Published on in Vol 8, No 5 (2019): May

Preprints (earlier versions) of this paper are available at, first published .
Evaluating the Feasibility and Impact of a Yoga Intervention on Cognition, Physical Function, Physical Activity, and Affective Outcomes in People Living With HIV: Protocol for a Randomized Pilot Trial

Evaluating the Feasibility and Impact of a Yoga Intervention on Cognition, Physical Function, Physical Activity, and Affective Outcomes in People Living With HIV: Protocol for a Randomized Pilot Trial

Evaluating the Feasibility and Impact of a Yoga Intervention on Cognition, Physical Function, Physical Activity, and Affective Outcomes in People Living With HIV: Protocol for a Randomized Pilot Trial


1Department of Physiotherapy, Dalhousie University, Halifax, NS, Canada

2Department of Physical Therapy, University of Toronto, Toronto, ON, Canada

3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

4Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada

5Department of Psychiatry, McGill University, Montreal, QC, Canada

6Department of Medicine, Dalhousie University, Halifax, NS, Canada

7Nova Scotia Health Authority, Halifax, NS, Canada

Corresponding Author:

Adria Quigley, BSc, MSc

Department of Physiotherapy

Dalhousie University

Forrest Building, 5869 University Avenue

PO Box 15000

Halifax, NS, B3H 4R2


Phone: 1 782 234 2121

Fax:1 (902) 494 1941


Background: Despite lower mortality rates due to combination antiretroviral therapy, people living with HIV (PLWH) are grappling with increasingly complex health issues, including cognitive impairments in areas such as memory, attention, processing speed, and motor function. Yoga has been shown to be an effective form of exercise and mindfulness-based stress reduction for many clinical populations. However, no randomized trials have evaluated the impact of yoga on cognitive and physical function among PLWH.

Objective: The aim of this pilot randomized trial was to determine the feasibility of a yoga intervention to lay the groundwork for a full-scale, multisite, community-based trial for PLWH. Specific objectives are to (1) assess the feasibility of study protocol and procedures, (2) compare cognition in the yoga group with the usual care control group after 12 weeks of the intervention in PLWH, and (3) compare the effects of the 12-week yoga intervention versus control on balance, walking speed, physical activity, mental health, medication adherence, and quality of life among PLWH.

Methods: We propose a pilot randomized trial with 2 parallel groups (yoga versus control). We will recruit 25 PLWH (>35 years) from community and health organizations in Halifax, Canada. After baseline assessment with blinded assessors, participants will be randomly assigned to the yoga or control group, using a random computer generator. Participants in the yoga group will engage in supervised 60-min group-based yoga sessions 3 times a week for 12 weeks at a yoga studio. Participants in the control group will maintain their current physical activity levels throughout the study.

Results: As per the Consolidated Standards of Reporting Trials extension for pilot studies, means of all outcomes, mean change, and 95% CIs will be calculated for each group separately. Two-tailed independent t tests and Fisher exact tests will be used to compare groups at baseline. We will analyze quantitative postintervention questionnaire responses using Chi-square tests, and open-ended responses will be analyzed thematically. Intention-to-treat and per-protocol analyses will be used to analyze secondary variables. Changes in outcome variables will be examined between groups and within groups. Effect sizes will be reported for each outcome. A priori adherence and satisfaction criteria will be met if participants attend >70% of the yoga sessions and if >70% of the participants are satisfied with the intervention as determined by a postparticipation questionnaire. Study enrollment began in January 2018, with results expected for October 2019.

Conclusions: This pilot randomized trial will be the first to investigate the feasibility and effect of a yoga intervention on cognitive and physical outcomes among PLWH. This work will inform the feasibility of further investigations in terms of capacity building, participant recruitment and retention, and assessment and intervention protocols.

Trial Registration: NCT03071562; (Archived by WebCite at

International Registered Report Identifier (IRRID): DERR1-10.2196/13818

JMIR Res Protoc 2019;8(5):e13818



Cognitive Impairment in People Living With HIV

Despite lower mortality rates due to combination antiretroviral therapy (cART), people living with HIV (PLWH) are grappling with increasingly complex health issues [1], including cognitive impairments in areas such as memory, attention, processing speed, and motor function [2]. Even with the widespread use of cART, 30% to 60% of PLWH experience cognitive impairment [2,3]. Given that the number of people with HIV-associated cognitive impairment is expected to increase 5- to 10-fold by the year 2030 [4], and the incidence of HIV infection is increasing among older adults [5], this issue has become a public health concern [6]. Aging and HIV appear to have combined deleterious effects on both brain structure and function, and some investigators have hypothesized that these effects could be synergistic [7,8]. As such, the combined effect of age and cognitive impairment in HIV has become a concern over the past decade, especially as PLWH now have a life expectancy that rivals that of their HIV-negative counterparts [9]. Proposed mechanisms for cognitive dysfunction include direct attacks of the virus on brain tissue and indirect processes such as local or systemic inflammation [10]. Glial cells, possible reservoirs for the virus, release proinflammatory cytokines and toxins associated with cognitive disorders and neuron degeneration [11]. Protein gp120 damages neurons by causing calcium overload and reducing brain-derived neurotrophic factor, the central growth factor involved in neurogenesis [12].

HIV-associated cognitive impairment has a profound impact on activities of daily living [13], social function [14], quality of life [15], employment [16], and adherence to pharmacological [17] and nonpharmacological treatment [18]. Despite the fact that ~95% adherence to cART is required for adequate viral suppression, 66% of participants in a HIV clinical trial simply forgot to take their medications [19]. Pharmacological adherence is a major priority, given that cART is the mainstay of proper HIV management. A study of 267 adults with HIV revealed that those with cognitive impairment performed worse on functional laboratory measures of shopping, cooking, finances, medication management, and work-related skills than those with normal cognition [20]. Furthermore, the authors discovered that poor executive function, learning, attention, working memory, and verbal abilities strongly predicted functional performance [20]. Authors of another study revealed that symptomatic cognitive impairment was associated with significantly worse scores in 8 domains of the Medical Outcomes Survey for HIV (MOS-HIV) [21]. PLWH with cognitive impairment are less likely to be employed [22], have a difficult time returning to work after disability [23], and have difficulties adapting to the demands of work [20].

Gait and Balance Impairments Among People Living With HIV

Although the cognitive aspects of HIV-associated neurocognitive disorder such as memory, attention, and processing speed have been studied in great detail, the motor aspects have not received much attention. There is evidence of a shared pathology between cognitive and motor functions; a large study of 1549 PLWH revealed a significant relationship between slowed gait and worsening cognitive function [24]. Balance and gait impairments are common among PLWH [25], and they are associated with frailty, higher rates of falls, and increased mortality [26]. Decreased gait speed is linked to higher fall risk, even in those taking cART with undetectable viral loads [26]. A recent systematic review and meta-analysis of 16 cross-sectional studies and 1 prospective cohort study conducted by Berner and colleagues (2017) evaluated the available literature on gait and balance dysfunction in PLWH [27]; a total of 3 [28-30] of 8 studies [25,26,28-33] that examined gait speed reported slowing of fast gait speeds among PLWH compared with controls.

