This is a group case study for Yoga Therapy for Fall Prevention and Balance (YFaB1). 7 participants, or PTs, signed up and all reported on Session 1 on May 28, 2023. Primary complaints are balance challenges. Common comorbidities include OA, OP.
CB CS2: 54 yo with diabetes 1, peripheral neuropathy in feet/hand; pain in R foot/L knee. Receives insulin injection.
JM CS2: 75. OP upper back, OA knees/elbows/fingers/thumbs/toes. T11, T7 compressed. Takes Prolia for OP. R knee replaced with limited ROM, Kyphosis.
LT CS2: 67. Bursitis R GHj, R FAj. unable to get down on the mat
MG CS2: 76. PO, OA hands/feet
SM CS2: 71. Pre OP medically controlled. Slight pain in L shoulder treated with a steroid shot
TG CS2 60. Hypertension, high glucose. History of R FAj subluxation
WB CS2: OA FAj, knee.

Group Session 1 on 5/28/23:
1. Introduction. Privacy and discussion guideline
2. Group intake to self-assess each student's baseline on balance. 1. Standing up from chair/bed, 2. Descending stairs, 3. Descending a hill. 4. Self-evaluation of core/lower body strength, alignment, and proprioception (explained what it means). Rated 1-5. 5 denotes very confident
3. Student education on yoga & balance. Why, how, what. PPT
4. Journaling: One thing that you would like to change to bring more balance into your life. And list 3 ideas as action items
Follwed by a 5 min break
5. Brief centering with interoceptive awareness/body scan
6. Seated warm-up to prepare for standing asana practice
7. Warm-up (JAPA) 5 min
8. Asana 30 min - group intake throughout (narrative)
- Gait awareness (Proprioception/awareness of feet sensation) - 1) get up from a chair, walk, back chair. 2) holding something in one hand 3) with drishti.
- Mountain (PPception, alignment, gait)
- F/B Side-to-side balance
- Neutral spine (Pelvic Tilt/Alignment)
- Crescent lunge sequence (PPception, alignment)
- Chair (Alignment, strengthening)
9. Group intake. Notice anything?
10. Deep relaxation in a chair or floor 7 min. (Body/breath awareness)
11. Deep breathing (breath awareness/counteract anxiety)
12. Post-session group intake. Reviewed HP.
During the self-intro, JM, LT, SM, and TG shared their experiences of recent falls. CB complained Achilles tendonitis PN. LT Unable to stand up from the chair hands-free. Difficulty getting up from a couch. "Terrified" going down a hill. SM stated being cautious when going down the stairs.

Observed during asana assessment:
LT: Instability in lower limbs, levoscoliosis. Presented nervous energy. WB: Levoscoliosis. Reserved, looks skeptical. JM: Kyphosis as reported, L shoulder ROM limited. MG: Minor head protrusion

Group’s self-reported confidence score for core/lower body strength was an average of 2.92. 2nd lowest average was alignment 3.2. They will be used as a baseline and data for the group goal setting. Group’s confidence score for proprioception got the highest score of 3.9, but I am not sure if PTs fully understood the definition. Three PTs expressed fear and anxiety from recent fall/s and will be considerations for CP. The baseline is documented in the Group Session Progress Tracking Form https://www.dropbox.com/s/k5h8yp3ffo2lhzg/3_YFaB%20ProgressTracking_Form.docx?dl=0

At the post-session group intake, several PTs reported heightened awareness--weight awareness in the feet and more trust in the body's structure. Explorative asanas given today show positive effects on self-awareness.

Expanding the “balance” theme, journaling homework was given for self-inquiry/reflection. "What is well-balanced life to you? Write down one thing you would like to change to bring more balance into your life, and list 3 three ideas as action items to achieve the goal". UW radio clip on yoga and balance was provided as educational material.

