Effectiveness of Aerobic Exercise in Adults

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CLINICAL SCIENCEClinical Investigation

Effectiveness of Aerobic Exercise in AdultsLiving with HIV/AIDS: Systematic ReviewKELLY O'BRIEN1 , STEPHANIE NIXON', ANNE-MARIE TYNAN 2 , and RICHARD H. GLAZIER 3'Departmentof Physical Therapy, University of Toronto, Toronto, ON, CANADA; 2St. Michael'sHospital, InnerCityHealth Research Unit, Toronto, ON, CANADA; 3Departmentof Family and Community Medicine, University of TorontoToronto. ON, CANADA

ABSTRACTO'BRIEN K., S. NIXON, A. M. TYNAN, and R. GLAZIER. Effectiveness of Aerobic Exercise in Adults Living with HIV/AIDS:Systematic Review. Med Sci. SportsExerc., Vol. 36, No. 10 , pp. 1659-1666, 2004. Purpose: The objective of this systematic reviewwas to examine the effectiveness and safety of aerobic exercise interventions on immunological/virological, cardiopulmonary. andpsychological outcomes in adults living with HIV/AIDS. Methods: Ten randomized trials of HIV-positive adults performing aerobicexercise three times per week for at least 4 wk were identified by searching 13 electronic databases, abstracts from conferences,reference lists, and personal contact with authors from 1980 to November 2002. At least two independent reviewers assessed articlesfor inclusion, extracted data, and assessed methodological quality. Random effects models were used for meta-analysis. Results: Mainresults indicated that aerobic exercise was associated with small nonsignificant changes in CD4 count (weighted mean difference: 14cells-mm- 3 , 95% CI: -26, 54), viral load (weighted mean difference: 0.40 loglO copies, 95% CI: -0.28, 1.07), and VO2,. (weightedmean difference: 1.84 mL-kg-1 ,min- , 95% CI: -0.53, 4.20). Individual studies suggested that aerobic exercise may improvepsychological well-being for adults living with HIV/AIDS. These findings are limited to those participants who continued to exerciseand for whom there was adequate follow-up. Conclusion: In conclusion, performing constant or interval aerobic exercise, or acombination of constant aerobic exercise and progressive resistive exercise for at least 20 min, at least three times per week for 4 wkmay be beneficial and appears to be safe for adults living with HIV/AIDS. However, these findings should be interpreted cautiouslydue to small sample sizes and large dropout rates within the included studies. Future research would benefit from increased.attentionto participant follow-up and intention-to-treat analysis. Key Words: COCHRANE COLLABORATION, META-ANALYSIS.SAFETY, HIV INFECTION. ACQUIRED IMMUNODEFICIENCY SYNDROME

T he profile of HIV infection has changed dramaticallysince the advent of highly active antiretroviral ther-apy (HAART). Once viewed as an illness progress-

ing steadily toward death, HIV infection can now present asa chronic and episodic disease for people who are able toaccess and tolerate HAART. These developments have beenmirrored by a perceived increasing prevalence of impair-ments, activity limitations, an d participation restrictions formany people living with HIV (19).Exercise is on e possible management strategy fo r ad-dressing these issues. Exercise has potential prophylactic

Address for correspondence: Kelly O'Brien, Department of Physical Ther-apy, University of Toronto, 50 0 University Avenue, 8th Floor, Toronto,ON , M5G IV7; E-mail: [email protected] for publication January 2004.Accepted for publication June 2004.0195-9131/04/3610-1659MEDICINE & SCIENCE IN SPORTS & EXERCISE,Copyright 2004 by the American College of Sports MedicineDOI: 10.1249/01.MSS.0000142404.28165.9B

benefits associated with increased lean body mass and cdiovascular fitness. Exercise is also closely linked to boimage, which has particular significance in certain HIaffected communities (Shemoff, M. Pumped up: gay mand gym culture. GayHealth,December 18. 2000. Availabat: www.gayhealth.com/iowa-robot/fitness/workout/?record= 340; accessed December 19, 2002). Exercise has beshown to improve strength, cardiovascular function, apsychological status in general populations (2), buteffectiveness and safety of aerobic exercise fo r adults liviwith HIV infection have no t been established. If the risand benefits of exercise fo r people living with HIV infectiare better understood, appropriate exercise prescription mbe practiced by health care providers and may enhanceeffectiveness of HIV management, thus improving overoutcomes for adults living with HIV infection.

Th e purpose of this systematic review and meta-analywas to examine the effectiveness and safety of aerobexercise interventions on immunological/ virological, cdiopulmonary, and psychological outcomes in adults liviwith HIV.


