Intake session was conducted on 5/30/2023, 4-6 PM, via Zoom. CT is a 56 yo Asian female residing in a suburb of Tokyo taking a sick leave from teaching at a high school. She lives with her husband and a college-aged daughter. DX: Breast Ca in 2023.2, L mastectomy and lumpectomy 2023.3. Rad tx 4/10-5/1/23. States: Letrozole, chemo every 3 weeks x13, 3 tx completed thus far. Reports lymphedema on L arm 2023.3~, complaint of tightness/heaviness, limited ROM. Pain (scale 2/5). Also, pain is felt in L chest (2/5). CT has med-controlled hypertension (Olmesartan). Family history of cancer (father, grandparents). She had a cholecystectomy in 2022 due to gallstone pancreatitis. Her doc encourages practicing yoga for LE but did not suggest a compression sleeve for physical practice. Her primary objective of the sessions is to reduce swelling from LE.

Physical assessment was taken seated in a chair. Visible swelling in L forearm, limited ROM in shoulder abd, add, horizontal ext, and external rotation CT states “visible swelling triggers fear of Ca recurrence,” and “restricting activities that may exert me and worsens LE”. No tx given by her doc for LE; she does self-massage w/YouTube videos, etc. CT also turns to YouTube for short meditation practice. Expresses interest in practicing more meditation “to take her mind off negative thoughts,” i.e., fear and anxiety of Ca recurrence, which “cannot be expressed to the family as it makes them worry”. No close friends to openly share her struggle. Practices self-reiki when she “wants to direct energy” to the incisions. Spending late-night hours with her daughter is the most enjoyable activity while “listening to what happened to her that day and being asked for advice”. CT stated, “feel stressed and mildly depressed” a few days prior to her chemo tx. She usually watches TV or reads books during the tx if not applying reiki to herself.

CT describes her relationship with Ca objectively and intelligently with great calmness, stating she is doing everything she can to prevent reoccurrence, including maintaining a healthy diet, mild exercise, and a sense of peace. Self-rated energy level usually 4/5, except 3-4 days post-chemo.

Yoga Assessment Summary:
CT presented mild yet visible swelling on L arm, limiting ROM at the shoulder with discomfort and heaviness. CT stated that the swelling is a visible reminder of Ca, triggering fear and anxiety about Ca returning. She stated she does not share her anxiety or negative thoughts with family or friends not to worry them. It could also be due to the cultural norms in which Ca patients tend not to openly discuss the disease. The lymphedema [LE] is not only affecting her physically but may also be causing stagnation and blockage to her energy and self-expression, impacting the Annamaya, Pranamaya, Manomaya, Vijnanamaya, and Anandamaya koshas.

CT expressed interest in yoga postures, breathing practices and meditation to help her with LE and managing emotional stability. Being a reiki practitioner, she is open to trying subtle practices to improve energy flow.

CT may benefit from: Brahmana asana practices while closing monitoring endurance, breathing practices to balance energy & emotions, vocalization and/or mantra repetition (Bhakti yoga) to assist in self-expression, mudras to help set intention and purpose, guided imagery to promote healing, meditation to facilitate self-awareness and compassion, yoga journaling to track physical, emotional, mental & spiritual well-being, sangha and social engagement (community/group support) to improve quality of life, and discussion of yoga philosophy, such as 4 locks and keys in the Yoga Sutras if she has consternation about socializing.

Communicated with CT to set expectations for the yoga therapy outcome. I presented to her that I identified only one research study that strongly supports asana’s benefit in reducing edema volume caused by LE and that if practiced 3 sessions weekly for 8 weeks. Yet, another study demonstrates a positive effect on arm ROM, strength, function, as well as QoL for people with BCa-related LE. CT appears realistic and wants to proceed with care plans focusing on 1) improvement in arm mobility/ROM and lymphatic flow, 2) improvement in QoL by reducing anxiety, improving sleep, and promoting a sense of peace through regular yoga practices.

At the end of four sessions scheduled thus far, we will reassess progress and determine if more follow-ups will benefit the CT.

Care plan outline:
Initial care plan:

Asana will be given to CT to balance Annamaya, Pranamaya, Manomaya kosha by:
Improving ROM, facilitating lymph drainage, releasing held emotion, and countering anxiety through the following:
• Repetitive joint-freeing movements for upper body/upper extremities, spine (including Cat & Cow for anxiety)
• Isometric contraction (Namaste press, DFD w/wall)
• Active heart-opening asanas, such as Warrior II, with lymphedema consideration (Exert-rest-exert- rest)
• Restorative poses (Final relaxation pose, etc.)

