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Impact of yoga on psychopathologies and QoLin persons with HIV: A randomized controlled study

Article in Journal of Bodywork and Movement Therapies · October 2018
DOI: 10.1016/j.jbmt.2018.10.005

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Impact of yoga on psychopathologies and QoLin persons with HIV: A randomized controlled study

Asha Kiloor, Sonykumari, Kashinath Metri

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DOI:

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S1360-8592(18)30446-7

https://doi.org/10.1016/j.jbmt.2018.10.005

YJBMT 1733

Journal of Bodywork & Movement Therapies

Received Date: 22 June 2017

Revised Date: 12 March 2018

Accepted Date: 28 July 2018

Please cite this article as: Kiloor, A., Sonykumari, Metri, K., Impact of yoga on psychopathologies and QoLin persons with HIV: A randomized controlled study, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2018.10.005.

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Title: Impact of yoga on psychopathologies and QoLin persons with HIV: A randomized controlled study

Authors:
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Asha Kiloor1, Msc (Yoga)

Yoga Therapist, SVYASA University, Bengaluru

Dr Sonykumari1, PhD

Associate Professor, SVYASA University, Bengaluru

*Dr Kashinath Metri1, MD, PhD

Assistant Professor, SVYASA University, Bengaluru

*Corresponding author: Dr Kashinath G Metri

Email: [email protected] Mobile: +01 9035257626

1Affiliation: Division of Yoga and Life Sciences, Sami Vivekananda Yoga

Anusandhana Samsthan (SVYASA – A deemed to be a University), # 1 Eknath

Bhavan Gavipuram Circle K G Nagar, Bengaluru-560019, India.

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ABSTRACT

Background: Evidence suggests that individuals with human immunodeficiency

virus (HIV) positive, often exhibit poor physical and mental health, which

contributes to a reduced Quality of Life (QoL). Yoga is a form of alternative
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therapy that has positive influences on general health and QoL.

Objectives: This study examined the effects of yoga on i) anxiety, depression

and psychological well-being, and ii) Quality of Life (QoL), among individual

with HIV positive.

Methodology: Sixty individuals with HIV-positive (aged30–50 years) from

rehabilitation centres across Bangalore were randomly assigned to the yoga

intervention group (n=30; 11 men) or the wait-listed control group (n=30; 10

men). Participants in the yoga group underwent 8 weeks of intense yoga

practice, performed an hour a day, for 5 days a week. The yoga practice

consisted of physical postures, breathing practices, relaxation techniques, and

meditation. Participants in the wait-listed control group followed their normal

routine. Anxiety, fatigue, depression, and QoL were assessed twice for all

subjects in each group – once at the start of the study to establish a baseline

and once more at the end of the2month study period to assess any changes.

Data analysis was performed on the assessments using SPSS software version 10.

Results: In the yoga group, a significant reduction in anxiety (p<0.001),

depression (p<0.001), and fatigue (p<0.001) was observed, associated with

significant improvements in well-being (p<0.001) and all domains of QoL

(p<0.001). However, in the control group, an increase in anxiety, fatigue, and

depression was observed, associated with a significant decrease in well-being

and QoL.

Conclusion: This study clearly indicates that yoga intervention improves the

psychological health and QoL of individuals with HIV-positive. Therefore, based

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on these findings, yoga is strongly recommended as a complementary therapy

to enhance conventional HIV care.

Keywords: HIV, Yoga, Fatigue, Anxiety, Depression, Quality of Life.

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INTRODUCTION

Approximately, 40 million people worldwide are living with human

immunodeficiency virus (HIV) infection (Alter et al 2006). Country-wise, India

records the second-highest number of HIV-infected persons, approximately 3–4
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million (Go et al 2004). HIV is an infectious disease that affects an individual’s

immunity, thus increasing vulnerability to various opportunistic infections.

Pharmacological treatments such as Anti-Retroviral Therapy (ART) are presently

used to increase life expectancy and control HIV progression. But, the ART

intervention is frequently associated with various side effects (Antoni et al 2002;

Hartmann et al 2006).