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METHODSSearch for primary studies. We performed a system-atic review and meta-analysis using methods of the Co-chrane Collaboration (3). We searched electronic databasesfor articles published between 1980 to November 2002(MEDLINE, EMBASE, SCIENCE CITATION INDEX,

AIDSLINE, CINAHL, HEALTHSTAR, PSYCHLIT, SO-CIOFILE, SCI, SSCI, ERIC, DAI, and Cochrane Collabo-rative Review Group databases) using subject headings suchas HIV, HIV infections, and exercise. We also reviewedabstracts from international and national AIDS conferences,searched reference lists from pertinent articles and books,made personal contact with authors, and hand searchedtargeted joumals to identify potential studies for inclusion.All languages were included.Selection of studies and abstraction of data. Ti-tles and abstracts of all citations were reviewed indepen-dently by two reviewers to identify studies which met thefollowing four inclusion criteria and included: 1) humanparticipants who were HIV positive, 2) participants 18 yr ofage or older, 3) an aerobic exercise intervention performedat least three times per week for at least 4 wk, and 4) arandomized comparison group. Two reviewers reviewedhard copies of an entire paper independently if one or bothraters believed a study met eligibility criteria. Three of fourpossible reviewers examined full text to determine finalinclusion. Disagreements were resolved through discussionand consensus.Two reviewers (out of eight possible reviewers) ab-stracted relevant data from included studies onto standarddata abstraction forms. Methodological quality of the stud-ies was assessed using criteria developed by Jadad et al. (5).We also assessed whether the groups were similar at base-line. Our outcome measures included immunological/viro-logical indicators (CD4 count, viral load), cardiopulmonarymeasures (VO2max), psychological measures, and adverseevents including death.Data analysis. We used RevMan (Version 4.1) soft-ware to perform statistical analyses. Where there were suf-ficient data available from the authors, and comparisonsmade practical sense, and in the absence of statistical het-erogeneity (P < 0.05), meta-analyses were performed. Forcontinuous variables, we used random effects models tocalculate the weighted mean difference (WMD) and 95%confidence intervals. None of the outcomes were dichoto-mous variables.Subgroups identified for separate analyses included: in-terval versus constant aerobic exercise and moderate versusheavy intensity aerobic exercise.For the purposes of this review, we considered 50cells-nm- 3 to indicate a clinically important change in CD4count, 0.5 loglO copies to indicate a clinically importantchange in viral load, and 2 mL.kg'-min-1 to indicate aclinically important change in VO2max. These values werebased on extensive consultation with the clinical and re-search community, and are consistent with values used in

previous literature (8,17,18). We considered a P value ofless than 0.05 as statistically significant.

RESULTSTrial characteristics. Searches of all sources retrieved

a total of 1187 citations, 30 of which were judged to meriscrutiny of the full article and 12 of which met the inclusioncriteria (1,4,6,7,9-16). Of the included studies, there weretwo groups of citations identified as being duplicate studies(LaPerriere et al. (6,7) and Lox et al. (9,10). In these in-stances, the earlier published study was included in thereview, and any additional outcomes reported in the laterstudies were also incorporated into the review. Thus, therewere a total of 10 studies that met inclusion criteria(1,4,6,9,11-16). Table 1presents summary data from the 10randomized trials eligible for this systematic review. Of the10 studies, seven included a nonexercising control group(1,4,6,9,12,14,15). One of the studies included two addi-tional study groups: exercise plus injection of 200 mg oftestosterone enanthate pe r week, and a testosterone onlygroup (4), which were not included in our analysis. Onestudy included a nonexercising counseling group (exercisevs counseling group) (13), one study included a progressiveresistive exercise (PRE) group (9), and two studies hadcomparison groups that compared heavy with moderateexercise (11,16). Th e studies included HIV-infected adultsin various disease stages with CD4 counts ranging from lessthan 100 to greater than 1000 cells-mm 3 . Studies includedboth men and women, although women made up less than15% of the total number of participants. The age of theparticipants ranged from 18 to 58 yr. Two studies includedparticipants who were on HAART (72% of participants inGrinspoon et al. (4), and 23% of participants in Smith et al.(14)), five studies included participants wh o were not onHAART; however, most, if not all, participants were takingsome form of antiretroviral therapy (ART) (1,9,11,12,15),and three studies did no t report on whether participants weretaking ART (6,13,16). Training intensities of participants inindividual studies were reported in % HRmax (1,4,6,12,16),% heart rate reserve (9,13), % maximal oxygen uptake(CV 2max) (11,14), % lactic acid threshold (LAT), and %difference between LAT and VO2max (15). The way inwhich training intensities were established varied amongindividual studies and included submaximal testing(6,13,1 1), graded exercise testing (12,14), maximal exercisetesting (1,15,16), and intensities prescribed based on theKarvonen formula and the American College of SportsMedicine guidelines (4,9). Other personal characteristicswere reported inconsistently across studies.

