The client is a female in her mid 60’s.
The client has been experiencing pain in the left SI joint.
Her rheumatologist diagnosed her with an auto-immune condition and suggested she has ankylosing spondylitis.
There is also pain in the C1 and C2 vertebrae of the spine due to a degenerative disc.
She has an eye condition (Iritis) that requires medication that causes fatigue. The fatigue is worse soon after taking the medication.
Her left hip is visibly higher than the right.
She is a yoga teacher and is quite self-aware of her movement throughout the day, as well as asymmetries within her body.
For exercise she walks 3 times a week and practices gentle yoga 3-4 times a week.
She has good social support with a husband at home and communication with her adult daughter.

The intake and all the sessions were completed online.

Client Goals:
1) She would like to strengthen the muscles around the SI joint for stability.
2) She would like to continue to bring body awareness to prevent further injury or pain.

Yoga Therapist Goals:
Koshas: _x_Annamaya __Pranamaya _x_Manomaya __Vijñanamaya __Anandamaya

Integral Yoga: _x__Hatha __x_Raja ___Bhakti ___Karma ___Jnana ___Japa

Short Term
I would like to have her strengthen the musculature around the SI joint and find poses that are the most helpful to relieve pain and the ones to avoid.

Long Term
Like the client, I would like her to bring awareness to her movement to prevent future injury or flare ups.

Stress Management TT Manual

Therapeutic Yoga Manual, Levels 1 & 2

Adaptive Yoga TT Manual

Myers, T, Anatomy Trains 4th ed. Elsevier, 2020

Le Huec JC, Tsoupras A, Leglise A, Heraudet P, Celarier G, Sturresson B. The sacro-iliac joint: A potentially painful enigma. Update on the diagnosis and treatment of pain from micro-trauma. Orthop Traumatol Surg Res. 2019;105(1S):S31-S42. doi:10.1016/j.otsr.2018.05.019
https://pubmed.ncbi.nlm.nih.gov/30616942/

Xiong Y, Cai M, Xu Y, et al. Joint together: The etiology and pathogenesis of ankylosing spondylitis. Front Immunol. 2022;13:996103. Published 2022 Oct 17. doi:10.3389/fimmu.2022.996103
https://pubmed.ncbi.nlm.nih.gov/36325352/

• Yes

Awareness practice
Neck warmups
Reed (lateral side stretch)
Seated pelvic tilt, cat/cow
Work on Therapeutic Yoga Reclining Half Moon stretch over bolster
Gentle twisting after coming up
Supported child’s pose to release
Yoga nidra with NO squeeze/release

The client will practice Reclining Half Moon up to 2 min on each side. (It doesn’t have to be every day.) The client can also try practicing Viparita Karina to see if it helps to anchor the femurs into the hip sockets through gravity. (We didn’t get a chance to practice it today.)

She reported she was feeling fine today. There was no mention of any tiredness, though I suspect if she were tired, she wouldn’t mention it unless it affected her ability to move.

The main focus of the practice today was to gently stretch the muscle and fascia on the lateral sides to allow for freer movement, since one side of her body was visibly tighter than the other side. Much of our time was spent setting up the props she had in a way that was accessible for her and comfortable to stay in for an extended period of time. Using the Reclining Half Moon pose was a way to passively stretch using gravity as well as providing a pose that might be more restful if she were experiencing fatigue that day.

If the client finds benefit from the Viparita Karina, we can incorporate that into our next session.

• Yes

Awareness practice
Neck warmups
Seated side stretch
Adapted– down dog, chair, malasana,
Adapted bridge (pushing laterally against strap) for bridge with single leg and on block
Viparita karina with no bolster – against wall
Yoga nidra

She will continue practicing the half moon and try to incorporate the stretches with the strap and bridge.

The client stated that after practicing the Restorative Half Moon the past week, she is now able to more naturally put weight down on her left side. She liked practicing it asymmetrically, repeating the left side again after doing the right side once. She felt that there was more movement/looseness and the ability to stretch on the left side. She also noted there seemed to be a connection between the low back and her neck. When there was a release in her low back, her neck felt better.

