I reviewed the intake form with JN & followed up on how her rehab of the left hamstring injury went. She reported that she stopped going to physical therapy a month ago and has continued some homework herself but not all.

JN showed me some of her current exercise routine & described her work as it relates to her neck/ upper back pain.

She said that can commit to 20 mins of yoga therapy homework per week day. She already has daily spiritual practices, meditation, pranayama, and teaches Asana 5x a week demonstrating throughout. She journals, spends time in nature daily, eats a nourishing vegetarian diet mainly prepared at home, and has good sleep and wake times.

Post Intake/ Assessment Homework: For JN to reflect about her schedule and where she could create a bit more balance each day. Rather than very busy days that require total rest days afterwards could there be a bit more balance? What would that look like?

2 different asana practices. One for her busy teaching days & one for the slow days she has each week

Plan A for busy days: 1:2 ratio breathing, neck stretches, towel (or yoga strap) assisted rotation, subclavius & paraspinal stretch, goddess arms at the wall with the block.

Plan B for light days: Brahmari, Serratus anterior wall slides with resistance of loop (or yoga strap), cervical retraction seated, chin tuck and nod for deep neck flexor strength, prone on bolster maintaining neutral spine (for head on neck alignment) add Y & W, on mat prone shoulder extension, side lying shoulder external rotation, horozontal abduction & cheerleader with resistance, Z fold blanket supine with restorative pec release.

1) Seidi F, Bayattork M, Minoonejad H, Andersen LL, Page P. Comprehensive corrective exercise program improves alignment, muscle activation and movement pattern of men with upper crossed syndrome: randomized controlled trial. Sci Rep. 2020 Nov 26;10(1):20688. doi: 10.1038/s41598-020-77571-4. PMID: 33244045; PMCID: PMC7692548.
While this study examined men with upper crossed syndrome I found the exercises and results helpful as a starting place to choose appropriate asana for JN who has similar imbalances.

2) Li Y, Li S, Jiang J, Yuan S. Effects of yoga on patients with chronic nonspecific neck pain: A PRISMA systematic review and meta-analysis. Medicine (Baltimore). 2019 Feb;98(8):e14649. doi: 10.1097/MD.0000000000014649. PMID: 30813206; PMCID: PMC6407933.
While this meta-analysis did not have specific practices listed in regards to methods it was helpful to look into the results across 10 trials. "We draw a very cautious conclusion that yoga can relieve neck pain intensity, improve pain-related function disability, increase CROM, improve quality of life, and boost mood."

3)Liu, Ai-Min & Chu, I-Hua & Lin, Hwai-ting & Liang, Jing-Min & Hsu, Hsiu-Tao & Wu, Wen-Lan. (2021). Training Benefits and Injury Risks of Standing Yoga Applied in Musculoskeletal Problems: Lower Limb Biomechanical Analysis. International Journal of Environmental Research and Public Health. 18. 8402. 10.3390/ijerph18168402.
I thought this would be helpful going forward if we ended up working on JN's hamstring recovery but there was no need and it did not have as much useful information as I had hoped about hamstring injuries.

• Yes

The session started with a follow up from the week before. JN reflected that she feels she could create a bit more balance and hold off on her heavy workouts prior to her busy work days. The session started with breath awareness & centering pranayama, leading into 1:2 ratio & nadi shuddhi. We moved on to very gentle assisted and active range of motion stretches for the neck, upper trapezius, & pectoralis.

Practice the gentle towel assisted stretches before teachinng daily.

JN reflected that she was very sore from her work week during this session.

Seeing how painful the gentle JAPA and self touch was this week I was able to scale back my expectations for JN and our work together. While she is a busy teacher and quite physically fit she also experiences lots of pain and tension related to teaching.

Teach some of the B plan of the care plan.

• Yes

After a follow up about the week and learning that JN had a massage the day prior and was feeling quite good we moved on to Plan B of the Care Plan. We started with centering, then 1:2 ratio breath, & brahmari, neck & pec stretches, & deep neck flexor and low trapezius strengthening asana in standing, prone, and supine.