Quality assessment of studi6s. Table 2 providesdetails of the assessment of quality. Only three studiesdescribed the randomization process and only two reportedon blinding. Withdrawals and drop-outs were described innine studies but drop-out rates were high, with six studiesreporting drop-out rates greater than 20% and tw o studiesgreater than 50%.


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TABLE 1. Characteristics of studies included in he systematic review.

Study MethodLaPerriere andomized exerciseet al. and ontrol groups

(6,7)

Sample Size(atbaseline)N=50(17 HIVt)

Rigsby et Randomized exercise N= 45al. (13) and ontrol groups (37 HIV+)

MacArthur Randomized-twoetal. 11) exercise groups N= 25

Stridger et Randomizedxercise N = 34al. (15) and ontrol groups

Pemat al. Randomizedxercise N = 43(12) and ontrol groups

Terry et al. Randomized-two N= 31(16) exercise groups

Geinspoonandomized exercise N = 54et al. 4) and control groups (4groups:ex +testosterone;ex +placebo;testosteroneonly;controlSmith et al. Randomizedxercise N= 60(14) and control groups

Lo x etal. Randonized--two(9,10) exercise groups andone ontrol groupN= 34

Baigis t al. Randomized exercise N = 123(1) and ontrol groups

Participants (atStudy Typeof% ale Completion) Exercise

100% Intervention group: Stationary bikeN = 30 (10 HIV+)Non-exercising controlgroup: N = 20(7HIV+)

100% Intervention group: Stationary bikeN= 16 (13HIV+)Nonexercisingcounselingcontrol group:N= 15 11HIV+)96 % (N= defined ascompliant Walking, jogging,with exercise programm) biking rowing, andHigh-intensity stair-steppinggroup: N= 3Low-intensity group:

N=3

NR Moderate-inte nsity Stationary cyclegroup: N = 9 ergometerHeavy-intensity group:N= 9Nonexercising control group:N=8

86% Intervention group: Stationary bikeN= 18Nonexercising control group:N=10

FrequencyTime an d Intensity of andDurationExercise of Exercise45 min total @80% 3x per week for 5 wkHRmax x 3 min, then@69-79% HRmax x 2minINTERVALEROBIC

60 min total @6-080% 3x per week for 12 wkHR reserve 20 min(2-min warm-up and3-min cool-down at lowintensity); stretching x10-15 minCONSTANTEROBICPREHigh-intensity exercise: 24 3x per week for 24 wkmin total @ 5-05%VOxm, 4 minute x 6intervalsLow-intensity exercise:0min total @50-60%VO2 - x 10 min x 4intervalsINTERVALEROBICModerate intensity exercise:3 x per weekor 6 wk60min @ 0% lacticacid threshold (LAT)Heavy-intensity exercise:30-40 mi n C 50% ofdifference between LATandVO2,.CONSTANTEROBIC45 min total @ 0-80% 3x per week for 12 wkHRmax x 3 min then 2min "off' (10-minstretch preandpost)INTERVALEROBIC

67% Moderate-inte nsity Walking, running, andModerate-intensity exercise:3x pe r week for 12 wkgroup: N= 10 stretching 30 min walking @ 5-High-intensity group: 60% Rmax (15-minN = 11 stretch preand ost)High-intensity exercise: 30min running @ 5-d5%HRmax (15-min stretchpreandpost)CONSTANTEROBIC100% Intervention group: Stationary bike+- 20-min aerobic en.on 3x per ee k for 12wkey + placebo: progressive stationary cycle t60 -N 10 resistance exercise 70% HRmax,5-minNonexercising control group: (PRE) cool-down followed byN= 12 resistance trainingCONSTANTEROBICPRE

87% Intervention group: Walking/jogg ing,N= 19 stationary bike,Nonexercising control group: stair stepper, andN = 30 cross-countrymachine.100% Intervention groups:AER:N= 11,PREN =12Nonexercising control group:N= 10

80% InterventIon group:N= 35Nonexercising control group:N= 34

Stationary bike

Minimum of 30min 3x per week for 12 wkconstant aerobicexercise at 60-80%vo,maCONSTANTEROBICApprox. 45 min total: 5- 3x per week for 12 wkmin warm-up(stretching), 24-mincycle ergometer at 50-60% heart rate eserve(HRR),5-mincool-downCONSTANTEROBIC

Skimachine 40 min total: 5-minstretching, 5-min warm-upon machine, 20 minconstant aerobicexercise at75-85%HRmax followed by 5-mi n cool-down and -mi n stretchingCONSTANTEROBIC

3x per week for 15wk

Supervision NotesNR LaPerdiere1991continuation ofstudy reported1990. ResultswereusedromLaPerriere99 0for this reviewavoid kewedresults/ Yes 'Control' groupreceived0-12mi n of counsel1-2 x per wefor 12 wk

NR

NR Forhe meta-analof exerciseersnonexercisingcontrol; resultsthe moderate aheavy exercisegroups werecombined

/ Yes For his review, aweighted averwa s caleulatecombine datacomplaint andnoncompliantexercisers foranalysisNR

/ Yes Forhis review,results wemoextracted fromcontrol group aexercise +placeboroup tisolate theeffecof exercise] Yes

/ Yes Forhe purposes othis review onlythe aerobicexercise groupthe control grouwerencluded inmeta-analyses;articles thatreported on thesame study werincorporated asone study for threview/ Yes

NR. not reported; PRE, progressive resistive exercise; AER, aerobic exercise.


