Disability profile of patients with HTLV-I-associated myelopathy/tropical spastic paraparesis using the Functional Independence Measure (FIM)

Epidemiological and clinical profile of HTLV-1 patients: a closer look at a reference center in Bahia, Brazil

The human T-lymphotropic virus type 1 (HTLV-1) affects over 5 million people worldwide and is endemic in Brazil. Though HTLV-1 is a notifiable disease, the last epidemiological report regarding HTLV-1 infection covered the period from 2012 to 2019. To understand the specific challenges and to develop the best strategies for controlling HTLV-1 infection, it is important to know the characteristics of each region providing care to people living with this virus. This descriptive cross-sectional study evaluated patients treated at the HTLV reference center in Vitória da Conquista, Bahia, Brazil, between July 2021 and August 2022. The data were obtained through the analysis of medical records and routine clinical consultations. A total of 67 patients were evaluated, with 79.1% being female, 79.1% identifying as black, indigenous, and people of color, 37.31% being married, 80.6% identifying as heterosexual, and 59.7% reporting inconsistent condom use. Additionally, 37.3% of the patients were diagnosed with HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP), a chronic disease with a considerable effect on the quality of life. Furthermore, 53.7% of the patients had incomplete/complete elementary education, and 52.2% had an income of up to one minimum wage. The data highlight the necessity for more specific public policies (such as health education strategies, aimed at reducing the number of new infections) targeting the described at-risk population.

Effectiveness assessment of a home-based exercise intervention in mitigating HTLV-1 associated disabilities: A validation study

To evaluate the effectiveness of a home exercise program called Home Exercise Booklet for People Living with Human T Lymphotropic Virus 1 (HTLV-1). This is a methodological study of content validation with expert judges. A questionnaire with a Likert scale was applied, containing 16 items referring to the content domain. Descriptive statistics were used to obtain the content validity index. In total, 46 judges participated, 24 physiotherapists (PG) and 22 professionals from other health areas specializing in methodological studies and HTLV-1 (EG). In the validation process, each evaluator judged the technology and scored their considerations. In the end, we obtained the following results for the Content Validity Index (CVI): PG CVI: 94.3%, GE CVI: 93.4%. Although the index was sufficient to consider the technology validated, modifications were made to the second and final version of the booklet, considering the judges' observations and suggestions, which we consider relevant. The technology proved to be valid for use with the target audience. The development and validation of this product provides support to help prevent functional decline in people living with HTLV-1; standardize guidelines for physiotherapy professionals who monitor these issues; start a home exercise program aimed at other comorbidities; open the possibility of creating and validating home exercise programs with other comorbidities.

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

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.

Integrative and Multidisciplinary Care for People Living With Human T-Cell Lymphotropic Virus in Bahia, Brazil: 20 Years of Experience

Brazil is home to the highest absolute number of human T-cell lymphotropic virus type-1 (HTLV-1)-infected individuals worldwide; the city of Salvador, Bahia, has the highest prevalence of HTLV-1 infection in Brazil. Due to the complex nature of several diseases associated with this retrovirus, a multidisciplinary health care approach is necessary to care for people living with HTLV-1. The Bahia School of Medicine and Public Health’s Integrative Multidisciplinary HTLV Center (CHTLV) has been providing support to people living with HTLV and their families since 2002, striving to ensure physical and mental well-being by addressing biopsychosocial aspects, providing clinical care and follow-up, including to pregnant/postpartum women, as well as comprehensive laboratory diagnostics, psychological therapy, and counseling to family members. To date, CHTLV has served a total of 2,169 HTLV-infected patients. The average patient age is 49.8 (SD 15.9) years, 70.3% are female, most are considered low-income and have low levels of education. The majority (98.9%) are HTLV-1 cases, and approximately 10% have been diagnosed with tropical spastic paraparesis/HTLV-1-associated myelopathy (TSP/HAM), while 2.2% have infective dermatitis and 1.1% have adult T-cell lymphoma. In all, 178 pregnant/postpartum women [mean age: 32.7 (±6.5) years] have received care at CHTLV. Regarding vertical transmission, 53% of breastfed infants screened for HTLV tested positive in their second year of life, nearly 18 times the rate found in non-breastfed infants. This article documents 20 years of experience in implementing an integrative and multidisciplinary care center for people living with HTLV in Bahia, Brazil. Still, significant challenges remain regarding infection control, and HTLV-infected individuals continue to struggle with the obtainment of equitable and efficient healthcare.

