-Intake form reported the primary goal of upper back pain and weakness.

-Client also reported longer term goals of maintaining balance, being able to walk daily for up to 30 mins, returning to yoga class, and returning to bike riding this Summer.

-Main goals are still UBP and improving strength and posture.

-Assessment - Observed client in Breath Awareness, as well as seated (on bed), quadruped, and supine asana.

-Client reported she would like to do 2 sessions a week rather than one. She has travel plans at the end of the month and would like to get started on work together before her trip.

-Initial thoughts: pitta & vata seem to be aggrivated both with lifestyle and conditions. The rajas tendancies to do even when retired and go rather than rest seem to be themes. Although this client mentioned she does not like "sedentary yoga" my initial thought was she could benefit from grounding / restorative practices or yoga nidra.

-Clarified questions from Intake (goals & concerns) Client reported additional goals of maintaining balance, being able to walk daily for up to 30 mins, returning to yoga class, and bike riding this summer. Main goals are still UBP and improving strength and posture.
Assessment - Observed client in Breath Awareness, as well as seated (on bed), quadruped, and supine asana. Client had a few issues with setting up the tablet so we will do some standing next time when she is on her laptop and can adjust the screen a bit more easily.
We discussed practices she likes, dislikes, and is open to. We finished with Cheri Clampett's cocoon of light and supported reclined butterfly pose and she seemed to really enjoy that.
Client reported she would like to do 2 sessions a week rather than one. She has travel plans at the end of the month and would like to get started on work together before her trip.

Post Assessment Homework: Exhale on exertion for daily tasks and knee folds in supine to activate deep core strength.

*Aim to practice daily asana + PT routine (see below) to familiarize the flow and build up tolerance.
Daily Asana & PT Homework Flow

Elongated Exhale & Ujjayi Pranayama

Joint Articulation Practice for All Warmup

Neck stretches, Upper Trap Leaning/ ear to shoulder stretch, shoulder rolls, gentle twist, knee to chest with ankle rotations, JanuSirsasana/ hamstring stretch, & seated piriformis stretch crossing ankle over leg.

Standing at the Wall

Mountain Pose with head press into wall

Goddess Pose Arms

Half Moon

Wall Chaturanga Dandasana/ Wall Push Ups (5 times this week)

Lunge/ Calf stretches

Wall Slides/ Chair Variation Near the Wall (5 slides do not hold)

Goddess near the Wall (4 times -do not hold the pose)

With Chair -Not Seated

Warrior 2 (+ straighten and bend front knee 3 times)

Side Angle, Warrior 2, Triangle (hold each pose for 10 seconds or 5 breaths this week)

Twist (Parivrtta Prasarita Padottanasana) with forearm on chair seat -Both sides (3 times each side)

Come to floor kneeling in all 4’s

Cat/ Cow

All 4’s to Child’s Pose

Shhh Breathing to activate deep core on all 4's

Quadruped Hip Extension (Alternating) / option to practice the slower version of bird dog (opposite hand and foot raise with shhh breath or exhalation then lower 3x then switch sides)

Move onto back

Dead Bug Pose / option to practice the knee fold we have been doing instead (using Shhh breath or exhale to lift the leg)

Pelvic Tilts

Bridging (adduction with Block between thighs) & Single Leg Raise (both sides) / option to combine single leg raise with bridging in the future for now you have the option to test it out by hovering one foot off the floor or lifting just the heel then switching- we will try to practice it this way on Monday and see how it feels.

Low Trunk Rotations / option to practice slow supine twist once on both sides instead of the multiple rotations

Finish with Yoga Nidra Recording in bed or on the floor in Mountain Brook -We will add this in with the recording next week but feel free to do a savasana after your practice tomorrow.

Options to continue from PT homework for days you are not walking or biking & feel up to it

Clam Shell in side lying (both sides)

Seated in chair -knee extension with 1# (both sides)

Seated in chair -Forward Bend / included this in brief JAPA warm up

Chair Flow with Abduction/ Green Band / included this without the band at the wall

Warrior 2 Walks & Lateral Walks with Green Band

*Guided Meditation/ Yoga Nidra/ Sequential Muscle Relaxation for bed in morning or evening if there is pain (this will be provided as a recording you can play on your phone, computer, or tablet).

*2 or more walks a week (in nature whenever possible). Adding the practice of So Hum meditation with each step. -If the weather is not great, practice inside a room slowly walking for 10 minutes practicing So Hum. Inhale So... step, exhale Hum... step, keep the pace at a rhythm that works for you and feel free to set a timer on your phone.

*Ujjaiyi & Elongated Exhale Breathing for pain management in daily practice and again throughout the day as needed if there is a flare. Elongated exhalation brings our body to a parasympathetic nervous system state allowing resting and repair.