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TABLE 2.Methodological quality of studies included in he systematic review.LaPerriere et l. Rigsby etal. MacArthur et al. Stringer et al. Pernat al. Terry et al. Grinspoon et l. Smith et al. Lox et al. Baigis et al.Quality Criteria (6,7) (13) (11) (15) (12) (16) (4) (14) (9,10) (1)

a)Study randomized? / Yes / Yes I Yes J Yes J Yes J Yes J Yes J Yes J Yes J YesRandomization ] Described J Described J Describedprocess described? randomization randomizationprocess process randomizatioprocessb)Study double- NR NR Single-blind NR NR NR NR Single-blind NR NRblind? (participants) (assessors)c)Rate of withdrawal? NR 35% 76% 24% 51% 32% 15% 18% 4% 44%Description of No J Yes J Yes J Yes J Yes J Yes J Yes J Yes I Yes / Yes

withdrawals/drop-outs provided?d)Groups similar at / Yes I Yes NR J Yes I Yes J Yes NR J Yes NR J Yesbaseline?

NR , not reported.

Immunological/virological measures. All 10 stud-ies used CD4 count as an outcome. Five meta-analyses wereperformed (Fig. 1), showing no difference in CD4 count forparticipants in any type of aerobic exercise interventiongroup compared with the nonexercising control group(weighted mean difference: 14 cells-mm 3 , 95% Cl:-26,54, N = 209), no difference in CD4 count of participants inthe constant aerobic exercise group compared with nonex-ercising control group (weighted mean difference: -4cells-mm-3 , 95% Cl: -50, 42 , N = 164) and nonsignificantimprovement in CD4 count of 70 cells-mnm3 (95% CI:-11, 151, N = 45) for participants in the interval aerobicexercise group compared with the nonexercising controlgroup. Although no t statistically significant, the point esti-mate is above 50 cells-mnuF 3 , which represents a possibleclinically important increase in CD4 count. There was nodifference in CD4 count in the moderate intensity aerobicexercise group compared with the heavy-intensity exercisegroup (weighted mean difference: -34, 95% CI: -156, 89,N = 39) and no difference in CD4 count for participants incombined aerobic and progressive resistive exercise groupcompared with nonexercising control group (weighted meandifference: 6 cells-mm- 3 , 95% CI: -71, 83, N = 46).

Meta-analysis of three studies demonstrated no differencein viral load for participants in the exercise interventiongroups compared with the nonexercising control group(weighted mean difference: 0.40 loglO copies, 95% CI:-0.28, 1.07, N = 63) (Fig. 1).Cardiopulmonary measures. Nine studies measuredcardiopulmonary status (1,6,9,11-16). Significant improve-ments were found among individual trials of aerobic exer-cisers when compared with nonexercising controls, bu tmeta-analysis could only be performed using VO2max due tovarying outcomes reported. Table 3 contains a description ofcardiopulmonary status results for individual studies.

Seven studies assessed VO 2max as an outcome(1,6,9,11,12,14,15). Three meta-analyses were performed(Fig. 2), showing nonsignificant improvement in VO 2max of1.84 mL-kg-t.min-t (95% CI: -0.53, 4.20, N = 179) forparticipants in the aerobic exercise intervention group com-pared with nonexercising control group, nonsignificant im-provement in VO2max of 1.56 mL.kg-'.min 5 (95% Cl:-0.94, 4.07, N = 151) for participants in the constantexercise group compared with the nonexercising control

group, and statistically nonsignificant greater improvemenin V0 2max of 4.29 mL.kg-1 .liin-(95% Cl: -1.23, 9.82, N= 24) for participants in the heavy-intensity aerobic exercise group compared with participants in the moderateintensity exercise group. This finding reached clinical importance bu t not statistical significance.

