The client is a female in her late 40’s.
She has been experiencing chronic pain in her right knee (arthritis) and left ankle (suspected arthritis).
She also experiences pain in her right elbow that radiates down the radial side of her forearm as a feeling of numbness or tingling. It skips the wrist and ends on the pinky side of her hand.
She experiences fatigue and is diagnosed as prediabetic. (Diabetes runs in the family.)
There is tightness on the right side of the pelvic floor as diagnosed by a Pelvic PT specialist.
She lives with her husband, 4 kids and 2 cats. She has the support of her family, but is the main child caretaker.
She walks for exercise, but can’t walk too far due to the pain.

Client Goals:
1) She wants to try to reduce the pain so she can do her daily activities. She also wants help to strengthen the muscles around the affected areas.
2) She would like to figure out a way to adjust her daily schedule to allow for more sleep so there is less fatigue throughout the day.

Yoga Therapist Goals:

Koshas: _x_Annamaya _x_Pranamaya _x_Manomaya __Vijñanamaya __Anandamaya

Integral Yoga: __x_Hatha _x__Raja ___Bhakti ___Karma ___Jnana ___Japa

Short term:
My main goal is to help the client reduce the feelings of pain, fatigue and pelvic floor tightness, and work with her on mindful body awareness.

Long Term:
I would like to introduce tools (e.g. breathwork and meditation practices) to help reduce the stress and to allow for more restful sleep.

Therapeutic Yoga Manuals 1&2

Stress Management Manual

Adaptive Manual

Biel, A. Trail Guide to the Body, 6th ed. Books of Discovery. 2019

Cheung C, Wyman JF, Bronas U, McCarthy T, Rudser K, Mathiason MA. Managing knee osteoarthritis with yoga or aerobic/strengthening exercise programs in older adults: a pilot randomized controlled trial. Rheumatol Int. 2017;37(3):389-398. doi:10.1007/s00296-016-3620-2
https://pubmed.ncbi.nlm.nih.gov/27913870/

• Yes

Awareness practice
Neck and shoulder warmup
Shoulder rolls with scapular awareness
Adapted Garudasana (Eagle) arms with flexion/extension
Lateral stretch
Dynamic twist
Tabletop isolated pelvic tilt to wave cat/cow
Prep for cobra
Sphynx
Cobra to lengthen front body and strengthen back body
Reclined half moon pose
Yoga nidra

The client needs to move and stretch more at work, since she is sitting down so much. Even doing seated movements will help.

The client noted that her knee has been bothering her. She suspects that it had to do with the shoes she was wearing that day. She felt bad about herself for choosing shoes with heels, but it was because the sandals she was going to wear broke and she had to leave in a hurry. She said her arm is feeling better and she is more aware of it when she is sitting. She noticed it felt asymmetrical: “The whole right side holds a lot of tension and stiffness.”

When I asked about the pain, she said her knee was about a 5-6 and her shoulder was about a 4. There is a constant dull ache, which she is not consciously aware of because it “feels like this is what it should be.”

Today’s session was about lengthening and stretching with a particular emphasis on the front body. Since the client had been less active due to the pain, most of her days were spent sitting and her psoas/hip flexor areas were tight. Spending dedicated time to stretch and lengthen felt freeing for the client, as these were movements she didn’t practice too often. By the end of the session she noticed more evenness in the shoulders. They didn’t feel so tense. In addition, her knee felt much better.

We will have her continue to work on loosening and releasing her tight muscles with the movements she learned today.

• Yes

Awareness practice
Neck warmups
Eagle (Garudasana) arms with spinal flexion/extension
Reed (lateral stretches)
Hip mobility from standing
Isolated pelvic tilt to wave cat/cow
Work on rhomboid pushup position (serratus anterior stability)
Happy puppy
Hip sway and hip circles
Tadasana
Hip shift on block
Hip glide
Yoga nidra

I gave her guidance on how to slowly build strength in her upper body so that she can practice it on her own at home.

There have been rainstorms in the client’s area recently and the weather has been affecting her knee. It has been feeling “twingey” and “achy and tight.” The front and sides of the knee have been affected and are in pain. She reported that her arm and shoulder are “better.” She tried lifting weights for exercise, but the 10 lb weights for bicep curls was too much. She would like to do more body weight type movements (e.g. pushups). Her PT had been encouraging her to increase her upper body strength.

