The client is a male in his mid 70s .
The main complaints are:
Osteoarthritis in both shoulder joints. (The right side is worse.)
OA is also present in wrist/hand/fingers.
He suffers from chronic pain and fatigue.

Comorbidities:
Pacemaker in heart
Prediabetic
Cataracts in eyes (monitored)
¾ of Parathyroid removed (fatigue)
Uses CPAP (for breathing during sleep)
Umbilical Hernia present (no pain)
Enlarged prostate (monitored for cancer)

The client is due to have complete shoulder replacement surgery in both shoulders, but is delaying it until he can finish his program as well as find personal support during recovery.

He lives alone with no pets. The neighbors are people who use the units as a vacation home on long weekends, so the neighboring units are usually empty. His main social support comes from colleagues over Zoom. His Primary Care Physician is over 100 miles away.

The intake and the following sessions were all completed online.

Client Goals:
1) Reduce pain.
2) Improve health.

Yoga Therapist Goals:
Koshas: _x_Annamaya __Pranamaya _x_Manomaya __Vijñanamaya __Anandamaya

Integral Yoga: _x__Hatha __x_Raja ___Bhakti ___Karma ___Jnana ___Japa

Short term
The client stated some very broad goals, so I will work with him to determine practical steps we can do to address the pain, fatigue and body strengthening.

Long term
I'd like to help the client find tools to reduce stress and perhaps brainstorm ideas to find support so he can do his surgery.

Carroll, C and Carroll R. Mudras of India. Singing Dragon. 2013

Clampett, C and Mithoefer, B. The Therapeutic Yoga Kit: Sixteen Postures for Self-Healing through Quiet Yin Awareness. Healing Arts Press. 2009.

Hirschi, G. Mudras: Yoga in Your Hands. Weiser Books. 2016

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

Sowa B, Thierjung H, Bülhoff M, et al. Functional results of hemi- and total shoulder arthroplasty according to diagnosis and patient age at surgery. Acta Orthop. 2017;88(3):310-314. doi:10.1080/17453674.2017.1280656
https://pubmed.ncbi.nlm.nih.gov/28121220/

• Yes

Awareness Practice
Neck/upper body warmups
Dynamic twist
Hand/finger/forearm stretch/strengthening/mobility
Hip internal/external rotation, Hope Mels movement
Hip shift on block
Standing Hip glide
Foot/ankle massage/joint articulation
Yoga nidra

He should continue to work with Kirtan Kriya with breath and visualization.

The client had just celebrated his birthday over the weekend, so had quite a bit of sugar for a treat. He could feel the effects in his body with pain in the GlenoHumeral Joint. He reported he had been doing the Kirtan Kriya daily and enjoys practicing it with the guided recording I sent. Otherwise, things were going well. He seemed chatty and nostalgic, probably because it was his birthday.

This client had listed very broad goals for the yoga therapy sessions. In narrowing them down to something that would be more achievable and useful for our time together, we looked at what it might take to prepare his body as much as possible before surgery. In this way, once he had his surgery, his recovery could be that much quicker and more easeful. To that end, today’s session was about working on mobility and strength in the hip area so that he could get around comfortably without having to use his arms. Additionally, we looked at releasing any tightness in the forearms, hands and wrists to create greater facility of movement at the shoulder. After the session was done, I realized that I should have checked in with the client more often, as I suspect he was tired with all the physical work we had done, especially around the hips.

I have also been discovering that this client needs help, not only with the physical aspects, but also the emotional attention that these sessions bring. Because he lives alone without much casual social interaction, these sessions are a way for him to be seen, gain an audience to hear his history and have community. Since he’s been starved for attention, the sessions have been tending to go long. (When I tried to do an imagery intake to create a personalized guided imagery for yoga nidra, he went off on tangents to tell stories about the meaningful symbols used to answer my questions.) I need to work with him to keep to our allotted time while still being present and being able to hold space for him.

The client will continue to practice the Kirtan Kriya on his own, as he enjoys it and finds it beneficial.

• Yes

Kept it mellow today due to all the stress from school and homework
Awareness practice
Neck warmups
Reed (Lateral stretches)
Thoracic stretch
Pelvic tilts to wave cat cow
Finger, hand, wrist mobility/strength work
Massage the hands/fingers
Supine eyes/tongue/hands practice
Yoga nidra (with imagery)

Try to bring more regularity into his schedule. This will help with the stress as well as help pacify Vāta.