Balance performance tests also reveal balance impairments among PLWH. Using the Single Leg Stance Time Test, Bauer and colleagues (2011) [25] revealed a significant decrease in nonpreferred single leg stance time among obese PLWH compared with seronegative controls in their sample of 86 seropositive and 121 seronegative individuals. Sullivan and colleagues (2011) [34] had similar findings in their sample of 40 female and male PLWH, but they found no differences between groups in tandem stance time. Using the Single Leg Stance Time Test with eyes closed in their sample of 308 PLWH, Tanon and colleagues (2017) [35] determined that 87% of participants demonstrated balance impairments. Performance on the Heel-To-Toe Walk Test with eyes closed [34], the Limits of Stability Test [25,31], and the 360-Degree-Turn Test (among PLWH with obesity only) [25] may also be impaired. Notably, PLWH appear to perform well on the Berg Balance Scale [26,27,36], which indicates that more challenging dynamic balance assessments are required to identify impairments in this population.

Exercise and Cognitive Function in People Living With HIV

Quigley and colleagues (2018) recently published a scoping review to map the available evidence regarding physical activity and cognitive outcomes (both objective and self-reported) among PLWH [37]. The scoping review included 16 studies: 5 randomized controlled trials (RCTs) [38-42], 3 pre-post single group observational studies [43-45], and 8 cross-sectional studies [46-53], with a total of 1701 PLWH [37]. The noninterventional research indicated a strong association between physical activity levels and cognitive performance as measured by a cognitive battery in PLWH; all 8 cross-sectional studies demonstrated positive associations [46-53]. However, only 2 of the 8 interventional studies—an RCT [41] of aerobic and resistance exercise and a single cohort study involving Tai Chi [43]—revealed positive outcomes regarding cognition in PLWH. McDermott and colleagues [42] conducted the only RCT to directly examine the effect of exercise on an objective measure of cognition in PLWH. Their 16-week aerobic exercise intervention, 3 times per week at 40% to 75% of heart rate reserve neither had an effect on Montreal Cognitive Assessment scores nor had an effect on Trails A and B scores [42]. However, the sample size comprised 11 participants, and the Montreal Cognitive Assessment may not be sensitive to cognitive impairment in PLWH [54]. Clearly, confirmatory evidence of the effect of exercise on cognition in this population is lacking.

The Effect of Yoga on Cognitive and Physical Function

Yoga has emerged as an effective form of exercise and mindfulness-based stress reduction across many clinical populations [55]. It is an ancient practice combining postures, mindfulness, spirituality, and breath control to enhance flexibility, strength, and balance, and it is increasingly being recognized as a mainstream intervention to promote a more preventative and holistic health care approach [56,57]. Findings of a meta-analysis of 15 RCTs suggest that yoga interventions lasting 1 to 6 months are associated with enhanced overall cognitive function (Hedges  g=0.33), attention and processing speed (Hedges  g=0.299), executive function (Hedges  g=0.27), and memory (Hedges  g=0.18) in people with and without chronic diseases [58]. In fact, it appears that acute bouts of yoga may be superior to aerobic exercise for improving inhibition and working memory, as determined by a repeated-measures study of 30 healthy younger women [59]. There are numerous mechanisms thought to underlie cognitive improvements with yoga interventions. It is possible that yoga may contribute to dominance of the parasympathetic nervous system [60,61] while downregulating the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis [61]. A systematic review of 25 RCTs conducted with healthy and chronic disease populations revealed that those who participated in yoga improved their cortisol levels, heart rate, and blood pressure relative to controls [62]. There is also evidence that yoga and other types of mind-body exercise (including Tai Chi) are associated with improved mood; a meta-analysis of 40 interventional studies revealed that Tai Chi has positive effects on both anxiety and depression [63]. Improvements in the stress response with mind-body exercise may contribute to improved cognitive performance [64]; an RCT of 118 older adults revealed that yoga participants had an attenuated cortisol response and improved executive function relative to the control group following an 8-week yoga intervention [64]. Of note, self-reported mood stress and cortisol levels predicted executive function performance [64]. Other potential mechanisms associated with yoga interventions include the learning of novel tasks, which is associated with changes in brain structure and function [58], sustained attention [65], activation of the default mode network (including learning and consolidation functions) [66], and improved meta-cognition (one’s conscious awareness of his or her cognitive processes), which is closely related to executive function [67].

Yoga is also an effective treatment for impaired balance in people with [68-71] and without physical impairments [72,73] because of its positive effects on strength [74], mobility [69], balance self-efficacy [70,71], and visuospatial memory [75]. A 2016 systematic review and meta-analysis of 6 RCTs confirmed that healthy older adults and individuals with various health conditions, such as stroke, Parkinson’s disease, and knee osteoarthritis, reap yoga-induced benefits to postural stability and mobility [76]. The investigators suggested that health care professionals should recommend yoga to older adults as a safe and effective intervention for balance and mobility limitations [76]. There is considerably less research evaluating the effect of yoga on balance, quality of life, and depression in PLWH. In their case-series study of 3 PLWH, Kietrys and colleagues (2018) observed improvements in several gait parameters (including double-limb support time, step length, stride length, stride velocity, and walking velocity) and balance (as measured by the Multidirectional Reach Test) in 2 of the 3 participants following a 4-week yoga intervention [77]. There is some RCT evidence for the benefits of yoga on quality of life [78] and depression [79] in PLWH; however, the former study did not involve yoga postures, and the latter intervention was only a month in total duration. To date, no RCTs have evaluated the impact of yoga on cognitive and physical performance among PLWH.

Purpose and Objectives

The purpose of this pilot RCT is to determine the feasibility of a yoga intervention to lay the groundwork for a full-scale, multisite, and community-based trial with PLWH. Specific objectives are to (1) assess the feasibility of the study protocol and procedures, (2) compare cognitive function in PLWH in a yoga intervention group with a usual care control group among PLWH after 12 weeks of the intervention, and (3) compare the effects of the 12-week yoga intervention versus control on balance, walking speed, physical activity, mental health, medication adherence, and quality of life in PLWH.


We propose a pilot randomized trial with 2 parallel groups, comparing the yoga group with a usual care control group using quantitative methods of data collection. Figure 1 outlines the sequencing of the study protocol. The conceptual framework for pilot and feasibility studies created by Eldridge and colleagues [80] and the Consolidated Standards of Reporting Trials (CONSORT) 26-item checklist for randomized pilot and feasibility studies will be employed to ensure methods are properly defined and reported [81]. The study is guided by a community advisory committee comprising 7 members of the HIV community and 3 representatives from local HIV organizations. Our research team held consultations with the community advisory committee to assist with study design and recruitment strategy.

Figure 1. Consolidated Standards of Reporting Trials flow diagram.
View this figure


We will identify cognitive concerns on the Communicating Cognitive Concerns Questionnaire (C3Q) with a cut-off of 35 points or less [82]; in addition, we will include a maximum total of 25 PLWH who are aged 35 years or older of any gender, are English speaking, live within 50 km of the study site, are able to provide informed consent, and are deemed medically stable as assessed by the Physical Activity Readiness Questionnaire Plus [83]. Study exclusion will include regular participation in a yoga program during the 6 months before study commencement.


Recruitment will occur via newsletters and posters at community organizations and health centers in Halifax, Nova Scotia. Furthermore, staff at the local HIV Clinic have agreed to approach eligible individuals and provide them with a study information brochure. To obtain a sample that is diverse in terms of ethnicity, gender, and severity of HIV disease, we will also employ snowball sampling techniques, whereby potential participants will be asked to identify other potential participants. All interested individuals will contact the study coordinator. The coordinator will explain the general purpose and procedures of the study, risks and potential benefits, time commitment, and responsibilities of the participants. Each potential participant will be informed that health care services will not be affected by study participation or withdrawal. A copy of the consent form will be provided and reviewed, and all the questions will be answered to the potential participant’s satisfaction. Potential participants who remain interested in enrolling in the study will be asked to sign the consent form approved by the local Research Ethics Board (REB).