Pranayama will be given to balance Pranamaya and Manomaya kosha by:
Stimulating lymphatic flow, improving energetic stagnation/blockage via vocalization, and engaging relaxation response before going to sleep.
• Deep Breathing e.g., Dirgaswasm
• Brahmari
• Alt. nostril breathing (w/pratipaksa bhavana/Bhakti)

Meditation will be given to balance Pranamaya, Manomaya and Anandamaya kosha by:
Energetically promoting lymphatic flow to the right side of the body, improving sleep, decreasing depression, reducing anxiety, down-regulating inflammatory genes, and upregulating immune system genes via vocalization.
• Guided imagery meditation adapted for lymphedema patients
• Breath awareness meditation [Removed from updated plan]
• Kirtan Kriya (Sa Ta Na Ma)
+ Mudra meditation, e.g., Ganasha Mudra meditation for self-confidence and strength [Updated 6/11/23]
+ Sound Bath meditation to help reduce anxiety and promote sleep [Updated 6/11/23]
+ Loving Kindness Meditation for increase sense of joy (Bhakti) and for Cytokine reduction [Updated 6/11/23]

Other yogic tools will be given to balance Pranamaya, Manomaya, Vijnanamaya, and Anandamaya kosha by:
Promoting self-reflection, self-expression, creativity and joy. Finding sangha [Removed from updated plan]
• Journaling- creative or reflective writing (Jnana)
• Support group* - connections with others, learning from each other [Removed from updated plan]
*Four locks & keys will be introduced if CT has consternation about interacting with people [Removed from updated plan]

Studies:
1. Levenhagen, Kimberly PT, DPT1; Davies, Claire PT, PhD2; Perdomo, Marisa PT, DPT3; Ryans, Kathryn PT, DPT4; Gilchrist, Laura PT, PhD5. Effect of Yoga Among Women at Risk and With Breast Cancer–Related Lymphedema: A Systematic Review. Rehabilitation Oncology ():10.1097/01.REO.0000000000000340, March 20, 2023. | DOI: 10.1097/01.REO.0000000000000340

“this review found that participation in yoga demonstrated a positive effect on arm range of motion, strength, function, and quality of life among women at risk for and with breast cancer–related lymphedema.”

2. Fisher MI, Donahoe-Fillmore B, Leach L, O'Malley C, Paeplow C, Prescott T, Merriman H. Effects of yoga on arm volume among women with breast cancer-related lymphedema: A pilot study. J Bodyw Mov Ther. 2014 Oct;18(4):559-65. doi: 10.1016/j.jbmt.2014.02.006. Epub 2014 Mar 1. PMID: 25440207.

“The results of this pilot study examining the effect of yoga on arm volume in women with BCRL are promising, showing a statistically significant decline in arm volume following 8 weeks of yoga
participation, providing women with BCRL with another exercise to assist in managing lymphedema.”

3. Cramer H, Lauche R, Klose P, Lange S, Langhorst J, Dobos GJ. Yoga for improving health-related quality of life, mental health and cancer-related symptoms in women diagnosed with breast cancer. Cochrane Database Syst Rev. 2017 Jan 3;1(1):CD010802. doi: 10.1002/14651858.CD010802.pub2. PMID: 28045199; PMCID: PMC6465041.

“Moderate-quality evidence supports the recommendation of yoga as a supportive intervention for improving health-related quality of life and reducing fatigue and sleep disturbances when compared with no therapy, as well as for reducing depression, anxiety and fatigue, when compared with psychosocial/educational interventions.”

4. Khalsa DS. Stress, Meditation, and Alzheimer's Disease Prevention: Where The Evidence Stands. J Alzheimers Dis. 2015;48(1):1-12. doi: 10.3233/JAD-142766. PMID: 26445019; PMCID: PMC4923750.

“ [Kirtan Kriya] has also been shown to improve sleep, decrease depression, reduce anxiety, down regulate inflammatory genes, upregulate immune system genes…”

5. Goldsby TL, Goldsby ME, McWalters M, Mills PJ. Sound Healing: Mood, Emotional, and Spiritual Well-Being Interrelationships. Religions. 2022; 13(2):123. https://doi.org/10.3390/rel13020123
“Sound healing, also referred to as sound bath, sound therapy, or sound meditation, is a specific integrative medicine therapeutic technique that utilizes vibration.”

