LW is a busy yoga therapist and yoga teacher. She is a parent to a 14 year old who is in boarding school and she cares for three cats. LW reflected that she currently has only one friend who she can talk to. However, he is usually busy traveling so she spends a lot of her time, outside of work, home alone. She reported that group social situations are not ideal due to having ASD and ADHD. LW self describes as obese and wants to build asana & exercise into her regular schedule. She believes she has hEDS/ HSD and has been diagnosed with pelvic organ prolapse (POP), stress urinary incontinence (SUI), and has a history of joint injuries, joint pain, anxiety, and digestive issues (GERD & interstitial cystitis). She avoids bladder irritants and practices pranayama regularly.

LW stated that her goals for our time together are to support a return to balance in body, mind, routine, diet, sleep -really all aspects. She would also like any of our physical practices to address her POP and SUI.

Post Intake/ Assessment Home Practice: The first home practice assignment is to create a regular routine around sleep and wake times. We discussed LW's challenges with going to bed prior to (or by) 10pm. She said it is difficult, not logistically, but rather in terms of practice and motivation. This week she can start by giving her cats a treat at 9:30pm. She believes this will modify their evening routine enough to naturally influence her to get to sleep closer to 10pm. To stay accountable to herself, she can indicate each day she gets to bed around 10pm by marking a moon on her sadhana board.

The first step in LW's care plan was to address wake and sleep times by adjusting the time she goes to sleep. Step two was to add some daily movement practices. First start with breathwork to influence visceral mobility and relaxation response, followed by down training the pelvic floor muscles (PFMs), working on supporting structures within the concept of overflow, and potentially even add on some up training once the breath and movement are coordinated. This plan was modified after our first session as she started her own daily movement practice by committing to a series of classes at a local Barre studio.

The modified new care plan kept in mind what practices might support her goals while also mitigating any persistent or increased pelvic floor symptoms she may have as a result of the barre class up training practices. The new care plan begins with pranayama (elongated exhalation for 1-3 minutes & Brahmari 7x). By downregulating the nervous system, the body can allow for more effective change, release of tension, and release of holding patterns. Pelvic organ prolapse is not generally an issue of laxity alone but rather tension and displacement causing organ pressure and descent. Pelvic breathing sitting on the bolster to release tension and provide feedback in the pelvic diaphragm is one tool we added. Next pelvic floor mapping, connecting with the coccygeus and superficial transverse perineal muscles bilaterally. Following that with a half moon pose on the bolster for lateral rib excursion. Afterwards LW can practice advasana with arms in crocodile pose and head centered focusing on pelvic drops (also referred to as reverse kegels) for down training of the pelvic floor muscles (PFMs) and encourage some posterior thoracic mobility.

1) Shelly Prosko, Yoga Therapy in Practice: Optimizing Pelvic Floor Health Through Yoga Therapy, Yoga Therapy Today, Winter, 2016.

Prolapse is "a condition of hyper or hypotonia of the pelvic floor muscles." "Addressing pelvic floor health is not always simply about performing an isolated Kegel or engaging mula bandha. Learning how to engage the PFMs with proper synergistic timing with other muscle groups with awareness, mindful movement, and breathing can be a daunting task."

2) 2) Ghetti C, Skoczylas LC, Oliphant SS, Nikolajski C, Lowder JL. The Emotional Burden of Pelvic Organ Prolapse in Women Seeking Treatment: A Qualitative Study. Female Pelvic Med Reconstr Surg. 2015 Nov-Dec;21(6):332-8. doi: 10.1097/SPV.0000000000000190. PMID: 26506161; PMCID: PMC4624225.

3) Lowder, Jerry & Ghetti, Chiara & Nikolajski, Cara & Oliphant, Sallie & Zyczynski, Halina. (2011). Body image perceptions in women with pelvic organ prolapse: A qualitative study. American journal of obstetrics and gynecology. 204. 441.e1-5. 10.1016/j.ajog.2010.12.024.

