Subjective:
HMG is the mother of a 16, 12, 6, 3, & (almost) 2 year old. She is currently lactating but reports she is close to weaning. has been living with chronic pain her whole life. She stated that she has medical PTSD and often feels providers don't know how to help her or work with her. She has a history of being in and out of PT, generally they do not know how to work with chronic conditions or how to bill for it so she discontinues. She is semi-ambulatory, being able to take a yoga session or go for a walk with her husband some days and needing to use the chair, cane, or stay in bed others. This has been the case for most of her life. She has hip pain that started during her pregnancy with her eldest child and has not gone away.

Objective: She has been diagnosed with Autism spectrum disorder-ASD, Ehlers-Danlos syndromes-EDS (including hEDS) and several sequelae conditions such as Postural orthostatic tachycardia syndrome-POTS, Dysautonomia, Mast cell activation syndrome-MCAS (she takes 2 medications for this), Gastroparesis, Gastroesophageal reflux disease-GERD, Migraines, Tethered Spinal Cord, & Supraventricular tachycardia-SVT. She sees a therapist for anxiety and had Eye movement desensitization and reprocessing-EMDR 3 years ago.

Assessment: On self assessment she self-reported diastasis recti (DRA) and her inter-rectus distance (IRD) was 3 cm above umbilicus and 3.5 at umbilicus with flexion. She has no known hernias. HMG has hyperkyphosis but it is not pathological. She does have bilateral rib flare, quadratus lumborum, & tensor fasciae latae holding patterns. She reports that her upper traps and rhomboids are sore and weak. Right coccygeus/ iliococcygeus is hypersensitive indicating potential hypertonicity.

Daily ahimsa journal: recalling situations where she took breaks and made choices that preserved her energy or peace of mind.
Tadasana body scan / svadhyaya every time HMG uses the bathroom or is about to get in the car she can take a moment to ask herself: "how does my body feel?" "what am I feeling?" and "where am I feeling it?"
Tools to downregulate: elongated exhales, brahmari, & vagus nerve stimulation tools that can be used anytime HMG notices tension in body, breath, or mind.
So Hum meditation 1-3 minutes during nap time 1x daily.
Sequential muscle relaxation: can be practiced with her smaller children at bedtime.

1) Li Q, Lei S, Liu Y, Liu Q, Chen Y, Lin X, Zhang X. Effectiveness of Yoga on the Interrectus Distance in Early Postpartum Women: A High-Frequency Ultrasound Study. Biomed Res Int. 2022 May 20;2022:8908095. doi: 10.1155/2022/8908095. PMID: 35647191; PMCID: PMC9142290.

"This study found that a 12-week progressive yoga rehabilitation exercise intervention effectively shortened the supraumbilical, umbilical, and subumbilical IRD."

2) Hamilton MJ. Nonclonal Mast Cell Activation Syndrome: A Growing Body of Evidence. Immunol Allergy Clin North Am. 2018 Aug;38(3):469-481. doi: 10.1016/j.iac.2018.04.002. Epub 2018 Jun 9. PMID: 30007464; PMCID: PMC6049091.

"Numerous studies have examined the relationship between depression, anxiety, and psychological stress with mast cell activation... Patients are encouraged to pursue activities for stress reduction such as yoga, meditation, and exercise."

3) National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Selected Heritable Disorders of Connective Tissue and Disability; Wedge RA, Cartaxo T, Spicer CM, et al., editors. Selected Heritable Disorders of Connective Tissue and Disability. Washington (DC): National Academies Press (US); 2022 Jul 8. 5, Heritable Disorders of Connective Tissue and Effects on Function.

"Lifestyle modifications, such as rest and relaxation techniques and good sleep hygiene, can also help alleviate some aspects of fatigue. Graded exercise therapy may be appropriate for some patients with joint hypermobility. Relaxation techniques (e.g., yoga, mindfulness, progressive muscle relaxation), other exercise regimens, physical therapy, and planned management of daily activities are also important therapeutic approaches to fatigue, but all of them must be tailored to the individual patient’s needs."