1) Mason H, Vandoni M, Debarbieri G, Codrons E, Ugargol V, Bernardi L. Cardiovascular and respiratory effect of yogic slow breathing in the yoga beginner: what is the best approach? Evid Based Complement Alternat Med. 2013;2013:743504. doi: 10.1155/2013/743504. Epub 2013 Apr 23. PMID: 23710236; PMCID: PMC3655580.
Elongated exhalation brings our body to a parasympathetic nervous system state allowing resting and repair. "Ujjayi resistance breathing, a breathing practice taught by the yogic tradition, reduces airflow, and during expiration it increases the intrathoracic pressure due to a slight contraction of the glottis muscles, potentially resulting in intensified vagal activity.”₁

2) Jerath R, Edry JW, Barnes VA, Jerath V. Physiology of long pranayamic breathing: neural respiratory elements may provide a mechanism that explains how slow deep breathing shifts the autonomic nervous system. Med Hypotheses. 2006;67(3):566-71. doi: 10.1016/j.mehy.2006.02.042. Epub 2006 Apr 18. PMID: 16624497.
Slower breathing affects "inhibitory impulses and hyperpolarization current are known to synchronize neural elements leading to the modulation of the nervous system and decreased metabolic activity indicative of the parasympathetic state"₂

3) Lu YH, Rosner B, Chang G, Fishman LM. Twelve-Minute Daily Yoga Regimen Reverses Osteoporotic Bone Loss. Top Geriatr Rehabil. 2016 Apr;32(2):81-87. doi: 10.1097/TGR.0000000000000085. Epub 2015 Nov 5. PMID: 27226695; PMCID: PMC4851231.
Standing & Supported Reclined Poses influenced by: “Out of the 1,000 people with osteoporosis who enrolled in the study, 241 patients practiced 12 yoga poses at least four days a week, holding each pose for at least 30 seconds. The study found statistically significant improvement in bone density for the spine and femur among those who practiced yoga.” The “side effects” of yoga include better posture, improved balance, enhanced coordination, greater range of motion, higher strength, reduced levels of anxiety, and better gait.8–17 Improved posture directly addresses spinal fractures, while all of these documented benefits of yoga reduce the risk of falling, which is the main cause of all other osteoporotic fractures.8–17" ₃

4) Ghasemi GA, Golkar A, Marandi SM. Effects of hata yoga on knee osteoarthritis. Int J Prev Med. 2013 Apr;4(Suppl 1):S133-8. PMID: 23717763; PMCID: PMC3665019.
"Findings showed that pain and symptoms were significantly decreased and scores of daily activities, sports, spare-time activities, and quality of life were significantly increased in the yoga group."₄

5) Singh P, Singh B, Dave R, Udainiya R. The impact of yoga upon female patients suffering from hypothyroidism. Complement Ther Clin Pract. 2011 Aug;17(3):132-4. doi: 10.1016/j.ctcp.2010.11.004. Epub 2010 Dec 18. PMID: 21742277.
"It can be concluded that yoga is valuable in helping the hypothyroid patients to manage their disease-related symptoms. Yoga may be considered as supportive or complementary therapy in conjunction with medical therapy for the treatment of hypothyroid disorder."₅

• Yes

-Follow up to check in with client about how she felt after the intake/ assessment session

-Client clarified how much time could be spent on homework

-Client added more travel plans after the vacation she has planned in two weeks so we readjusted our schedule to meet a bit more frequently before her trip to familiarize with the care plan and get a healthy habit/ routine going with it.

-Asana started with JAPA in Chair, Chair pose hovering over the chair with shoulder flex/ extension 3x, small pulses in chair pose 3x

-Using the wall as support: Standing cervical retraction 3x, roll down 1/2 way, Angel arms 3x, Tree (a few inches away from wall) Bilateral, Goddess 6x, Bilateral Warrior 2 (flex/ extension of front knee + shoulder ab/adduction). Bilateral Standing Twist (Parivrtta Prasarita Padottanasana) forearm on chair seat 2x ea.

-Kneeling: Supported child's pose, Cat/Cow, Bilateral Bird/dog 3x ea., Wags

-Supine: Shhh breath to activate deep core, Shhh with knee fold (supine hip flexion), Articulated Bridge with block at thighs 3x (once with arms moving), Supine twist, Supta Padangusthasana (with strap) forward and across Bilateral, Knee across chest.

-Supported reclined butterfly for deep relaxation

Homework for this week is to practice the breathwork

Client seems eager to get started with the homework and practiced the breathwork and knee fold core strength work we covered last intake/ assessment session.

Client is not as interested in the practices I have chosen for her that I feel would best suit both PMR, OA, Hashimotos, and her rajistic tendancies to busy herself with work even while retired. While I am keen on choosing cooling, subtle, restorative & reflective practices she is eager for a workout to reduce pain, build, strength and improve posture. I feel like I have to sprinkle in small bits of mindfulness and rest as she is a bit less interested in this part of the plan. I have explained that this is not a replacement for PT and that it is a whole person approach at length but I do not feel we are at the stage she'd like to work on more than the physical with me yet.

Client is moving abroad in April so she is unclear if she can continue but has expressed she would like to accommplish her goal of walking daily 20-30 mins and biking in the summer by end of May. We will do 2 sessions a week till she goes on vacation (last week of april) and then take 2 weeks off in early April for her to get moved and settled.

• Yes

15 minutes of follow up checking in about how the last practice felt and if there was time to practice anything from the list during the day between.

