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31 August 2023

Physiotherapy Methods Applied in the Prevention of Functional Loss Associated with Human T-Lymphotropic Virus 1 Infection: An Overview

,
and
1
Center for Tropical Medicine, Federal University of Pará, Belém 66055-240, Brazil
2
Institute of Health Sciences, Federal University of Pará, Belém 66055-240, Brazil
*
Author to whom correspondence should be addressed.
Infect. Dis. Rep.2023, 15(5), 478-493;https://doi.org/10.3390/idr15050048
This article belongs to the Topic Ecosystem Change, Infectious Diseases Transmission and Early Warning
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Abstract

To achieve the objective of this study, we conducted a narrative review on physical therapeutic modalities applied to prevent functional losses associated with human T-lymphotropic virus 1 (HTLV-1) infections to promote health education and viable and accessible alternatives in the development of health education technology adapted to the home environment. This study comprised a qualitative stage of theoretical development to construct a digital booklet with an observational basis based on studies that reiterate themes about educational technologies as tools to conduct a home protocol of guided exercises without the direct supervision of professional physical therapists. Results indicate a lack of research on the development of health education technologies to assist patients with HTLV-1 without tropical spastic paraparesis or HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). We believe that this narrative review can initiate a theoretical framework to conduct a home exercise program aimed at people with HTLV-1 who have subtle symptoms, and also at people without the clinical definition of HAM/TSP, helping to train human resources for care and research on the subject and increase scientific production in physical therapy.

1. Introduction

The human T-lymphotropic virus 1 (HTLV-1) is a retrovirus in the Retroviridae family that affects human blood T lymphocytes and can cause neurological disorders. This infection is characterized by silent, long-term persistence in the host. Despite its irregular distribution, estimates suggest that at least 20 million people are infected with HTLV-1 worldwide [1,2,3,4,5], whereas, in Brazil, about two million people live with the infection, but its distribution is heterogeneous and varies geographically [3,6].
The development of serious diseases has been pointed out in association with the virus, such as adult T-cell leukemia/lymphoma (ATL) and tropical spastic paraparesis or HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). The latter is characterized by the installation of classic motor disabilities in patients and the slow, progressive, and non-remitting inflammation of the spinal cord, which affects 4 to 5% of infected subjects, causing more proximal motor weakness, spasticity of the lower limbs (LLLL), pain and bladder, intestinal and sexual dysfunctions, and, consequently, functional limitations such as impaired walking, ascending and descending stairs, washing, dressing, and urinary continence [7].
Faced with these significant motor disabilities, physical therapy has been prescribed for neurological complications associated with HTLV-1 because it improves functional status, reduces symptoms, and positively impacts patients’ quality of life [8,9,10]. Considering the importance of implementing physical exercise programs, the development of protocols that can be performed at home provides an alternative for treatment and continued care to resolve health conditions. Professionals must constitute methodologies that successively stimulate patients, as well as the teaching–learning process. Strategies to encourage adherence and motivation are fundamental for the success of treatment performed at home without the direct guidance of a health professional [11].
Such protocols are envisaged as auxiliary strategies for patients with difficulties attending rehabilitation centers as they propose to enable their performance with the use of low-cost materials, promote autonomy and confidence, resume social roles, and seek to provide general data of health conditions associated with HTLV-1 in this population since the levels of evidence and the strength of recommendation for these protocols are yet to be well-established.
Observing the presence of neurological signs and symptoms in HTLV-1 carriers living in the municipality of Belém (PA) [12] in unfavorable socioeconomic conditions, alongside the greater involvement of older women in relation to their presence, their prevalence among the Brown/Black population [13,14,15,16,17,18], as well as the limitations of access to vacancies in therapeutic programs regulated by the Unified Health System [19], the use of new interventions (such as the home exercise program) to strengthen patients’ muscles, improve their flexibility and joint mobility, adjust their postural disorders, and enable economic and cognitive access to other platforms would positively impact these individuals’ quality of life.
Therefore, it is important to conduct a narrative review on how and which physical therapy modalities are applied to prevent functional losses associated with HTLV-1 that can contribute to a safe and supported home clinical practice and highlight new paths in the production of health education technologies.