Ayurvedic Perspective of POP/ Prasramsini Yonivyapad (from POP presentation in yogaville)
Vata Accumulation → Aggrivation (Dry, cold, light, mobile)
Damage to tissue, organ, & system and loss of muscle tone & tissue
Hyper or Hypotonia (Rajas or Tamas)
Variable elimination (constipation & frequent urination)
Anxiety, Worry, Fear
Raw, dry, crunchy, stimulating & sugary foods & drink (carbonated & caffeinated)
Disregard for body’s need for food & sleep
Choosing activities that exceed one’s energy level
Look out for escapism, fantasizing, & daydreaming
Avidya- forgetting we are not the body-mind
Asmita -over-identifying with pre pop self & difficulty asking for help(2)
Raga -attachment to youth and activities enjoyed prior to pop(3)
Dvesha –shame & avoidance of activities that can cause symptoms or SUI(3)
Abhinivesha -fear of mortality associating POP with old age & fear of death(2)

5) Goodridge SD, Chisholm LP, Heft J, Hartigan S, Kaufman M, Dmochowski RR, Stewart T, Reynolds WS. Association of Knowledge and Presence of Pelvic Floor Disorders and Participation in Pelvic Floor Exercises: A Cross-sectional Study. Female Pelvic Med Reconstr Surg. 2021 May 1;27(5):310-314. doi: 10.1097/SPV.0000000000000813. PMID: 32217913; PMCID: PMC7381369 

“A gap exists between knowledge and willingness to participate in Pelvic Floor Exercises”

4) AIRBAG - Toilet Meditation https://youtu.be/w9zsTUvNn-8 (handout provided by Shelly Prosko)

• Yes

Our first session began with a check in followed by centering, breath awareness, pelvic breathing. We moved on to some poses at the wall (cervical retraction, roll down, half moon, pec stretch with block, & wall chair). Then moved on to asana & relaxation on the mat (cat/ cow, wags, child's pose, bridging, supine twist, advasana, & savasana).

Continue with practices of earlier bedtime and wake time from last week. Attend barre and notice how your body feels after class and see if there is any change in symptoms. Practice reverse kegel in bed prone before sleep each evening.

LW seemed very excited to share that she signed up for Barre class this month. She said she has not practiced barre before this but feels it is going to be helpful to rebuild strength and endurance she has lost with her current work that is often at a desk rather than in the studio.
LW mentioned that she signed up for a new student challenge and she will aim to attend 3-6 a week as part of this new goal. LW has also started to set an earlier bedtime when possible. She also noted that by practicing barre class 3x so far this week helped to modify her regular sleep/ wake times due to the early time of the class.

I noticed an improvement in LW's mood and a real excitement and enthusiasm to pursue her goals head on this week. One concern that I have is that this front loading of new activities could be unsustainable. In addition, this particular type of movement can sometimes cause an increase in POP/ SUI symptoms. I feel that the improved mood and motivation to make healthy life changes outweighs the risks of increased prolapse and incontinence symptoms for this particular client. I am also curious how this movement may create some more bulk/ support around the hips and thighs. This could, in a sense, be an alternative to overflow exercises that I had planned to practice with LW long term. I will continue to check in with LW to note any changes, if any, in symptoms.

Present and review a newly modified care plan focusing on downtraining the pelvic floor and building interoceptive awareness around holding patterns as well as symptoms.

• Yes

Our session began with a follow up of how the sleep and movement practices went during the week. We started with breath awareness, elongated exhale, pelvic breathing, & 3 brahmari breaths followed by palming eyes & jaw. Next we practiced some 1st & 3rd layer PFM release with pelvic breathing and pelvic floor mapping with props she had available. Breath awareness in restorative half moon pose, slowly rocking the bolster up the side body from iliac crest to latissimus attachment. Reverse kegel in balasana, crocodile pose, and hook lying. From hooklying we practiced diaphragmatic breathing & pelvic drops with the pelvic diamond image. Shhhh breath to feel transversus activation, added adduction with prop and knee folds (acetabulofemoral-pelvic dissociation) with the shhh breath.

Homework this week was to continue to log early bedtimes on the sadhana chart, practice pelvic breathing in Crocodile pose 1x a day, and add on the new restorative release work before Barre class. Make an effort to check in with how the body is feeling after barre class later today applying the concept of “lengthen before you strengthen.”