However, despite ART intervention, several psychological issues associated with

HIV, continue to persist among persons with HIV-positive (Green & Smith 2004;

Rodger et al 2013; Rosenfield et al 1996).

Additionally, individuals with HIV-positive experience social stigmas, feelings of

guilt, uncertainty about the future, feelings of isolation, lack of social

reinforcement, and worry about frequent infections, thus making them prone to

chronic psychological problems such as anxiety disorder and depression (Bogart

LM et al 2000; Vogl et al 1999). Several cross-sectional studies have

demonstrated a high prevalence of anxiety disorder and depression among

individuals HIV-positive, with the risk of depression being four times more as

compared to normal individual. The prevalence rate of depression among HIV-

infected individuals ranges from 5% to 45%, and the prevalence rate of anxiety

disorder is up to 38% (Bogart LM et al 2000; Elliott A et al 1998). Also, individuals

with HIV positive have depression have higher suicidal tendency than non-HIV

depressed individuals (Chandra P et al 1998; Cluver et al 2007; Penzak et al

2000).

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Further studies have shown that the presence of depression in HIV-infected

individuals is associated with a decreased CD4 cell count, an increased viral

load, and reduced compliance with ART (Yun LW et al 2005).

Apart from frequent infections, weight loss and fatigue are observed
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prominently among individuals with HIV-positive. Such symptoms affect daily

work and lead to more disability and dependency in the persons with HIV

(Cleary PD et al 1993; Low et al 2011; Ferrando et al 1998; Breitbart et al 1998).

Collectively, these issues such as anxiety, depression, poor immunity, and HIV-

associated symptoms lead to reduced psychological well-being and

significantly affect quality of life (QoL) among individuals with HIV-positive

people (Adewuya et al 2008; AminiLari et al 2013; Aranda et al 2004).

Non-drug interventions such as yoga, meditation, tai chi, or Cognitive

Behavioural Therapy (CBT) have been found to be effective in improving several

physical and psychological symptoms associated with chronic health

conditions, including HIV (Antoni et al 2002; Naoroibam et al 2016; Bhargav et al

2016; Ferrando et al 2004; Taylor et al 1995).

Yoga

Yoga is a form of mind–body intervention consisting of physical practices,

breathing techniques, and meditation. The science of Yoga is considered to be

approximately more than 5000 years old (Keley et al 2010). Spiritually, the

practise of yoga aims to achieve the highest goal of life called Moksha, which

refers to liberation (Siddiqui et al 2016). Scientific investigations have noted the

many physiological and psychological benefits of yoga practice in both clinical

and nonclinical populations (Yang et al 2007; Raju et al 1986).

The practise of yoga has disease preventive effects and beneficial effects on

wellness. Scientific evidences have confirmed the various wellness benefits of

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yoga for various health conditions, such as diabetes mellitus (Hemmer et al 2008;

Mahapure et al 2008), cardiovascular disease (Ashish et al 2015), neurological

disorders (Sharma, 2015), gastrointestinal disorders (Kaswal et al 2013; ), and

many psychological troubles. A significant portion of yoga research has focused
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on studying its impact on psychological health and well-being. Yoga and

meditation intervention studies show reduction in anger (Bhushan & Sinha 2001),

anxiety (Eppley et al 1989), and depression (Krishnamurthy & Telles 2007; Woolery

et al 2004), as well as increase in well-being (Netz & Lidor 2003). The potential of

yoga to increase psychological well-being, including improved energy, and

overall QoL has been demonstrated in older adults (Oken B et al 2006).Yoga

practice reduces depression symptoms in pregnant woman (Mitchell,

2012).Yoga can be considered an ancillary treatment option for people with

depressive disorders and individuals with elevated levels of depression (Cramer

& Langhorst 2013).Yoga practice results in a significant decrease in anxiety levels

and a positive change in subjective well-being among students (Jadhav &

Havalappanavar 2009).Yoga practice reduces anxiety and blood pressure and

improves QoL more significantly than physical exercise (Marefat &

Peymanzad2011).