Psychological measures. Meta-analysis was no t possible for psychological status due to the breadth of outcomeused. Results of psychological measures of individual studies (Table 3) show improvement in anxiety and depression(6), general health (11), mood and life satisfaction (10), anquality of life (1,15) among those in the exercise intervention groups. In one study, exercise was not associated withchange in depression (16).Safety measures. The only death reported was inRigsby et al. (13). This death was not attributed to aerobiexercise. No other adverse events such as sports injuryhospitalization or disease progression were reported.DISCUSSION

We could not confirm an overall effect of aerobic exerciseon CD4, viral load, or VO2m,x, either in individual studieor in meta-analysis. Despite statistical nonsignificance, results demonstrated the possibility of clinically importanimprovements in VO2max among exercisers compared witnonexercising controls, and greater improvements iVO2max among individuals exercising at heavy versus moderate intensity. Eight of the nine individual studies thameasured cardiopulmonary status demonstrated statisticallsignificant improvements in various cardiopulmonary parameters among exercisers. The fact that results did noreach statistical significance may have been due to a lack ostatistical power to detect a difference secondary to smalsample sizes, or inadequate intensity, duration, and mode oexercise prescribed within the individual studies. The fivstudies that measured psychological status among an exercise versus control group found statistically significant improvements in psychological parameters for the exercisintervention groups compared with the nonexercising control groups.

Results of this review indicate that aerobic exercise foadults living with HIV appears to be safe. This finding ibased on the absence of reports of adverse events amon


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CD4 count (cells- mmr (a-e)a) Constant or interval exercise compared with non.exercise

Treatment Centrot W10lDStudr n meonlsd) n meenisd) 95teClRandom) Weight WMtX (n96CI Random)Bdgis2002 35 13.20(15300) 34 -320(15800) 298 17,10)-05B51.0.711LaPerrare 190 1D 38.00(92.O) 7 .6100(13500) 120 000.10.77,214.771Lox1i99.15 9 5 I 9.09(302A3) 0 -"7.90(341'57) 1.5 86.99.227.02,401.001Pemnaltm 1B 3.12(1ES.05) 1 43920(13320) 12.7 4232[.70.31,154.9Sm1h2001 10 7.20127.00) 30 3250(118.10) .t. 30S .2530[.9751,47011S1rhger1995 18 S.00(150.00) 8 18.00(125.00) - 130 -13M00-124.47,9BA71

ToteaUS70%) 110 99 * 1000 14Z3A.25ASA4.48Tentforvoeret effect z=0.70 p.OS

.1050 .003 0 000 18WWFavours turl F-voursOetmr tb) Constant exercise vs. non-exerdcse.

Treatment Control WMo Weight WMDStudy meenlsd) n meonWd) (SMCI random) % (5S%CIRandom)

Betgis2002 35 1320(183.00) 34 -3.5t158.80) _1- 390 17.10.-5551,90.711Lox 1955.1963 11 99(392,43) 10 .77500(341.07) 22 80_90.227.02,401 .00SmAh001 10 7.201727.00) 30 3200(118.10) 41.0 -25301-97.1,47.011Strkiger,19t 18 S.0010.00) 8 18.00(12S00) 17.3 -13.0Q-124.47A8A7j

Torti9%aC) 82 82 a 100.0 -3.9614025,42341Testrfor veneleted z-0.17 p.08

.1080 .fOD 0 500 1000F.v-um -ocnl Favoursreaten,c) Interval-exercise vs. non-exercise.

Treetmer* Control VOAO WeigtA SnJ0Study n meen(ad) n meen(ld) (9SCl RPandom) % (05SCI Random)L.P.-.i1500 10 38.00(92.00) 7 .9100(135.00) 1 40B 99.00-16.774.771P8n01 m8g 10 63..13520 1M0 201332.0) 01A 4232[.7031.154.951

TetAa89%CJ) 28 17 v 1000 &S008.10.00,150011Test for overa effect o1.70 p-0 09

IW .60 0 660D IDDDFae- ..emsI Fa- uremennd) Moderate exercise vr . heanvy exercise.

H e..y Modertde WW Weight wmosuody n mr_n(.d) n meen(sd) (95CI Random) % (85%CIRandom)SLrnger 99a 9 .3.00(1WOO0) 9 13SW01W ) - 77B -18BO[-154.59,12.591Terry 1999 11 .4.00(31.00) 10 01 3291.00) 222 _ 9S[4-354.62,14.521

Tcte(S5%CI) 20 189 . 1000 -3302-155.78,8.741Test fIr overdl effect z=0.54 p=0.6

.IWD0 .501 D 005 tODOF vesfsmdre 70Fev-h.tee) Constant or interval aerobic exercise and progressive resistive exercise compared with no exercise

Treatment Control WPAD Weight w1DStudly n m..n(ad) n .een(ad) (StCI Rasndom) % (85%CIRandam)Oripon 2000 1 0 31.00(125WM) 1 2 33JDDSOM) t -- 87~2 -200q84A8,8WA0jF6gsby1992 13 53.07(220J57) 11 -200302AB): 12fi 60.071-155.20,275341