4) Buryk-Iggers S, Mittal N, Santa Mina D, Adams SC, Englesakis M, Rachinsky M, Lopez-Hernandez L, Hussey L, McGillis L, McLean L, Laflamme C, Rozenberg D, Clarke H. Exercise and Rehabilitation in People With Ehlers-Danlos Syndrome: A Systematic Review. Arch Rehabil Res Clin Transl. 2022 Mar 4;4(2):100189. doi: 10.1016/j.arrct.2022.100189. PMID: 35756986; PMCID: PMC9214343.

"Our results suggest that exercise and rehabilitation can help to achieve benefits earlier than 6 weeks as previously described. Although exercise interventions were observed to be effective in the relative short-term, [...] the relationship between the length of the intervention and strength gains for individuals with HSD/hEDS were linear, suggesting that interventions continuing over a longer period of time will effect greater change in strength. Therefore, to optimize therapeutic outcomes, future programs could consider the incorporation of education and strategies to further enhance long-term maintenance of exercise and rehabilitation engagement."

• Yes

Seated: check in, centering, breath awareness, elongated exhalation, brahmari pranayama sitting on a bolster in bound angle with a blanket ankle roll under the feet and the back against the wall.
Standing at the wall: tadasana (with a block between shoulders), shoulder flexion into goddess arms.
Quadruped: cat/ cow, wags, circles, restorative child's pose (with bolster and blanket focusing on posterior rib excursion).
Reclined: side lying- half moon (over round bolster), arm semi circles, TFL release with Z position (focussing on lateral rib excursion and thoraco-lumbar myofascial release).
Supine: legs up the wall (with neck roll, folded blanket on abdomen, bolster behind the knees, & strap above the knee).
Final resting pose: blanket in Z fold at spine (for heart opening), neck roll, knee roll on rectangular bolster, & ankle roll under feet.

Start to practice the daily body scan / svadhyaya and elongated exhalations throughout the day.

During our check in HMG shared that she felt tired and that 3 of her smaller kids woke up at various times in the night and came into her bed. Her youngest child turned 2 yesterday so she was busier than usual with the party. We reviewed the care plan I created and discussed times of day it might fit naturally into her day. She noted that she has learned some of these tools and practices them from time to time but often forgets to do them consistently especially when she needs them most. She reflected that she is more likely to remember to use these tools if she is held accountable and it is given as "homework."

After our session, HMG reported that she feels like she worked her body but doesn't feel tired or sore. She was able to let me know when she wanted more support & when a pose was starting to feel uncomfortable. When we started working on the posterior and lateral breathing and discussed the concept of post pregnancy rib flare she got excited and said she has been looking into this lately. I explained how the restorative balasana and half moon are options she can explore with a pillow to create more space in the side and back body while still supporting the body. I spent a little time showing her (with two bowls) how the rib cage shifts in pregnancy and how to swing the ribs back over the hips as a reminder to create length in the low back and strength in the deep muscles of core support. Having an understanding of this imagery helped her notice how her ribcage was suspended over her pelvis and when it shifted up and forward versus back and in. Continuing to take time to visualize and feel her body in space while providing time for her to build some proprioceptive feedback would be helpful for her.

I need to remember to bring more blankets into the space. In the first seated pose I added folded blankets under her forearms and it seemed to allow her upper traps to relax more. I had 4 blankets and she could have used 6 or more for final relaxation while I created a make shift support with towels under her ankles her elbows could have used some support. Weight and boundaries are especially helpful for HMG due to ASD and EDS. I noticed after placing a folded blanket on her abdomen and threaded a yoga strap around her thighs in Viparita karani that her breath slowed down.

Add more of the vagal stimulation exercises that Mala taught in psychology & mental health. Ask if HMG would like to have her guided relaxation with singing bowls.

• Yes

Seated: check in, breath awareness, elongated exhalation, & brahmari in supported bound angle pose.
Quadruped: cat/cow, wags, circles, bird dog, & balasana.
Seated: Z position hip extension, obturator internus exercise/ external rotation, deer pose with one leg extended, articulated bridge w light loop resistance band (to create a boundary and provide proprioceptive feedback), exercises focusing on vagus stimulation (palming the jaw, bunny ears, ear massage, ear circles, and neck stretch with eye movement.
Reclined: side lying-half moon on a bolster (with arm circles & TFL release).
Supine: supported relaxation pose, tense + release, body scan, focus on the breath, observe thoughts, so hum breathing, rest with crystal singing bowl sounds.