“Additionally, the vagus nerve may be activated or stimulated during sound healing, which may potentially induce increased feelings of well-being, as was suggested in a recent vibrational music study (Sigurdardóttir et al. 2019).”

“This technique has demonstrated considerable promise in significantly reducing undesirable mood variables as well as substantially increasing the potentially desirable variable of spiritual well-being, which is associated with increased feelings of inner peace (Delgado 2005; Saiz et al. 2021). Additionally, the relationship discovered in the present study between improvement in spiritual well-being and improvement in mood variables post-treatment shows potentiality for well-being benefits that may be beneficial on a number of levels.”

6. Patel, D.I., Almeida, G.J., Darby, N.T. et al. Therapeutic yoga reduces pro-tumorigenic cytokines in cancer survivors. Support Care Cancer 31, 33 (2023). https://doi.org/10.1007/s00520-022-07536-y
“Study participants were asked to participate in a 16-week therapeutic yoga program three times per week on-site at the Mays Cancer Center at UTHSA. Each session lasted 75 min and included structured sequence of combined yoga postures (asanas), breathing practice (pranayama), and loving-kindness meditation (LKM), referred to as the therapeutic yoga protocol (TYP) “ “TYP led to significant reduction in circulating cytokines associated with chronic inflammation in a heterogeneous sample of cancer survivors." “

Asanas/Pranayama:
Yoga therapy protocol for anxiety, depression. Cancer-Related PTSD and Racial Equity: Bridging the Treatment Gap, Cheryl Fenner Brown, C-IAYT, E-RYT500 (SYTAR Presentation, 2023.6)

Left Arm Lymphedema Massage: Full Manual Lymphatic Drainage Massage By a Lymphedema Therapist on YouTube. Specific Considerations for Lymphedema

Cancer Research UK
https://www.cancerresearchuk.org/about-cancer/coping/physically/lymphoedema-and-cancer/treating/exercise
“Deep breathing is helpful for all types of lymphoedema, even head and neck swelling. It works by changing the pressure in your tummy (abdomen) and chest. This encourages lymph to flow back into the blood system”

10 Powerful Meditation Mudras and How to Use Them (on Ganesha Mudra)
https://chopra.com/articles/10-powerful-mudras-and-how-to-use-them

Spiritual Healing Sound Bath (3-hour YouTube video performance by Healing Vibrations) https://youtu.be/FDuDgCZyGUg

Lovingkindness Meditation adaptation in Japanese by Kayko Watanabe https://ggia.berkeley.edu/practice/loving_kindness_meditation

Guided meditation, Therapeutic Yoga Application for Lymphedema by Cheri Clampett; adaptation in Japanese by Kayko Watanabe

Yoga Sutra of Patanjali 1.3 with Swami Satchidananda commentary “I am not the body, I am not the mind…”

• Yes

Date: 6/4/23 Time: 4:00 – 5:30pm Location: Virtual

Activities
1. Check-in
2. Home Practice progress report and CT feedback, Qs
3. Self-evaluation on changes in swelling, pain, discomfort in shoulder, energy, sleep quality, anxiety in the last 7 days
4. Discussed short-term and long-term goals. Shared summary of scientific studies
5. Witness Practice (Koshas) – CT feedback
6. Joint Freeing Practice. JAPA. Hands/fingers, neck, shoulders
7. Isometric contraction squeeze fists, Namaste press, DFD w/wall
8. Breathwork: Diaphragmatic 3-part breath
9. Kiritan Kriya with audio - Sa Ta Na Ma

CT post-session self-assessment – Pain scale, discomfort in L arm/chest, energy

Homework assignment to the client:
• Daily journaling to monitor your well-being – physical, emotional, mental, and spiritual. Note anything you noticed.
• Kirtan Kriya (12 mins) – Japa/Bhakti yoga
• Chair Joint Freeing Series
• Pranayama: 3-part breath (2-3 mins)

Handouts given at today’s session:
• Chair Joint freeing series by Ann Swanson
• Pranayama instructions in Japanese (original translation)
• Kirtan Kriya article (Dr. Khalsa) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4923750/
Audio: Adi Bachan https://www.youtube.com/watch?v=HTzR9Ru-pSg
Nirinjan Kaur https://www.youtube.com/watch?v=Zg9NOOM2neA

