Profile: Age: 67 Male, Retired, European origin

Client’s primary complaint is sensory peripheral neuropathy (“PN”) in calves and feet. Experiences numbness and discomfort at night, disturbing sleep.
Other complaints include lower back pain, ITB Syndrome; Depression, and alcohol use disorder, both of which are medically controlled.

Spinal surgery x2 1) laminectomy and diskectomy in his 30s – L4/5, S1. and top part of L. Left him with lost sensation in L heel, permanent damage. Ct suspects PN manifestation in the recent year results from spinal nerve damage, although it contradicts his neurologist's report, which states suspected prediabetic sensory neuropathy with exacerbation from alcohol.

Ct’s stated objectives for participating in yoga therapy as 1) Reduce spine/nerve pain, including neuropathy symptoms in feet and legs. 2) Reduce alcohol consumption.

Scheduled discussed: 4 in-person sessions over three weeks. Home practice will be given.

Assessment was conducted in seated in a chair/floor, standing, and supine positions. Breath and energy were observed throughout.

Annamaya:
- Physically balanced in standing, sitting in a chair, supine position. Good awareness of posture.
- Alignment: Minor pronation observed in R heel
- Balance: Instability in feet when standing with plantar flexion
- ROM/Flexibility: Fair. Tight hamstrings and gluteus
- After a restorative yoga with a gentle backbend client reported minor twinges in his left lower back.
Pranamaya:
- Deep abdominal breathing in the supine position
- Balanced energy overall
- Comfortable with Dirgha Swasam. Practiced Kapalabhati before
Manomaya:
- Talkative and expressive during the intake interview
- Slight nervous energy presented when talking about family relationships and loneliness
- Ct stated the cause of stress is too much time alone when energy focuses on inner conflict, and drinking is a coping mechanism
Vijanamaya:
- Demonstrated objectivity and witnessing skill
- Intelligent, analytic, left-brain dominance
Anandamaya:
- Ct. expressed struggles with loneliness
- Represents a strong connection with nature
- Grief and loss of purpose in life. Estranged with older and young brother. Death of a partner of 20 years due to drug overdose. Loss of beloved pet. All happened within the last five years.
- Enjoys a small but close network of friends

Vata dominance may be manifested in a drinking problem due to the desire to escape loneliness, leading to depression.
Ct may benefit from Brahmana type of asana and pranayama to counteract depression and nourish.

Summary:
The client presents with an imbalance in Manamayakosha/Anandamayakosha due to living alone and the deaths of loved ones he has been caring for, compounded by an estranged relationship with siblings. These findings could directly correlate with his drinking issue and depression, and possibly with his primary complaint, peripheral neuropathy in the lower extremities.

Short team goals agreed upon:
1. Reduce the intensity and frequency of discomfort in the calves and feet
2. Reduce alcohol consumption

Initial Care Plan:
- Increase blood circulation in lower extremities through stretching/asanas to enhance musculoskeletal balance
- Regulate the autonomic nervous system and build resilience to stress
- Foster a connection to a sense of purpose and meaning; explore hope and potential through active participation in society--> UPDATED: Cultivate gratitude and joy

Planned Interventions:

Asana Objectives
• Improve blood /lymphatic circulation in the feet/calves
• Connection with the body and balance
• Improve proprioceptive awareness

Asana Specifics
• Feet/Planter group stretch (Flexor digitorum brevis)
• Restorative pose with easy inversion
• Long exhalations, don’t hold poses/multiple repetitions
• Balance poses

Pranayama Objectives
ANS regulation

Pranayama Specifics
• SNS activation via Kapalabhati
• PSN activation via Ujjai

Aparigraha/non-attachment - Meditation for observing the mind and separating from emotions to “let go”

Karma Yoga - Explore opportunities for service for building a connection with others/society

1) Peripheral Neuropathy + Yoga:
Telles S, Sayal N, Nacht C, Chopra A, Patel K, Wnuk A, Dalvi P, Bhatia K, Miranpuri G, Anand A. Yoga: Can it be integrated with treatment of neuropathic pain? Ann Neurosci. 2019 Apr;26(2):82-91. doi: 10.5214/ans.0972.7531.260208. Epub 2019 Apr 1. PMID: 31975778; PMCID: PMC6894618.