Hence, the present study intended to assess the impact of a 2-month integrated

yoga intervention on psychological health, QoL, and well-being among HIV-

infected persons, when compared with a matched wait-list control group.

Methods and materials

Participants

HIV-infected people aged 30–50 years on ART were recruited in this

study.We considered the participants within this age range because, after the

age of 50, people with HIV usually experience severe weight loss, and co-

morbid conditions such as tuberculosis, hepatitis B, fatigue syndrome etc.

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rendering them unable to perform yoga. Also, the lower age limit is chosen as

30, as any HIV person below 30 years of age is usually in less advanced stages of

disease.

We approached two HIV rehabilitation centres located in Bengaluru city, India.
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A total of 88 participants was approached for participation, and they were

screened for eligibility criteria.

Among 88 participants, 63 were found to be eligible for the study. Of 63

potential participants, 2 declined to participate in the study. Finally, we selected

60 potential participants for the study. For the equal distribution of subjects

across both groups, we did not consider the data of one subject from yoga

group, although he received IY (See Flow Chant 1). None of the participants

had CD4 count<300 indicating AIDS.

Randomization

Participants’ names were fixed up in alphabetical order and then listed in serial

order from 1 to 60. Using a computer-based random number generator, two

groups were formed. The groups were named 'A' and 'B'. Group A was selected

as intervention group and B as a wait-list group using tossing method.

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Flow Chart 1
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Subjects screened = 88

Eligible subjects = 63

Drop outs=2 Due personal reasons

60 subjects

Yoga group = 30 subjects

Pre assessment n=30

2 Months yoga + ART

Post assessment n=30

Control group = 30 subjects

Pre assessment n=30

ART only

Post assessment n=30

Figure 1: Participant recruitment

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Inclusion criteria
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· HIV-positive and within the age range of30–50 years

· Willing to participate in the study

· Participants of Both genders

Exclusion criteria

· Prior exposure to yoga

· Physical handicap or Severe disability

· Recent surgery

· Acute respiratory infections

· History of psychiatric illness or usage of antipsychotic medication

· Drug addiction

Ethical consideration

Participants were informed about the study protocol in their respective mother

tongue, and written informed consent was obtained before the

commencement of the study.

This study was approved by an Institutional Review Board (IRB) of Directorate of

Distance Education, SVYASA University, Bengaluru, India.

Intervention

All subjects in the yoga group performed2 months of yoga practice consisting of

loosening practices, Suryanamaskara, breathing practices, Asanas, Pranayama,

meditation, and relaxation techniques (See Table:1), which were performed

daily for 1hour, 5 days a week. The subjects in the control group followed their

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normal routine activity. Regular attendance was monitored by maintaining an

attendance register and subjects who attended <70% of the sessions were

excluded from analysis. A total of 95% of the subjects attended all sessions, none

of the subjects had attendance less than 70%.
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The yoga module used in the study by Rosy et al (2015) was applied in this study.

(Please add Table 1 Here)

Table 1: List of practices performed by the yoga group

Sl.No. Name of Practices Starting Prayer
Shithilikarana practices
1 Forward and backward bending

Number of rounds

5 rounds

Duration 2 min

2 min

2 Twisting
3 Side bending

5 rounds 2 min 5 rounds 2 min

Suryanamaskara
Quick Relaxation Technique
Breathing Practices

6 rounds 8 min
3 min

1 Hands in and out breathing 2 Ankle stretch breathing
3 Bhujangasanabreathing
4 Straight leg- raise breathing
Asanas
1 Ardhakatichakrasana
2 Ushtrasana
3 Paschimothanasana 4 Bhujangasana
5 Shalabhasana
6 Setubandasana

5 rounds 2 min 5 rounds 2 min 5 rounds 2 min 5 rounds 2 min

1 round 2min 1 round 1 min 1 round 1 min 1 round 1 min 1 round 1 min
1 round 1min

