.ukwww.i-base.org.uk www.avert.org.ukwww.avert.org.uk www.unaids.comwww.unaids.com

http://www.hivinsite.com/

http://www.clinicaloptions.com/

http://www.nam.org.uk/

http://www.i-base.org.uk/

http://www.avert.org.uk/

http://www.unaids.com/

neurological complications of hiv will chegwidden, senior occupational therapist & emma...

Documents

cns hiv

hiv disease

understood slide

hiv unsure

discussion slide

blood brain barrier

peripheral neuropathy

vzv neurosyphilis slide