Care Plans, Kosha by Kosha:
*Annamaya:
Sessions 2&3 are dedicated to alignment and PPception; 4&5 for core strengthening. Warm-up to address OA, common comorbidities (Joint Freeing/JAPA)
• Core strengthening asanas - Chair, Warrior I, etc.
• Balancing asanas in a unilateral stance – Warrior II, Triangle with a chair, etc.
• Stimulate single-leg balance – Tree, standing half locust, Stork pose, etc.
• Gait Awareness Walk to improve balance in motion. Walk while carrying weights. etc.
• Alignment, neutral pelvis - Tadasana.
• Introduce bahya drishti as an external gazing point

*Pranamaya/Manomaya:
• Pranayama: Start with a simple deep belly breathing technique, 3-part breath, then alt. nostril breathing/ujjayi
• Breath awareness imagery in preparation for meditation

*Manomaya/Vijnanamaya/Anandamaya:
Explore Dharana: Focus on one single thing for stabilizing the mind
• Meditation by employing antara drishti, an internal gazing point
• Meditation while moving, walking, sitting

*Manomaya/Vijnanamaya/Anandamaya:
• “Witnessing” awareness practice (body, breath, emotion, energy, thoughts) to be able to enhance somatic awareness (Interoception, proprioception) and recognize anxious energy w/o identifying with the emotions and thoughts
• Journaling, sadhana for self-reflection
• Establish safe place guidelines/privacy
• Sharing and discussion

Updates to the initial care plans listed above:
6/4/23: + Teach how to use the breath to handle anxiety skillfully; lead meditation using drishti to improve focus and mental stability
6/11/23: + + Balancing asanas in lateral movements – Crescent, moon salutation variation
+ High lunge + stepping back movement [Updated based on the PT feedback at Follow-up Session 1 on 6/4/23]
6/11/23: + Four locks & keys for challenging relationships and maintaining emotional stability [Updated based on the PT feedback at Follow-up Session 1 on 6/4/23]
6/25/23: + Introduce chakras. Ajna chakra as dristhi for meditation
7/2/23: + Introduce mudras. Adhi Mudra for anxiety and grounding

Asanas references:
Gait Awareness
https://www.acefitness.org/resources/everyone/blog/5478/chair-yoga-poses-7-poses-for-better-balance/

Ann Swanson video on YouTube - Balance Sequence

JAPA Warm-up Sequence (Human Body Ease and Dis-ease training notes)

Studies:
1. Research Summary for Yoga Therapists: Yoga Therapy for Balance and Mobility in Older Adults by Pam Jeer and Timothy McCall, IAYT publication

2. Youkhana S, Dean CM, Wolff M, Sherrington C, Tiedemann A. Yoga-based exercise improves balance and mobility in people aged 60 and over: a systematic review and meta-analysis. Age Ageing. 2016 Jan;45(1):21-9. doi: 10.1093/ageing/afv175. Epub 2015 Dec 25. PMID: 26707903.
"Conclusions: yoga interventions resulted in small improvements in balance and medium improvements in physical mobility in people aged 60+ years" “The review provides preliminary evidence that balance and mobility can be safely improved with participation in yoga by people aged 60 and over”

3. Magnon V, Dutheil F, Vallet GT. Benefits from one session of deep and slow breathing on vagal tone
and anxiety in young and older adults. Sci Rep. 2021 Sep 29;11(1):19267. doi: 10.1038/s41598-021-98736-9. PMID: 34588511; PMCID: PMC8481564.
“this study provides evidence that: 1) DSB seems to reduce anxiety level and increase vagal outflow (which are negatively correlated with each other) in both young and older adults; 2) DSB could have a greater effect on parasympathetic activity in older adults.”

