GJ is a 74 year old retired editor and newspaper manager who last worked in 2020. After being laid off from her management, editorial, and receptionist work she went from 45-50 hour work weeks to retirement all at once. She has hobbies, faith (but no current spiritual practice), and reports difficulty getting motivated to exercise or go out on walks. She takes 3 medications for depression and sees a provider semi-regularly for that however she does not attend regular therapy. GJ is also on a water pill for HBP prevention, and a sinus medication daily. In the summer of 2022 she had a total knee replacement (TKR) on the left knee, after 5 years of living with it "bone on bone." Her right knee, both hands, fingers (one trigger finger), toes, and neck osteoarthritis (OA) causes her regular aches and pains that affect her ability and motivation to stay active.

Post-intake/ assessment homework: Call the senior center to check when the next walking group is meeting and consider signing up.

Annamaya Kosha: Asana practice: Chair JAPA head to toe (taking extra care and attention with fingers and toes), marches (alternating leg lifts with and without knee extension).
Standing at the chair: tree pose (for bone health, balance, proprioception, and longevity).
Incorporated physical therapy homework: piriformis stretch in the chair.
Standing at the chair: hip abduction and extension (locust), hamstring curls, lunge (gastrocnemius stretch), and sit to stand (dynamic chair pose).

Pranamaya Kosha: Diaphragmatic breathing/ breath awareness as a foundation, sitkari, and elongated exhale breathwork to manage OA flares, and kapalabhati (deconstructed as a HA breath) to build agni, take action, and motivate. This practice could help to both strengthen the transversus abdominis and also help to shift from tamas accumulation/ stagnation into balance.

Manomaya Kosha: Spending some time in nature each week could be helpful for GJ to shift out of negative thought patterns and loneliness. GJ lives alone and reflects that she does not have at least 5 people she could call in an emergency. I think that a volunteer activity/ karma yoga in a group setting or a walking group at the senior center may open her circle of support a bit and uplift her spirits over time.

Vijnanamaya Kosha: GJ was an English major in school and enjoys recreational writing. For this reason, a gratitude journal might be helpful as a means to practice santosha, svadhyaya, and uplift the mood.

Anandamaya Kosha: Cheri Clampett’s cooling water-arthritis and inflammation guided imagery.

1) Deepeshwar S, Tanwar M, Kavuri V, Budhi RB. Effect of Yoga Based Lifestyle Intervention on Patients With Knee Osteoarthritis: A Randomized Controlled Trial. Front Psychiatry. 2018 May 8;9:180. doi: 10.3389/fpsyt.2018.00180. PMID: 29867604; PMCID: PMC5952125.

Om chanting, elongated exhalation, nadi shuddhi, brahmari, sitali, sitkari, & kappalabhati were used in this RCT in sessions lasting 90 minutes, once a week, over the course of 8 weeks. Other practices used: twist, side bend, seated forward bend, cobra locust, bridge, and corpse pose.

"Yoga showed a reduction in pain, depression and more significant improvement in life satisfaction after intervention [...] In a comparison of conventional therapy and add-on yoga for 56 patients of knee rehabilitation after total knee arthroplasty showed that there was a significant change for pain, stiffness and functional subscales of Western Ontario and McMaster Universities OA Index (WOMAC) Scale in both groups. This indicated that yoga asana protocol works better than physiotherapy alone." "Yoga therapy intervention may increase cartilage proteoglycan content and prevent cartilage degeneration [...] yoga practice may prevent synovial fluid volume deterioration by stretching and strengthen[ing] different parts of the body." "Yoga practice helps in reducing several psychological factors such as stress, anxiety, mood disturbances, and enhance self-esteem and quality of life in individuals with chronic pain and arthritic conditions." "Yoga is an acceptable and safe intervention, which may result in clinically relevant improvements in pain and functional outcome associated with a range of musculoskeletal conditions such as muscular dystrophy, osteoarthritis, rheumatoid arthritis, etc."

2) Moonaz SH, Bingham CO 3rd, Wissow L, Bartlett SJ. Yoga in Sedentary Adults with Arthritis: Effects of a Randomized Controlled Pragmatic Trial. J Rheumatol. 2015 Jul;42(7):1194-202. doi: 10.3899/jrheum.141129. Epub 2015 Apr 1. PMID: 25834206; PMCID: PMC4490021.

The 8 week RCT compared Integral-based hatha yoga and waitlist groups. Participants met twice a week for 60 minutes involving: sharing (5 mins), chanting & breathing (5 mins), warm-up and moving sequence (surya namaskara; 15 mins), and isometric poses (asana 20 mins), deep relaxation (10 mins), and closing chant & meditation (5 mins).

"Preliminary evidence suggests yoga may help sedentary individuals with arthritis safely increase physical activity, and improve physical and psychological health and HRQOL."

3) Haaz S, Bartlett SJ. Yoga for arthritis: a scoping review. Rheum Dis Clin North Am. 2011 Feb;37(1):33-46. doi: 10.1016/j.rdc.2010.11.001. Epub 2010 Dec 3. PMID: 21220084; PMCID: PMC3026480.