LW is adding a lot on to her schedule with regular barre classes and workshops in addition to her work. She seems quite motivated by these classes and the confidence and connection to her body it gives her. She is still having difficulty feeling the release during pelvic breathing and drops but notices some more connections in identifying holding especially with the pelvic mapping work. She reports soreness after barre class but seems to enjoy that sensation and associate it with muscle strength. It seems weight, POP, and SUI are things she associates with being older or "out of shape." She says she is in the early stages of menopause and she never had issues as bad as she does at this stage of life. She also asked if she might have diastasis recti (DRA) because she has "gained so much weight" (by her standards). This over identification with her body and the desire to have a previous version of it seems to be motivating her goals. Rather than finding balance it seems a bit that these goals are ego centered. Despite that possibility the earlier bedtime and more frequent movement patterns are having a positive effect on her mental health, mood, and self image.

Past experiences with clients who have POP/SUI that practiced Barre may influence my work with LW. I am making an effort to view this work together as a new experience that may have different outcomes. LW has chosen this type of movement and it has already seemed to improve her mood. That said I cannot ignore the mechanics of Barre workouts and the "ab" section at the end. These movements are perfectly fine for people with prolapse to build up to but LW is going from zero to 100 with these classes. Oftentimes when a professional mover transitions out of their training days into a more sedentary lifestyle their expectations for returning to movement are unfair and can have a self sabotaging effect. Going too fast into any new practice can lead to injury but especially practices that cause an increase in pelvic and abdominal pressure when the conditions one has are due to issues in the core canister it seems as though this is a recipe for disaster. I am balancing my own personal and professional beliefs with her reported outcomes as well as the risk versus the benefit for the client. I have already discussed prolapse and how an increase in pressure, pain, or leaking is a sign a movement practice may have been too much and to scale back accordingly and build back up more slowly over time. It is my hope that some of the interoceptive awareness practices for the pelvic floor will help to notice if or when there are changes in symptoms. This will help influence the direction we take and if we should add on up training over time or continue to focus on managing the effects of Barre.

Discuss toilet habits, intra-abdominal pressure (IAP), and how to use the breath to support the pelvic floor. Review the specific elements of Shelly Prosko’s Toilet Meditation using the AIRBAG acronym (Awareness, Imagination, Release, Breathe, Allow, Gratitude). Potentially add the before Barre practices after Barre class as well.

• Yes

We started this session with a body scan in savasana, elongated exhale, and 1:2 ratio breath. At LW’s request we spent some time discussing how to self check for DRA and feel differences in the fascial integrity at the linea alba and changes in the Inter-rectus distance (IRD) during forward flexion and movements that typically increase IAP and pelvic pressure.We moved on to a diaphragm release, roll up the side for thoraco-lumbar fascia in half moon pose, and pelvic breathing in crocodile pose. Discussed toileting and reviewed the Toilet Meditation (AIRBAG).

Continue to work on sleep/ wake time regularity, practice downtraining homework before and after class, and identify any movements in Barre that might be increasing pressure. Apply the Shhh breath or exhale on the effort to these exercises and see how that feels. Add on diaphragmatic breathing or AIRBAG whenever there is time when voiding.

During our check in this week LW shared she has been waking up at 4am to attend a workshop with Heather Mason. The focus is the pelvic floor and while she felt it was relaxing, waking up early has been difficult as she is getting even less sleep. The before and after barre practices did not get practiced more than once or twice because she has been tired and sore. When she did practice, LW noticed that it brings awareness to this specific area and helps to differentiate different areas of the PFMs from each other. LW practiced AIRBAG 4 or 5 times during the week and described it as a bathroom oasis away from the cats. In addition to the pelvic floor workshop, Barre class, and our work together she has started taking an anti-inflammatory course with Amy Wheeler and noted that she feels like her kapha dosha is overpowering at the moment. While we discussed modifying abdominal work in her classes to reduce IAP she was not interested in modifying during class or telling the teacher she may skip certain movements.