Other resources:
Focusing on a Drishti (definition, purpose and use), Yoga Basics https://www.yogabasics.com/learn/focusing-on-a-drishti/

Third eye chakra or Ajna chakra, Article on Ekhart Yoga website
https://www.ekhartyoga.com/articles/practice/third-eye-chakra-ajna-
chakra#:~:text=Ajna%20(the%20most%20common%20Sanskrit,the%20inner%20and%20outer%20worlds

Contraindications for Hip Bursitis: https://orthopedicnj.com/news/seven-exercises-to-avoid-with-hip-bursitis

Client Education:
Audio programs
"For Older Adults, Yoga Can Reduce Risk Of Falls, UW Study Finds" (7 mins)
https://www.wpr.org/listen/1190006

Stressed? Instead of distracting yourself, try paying closer attention (17 mins)
https://www.npr.org/2021/12/21/1066585316/mindfulness-meditation-with-john-kabat-zinn

• Yes

Group Session 2 on 6/4/23
1. Check-in. Feedback from last week's session. Any changes? Discussed shared goals of the workshop.
2. Sharing circle. Discussion about last week’s HP assignment.
- What does “well-balanced” life look like to you?

3. “Witnessing” YCat awareness practice, kosha by kosha

4. Joint warm-up, including feet

5. Asanas focusing on Alignment awareness and Proprioception 1/2:
- Proprioception and gait awareness exploration cont. Stand up from chair w/o hands, walk, back to chair, repeat. Carrying bags L/R/both hands

- Neutral spine (pelvic rock)
- F/B, Side-to-side balance
- Mountain. Feet together, feet separate
- Crescent lunge sequence. Experimented with foot positioning
- Tree w/Drishti, then w/o Drishti (15 sec x2 each leg)

6. Baseline assessment “Do you use your breath to reduce anxiety?” Never, rarely, sometimes, often, always The baseline is documented in the Group Session Progress Tracking Form https://www.dropbox.com/s/k5h8yp3ffo2lhzg/3_YFaB%20ProgressTracking_Form.docx?dl=0
7. Introduced 3-part breathing
8. Post-session feedback
9. Reviewed HP assignments, Q&A

Group Session 2 on 6/4/23
1. Self-check-in before the HP practice using awareness practice
2. Asana for balance and alignment. Mountain, Crescent Lunge, up to Tree. Practice along Ann Swanson video on YouTube (10 mins).

- Hold onto a chair during the lunge sequence
- Practice Tree in the kickstand position
- Take it slow
- Establish a schedule for the asana practice
3. 3-part Breathing when feeling anxious

4. Continue journaling on progress on HP and note any changes - body, mind, energy level, spirit

Group Session 2 on 6/4/23
After check-in, I shared the summary of the group intake taken at the initial session. Common challenges are identified and used as a basis of the initial goals of this workshop. PTs agreed on the updated goals and objectives, which are: 1. Improve balance. Improve core & lower body strength and alignment; 2. Acknowledge fear and anxiety and handle the emotions skillfully; improve focus, and mental stability (updated after initial intake).

I introduced witnessing practice for awareness in Annamaya, Pranamaya, Manomaya, and Vijnanamaya kosha. JP and SM reported they noticed a restless mind; MG wants to incorporate it during the week. No negative experience was reported. We will continue this for centering for each session.

Today, we focused on alignment and proprioception. Tree pose is going to be used to monitor progress on balance. We started with 15 sec x2 each leg, with or without dristhi. JM and SM showed instability during R leg balance. TG and WB demonstrated stability. MG reported that the drishti introduced during Tree was helpful.

During the high lunge, I instructed PTs to explore with foot positioning for greater stability. It included moving the front foot to the edge of the mat. This unplanned experiment was effective in raising proprioceptive awareness, as a few PTs expressed afterward. I will try this explorative exercise for Warrior poses. Various asanas helped WB “feel good” about her balance. I provided the link to Anne Swanson’s YouTube video for home practice. We will continue to work on alignment and proprioception in the next session.

When asked if they ever use the breath to reduce anxiety, TG responded “rarely,” and the rest responded “sometimes”. I introduced 3-part breathing today and gave PTs the assignment to try when they notice anxiety and stress. I will get the feedback during the next sharing circle.

