Response to comment on the article, “Yoga protocol for treatment of breast cancer-related lymphedema”

Byline: S. Narahari, Madhur. Aggithaya, Liselotte. Thernoe, K. Bose, T. Ryan Dear Sir, We welcome the suggestion by Loudon et al . that the currently available evidence of use of yoga in lymphedema affecting both upper and lower extremities should be enhanced by valid research and a valuable academic debate could now be beginning. Our paper explained how we used yoga and breathing as a self-care intervention for breast cancer-related lymphedema (BCRL). [sup][1] We compared Loudon et al ., using yoga as an intervention for BCRL for ease of practice by patients and its alignment, with Foldi et al .'s principles of lymph drainage. [sup][2] Loudon et al . adopted the yoga postures from Satyananda Saraswati's book, "Asana, Pranayama, Mudra Bandha." [sup][3] Although they do not name their methods of practicing postures as a "yoga protocol," their methods section states that the study was based on their previous publication on the study protocol, [sup][4] in which they called it a yoga intervention. There are multiple definitions of "protocol." We prefer it as a "precise and detailed plan for the study of a biomedical problem or for a regimen of therapy." The protocols are "instructions on what to do in particular circumstances. They are similar to guidelines but include less room for individual judgment. They are often provided for less experienced staff or for use in situations where eventualities are predictable." [sup][5] The yoga sessions in Loudon et al .'s practice included "documented breathing, physical postures, meditation, and relaxation techniques" according to the Satyananda Yoga tradition as explained in Table 1 of their article. There is consequently little room for individual judgment and practice has to be carried out as explained in the reference; hence, the yoga module used by Loudon et al . is named by us as a "protocol." The module was initially published under the "study protocol" and the same methodology was followed while doing a randomized controlled trial. Our study identified the yoga sequence to be practiced as self-care in BCRL. [sup][1] It began with warm up, prolonged exercise with appropriate rests, and suitable education of training staff. There is growing evidence to support this kind of exercises in BCRL. [sup][6] Table 1 of Loudon et al . lists 17 postures that are numbered from 1a to 17. We assumed that patients are advised to carry out this yoga in that sequence. More so, if given in digital video disc, patients are likely to follow the same sequence, unless instructed otherwise. We compared both methods of using yoga in Figure 5 of Narahari et al . [sup][1] Detailed explanation of the postures carried out was not mentioned by Loudon et al . instead they cited Satyananda Saraswati's book. We have adopted full descriptions of each practice of reference 3 of Table 3 from Loudon et al . Although Loudon et al . did not describe the variations from Satyananda Saraswati in their study protocol/trial, they described variations adopted by Satyananda Saraswati in response to our article. Since there was no description of the variation, we compared our yoga protocol to their method of using yoga as described in the cited reference. For example, Satyananda Saraswati describes the initial position of Marjari asana ( Marjari = cat) as Vajra asana , a sitting position. From the Vajra asana position, the person should rise while the buttocks and knees should be kept touching the floor. Then, the person should bend forward place the hands on the floor with the fingers facing anteriorly. The final position looks like a standing cat, hence named as Marjari asana . Loudon et al . changed this initial position to a standing cat. The yoga positions were developed by either mimicking the movements of animals (viz., backward bending in Bhujanga asana resembles the snake posture; Bhujanga = snake) or comparing the shape of the body in its final position ( Gomukha [like cow's face] asana ). …