Dietary Intake and Serum Selenium Levels Influence the Outcome of HTLV-1 Infection

Human T cell leukemia virus type 1 (HTLV-1)-associated myelopathy/tropical spastic paraparesis (HAM/TSP), as the most common neurological emersion related to HTLV-1, is a debilitating and lifelong treating disease with no definitive treatment. Furthermore, it has been determined that dietary compositions (inflammatory and anti-inflammatory) and some micronutrients (such as vitamin D and selenium) have an effect on inflammatory and immune processes and with this background; the study was done to compare the nutritional status between age- and sex-matched with infected and non-infected HTLV-1. In a multi-center setting, 70 healthy controls (HCs), 35 asymptomatic carriers (ACs), and 35 HAM/TSP patients were recruited in the HTLV-1 Foundation, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. Nutritional status including anthropometric indices, dietary (micro- and macronutrient) intake, and serum vitamin D, vitamin B12, zinc, and selenium were measured. In anthropometric indices, mean waist circumference (WC) in the carrier group was significantly higher than the patient and the control groups (p = 0.008). In the dietary intake, the patient group received less energy, protein, mono-unsaturated fatty acids (MUFA), and oleic, but more fat than the HTLV-1 carrier and control groups, and these differences were remarkable in three groups (p = 0.002, 0.005, 0.001, 0.01, and 0.001, respectively), whereas the carrier group received more saturated fatty acid and less poly-unsaturated fatty acids (PUFA), linoleic, and linolenic than patient and control groups with a different significant (p = 0.01, 0.007, 0.005, and 0.006, respectively) in three groups. In micronutrient intake, although selenium, zinc, and vitamins B12 and D were lower in the patient group than the carrier and control group, however, no significant differences were observed. In comparison with micronutrient serum concentrations, vitamins B12 and D and selenium in the patient group were lower than the carrier and control groups, but statistically, the considerable difference was found only in the selenium concentration (p = 0.001). The study showed that there were differences in dietary intake (including energy, macronutrients, and fatty acids), WC, and selenium serum levels between HAM/TSP patients and HTLV-1 carriers, suggesting that nutritional statues influence the inflammatory immune response in HTLV-1 infection.

Balance assessment in HTLV-1 associated myelopathy or tropical spastic paraparesis

INTRODUCTION

A good rating of the device in people with HTLV-1 in this population is essential for accuracy in prescribing data (walking). Thus, this study aimed to analyze the counterpart assessment methods that are best suited to patients with human T-cell lymphotropic virus (HTLV)-1 associated myelopathy or tropical spastic paraparesis (HAM/TSP).

METHODS

This cross-sectional study related stabilometric and kinematic variables of postural oscillations with Berg's balance scale (BBS) and Timed Up and Go (TUG) in subjects with HAM/TSP compared to asymptomatic subjects. To assess the posterior and lateral postural projection, baropodometry and the Footwork® system was used, and the CVMob system was applied to kinematic parameters. The means comparison tests and correlations were applied with an alpha of 5%.

RESULTS

Thirty-nine subjects (predominantly female) made up the sample. There was an increase in barodopometric oscillations, in the total oscillation area (p = 0.004), in the anteroposterior oscillation in the left (p = 0.015) and right views (p = 0.036), and in the lateral oscillation (p = 0.039) in the HAM/TSP group. Moderate correlations were found between oscillation baropodometry and the angular variation of the ankle, as well as with the BBS in the three angles and the TUG for lateral oscillation (p = 0.406).

CONCLUSIONS

Each method has advantages and disadvantages, including cost accuracy. The best resources available at no additional cost for outpatient to use are the kinematic evaluation using a simple smartphone camera and free analysis software, and the TUG.

Intrarater and interrater agreement and reliability of vestibular evoked myogenic potential triggered by galvanic vestibular stimulation (galvanic-VEMP) for HTLV-1 associated myelopathy testing

BACKGROUND

The vestibular evoked myogenic potential triggered by galvanic vestibular stimulation (galvanic-VEMP) has been used to assess the function of the vestibulospinal motor tract and is a candidate biomarker to predict and monitor the human T-cell lymphotropic virus type 1 (HTLV-1) associated myelopathy (HAM). This study determined the agreement and reliability of this exam.

METHODS

Galvanic-VEMP was performed in 96 participants, of which 24 patients presented HAM, 27 HTLV-1-asymptomatic carriers, and 45 HTLV-1-negative asymptomatic controls. Galvanic vestibular stimulation was achieved by passing a binaural and bipolar current at a 2 milliamperes (mA) intensity for 400 milliseconds (ms) between the mastoid processes. Galvanic-VEMP electromyographic wave responses of short latency (SL) and medium latency (ML) were recorded from the gastrocnemius muscle. Intrarater (test-retest) and interrater (two independent examiners) agreement and reliability were assessed by standard error of measurement (SEM), coefficient of repeatability (CR), intraclass correlation coefficient (ICC), and Kappa coefficient.