7 Vipareetakarani Quick Relaxation Technique
Pranayama

1 round 2 min 3 min

1 Kapalabhati
2 Sectional Breathing
3 Nadishudhi

60–80 rounds/min 2 min 5 rounds 5 min
10 rounds 5 min

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4 Seetkari/Seetali/Sadanta 5 Bhramari

5 rounds 2 min 10 rounds 5 min

Meditation
1 Nadanusandhana Deep Relaxation Technique
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Closing Prayer

9 ×4 5 min 10 min
2 min

Assessments and tools

Primary outcome measures

WHO Quality of Life- HIV Brief (WHOQOL-HIV BREF)

Both groups were administered WHOQOL-HIV BREF before and after 2 months of

(Hsiung PC et al 2011).

The WHOQOL-HIV BREF is considered to be a valid &a reliable tool to assess

different domains of QoL among HIV infected persons. It comprises of 31 items,

each using a 5-point Likert scale ( 5 most 1 least?). The 31 items are distributed

across six domains. The six domains of QoL are as follows: physical health,

psychological health, level of independence, social relationships, environment,

and spirituality/religion/personal beliefs. The physical health domain measures

pain and discomfort, energy and fatigue, and sleep and rest. The psychological

health domain measures positive feelings, thinking, learning, memory and

concentration, self-esteem, body image and appearance, and negative

feelings. The level of independence domain measures mobility, daily life

activities, dependence on medications or treatments, and work capacity. The

social relationships domain includes personal relationships, social support, and

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sexual activity. The environment domain measures physical safety and security,

home environment, financial resources, health and social care, accessibility and

quality, opportunities for acquiring new information and skills, participation in
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and opportunities for recreation and leisure activities, and physical environment

(pollution, noise, traffic, climate, and transport) (Fatiregun, 2009).

Secondary outcome measures

Hospital Anxiety and Depression Scale

Anxiety and depression were assessed using the Hospital Anxiety and Depression

Scale.

The Hospital Anxiety and Depression Scale (HADS) is a valid tool to assess

symptom severity and anxiety disorders and depression in both individuals under

somatic, psychiatric, and primary care as well as those in the general

population. The scale contains a total of 14 items, of which 7 items assess

subjective anxiety and 7 assess depressions. (Zigmond AS; Snaith et al RP 1983)

Fatigue

For both groups, subjective fatigue was assessed using the Fatigue Severity Scale

(FSS) before and after 2 months.

Fatigue Severity Scale

The FSS is a valid tool to assess subjective fatigue. For both groups, the FSS was

administered before and after 2 months. The FSS is a method of evaluating the

impact of fatigue (Valko P et al 2008).

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WHO (Five) Well-Being Index (1998 version)

Both groups were administered WHO (Five) Well-Being Index (1998 version)

before and after 2 months of the yoga intervention (Huen & Bonsiqnore M 2001).
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It is a valid &reliable tool to assess the subjective well-being of individual

(Saipanish, 2009; Heun et al 2001).

Data analysis

Data analysis was performed using SPSS version 10 (IBM, Chicago, USA).

Data was subjected tothe Shapiro–Wilk test normality test and all variables were

found to be normally distributed. Descriptive statistics were presented as mean

and standard deviation. Paired sample t test and the independent sample t test

were used to compare the characteristics within-group and between-group,

respectively.

P value (significance) more than 0.05 was considered to depict a statistically

significant change.

Results

Demographic characteristics of participants did not differ between the two

groups; hence, the groups were comparable at baseline (Table 2).

Table 2: Comparison of demographics between the groups at baseline

Variable Yoga group, (n=30; 10 men; 20
women)

Control group, p value (n=30; 11 men; 19
women)

[Mean±SD] [Mean±SD]

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Age (years)

History of HIV infection

(years)
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Fatigue

Psychological well-

being

Anxiety

Depression

Physical QoL

Psychological QoL

Overall QoL &General

health

Social relations

Environmental

Spirituality

41.90±7.02

6.82±1.83

47.87±4.47

11.26±3.52

11.29±2.15

9.16±2.15

10.71±1.16

10.27±0.85

12.39 ± 1.41

9.58 ± 0.81

11.58 ± 0.98

11.68 ± 1.25

42.1±7.32 0.13

6.65±1.36 0.15

48.42±1.18 0.51

9.87±1.54 0.51

11.45±2.17 0.71

9.19±2.04 0.92

10.77±1.15 0.81

10.01±1.01 0.50

12.32 ± 1.17 0.81

9.48 ± 0.63 0.60

11.47 ± 0.89 0.84

11.26 ± 1.12 0.17

The yoga group consisted of 30 participants (11 men and 19 women), and the

wait-listed control group consisted of 30 participants (10 men and 20 women).