CT is scheduled to receive chemo tx this week and experiencing anxiety “all the time” with a sleep quality score 2 out of 5. She experienced warmth in the forehead during Kirtan Kriya and the vocalization lifted her mood. She feels reluctant to join a support group as certain topics such as unfavorable outcomes of tx may adversely affect her emotion. CT reported that the arm felt lighter after the session (Score 3-->2)

CT demonstrated strong awareness during the Witness Practice. She reported sadness and depression in the emotional layer, and restlessness in the energy layer (scale 4 out of 5). She also noticed restriction during exhalation while scanning her breath, which may be caused by her tendency to keep emotions to herself. She reported her breath became smoother after 3-part breathing, showing improvement in breath flow.

CT has responded positively to the yogic interventions that work with subtle layers. She demonstrated no issues during physical practice and is ready to practice more active asanas that promote strength and body expression. We can work more on her sleep disturbance. Sensing her resistance, I didn’t push her on the sangha idea; we will put it on hold for the time being.

CT will be introduced:
- Cat & Cow with L arm supported, Warrior II
- Guided Imagery Meditation for LE in restorative posture Mountain Brook to free restriction in the chest and assist breathing
- Alt. Nostril Breathing with pratipaksa bhavana
- Sound Bath meditation to address sleep issue

• Yes

Date: 6/13/2023 Time: 4:00 – 5:30pm Location: Virtual

Activities:
1. Check-in
2. Home Practice progress report and CT feedback, Qs
3. Self-evaluation on changes in swelling, pain, discomfort in shoulder, energy, sleep quality, anxiety
4. Review Witness Practice – CT feedback
5. Joint Freeing Practice - JAPA. Hands/fingers, neck, shoulders
6. Isometric contraction squeeze fists, Namaste press
7. Cat & Cow and Sunbird Balance sequence with L arm supported
8. Tadasana, Warrior II, Child pose
9. Guided Imagery Meditation for Lymphedema in restorative posture (Mountain Brook)
10. Alt. Nostril Breathing with pratipaksa bhavana

CT post-session self-assessment – Pain scale, discomfort in L arm/chest, energy

Homework assignment to the client:
• Daily journaling
• Continue Chair Joint Freeing Series
• Review Warrior II using a video
• Pranayama: Nostril Breathing with pratipaksa bhavana (2-3 mins)
• Sound Bath meditation to help sleep
•
Handouts given at today’s session:

• Chair Joint freeing series by Ann Swanson
• How to do Warrior II, Yoga Journal Japan
• Pranayama instructions in Japanese
• Spiritual Healing Sound Bath (3-hour YouTube video performance by Healing Vibrations) https://youtu.be/FDuDgCZyGUg

CT did Witness Practice during her chemo last week. It reduced the side effects she normally experiences, including diarrhea, fatigue, and heaviness in the body. Her energy level returned to almost normal the day after the tx, which was a significant improvement. During the chemo, she also sent a mental message to the body saying the chemo was “a helper” trying to heal the body. Her awareness of the body has increased, and she is noticing the sensations in the parts that have been desensitized since the surgery. Her anxiety was reduced. She is able to let go of worries and feels one step closer to her normal self. She enjoys her daily 3-part breathing, which clarifies her mind and washes out negative emotions. She is fascinated by the effect of Kirtan Kriya that makes her forehead warm whenever she spends 12 mins practicing. She kept up journaling. It helped motivate her to have fun and expand her activity beyond her daily routine.

CT continues to demonstrate strong commitment and adherence to the home practice. She also demonstrates a high level of awareness and the ability to sustain great focus in subtle practices. She appears to be ready to go deeper into yogic philosophy. Therefore, I discussed the concept behind the Witness Practice and its approach to finding peace and equanimity. I introduced her to Yoga Sutra of Patanjali, Sutra 1.3 in particular. I shared the interpretation of “when the mind is calm, the spirit experiences itself.” She was listening intently and taking notes.

More active asanas were introduced to boost energy and confidence, to which she responded well. Her affected arm was propped up during Cat & Cow for lymphedema support. Warrior II was introduced for heart-opening, which needs adjustments in lower body alignment. Her discomfort in the affected arm reduced from 3 to 2, post-session. The next chemo is scheduled for 6/29/23

Her endurance today supports her being physically ready for Brahmana type of asanas. With her strong focus and commitment, and intention to apply the yogic tools introduced to her, she has greatly benefited from the interventions. Although I could not observe a noticeable change, CT stated that swelling is down in the posterior forearm. Discomfort and mobility have improved from regular asana practice. Anxiety score has reduced--from “all the time” to “sometimes”.