RESULTS

In the total sample (n = 96), SL and ML medians were 56 ms (IQR 52-66) and 120 ms (IQR 107-130), respectively. The intrarater repeatability measures for SL and ML were, respectively: SEM of 6 and 8 ms; CR of 16 and 22 ms; ICC of 0.80 (p<0.001) and 0.91 (p<0.001); and a Kappa coefficient of 0.53 (p<0.001) and 0.82 (p<0.001). The interrater reproducibility measures for SL and ML were, respectively: SEM of 3 and 10 ms; CR of 8 and 27 ms; ICC of 0.95 (p<0.001) and 0.86 (p<0.001); and a Kappa coefficient of 0.77 (p<0.001) and 0.88 (p<0.001).

CONCLUSION

Galvanic-VEMP is a reliable and reproducible method to define the integrity of the vestibulospinal tract. Longitudinal studies will clarify its validity in the clinical context, aimed at achieving an early diagnosis and the monitoring of HAM.

Balance, functional mobility, and fall occurrence in patients with human T-cell lymphotropic virus type-1-associated myelopathy/tropical spastic paraparesis: a cross-sectional study

INTRODUCTION

Human T-cell lymphotropic virus type-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) may lead to reduced functional mobility and balance. It is important to establish specific parameters that identify these changes and predict the risk of falls in these patients. The aim was to compare balance, functional mobility, and occurrence of falls among patients with and without HAM/TSP and to suggest values to predict the risk of falls in these patients.

METHODS

A cross-sectional study in patients with and without HAM/TSP involved balance assessments based on the berg balance scale (BBS) and functional mobility evaluation based on the timed up and go (TUG) test. From reports of falls, the sensitivity, specificity, and best cutoff points for the risk of falls assessed by these instruments were established using the receiver-operating characteristic (ROC) curve; 5% alpha was considered.

RESULTS

We selected 42 participants: 29 with HAM/TSP and 13 without HAM/TSP. There was a statistically significant difference in the occurrence of falls, balance, and functional mobility between the groups (p<0.05). Good accuracy was determined for the BBS (77%) and TUG test (70%) and the cutoff points for the risk of falls were defined as 50 points for the BBS and 12.28 seconds for the TUG test.

CONCLUSIONS

Patients with HAM/TSP present reduced functional mobility and balance in relation to those without HAM/TSP. The risk of falls increased for these patients can be evaluated by the values ​​of 50 points using the BBS and 12.28 seconds using the TUG test.

Home-based exercise program in TSP/HAM individuals: a feasibility and effectiveness study

Objective

To investigate the feasibility and effectiveness of a home-based exercise program in TSP/HAM individuals.

Methods

Twenty-three TSP/HAM individuals divided in two groups according to Timed Up and Go (TUG) score (<20s vs ≥20s) performed a 20-week home-based exercise program. The primary outcomes were exercise adherence, maximum voluntary isometric contraction of lower limbs (MVIC), Barthel Index and SF-36. Secondary outcomes were adverse effects and barriers to exercise practice.

Results

MVIC and the social functioning domain in SF-36 improved significantly in TUG <20s group. The individuals in the TUG ≥20s group improved significantly their physical functioning domain in SF-36. The total adherence to the 20-week home-based exercise program was 90%. There were mild to moderate adverse events related to exercise program. There were no adverse events related to MVIC test.

Conclusions

The home-based exercise program was feasible and effective in improving disability and quality of life in individuals with TSP/HAM.

Pain prevalence, characteristics and associated factors in human T-cell lymphotropic virus type 1 infected patients: a systematic review of the literature

Objective

To describe the pain in patients infected with human T-cell lymphotropic virus type 1, clinically and epidemiologically.

Methods

This systematic review was based on The PRISMA Statement. Four reviewers searched PUBMED, SciELO, LILACS and BIREME for data from observational studies and clinical trials (n ≥ 30) regarding pain prevalence, characteristics, and associated factors in patients with human T-cell lymphotropic virus type 1. No limits on publication date or language were established. Studies that did not have pain as an outcome measure or not involving human T-cell lymphotropic virus type 1 infected patients were excluded.

Results

A total of 3013 articles (including duplicates) were found of which seven met the predetermined criteria. The most common pain region was the lower back (53.0%). Non-neuropathic type (ranging from 52.6% to 86.8%) was more frequent in human T-cell lymphotropic virus type 1-associated myelopathy/tropical spastic paraparesis participants, and neuropathic pain was more common in human T-cell lymphotropic virus type 1 carriers (53.1%). The pain was mostly reported as moderate or severe. One study showed that chronic pain was negatively associated with quality of life.