Sudarshan Kriya Yoga’s effect on depression and anxiety “… the patients suffering from depression reported antidepressant effects which were correlated with increased serum levels HDRS score reduction and rise in BDNF [Brain-derived neurotropic factor] levels were reported in yoga group alone.”

2) Sudarshan Kriya Yoga:
Zope SA, Zope RA. Sudarshan kriya yoga: Breathing for health. Int J Yoga. 2013 Jan;6(1):4-10. doi: 10.4103/0973-6131.105935. PMID: 23440614; PMCID: PMC3573542.

“Detailed descriptions of the four main SKY breathing techniques are as follows.[5]
1. Ujjayi or “Victorious Breath”: This involves experiencing the conscious sensation of the breath touching the throat. This slow breath technique (2–4 breaths per minute) increases airway resistance during inspiration and expiration and controls airflow so that each phase of the breath cycle can be prolonged to an exact count. The subjective experience is physical and mental calmness with alertness.
2. During Bhastrika or “Bellows Breath,” air is rapidly inhaled and forcefully exhaled at a rate of 30 breaths per minute. It causes excitation followed by calmness.”

3) Depression+ Ujjai Breath:
Depression, Yoga for Medicine, Dr. Timothy McCall pp.277-278
“For tamastic depression, pranayama techniques that focus on inhalation can also be useful… practices like simple ujjai breathing, which tends to lengthen both the inhalation and the exhalation… can help”.

4) Justine Shelton article on Yoga Vista
Video clip https://youtu.be/wl5RScx-eg8
1. Balancing version of Tadasana
2. Dorsiflex stretch

5) Depression, Yoga for Medicine, Dr. Timothy McCall pp.276
Exercise #13 Supported Relaxation Pose

• Yes

We conducted a 90 mins follow-up session #1.

1. Check-in
2. Centering
3. Follow-up questions. Cont. assessment on Manomaya, and more subtle koshas imbalance
4. Asanas – Feet/calf muscle stretches
- Toe balance
- Dorsiflexion stretches against a wall w/block

5. Viparita karani inversion
6. Kapalabhati and Ujjai
7. Review Home Practice, Q&A

1. Feet stretch daily, invert daily at the end of the day
2. Pranayama (KB 20x3, Ujjai 2-3 mins)
3. Yoga journaling to keep track of home practice and anything noticed (physical, mental/emotional, thoughts)

Handout:
- Summary of HP on a paper note, texted images.
- Link to a review article: “Yoga: Can it be integrated with treatment of neuropathic pain?”

Progress summary of the asana given during the class:
Ct reported there was no change in the pain scale but stated that he feels more stable when shifting weight to the balls of his big toes during standing-toe balance.

Observed progress in emotional awareness/analytical thinking presented as his openness to discuss his drinking issue. When creating the goals together, he voluntarily asked for help with “keeping an eye on drinking.” He stated that he wants to continue to cut down the alcohol consumption.

He also mentioned his struggle with a loss of life purpose. Ct responded to HP positively.

Ct. enjoyed the feet stretch and standing toe balance practice. He appears to be ready for more challenging balancing asanas, which will be incorporated into the next session. He was more open to discussing his internal struggle and drinking issue; asking for help is a positive change. He clearly sees a correlation between drinking and depression -- and even with PN flare-ups.

Check-in on progress on Home Practice. Challenges/questions. Notice anything?
- Centering
- Warm-up (C&C, calf stretch in all 4s)
- More advanced balance pose. Tree, Warrior 2/reverse warrior
- Restorative yoga (supported reclining pose)
- Breathing practice review (KB, Ujjai)
- Discuss awareness of drinking/depression

• Yes

We met for a 90 mins follow-up session #2.

- Check-in. Discussed progress on Home Practice. Challenges.
- Centering
- Warm-up (C&C, calf stretch in all 4s)
- Balance pose/Tree, Warrior 2/reverse warrior
- Restorative yoga (supported reclining pose) 10 mins
- Skasana
- Breathing practice review (KB, Ujjai)
- Reviewed HP, explored the ways to maintain a regular practice

Continue feet stretch and inversion at the end of the day. Add standing balance asanas (Tree, Warrior 2, Rev Warrior). Keep up with KB and Ujjai. Journaling to monitor HP, alcohol intake, and their effects. Gratitude journaling – Write down one thing he felt grateful for at the end of the day.