Added on the remaining practices from the care plan that we did not cover in the first session:

Wall: Half Moon, Wall Push Up/ Chatturanga, Calf Stretches, Sliding Chair Pose

Wall with Chair near front foot for balance: Side Angle & Triangle

Practice the HW that we covered in past two sessions 3x a week to daily

Reclined Resting Pose instead of Butterfly/ Restorative Reclined Butterfly Caused pain for her knees.

Goddess pose also caused discomfort when held but not dynamically moving in and out. We discussed cutting Goddess, Restorative Child's Pose, and Reclined Butterfly out of the plan because it caused pain in her knees. I think that this practice would be better suited on the bed or couch next time. Weight bearing external rotation and flexion seems especially problematic as well as holding for long periods in that position.

Next session I will have her run through the entire routine herself to see if she has any questions or adjustments to the plan.

• Yes

There were two additional sessions between this and the last noted above. During this time KN shared how it was hard for her to follow the homework notes and she would like something with pictures and a larger font. In addition, she reflected that the inital commitment of 30 minutes per day was too ambitious and she prefers to practice a "YTh routine" only 10-15 minutes a day going forward and have a walk or ride the stationary bike as an additional option when pain is not flaring up. She stated she did not want to have the yoga nidra included in the homework and the so hum walking meditation.

We revised care plan & discussed how it might work best during the next month(s) she will be travelling. A practice includes the chair JAPA and standing asana. B practice includes the quadruped and reclined practices (which can be done from a bed). Setting the goal to practice from A or B daily with the understanding that some days she will need to take off or rest. KN mentioned if she has it set for every day she is more likely to do it.

We had had some discussion around the timeline she gave herself to achieve her goals and also that one needs to practice something before they can see progress from that practice. We discussed journalling in the past but she was not a fan of it. I asked if instead of a journal having a calendar she can tick off days she practices on to chart her sadhana would be better suited. Next session she not only reported having charted her energy, pain, and activities she also purchased a special agenda book for this sole purpose.

At the start of this session we spent time following up on how the last week went. KN reported that she adjusted her Pain management from 1mg to 4-5mg Prednisone per day (with Dr supervision). She has been walking daily 30+ mins without her normal need for a rest day. She got to both A and B once each despite being on vacation last week.

KN is moving abroad tomorrow. She reported she would like to practice Yoga Nidra and pranayama on the plane. She plans to practice her A or B HW daily at most and 3x a week at least.

Client reported that she felt like after 2 years she should be in complete remission with PMR but it was still causing some pain. She reflected that she had titrated down very quickly from 40mg a day to 1/2-1mg prior to our working together. On the lower dosage she had to rest every other day after PT or yoga or walking and had low tolerance and stamina on walks longer than 10mins.

When she went up to 5mg she had no pain at all. She reported that it was wonderful and she doesn't think its so bad to stay on the prednisone a bit longer if it can help her live pain free. This shift in her relationship to the medication and PMR symptoms is a huge transition. She reflected how she isn't her PMR or her medication. This is just a tool for her to live her life with less limitations.

The most remarkable thing about this session was how KN mentioned her relationship to her body and condition and her medications for it. At the start her relationship to her body was one where she would call it names. She felt she should be in different shape and not have pain she did after 2+ years of PMR. After starting yoga therapy, charting her sensations, energy, and her activity she made a shift with her doctor so that she is not experiencing as much pain daily. She was able to let go of her attachments to being without medication or being PMR free. She was able to see herself as her true self in a sense and by seeing this she doesn't need to be defined by a condition or medication. It is simply a tool to assist her life's work with less pain.

I did not expect this turn of events but was very moved by it. Our work seemed to focus on the physical but once we were able to add the vijnanamaya kosha in with reflection and reviewing the big picture it seemed that things fell into place much more naturally.

I came into this first case study client work a bit too zelous. I wanted to ground her and she wanted to literally take flight (travelling to 4 different locations over the course of 3 months). I wanted to slow her down with restorative and reflective practices in her vata stage of life when she seemed quite pitta and rajistic in nature. KN alternatively wanted to amp things up and seemed to want to reverse her condition through asana. I think we both found a common ground and learned from this work together. The practice of charting rather than journalling worked to provide deeper insights. In the end she was suggesting restorative and subtle practices for her plane ride to calm her travel nerves.

I think I learned two things about this client experience. One lesson was to not front load the client with the whole care plan right away but ease into practices and adjust as we go. I also needed to add a section to clarify how long the client can comit realistically to practice each day or week as this kept shifting with KN. Establishing that information earlier on would have saved us time and not overwhelmed her with material. The other thing I learned was that physical practice can yeild profound insights too and is not in any way less than the more subtle practices I was itching to use with her. In the end this was not just about her upper back pain or PMR pain, etc but rather about self observation, acceptance, and shifting her view of herself while living with conditions that requires medication.

I feel very fortunate to have worked with this client both for her patience and time she invested into our sessions.

We have plans for a follow up session once KN is settled in her new volunteer position abroad in a few weeks. We set the goal to practice what she can (A or B and or walks) with the understanding she may or may not have time or energy for it.