2. Methods

This is a qualitative narrative literature review with an observational basis. This research was submitted to the Ethics Committee for Research Involving Human Beings (CEP) of the Oncology Research Center of the Federal University of Pará, following the Declaration of Helsinki and the norms of Resolution 466/12 of the National Health Council regarding research on human beings (CAAE: 36688020.1.0000.5634).
To conduct this review, the guiding question was first identified, descriptors were selected, and inclusion and exclusion criteria were constituted. Then, the following steps were taken: the sample was selected by searching databases, the information extracted from the selected works was summarized, studies were evaluated, results were interpreted and discussed, and, finally, the review was described and the produced knowledge was synthesized [20].
The guiding question of this study was “What physical therapy approaches can help people affected by HTLV-1 with problems of rehabilitative interest and how?” The construction of the question involved the acronym PICO [21], i.e.,: P for population (people affected by HTLV-1); I for intervention (physical therapy approaches of preventive and rehabilitative interest); C for control (comparison terms were ignored); O for results (functional, quality of life, and perceived pain improvement and hypertonicity reduction).
The following databases were used: Scientific Electronic Library Online (SciELO); Latin American and Caribbean Literature in Health Sciences (Lilacs); US National Library of Medicine (PubMed); and Google Scholar. Data were collected in institutional repositories of theses and dissertation. The inclusion criteria were: (a) articles with full text; (b) drafts in Portuguese or English; (c) exercise protocols aimed at HTLV-1 carriers. No restrictions were set on the sample to maximize search results. The following were excluded: (a) monographs; (b) annals of events; and (c) duplicates. Data were extracted by a standardized form containing information on the method, sample, intervention, markers, and outcomes of the chosen studies.
The following controlled descriptors (indexed to the MeSH terms) were used: human T-lymphotropic virus 1; problems and exercises; physical therapy modalities; Boolean operator “E”. These descriptors in English were also used: “Problems and Exercises”; “HTLV-1”; “HTLV I Associated Myelopathy”; “Physiotherapy Modalities”. A combination of descriptors with the Boolean operator “AND” was used for each of the selected databases due to their specific characteristics, with the guiding question and established inclusion criteria as the guiding principle of this search, without the use of filters.
The search was carried out using online access and considering the period from 2006 to 2022. To select the studies, the recommendations of PRISMA [21] were followed (as shown in Figure 1). In total, 16 studies were included in this review.
Figure 1. Flowchart of the process of identification, selection, and inclusion of studies.

3. Results

Of the sixteen chosen studies, thirteen are scientific articles, two are doctoral theses, and one is a master’s dissertation. The types of studies in this review include six analytical interventions, two literature reviews, a case report, a short communication, two theses, and a dissertation with an observational descriptive study.
Following the chronological order of the selected study (Table 1), we observed that their results indicate several modalities of physical therapy and specific exercises as promising to treat symptoms associated with HTLV-1. Klautau et al. (2020) [22] showed that the Pilates modality reduced patients’ pain, improved quality of life and trunk balance in wheelchair users, and shortened the progression of lower limb spasticity.
Table 1. Synthesis of selected studies in the narrative review.
In urinary incontinence associated with the virus, results also point to reduced symptoms after the implementation of behavioral therapy, kinesiotherapy, and electrical stimulation, increasing perineal strength and improving urodynamic parameters (Andrade et al., 2016) [23].
Regarding the evaluation, the use of ICF codes showed a greater functional independence and quality of life in patients after therapy, emphasizing the effectiveness of physical therapy in controlling spasticity and the value of ICF as a tool to analyze spasticity in patients with HAM/TSP (Rodrigues et al., 2015) [24].
PNF increased lower limb ROM, reduced hypertonia/spasticity, and restricted ambulation (Costa et al., 2018) [9]. Regarding adjuvant treatments, repetitive transcranial magnetic stimulation may decrease spasticity and pain in patients with HAM/TSP, but failed to influence patients’ muscle power and quality of life. This intervention can be used as adjunctive therapy in patients with a clinical diagnosis of HAM/TSP (Amiri et al., 2014) [25].
In comparative studies between PNF and outpatient physical therapy, results point to a decrease in low back pain and an increase in functional independence in both treatments (Britto et al., 2014) [26].
The findings of the literature reviews address the importance of implementing specific exercise programs that seek to improve flexibility, range of motion, muscle strengthening, and postural control, as well as the discussion about perspectives to develop knowledge in the area (SÁ et al., 2015; Lannes et al., 2006) [8,27].
Figueiredo et al. (2013) [28] evaluated the impact of a muscle-strengthening program in therapeutic activities on the functional performance of patients with HAM/TSP and found that the program, lasting eight weeks and performed thrice a week for 50 min per session, improves functional performance measures.
By assessing balance in people with HAM/TSP, Patrício et al. (2020) [29] point out that this population has a high balance deficit, and that the use of tools available at no additional cost in outpatient clinics, such as free software for movement analysis (e.g., CYMOB), help identify movement pattern discrepancies and analyze gait performances. Arnaut (2014) [30] also contributed to the investigation on the use of Nintendo Wii as virtual therapy in the treatment of pain and quality of life, positively impacting these two variables.
Mota (2017) [19], who evaluated the impact of a home exercise program with and without supervision on functional mobility and pain in people with HAM/TSP, observed that the home exercise program benefited participants’ mobility and functionality in both supervised and unsupervised groups.
Facchinetti (2013) [31] evaluated the effects of a home exercise program and its adherence rate in individuals with PET/MAH and found that the proposed program effectively improved some disabilities and the quality of life of individuals with PET/MAH.
For Vasconcelos et al. (2019) [32], the subtle balance impairment in patients without defined HAM/TSP (i.e., undetected in clinical scales) suggests that these patients may be between healthy patients and HAM/TSP and, thus, may show a risk of developing severe imbalance postural control.
Finally, for Costa et al. (2022) [34], balance severity directly relates to the degree of signs and symptoms of HAM/TSP, and Almeida et al. (2022) [33] claim that the clinical evaluation of this population should include postural stability interventions during rehabilitation programs.