Discussion

Pain is a common complaint in human T-cell lymphotropic virus type 1 infected patients, with lower back pain as the most frequent site. Pain can either be nociceptive, neuropathic, or both, is frequently severe, and negatively affects quality of life. Only studies of two countries were included in this review, limiting the external validity of the conclusions. The heterogeneity of variables prevented us from implementing a meta-analysis. Further research should better characterize the pain and explore its impact on quality of life, especially using longitudinal study design.

Quality of life and pain multidimensional aspects in individuals with HTLV-1

HTLV-1 creates a chronic health condition that involves moderate to severe pain with a negative impact on quality of life (QoL). There is no consensus on which attitudes to pain are more related to the worsening of QoL in HTLV-1 infected patients. The aim of this study was to investigate the correlation between QoL and multidimensional aspects of pain in patients with HTLV-1. A cross-sectional study was conducted in Salvador, Bahia, Brazil. The study included individuals diagnosed with HTLV-1. The Short Form 36 Questionnaire was used to analyze QoL, and the Brief Pain Inventory was used to assess multidimensional aspects of pain. The mean pain intensity was 4.88±3.06 on the visual pain scale, and the average impact on QoL corresponded to a loss of approximately 40%. Moderate to high correlations between pain intensity and all domains of QoL were observed and compared reaction attitudes for general activity, mood, ability to walk, ability to work, relationships, sleep, and ability to enjoy life (r>0.40; p<0.05). Moderate correlations were found between all domains of QoL, pain intensity, and reactive attitudes to pain. The greatest pain intensity impacts involved difficulty to walk and to work, and interpersonal relationships in the emotional aspect of QoL.

Assessing Walking Ability in People with HTLV-1-Associated Myelopathy Using the 10 Meter Timed Walk and the 6 Minute Walk Test

Background

Five to ten million persons, are infected by HTLV-1 of which 3% will develop HTLV-1-associated myelopathy (HAM) a chronic, disabling inflammation of the spinal cord. Walking, a fundamental, complex, multi-functional task is demanding of multiple body systems. Restricted walking ability compromises activity and participation levels in people with HAM (pwHAM). Therapy aims to improve mobility but validated measures are required to assess change.

Study Design

Prospective observational study.

Objectives

To explore walking capacity in pwHAM, walking endurance using the 6 minute walk (6MW), and gait speed, using the timed 10m walk (10mTW).

Setting

Out-patient setting in an inner London Teaching hospital.

Methods

Prospective documentation of 10mTW and 6MW distance; walking aid usage and pain scores measured twice, a median of 18 months apart.

Results

Data analysis was completed for twenty-six pwHAM, (8♂; 18♀; median age: 57.8 years; median disease duration: 8 years). Median time at baseline to: complete 10m was 17.5 seconds, versus 21.4 seconds at follow up; 23% completed the 6MW compared to 42% at follow up and a median distance of 55m was covered compared to 71m at follow up. Using the 10mTW velocity to predict the 6MW distance, overestimated the distance walked in 6 minutes (p<0.01). Functional decline over time was captured using the functional ambulation categories.

Conclusions

The 10mTW velocity underestimated the degree of disability. Gait speed usefully predicts functional domains, shows direction of functional change and comparison with published healthy age matched controls show that these patients have significantly slower gait speeds. The measured differences over 18 months were sufficient to reliably detect change and therefore these assessments can be useful to detect improvement or deterioration within broader disability grades. Walking capacity in pwHAM should be measured using the 10mTW for gait speed and the 6MW for endurance.

Nation-wide epidemiological study of Japanese patients with rare viral myelopathy using novel registration system (HAM-net)

Background

At least one million people are infected with human T-lymphotropic virus type 1 (HTLV-1) in Japan, a small percentage of whom develop HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) or adult T-cell leukemia/lymphoma (ATLL). Patients with HAM/TSP suffer from progressively worsening myelopathic symptoms, such as motor disability and bladder dysfunction, and may become wheelchair-bound or even bedridden.

Methods

To learn more about this rare, debilitating disease, we established the national registration system “HAM-net” in March 2012. We continuously obtain detailed data from enrolled patients using the registration forms and an annual telephone interview. In this retrospective study, we describe the demographics and clinical histories of 383 registered patients from all over Japan.

