| Case Study Title | ELW CS5 |
|---|---|
| Select your mentor | Marie Prashanti Goodell |
| Agreement |  I have read and understand the Case Study Submission guidelines |
| Intake summary | Intake summary: She wants to maintain her physical fitness to pursue her passion, birdwatching. She walks daily when the weather allows and uses NuStep cross trainer a few times/week. Her personality is “optimistic and forward-looking,” but she recently developed anxiety about falling. She was a “high-stressed” person during her tenure, anxious about navigating obstacles and work-related personal relationships. Being an active volunteer at a local chapter of the Women’s Voter League, she experiences emotional disturbance due to current political events and discourse in the country. Her objectives for seeking YTh are improving physical balance, flexibility, and upper body strength. She also wants to learn breathing techniques. She has a previous experience with yoga but “could not do much” because it was not was adapted yoga class. Assessment: CT presents limited mobility in her lower body due to a paralyzed leg. She has limited ROM in L FAj (ext/internal rotation and add/abduction) and mechanical limitation in the L knee joint as she wears a full-length brace: limited elbow/HUj extension. Presented pain during L shoulder flexion at around 150 degrees; limited L shoulder abduction at ~160 degrees. Transferring from standing/to a chair or from/to a mat takes time, but it is possible, and CT is willing. Shoulder height asymmetry is observed, indicating levoscoliosis and tightness in the R side of the trunk, which may be attributable to her lower back pain. Lengthening the R side of the body can be beneficial. Also, limited extension of the finger joints (esp. R) was observed due to tendon contracture. Gentle stretching is supported in the research on Dupuytren's. Pain is relatively low today: No pain in 0/5 for knee or shoulder; 1.5/5 in the lower back. She is self-controlled and poised. Presents minor rigidity in facial expression and vigilant/protective. Self-described as high-stress/anxious, she appears to be holding back emotions. CT is well-versed in mindfulness practices and related literature, practicing meditation regularly, and understands the importance of discernment faculty. CT presented the imbalance in the: |
| Care Plan outline | Initial Care Plans: Agreed-Upon Goals: Short-term: Learn how to maintain and improve flexibility through gentle joint mobilization, stretching, and strengthening asanas while addressing OA and lower back pain. Improve proprioceptive awareness and balance. Learn yogic techniques to self-regulate against physical and emotional interference and stay grounded. How Yoga Therapy can help the client: * “Learn to better cope with physical and emotional pain through breathing practice” was added to the initial care plan at Follow-up Session 2 Specifics of Care Plans: Asana will be given to balance Annamaya, Pranamaya, and Manomaya by: • Joint Freeing Exercise for fingers/hands Pranayama will be given to balance Annamaya, Pranamaya, Manomaya Vijnanamaya by: Meditation and other yogic tools will be given to balance Pranamaya, Manomaya, Vijnanamaya, and Anandamaya by: |
| Resources and references that informed your Care Plan | Post-polio syndrome: Polio and the late effects of polio (LoEP): Post-Polio Health International https://post-polio.org/ Dupuytren Contracture: Flexibility: Yoga AND Polio: Yoga Benefits Polio Survivors https://post-polio.org/living_with_polio/yoga-benefits-polio-survivor/ Summary article on IAYT (2005 publication) DeMayo, William, Betsy Singh, Barbara Duryea, and David Riley. Hatha yoga and meditation in patients with post-polio syndrome. Alternative Therapies in Health and Medicine, Mar-Apr 2004, 10(2):24-25. PMID: 15055090. “These results showed significant improvements in a patient population where a lack of deterioration is often viewed as success. These patients improved and at the end of 12 weeks they were actively involved in self-care. Subsequent studies will be designed so that multiple centers can be involved and data can be pooled to produce a hardy set for subsequent analyses.” Video used in the study is found on YouTube - “Yoga for Post-Polio Patients” Mudras: Chakras: Sutras: Simple Yoga by Ruben Vasquez |
| Session 1 | |
| Session 1 Complete? |
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| Session 1 - Activities | Session 1 • Lengthen - R side of the trunk. Ham & Glutes (R only) |
| Session 1 - Homework assignment to client/group | Weekly HP is shared with CY in a GoogleDoc at https://docs.google.com/document/d/1UKTZJVDo0guJAzKML1CZfGZ4q-KE01e-PwOdAP5vv3s/edit 1. Witnessing Practice (Body, breath, emotions, energy level, thoughts, back to breath) 4. Yoga for PPS modified sequence Keep track of your practice using My Home Practice Chart |
