40yr M
The client is experiencing pain in the GH joint when performing weighted effort with the arm extended behind the torso.
Otherwise, he is healthy and has a regular yoga and meditation practice.
His occupation as a construction worker is physically demanding, so he stays in shape that way as well.
He lives alone with two dogs, but has communication with family and friends.
He seems content with his life.

Client Goal:
He would like to strengthen the muscular imbalances in his body to prevent further injury. He does not have a secondary goal.

Yoga Therapist Goal:
Koshas: _x_Annamaya __Pranamaya __Manomaya _x_Vijñanamaya __Anandamaya

Integral Yoga: _x__Hatha __x_Raja ___Bhakti ___Karma __x_Jnana ___Japa

My short term goal is to strengthen his posterior side in order to stabilize the scapula during arm movements. This will help not only during the strenuous portions of his occupation, but also allow him to move safely during his personal daily asana practice. (Annamaya, Hatha)

My long term goal is to introduce mindfulness during his everyday movement to prevent further injury and flare ups in inflammation. (Vijnanamaya, Raja, Jnana)

Adaptive Yoga Manual

Keil, D. Functional Anatomy of Yoga: A Guide for Practitioners and Teachers. Lotus Publishing. 2014

Stiles, M. Structural Yoga Therapy: Adapting to the Individual. Red Wheel Weiser. 2000

Howell AJ, Burchett A, Heebner N, et al. Effectiveness of Scapular Stabilization Versus Non-Stabilization Stretching on Shoulder Range of Motion, a Randomized Clinical Trial. Int J Sports Phys Ther. 2022;17(4):695-706. Published 2022 Jun 1.
https://pubmed.ncbi.nlm.nih.gov/35693853/

• Yes

Highlights:
Awareness practice
Netra vyayamam
Upper body warm ups including forearm/wrist/hand/finger stretches
Pelvic tilts, seated
Hip mobility movements
Detailed breakdown of the following poses:
Downdog
Tadasana
Pyramid pose
Yoga nidra

He will continue with mindfully observing the use of his body in his work.

This client was a joy to work with; he was open to trying new things and integrating them right away into his activities. I had introduced some joint mobility work during the intake session and he said he was surprised to note some soreness afterwards. Even though his job is physically demanding, it showed him that certain muscles didn’t get used often. He appreciated becoming aware of tightness in his forearm so he could pay more attention to how he uses it during the workday. He also mentioned that he incorporated some of the stretches he learned from me throughout the day.

Because the client was healthy for the most part, my intention was to continue introducing practices that used his muscles differently than the workday required. Even though his main concern was regarding his shoulder, he mentioned his hamstrings were tight today. It also made sense to address how he moved his whole body during this session. Since he was not familiar with Netra vyayamam, I introduced that practice as a way to stimulate the brain.

We did a detailed analysis of several poses and explored how he could practice them in his body. This would be helpful to prevent injury during his personal practice. For Downward dog, we focused on scapular awareness and positioning to create a strong base from which to practice the pose. This had the added benefit of recruiting the serratus anterior as a main stabilizer for the scapula. For Tadasana, we focused on proprioception: posture, weight of the body in relation to the feet, and the sensation of the feet as a grounding/stabilizing force. For Pyramid pose, we focused on pelvic positioning to keep a neutral spine while allowing him to continue to stretch the hamstrings. He had been in the habit of bending at the waist to make the pose “deeper,” so learning how to “hinge” at the hip brought a greater awareness/understanding of the true range of his hamstrings and the position of his spine.

Because he wanted to focus on his hamstrings today, we didn’t get a chance to give as much attention to his shoulders. My plan is to incorporate more posterior shoulder strengthening for the next session.

• Yes

Highlights:
Awareness practice
Upper body warm ups including forearm/wrist/hand/finger stretches
Pelvic tilts/cat/cow
Sunbird
Hip/ankle mobility
Detailed breakdown of the following poses:
Cobra
Sphynx (with forearm stretch)
Locust/boat with weighted arms in different positions (back, T, overhead)
Windshield wiper
Yoga nidra

He will try to incorporate some of the prone poses from today to help strengthen his posterior side. He will also try to include the ankle mobility practices because they offered a release for him.

