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Methods
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Participants
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There were 47 persons, of whom 16 were (EP) and 31 were second-generation immigrants from the ML. The groups were comparable with respect to education, socio-economic status and age range (28–50 years), but differed in their (i) social organization and (ii) religion.
Both groups had lost their relatives and friends or their homes as a result of the tsunami. All of them were in normal health based on a routine clinical examination and were able to perform the yoga practices. All particip- ants gave their consent to take part in the study.
The project was approved by the institutional ethics committee.
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Design
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All 47 participants were assessed on day 1 and on day 8 after receiving a 1 week program of ‘Vivekananda yoga’, detailed under ‘Interventions’ subsequently
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Assessments
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Self rated Symptoms of Distress
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The participants rated the intensity of their feelings with respect to four symptoms, using a 1 0 c m visual analog scale (VAS). The four symptoms were fear, anxiety, disturbed sleep and sadness. These four symptoms were selected as they are commonly reported by disaster survivors (3). The electrocardiogram (EKG), breath rate and skin resistance were recorded in all participants. These recordings were made simultaneously using a digital four channel polygraph (Medicaid, Chandigarh, India), with the participants seated in a quiet room which was set aside for medical treatment of camp participants.
After coming to the recording room the participants were asked to be seated for 5 min followed by 10 min of recording.
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Assessment Procedure
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Visual Analog Scales
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Emotional impact in terms of fear, anxiety, disturbed sleep and sadness were calculated by measuring the distance in millimeters from the left of the analog scale (where the left end of the scale corresponded to ‘0’ and the right end to ‘10’). All the analog scales were scored in one direction to make it easier to explain the method to the participants.
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Autonomic and Respiratory Measurements
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Polygraph recordings were taken of the (i) ECG using standard limb lead I, to obtain the heart rate by counting the number of QRS complexes in a minute, (ii) respiration using a mechanical stethograph placed below the costal margin, to get the breath rate and (iii) the skin resistance using Ag/AgCl electrodes placed in contact with the volar surfaces of the middle and ring fingers of the right hand, with a current of 15 m A passed between the electrodes.
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Intervention
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Philosophy of Vivekananda Yoga
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65 brings about relaxation and also induces a balanced mental state. The participants were taught ‘Vivekananda Yoga’ which is an integrated yoga program combining practices intended to act at physical, emotional, intellec- tual and even at spiritual levels. This yoga program is derived from principles in ancient texts (Patanjali ’ s Yoga Sutras and Taittreya Upanisad ) which emphasize that yoga should promote health at all levels (4,5). Another ancient Indian text (the Mandukya Upanisad) considers the ‘body’ as three parts namely. the physical part ( sthula sharira), a subtle or inner part (sukshma sharira ) and the causal body ( kaarana sarira ) (7). These three parts are represented as five levels of existence (pancha koshas) (5). These are the physical level ( annamaya kosha ), the level of subtle life energy ( pranayama kosha ), the level of emotional thinking (manomaya kosha ), the level of rational thinking and judgment ( vijnanamaya kosha) and the level of complete health and happiness (anandamaya kosha ). In this description the physical level and physical part (of the body) (sthula sharira) are the same. The levels of 85 subtle energy, emotional and rational thinking form the ‘subtle inner part’ ( sukshma sharira ) and the level of complete health and happiness is the causal body (kaarana sharira ). A balance between these three parts (shariras ) i s believed to be necessary for complete health. Swami Vivekananda Yoga Research Foundation, Bangalore is an established yoga center specializing in yoga education and using yoga as a therapy. The institute has developed an integrated yoga program based on the principles mentioned above and the ‘eight limbed yoga’ (astanga yoga) o f Sage Patanjali which acts at different levels of existence. These eight ‘limbs’ are: (i and ii) rules for good conduct (yamas and niyamas ), (iii) physical postures (asanas ), (iv) voluntarily regulated breathing (pranayama ), (v) sensory withdrawal ( prathyahara ), (vi) focused thinking ( dharana ), (vii) meditation (dhyana ) and (viii) experience of transcendence ( samadhi ).
The practices which act at different levels are as follows: (i) and (ii) act at the level of rational thinking and judgment; (iii) at the physical level; (iv) at the level of subtle life energy; (v) and (vi) at the level of emotional thinking (vii) and (viii) at the level of complete health and happiness. This traditional style of yoga has come to be known as ‘Vivekananda Yoga’ (8).
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Vivekananda Yoga Program
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The yoga sessions were conducted in small groups with one teacher for around ten participants. The teachers 15 were trained in the ‘Vivekananda system’ with a 1-year certificate course. The sessions were for 60 min daily, for 8 days and included: loosening exercises (shithilikarana vyayama, 1 0 min), physical postures ( asanas , 2 0 min), voluntarily regulated breathing ( pranayama, 1 5 min), and yoga-based guided relaxation (15 min). Loosening exercises ( Sithilikarana Vyayama ,in Sanskrit) are a set of practices intended to increase mobility of joints and to prepare for the practice of yoga postures. The techniques involve repetitive movements of 25 all the joints from the toes up to the neck. For example, more complex joints such as the shoulder could have movements such as rotation, flexion, extension, abduc- tion and adduction. For the practice of yoga postures ( asanas ) participants were asked to be in a posture as long as they could with comfort and with normal breathing. The following yoga postures were taught: mountain posture (tadasana ), lateral arc posture ( ardhakatichakrasana ), hand-to- foot posture ( padahasthasana), half wheel posture (ardhachakrasana ), sitting with a sideways twist posture (vakrasana ), back-stretching posture ( paschimothanasana ), half lotus posture ( ardha-padmasana ), diamond posture (vajrasana ), camel posture (ushtrasana ), moon posture (shashankasana ), crocodile posture (makarasana ), cobra posture ( bhujangasana ), locust posture (shalabhasana ), shoulder stand posture ( sarvangasana ), fish posture (matsyasana ), and corpse posture ( shavasana). These postures are shown in Fig. 1. While seated with eyes closed keeping the neck and back as straight as possible, voluntarily regulated breathing techniques (pranayamas ) were practiced where the nostrils were manipulated by adopting a specific hand gesture ( mudra) where the index finger and middle fingers were flexed against the palm keeping the thumb and other fingers extended. The ring and little finger were used to regulate the breathing through the left nostril while the thumb was similarly used for the right nostril. For right nostril yoga breathing ( surya anuloma viloma ) and left nostril yoga breathing (chandra anuloma viloma )
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inhalation and exhalation were exclusively through the right and the left nostril respectively. These were practiced for nine rounds each. During alternate nostril breathing ( nadishudhi ) the practice began with exhalation through the left nostril, inhalation through the same side followed by exhalation and then inhalation on the right side. This was considered as one round and practiced for nine rounds. Bumble bee practice ( brahmari ) involved exhalation with a humming sound with the mouth closed and the index fingers on either side in the ears. This practice was performed for five rounds. Guided relaxation involved lying in the corpse posture ( shavasana ) and relaxing parts of the body beginning with the toes and moving upwards according to instructions. These techniques were selected either because previous research showed that they reduced physiologic arousal (9,10) or based on our unpublished, clinical observations.
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Data analysis
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The data of the two groups (EP and MS) recorded before and after the yoga intervention were compared for each group separately, with a two-tailed t -test for paired data. The correlation between each of the self rated indicators of distress (fear, anxiety, sadness and disturbed sleep) and each of the psycho-physiologic variables (i.e. the heart rate, breath rate and skin resistance) was assessed using the Pearson correlation coefficient test.
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