We moved to more advanced balancing asanas. During Tree, ct. can comfortably perform on his "good" leg; unstable on his "bad" leg (L). Since the last session, he didn’t make much progress on the HP.

He reported that his PN had been aggravated by recent episodes of excessive drinking and sugar intake, disturbing his sleep and making him lethargic. He was at his cousin’s cabin, drinking socially for three nights last week. He also had dinner at a friend's house the night before. He acknowledges the direct correlation between alcohol/sugar intake and PN flare-ups. He states it is hard to resist not drinking in such a social setting. We discussed a workaround without offending people: to be open about his intention to cut down on drinking and about his PN.

Ct. wants to try practicing pranayama in a comfortable seated posture on the floor. Played around with props and practice sukasana. Asked for a recommendation for purchasing a zafu.

Updated the initial care plan by adding Santosha to cultivate a sense of gratitude and contentment through gratitude journaling. Removed Karma yoga as he is not interested in it.

Ct shows disappointment and frustration about the regression but is eager to address it openly and explore the workaround. Suggested practicing pranayama before the day starts since he doesn't want to be “too quiet to listen to his (negative) inner voice at the end of the day.” Put on hold meditation homework not to overload him.

- Discuss progress on overall goals, Home Practice and journaling. Identify obstructions/challenges.
- Review asanas

• Yes

- Check-in. Discussed progress on Home Practice. Challenges.
- 3-part breath, Ujjai (to prepare for balancing asana)
- Balance pose. Toe balance, Tree
- Guided meditation in savasana – Breath awareness
- Ct. Post-session reflection
- Discuss strategies for regular practice
- Future plans

Continue HP assignment from previous sessions. If no time, do pranayama at a minimum. Try for two weeks first and see if anything changes. Document what you did and the effects on PN, mood. Breath Awareness audio recording was given so that he can listen and practice relaxation during viparita karani inversion recording.

Ct. reported his balance is really bad today, so we tried to do some calming breathing before asanas. It did ground him on his good leg and improved his balance during Tree.

Ct. is able to gain focus on awareness of his body. He recognizes the aggravation of the PN at night when pushing him too much physically during the day. Also now really feels the aftereffects of having excessive alcohol, which he starts having a strong dislike. He recognizes an increased level of awareness and is “no longer in denial.” He recognizes the benefit of the gratitude journaling exercise as it memorializes joyful events and “takes him back to the happy moment.”

I observed that the client has gained more insight into what types of activities would adversely affect his PN and is eager to continue to work on them despite occasional setbacks. I shared a quote from Golden Present by Sw. S about climbers pitching a camp without going back to the starting point. It is nice to see that he became receptive to journaling, which could help him focus on the simple joy of life.

This was my first session with a client. Since Ct. and I have already known each other from my yoga class, the sessions were held in a friendly and relaxing atmosphere. He was generally talkative, and it was not easy to manage the session plan without cutting him off. I would imagine it would take a lot of practice to let ct. talk while constantly making efforts to assess whether the information is pertinent to the yoga therapy session. That also requires improvement of my note-taking skills to synthesize the information rather than jotting it all down.

Ct. expressed his heightened awareness of his physical and emotional state since he started the sessions three weeks ago. He recognizes immediate benefits and feels he is now better informed on the medical treatments he seeks for PN and alcohol use disorder. That was his takeaway from this 3-week session. Pain scale of PN did not improve after the intervention after all.

It was a privilege to work with someone who was willing to share his own personal struggle so openly. Although the interventions didn’t have much effect on the frequency and intensity of sensory PN, he is eager to continue the home practice, especially pranayama, and asked me to monitor his progress on drinking.

Ct. will continue asana, pranayama and gratitude journaling and create a spreadsheet to keep track. Follow-up in two weeks, which is to be scheduled. Will meet one-hour in-person session to check on the progress of HP and drinking.