TolakSMO) 23 23 1 1WO. 5.95t-71.07,2.961Testforcveret effect -0.1J p.OA

.io 4 a A IDFarr-rssrtf F-soutnotrr

Viral Load (loclO copies)Constant or intervral exercise compared With non-exercise

Tretosent Control 'nO Weight WrADStudy n me.n(.d) n .e.ne(d) (380CI Random) X (25%CtRandom)Smlh2001 13 0.1(lo.) 24 .038(10) 89300 8A0{27A1o.7)st9rgerI993 18 .000(1407) 8 -20301103) 1tB 0.30)-103820b0

TotO(8OVeC) 31 32 1000 OA0(-028.1.071Testforsvere effect z.t.15 p.O2

FaNeooreamnr F-vurs ..m

FIGURE 1-Immunological/virological measures: CD 4 count (cells-mm- 3 ) (a-e) and viral load (loglO copies) (f) CD4 count (cells-mm-3); W1IIweighted mean difference; CI, confidence interval; sd, standard deviation.

exercisers. The stability of immunological and virologicalmeasures during regular aerobic exercise can also be seen asevidence for the safety of this intervention. These results are

based on those participants wh o completed the exerciprograms and for those where there wa s adequate follow-udata.


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TABLE 3. Outcomes and author's conclusions of individual studies included in the systematic review.Study Immunological/Virological Cardiopulmonary Psychological Author's Conclusions

LaPerriere et al. CD4 count: HIV+(6) exercisers showed anincrease in CD4 count by38 cells/mm3; HIV+non-exercisers showed adecrease inCD4 countby 61 ells/mm3Rigsby et al. CD4 count: no significant(13) changes

MacArthur et al. CD4 count: no significant(11) changes

Stringer et al. CD4 count and viral load:(15) no significant changes inall three groups

Perna et al. CD4 count: compliant(12) exercisers-increase inCD4 count by 13 % andnoncompliantexercisers-decreasedby 18%.Controls-decrease in CD4count of 10 %Terry et al. (16) CD4 count: no significantchanges.

Grinspoon et al. CD4 count and viral load:(4) no significant change inCD4 count or viral load

Smith et al. CD4 count and viral load:(14) no significant changes.

Lox et al. (9,10) CD4 count: no significantchanges.

Baigis et al. (1) CD4 count: no significantchanges.

VO,_:X 10% improvement inVO2maxn both HIV+ andHIV- exercisersNo change inVO2maxnnonexercising controls

Significant increases in erobiccapacity were shown in heexercise group with no changeinnonexercising control groupSignificant decreases inHR andincreases in otal time exerciseto voluntary exhaustionSignificant increases incompliant exercisers (N= 6)for VO2max24%), minuteventilation (13%), oxygenpulse (24%)Intensity aerobic training effectseen (heavy > mod) relativeto the nonexercising controlgroupVO2maxnd work rate maxincreased significantly in heheavy groupLAT increased significantly inboth intervention groups.

V02max12%), 2 pulse (13%).max TV (8%), VE (17%)significantly improved incompliant exercisersNo significant differences werefound innoncompliantexercisers and nonexercisingcontrol groupsPeak HR unchanged for bothgroupsPeak systolic BP increasedsignificantly only in he highintensity groupNA

VO2max:ignificantimprovements in heexperimental group(2.6 mL-kg- 1 min'1)compared with control group(1mL-kg.-1min-1)Significant decrease in atigue inthe exercisers compared tononexercisersNo significant effect on rate ofperceived exertion (RPE) ordyspnea ineither groupVO,2mx: significantimprovements amongexercisers compared tononexercisersV02max: no significantdifferences between exercisersversus non-exercisers; resultswere-attributed to the level ofintensity and duration ofexercise

Anxiety and depression: HIV+nonexercising controls showedsignificantly larger increases inanxiety and depression than theexercise groups

NA

Aerobic exercise is abeneficialst ress management intervention,which may be a useful strategyfor attenuating an acute stressorsuch as postnotification of HIVstatus.HIV* me n can experienceincreases incardiorespiratory

fitness: Increased fi tness mayoccur without negative effectson immune status.

General health questionnaire: scoresimproved for the six compliantparticipants

QOL questionnaire: significantimprovements inboth interventiongroups compared with thenonexercising control group (nodifferences between the twointervention groups)

Physician-rated health status: nosignificant differences

Depression scale: no significantchanges

NA

NA

Mood and l i fe satisfaction: significantimprovements inmood and lifesatisfaction in he aerobic exercisegroup compared with nonexercisingcontrolsHRQL: nonsignificant trend favouringexercisers compared withnon-exercisers: significantimprovement in overall healthsubscale of the' MOS-HIV foundamong exercisers compared withnonexercisers