Results

Patients were diagnosed at a median of 53 years old, long after disease onset at 45. Most (55.3 %) were originally from the southernmost regions, Kyushu and Okinawa. The main initial symptoms were difficulty walking (81.9 %), urinary dysfunction (38.5 %), and lower limb sensory disturbances (13.9 %). Many patients reported frequent leg numbness and leg pain, and the vast majority required medical intervention for urinary symptoms and constipation. A median of 8 years elapsed from the onset of motor symptoms to Osame Motor Disability Score (OMDS) 5 (requiring unilateral support), 12.5 years to OMDS 6 (requiring bilateral support), and 18 years to OMDS 9 (unable to walk). Health Assessment Questionnaire - Disability Index (HAQ-DI) tasks related to mobility, as opposed to hand motions, were very difficult for HAM/TSP patients and well-correlated with OMDS. Scores on the MOS 36-Item Short-Form Health Survey (SF-36) indicated that physical functioning was severely impaired in HAM/TSP patients. Patients with a history of blood transfusion (19.1 %) were older and suffered from more severe disability as indicated by their high HAQ-DI scores. Patients with a family history of HAM/TSP (8.4 %) were younger and had relatively mild symptoms given their long disease durations; many (15.6 %) also had a relative with ATLL.

Conclusions

The HAM-net national registration system has been an effective tool for gathering personal and clinical data from HAM/TSP patients scattered throughout Japan. We expect to conduct many retrospective and prospective epidemiological studies using HAM-net in the future.

Applicability, validation and reproducibility of the Spinal Cord Independence Measure version III (SCIM III) in patients with non-traumatic spinal cord lesions

PURPOSE

To verify the applicability, reproducibility and validity of the SCIM III patients with non-traumatic spinal cord injury.

METHOD

The cross-sectional study included 30 patients (66% females; 41.5 ± 14.7 yo) with non-traumatic spinal cord injury of any etiology. Subjects were subjected by computerized gait analysis and answered the Brazilian versions of SCIM III (0-100 points) and FIM™ (18-126 points) by two raters (A and B) at the same day and 1 week later (A).

RESULTS

The intraclass correlation coefficient for the use of SCIM III indicated appropriated intra- and inter-evaluator reproducibility (ICC = 0.9). Correlation between the SCIM III and the motor FIM™ was appropriate (r = 0.6; p = 0.0). SCIM III subscales and FIM™ domains correlated strongly for self-care (r = 0.8; p ≤ 0.001), moderately for transfers (r = 0.6; p = 0.0005) and locomotion (r = 0.6; p = 0.0006). SCIM III mobility subscale positively correlated with the cadence (r = 0.8; p ≤ 0.01), gait speed (r = 0.7; p ≤ 0.01) and step length (r = 0.6; p ≤ 0.01).

CONCLUSIONS

SCIM III is a reproducible functional assessment instrument and capable of evaluating the level of independence of the individual with non-traumatic spinal cord injury. The SCIM III is more sensitive than the MIF™ for non-traumatic spastic paraplegic patients with higher levels of independence, particularly if they can walk independently. Linear gait parameters correlated with its mobility subscale. Implications for Rehabilitation Applicability, validation and reproducibility of the Spinal Cord Independence Measure version III (SCIM III) in patients with non-traumatic spinal cord lesions. There are not many studies focused on patients with non-traumatic spinal cord lesion. Disability varies in severity, but frequently contributes to limitations in the activities of daily living (ADL) and participation. We do not find in the literature studies that assess the functionality of these individuals as comprehensive as ours.

Inflammatory manifestations of HTLV-1 and their therapeutic options

Human T lymphotropic virus type 1 (HTLV-1) is one of the most intriguing retroviruses infecting humans. Most commonly, infection remains undetected, since it does not cause obvious harm, yet in 4-9% of patients, this infection can be devastating, causing adult T-cell leukemia/lymphoma and/or HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP). This review concentrates on all inflammatory aspects of HTLV-1 infection: HAM/TSP, HTLV-1 associated uveitis, HTLV-1 associated conjunctivitis, sicca syndrome and interstitial keratitis, HTLV-1 associated Sjögren's syndrome, Hashimoto's thyroiditis and Graves' disease, HTLV-1 associated pulmonary disease, infective dermatitis associated with HTLV-1, HTLV-1 associated inflammatory myositis and HTLV-1 associated arthritis. With the exception of HAM/TSP treatment, studies of these conditions are sparse and even for HAM/TSP, the level of evidence is limited. While control or elimination of infection remains a goal, most therapy beyond symptomatic management is directed at the immune response to HTLV-1.