Home practices: tadasana in car and every trip to the bathroom, breathwork/ vagal stimulation as needed, so hum 1 min daily at nap time, ahimsa reflection journal (one or two bullet points from the day at night). Sequential muscle relaxation before bed with the little ones.

HMG is doing a good job checking in with her body and reflected 2 times this past week that she was able to outsource her chores to her children. These chores typically leave her feeling fatigue and pain. C (her eldest) carried several loads of laundry upstairs for her to fold. A & H were tasked with cleaning small items out of the car for 10 cents each. This preserved her energy for the things she wanted to do while still accomplishing what needs to be done. She had a very positive outlook today, despite sharing that her custody battles regarding her eldest 2 children with her ex-husband have not gone as expected. HMG reported she had a lot of energy after our practice last week and felt "very relaxed" after our session this week. Anxiety is a common comorbidity for hEDS, while HMG is positive she is often in a heightened state and very nervous. She said the practices we have started to work on together are helping and she remembers to use them now throughout the day.

During the vagus nerve stimulation practice HMG noted that Ada (her 3 year old) also puts her finger in her ear before bed. She also reflected that she could see how brahmari helps to clear the mind. She noted how tight her adductor felt in half wide angle/ deer pose. During deep relaxation, I observed a slowing down of the pace and also a deepening of her breath once I added the sound with crystal bowls.

I have been checking in regularly with HMG and giving her options for support with propping. Focusing on creating sensory boundaries with the blankets and yoga strap for example. I’ve noticed that she is able to tell me when something needs more support or is uncomfortable. I noticed that she was not understanding my verbal cue during the deer pose and she was in a bit of a side bend. I placed a hand at her side and asked her to move away from my hand. This is something I have not done in a long time with my teaching so it was surprising to me though she did not react negatively. I generally avoid touch cues in person and almost always ask first before offering a touch cue even after several sessions. She was able to quickly grasp the assist and adjust herself. I paused and was a bit thrown off as it's been a while since I have forgotten to ask permission to use touch. While this was our third session together and she does greet me with a hug I still feel it is important to ask. This client has had so many negative experiences with providers it is especially important to remind her in even subtle ways that she gets to choose and have autonomy in our work together. This may have been why I was upset with myself at that moment because I really went into rote teacher mode and dipped out of the yoga therapist role. HMG didn’t seem to perceive anything was wrong or out of the ordinary as she is used to hands on work during yoga classes. I just noted within myself a bit of self criticism when I was a bit less present with our larger goals for working together.

Next session I plan to add on a few more standing wall poses and use resistance bands and/ or a yoga strap to create boundaries for her joints. I will continue to use music in deep relaxation but might try using Cheri Clampett's chronic pain guided meditation next week.

• Yes

Seated: check in, centering using the imagery of grounding into the earth, breath awareness, OM & Brahmari 3x, palming of jaw + self massage of face, jaw, neck, and shoulders, JAPA for the neck, spine, and shoulders, bunny ear vagus nerve stimulation, gentle seated twist.
Quadruped/ kneeling: cat/ cow, wags, child’s pose focusing on posterior mediastinum/ rib excursion, pelvic breathing/ reverse kegel/ drops, plantar rocker for deep back line, thunderbolt with plantar stretches 3x and shoulder circles/ wrist rolls, bird dog + side bend.
Side Lying: (pillow under head) clam shells, internal + external rotation at 90/90, half moon with bolster under waist (upper arm stretch + Z position).
Supine: Adduction with small pillow at knees, articulated bridging activating deep back line/ pressing into hands and heels, piriformis stretch at the wall, & final relaxation propped up.

Continue to practice daily so hum meditation at nap time, breathwork and vagal stimulation exercises (as needed), tadasana check in (throughout the day), and sequential muscle relaxation before bed. I recorded a water guided imagery meditation to play if she has 10 minutes (or needs 10 minutes) to herself.

