The client is female, in her late 40’s.
She has pain in the right shoulder, probably due to the way she sleeps.
She has hip pain on both hips around the acetabular joint.
She sometimes experiences lower back pain.
She is recovering from an ankle injury.
Her stress level is 6/10, most likely due to her occupation as an attorney.
Additional symptoms include:
Migraines (info from intake); perimenopause from conversation during a session
She has a good home/social support with her husband and 2 kids.

The intake and all the sessions were completed online.

Client Goals:
1) She would like to decrease her pain.
2) She would like to maintain her health and increase her strength.

Yoga Therapist Goals:
Koshas: _x_Annamaya _x_Pranamaya _x_Manomaya __Vijñanamaya __Anandamaya

Integral Yoga: __x_Hatha __x_Raja ___Bhakti ___Karma ___Jnana ___Japa

Short Term: I would like to help her reduce the pain and regain balance in her body through strength and mobility work.

Long Term: I would like to help her manage her stress levels through incorporating meditation and/or breathing practices.

Stress Management Manual

Adaptive Yoga Manual

Rountree, S. The Runner’s Guide to Yoga: A Practical Approach to Building Strength & Flexibility for Better Running. Velopress. 2012.

Stiles, M. Structural Yoga Therapy: Adapting to the Individual. Red Wheel Weiser. 2000

Lorenc A, Feder G, MacPherson H, Little P, Mercer SW, Sharp D. Scoping review of systematic reviews of complementary medicine for musculoskeletal and mental health conditions. BMJ Open. 2018;8(10):e020222. Published 2018 Oct 15. doi:10.1136/bmjopen-2017-020222
https://pubmed.ncbi.nlm.nih.gov/30327397/

• Yes

Awareness practice
Neck/Upper body warmups
Tabletop pelvic tilt/wave cat/cow
Hip stretches (Mukunda Stiles)
Sunbird
Modified Vasisthasana (side plank)
Progression of Bridge to block to 1 legged bridge
Windshield wiper
Yoga nidra

Her homework was to continue to work on intrinsic foot strengthening work for balance and stability.

She had started an exercise plan to lose weight and gain strength back in October of last year.
Her plan involved following the Mayo Clinic weight loss videos as well as incorporating a separate a running program for weight loss. She was pleased with her progress, but in the process had injured her ankle. Her ankle seems to be mostly healed now and the pain seems to be resolved. She did not mention any other pain during the check in.

Today’s session seemed like the one in which we finally settled into a rhythm of physical and mental practices that felt more natural. The client was more focused on the physical practices as being immediately helpful for her. She was not opposed to incorporate a mental practice (i.e. meditation or mindfulness) but it was not a high priority for her at home, and since she was so busy it typically didn’t happen if it was given for homework.

Because she seemed to be in a good place, we worked on overall strengthening including torso/core, spinal extensors and leg strength. Her left hamstring cramped a little while performing the bridge, so we immediately stopped and worked to stretch it out.

I need to remember every day is different. Because she had said the previous week she wasn’t experiencing any pain, I assumed that the pain was gone and that she wasn’t experiencing any pain this week. However, when I asked, she did say she had some minor pain—though she didn’t show it through her movements or facial expressions.

I’d like to introduce more mental practices we can do during our session for calming, focusing and/or stress relief, as she doesn’t mind practicing them when we are together. It’s just more difficult for her to find motivation to do them on her own at home.

• Yes

Awareness practice
Eye exercises
Neck warmups
Reed (lateral stretch)
Dynamic twist
Pelvic tilt/wave cat cow
Hip warmups
Downdog to Warrior 1 with warm ups
Mental alternate nostril breath
Supine windshield wiper
Yoga nidra

She liked the concentration required to do the mental alternate nostril breathing. We talked about how she could incorporate it throughout her day--perhaps while waiting in line, at a doctor’s office, etc. If so, she could practice 3 rounds.

During the check in, the client said she was doing ok, but could feel the beginnings of a headache. It didn’t manifest fully at the time that we met, and she felt fine to move forward with the session. She also did not go running earlier. She did not have any pain other than the headache.