The intervention was found to be feasible, which is evidenced by a regular

attendance rate ofmore than 90%.

Shapiro-Wilk Test: Data was subjected to Shapiro-Wilk test and all the variables

found to be normally distributed with p value more than 0.05. Hence we used

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the paired sample t-test to assess the changes within each group before and

after 2 months and the independent sample t-test were used to compare the

differences between the groups.

Yoga group (Table 3)
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In the yoga group, we noted significant improvement in depression (p <0.001),

anxiety (p <0.001), psychological well-being (p <0.001), fatigue (p <0.001), and

all domains of QoL after2 months of yoga intervention when compared with

those at baseline (Table 3).

Control group (Table 3)

In contrast to the yoga group, we observed a significant increase in anxiety (p

<0.001), depression (p <0.001), and fatigue (p <0.005), along with asignificant

decrease in all domains of QoL and well-being (p <0.001), after 2 months

compared with those at baseline in the control group (See Table 3).

Table 3: Pre–post comparison of variables of yoga and wait-listed control groups

Group Yoga group Control group

Pre M ± SD Post M ± SD

p %
value change

Pre M ± SD Post M ± SD p value

Between-
% group
change compariso
n p value

Fatigue

Well-being

Anxiety

Depression

47.87 ± 4.47

11.26 ± 3.52

11.29 ± 2.15

9.16 ± 2.15

22.77 ± 2.51 <0.001

19.03 ± 1.97 <0.001

5.45 ± 1.34 <0.001

4.74 ± 1.12 <0.001

−52 48.42 ± 1.18

69 9.87 ± 1.54

−52 11.45 ± 2.17

−48 9.19 ± 2.04

49 ± 35 0.005 2 <0.001

8.61 ± 2.56 0.001 −13 <0.001

12.48 ± 2.20 <0.001 9 < 0.001

10.23 ± 1.93 <0.001 11 <0.001

QOL PH 10.71 ± 1.16 15.77 ± 1.12 <0.001 47 10.77 ± 1.15 9.84 ± 1.1 <0.001 −9 <0.001

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Psy 10.27 ± 0.85

LOInd 12.39±1.41

SRln 9.58±0.81
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Envmt 11.58±0.98

PBlfs
11.68±1.25

14.94 ± 0.84 <0.001 45

15.68±1.17 <0.001 27

13.29±0.59 <0.001 39

15.71±0.57 <0.001 36

<0.001
15.94±0.96 36

10.01±1.01

12.32±1.17

9.48±0.63

11.47±0.89

11.26±1.12

9.08±0.91 <0.001 −9 <0.001

10.97±1.49 <0.001 −11 <0.001

9.26±0.58 0.03 −2 <0.001

10.87±0.67 0.002 −5 <0.001

10.84±1.07 0.11 −4 <0.001

Abbreviations: “<” values are p values’ Fatg, Fatigue;WBng, Well-being;Anx, Anxiety;Dpr, Depression;QOL

Ph, QOL Physical;QOLPsy, QOL Psychological. QOL LOInd, QOL Level of Independence;QOL SRln, QOL Social
Relation;QOL Envmt, QOL Environment; QOL PBlfs, QOL Personal Beliefs

Between-group comparison

The yoga group showed a higher improvement in anxiety (p <0.001), depression

(p <0.001), fatigue (p <0.001), psychological well-being (p <0.001), and all

domains of QoL. Thus, we found significant differences between theyoga and

control groups (Table 3).

