HIV and Exercise: Updates from Two Cochrane Collaboration - - PowerPoint PPT Presentation

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HIV and Exercise: Updates from Two Cochrane Collaboration - - PowerPoint PPT Presentation

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HIV and Exercise: Updates from Two Cochrane Collaboration Systematic Reviews of Evidence Kelly OBrien, Anne -Marie Tynan, Stephanie Nixon, Rick Glazier Department of Physical Therapy, University of Toronto OHTN Endgame I Conference Tuesday

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HIV and Exercise: Updates from Two Cochrane Collaboration Systematic Reviews of Evidence

Kelly O’Brien, Anne-Marie Tynan, Stephanie Nixon, Rick Glazier Department of Physical Therapy, University of Toronto OHTN Endgame I Conference Tuesday October 25, 2016

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Presenter Disclosure

  • Presenter: Kelly O’Brien
  • Relationships with commercial interests
  • Grants / Research support:
  • Kelly O’Brien & Stephanie Nixon
  • Supported by CIHR New Investigator Awards
  • Rick Glazier
  • Department of Family and Community

Medicine, St. Michael’s Hospital and University of Toronto

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Background

  • People with HIV live longer and may experience physical, cognitive,

social and psychological health-related challenges of HIV, multi-morbidity and aging.

  • Rehabilitation can assist in managing the health challenges (or disability)

associated with HIV, and complex multi-morbidity.

  • However, few accessing formalized rehabilitation services (HIV

Health and Rehabilitation Survey, 2016)

  • Exercise is one rehabilitation intervention and living strategy that can be

used to mitigate health challenges and enhance health and promotion.

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Purpose

To assess the effectiveness of aerobic (AER) and/or progressive resistive exercise (PRE) on…

  • Immunological and virological
  • Cardiopulmonary
  • Weight and body composition
  • Strength and
  • Psychological outcomes

among adults living with HIV

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Methods – 2 systematic reviews

Study Design

  • Systematic review using Cochrane Collaboration protocol.

Inclusion Criteria

  • Randomized controlled trials comparing exercise with another intervention
  • Adults (18 years of age or older) living with HIV
  • Exercise at least 3 times per week for at least 4 weeks

Study Selection

  • Electronic Databases (updates from 2009-2013)
  • Abstract review - 2 independent reviewers

Data Extraction and Analysis

  • Data extraction
  • Cochrane Risk of Bias assessment – GRADE rating
  • Meta-analyses using random effects model & RevMan software
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Characteristics Aerobic Exercise Review Resistive Exercise (PRE) Review # studies met inclusion criteria 24 studies 20 studies # participants @ baseline 1242 participants 959 participants Mean age range (years) 30-49 years 32-49 years % women @ completion 22% 23% Withdrawal rate ~24% (0-76%) ~20% (0-38%) % studies published >1996 20 (83%) 17 (85%) Length of intervention 5 to 52 weeks 6 to 52 weeks Supervised exercise 18 (75%) 17 (85%) # meta-analyses performed 58 34

Results – Characteristics of Included Studies

14 studies overlap (PRE+AER; or PRE versus AER versus no exercise)

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CD4 count (AER review)

Aerobic (or AER+PRE) versus No Exercise

No significant difference in change in CD4 count

  • Non-significant trend here towards increase in CD4 count among exercisers

compared with non-exercisers (n=479; n=14 studies).

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Viral load (AER review)

Aerobic (or AER+PRE) versus No Exercise

No significant difference in change in viral load between groups (n=162)

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Cardiopulmonary Fitness: VO2max (AER)

Aerobic (or AER+PRE) versus No Exercise

Statistically significant (and potential clinically important) increase (improvement) in maximum oxygen capacity (VO2max) of 2.87 ml/kg/min (95% CI: 1.69, 4.04, n=358) for exercisers compared with non-exercisers.

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Cardiopulmonary Fitness: Exercise Time

Aerobic (or AER+PRE) versus No Exercise

Statistically significant increase (improvement) in exercise time of 2.66 min (95% CI: 0.12, 5.19, n=129) for exercisers compared with non-exercisers.

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Weight (PRE review)

Aerobic (or AER+PRE) versus No Exercise

Statistically significant increase in body weight of 2.50 kg (95% CI: 0.32, 4.67, n=129) for exercisers compared with non-exercisers. Assuming increase in body weight is favourable outcome; Potential for increase in muscle mass with PRE Greater increases with PRE versus no exercise (4.24 kg; 95% CI: 1.82, 6.66)

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Body composition

PRE versus no exercise (PRE review)

Statistically significant increase in arm and thigh girth of 7.91 cm (95% CI: 2.18, 13.65, n=46) for exercisers compared with non-exercisers.

PRE+AER versus no exercise (AER review)

Statistically significant increase in leg muscle area of 4.79 cm2 (95% CI: 2.04, 7.54, n=60) for exercisers compared with non-exercisers.