After baseline assessment, an individual not directly involved in the study will randomly assign participants in a 1:1 ratio to the yoga or control group using a random computer generator. Group assignment of each participant will be concealed in individual opaque envelopes that will remain sealed until after completion of the baseline assessment. The number of participants screened and randomized to each group will be recorded, as per the CONSORT extension for randomized pilot trials [81].

Ethical Considerations

The study protocol was approved by the REB (protocol reference #1022158). The procedures will be followed in accordance with institutional ethical standards and the Helsinki Declaration. The trial was registered on Proposed amendments to the protocol will be submitted for review to the REB. For ethical reasons, we cannot ask participants to avoid making medication changes; any changes participants make to their medications will be documented. Unanticipated or adverse events will be reported immediately to the REB. Participant confidentiality and autonomy will be maintained throughout the study, and data will be anonymized and secured. Study data will be stored in a locked office at Dalhousie University. Electronic data will be stored in encrypted form and will exclusively be accessed by the research team. Restricting access to data on-site until the data have been appropriately coded and deidentified will mitigate the risk of residual disclosure. All data will be destroyed after 7 years. Decisions to stop participating will be respected. To offset participants’ personal and travel costs, we will provide bus tickets for assessments and yoga sessions, and we will provide parking reimbursement, snacks, and honoraria for the assessments.

Intervention Protocols

Yoga Group

Groups of 4 to 5 participants will engage in 60-min group-based Hatha-style yoga sessions 3 times per week for 12 weeks under the supervision of a yoga-certified physiotherapist at a local yoga studio. Classes will begin with a 15-min warm-up, which includes seated meditation, breathing exercises, shoulder and neck stretches, back mobility exercises, and sun salutations. Then, participants will perform 10 min of standing and 15 min of balance poses, followed by 10 min of abdominal work and back-bends. The class will finish with 5 min of final rest (savasana). The yoga protocol can be seen in Table 1.

Table 1. Yoga protocol.
Warm-up (15 min)Standing poses (10 min)Balance poses (15 min)Abdominals and back bends (10 min)Cool down (10 min)
Seated meditation; alternate nostril breathing; bellows breath; shoulder/neck stretches; cat-cow forward fold; sun salutationsWarrior 1; warrior 2; triangle; extended side angle; reverse warrior; high lunge with twistTree pose; eagle pose; standing holding knee; modified warrior 3 (chair support); half moonBird-dog; side plank; bridge; cobra; sphinxTwist; cobbler’s pose; hip stretches; corpse pose; side-lying; seated om
Yoga Protocol

Yoga mats, blocks, chairs, and straps will be provided to the participants. Postures will be modified for people with balance impairments or neuropathies. If participants are unable to get down to the floor or balance without support, postures will be performed with the use of a chair or other props. As Indigenous people are overrepresented in the HIV epidemic in Canada (they represented 11.3% of all new infections in 2016) [84], the sample population should reflect the cultural diversity within the catchment area of the study. Every month, a smudging ceremony with an Elder representing the Indigenous people will take place for 5 to 10 min before class commencement. The rationale for performing the smudging ceremony is that it is commonly associated with yoga practices [85]; in fact, a recent survey of 360 yoga practitioners identified spirituality as a common reason for starting and maintaining their yoga practice [86].

Attendance Policy

Of the total of 36 sessions (3 classes a week for 12 weeks), each participant will be encouraged to attend 70% of classes. Consideration will be given to withdrawing a participant from the study if the participant cancels or does not attend more than 6 sessions for reasons other than illness. In the event of a reversible illness that results in the participant being absent for more than 6 sessions, the participant will be withdrawn from the study and offered to be reenrolled in the yoga group after an 8-week washout period. If a session is cancelled, a make-up session will be scheduled.

Control Group

The control group will be asked to continue with its regular exercise routine, and the group will be asked to not make any changes during the study. Interested participants in the control group will be offered the opportunity to attend ongoing yoga classes as frequently as they would like, following study completion.

Assessment Protocol

As per the CONSORT extension for pilot RCTs, the number of participants screened for eligibility, randomly assigned, received intended treatment, and assessed for each objective will be recorded [81]. Study data will be collected in the Physiotherapy department at Dalhousie University and managed using Research Electronic Data Capture (REDCap) software (REDCap Inc) [87]. The authors will provide access to the study’s REDCap (REDCap Inc) data upon request. Table 2 outlines the outcome variables and measurement tools.

Table 2. Outcomes and measurement tools.
OutcomeMeasurement toolObjective measure or self-report
Yoga readiness (previous experience with yoga, injuries and ability level)Yoga readiness questionnaire (yoga group only)Self-report
Cognitive performanceCommunicating Cognitive Concerns questionnaire; Brief Cognitive Ability MeasureSelf-report; objective
Motor function (balance, walking speed)Community Mobility and Balance Scale; 10-meter walk testObjective; objective
Mental healthHospital Anxiety and Depression ScaleSelf-report
Quality of lifeMedical Outcomes SurveySelf-report
Medication adherenceSimplified Medication Adherence QuestionnaireSelf-report
Physical activityRapid Assessment of Physical Activity; Fitbit Flex 2—total distance walked (km) and steps taken per daySelf-report; objective
Participant satisfaction, safety, comfort, fatigue, and benefitsPostparticipation survey (yoga group only)Self-report

Outcome Variables and Measurement Tools

Demographic Information

We will administer a 13-item paper-based self-reported questionnaire asking about age, sex, gender, ethnicity, education level, employment, income, comorbidities, year diagnosed with HIV, viral load (if known), CD4 count (if known), medications, comorbidities, and physical activity (how often the participant was physically active in the previous week) at baseline to describe the sample and assess group comparability. Participants randomized to the yoga group will be asked to fill out a yoga-readiness questionnaire we created to provide the yoga instructor with safety and injury information.

Primary Measures

Many domains of feasibility will be assessed by both participants and study personnel using monitoring processes and a 13-item paper-based post-intervention questionnaire, which includes both questions on a Likert scale ranging from strongly disagree to strongly agree and open-ended questions (see Multimedia Appendix 1):

  1. Project coordination (team building, communication and meetings, collaboration, consensus building, troubleshooting, scheduling, protocol consistency, and timelines). Any issues with (or changes to) the study protocol or scheduling will be documented.
  2. Participant issues (recruitment, comfort, satisfaction, safety, attendance, time commitment, attrition, and reasons for ineligibility drop out/declining to participate), as assessed by the postintervention questionnaire and documentation by the study coordinator.
  3. Assessment protocol elements (time and personnel requirements, usefulness of outcome variables, participant burden, and feasibility) will be recorded by the study coordinator.
  4. Intervention protocols (time, equipment, and personnel requirements) will be recorded by the study coordinator.
  5. Data quality (completeness, intra/interparticipant variability, interpretability, and trends) will be checked by the study coordinator. Per the CONSORT checklist, our a priori adherence and satisfaction criteria will be met if participants attend 70% of the yoga sessions and if 70% of the participants are satisfied with the yoga intervention as per the postparticipation questionnaire.
Secondary and Tertiary Measures

Cognition, physical performance (balance, walking speed), physical activity, and affective (mental health, quality of life, and medication adherence) evaluations will be administered at baseline and postintervention (12 weeks) by a trained assessor, blinded to the group assignment. The rationale for blinding the assessor is to reduce bias in scoring during the assessment sessions. The estimated length of time for the assessment sessions is 2 hours per participant. We will measure cognitive function using the Brief Cognitive Ability Measure (B-CAM), a computerized cognitive test developed for PLWH, using Rasch measurement theory and analysis that takes 30 min to administer [88,89]. The B-CAM provides a measure of global cognition that is calibrated—the intervals between logits are equal, meaning the data are continuous [88,90].