She has not taken any action to join a BCa support group. It will be removed from the current care plan.

CT will be introduced:
- Tadasana to Tree for stability
- Reverse Warrior and Triangle with chair
- Ganesha Mudra, calling upon strength (Bhakti)
- Loving Kindness meditation in heart-opening restorative posture (Raja yoga)
CT and YTh will discuss the regular practice regimen beyond these 4-week sessions

• Yes

Date: 6/25/2023 Time: 4:00 – 5:30pm Location: Virtual

Activities:

1. Check-in
2. Home Practice progress report and CT feedback, Qs
3. Self-evaluation on changes in swelling, pain, discomfort in the shoulder, energy, sleep quality, anxiety
4. Review Witness Practice – CT to write down what she noticed
5. Joint Freeing Practice - JAPA. Hands/fingers, neck, shoulders
6. Isometric contraction squeeze fists, Namaste press
7. Cat & Cow and Sunbird Balance sequence with L arm supported
8. Tadasana, Warrior II, Rev Warrior, Tree w/chair, Child pose
9. Loving Kindness Meditation in restorative posture (Supported reclining pose for heart opening)
10. Ganesha Mudra (Strength/Bhakti)

CT post-session self-assessment – Pain scale, discomfort in L arm/chest, energy

Homework assignment to the client:
• Continue asana, pranayama and any other practice
• Daily journaling to monitor your well-being
• Design own home practice regimen. Be realistic and sustainable. Before/after/during chemo. CT will email me.

Handouts given at today’s session
Patel, D.I., Almeida, G.J., Darby, N.T. et al. Therapeutic yoga reduces pro-tumorigenic cytokines in cancer survivors. [The study discusses the benefit of LK meditation]

CT has been practicing asanas every other day and has noticed its effect of elevating her mood and state of mind since we last met. Her BP has been stable. She noticed her breath flowed smoother after practicing alt. nostril breathing. She practices Kirtan Kriya daily. CT also noticed that swelling in the posterior forearm decreased.

CT was able to sustain Tree for 30 seconds on each side, resting a shin on the chair. Warrior II was much steadier than the last session, demonstrating her regular practice. She was able to relax into a restorative position for 10 minutes and appeared well-rested afterward.

Although I could not perform a precise visual assessment, CT self-rated the swelling of the affected arm at 2 out of 5, which was a notable reduction from the baseline taken at the first session (4/5). Similarly, discomfort and pain were reduced by two notches. Anxiety improved from “all the time” at baseline to “sometimes” at the end of four weeks.

It is evident that four weeks of yogic intervention benefited the CT, addressing the multilevel of her being (koshas) and improving her sense of well-being.

It was a rewarding experience working with someone who is highly disciplined and engaging in doing home practice. She takes it seriously, and it was clear at each meeting that she was actually doing it. Witness practice will be helpful for her as a tool for physical and psychological check-in. I usually asked her what caught her attention after the practice, but this time I asked her to jot down in her notebook. I encouraged her to do it daily as part of self-study. With the tools she has been given, I hope she feels she has more control over her chemo tx experience as well.

CT gained self-efficacy to cope with emotional fluctuation, demonstrating her understanding of the intimate connection among koshas – Annamaya-Pranayama-Manomaya-Vijnanamaya-Anandamaya. She commented that with regular practice, her anxiety level toward the unknown has reduced—she feels “positive and happier than before” and “at ease.” Although she didn’t use the exact words, she experiences a more profound sense of inner peace in her bliss layer. Working with YAK showed me the yogic healing in working as an intact system. It effectively affected her being across layers, expanding the healing beyond her primary complaint, lymphedema.

Leveraging what I have learned from working with my first practicum client and the mentor feedback, my approach was more methodical and logical, and I was able to apply the broader array of yogic tools/interventions available for this case study. I made multiple updates to the initial care plan according to the CT's feedback and via observation. I translated scripts for breathing, imagery, and loving-kindness. They will be handy for supporting my future Japanese-speaking clients. Quantitative assessment (1-5 score) at the beginning and the end of each session was also helpful in measuring progress.

CT expressed her interest in continuing the sessions. We will meet every two to three weeks when both are available. YTh will follow up via email communication.