Since our time was short, due to her schedule she suggested that we could “skip yoga nidra,” so she could do more “work,” even though she really enjoyed and appreciated the yoga nidra. I reminded her that deep relaxation and stress reduction is as important as movement and that it is an essential part of our sessions.

Today we worked on issues that were brought up at a recent PT visit. We focused on what would be helpful for creating movement and strength in the upper body/shoulder/arm area. During our exploration we discovered limitations of movement in her upper back/shoulder area near the rhomboids. After some practice and repetition, we got to the point where she could move it more freely. This allowed her to create a stable foundation from which to perform the strength movements in a safe manner. We talked about how she could progress to more challenging/weight bearing positions as she gained strength. She was pleased to have these incremental options for growth.

Since her plans are usually influenced by her PT visits, we can see what her PT suggests and use that as a guide for our next session.

• Yes

(no awareness practice)
Neck warmups
Shoulder rolls
Reed (lateral stretch)
Dynamic twist
Seated isolated pelvic tilts/rocks transition to seated cat/cow with cactus arms
standing hip mobility
Heel raises/ankle circles
Yoga nidra

We both agreed that she should practice doing things “with intention” (whether making a shoe purchase or deciding how to spend her time and energy). Regarding her outlook, she should also try to focus on something positive vs. worrying about something that may not happen.

The client stated that things had been steadily busy and that she hadn’t been checking in with herself. Her knee was bothering her today. It was achy probably due to the types of sandals she was wearing and because she wasn’t able to move as much recently. She had been trying to do more stretching, but she was aware she had been sitting more. She was shocked that she didn’t reach the stand goal on her watch one day.

After talking about those physical issues, she finally brought up a disturbing incident at her church that happened when she was working there with her children. An unfamiliar person dressed all in black with a utility belt came onto the grounds and started wandering around. She said everyone “started freaking out” because the pastor was on vacation and no one knew what to do. People were concerned it might be a shooter and called the police. It turned out to be person who was mentally ill, but until it was resolved, it gave everyone quite a scare.

This session was more about holding space and being able to mentally process an event that felt traumatic in the moment, not only for the client, but for her daughters as well. That feeling of helplessness and not being able to soothe or comfort her children was hard to deal with. We talked about trauma and how the body can hold onto it. We also talked about the idea of “being stuck” and how hard it could be to move on. There was the idea of being “attached” to a certain idea or outcome of how something “should” be. We talked about intention being so important to how we go about doing things in life. We also talked about how the teachings of yoga can act as a supplement to her own faith. We spent a lot of time discussing and holding space so our practice was a little bit shorter. However, the whole session felt well spent on both our parts.

We did 1 intake and 4 sessions.

Over the course of the sessions, we were able to take care of the need that had the highest priority for the client. Not only were we able to address the pain in her knee, we were able to reduce pain in other parts of her body (shoulder, lower back, hips) as well. (Annamaya, Manomaya, Hatha) We talked about what habits and choices she could avoid that contributed to the pain and what she could do for prevention as well.

I had hoped to do some breathwork with her during one of the sessions to help with stress reduction (Pranamaya, Manomaya), but when the focus shifted to relieving the pain, we decided to let that go. As a result, we adhered to doing more diaphragmatic breathing during our session vs. specific pranayamas to reduce stress.

Because of an unfortunate occurrence that shook her up emotionally, we were able to go deeper into talking about some of the philosophies of yoga that could help her get past it. In our discussion, she saw how these philosophies complemented and could aid and support her faith. This new perspective allowed for an effective way of handling stress in that instance, while giving her tools for future stressful situations. (Raja)

Although my initial plans were sidetracked, the experience worked out well overall. We were able to adjust to the situations as they presented themselves and still get her needs met. Meeting her where she was at in the moment was the key in supporting her. Through it all, the client was quite happy with how she felt physically, mentally and emotionally at the end of our time together.

If we have a chance to meet again, we agreed it would be good to focus on relaxing and working with the pelvic floor to address some of the items the pelvic floor PT specialist mentioned in a previous session.