4. Discussion

Although Brazil has a prominent place in scientific production in physical therapy for people with HTLV-1, this production is still in its infancy, mainly testing therapeutic procedures.
A scientometric study on the subject only found 68 studies involving physical therapists, 21 of which were interventional [35]. The most tested therapeutic resources were individual and group functional exercises, including Pilates, home exercise booklets, virtual therapy, and proprioceptive neuromuscular facilitation.
Therapeutic exercise protocols must be improved, especially regarding dosage and progression. On the one hand, individualized exercises, as in PNF, positively reduce spasticity and improve movement control and functionality levels, but they are isolated cases, as in Costa et al. (2018)’s work [9], which reported five cases of patients with HAM/TSP which, thus, may have a higher cost. Group exercises are more accessible, may include a professional assisting a group (which reduces costs), and include the aspect of sharing experiences among peers, as in Klautau (2020)’s work [22], which carried out a pilot study with eight patients divided into two groups, one of wheelchair users and the other with gait impairment. As in Mota (2017) [19] and Facchinetti (2013) [31], home exercises stimulate autonomy for self-care and generate access opportunities for those who are unable to participate in outpatient services.
In view of this, the three modalities of therapeutic exercises should be tested in randomized clinical trials with a larger sample size and more detailed protocols, considering a reasonable follow-up time to enable the measurement of a larger effect size, produce better levels of recommendation, and provide greater security in its reproducibility.
Home care has become one of the main pillars of providing services at different levels of health as it meets the needs of patients with chronic health conditions, improves quality of life by controlling signs and symptoms, and decreases the risk of complications. Thus, the effectiveness of the practice of home exercises after an injury demands that patients, family members, and caregivers understand the importance of therapy, thus reaching an adequate process with greater possibilities of good results [36].
Studies have been using the home approach for physical exercise, considering feasibility and long-term maintenance [37,38,39,40,41], with a more accessible approach to exercise plans that can be performed at home and without the use of special equipment. Home exercise programs are widely used as an alternative strategy for patients with different conditions, such as Parkinson’s disease [42], traumatic spinal cord injury [43,44,45], multiple sclerosis [46,47], Huntington’s disease [48], strokes [49,50], post-polio syndrome [51], cardiovascular diseases [52], etc.
Home exercises remove the need for accessibility to training facilities [53], is cost-effective [54,55,56], and reduces barriers to commuting time [54]. Moreover, standardized home exercise protocols guided by socio-educational materials such as booklets have been found as effective treatments of chronic degenerative diseases, stimulating individuals’ autonomy to manage their condition [57,58,59,60,61].
Thus, gathering evidence with a broad review should precede actions that help prevent functional declines associated with HTLV-1, such as the implementation of public health programs aimed at HTLV-1 carriers without defined HAM/TSP.

5. Conclusions

More studies on physical therapy modalities aimed at people affected by HTLV-1 must be developed and tested in randomized clinical trials with a larger sample size and more detailed protocols. We believe that this narrative review can contribute to a safe and evidence-based home clinical practice and point out new paths in the production of health education technologies that are sensitive to the reality of this population.

Author Contributions

Conceptualization, M.S.d.S. and B.C.; writing—preparation of the original draft, I.M.d.A.; writing—proofreading and editing, I.M.d.A., M.S.d.S. and B.C.; supervision, M.S.d.S. and B.C. All authors have read and agreed to the published version of the manuscript.

Funding

This study was supported by the Dean of Research and Graduate Studies at UFPA (PROPESP/UFPA/PAPQ-2023).

Institutional Review Board Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

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