He was feeling reflective today. He meditates daily and noticed how his intention of “being of service” draws people to him. Personally, I thought it was cool that it was so similar to Integral’s philosophy and quite serendipitous that he came up with it on his own. On the physical level, he mentioned he had done some biking and light running, so was feeling tightness in the hips.

I’m glad I continued to incorporate joint/mobility work for the rest of the body in addition to the focus on the posterior shoulder strength. The client appreciates it because not only does he get great benefit from the movement, it also points to areas in his body that could use more attention. He wasn’t really conscious of how his work boots (8” high) squeezing his ankles had been affecting his movement until he felt the loosening through the practice. By paying attention to his scapula, we also woke up some muscles (rhomboids/serratus anterior) that he wasn’t utilizing optimally. Learning this allowed him to create more movement as well as stability. We adapted some of the prone poses by finding something in his house to add weight to the movements for more challenge.

On the more subtle side, it was nice to be able to hold space for him in his reflective mood and discuss what it meant to him to be able to help others. He volunteers when he has time outside of his other commitments.

Since we worked on posterior strength in the prone position, we can continue incorporating alternative posterior strengthening exercises in a standing position for variety.

• Yes

Highlights:
Awareness practice
Neck/upper body warmups
Standing posterior shoulder mobility/strengthening practices
Stop/tray/twist
Pelvic tilts/cat/cow
Sunbird
Hip/ankle/foot mobility
Breakdown of Warrior 2 including warmups
Viparita karina
Windshield wiper
Yoga nidra

The client will continue to practice mindfulness in movement as well as use the practices he learned with me. He is now aware that his ankle is another area that requires his work and attention.

The client was feeling fine today; there wasn’t anything specific he felt the need to address. When I asked him if he had any special requests, he said that found benefit from each of the sessions we had done so far. He noted he got a little sore from the prone asana work we did, so it confirmed to him that he needed to work on it.

The client appreciated having another way to strengthen the posterior side of his shoulders in a different plane with respect to gravity. While the previous practices in a prone position were more intense, today’s standing practices were more accessible. They could be performed throughout the day in between other activities without having to go down to the floor.

Working on Warrior 2 in more detail was educational for him, because he tended to flow through his poses. Paying attention to the details of positioning his upper and lower limbs, as well as holding the pose for an extended amount of time asked him to use his muscles in a different way than he was used to. He appreciated feeling the difference.

We had noted in the previous session that he could benefit from the ankle mobility work. In this session I noticed that his plantar flexion was not optimal. (He had a bend in his ankle when trying to point his toes.) This is a good reminder not to forget to broaden my attention from the stated need. Just because the client is focused on one area, doesn’t mean that other areas do not need help as well. (He didn’t know what he didn’t know.) This is true in both the physical body as well as the mental and spiritual layers.

Even though his case was fairly straightforward and he had a healthy physical and mental/spiritual state, there were some nuances to be discovered. On the physical level (Annamaya Kosha, Hatha Yoga), the client appreciated the different ways of moving, stretching and holding his body to ease pain and create strength. On the more subtle/mental levels (Vijñanamaya Kosha, Raja Yoga, Jnana Yoga), it was eye opening for him to learn how he moved and held himself could affect his mobility and strength to such a degree. For example, until he started witnessing and bringing awareness, he didn’t realize the way he held his tools and the shoes he was wearing was decreasing his mobility.

I usually have an idea of what we can cover for the session, but being present and open to the moment afforded a chance for exploration I never would have considered otherwise. For example, being open to what the client was experiencing at the time (session 2) allowed me to offer room for his reflections on his volunteer work. I held space while he shared about something that was so meaningful for him. By doing so, we were able to have a conversation around Karma Yoga, which is something I had not initially included in the care plan. Had I insisted on starting out with my original plan, I would have missed this opportunity.

I believe that in this case study, we achieved both the client’s goals as well as my own. He mentioned that he benefitted from what he learned. By the end of our time together I felt that he had the tools he needed to continue what we started.

This was our last session, but if we were to meet again, I would check in with him to see how he was doing, if there was any improvement, and if there was a new goal he wanted to focus on, whether physical or not.