| Session 1 - Client/Group progress summary | CT experienced stress relating to her young nephews, for whom she has become our guardian. She lost sleep after late-night phone calls throughout the week. She suffered an acute backache after the morning stretches. The pain started in the mid back and lasted in R lower back for 2-3 days. Did not have any fall or near-fall this week. The most recent episode was in June 2023, tripping over a curve. Once she loses balance, she has no control over her paralyzed L leg to compensate. Reported “enjoyed the witness practice, felt relaxed,” and, “noticed tightness in the lower back; feeling quite energetic but also noticed I am tired. Had no problem letting thoughts pass.” CT also liked alt. n. breathing as it’s “calming.” She will do daily meditation for 5 mins focusing on the breath as a focal point. She appreciates considering modifications to the asanas (Yoga for PPT) as some exercises “just don’t work” for her. Levoscoliosis was never discussed with her PCP, but it was visible when a family member checked. She also notices chronic tightness in the R side of the torso compared to the other. CT agrees to work on stretching the R side when suggested. She watched the video (Yoga for PPS) at home and wanted the sequence to be modified, particularly for the spinal twist, which we did as follows: • CT presented limited ROM in L shoulder when reaching the arm up CT will V-shape the arm instead. (Addresses OA in L shoulder) CT presented irritability during asanas that were perceived as challenging to her, and she was not receptive to my suggestions on several occasions. Tension was observable in her energy. She returned to a more relaxed state during and after breathing practice. Alt n breathing comes naturally to her. I suggested she practice it before going to sleep. Stress and lack of sleep might have contributed to the recent episode of backache. I suggested she use witness practice as a daily physical & psychological check-in and take care of stretching early in the morning when the body is not fully awake, especially when she didn’t get a good night’s sleep. She responds positively to the pranayama, meditation, and journaling portion of the Home Practice compared to the asanas. Modifying the Y for PPS will help her feel more comfortable with physical practice |
| Session 1 - Reflection and Self-evaluation | If I could have scheduled another session this week, I would have slowed down the pace or reduced the number of asanas today to give her a more comfortable pace and room to explore. With stress and lack of sleep, she was tired. She appears to be taking on a heavy responsibility for her sister’s children. Hopefully, the new sutra I will introduce next week will inspire her, and she will apply it to the situation to help alleviate the emotional toll. |
| Session 1 - Plan for Session 2 | I will follow up on her stress and sleep patterns at the next session. Additional breathing techniques will be introduced for PSNS activation. Introduction to mudras or chakras may benefit her meditation practice as it would give another dimension. Updates the care plan: |
| Session 2 | |
| Session 2 Complete? |
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| Session 2 - Activities | Date: 7/22/23 Time: 7-8:30 AM Location: Virtually on Zoom 2. Breath Awareness Practice (SMTT/Version B) In the manual 4. Yoga for PPS 5. Pranayama |
| Session 2 - Homework assignment to client/group | Home Practice: Handouts: |
| Session 2 - Client/Group progress summary | CT reported feeling good about making progress as she practiced the Yoga for PPS sequence daily. She also reported paying more attention to her “body’s feeling.” She almost lost balance inside the house twice but was able to recover. The source of stress continued to be her involvement in supporting her young nephews. Attending meetings or watching the recording late at night has been disturbing; she noticed the pattern of ruminating afterward. She reported that she loved the calming effect of alt. n. breathing and body scan, and regular meditation practice before sleep, all of which are helpful to keep herself grounded. CT didn’t do journaling on Pratipaksa Bhavana and wants to continue working on it again this week. [This prompted me to postpone the introduction of Sutra 2.46 to the final session.] CT presented less rigidity and more fluid during the asana practice. Improvement in the L shoulder ROM and the heightened awareness for the alignment were observable. Her facial expression was softer as she presented calmer energy than last week's. Although reporting “it was another busy and stressful week,” she seemed to be handling it well. She stated, “There are things in life that we cannot fix or outside of our control, and that’s OK”, demonstrating discriminated faculty and the ability to let go. She was fully engaged in the asana portion of the Home Practice, detailed what worked and what did not, and requested further modifications positively. For some asanas, she even opted for a more active version. A few modifications were added to the Y for the PPS sequence based on the feedback (noted in the Plan) CT presented enthusiasm for pranayama: Breath Awareness Practice “kept my focus for the entire time.” She also reported she enjoyed the alt. n. breathing with extended exhalation and brahmari introduced today. She was receptive to mudra. CT made noticeable progress on asana home practice. She actively participated during the session, demonstrating improved intero- and proprioceptive awareness. She appeared to be gaining a sense of embodiment and experiencing the joy of movements, which could be a rare experience. Her quick recovery from the recent near-fall episode must have been motivating. She gained the skill to witness her emotions and thoughts and to self-regulate using pranayama and meditation during times of stress. She also demonstrated the practice of non-attachment and surrender, Ishara Pranidhana. |
| Session 2 - Reflection and Self-evaluation | It was inspiring to see her enjoying asanas during this session. It could have been a precious experience for someone with a physical disability throughout their life. On a more practical side, the session was well-paced and ended on time. |