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Body composition - % body fat (AER)

Constant aerobic versus no exercise

Statistically significant greater decrease in % body fat of 1.12% (95% CI:-2.18, -0.07, n=119) among exercisers compared with non- exercisers.

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Strength: upper and lower body (PRE)

PRE versus Aerobic exercise

Statistically significant greater increase in upper body strength (combined 1RM or 3RM) of 14.56 kg (95% CI: 10.63, 18.49, n=41) and lower extremity strength 23.09 kg (95% CI: 13.01, 33.18) among PRE exercisers compared with AER exercisers.

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Quality of life: SF36 questionnaire (AER)

Aerobic (or AER+PRE) versus No Exercise

Domain Weighted Mean Difference (WMD) (95% CI) General Health 4.73 (3.13, 9.75) Mental Health 11.58 (1.35, 21.81) Role Physical 6.56 (3.17, 9.96) Role Emotional 10.95 (8.19, 13.71) Pain

  • 6.59 (-9.83, -3.36)

Physical Function 16.30 (6.89, 25.72) Energy / Vitality 5.03 (1.33, 8.72) Social Function 2.73 (-4.84, 10.30)

Statistically significant improvement on 6 out of 8 SF36 domain QOL sub- scales for exercisers compared with non-exercisers (n=59; 2 studies).

Clinically Important Improvement

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Methodological Quality - Risk of Bias

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Conclusions

Exercising at least 3X per week for at least 5 weeks is safe and can lead to improvements in….

  • Cardiopulmonary Fitness
  • VO2max*, exercise time
  • Body Composition
  • Decrease in % body fat
  • Increases in weight*, arm and thigh girth*, leg muscle area among

exercisers

  • Strength
  • Increase in upper and lower body strength among exercisers (greater

increases among PRE versus AER)*

  • Quality of Life*

What about CD4 count and Viral Load?

  • Despite trend towards improvement in CD4 count for some meta-analyses,

majority continue to be non-significant

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Considerations

Methodological Quality

  • High risk of…
  • performance bias (inability to blind participants to exercise)
  • Withdrawal bias (results based on participants who completed

the exercise) Majority of included studies…

  • Men, 30-49 years of age, little multi-morbidity
  • Resource rich countries
  • Highly supervised exercise by highly trained personnel
  • Trend towards combined AER and PRE interventions
  • Highly supervised settings by highly trained personnel
  • Sustainability in real world community setting over long term less clear.
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https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-016-1478-2

Effectiveness of Progressive Resistive Exercise (PRE) for Adults Living with HIV: Systematic Review and Meta-Analysis Using the Cochrane Collaboration Protocol – Under Review

For more detail - the full review

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Stephanie Nixon & Kelly O’Brien Funded by CIHR New Investigator Awards Centre for Urban Health Studies, St. Michael’s Hospital

Acknowledgements

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kelly.obrien@utoronto.ca @kellyobrien25

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Extra slides

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Outcomes WMD (95% confidence interval) # participants Quality of evidence Interpretation Viral Load (log10 copies) 0.18 log10 copies higher in exercise group (95% CI: -0.13 to 0.48) 162 (6 RCTs) ⊕⊕⊕⊝ MODERATE No significant difference in change in VL Cardiorespiratory (VO2max; ml/kg/min) 2.87 ml/kg/min higher in exercise group (95% CI: 1.69 to 4.04) 358 (8 RCTs) ⊕⊝⊝⊝ VERY LOW Significant improvement in VO2max Strength (upper body chest press; 1RM) 11.86 1RM higher in exercise group (95% CI: 2.37 to 21.36) 44 (2 RCTs) ⊕⊕⊝⊝ LOW Significant improvement in upper body strength Strength (lower body leg press; 1RM) 50.96 1RM higher in exercise group (95% CI: - 13.01 to 114.92) 44 (2 RCTs) ⊕⊝⊝⊝ VERY LOW No significant difference; trend towards increase Weight (kg) 0.38 kg higher in exercise group (95% CI: -1.55 to 2.31) 151 (5 RCTs) ⊕⊕⊕⊝ MODERATE No significant difference in change Body Composition (body mass index; kg/m2) 0.07 kg/m2 higher in the exercise group (95% CI: -0.52 to 0.66) 227 (6 RCTs) ⊕⊕⊕⊕ HIGH No significant difference in change Quality of Life (SF36 subscale scores) 6.47 points higher in exercise group (95% CI: 3.18 to 9.75) 472 (2 RCTs) ⊕⊝⊝⊝ VERY LOW Significant improvement in QOL scores

GRADE Rating – Quality of Evidence (AER)

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Aerobic (or AER+PRE) versus No Exercise

Body Composition: Lean Body Mass

Statistically significant increase in lean body mass of 1.75 kg (95% CI: 0.13, 3.37, n=89) for exercisers compared with non-exercisers.