Cognitive domains tested with the B-CAM include visual detection (reaction time), Flanker task (response inhibition) [91], memory (learning and recall of 8 words), Shape 2-back (working memory) [92], Corsi block-tapping forward and back tests (visuospatial memory) [93], verbal fluency (letters F-A-S in English) mini Trail Making Test B (executive function) [94], and the Tower of London test (planning) [95]. The scoring of the B-CAM ranges from 0 to 24, with higher values indicating better global cognition [90]. To reduce the likelihood of practice effects, different versions of the B-CAM are performed at baseline and final assessments [90]. Group-based trajectory analysis has revealed that no practice effects were found at the item level [90].

Self-reported cognition will also be assessed using the C3Q, an 18-item paper-based questionnaire that was developed to estimate the presence and frequency of memory, attention, executive function, visuospatial, speech and language, behavior and emotion, and cognitive challenges among PLWH [82]. The frequency of such challenges are recorded by the participant on a 3-point scale: frequently (almost every day), sometimes (once a week), or rarely (once a month) [82].

Balance will be measured using the Community Balance and Mobility (CB&M) test, a high-level balance assessment of tasks performed in the community, developed for people with traumatic brain injury [96]. It is a valid and reliable measure of dynamic postural control in people with traumatic brain injury [96,97] and older community-dwelling individuals [98], and it is not as susceptible to ceiling effects as the Berg Balance Scale [98,99]. Walking speed will be measured using the 10-meter walk test because of the association of gait speed with cognitive performance in PLWH [24], its previous use in the HIV literature [26], and its ability to predict survival in older adults [100]. Depression will be assessed using the Hospital Anxiety and Depression Scale, a paper-based self-report questionnaire [101], which has very good to excellent internal consistency, test-retest reliability and convergent validity, and acceptable discriminant validity in PLWH [102]. Quality of life will be assessed using MOS-HIV, a paper-based questionnaire that comprises 10 domains (physical function, social function, role function, cognitive function, pain, mental health, energy, health distress, quality of life, and overall health), with good to high internal consistency and construct validity in PLWH [103]. Physical activity will be assessed using the Rapid Assessment of Physical Activity, a 9-item paper-based questionnaire that measures moderate and vigorous physical activity, including strength and flexibility within the last week [104]. It was validated in older adults [104], and it has been used in studies with people with HIV [105]. Objective levels of physical activity (total distance walked, and number of steps taken per day) will be measured using accelerometers (Fitbit flex 2) [106]. Accelerometer data will be electronically synced and downloaded after weeks 1 and 12 and stored in an encrypted file. Participants will also be asked about Medication adherence (specifically cART), measured with the paper-based Simplified Medication Adherence Questionnaire (SMAQ), which has 72% sensitivity, 91% specificity, and a likelihood ratio of 7.94 for nonadherent patients [107].

Participant Safety

Participants will be monitored throughout the yoga sessions and the assessments. If a participant presents with any medical or safety concerns, the supervising physiotherapist will provide the appropriate first aid or injury treatment; then, the supervising physiotherapist will refer the participant to the participant’s family physician for follow-up. Any harms or unanticipated effects will be recorded as per the CONSORT checklist [81]. Owing to the low-risk nature of the study, we do not anticipate any additional safety or medical issues associated with the yoga interventions.

Data Analysis

All questionnaires and measures will be assessed for missing data. The data will be analyzed to determine if the assumptions for parametric tests are met. Descriptive statistics will be used to characterize the participants. As per the CONSORT extension for pilot studies, means of all outcomes, mean change, and 95% CIs will be calculated for each group separately. We will also follow the Sex and Gender Equity in Research guidelines [108] by disaggregating data by sex and gender. Participant dropouts will also be reported disaggregated by sex.

Independent t tests and Fisher exact tests will be used to compare the 2 groups at baseline. If the 2 groups differ at baseline, that variable will be included in the analysis as a covariate. We will analyze quantitative postintervention questionnaire responses using Chi-square tests, and open-ended responses will be analyzed thematically. Intention-to-treat and per-protocol analyses will be used in the analysis of the secondary variables. Changes in outcome variables will be examined between groups and within groups. Floor and ceiling effects will be calculated for the CB&M test. Effect sizes will be reported for each outcome. Alpha level will be set at .05, using 2-tailed for all inferences, and data will be analyzed with SPSS Version 25 (SPSS Inc). As this is a pilot study, sample size calculations are not recommended [81]. This pilot study will not be adequately powered to conclusively state the influence of the intervention on study outcomes, but if trends are promising, a future, more adequately powered trial will be planned. This pilot study will provide preliminary data for future sample size calculations.

Study enrollment began in January 2018, with results expected in October 2019.


Study results will be disseminated to PLWH, researchers, health care providers, community-based organizations, stakeholders, and policy makers. Knowledge translation will take place via peer-reviewed journals, podium and poster presentations at conferences and forums, newsletters, and presentations at community-based organizations.

Study Strengths

This pilot implementation trial will be the first to investigate the effect and feasibility of a yoga intervention on cognitive and physical outcomes in PLWH. Not only will the study generate preliminary data about the effects of yoga on cognitive and physical function, but it will also inform the feasibility and utility of further investigation in terms of team capacity building, recruitment and retention strategies, and assessment of intervention protocols. The focus of the project is clearly aligned with a key research priority of the Canada-International HIV and Rehabilitation Research Collaborative, which is to determine the effectiveness of rehabilitation interventions and service delivery models [109].

Our research addresses HIV beyond a biological perspective to reduce not only physical limitations but also the social impact of HIV. By targeting an inexpensive nonpharmacological intervention, we hope to identify feasible community-based strategies that may contribute to slowing the health-related consequences of HIV while improving quality of life for PLWH.

Anticipated Challenges and Limitations

Potential challenges will include recruitment and retention of participants over the course of the 12-week intervention. With approximately 500 PLWH living in the local area [110], we anticipate that by involving community leaders and end users from the outset of conceptualization and planning and conducting the study in a familiar community setting, we will successfully recruit 25 PLWH. Although attrition is of concern in exercise studies requiring multiple visits, a 2015 study on yoga and meditation reported an overall attendance rate of 89% among PLWH [111].

Study limitations include a lack of mechanism to confirm HIV diagnoses for participants not recruited from the HIV clinic and limited study inclusion to individuals who speak and understand English, which may reduce the generalizability of our findings. Participants were also not asked about substance abuse or specific comorbidities, such as peripheral neuropathy, which may affect cognitive and physical performance.


The authors would like to thank Dr Jaqueline Gahagan for her contribution to the project. This work is supported by a Canadian Institutes of Health Research Catalyst Grant in HIV/AIDS Community Based Research. As the authors received their funding, the protocol has had some minor deviations, including changing the comparison from an exercise group to a passive control and increasing the maximum number of participants.

Conflicts of Interest

None declared.

Multimedia Appendix 1

Postparticipation questionnaire.