Practice Plan A on heavy work days and Plan B on light work days for 10-20 mins a day prior to teaching.

JN seemed eager to address her pain and adjust the patterns of over use leading to over rest in her schedule. She also reflected that she was able to demonstrate using 85% of her energy rather than 100% and her students still understood what she was teaching. She said she will continue to do this to safeguard her energy.

JN's pecs seem quite tight which is limiting her range of motion and leading to compensation patterns. I noted that the block in Goddess arms at the wall was painful so we removed it and she reflected that she still felt quite a deep stretch. Her pain seems to be more serious than she may have made it out to be in our previous sessions.

I am enjoying working with this client. If I could continue on with her I would like to see where her hamstring injury and balancing her schedule unfold as well.

Provided JN feels comfortable with Plan B work we will add on a few of the exercises from the care plan that we did not cover last week.

• Yes

Follow up, seated pranayama starting with 3 cleansing breaths, 3 rounds of brahmari, and elongated exhalation leading into nadi shuddi without arms (hand sweeze). Neck stretches/ gentle JAPA was too painful so we started with the serratus anterior slides at the wall without any band and in a limited ROM. Door frame pect stretch caused tingling in her fingers so we stopped and focused on self massage of subclavius/ pectoralis minor with an elongated exhale. Prone shoulder extension & W (V caused a headache like pain), and thread the needle followed by supine twist and restorative pec stretch on a blanket with a Z fold.

Pause on all strength work and check in with a provider to see if they recommend medical massage and/ or PT. Continue to practice pranayama and stretches that are helpful from Plan A.

In our follow up JN reflected that she was quite sore after the last session. While she practiced the stretches (apart from the towel stretch) the strength work seemed a bit too ambitious for now. She has been taking more breaks while teaching, demoing less and with even less energy than last week, and noticed her regular kettle bell workout she does was too much for her this week. She said she may need to go back to get another massage.

After JN said she wanted another massage, I mentioned it might be a good time to see a doctor as her neck pain can cause headaches too. While I think her Plan A is appropriate and appears to be helpful, Plan B may need to wait.

On reflection, I was excited to work with a fellow yoga teacher. I believe that I took into account her tendancy to load on a lot of movement on heavy work days and then report feeling pain and needing to rest entirely afterwards. I did not take into account how well she was managing quite serious neck pain. I am not sure if she played her pain down or if her positive attitude led me think it was less serious. As our month together progressed I realized the downtraining and gentle JAPA was more than enough for her. We adjusted the plan to work on Plan A alone rather than alternate based on work days and pain symptoms. Based on the study on upper crossed syndrome I reviewed it was carried out over 12 weeks. Perhaps after more time practicing the release work and SNS downtraining JN will be ready for some very slow progressive strength work.

In IYTh we have been taught that pain is a messenger. What is this pain telling JN? Although JN does journal regularly the reflection is not a pain journal. Perhaps a pain journal would provide insight that could initiate some self motivated changes for JN. While the brahmari pranayama and stretches did provide some temporary relief, Plan B work was too much and too soon. I considered that JN teaches vinyasa and hatha classes that require quite a bit more upper body work that could continue to exaserbate her symptoms. We decided to scale back strengthening asana and focus on relaxation, release, and recovery for the next few weeks, perhaps longer.

One positive observation is the realization that JN could conserve both her energy and reduce some pain on busy work days by simply giving less energy in demonstration and demonstrating less overall. This reduced her pain and made her longer days more manageable. While, I don't think we have come to resolution with this issue or made drastic changes over night, I do think these more subtle adaptations and realizations are powerful. The takeaway from these sessions has been that the formula to meet each clients goals will always be different, take its own time, and sometimes we wont see great progress in the area of the clients main concern or goal but we will see their progress in managing living with it.

For the next two weeks JN is going to check in with me and practice her pranayama, gentle JAPA, and stretches. We will meet mid June for a follow up session.