CB had a metatarsal stress fracture on R foot and has to wear a boot for 2-4 weeks. Upon my recommendation, she withdrew from the workshop and expressed interest in joining again if a new class starts in August.

PTs’ level of participation increased at this second session. Active sharing and feedback during the session and post-session feedback informed me well as I continue to update the CP and session plan. (Individual statements and yth observations are tracked in 3_YFaB ProgressTrackingForm https://www.dropbox.com/s/k5h8yp3ffo2lhzg/3_YFaB%20ProgressTracking_Form.docx?dl=0)

SM and WB expressed challenges in keeping balance during lateral movements, such as at a sudden jolt in a subway. MG stated she " fears falling backward” and is “easily get distracted when walking and loses balance.”. Based on these comments, I will incorporate standing asanas with lateral and stepping-back movements (Plan for Group Session 3).

In response to the journaling HP, PTs wish to bring more balance into life by being more physically active (e.g., “getting out of the house” and “not anchored to a chair”), gaining emotional stability (“Fewer ups/downs with husband and kids”), and taking time for spiritual practice. Meditation will be introduced at the next session (Follow-up Session #3) to incorporate the responses. Teaching 4 locks and 4 keys may benefit some PTs as they navigate relationship challenges (Plan for Group Session 4 or 5).

Plan for Session 3 on 6/11/23
Based on the challenges/interests PTs reported, I will add the following asanas and intro to meditation in Session 3
+ Balancing asanas in lateral movements – Crescent, moon salutation variation
+ High lunge + stepping back movement
Meditation w/antara dristhi (breath)
2. Educational material on mindfulness and awareness intro to meditation
Stressed? Instead of distracting yourself, try paying closer attention (17 mins)
https://www.npr.org/2021/12/21/1066585316/mindfulness-meditation-with-john-kabat-zinn

Activities for Session 3 on 6/11/23
1. Check-in
2. Sharing circle. Discussion about last week’s session and HP assignments.
3. “Witnessing” YCat awareness practice, kosha by kosha
4. JAPA joint warm-up, including feet

5. Asanas focusing on Alignment awareness and Proprioception, 2/2:
Review HP + new postures/movements:
- Neutral spine (pelvic rock)
- F/B, Side-to-side balance
- Mountain. Feet together, feet separate
- Crescent lunge sequence. Experimented with foot positioning
+ Stepping back & forth from high lunge
- Tree w/Drishti, then w/o Drishti (20 sec x2 each leg)
+ Moon Salutation Variation (Use a chair for Triangle)

6. Relaxation with Breath Awareness Meditation
7. Review 3-part breathing
8. Meditation w/ antara drishti, an internal gazing point on breath
9. Post-session feedback
10. Review HP assignments, Q&A

Home Practice
1. Self-check-in before the HP practice using awareness practice
2. Continue asana practice for balance and alignment. Mountain, Crescent Lunge, up to Tree. Practice along with Ann Swanson video on YouTube (10 mins).
3. Practice Breath Awareness Meditation using the audio script
4. Continue journaling on progress on HP and note any changes - body, mind, energy level, spirit

• Yes

Group Session 3 on 6/11/23

1. Check-in
2. Sharing circle. Discussion about last week’s session and HP assignments. Asana practice w/Ann? Proprioception reading material. Life balance goal action items?

3. “Witnessing” YCat Awareness Practice, kosha by kosha – what did you notice?
4. Standing warm-up – helicopter swing, shoulder shrug&drop/fist circles

5. Asanas focusing on Alignment awareness and Proprioception, 2 of 2:
Review HP + new postures/movements:
- Neutral spine (pelvic rock)
- F/B, Side-to-side balance
- Mountain. Feet together, feet separate
- Crescent lunge sequence. Experimented with foot positioning
+ Stepping back & forth from high lunge. Added per PT’s comments
- Tree w/Block, w/Drishti, then w/o Drishti (20 sec x2 each leg)
+ Moon Salutation Variation (Use a chair for Triangle) Added per PT’s comments
what did you notice?