PDF File (Adobe PDF File), 40KB

Multimedia Appendix 2

Canadian Institutes of Health Research peer-review reports.

PDF File (Adobe PDF File), 1008KB

  1. Guaraldi G, Orlando G, Zona S, Menozzi M, Carli F, Garlassi E, et al. Premature age-related comorbidities among HIV-infected persons compared with the general population. Clin Infect Dis 2011 Dec;53(11):1120-1126. [CrossRef] [Medline]
  2. Grant I. Neurocognitive disturbances in HIV. Int Rev Psychiatry 2008 Feb;20(1):33-47. [CrossRef] [Medline]
  3. Goodkin K. Psychiatric Aspects of HIV Spectrum Disease. Focus (Madison) 2009;7(3):303-310. [CrossRef]
  4. Cysique L, Bain M, Brew B, Murray J. The burden of HIV-associated neurocognitive impairment in Australia and its estimates for the future. Sex Health 2011 Dec;8(4):541-550. [CrossRef] [Medline]
  5. Public Health Agency of Canada. 2010. HIV/AIDS Epi Updates: HIV/AIDS among older Canadians   URL: [accessed 2019-05-06] [WebCite Cache]
  6. Vance DE, McDougall GJ, Wilson N, Debiasi MO, Cody SL. Cognitive consequences of aging with HIV: implications for neuroplasticity and rehabilitation. Top Geriatr Rehabil 2014 Jan;30(1):35-45 [FREE Full text] [CrossRef] [Medline]
  7. Hardy D, Vance D. The neuropsychology of HIV/AIDS in older adults. Neuropsychol Rev 2009 Jun;19(2):263-272. [CrossRef] [Medline]
  8. Cohen RA, Seider TR, Navia B. HIV effects on age-associated neurocognitive dysfunction: premature cognitive aging or neurodegenerative disease? Alzheimers Res Ther 2015;7(1):37 [FREE Full text] [CrossRef] [Medline]
  9. Sabin CA. Do people with HIV infection have a normal life expectancy in the era of combination antiretroviral therapy? BMC Med 2013 Nov 27;11:251 [FREE Full text] [CrossRef] [Medline]
  10. Gongvatana A, Harezlak J, Buchthal S, Daar E, Schifitto G, Campbell T, et al. Progressive cerebral injury in the setting of chronic HIV infection and antiretroviral therapy. J Neurovirol 2013 Jun;19(3):209-218 [FREE Full text] [CrossRef] [Medline]
  11. McArthur JC, Steiner J, Sacktor N, Nath A. Human immunodeficiency virus-associated neurocognitive disorders: mind the gap. Ann Neurol 2010 Jun;67(6):699-714. [CrossRef] [Medline]
  12. Mattson MP. Exercise and the brain: a slap on the HAND. J Neurovirol 2013 Oct;19(5):407-409 [FREE Full text] [CrossRef] [Medline]
  13. Alfahad TB, Nath A. Update on HIV-associated neurocognitive disorders. Curr Neurol Neurosci Rep 2013 Oct;13(10):387 [FREE Full text] [CrossRef] [Medline]
  14. Hopcroft L, Bester L, Clement D, Quigley A, Sachdeva M, Rourke SB, et al. "My body's a 50 year-old but my brain is definitely an 85 year-old": exploring the experiences of men ageing with HIV-associated neurocognitive challenges. J Int AIDS Soc 2013 Jul 23;16:18506 [FREE Full text] [CrossRef] [Medline]
  15. Tozzi V, Balestra P, Murri R, Galgani S, Bellagamba R, Narciso P, et al. Neurocognitive impairment influences quality of life in HIV-infected patients receiving HAART. Int J STD AIDS 2004 Apr;15(4):254-259. [CrossRef] [Medline]
  16. Gorman AA, Foley JM, Ettenhofer ML, Hinkin CH, van Gorp WG. Functional consequences of HIV-associated neuropsychological impairment. Neuropsychol Rev 2009 Jun;19(2):186-203 [FREE Full text] [CrossRef] [Medline]
  17. Becker BW, Thames AD, Woo E, Castellon SA, Hinkin CH. Longitudinal change in cognitive function and medication adherence in HIV-infected adults. AIDS Behav 2011 Nov;15(8):1888-1894 [FREE Full text] [CrossRef] [Medline]
  18. Hinkin CH, Castellon SA, Durvasula RS, Hardy DJ, Lam MN, Mason KI, et al. Medication adherence among HIV+ adults: effects of cognitive dysfunction and regimen complexity. Neurology 2002 Dec 24;59(12):1944-1950 [FREE Full text] [Medline]
  19. Chesney M, Morin M, Sherr L. Adherence to HIV combination therapy. Soc Sci Med 2000 Jun;50(11):1599-1605. [Medline]
  20. Heaton R, Marcotte T, Mindt MR, Sadek J, Moore DJ, Bentley H, HNRC Group. The impact of HIV-associated neuropsychological impairment on everyday functioning. J Int Neuropsychol Soc 2004 May;10(3):317-331. [CrossRef] [Medline]
  21. Simioni S, Cavassini M, Annoni J, Rimbault Abraham A, Bourquin I, Schiffer V, et al. Cognitive dysfunction in HIV patients despite long-standing suppression of viremia. AIDS 2010 Jun 01;24(9):1243-1250. [CrossRef] [Medline]
  22. Woods SP, Weber E, Weisz BM, Twamley EW, Grant I, HIV Neurobehavioral Research Programs Group. Prospective memory deficits are associated with unemployment in persons living with HIV infection. Rehabil Psychol 2011 Feb;56(1):77-84 [FREE Full text] [CrossRef] [Medline]
  23. van Gorp WG, Rabkin J, Ferrando S, Mintz J, Ryan E, Borkowski T, et al. Neuropsychiatric predictors of return to work in HIV/AIDS. J Int Neuropsychol Soc 2007 Jan;13(1):80-89. [CrossRef] [Medline]
  24. Robertson K, Parsons T, Sidtis J, Hanlon Inman T, Robertson WT, Hall CD, et al. Timed Gait test: normative data for the assessment of the AIDS dementia complex. J Clin Exp Neuropsychol 2006 Oct;28(7):1053-1064. [CrossRef] [Medline]
  25. Bauer LO, Wu Z, Wolfson LI. An obese body mass increases the adverse effects of HIV/AIDS on balance and gait. Phys Ther 2011 Jul;91(7):1063-1071 [FREE Full text] [CrossRef] [Medline]
  26. Richert L, Brault M, Mercié P, Dauchy FA, Bruyand M, Greib C, Groupe d’Epidémiologie Clinique du SIDA en Aquitaine (GECSA). Decline in locomotor functions over time in HIV-infected patients. AIDS 2014 Jun 19;28(10):1441-1449. [CrossRef] [Medline]
  27. Berner K, Morris L, Baumeister J, Louw Q. Objective impairments of gait and balance in adults living with HIV-1 infection: a systematic review and meta-analysis of observational studies. BMC Musculoskelet Disord 2017 Aug 01;18(1):325 [FREE Full text] [CrossRef] [Medline]
  28. Erlandson KM, Allshouse AA, Jankowski CM, Duong S, MaWhinney S, Kohrt WM, et al. Risk factors for falls in HIV-infected persons. J Acquir Immune Defic Syndr 2012 Dec 01;61(4):484-489 [FREE Full text] [CrossRef] [Medline]
  29. Simmonds M, Novy D, Sandoval R. The differential influence of pain and fatigue on physical performance and health status in ambulatory patients with human immunodeficiency virus. Clin J Pain 2005;21(3):200-206. [Medline]
  30. Beans J, Stevenson T, Katzel LI, Sorkin JD, Warner AL, Gottlieb SS, et al. Ambulatory Function in Men with and without HIV Infection: Association with Cardiorespiratory Fitness. J AIDS Clin Res 2013;s9:003. [CrossRef]