| Session 2 - Plan for Session 3 | We will update the Y for the PPS sequence with modifications: 1. Seated Cat & Cow with cactus arms/palms together; 2. Standing hip joint abd/add holding on to a chair on your right side. 3. Supine hip flexion/extension. Stabilize the left leg against a couch/wall so it won’t splay out to the side. The final session will focus on balance and grounding/rooting. Progress assessment will be conducted. |
| Session 3 | |
| Session 3 Complete? |
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| Session 3 - Activities | 1. Check-in. Stress? HP: New progress? Setbacks? HP? Anything you want to go over before ending the session? 7. Balancing asanas b. Lateral balance/stretches (one arm) 9. Sutra study. S.46 Steady and joyful is asana |
| Session 3 - Homework assignment to client/group | Home Practice: 1. Breathwork before meditation 3. Journaling on Yoga Sutra “Steady and joyful posture is Asana.” Feel free to use these prompts Handouts: |
| Session 3 - Client/Group progress summary | CT traveled and spent time with her family last week; she walked a lot, visiting museums and other interests. While taking extra caution on the unfamiliar ground, she “was not feeling fearful” and had no incident of losing balance or near fall. She reported she has gained “self-awareness of body positioning” and feels “more flexible and stable” than before. She also reported that she has been devoting more time to contemplative practice; she practiced body scans and witness practice before meditation. She often ended meditation with pranayama and mudra. CT and I reviewed the therapy goals and assessed the progress together. Both agreed that the therapy sessions supported her, and she made noticeable progress on each objective. She has memorized most of the movements for the asana home practice, so she no longer needs to watch the video. Improvement in ROM in the L shoulder and the axial alignment are observable. She asked how to keep up with the asana practice when traveling; I taught her easy stretching exercises for traveling, using the stationary chair and benches at the airport. At the conclusion of the 4-week session, CT reported that “yoga has become a routine,” which was her primary objective of the yoga therapy. Already an experienced meditation practitioner, she now actively participates in her physical practice and appears to feel empowered. She is more attuned and embodied during asana practice demonstrating improvement in intero-and proprioceptive awareness. The extensively modified asana practice might have positively impacted her body connection. As committed as she is, I trust she will continue to progress toward peace and contentment through the holistic approach of yoga. |
| Session 3 - Reflection and Self-evaluation | At the conclusion of the 4-week session, CT reported that “yoga has become a routine,” which was her primary objective of the yoga therapy. Already an experienced meditation practitioner, she now actively participates in her physical practice and appears to feel empowered. She is more attuned and embodied during asana practice demonstrating improvement in intero-and proprioceptive awareness. The extensively modified asana practice might have positively impacted her body connection. As committed as she is, I trust she will continue to progress toward peace and contentment through the holistic approach of yoga. |
| Finishing up | |
| Overall Final Self-evaluation, reflection | ELW was my second client with a disability from paralysis, as I had worked with someone with a spinal injury during a final project (TCA) for adaptive yoga training in 2022. Working with someone with a severe physical disability can be challenging in many ways, both technically and emotionally. It can even be intimidating due to our preconceptions or worries about saying wrong things that might offend or hurt that person. However, I learned to appreciate the unique challenges presented by learning to stay honest and objective to meet the person as a complete whole. My client is an exceptionally intelligent, insightful, and inspiring human being who understands the limitation of human ability and imagination. The knowledge comes from her lived experience. In the Client Feedback, ELW wrote that the program exceeded her expectations. “I loved the way that the program evolved over time,” and “primary condition has improved after attending the program.” Also, she wrote that “the program inspired me to take yoga seriously and to incorporate the program we developed into my daily life. I am already feeling the positive results and look forward to many additional benefits in the future.” I appreciate that she said, “*we* developed.” She might have found asana practice unapproachable at first. Still, with the highly adaptable nature of yoga and as we work in collaboration, she was able to experience the potential to be at ease with her body. ELW and I agreed that the therapy goals had been met, addressing the imbalance across the koshas, particularly Annamaya and Manomaya, in how she relates and connects to her physical body. I feel privileged to witness her progress over the four weeks. |
| Future session plan | Four-week YTh program has concluded. CT is going to curate her home practice regimen for August, referencing the List of Weekly Home Practice shared doc. I will send the Client Feedback Form for her to evaluate the program. |
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