Exercise training is easible andbeneficial for moderately toseverely immunocomprimisedHIV+ individuals.Exercise training resulted inasubstantial improvement inaerobic function (heavy > mod)while immune indices wereunchanged: QOL markersimproved significantly withexercise; exercise training is

safe and effective and should bepromoted for HIV+ individuals.Aerobic exercise ma y significantlyincrease CD4 count amoungsymptomatic HIV+ individuals;exercise noncompliance may beassociated with faster CD4decline.Short-term aerobic exerciseprograms ma y be safelyrecommended to HIV+individuals for improvement infunctional capacity.Exercise has a significant effect on

lean body mass and musclearea independent oftestosterone; muscle mass andstrength may increase inresponse to combined exerciseand testosterone therapy:exercise may be astrategy toreverse muscle loss in hispopulation.Supervised aerobic exercisetraining safely decreases fatigue,in HIV-infected individuals.

Exercise results in mprovementsin body composition, strength,cardiopulmonary fitness, andmood and life satisfaction forHIV-infected individuals.Exercise appears to be safe inHIV-infected individuals.

NA, no t assessed.


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a) Constant or interval exercise compared with non-exerciseTreatment Controln mean(sd) n meantsd)tudy vWMo(95%CIRandom) Weight WMD% (95%CIRandom)

Belgis 20X2 43 0301(.40) 35 -12!0(8.50) 4.2 1 SDq-190,4.90PemeIS55 1B 2.18(8.12) 10 -1.8(9.650) 11.3 3.Ot-3.05,11.1jSmevh2001 1a 2.06.10) 29 1.0(.90) 39.2 1.60-2.17,5371StrkrgerI998 1B 0.80(28.2) 8 -2.10(2324) 1.3 2.9q-17.81,23Si]

Tcdtdl(S%C3) 97 82 100.0 1 84[-0.53,4.20]Test lor overall ffed z-1.52 p=0.13

10 -5 0 5 10Fav.ursrol Fa2ousnZtmetb] Constant exercise us. non-exercise.

Treatment Control WMob Weight WMDStudy n mrean(ad) n mean(sd) (95%CIRandom) % (95%CI Random)BOigis002 43 0.30(A.40) 35 -1.20(8.50) 54.3 15q-1 .5,450]Srndh2D01 18 2.50(6.10) 29 1.00(5.0) 44.2 1.506-2.17537]strkrgerl0 18 0.80(2820) a -2.10(23.24) > 15 2S941731,23.]

Tota9%seco 79 72 _ _100 1.5X4-0.94,407]Test r overallffect x=1 22 p=D.2

.10 .- D 5 10C)

FP.00.0contro Fa-our r.aru,rrtModerate exercise vs heavy exercise.

Heavy Moderate WMD Weight WMDstudY n mean(sd) n mean(sd) (SS%CI andom) % (95%CIRandom)MmcAtthtr 1993 3 10.10(3.20) 3 5.dOt3.90) - ( ) 93.7 4.30[14A1,11D;011Strier 199a 9 2,90(1830) 3 -1.30(28.20) _ 63 4.20[-17.J6,26.16]

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resistance exercise for at least 20 min three times per weekfor at least 4 wk may be beneficial and appears to be safe foradults living with HIV/AIDS. Results from the meta-anal-yses indicate that immunological and virological measuresappear to be unaffected by aerobic exercise, a finding thatshould reassure those contemplating starting an exerciseprogram. We found strong trends toward improved cardio-pulmonary fitness and improved psychological healthamong those exercising, suggesting that adults living withHIV can expect to experience many of the well-establishedbenefits of aerobic exercise. Given the lack of informationon participants who dropped ou t of exercise, those exercis-ing should be closely followed for changes in clinical status,especially in more advanced stages of immunosuppression.Furthermore, results should be interpreted cautiously due tothe small sample sizes and large withdrawal rates within theindividual studies.

REFERENCES1. BAIGIS, J., D. M. KORNIEWIcz, G. CHASE, A. BuTrz, D. JACOBSON, and

A. Wu . Effectiveness of a home-based exercise intervention forHIV-infected adults: a randomnised trial. J. Assoc. Nurses AIDSCare 13(2):33-45, 2002.2. BoucHARD, C., R. J. SHFPHFRD, and T. STEPHENs. PlhysicalActivity,Fitness, andHealtlh: InternationzalProceedingsandConsensuls State-ment. Champaign, IL: Human Kinetics, 1994, pp. 9-76. 119-133.3. CLARKE, M., and A. D. OXMAN (EDs.). CochraneReviewers' Hand-book 4.1.5 [updated April 2002]. In: The CochraneLibrary,Issue2, 2002. Oxford: Update Software, Updated quarterly.4. GRINSPOON, S. , C. CORCORAN, K. PARLMAN, et al. Effects of testos-terone and progressive resistance training in eugonadal men withAIDS wasting. Ann. Intern Med. 133:348-355, 2000.