During our session she did make some new connections, reporting that the right side or her rectus abdominis “gaps out more.” Yet on her DRA self check the IRD and depth did not seem significant based on her descriptions. I explained this imbalance or gapping on one side often happens if we have a holding pattern in the thoraco-lumbar fascia, quadratus lumborum, and obliques. LW confirmed that her right quadratus lumborum was more sensitive to pressure which is consistent with the right side gap she felt. LW reflected that the right side of her body is consistently more tense and interestingly she shared that the injuries/ breaks she has had were all on the right side of her body noticing a pattern there. LW noted a brief bit of transient nausea on the self check of DRA (this may have been due to pressing too hard despite cues to press gently) so we moved on to other things. While LW is making connections she is losing a bit of focus and direction too.

While this session went well it was challenging to not feel discouraged learning about all the new things that LW has added to her schedule. It felt a bit like she might be bored, dissatisfied with the work we had started to implement, or that it was not enough for her. While I know this tendency to look for the next exciting workshop there is value in practicing and observing smaller changes over time. It was especially concerning that one of the workshops she chose to take requires a 4am wake up due to time differences. I think this is almost a form of self sabotage as we require sleep to function and heal. I am learning to manage my own disappointment when a client loses interested in working with the plan we created together. It may be that this was not what she wanted or it may be revealing some deeper concepts that are uncomfortable to face at this time. Either way I think it can open up some opportunities for my own as well as the client’s growth when this happens.

Working with LW was both enjoyable and frustrating at the same time. While we share a common interest, profession, and practice of yoga, it was challenging to accomplish what we set out to do in the time we had with so many changes. LW was trying out several methods, workouts, and even approaches to pelvic health practices. It can be a bit difficult to determine what is helping versus what is hurting when each week new practices, teachers, and classes are added to the schedule.It can be hard to note progress when there are changes in the plan.

In the past I have worked with clients who self describe as experienced yet require regression in their training as they progressed too quickly or lack fundamental connections to move on to more challenging work safely. Although I did not feel that LW was in danger, I also did not believe the choices she was making were supportive to her stated goals. Sometimes we can have too much of a good thing and it loses some of its goodness. I noticed that it did make me feel that our work was less appreciated or as though our work was not enough to need to seek out more. This led to challenges for us to co-create and recreate the plan to her new schedule. It is possible that due to having ASD and ADHD, LW may lose interest in a plan or movement practice more easily. Unfortunately we do not see progress or benefit from the results when we dabble.

Another barrier was that this client is already a yoga therapist. I felt a bit that while she was excited and eager to work together she questioned my approach. She seemed open to downtraining but kept stating that her POP was related to weight (while this could be there is less evidence to back up weight loss as a way to reduce symptoms). In some ways I think she would have benefitted from more education about SUI and POP to buy into the approach of downtraining before uptraining in modern pelvic health. Had she understood it she might have been more keen to stick with it and less prone to add on extra classes to fill the perceived gaps in the plan. Just as the yoga sutras advise, we need to have regular practice for a long time without breaks with full enthusiasm.

One thought I have in reflecting about this particular work is how prolapse is representative of a drop, or failing, or falling out of our security and stability represented by the root chakra. In researching POP/ SUI, many women identify their conditions with aging and infertility or even mortality. Confronting a condition and the feelings it brings up for us in this way can be quite uncomfortable. Our association with the body and youth or a specific shape is often an over identification with the ego and underidentification with the atman. I am not sure that we were the right match to dive into these raja yoga concepts together. I was also not sure if LW was ready to address these issues in that way herself. Working with LW was a good example of learning when it might be a good time to take a break or re-evaluate goals with a client to ensure they are getting what the most out of the yoga therapy sessions together. It might also be a sign she would benefit from working with someone else instead. Knowing when to address a plan that doesn’t go quite as planned has been a valuable lesson with this client.

Discuss how her new schedule might be positively or negatively affecting her other goals. Check in to see how Barre classes and gauge if pressure or leaking symptoms have changed or stayed the same. Ask how our sessions might shift to support her new schedule or any changes in her goals.