  31. Bauer L, Ceballos N, Shanley J, Wolfson L. Sensorimotor dysfunction in HIV/AIDS: effects of antiretroviral treatment and comorbid psychiatric disorders. AIDS 2005 Mar 25;19(5):495-502 [FREE Full text] [Medline]
  32. Erlandson K, Allshouse A, Jankowski C, Duong S, Mawhinney S, Kohrt WM, et al. Comparison of functional status instruments in HIV-infected adults on effective antiretroviral therapy. HIV Clin Trials 2012;13(6):324-334 [FREE Full text] [CrossRef] [Medline]
  33. Erlandson KM, Allshouse AA, Jankowski CM, Mawhinney S, Kohrt WM, Campbell TB. Relationship of physical function and quality of life among persons aging with HIV infection. AIDS 2014 Aug 24;28(13):1939-1943 [FREE Full text] [CrossRef] [Medline]
  34. Sullivan EV, Rosenbloom MJ, Rohlfing T, Kemper CA, Deresinski S, Pfefferbaum A. Pontocerebellar contribution to postural instability and psychomotor slowing in HIV infection without dementia. Brain Imaging Behav 2011 Mar;5(1):12-24 [FREE Full text] [CrossRef] [Medline]
  35. Tanon A, Diallo Z, Lenaud S, Niangoran S, Peres K, Eholié SP, et al. Aging with HIV infection and locomotors disorders: experience of the infectious and tropical diseases unit, Abidjan, Côte d'Ivoire. J AIDS Clin Res 2017;8:680 [FREE Full text] [CrossRef]
  36. Richert L, Dehail P, Mercié P, Dauchy FA, Bruyand M, Greib C, Groupe d'Epidémiologie Clinique du SIDA en Aquitaine (GECSA). High frequency of poor locomotor performance in HIV-infected patients. AIDS 2011 Mar 27;25(6):797-805. [CrossRef] [Medline]
  37. Quigley A, O'Brien K, Parker R, MacKay-Lyons M. Exercise and cognitive function in people living with HIV: a scoping review. Disabil Rehabil 2019 Jun;41(12):1384-1395. [CrossRef] [Medline]
  38. Baigis J, Korniewicz D, Chase G, Butz A, Jacobson D, Wu A. Effectiveness of a home-based exercise intervention for HIV-infected adults: a randomized trial. J Assoc Nurses AIDS Care 2002;13(2):33-45. [CrossRef] [Medline]
  39. Galantino M, Shepard K, Krafft L, Laperriere A, Ducette J, Sorbello A, et al. The effect of group aerobic exercise and t'ai chi on functional outcomes and quality of life for persons living with acquired immunodeficiency syndrome. J Altern Complement Med 2005 Dec;11(6):1085-1092. [CrossRef] [Medline]
  40. Gillespie J. The Ohio State University. 1997. Health promotion and quality of life in HIV-1 infected individuals   URL:!etd.send_file?accession=osu1487948158627446&disposition=inline
  41. Fillipas S, Oldmeadow L, Bailey M, Cherry C. A six-month, supervised, aerobic and resistance exercise program improves self-efficacy in people with human immunodeficiency virus: a randomised controlled trial. Aust J Physiother 2006;52(3):185-190 [FREE Full text] [Medline]
  42. McDermott A, Zaporojan L, McNamara P, Doherty CP, Redmond J, Forde C, et al. The effects of a 16-week aerobic exercise programme on cognitive function in people living with HIV. AIDS Care 2017 Dec;29(6):667-674. [CrossRef] [Medline]
  43. Robins J, McCain N, Gray D, Elswick R, Walter J, McDade E. Research on psychoneuroimmunology: tai chi as a stress management approach for individuals with HIV disease. Appl Nurs Res 2006 Feb;19(1):2-9 [FREE Full text] [CrossRef] [Medline]
  44. Brown D, Claffey A, Harding R. Evaluation of a physiotherapy-led group rehabilitation intervention for adults living with HIV: referrals, adherence and outcomes. AIDS Care 2016 Dec;28(12):1495-1505. [CrossRef] [Medline]
  45. Schlabe S, Vogel M, Boesecke C, Schwarze-Zander C, Rockstroh JK, Körner C, et al. Moderate endurance training (marathon-training) - effects on immunologic and metabolic parameters in HIV-infected patients: the 42 KM cologne project. BMC Infect Dis 2017 Dec 08;17(1):550 [FREE Full text] [CrossRef] [Medline]
  46. Fazeli P, Marquine M, Dufour C, Henry BL, Montoya J, Gouaux B, HNRP Group. Physical activity is associated with better neurocognitive and everyday functioning among older adults with HIV disease. AIDS Behav 2015 Aug;19(8):1470-1477 [FREE Full text] [CrossRef] [Medline]
  47. Dufour CA, Marquine MJ, Fazeli PL, Henry BL, Ellis RJ, Grant I, HNRP Group. Physical exercise is associated with less neurocognitive impairment among HIV-infected adults. J Neurovirol 2013 Oct;19(5):410-417 [FREE Full text] [CrossRef] [Medline]
  48. Mapstone M, Hilton T, Yang H, Guido JJ, Luque AE, Hall WJ, et al. Poor aerobic fitness may contribute to cognitive decline in HIV-infected older adults. Aging Dis 2013;4(6):311-319 [FREE Full text] [CrossRef] [Medline]
  49. Monroe A, Zhang L, Jacobson L, Plankey MW, Brown TT, Miller EN, et al. The association between physical activity and cognition in men with and without HIV infection. HIV Med 2017 Dec;18(8):555-563 [FREE Full text] [CrossRef] [Medline]
  50. Ortega M, Baker L, Vaida F, Paul R, Basco B, Ances BM. Physical activity affects brain integrity in HIV+ individuals. J Int Neuropsychol Soc 2015 Nov;21(10):880-889 [FREE Full text] [CrossRef] [Medline]
  51. Honn V, Para M, Whitacre C, Bornstein R. Effect of exercise on neuropsychological performance in asymptomatic HIV infection. AIDS Behav 1999;3(1):67-74. [CrossRef]
  52. Fazeli P, Woods S, Heaton R, Umlauf A, Gouaux B, Rosario D, HNRP Group. An active lifestyle is associated with better neurocognitive functioning in adults living with HIV infection. J Neurovirol 2014 Jun;20(3):233-242 [FREE Full text] [CrossRef] [Medline]
  53. Dufour C, Marquine M, Fazeli P, Umlauf A, Henry BL, Zlatar Z, HIV Neurobehavioral Research Program Group. A longitudinal analysis of the impact of physical activity on neurocognitive functioning among HIV-infected adults. AIDS Behav 2018 Dec;22(5):1562-1572 [FREE Full text] [CrossRef] [Medline]
  54. Janssen MA, Bosch M, Koopmans PP, Kessels RP. Validity of the Montreal Cognitive Assessment and the HIV Dementia Scale in the assessment of cognitive impairment in HIV-1 infected patients. J Neurovirol 2015 Aug;21(4):383-390 [FREE Full text] [CrossRef] [Medline]
  55. Field T. Yoga research review. Complement Ther Clin Pract 2016 Aug;24:145-161. [CrossRef] [Medline]
  56. Ross A, Williams L, Pappas-Sandonas M, Touchton-Leonard K, Fogel D. Incorporating yoga therapy into primary care: the Casey Health Institute. Int J Yoga Therap 2015;25(1):43-49. [CrossRef] [Medline]