6. Relaxation with Breath Awareness Meditation – what did you notice?
When would this practice be helpful?

7. Review 3-part breathing (omitted, not enough time)
8. Meditation w/ antara drishti, an internal gazing point on breath

9. Post-session feedback
10. Announce HP assignments, Q&A

1. Self-check-in before the HP practice using awareness practice
2. Continue asana practice for balance and alignment. Mountain, Crescent Lunge, up to Tree. Practice along with Ann Swanson's video on YouTube (10 mins).
3. Practice Breath Awareness Meditation using the audio script I recorded https://drive.google.com/file/d/1Naig06XcOASR2cIBZIrha1YS5LpM9wtZ/view
4. Continue journaling on progress on HP and note any changes - body, mind, energy level, spirit

Reading materials/handouts:
Stressed? Instead of distracting yourself, try paying closer attention (Audio interview,17 mins)
https://www.npr.org/2021/12/21/1066585316/mindfulness-meditation-with-john-kabat-zinn

Four Locks, Four Keys: A Simple Approach to Relationships, Integral Yoga Magazine – For discussion on 6/21/23. This is an update to the initial care plan based on PTs’ reported challenge in relationships to achieve a “balanced life.”
https://integralyogamagazine.org/four-locks-four-keys-a-simple-approach-to-relationships/

Attended by JM, TG, SM, WB (Absence MG, LT; CB withdrawal)
SM reported she used 3-part breath when she had a Moh surgery which helped her take mind off from anxiety.

Discussed external and internal dristhi and practiced them during asanas and meditation, respectively. PTs noted more stability when using dristhi during Tree.

Modified moon salutation for lateral alignment was introduced. WB expressed difficulty in goddess pose due to FA joint bursitis. Some PTs showed limited ROM in GHj bilateral flexion during the Crescent pose. As the sequence is new to the majority of them, we will review it in the next session.

Group Session 3 on 6/11/23
Repeated cues in the last two sessions appeared to take effect as PTs start using dristhi during balancing postures without being instructed. This “dristhi” concept will be expanded to meditation for the remaining sessions. Not enough time left to discuss the reading assignment at the end of the session (John Kabat-Zenn on Stress, 4 locks&keys). It could have been beneficial to highlight the relevance to PTs’ day-to-day life for generating motivation to read.

Plan for Session 4 on 6/21/23
Discuss Four Locks, Four Keys: A Simple Approach to Relationships, Integral Yoga Magazine (handout).
Review Moon salutation
Asanas focusing on Core Strength, 1 of 2. Slide presentation on major core muscles.
A quick intro to chakras – meditation with dristhi on Ajna chakra for clarity and focus

• Yes

Group Session 6 on 7/2/23 (Last session)
1. Check-in. Asked to fill out an exit survey recently mailed.
2. “Witnessing” YCat Awareness Practice, kosha by kosha. Document reflections on the notebook. Prompts: What did you notice? Has the practice been helpful? In what way? Followed by a discussion.
3. Sharing circle cont. Personal Goals: Self-evaluation on progress/changes. Prompts: Challenges and unexpected benefits? Anyone has a similar challenge? Followed by a discussion.

