International Journal of Yoga

: 2017  |  Volume : 10  |  Issue : 1  |  Page : 50--51

Response to yoga protocol for treatment of breast cancer-related lymphedema

Annette Loudon1, Tony Barnett1, Neil Piller2, Maarten A Immink3, Andrew D Williams4,  
1 Centre for Rural Health, University of Tasmania, Launceston, Tasmania 7250, Australia
2 Department of Surgery, School of Medicine, Flinders University, Adelaide 5042, South Australia, Australia
3 School of Health Sciences, University of South Australia, Adelaide 5000, South Australia, Australia
4 School of Health Sciences, University of Tasmania, Launceston, Tasmania 7250, Australia

Correspondence Address:
Andrew D Williams
School of Health Science, University of Tasmania, Locked Bag 1322, Launceston, TAS 7250

How to cite this article:
Loudon A, Barnett T, Piller N, Immink MA, Williams AD. Response to yoga protocol for treatment of breast cancer-related lymphedema.Int J Yoga 2017;10:50-51

How to cite this URL:
Loudon A, Barnett T, Piller N, Immink MA, Williams AD. Response to yoga protocol for treatment of breast cancer-related lymphedema. Int J Yoga [serial online] 2017 [cited 2023 Mar 24 ];10:50-51
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Full Text

Dear Sir,

In their recent article, Narahari et al.[1] cite and examine our article, "Yoga management of breast cancer-related lymphoedema: A randomised controlled pilot-trial" [2] and make several important factual errors, the most significant of which is that they incorrectly call our publication a "Protocol for Yoga and BCRL." In fact, the aim of our publication is quite different:

This paper presents the results for the primary outcomes of arm volume of lymphedema and extracellular fluid and the secondary outcomes of tissue induration, sensations, and their limiting effects and quality of life. [2]

We believe the incorrect assumptions that Narahari et al. have made are based on their interpretation of [Table 1] in our publication which provided a list of the practices and postures used in our trial. This table did not provide a detailed explanation of the way the postures were carried out or of their purpose and was intended to be understood as a basic outline only. We also provided reference to the rationale for our choice of practices in an earlier publication by our team. [3] Our intention is to publish the yoga protocol used in our trial which will offer the full description of how yoga was used to maximize lymphatic clearing, improve kinematic movement patterns, stability of the shoulder and lower body, improve posture, and reduce stress. Nevertheless, we shall address some of the incorrect assumptions made by Narahari et al.{Table 1}

Firstly, the positions of our postures and ease of movement during positional change have been misrepresented. The position in which the postures were actually carried out is given in [Table 1] below, reflecting ease of positional change. In addition, contrary to what Narahari et al. postulate, our practices were based on clearing the lymphatic system proximal to distal and using the breath with each movement. [3] The peripheral joints of wrists, fingers, ankles, and feet were fully used, based on the method described by Moseley et al. [4] Our reasoning for using the three-part yoga breath for this cohort of women will appear in our protocol publication.

As Narahari et al. point out, we did not use bhastrika. To clear the lymphatic system back into the venous system, we used the full yoga breath, chanting, and abdominal contraction with exhalation, including several postures with abdominal contraction and strong exhalation. [3] The focus in our trial was on safety and as is the practice in Australia, we were conservative in our choice of pranayama techniques for this cohort of women, only two of whom had previously done yoga. We consider different cultural applications of yoga for breast cancer-related lymphedema a benefit.

Unlike our randomized controlled study, Narahari et al. provide no evidence of a control group. We stated that in comparison to the control group, there was no reduction in arm volume of lymphedema measured by circumference; however, within the yoga intervention group, there was a significant reduction. This result, we believe, would be a fairer comparison for Narahari et al. to make. One month after the completion of the yoga intervention, the significant reduction in arm volume for the yoga intervention group had changed back to the original volume and we proposed that a longer trial was needed to maintain the volume difference. As the trial of Narahari et al. was over 3 months, the reduction their women experienced adds evidence to our supposition. However, perhaps a valid comparison of these two trials is difficult as the method used by Narahari et al. to calculate arm volume was not reported. In addition, we note that yoga is only one component of the integrated intervention they offered their eight women.

While we believe that our yoga protocol has been incorrectly interpreted from the brief description in the paper discussing the primary outcomes of our pilot trial, we invite discussion with Narahari et al. on this important area of yoga. We believe the philosophy of yoga supports collaboration and unity to improve the condition of those with lymphedema who live in a variety of cultures and environments. As researchers in this field, we share with Narahari et al. our dedication to support valid research methodology to improve the lives of this cohort of people worldwide.

Financial support and sponsorship

This study was supported by grants from the Swan Research Institute and the Faculty of Health Sciences Seed Funding, UTAS.

Conflicts of interest

There are no conflicts of interest.


1Narahari SR, Aggithaya MG, Thernoe L, Bose KS, Ryan TJ. Yoga protocol for treatment of breast cancer-related lymphedema. Int J Yoga 2016;9:145-55.
2Loudon A, Barnett T, Piller N, Immink MA, Williams AD. Yoga management of breast cancer-related lymphoedema: A randomised controlled pilot-trial. BMC Complement Altern Med 2014;14:214.
3Loudon A, Barnett T, Piller N, Williams A, Immink MA. Using yoga in breast cancer-related lymphoedema. J Lymphoedema 2012;7:27-36.
4Moseley AL, Piller NB, Carati CJ. The effect of gentle arm exercise and deep breathing on secondary arm lymphedema. Lymphology 2005;38:136-45.