HTLV-1-associated myelopathy/tropical spastic paraparesis

Human T-lymphotropic virus 1 (HTLV-1)-associated myelopathy/tropical spastic paraparesis (HAM/TSP) is a progressive disease of the CNS that causes weakness or paralysis of the legs, lower back pain and urinary symptoms. HAM/TSP was first described in Jamaica in the nineteenth century, but the aetiology of the condition, infection with the retrovirus HTLV-1, was only identified in the 1980s. HAM/TSP causes chronic disability and, accordingly, imposes a substantial health burden in areas where HTLV-1 infection is endemic. Since the discovery of the cause of HAM/TSP, considerable advances have been made in the understanding of the virology, immunology, cell biology and pathology of HTLV-1 infection and its associated diseases. However, progress has been limited by the lack of accurate animal models of the disease. Moreover, the treatment of HAM/TSP remains highly unsatisfactory: antiretroviral drugs have little impact on the infection and, although potential disease-modifying therapies are widely used, their value is unproved. At present, clinical management is focused on symptomatic treatment and counselling. Here, we summarize current knowledge on the epidemiology, pathogenesis and treatment of HAM/TSP and identify areas in which further research is needed. For an illustrated summary of this Primer, visit: http://go.nature.com/tjZCFM.

Update on Neurological Manifestations of HTLV-1 Infection

The human T cell lymphotropic virus type 1 (HTLV-1) is a retrovirus that infects 10-20 million persons around the world. Initially associated with the hematological malignancy adult T cell leukemia/lymphoma (ATLL), HTLV-1 is also the cause of a chronic progressive myelopathy named "HTLV-1-associated myelopathy/tropical spastic paraparesis" (HAM/TSP). HAM/TSP arises as the tip of the iceberg of an assortment of neurological syndromes triggered by the virus such as inflammatory myopathies, polyneuropathies, amyotrophic lateral sclerosis (ALS)-like syndromes, dysautonomia, and cognitive impairment. HAM/TSP typifies a chronic progressive spastic paraparesis with neurogenic bladder and minimal sensory signs. The neuropathology of HAM/TSP is concentrated in the thoracic spinal cord and is typically biphasic. Initially, there is a perivascular lymphocytic cuffing and mild parenchymal mononuclear infiltrates. Subsequently, this is replaced by gliosis and scarring. The neuropathogenesis of HTLV-1 is still partially understood. At present, the therapy of HAM/TSP remains basically symptomatic.

Physiotherapy for human T-lymphotropic virus 1-associated myelopathy: review of the literature and future perspectives

Human T-lymphotropic virus 1 (HTLV-1) infection may be associated with damage to the spinal cord – HTLV-associated myelopathy/tropical spastic paraparesis – and other neurological symptoms that compromise everyday life activities. There is no cure for this disease, but recent evidence suggests that physiotherapy may help individuals with the infection, although, as far as we are aware, no systematic review has approached this topic. Therefore, the objective of this review is to address the core problems associated with HTLV-1 infection that can be detected and treated by physiotherapy, present the results of clinical trials, and discuss perspectives on the development of knowledge in this area. Major problems for individuals with HTLV-1 are pain, sensory-motor dysfunction, and urinary symptoms. All of these have high impact on quality of life, and recent clinical trials involving exercises, electrotherapeutic modalities, and massage have shown promising effects. Although not influencing the basic pathologic disturbances, a physiotherapeutic approach seems to be useful to detect specific problems related to body structures, activity, and participation related to movement in HTLV-1 infection, as well as to treat these conditions.

Falls in patients with HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP)

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To determine the prevalence of falls in human T-cell lymphotropic virus type I (HTLV-I)-associated myelopathy/tropical spastic paraparesis (HAM/TSP) patients and possible factors associated to their occurrence.

SETTING

Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ) - Brazil.

METHODS

Thirty-six HAM/TSP patients able to walk at least 20 m were assessed by a questionnaire. Data regarding gender, age, duration of disease (DD), HTLV-I proviral load (HPL), frequency of physical activity (FCA), use of walking aids, functional ambulation level, the number of falls and associated injuries in the last year were reviewed. Multiple correspondence analysis was used to group characteristics of this sample according to the fall occurrence.

RESULTS

The prevalence of falls was 63.9% and we observed injuries in 47.8% of the cases. Four groups were identified in the descriptive analysis. One group was formed by faller individuals, men <60 years, independent ambulation, FCA≥3 times per week and HPL <6.6 copies per 100 cells (group B). The other one comprised non-faller patients, women ≥60 years, restricted ambulation, DD ≥7 years, use of orthosis, FCA 0-1 time per week and HPL ≥6.6 copies per 100 cells (group D). The others two groups comprised individuals that did not use orthosis (group A) and those that FCA was two times per week and DD <7 years (group C).

