The medical management of people living with the Human Immunodeficiency Virus that ultimately leads to the development of Acquired Immunodeficiency Syndrome has progressed dramatically since the beginning of the pandemic in the early 1980's. Despite advances in management and prevention, it is estimated that 33 million people worldwide are infected with this virus. Of those, 1.1 million people living with HIV/AIDS reside in the United States, while 56,000 new cases are added to this total every year. Medical providers are challenged to achieve a delicate balance between offering effective anti-retroviral therapeutic interventions while monitoring undesired side effects in an aging population of "People Living with HIV/AIDS" (PLWA). Indeed, the life expectancy of PLWA has continued to increase in the industrialized world, approaching parity with non-infected individuals.
Pain and sleep disturbances are commonly associated with chronic systemic diseases such as fibromyalgia, arthritis, chronic liver disease and HIV/AIDS. Data collected from a cohort of 317 PLWA, indicate that 55% of them experienced and ranked increases in pain and sleep disturbances among the top four symptoms associated with living with HIV/AIDS. Pain and sleep disturbances were only preceded in reported prevalence by self-reported fatigue and drowsiness. A review of systemic diseases' impact on sleep, suggests that alterations in rapid eye movement (REM), non-REM sleep stages, as well as an increase in sleep disturbances are associated with HIV disease progression into AIDS; moreover, 26% of the variance in sleep disturbances experienced by PLWA in that study was attributed to pain and other psychosocial factors.
Peripheral neuropathy (PN) is among the most common complications associated with long-term survival with HIV/AIDS. It is estimated that 30-60% of all PLWA will develop PN at some point during the course of the disease, with an increased prevalence seen in this patient population as the disease progresses from HIV into AIDS. Functional impairments have also been reported in the presence of neuropathies. Different authors have reported significant differences in gait quality, walking speed and total distance walked in individuals with damage to the peripheral nervous system. Despite advances in medical management of HIV infection, the direct impact of commonly experienced symptoms associated with living with HIV/AIDS, such as pain and sleep disturbances in the current era of anti-retroviral therapy has not been extensively reported in the literature.
In a recent pilot study, conducted by this author and colleagues, the use of night time lower extremity (LE) splinting showed promising results in the management of pain and sleep disturbances. This pilot study design was a crossover study that included 22 PLWA with PN and evaluated the effects of a three-week bilateral lower splints application on pain and sleep. A 20% improvement in both pain and sleep scores was reported in this pilot study. Additionally, a moderate effect size for pain and sleep scores was found. The results suggested that the analgesic effect of the splint application persisted for a period of several weeks following discontinuation of the lower splint application. These results were obtained using a relatively small sample of patients and without a long-term follow-up post-splinting application. Finally, that study could not determine whether the source of the pain inhibition was due to the application of a full contact protective sheath on the lower leg or the short-term immobilization at the ankle joints provided by the splints.
Purpose and Hypotheses
Therefore, the purpose and primary aim of this study is to evaluate the management of pain and sleep disturbances in people living with HIV/AIDS-related PN with the use of bilateral LE splints versus a control/placebo intervention of bilateral LE splint liner application. The null hypotheses for the primary aim are:
* There is no difference in pain and sleep scores between the bilateral LE splints and those obtained using the splint liners only following a three and six-week application.
* There is no difference in pain and sleep scores between baseline and following a six-week LE splint application.
The secondary aim is to identify factors influencing function, as measured by the functional reach test and the six-minute walk test; and their relationship with pain and sleep disturbances in the presence of HIV/AIDS related neuropathy.