"No adverse events were reported, and attrition was comparable or better than that typical for exercise interventions. Evidence was strongest for reduced disease symptoms (tender/swollen joints, pain) and disability and for improved self-efficacy and mental health. Interventions, research methods, and disease diagnoses were heterogeneous."

• Yes

Chair: Centering followed by breath awareness (spent time to notice movement in the chest and abdomen especially) and elongated exhalation.
Chair JAPA: neck, shoulders, netra vyayamam vertical movements (added on the layer of inhale up and exhale down), cat/ cow, torso circles, half moon, forward bend, toes, arms, gentle piriformis stretch, marches/ hip flexion with shhh breath. Spent some time explaining kapalabhati and the action of the abdomen in both regular breathing and this particular breath practice. Then we practiced creating an imaginary mirror with the hand and exhaling HA to fog the mirror a few times. The first time just learning the practice, the second time noticing if the abdomen snapped in or not, the third time trying to snap the abdomen in actively while HA/ exhaling the breath out.
Standing: sit to stand/ dynamic chair pose, locust pose, standing abduction.
Yoga Nidra: Reclined on the couch we needed a bit more time so I did not use the guided imagery during this session.

HA/ deconstructed kapalabhati 5 expulsions in the morning and piriformis stretch in afternoon when seated at lunch time.

GJ was focused and seemed in a positive mood today. She reported that over the past week she had called her senior center and scheduled a walk with the group for the end of the month. I noticed that she picked up my cat/ cow correction nicely and is starting to get more rib excursion during breath awareness so we added on a bit more pranayama today. GJ called her Doctor this past week about the pain she has had in her hand (esp right hand and thumb) which is a great step towards caring for herself after many months of experiencing pain with it. I observed a lateral curve (similar to what one sees with scoliosis though nothing like this was shared in her intake). This curve could not be corrected with cuing alone so it may be structural.

I went a bit slower with directions this week and gave some balance work which appeared to suit her. She seemed happy to work gently but was also up to a bit of a challenge too. I notice that I need to demo a bit more and remember to demo despite her past years of experience with yoga.

Next week I plan to add on more opportunities for balance in standing such as locust and tree pose by testing taking one or both hands off the chair. I would like to work on some functional movement with GJ (other than sit to stand) so that she feels confident coming to the floor and getting up without pain. This is more of a long term goal that would likely need to extend past this month’s plan of work together but could potentially improve her confidence, safety living at home, and quality of life too.

• Yes

This session started with a follow up where GJ mentioned she has had pain in her hand that she believes might have been from a fall she had earlier in the year. She has not mentioned it to the doctor but sees her rheumatologist next week. I encouraged her to mention it to him.
Seated in the chair: centering with breath awareness, Om 3x, elongated exhalation, neck stretches, JAPA from head to toe, cat/ cow, shhh with march, side bend, twist, forward bend, and piriformis stretch.
Reviewed kapalabhati with the image of fogging a mirror saying HA and added on the silent opened mouth version after a few rounds.
Standing: dynamic chair pose/ sit to stand with a hold half way up. Standing at back of the chair: hip extension/ locust pose testing balance by removing opposite hand as gesture leg, hip abduction, lunge gastrocnemius stretch bilaterally, and tree pose holding on with one hand.
Supine on the couch: Guided relaxation of cooling water imagery (spent extra time with the water running over the hands and between the fingers).

Continue to practice HA/ deconstructed kapalabhati 5 expulsions and add on 5 expulsions without sound. Continue to practice the piriformis stretch in the afternoon when seated at lunch time but add on the sit to stand, locust, abduction, and lunges holding on to the chair.

While GJ reports feeling her belly move when she breathes I do not see it well. This could just be lighting or it could be a subtle movement but I am noticing occasionally her shoulders lift on the exhale. This seems to be more in line with paradoxical and apical breath patterns. I am concerned that GJ doesn't always hear me well when I am demoing, despite my checking if she can see and hear me. I get a sense that she wants to be a “good student” and rather than stop the flow of our work she nods or says yes when she may have more questions.

I am working to find a balance between demoing and providing time and space for GJ to recall the movements on her own to build some confidence with them and take control of her own autonomy. Sometimes I forget that the set up of these poses or the alignment can be confusing or challenging at first. I find myself having to slow down a bit or reword a cue and demo at different angles to see if that works better for poses we have been working on as well as new poses. It is possible that GJ struggled with proprioception prior to her TKR or it is possible it is taking her additional time to regain confidence. One other possibility I am considering is some cognitive decline due to her solitary retired lifestyle combined with aging. Either way I am trying my best to explain things methodically and slowly to ensure she understands while we are together. My concern is that during homework it might be practiced in a different way again.

Focus on diaphragmatic breathing and return to the original HA/ fog the mirror more slowly. Add on sitali if it seems to be going well with the other practices. In standing add on hamstring curl and heel raise at the back of the chair holding on.