4. Standing warm-up – helicopter swing, shoulder shrug&drop/fist circles, hip joint, knee joint warm-up

5. Asana Review (Core, balance, alignment. Using Drishti):
• Tadasana
• High lunge > Step back/forward, Warrior 1
• Chair pose
• Stork/one leg balance wo/block (hip flexion, 30 sec) Keep the chair next to you.
• Tree w/o chair. Step away few inches from the chair (30 sec x2 each leg)
• Krishna’s side bend

6. Exit Self-Assessment
Self-evaluation on progress/changes. (Slide: How confident are you…? Score 1-5). Followed by discussion and sharing

7. Future Plans
Reviewed home practice assignments during the six-week workshop (Googledoc)
Prompts: “What worked and didn’t work for you?”. Does anyone have a similar challenge? Any suggestions?
Activity: Design your weekly/daily regimen and write it down in the notebook. Keep track of the progress chart.
• Try it for 21 days!
• Suggestion for regular meditation practice. Pranayama + meditation

8. Pranayama:
a. “HA” > Rapid Diaphragmic Breathing for SNS activation and diaphragm strengthening (New)
b. Alt. Nostril Breathing (Review) + pratipaksha bhavana (EHX anxiety INH stability)

9. Meditation (Using drishti):
a. Breath
b. Chakra (Review)
c. Mudra (Adhi Mudra)

10. Closing

The six-week workshop concluded today. Participants were encouraged to keep up with their designed weekly/daily regimen. They were asked to respond to the Exit Survey to give their feedback for the workshop via GoogleForms.

Group Session 6 on 7/2/23 (Last session)
Attended by JM, MG, LT, TG, SM (Absence: WB due to illness)
At this final session, the group spent half the time on progress evaluation, reflection, and sharing. MG and SM find the witnessing practice helpful as it grounds them and allow them to let go of a sense of urgency to tackle the to-do list. The group discussed the importance and challenges of sticking to regular practice as they work towards personal goals (e.g., going outside more often). Some tips are shared. The concept of samskara was introduced to create a “groove” to enforce positive habits.

During the balancing asana, each chose arm and foot positioning based on their ability/comfort level. Tree pose was held for 30 seconds x2/each leg; Stork pose for 30 seconds x2/each leg, presenting meaningful progress across the participants. JM demonstrated instability on R leg but came out and came back up again with ease.

The Exit Self-Assessment indicated moderate progress from the baseline for each PT. Some noteworthy changes are as follows: JM improved confidence in physical strength and core & lower body by 2 points. LT reduced the fear of walking downhill by 1 point, which had been her major challenge. Each response showed either unchanged or improvement. Finally, the average score for self-confidence in alignment and core & lower body strength was compared before and after the workshop for those PTs who attended today. Notable improvement was presented in self-confidence in both skeletal alignment (3.0-->3.8) and core & lower body strength (3.1-->3.8).

To the question, “I feel more confident in handling anxiety about falls after attending the workshop,” one PT responded 5/very much agree, two PTs 4/agree, and one PT responded 3/neither agree nor disagree.

Breathing practice had to be cut short. Time management needs to be improved.

At this final session, I started to see more exchanges and helpful suggestions to one another; a stronger connection just began to emerge. It was nice to see everyone logging off smiling.

While I enjoy teaching yoga in a group setting, conducting yoga therapy group sessions was a very different experience as it is highly interactive. My primary challenge was to create a supportive and safe environment for active discussion and sharing among seven participants who had never met before. The group sharing & discussing protocol I studied at the Stress Management TT helped set a guideline. As the workshop progressed, I felt more comfortable moderating discussions and giving everyone a chance to speak or pointing someone to talk.

On a logistical side, it was practical that I kept each session in a similar format. While I incorporated various components such as client education via a slide presentation, discussion and sharing, journaling, and other yogic tools, there was no confusion. Keeping it simple is important when teaching the older population, particularly when it is delivered virtually.

Even temporarily, group therapy sessions can create a supportive community, which is healing and can be an effective therapeutic tool. I want to explore further on this approach.

Another takeaway is the use of quantitative assessment to keep track of progress. I also used the group average to identify their lowest score to set objectives and design care plans. I was so happy when the before-after result came out favorably!

The next round of the six-week balance workshop, YFab2, will start on July 30, 2023. Four people have signed up as of 7/6/23, including CB, who withdrew at the second session of YFab1 due to injury.