The client arrived stressed out as he was taking a course that was very time intensive with a lot of homework. In addition, a friend died yesterday. He commented that the friend was only 5 years older than him and the friend’s wife, who was only 1 year older died 3 years ago. He revealed he was reading obituaries recently to “see what’s going on.” His mortality has been on his mind. He did state, though, that he had been practicing the Sandhi (joint) Mudra more often as it helped him focus and kept him “on task.” He really liked it for meditation

He then transitioned to good news saying he had a “great check-up” when he went to visit his doctor. He was able to remove one of his medications and his test results looked good. He also received shots in his shoulders for the pain; so that helped. On another note, he mentioned that his middle finger had been tremoring with twitches. His doctor thought that it was possibly due to the nerves from the arm.

I made myself available to hold space while he reminisced about the friends who had died and his concerns about his own mortality and health. We also talked through some of his concerns with his workload and the added stress he was experiencing these past few weeks. We brainstormed techniques he could use for studying to create more efficiencies in his workload. Being present with him and letting him know he wasn’t alone was a huge help in regulating his feelings.

Because he was experiencing so much mentally and emotionally, we kept the asana portion of the session more low key. We practiced the more familiar, stretchy type movements that he enjoyed. I also introduced the eye/tongue/hand practice as a tool he could use whenever he was feeling overwhelmed. In fact, it relaxed him so much he told me later that he did not need the squeeze/release portion of yoga nidra—he was in pretty deep already.

Given that much of our work together is holding space, I will plan to be open to his needs at the time that we meet and go from there.

• Yes

Awareness practice – holding a mudra of his choice
Netra vyayamam (using arms/thumb)
Neck warmups
Reed (Lateral stretch)
Thoracic twist stretch
Dynamic twist
Internal/external hip rotation (Hope Mels)
Raise straight leg on inhale and lower 3 counts on exhale
Ankle mobility/strength
Yoga nidra

Continue with his meditation practice, use of mudras, and keep up strengthening his lower body and torso to prep for surgery.

The client was a little stressed when we started our session. His sleep schedule had been “out of whack” for the last 2 weeks. (He had been staying up till 6am to work, then sleeping until 11am.) He reported that his inflammation increased due to eating “comfort food” (Ice cream). His weight fluctuated. He started talking about a previous class and how going over various diseases or conditions felt like “arrows” hitting him; it was “depressing” to hear all the information because he felt he had so many of those diseases or conditions. He was also a little sad about this being our last session.

Today’s session started with a lot of active listening, holding space, and just being present for the client. After the client got into a calmer state, the rest of the session seemed to go well. We kept it low key to keep the energy calm for the rest of our time together. He particularly enjoyed the awareness practice today—he “reveled in it.” He felt himself going deep into the practice and noticed his “breath was very shallow.” I tried to offer practices that he could use to help prepare for surgery on his own. I gave extra explanations for the reasonings and purpose behind the movements we were performing, so that if he were to teach it, he could give good clarifications to his students. He enjoyed learning the expanded information and was excited to be able to share it in the future.

We had 1 intake and 10 sessions.

The client’s stated goals ended up being quite different than what he actually needed from me at the time that we met. It was a higher priority for the client to be heard and have social interaction and support, than to work on strengthening his leg muscles, even though he needed that, too. I would say that we met his unspoken goals and therefore, had a successful therapeutic interaction.

The duration of our meetings spanned his birthday, the death of a friend, important doctor’s visits and stressful courses, which helped him maintain his equilibrium and keep his peace when he otherwise would have been going through all of those milestones alone. (Raja, Manomaya) In our conversations, he revealed he had a deep prayer/meditation practice and talked to me of what that meant to him. (Bhakti) We talked of how we could weave in his yoga practices with his devotional practices. If we didn’t have the space for these discussions, he might not have had that revelation. In addition, he did learn new physical and subtle tools (Hatha, Annamaya, Pranamaya) that he can use both for himself and for his own students. While we might not have spent enough time to show an increase in physical capabilities, he has the tools to pursue these changes by himself.

Being present for him emotionally and supportively during this sensitive time was the more important goal that was achieved. The ability to be open and flexible to the needs of the client as he was in that moment helped to create a therapeutic relationship that was meaningful and met his truest and most urgent needs.

He has enjoyed practicing the mudras with his meditation, so will continue doing that. He has some new concepts for movement and strengthening that he can use in preparation for surgery when he is ready to have it.