5. JADAD, A. R., A. MOORE, D. CARROLL, et al. Assessing the qualityof reports or randomised clinical trials: is blinding necessary?Controlled Clini. Trials 17:1-12, 1996.

6. LAPERRIERE, A. R., H. ANTONI, N. SCHNEIDERMAN, et al. Exerciseintervention attenuates emotional distress and natural killer celldecrements following notification of positive serologic status forHIV-1. Biofeedback Self-Regul. 15:229-242, 1990.7. LAPERRIERE, A. R., M. A. FLETCHER, M. H. ANToNI, N. KLIMAS, an dN. SCHNEIDERMAN. Aerobic exercise training in an AIDS riskgroup. Int. J. Sports Med. 12:S53-S57, 1991.8. LEDERGERBER, B., M. EGGER, M. OPRAVIL, et al. Clinical progres-sion and virological failure on highly active antiretroviral therapyin HIV-1 patients: a prospective cohort study: Swiss HIV CohortStudy. Lancet 353:863-868, 1999.

9. Lox, C. L., E. McAuLEY, and R. S. TUCKER. Aerobic and resistanceexercise training effects on body composition, muscular strength,and cardiovascular fitness in an HIV-1 population. Intenm. J.Behav. Med. 3:55-69, 1996.10. Lox, C. L. , E. McAuLEY, and R. S. TUCKER. Exercise as anintervention for enhancing subjective well-being in an HIV-1population. J. Sport Exerc. PsychoL 17:345-362. 1995.

Sources of support: The authors gratefully acknowledge the Ontario HIV Treatment Network, Ontario, Canada, and the Inner CitHealth Research Unit, St. Michael's Hospital, Toronto, Ontario, Canada, for their support:The Inner City Health Research Unit is sponsored by the OntariMinistry of Health and Long-Term Care. The opinions, results andconclusions are those of the authors and no endorsement by thMinistry is intended or should be inferred.The authors would like to acknowledge the contributions of JimMarianchuk, Sian Owen, Wayne Stump, and Tracy Xavier for therole indata abstraction in he original review; and Angela Eady, MLSHealth Information Research Unit, McMaster University, for her assistance in conducting the literature searches and refining thsearch strategy.The following authors or coauthors were invaluable in providinadditional data or information about their reviews that helped witthis update: William Stringer, Sheldon Levine (for R. D. MacArthur)Allen Jackson (for L. W. Rigsby), Jorge Ribeiro (for L. Terry), anFrank Perna.The results of the present study do not constitute endorsement othe product by the authors or ACSM.

11. MACARTHUR, R. D., S. D. LFvINE, and T. J. BIRK. Superviseexercise training improves cardiopulmonary fitness in HIV-infected persons. Med. Sci. Sports Exerc. 25:684-688, 1993.

12. PERNA, F. M., A. LAPERRIERE, N. KLIMAS, et al. Cardiopulmonary and CD4 changes in response to exercise training in earlsymptomatic HIV infection. Med. Sci. Sports Exerc. 31:973979, 1999.

13 . RiGSBY, L. W., R. K. DISHMAN, A. W . JACKSON, G. S. MACLEAN. anP. B. RAvEN. Effects of exercise training on men seropositivforthe human immunodeficiency virus-I. Med. Sci. Sports Exer24:6-12, 1992.

14. SMITH, B. A. , J. L. NEIDIG, J. T. NICKEL, G. L. MITCHELL, M. FPARA, and R. J. FAss. Aerobic exercise: effects on parameterrelated to fatigue, dyspnea, weight and body composition in HIVinfected adults. AIDS 15:693-701, 2001.

15. STRINGER, W. W., M. BERESZOVSKAYA, W. A. O'BRIEN, C. K. BECand R. CASABURI. The effect of exercise training on aerobic fitnesimmune indices, an d quality of life in HIV+ patients. Med. ScSports Exerc. 30:11-16, 1998.

16. TERRY, L., E. SpRmzr,and J. P. RIBEIRO. Moderate and high intensity exercise training in HIV-1 seropositive individuals: a randomised trial. Int. J. Sports Med. 20:142-146, 1999.

17. WOOD, E., R. S. HOGG, B. Yipw P. R. HARRIIGAN, M. VO'SHAUGHNESsY, and J. S. MONTANER. The impact of adherence oCD4 cell count responses among HlV-infected patients. JAID35:261-268, 2004.

18. WooD, E. , R. S. HOGG, B. YIP. et aL . Discordant increases in CDcell count relative to plasma viral load in a closely followed cohoof patients initiating antiretroviral therapy. JAIDS 30:159-162002.

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TITLE: Effectiveness of Aerobic Exercise in Adults Living with

HIV/AIDS: Systematic Review

SOURCE: Med Sci Sports Exercise 36 no10 O 2004

WN: 0428301727001

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