• Yes

Body scan, breath awareness, elongated exhalation, 3 OMs, JAPA: head, shoulders, spine, Swami Vidyananda’s elbow twist, toe yoga, ankle circles, janusirsanana, piriformis stretch, marches with shhh, leg lift with extension alternating, set up for HA then hand on abdomen exhale through the nose, 2 rounds of 5, Sitali 5x, sit to stand. Standing holding on to the chair: locust with the opposite arm off the chair to work on balance, hip abduction, heel raise, gastrocnemius stretch, hamstring curls standing facing the chair. Deep relaxation on the couch with cool water imagery.

Continue to practice kapalabhati this time with mouth closed expulsions coming out of nasal passage for 5 expulsions. Continue to practice the piriformis stretch in the afternoon when seated at lunch time but add on the sit to stand, locust, abduction, and lunges holding on to the chair.
Start to journal one thing a day that you are grateful for. Notice if you have discomfort after a walk or physical therapy homework and jot it down on your calendar. Our next session is after the walk at the senior center so we can also check in about it then. Remember to set up the strap and block GJ has so that we can use them next time.

GJ noted that she walked the day before yesterday but it was painful. When asked more questions she explained that she did not notice the pain in her shins till yesterday when she was practicing her physical therapy exercises. When I observed GJ practicing the movement that was causing the pain the day before (sit to stand) I noticed that her feet were tucked under the chair a bit causing more pressure on the knees than was needed. I cued her to move her feet forward and she noted no pressure with that movement. I also noticed that she has valgus knees and the left was more difficult for her to correct muscularly with cuing than the right. It may benefit her to have some external rotation work for the hips in the future to help address this tendency.

GJ could use more proprioceptive, interoceptive, and spatial awareness and with more time I would continue to bring focus to this while also working on practices that benefit her arthritis pain management, TKR rehabilitation, and depression. Sometimes GJ perceives that her body is in alignment (for example knee over foot vs falling inward) but it appears to be muscle tension, hypertonicity, or a disconnect where the body’s sensations are not providing clear feedback. Some more education around how to articulate feelings (sharp, dull, hot, shooting, persistent, etc) and how to locate where she might be feeling them could help her advocate more clearly in doctor visits, our sessions, and also with her own observations as well.

In the past I overloaded several care plans with clients giving them lots of things to practice. While I do not feel I did this with this GJ and we did build up to these practices adding just a little more each week, it still may have been a bit too much too fast. I thought that several practices she had already in place from what she shared about her previous yoga experience and also from our time checking in while she was on the mat. It is possible looking back that she wanted to do “well” and “get it” so she may not have said or even noticed if things were confusing or not feeling quite right. I need to be especially deliberate with my own body language and alignment and break down movements to build them up more over time with GJ. I think I could offer more time for reflection during our movement and breath practices as well in the future.

GJ has been a lovely person to work with. Although we did not make leaps or bounds towards her goals, I do feel that we did make some progress together in a healing relationship. GJ was recently able to share with me that she really didn’t understand the breathwork we had been practicing. After that, we were able to break down the practices a bit more in our last session. Additionally, I would like to break down the standing practices and then rebuild them up over time. Providing GJ with more time to work on her alignment, balance, and build more confidence in her body and understanding of each movement seems key. Also providing some education around why we practice any given thing seems to help GJ focus more on the technique and tune into her proprioception and interoception.

While the plan we had was not long or complicated for someone with her background in yoga, it was a bit too complicated for GJ in the time frame it was given. If we have a bit more time to work with each other in the future, it might be helpful to practice some additional functional movements like kneeling down and getting up off of the floor. GJ lives alone and may need more insight about how to safely care for herself at this stage in her life and recovery with her TKR and OA. Based on my observations with her taking a bit more time to learn new practices or recall corrections from past sessions, more practice with even less homework may serve her better. In the future I would like to continue to work with GJ and focus a bit less on pranayama and asana homework and more on raja yoga tools and social interaction. Perhaps some karma yoga would be helpful in getting her out of the house and socializing a bit more. During session time I would focus on providing more opportunities for GJ to move mindfully in our sessions for reflection. I feel these insights on the mat could translate into deeper observations that lead to positive lifestyle shifts over time too.

While these sessions taught me a few things, one obvious insight is that this work doesn’t have a typical timeline. Some clients may take 4 or 6 sessions to gain some noticeable changes while others will have less dramatic shifts. I do feel some subtle changes in GJ’s mood and motivation to care for herself took place. Although this isn’t as dramatic as some case study work it was a big step in the right direction for her. GJ made some positive shifts by signing up for the walking group with the senior center and reaching out to her doctor to mention the pain that she’s been having for the past several months in her hands and thumb. While these changes are seemingly small they did take real effort to shift out of her comfort zone.

I would ask GJ to show me how she executes her home practices to ensure she is doing them safely. Continue with journaling. More long term goals would be to set up a meditative practice like a walking meditation.