HMG was tired and has had what seems like a cold for about a week. She said the humidity has been making her feel even more exhausted. During our session after we practiced the gentle yoga she reflected that she felt much more energy than she had before we started. It was surprising to her as she had used effort to practice today but she also felt very relaxed and did not feel tired anymore. After our practice was over HMG said that she had the image of waves in her mind right before we started the cool water relaxation. She did not know that was what we would be focusing on but when we did she said that it was very comforting as she had been already seeing that imagery in her mind.

I have enjoyed working with HMG and would like to continue to practice with her in the future. I believe these practices could be helpful for the continued maintanenece of her body and mind. Working with someone who has chronic pain and lifelong conditions is a bit different than working with other clients who develop a condition or diagnosis over time. HMG has a bit less difficulty accepting her lifelong conditions as she does gauging when she has overexerted herself and may need more time to recover as a result of it. The daily self study (tadasana body scan/ svadhaya), connection to the true self (so hum meditation), and the ahimsa journal has allowed HGM opportunities to step out of the strong identifications she has with her conditions and gain insights about how to observe her feelings and sensation and better conserve or sustain her energy too. Tools we used to manage discomfort and stress in the body mind use a bottom up somatic approach that seems to work quite well for her. By keeping practices simple the homework was more achievable and easier to build mastery and confidence in their daily use. She mentioned that when she feels good after a practice she is more likely to continue to do it and use it when she needs it most.

Working in-person with HMG helped me notice nuances about my own energy levels and how they might influence my ability to be fully present in our time together. I noticed these differences when we met during the week in the afternoon after I had several other sessions versus on Saturday mornings. In-person sessions require a different amount of energy than in-person group facilitation. I noticed my ability to think on my toes was not always as strong as it is in virtual yoga therapy or in-person sessions that are not categorized as yoga therapy for my regular job. I noticed that whenever I am a bit tired or have had a long day I need to pause more before speaking or doing something in the session. The session itself becomes a bit of a mindfulness practice, staying alert yet relaxed and aware so that I can make deliberate choices with my words and actions. For example, during the session where I made the hands on assist HMG was in a safe shape. Technically it didn’t need to be adjusted, but she was not achieving the stretch in the muscle group that was intended in the shape she was in. By adjusting with her she was able to feel the pose in the intended way and ultimately get to the "essence of the pose." I think knowing how and when to make these choices is what defines us as teachers, therapists, or whatever role we have with a client. I do not want to take on the role of "fixing" anyone as this can give off the wrong message that HMG somehow cannot move her body correctly without me or my instruction. This is of course untrue and while I do feel there is room for hands on assists and even gentle/ appropriate touch from time to time this wasn't totally necessary. How anyone approaches touch and how their client feels about touch in any given pose on any given day are very fluid distinctions that I believe require clear consent.

By noticing my own energy shifts and attempting to use touch cues versus adapting my verbal or visual instruction during that session, I learned more about what is needed from me both energetically and mentally in this work. I will continue to strive to remember to ask prior to offering a prop or touch to assist. This particular situation reminded me why I felt it was so important even though the client seemed to not notice anything out of the ordinary had occurred. She is unfortunately used to having providers that do not listen to her and be in situations where her disabilities, access, and feelings are ignored. I do feel that by prioritizing confidence in her body over achieving a particular stretch benefits her more. I also feel that giving her options to choose from sets a different (more empowering) tone than the experiences she has had in medical environments. It is not lost on me that with a client whose homework was to be kind to herself and journal activities that were not helpful towards her goals; I, as a yoga therapist, was able to observe when I needed to take a break or reschedule to sustain my own energy too.

In writing this 12th case study I see the benefit of having space to reflect on my own experience working with a client and developing my voice in this work. Beyond writing out client notes which I expect to continue long after this practicum, these opportunities to share reflections have been quite helpful too. I think that as a yoga therapist it might be nice to have a space for my own reflections about this work in my notes that is based on my observations and my approach to this work, not just my clients and their progress.

HMG and I plan to meet a few more times before we both go on vacations. I think continuing to balance deep restoration and restorative practices and poses with some gentle yoga to strengthen and maintain muscles of postural support would be a good plan for HMG. Adding some standing work at the wall again on a day she feels energized and offering more grounding work when she feels a bit tired seems to have worked well for her. Depending on how she is feeling next session, I will incorporate the gentle yoga into our session accordingly.