On the physical level, we kept the session low-key, but incorporated some poses that provided a challenge for balance, strength and endurance. We did a breakdown of downward dog to provide a stable foundation of strength for her arms and shoulders. Performing this asana was helpful in addressing upper body and back strength, which she wasn’t focused on with her previous activities. The transition to Warrior 1 provided an opportunity to stretch the muscles that she uses for running as well as to provide a more natural way to focus on her strength and balance.

I introduced Netra vyayamam and a mental version of the alternate nostril breathing for more subtle practices for the client to work with. The eye exercises provided a nice way to mindfully stimulate and relax the mind through the physical stimulation and relaxation of the eyes. The client also shared that she really enjoyed the mental version of alternate nostril breathing. The practice required so much concentration on her part, that it compelled her to truly focus and clear her mind.

She has enjoyed these more spontaneous sessions, so we will continue to take each day as it comes and create a practice that incorporates how she is feeling when we meet. I will continue to make sure I introduce some sort of relaxation or stress reducing practice as part of the session.

• Yes

Awareness practice
Neck warmups
Reed – (lateral stretch)
Dynamic twist
Thoracic twist
Pelvic tilt, Wave cat cow
Hip stretches/circles
Sunbird
Downdog – 3 legged to open hip
Triangle to half moon balance and hold
Windshield wiper
Yoga nidra
Nadi suddhi
Eyes/tongue/hands practice

She will take the next few days to notice if she uses one side more than another or holds an asymmetrical position—basically notice how she uses each side of her body.

She can also use the eye/tongue/hand practice whenever she notices stress or before sleep.

It had been over a month since our last session. The client stated that recently her left hip had been creating a “clicking, snapping sensation” as she walked. It didn’t always happen every time, but when it did, it felt “disturbing”—it “doesn’t feel right.” She reported that otherwise things were ok. She also mentioned that she had been busy because it was the end of the school year.

This session felt nice because we just let things flow naturally, which I think allowed us to pick up where we left off without too much effort. After checking in and confirming that at the time of the session, there was no pain on the left leg, we agreed to continue with strengthening work. A mini sequence included downward dog in the warm up, again for supporting the upper body. The graduated balance work of triangle to half moon revealed that there was weakness in the left side of her body—the same side with the clicking sensation. This came as a slight surprise to the client, as she thought she had been diligent about exercising in an even manner. This provided a good segue into talking about being mindful about her movement throughout the day in case she was favoring one side without noticing it. The mindful moment could also create a pause in her day when she could rest her mind and really tune in to the present moment.

I wanted to suggest another simple tool she could use to aid in stress reduction and to help with relaxation. I offered the eyes/tongue/hands practice after the yoga nidra as a short, stress relieving exercise that could produce considerable effects. This was something she could potentially use if she found her mind keeping her awake at night. She did find it helpful.

Since this client was my first Case Study, it took a few sessions for me to get into a rhythm to figure out how to offer yoga therapy and what that meant. Discussions with my mentor helped bring clarity and things proceeded more smoothly from that point on.

The client enjoyed and felt benefit from the physical practices we did—especially since she was focused on strength and balance for our time together. I was able to create sequences that were both mentally and physically challenging, yet gentle on her joints and body. (Annamaya, Hatha) It was difficult for me to discern if there was a lessening of pain overall because the client did not provide clues through body language or facial expression. (Manomaya) During the sessions where I inquired, the pain remained the same – neither increasing nor decreasing. For the future, in addition to observation, I will have to figure out language to use at least in regards to pain. When I specifically asked about pain for the purposes of the practicum notes, it tended to interrupt the flow of the session and seemed more of an annoyance to the client.

Although she wanted to concentrate on the physical, I wanted to be able to offer her other simple tools she could use to manage her stress and the more subtle aspects of her being. We talked about subjects including breathwork and mindfulness as methods she could use to calm the nervous system, slow down the mind, and reduce stress. (Pranayama, Manomaya, Raja) In conversations, it seemed that working on these practices were not as much of a priority as the physical practices for the client. On a positive note, she was willing to do these practices with me during our sessions. Hopefully over time, she will be able to see the benefits of a daily or consistent mindfulness or meditation practice. At the end of our time together, she was pleased with her progress and would be happy to continue with me at a future date.

1 intake and 7 sessions

We’re ending the sessions for now, as she is in a good place. She has some tools she can use if she can remember and make time to use them.