  57. Slocum-Gori S, Howard A, Balneaves L, Kazanjian A. Investigating the perceived feasibility of integrative medicine in a conventional oncology setting: yoga therapy as a treatment for breast cancer survivors. Integr Cancer Ther 2013 Mar;12(2):103-112 [FREE Full text] [CrossRef] [Medline]
  58. Gothe N, McAuley E. Yoga and cognition: a meta-analysis of chronic and acute effects. Psychosom Med 2015 Sep;77(7):784-797. [CrossRef] [Medline]
  59. Gothe N, Pontifex M, Hillman C, McAuley E. The acute effects of yoga on executive function. J Phys Act Health 2013 May;10(4):488-495. [Medline]
  60. Innes KE, Bourguignon C, Taylor AG. Risk indices associated with the insulin resistance syndrome, cardiovascular disease, and possible protection with yoga: a systematic review. J Am Board Fam Pract 2005;18(6):491-519 [FREE Full text] [Medline]
  61. Ross A, Thomas S. The health benefits of yoga and exercise: a review of comparison studies. J Altern Complement Med 2010 Jan;16(1):3-12. [CrossRef] [Medline]
  62. Pascoe MC, Bauer IE. A systematic review of randomised control trials on the effects of yoga on stress measures and mood. J Psychiatr Res 2015 Sep;68:270-282. [CrossRef] [Medline]
  63. Wang C, Bannuru R, Ramel J, Kupelnick B, Scott T, Schmid CH. Tai Chi on psychological well-being: systematic review and meta-analysis. BMC Complement Altern Med 2010 May 21;10:23 [FREE Full text] [CrossRef] [Medline]
  64. Gothe NP, Keswani RK, McAuley E. Yoga practice improves executive function by attenuating stress levels. Biol Psychol 2016 Dec;121(Pt A):109-116. [CrossRef] [Medline]
  65. Gothe N, Kramer A, McAuley E. Hatha yoga practice improves attention and processing speed in older adults: results from an 8-week randomized control trial. J Altern Complement Med 2017 Jan;23(1):35-40. [CrossRef] [Medline]
  66. Simon R, Engström M. The default mode network as a biomarker for monitoring the therapeutic effects of meditation. Front Psychol 2015;6:776. [CrossRef] [Medline]
  67. Fernandez-Duque D, Baird JA, Posner MI. Executive attention and metacognitive regulation. Conscious Cogn 2000 Jun;9(2 Pt 1):288-307. [CrossRef] [Medline]
  68. Schmid A, Van Puymbroeck M, Altenburger P, Schalk NL, Dierks TA, Miller KK, et al. Poststroke balance improves with yoga: a pilot study. Stroke 2012 Sep;43(9):2402-2407. [CrossRef] [Medline]
  69. Guner S, Inanici F. Yoga therapy and ambulatory multiple sclerosis assessment of gait analysis parameters, fatigue and balance. J Bodyw Mov Ther 2015 Jan;19(1):72-81. [CrossRef] [Medline]
  70. Schmid A, Van Puymbroeck M, Miller K, Schalk N. Group yoga intervention leads to improved balance and balance self- efficacy after stroke. BMC Complement Altern Med 2012;12(Suppl 1):P222 [FREE Full text] [CrossRef]
  71. Schmid A, Van Puymbroeck M, Altenburger P, Dierks TA, Miller KK, Damush TM, et al. Balance and balance self-efficacy are associated with activity and participation after stroke: a cross-sectional study in people with chronic stroke. Arch Phys Med Rehabil 2012 Jun;93(6):1101-1107. [CrossRef] [Medline]
  72. Schmid A, Van Puymbroeck M, Koceja D. Effect of a 12-week yoga intervention on fear of falling and balance in older adults: a pilot study. Arch Phys Med Rehabil 2010 Apr;91(4):576-583. [CrossRef] [Medline]
  73. Tiedemann A, O'Rourke S, Sesto R, Sherrington C. A 12-week Iyengar yoga program improved balance and mobility in older community-dwelling people: a pilot randomized controlled trial. J Gerontol A Biol Sci Med Sci 2013 Sep;68(9):1068-1075. [CrossRef] [Medline]
  74. Halder K, Chatterjee A, Pal R, Tomer OS, Saha M. Age related differences of selected Hatha yoga practices on anthropometric characteristics, muscular strength and flexibility of healthy individuals. Int J Yoga 2015 Jan;8(1):37-46 [FREE Full text] [CrossRef] [Medline]
  75. Eyre H, Acevedo B, Yang H, Siddarth P, Van Dyk K, Ercoli L, et al. Changes in neural connectivity and memory following a yoga intervention for older adults: a pilot study. J Alzheimers Dis 2016;52(2):673-684 [FREE Full text] [CrossRef] [Medline]
  76. Youkhana S, Dean CM, Wolff M, Sherrington C, Tiedemann A. Yoga-based exercise improves balance and mobility in people aged 60 and over: a systematic review and meta-analysis. Age Ageing 2016 Jan;45(1):21-29. [CrossRef] [Medline]
  77. Kietrys DM, Galantino ML, Cohen ET, Parrott JS, Gould-Fogerite S, OʼBrien KK. Yoga for persons with HIV-related distal sensory polyneuropathy. Rehabil Oncol 2018;36(2):123-131. [CrossRef]
  78. Mawar N, Katendra T, Bagul R, Bembalkar S, Vedamurthachar A, Tripathy S, et al. Sudarshan Kriya yoga improves quality of life in healthy people living with HIV (PLHIV): results from an open label randomized clinical trial. Indian J Med Res 2015;141(1):90. [CrossRef]
  79. Naoroibam R, Metri KG, Bhargav H, Nagaratna R, Nagendra HR. Effect of Integrated Yoga (IY) on psychological states and CD4 counts of HIV-1 infected patients: a randomized controlled pilot study. Int J Yoga 2016;9(1):57-61 [FREE Full text] [CrossRef] [Medline]
  80. Eldridge S, Lancaster G, Campbell M, Thabane L, Hopewell S, Coleman CL, et al. Defining feasibility and pilot studies in preparation for randomised controlled trials: development of a conceptual framework. PLoS One 2016;11(3):e0150205 [FREE Full text] [CrossRef] [Medline]
  81. Eldridge S, Chan C, Campbell M, Bond CM, Hopewell S, Thabane L, PAFS consensus group. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. Pilot Feasibility Stud 2016;2:64 [FREE Full text] [CrossRef] [Medline]
  82. Askari S, Fellows L, Brouillette M, Moriello C, Duracinsky M, Mayo NE. Development of an item pool reflecting cognitive concerns expressed by people with HIV. Am J Occup Ther 2018 Mar;72(2):1-9. [CrossRef] [Medline]
  83. Bredin SS, Gledhill N, Jamnik VK, Warburton DE. PAR-Q+ and ePARmed-X+: new risk stratification and physical activity clearance strategy for physicians and patients alike. Can Fam Physician 2013 Mar;59(3):273-277 [FREE Full text] [Medline]
  84. Public Health Agency of Canada. Public Health Agency of Canada. 2016. Summary: estimates of HIV Incidence, Prevalence and Canada's Progress on Meeting the 90-90-90 HIV Targets   URL: [accessed 2019-01-05] [WebCite Cache]
  85. Kripalu Center for Yoga & Health. The Sacred Art of Smudging   URL: [accessed 2019-02-25] [WebCite Cache]