CONCLUSION

Falls occur in roughly two-thirds of ambulatory HAM/TSP patients and are associated with significant morbidity. Further studies with a larger number of patients are necessarily to identify risk factors in order to elaborate specific programs to prevent falls in this population.

Quality of life in patients with HTLV-I associated myelopathy/tropical spastic paraparesis

OBJECTIVE: To assess the quality of life (QoL) of patients with HTLV-I-associate myelopathy/tropical spastic paraparesis (HAM/TSP) and to correlate it with specific aspects of the disease. METHODS: Fifty-seven HAM/TSP patients completed the SF-36 QoL questionnaire. They were also asked about common complaints related to the disease, and we looked for associations between QoL and these complaints. RESULTS: Patients with HAM/TSP showed a strong negative association to QoL. Pain was the condition which most affected their QoL. The practice of physical activity is associated with better QoL in five out of eight domains of the scale. CONCLUSION: HAM/TSP leads to a poor QoL, mostly influenced by pain. Physical activity may have a positive association to QoL of these patients.

Implications of HAM/TSP functional incapacity in the quality of life

OBJECTIVE: To identify the functional status and quality of life of HAM/TSP patients. METHOD: We evaluated prospectively 30 HAM/TSP patients (20 females) seen in the Neuroinfection Clinic of the HUGG. The functional capacity was analyzed by the functional independence measure (FIM), the expanded disability status (EDSS) scale and the Osame's motor disability score (OMDS). The quality of life was assed by the Short-Form Health Survey 36 (SF-36)TM. RESULTS: All patients need assistance device. The FIM, OMDS and EDSS scores classified 70%, 67% and 67% of the patients as dependent, respectively. The lowest scores of the SF-36 survey were found in the domains related to the physical health (D1, D2), role-emotional functioning (D7) and social functioning (D6). CONCLUSION: Our data suggest that the HAM/TSP physical impairment has an impact in the emotional and social issues, considering the limitation in the daily activities.

Isokinetic trunk and knee muscle strengths and gait performance in walking patients with T-cell lymphotropic virus type 1-associated myelopathy/ tropical spastic paraparesis (HAM/TSP)

The aim of this study was to investigate the isokinetic trunk and knee muscle strengths, and examine the clinical relevance of dynamic muscle strengths and gait performance in walking patients with human T-cell lymphotropic virus type 1-associated myelopathy/ tropical spastic paraparesis (HAM/TSP). Thirteen patients with HAM/TSP (8 females and 5 males, aged 38-76) and 13 sex- and age-matched healthy control subjects participated in the study. We assessed gait speed, stride length, cadence; and maximal isokinetic torque of trunk and knee extensors and flexors at 30°/s, 60°/s and 90°/s using a Biodex System 3 dynamometer. Furthermore, we calculated the isokinetic trunk extensor/flexor (E/F) and hamstrings/quadriceps (H/Q) strength ratios (parameter of the muscle strength balance about the trunk and knee joint). Compared with the age-matched controls, the patients with HAM/TSP had significantly reduced gait speed, stride length and cadence (P < 0.05). Peak torque values related to body weight (PTBW) were significantly reduced, especially for the knee flexors (P < 0.05). For the knee extensors, the PTBW values were significantly reduced at an increased angular velocity (P < 0.05). The PTBW of knee flexors was positively correlated with gait speed and cadence in the patients with HAM/TSP. The H/Q ratio but not E/F ratio was significantly decreased compared with the control. Our results indicated that the isokinetic trunk and knee muscle performance had reduced from the ambulatory stage, and suggested the deterioration in knee muscle performance to be associated with gait disturbance in walking HAM/TSP patients.

HTLV-1 and neurological conditions: when to suspect and when to order a diagnostic test for HTLV-1 infection?

HTLV-1 is a retrovirus associated with a myriad of clinical conditions, especially hematological and neurological ones. Regarding nervous system diseases, it is of utmost importance to select those cases in which HTLV-1 infection could really be associated. This is particularly true for patients from endemic areas and for HIV-infected patients and drug users, since that these groups are at a higher risk for HTLV infection. This caution in selecting neurological patients for HTLV diagnostic tests is justified by the fact that in some circumstances the seropositivity may merely represent an epiphenomenon. In this paper we enroll some neurological conditions that have been associated with HTLV-1/2 infection in the literature and discuss the real need for HTLV-1/2 diagnostic tests in each one. Because HIV/HTLV-co-infected patients seem to be at an increased risk for neurological diseases development, a special consideration about this matter is also made.