Today we attempted some different things to address stretching, strengthening and seating the femurs into the hip joint. The purpose was to create a more stable foundation to her movements with the idea of reducing pain in the SI joint. The idea for the strap stretch in 3 positions was taken from a scoliosis practice to lengthen both sides of the body evenly, while allowing gravity to help seat the legs into the hip sockets. The bridge with legs pushing laterally against the strap was to strengthen the supporting muscles around the hips, core, back and legs through this extension against gravity with gentle abduction. I couldn’t tell how helpful the movements were, but she was willing to try things out.

She will see the PT next week and I would like to hear their diagnosis to inform what we will do next.

• Yes

Awareness practice
Neck/upper body warmups
Reed – lateral stretches
Dynamic twist
Workshop the resting back extension w/o flexing neck using existing props/furniture
Yoga nidra

She will continue to see PT and practice the back extensions to help reduce the pain.

She saw the PT last week and he disagreed with the ankylosing spondylitis diagnosis. He said she had a “flat back” as well as tight adductors and that her pain was due to an overuse injury. He prescribed back extensions to help with the pain. He demonstrated cobra with straight arms and pelvis on the floor. We both thought the shape was too extreme, but agreed that back extensions in general would be helpful moving forward.

I am glad I took the time to ask if certain practices had been beneficial for her. When I asked about the usefulness of the modified poses using the strap, she said it wasn’t that helpful, but I appreciated her willingness to try it. When we talked about her doing a reclining backbend in order to stay in the pose without as much effort, she shared that it was difficult for her to hold the pose, as the resulting flexion in her neck was painful.

From that conversation we chose to spend this last session workshopping a reclining back extension set up with her existing props that would not create flexion in her neck. (She had ordered some additional props, but it would take some time for them to arrive.) After we created the set up that worked and would not cause pain in her neck, she was able to recline for 3 minutes as proof of concept. She appreciated that we spent the time to figure it out, as it is something that she would not have done on her own.

We met for 1 intake and 4 sessions.

It was good to work with this client, but not in the way one might expect. She was so accommodating to my suggestions for practices to help out that it was hard to know if something was beneficial unless I asked her directly. For example, she did not indicate pain during any of our previous sessions, nor did her facial expressions or body show any physical signs, so I didn’t think to ask her if she was in pain. However, after learning about the back extensions from her PT, her enthusiasm for doing the practice led me to think it was helpful for some pain relief. I’m grateful that I was able to observe that nuance. It was a good reminder that asking questions is just as important part of the therapeutic process as coming up with a care plan.

I’m also discovering that it’s a balance to stay within the yoga therapist scope while relying on an expert’s diagnosis, when different experts have varying opinions and diagnoses. Because I worked with the rheumatologist’s diagnosis and my observations, there were some benefits from some of the practices, but not necessarily a noticeable reduction in pain. (e.g. there was more freedom and movement in the client’s body after working with and lengthening the constricted left laterals.) (Annamaya, Hatha) But after receiving the PT’s diagnosis and incorporating extensions, there was at least an improvement in the pain. (Annamaya, Manomaya, Hatha)

On the more subtle level, the client was open to working with mudras. I showed her the Sandhi Mudra, which is helpful for joint health. Not only did she incorporate it during the awareness practice for our sessions, but also during her mindfulness practices at home. She had an insightful thought about being “stuck” mentally/emotionally as well as physically in relationship to the pain in her lumbar area, which led to a conversation about the chakras. Additionally, she was diligent about bringing awareness to and witnessing how her body was doing and changing, especially with the adjustments we were incorporating with our sessions. (Annamaya, Manomaya, Hatha, Raja)

I believe that we were able to partially achieve both my and the client’s goals. Starting from an inaccurate diagnosis affected the utility of our practices. Although they were helpful, there was infinitely more benefit when we created practices with the correct diagnosis. Also, working with this client in particular, because she was knowledgeable about her body, it felt like more of a collaboration when devising the practices we would use. It was a really nice experience for me, and hopefully for her as well.

This was also a good reminder of working within the scope of a yoga therapist and the benefits that can be gained from understanding what I can offer as a yoga therapist vs. a PT.

The client will continue to counterbalance the more physically demanding work with the PT with more restorative and subtle practices. She can use mudras during meditation and/or allow herself time to practice the restorative poses we had worked on together. Allowing herself that restful state will aid in the healing process.