Discussion

In this study, we found a significant improvement in depression, anxiety, fatigue,

well-being, and QoL following 2 months of the yoga intervention in HIV-infected

participants. In contrast to the yoga group, a significant increase in depression,

anxiety, and fatigue and the deterioration of QoL and well-being were

observed in the control group. Worsening of the control group characteristics

may be attributed to the progression of the disease. Previously ssurveys have

shown that the natural advancement of disease involves worsening of anxiety

and depression symptoms along with reduction of CD4 counts in HIV patients.

Both these factors are known to have are reciprocities spiraling effect on each

other, resulting in a vicious cycle. Addition of yoga may break this cycle by

preventing or retarding progression of psychopathology (Marry et al 2002). Rosy

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et al 2016 also observed that there was an increase in anxiety and depression in

HIV positive patients on ART after one month of routine conventional treatment

as compared to the baseline.

This study suggests that yoga practice enhances the mental health by improving
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the well-being and reducing anxiety, depression and fatigue. Further, these

findings suggest the importance of yoga as an alternative intervention in

conventional HIV care. This study also showed the significance of the yoga

intervention as an add-on therapy to ART in HIV care.

Few studies have shown the potential use of the yoga intervention in HIV-

infected persons.

Another randomized controlled trial by Mawar et al 2015 reported significant

improvement in the health related QoL domains (12% in physical health; 9% in

level of independence; 11% in psychological health) (Mawar et al 2015)

In a randomized controlled trial, Rosy et al (2016) reported significant

improvement in depression scores (p=0.04, −13.39%) and a non-significant

reduction in anxiety scores (p=0.13, −8.2%) following 1 month of an integrated

yoga intervention in persons with HIV; in contrast to the yoga group, the control

group showed a significant increase in anxiety and depression over the same

period. The findings of our study are consistent with this previous study by Rosy et

al (2016) with a notable difference being the longer duration of 2 months. The

longer duration in our study may explain the comparatively higher improvement

in depression (48%) and anxiety (52%) in the yoga intervention group. Similarly,

asignificant increase in anxiety and depression in the control group was

observed at post-assessment; which may be attributed to HIV-associated

depression and anxiety.

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In another randomized controlled trial, Ram et al (2016) reported significant

improvement in QoL domains following 4 months of the yoga intervention in HIV

persons with cocaine addiction (Agarwal et al 2015). Consistent with this study,

our study also found significant improvement in QoL domains following 2 months
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of yoga intervention. However, the frequency of the yoga intervention in our

study was 5 days per week, as compared to 1 session per week in the previous

study. Also the type of yoga module differed from the previous study. These

variations could explain the greater improvement in QoL domains observed in

our study,

Our findings are also supported by a pilot RCT study by Menon et al 2013 in

which significant improvement in physical health, psychological well-being and

CD4 count following 10 weeks of yoga intervention among the adolescents with

HIV positive (Menon et al 2013).

The exact mechanism action of yoga is not known. However, based on earlier

findings, we can hypothesize that yoga practice leads to decreased stress

response through down-regulation of the HPA (hypothalamus-pituitary-adrenal

axis) (Ross et al 2009), which could have contributed to a reduction in anxiety.

Most of the yoga postures involve active stretching, which might have

contributed to increased parasympathetic activity and enhanced secretion of

positive Neuro-hormones such as serotonin, oxytocin which have anti-

depressant action (Sharma et al 2005). Decreased anxiety and depression is

shown to improve QoL (Chandwani et al 2009).

This study has a few limitations such as a small sample size, with no sample size

calculation done prior to the study. Additionally, the control-group has not had

any type of intervention, while the yoga group is a short term intervention.

Conclusion

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This study clearly indicates that yoga intervention improves the psychological

health and QoL of individuals infected with HIV. Therefore, based on these

findings, yoga is strongly recommended as a complementary therapy to

enhance conventional HIV care.
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Conflict of Interest

Authors declare no conflict of interest.

Acknowledgement

We are grateful for the constant support we received from the HIV Centres
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throughout the study.

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