Human T-lymphotropic virus 1: recent knowledge about an ancient infection

Human T-lymphotropic virus 1 (HTLV-1) has infected human beings for thousands of years, but knowledge about the infection and its pathogenesis is only recently emerging. The virus can be transmitted from mother to child, through sexual contact, and through contaminated blood products. There are areas in Japan, sub-Saharan Africa, the Caribbean, and South America where more than 1% of the general population is infected. Although the majority of HTLV-1 carriers remain asymptomatic, the virus is associated with severe diseases that can be subdivided into three categories: neoplastic diseases (adult T-cell leukaemia/lymphoma), inflammatory syndromes (HTLV-1-associated myelopathy/tropical spastic paraparesis and uveitis among others), and opportunistic infections (including Strongyloides stercoralis hyperinfection and others). The understanding of the interaction between virus and host response has improved markedly, but there are still no clear surrogate markers for prognosis and there are few treatment options.

Disability and determinants of gait performance in tropical spastic paraparesis/HTLV-I associated myelopathy (HAM/TSP)

STUDY DESIGN

Cross-sectional.

OBJECTIVES

The aim of this survey is to describe the disability profile in a group of tropical spastic paraparesis/HTLV-I-associated myelopathy patients, identifying the requirements for community ambulation.

SETTING

Tertiary care unit, Rio de Janeiro, Brazil.

METHODS

Seventy-two patients were assessed (49 female and 23 male), referred by tertiary care centers, when a clinical protocol was applied.

RESULTS

The sample had an average age of 40 years and an average of 137 months of duration of the disease. The most prevalent aspects of disability found were in gait and sphincter control areas. A total of 72% of the patients were community ambulators and 17% were restricted to wheel chair. Age, strength and low-back pain interfere in activities of daily living (P<0.05). A positive correlation was found between community ambulation and the knee extensors (r=0.80) and ankle plantar flexors (r=0.74). Strength, age, low-back pain, duration of disease, asymmetric onset of the symptoms and spasticity interfered in the ability to walk (P<0.05). A rehabilitation program was proposed focusing on modifiable factors that affect disability level.

CONCLUSION

It was possible to describe the profile of disability in this group of patients, identifying the requirements to the community ambulation.

Medidas de Avaliação na Paraparesia Espástica Tropical

Introdução. A paraparesia espástica tropical/mielopatia associada ao HTLV-1 (PET/MAH) é uma doença causada pelo retrovírus T linfotrópico humano tendo como manifestação principal a paraparesia espástica progressiva. Objetivo. Promover uma revisão de literatura sobre o uso de escalas funcionais para avaliação de indivíduos com PET/MAH, para melhor orientação dos profissionais envolvidos na reabilitação desses pacientes. Método. Neste estudo de revisão de literatura, foi realizada uma busca nas bases de dados Bireme, Scielo e Pubmed a respeito dos principais perfis, medidas e indicadores de avaliação utilizados em pacientes com injúrias neurológicas. Discussão. Diversas avaliações têm sido propostas no sentido de acompanhar indivíduos com disfunções neurológicas durante o percurso de suas vidas, entretanto, recomendações para a utilização destes instrumentos são pouco abordadas em pacientes com PET/MAH. Conclusão. A literatura não apresenta uniformidade nos métodos e procedimentos de pesquisa. A Medida de Independência Funcional (MIF) parece ser a mais indicada para avaliação de pacientes com PET/MAH, uma vez que é capaz de mensurar as modificações funcionais do paciente ao longo do curso da doença.

Paraparesia Espástica Tropical - Mielopatia associada ao vírus HTLV- I:

Introdução: A Paraparesia Espástica Tropical/Mielopatia (PET/MAH) é uma complicação crônica e progressiva associada à infecção pelo vírus HTLV-I, que além de outras afecções, ocasiona um processo inflamatório medular, predominantemente em seus níveis baixos, devido à invasão desorganizada dos linfócitos T modificados. Devido à escassez de pesquisas em Fisioterapia voltadas para a PET/MAH, o presente artigo de revisão visa adaptar abordagens em relação à reabilitação motora, com suas respectivas justificativas teóricas. Desenvolvimento: Um dos aspectos mais limitantes da doença está na fraqueza e espasticidade dos membros inferiores, com comprometimento da funcionalidade da marcha, podendo em alguns casos confinar os pacientes à cadeira de rodas. Através de uma análise detalhada da fisiopatogenia dos sintomas, acredita-se que condutas fisioterapêuticas podem amenizar as seqüelas neurológicas e promover uma melhora da qualidade de vida dos indivíduos acometidos. Conclusão: A fisioterapia, baseada nas fundamentações teóricas propostas, parece ser eficaz na recuperação funcional dos pacientes com PET/MAH.