  86. Park C, Riley K, Bedesin E, Stewart V. Why practice yoga? Practitioners' motivations for adopting and maintaining yoga practice. J Health Psychol 2016 Dec;21(6):887-896. [CrossRef] [Medline]
  87. Vanderbilt. REDCap Software.   URL: [accessed 2019-01-05] [WebCite Cache]
  88. Mayo NE, Brouillette M, Fellows LK, Positive Brain Health Now Investigators. Understanding and optimizing brain health in HIV now: protocol for a longitudinal cohort study with multiple randomized controlled trials. BMC Neurol 2016 Jan 14;16:8 [FREE Full text] [CrossRef] [Medline]
  89. Koski L, Brouillette M, Lalonde R, Hello B, Wong E, Tsuchida A, et al. Computerized testing augments pencil-and-paper tasks in measuring HIV-associated mild cognitive impairment(*). HIV Med 2011 Sep;12(8):472-480 [FREE Full text] [CrossRef] [Medline]
  90. Brouillette M, Fellows LK, Finch L, Thomas R, Mayo NE. Properties of a brief assessment tool for longitudinal measurement of cognition in people living with HIV. PLoS One 2019;14(3):e0213908 [FREE Full text] [CrossRef] [Medline]
  91. Eriksen BA, Eriksen CW. Effects of noise letters upon the identification of a target letter in a nonsearch task. Percept Psychophys 1974;16(1):143-149. [CrossRef]
  92. Kane MJ, Conway AR, Miura TK, Colflesh GJ. Working memory, attention control, and the N-back task: a question of construct validity. J Exp Psychol Learn Mem Cogn 2007 May;33(3):615-622. [CrossRef] [Medline]
  93. Robbins TW, James M, Owen AM, Sahakian BJ, Lawrence AD, McInnes L, et al. A study of performance on tests from the CANTAB battery sensitive to frontal lobe dysfunction in a large sample of normal volunteers: implications for theories of executive functioning and cognitive aging. Cambridge Neuropsychological Test Automated Battery. J Int Neuropsychol Soc 1998 Sep;4(5):474-490. [Medline]
  94. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005 Apr;53(4):695-699. [CrossRef] [Medline]
  95. Phillips LH, Wynn VE, McPherson S, Gilhooly KJ. Mental planning and the Tower of London task. Q J Exp Psychol A 2001 May;54(2):579-597. [CrossRef] [Medline]
  96. Knorr S, Brouwer B, Garland S. Validity of the Community Balance and Mobility Scale in community-dwelling persons after stroke. Arch Phys Med Rehabil 2010 Jun;91(6):890-896. [CrossRef] [Medline]
  97. Howe J, Inness E, Venturini A, Williams J, Verrier M. The Community Balance and Mobility Scale--a balance measure for individuals with traumatic brain injury. Clin Rehabil 2006 Oct;20(10):885-895. [CrossRef] [Medline]
  98. Balasubramanian CK. The community balance and mobility scale alleviates the ceiling effects observed in the currently used gait and balance assessments for the community-dwelling older adults. J Geriatr Phys Ther 2015;38(2):78-89. [CrossRef] [Medline]
  99. Inness E, Howe J, Niechwiej-Szwedo E, Jaglal SB, McIlroy WE, Verrier MC. Measuring balance and mobility after traumatic brain injury: validation of the Community Balance and Mobility Scale (CB&M). Physiother Can 2011;63(2):199-208 [FREE Full text] [CrossRef] [Medline]
  100. Studenski S, Perera S, Patel K, Rosano C, Faulkner K, Inzitari M, et al. Gait speed and survival in older adults. J Am Med Assoc 2011 Jan 5;305(1):50-58 [FREE Full text] [CrossRef] [Medline]
  101. Zigmond A, Snaith R. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983 Jun;67(6):361-370. [Medline]
  102. Savard J, Laberge B, Gauthier J, Ivers H, Bergeron M. Evaluating anxiety and depression in HIV-infected patients. J Pers Assess 1998 Dec;71(3):349-367. [CrossRef] [Medline]
  103. Skevington S, O'Connell K. Measuring Quality of Life in HIV and AIDS: A Review of the Recent Literature. Psychol Health 2003;18(3):331-350 [FREE Full text] [CrossRef]
  104. Topolski TD, LoGerfo J, Patrick DL, Williams B, Walwick J, Patrick MB. The Rapid Assessment of Physical Activity (RAPA) among older adults. Prev Chronic Dis 2006 Oct;3(4):A118 [FREE Full text] [Medline]
  105. O'Brien K, Bayoumi A, Solomon P, Tang A, Murzin K, Carusone SC, et al. Evaluating a community-based exercise intervention with adults living with HIV: protocol for an interrupted time series study. BMJ Open 2016;6(10) [FREE Full text] [CrossRef]
  106. Fitbit. 2018. Fitbit Flex 2TM Fitness Wristband   URL: [accessed 2019-02-25] [WebCite Cache]
  107. Knobel H, Alonso J, Casado JL, Collazos J, González J, Ruiz I, et al. Validation of a simplified medication adherence questionnaire in a large cohort of HIV-infected patients: the GEEMA Study. AIDS 2002 Mar 8;16(4):605-613. [Medline]
  108. Heidari S, Babor TF, De Castro P, Tort S, Curno M. Sex and Gender Equity in Research: rationale for the SAGER guidelines and recommended use. Res Integr Peer Rev 2016 May;1:2 [FREE Full text] [CrossRef] [Medline]
  109. O'Brien K, Ibáñez-Carrasco F, Solomon P, Harding R, Cattaneo J, Chegwidden W, et al. Advancing research and practice in HIV and rehabilitation: a framework of research priorities in HIV, disability and rehabilitation. BMC Infect Dis 2014 Dec 31;14:724 [FREE Full text] [CrossRef] [Medline]
  110. Nova Scotia Health and Wellness. 2011. Surveillance Report On HIV/AIDS In NOVA SCOTIA: 1983 to 2011   URL: [accessed 2019-01-05] [WebCite Cache]
  111. Agarwal R, Kumar A, Lewis J. A pilot feasibility and acceptability study of yoga/meditation on the quality of life and markers of stress in persons living with HIV who also use crack cocaine. J Altern Complement Med 2015 Mar;21(3):152-158 [FREE Full text] [CrossRef] [Medline]

B-CAM: Brief Cognitive Ability Measure
C3Q: Communicating Cognitive Concerns Questionnaire
cART: combination antiretroviral therapy
CB&M: Community Balance and Mobility
CONSORT: Consolidated Standards of Reporting Trials
MOS-HIV: Medical Outcomes Survey for HIV
PLWH: people living with HIV
RCT: randomized controlled trial
REB: Research Ethics Board
REDCap: Research Electronic Data Capture

Edited by G Eysenbach; submitted 26.02.19; peer-reviewed by A Monaghan, K Berner; comments to author 10.04.19; revised version received 16.04.19; accepted 16.04.19; published 21.05.19


©Adria Quigley, Kelly K O'Brien, Marie-Josée Brouillette, Marilyn MacKay-Lyons. Originally published in JMIR Research Protocols (, 21.05.2019.

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