The client is a female in her 30s.
She was tested and has high ANA (antinuclear antibodies), a potential sign of auto-immune disease.
She has 1 Sjogren Marker but no official diagnosis.
She has hypermobile joints, especially in the hips and elbows.
She had Dengue Fever 5 years ago. The pain started after that. She suspects the virus infection caused the auto-immune response.
She feels a burning, ongoing pain throughout her whole body. (“24/7”)
She experiences Lhermitte’s sign (electrical shock sensation) in her neck. (7/21/23)
She has muscular pain throughout her whole body, especially in the feet, neck and legs.
She has joint pain in the hips and knees.
She experiences fatigue.
For exercise, she walks when she can, and does light weights.
She has the support of her husband and 3 children.

Client Goal:
Her one goal is to connect the mind and body for pain reduction.

Yoga Therapist Goals:

Koshas: _x_Annamaya _x_Pranamaya _x_Manomaya __Vijñanamaya __Anandamaya

Integral Yoga: __x_Hatha _x__Raja ___Bhakti ___Karma ___Jnana ___Japa

Short term:
I would like to educate her on stress reduction and deep relaxation techniques (yoga nidra) to activate her body’s healing response to address the pain.

Long term:
I’d like to work with her on techniques to improve her sleep so she is less fatigued and can heal.

Stress Management Manual

Therapeutic Yoga Manual Levels 1 & 2

Adaptive Yoga Manual

HBED resources

Estevao C. The role of yoga in inflammatory markers. Brain Behav Immun Health. 2022;20:100421. Published 2022 Feb 1. doi:10.1016/j.bbih.2022.100421
https://pubmed.ncbi.nlm.nih.gov/35199049/

• Yes

Awareness practice
Neck warmups: right/left, chin glide, waterfall, head tilt
Shoulder circles with scapular awareness
Elbow circles to touch elbows and wrists
Eagle arms
Reed stretch – lateral
Dynamic twist
Isolated pelvic tilt to wave cat/cow
Scapular awareness in tabletop to engage serratus anterior (imp due to hypermobility)
Happy puppy
Hip sway
Kneeling hip circles
Sunbird
Standing hip glide
Yoga nidra

The client should practice yoga nidra and try to find personal time away from the family.

Since our last visit, the client reported she had been sick “for the longest time” (in bed for 4 days). She had been in “such pain” that she was “at a loss” and tried a desperate remedy. She believes her body reacted to the remedy and she became ill.

Our discussions from the last visit had prompted her to reflect on an issue that wasn’t quite resolved for her. She ended up following her original plan, but having gone through the process of conscious deliberation allowed her to truly feel satisfied with her decision. I held space while she talked through these thoughts with me during our check in.

Since the client enjoyed strengthening work and wanted to concentrate on her hips, the focus for today was Sunbird for strengthening and practicing hip movement sequences. Because she has hypermobile joints, we emphasized stabilizing the joint first before performing a movement. The warmups and movements we did were to bring awareness particularly to the position of the scapula and the pelvis before doing bigger movements involving the limbs.

I would like to find more stretches for the neck to release tension without aggravating the Lhermitte’s Sign reaction.

• Yes

Awareness practice
Netra vyayamam
Neck warmups: right/left, chin glide, waterfall, Head tilt with PNF (proprioceptive neuromuscular facilitation – isometric contraction against the hand), arm rotations
Garudasana (Eagle) arms with flexion/extension
Shoulder circles with scapular awareness
Elbow circles to touch elbows and wrists
Arms overhead, cross clasp hands, raise and lower hands with breath
Twist to same side as front hand, lower arms down to leg and back, switch sides
Hand exercises, web, claw, web, beak, paw, pinkie wrist train, playdough, lift fingers with resistance, alternating
Wrist stretch, pointer tucked
Massage hand
Tabletop pelvic isolation
Pelvic breathing
Wave cat/cow
Hip sway
Kneeling hip circles
Sunbird
Hip glide
Supine windshield wiper
Yoga nidra

She should continue practicing yoga nidra.

The client mentioned that her sleep is broken because her youngest still nurses at night. It’s tough for her to let go, but there is less insomnia because the baby has been sleeping through the night recently. She mentioned that if she wakes up in the middle of the night, she can fall back asleep right away now. Before starting yoga therapy, she would remain awake for a while. We both attributed the better sleep to the yoga nidra practice. Because the quality of her sleep has improved, she has more energy and feels less fatigue throughout the day. Yay!

Last session, the client had mentioned that she experiences Lhermitte’s Sign, a painful, electrical shock sensation that originates at the neck and travels down the arm or back. She had asked for stretches to help relieve tension there so she could feel freer with movement around the neck, especially the right side. The client really enjoyed the new movements we integrated for the neck and shoulders, including a gentle PNF (proprioceptive neuromuscular facilitation) stretch during the head tilt. We also incorporated some hand/wrist/forearm stretching to address sensitivities in her wrist joint, which she found quite beneficial.

Perhaps due to the stretches or perhaps due to the client’s earlier activities, her wrists were more sensitive during the tabletop poses today. I offered adaptations using props to adjust the wrist angle, using a loose fist or using the forearms. The client was willing to move forward with the original poses, which she enjoyed, but in hindsight I should have changed tactics during our session. In the moment, it was difficult for me to balance honoring the client’s wishes, especially if they’re willing, with making a change and over-protecting them. This is something I will have to consider in the future, especially when I am still getting to know the client and their capabilities.

I would like to offer more stress reduction and relaxation mental practices for the client.

• Yes

Awareness practice
Neck warmups: right/left, chin glide, waterfall, head tilt with PNF, arm rotation
Shoulder circles with scapular awareness; shoulder/wrist tap, crossed hands to twist
Garudasana arms with flexion/extension
Reed (lateral stretch)
Dynamic twist
Isolated Pelvic tilt to cat/cow with cactus arms
Breath awareness to rib cage
Eye/tongue/hands practice
Foot/toe mobility work, marma point
Ankle circles on ball of foot
Supine diaphragmatic breath/pelvic floor awareness
Supine windshield wiper to Happy Baby
Yoga nidra

She should find time physically away from family so that she can practice deep relaxation for healing herself. She keeps getting interrupted when she’s at home.

The client reported that she had “a lot of pain” in her wrists due to some overuse earlier in the day. She asked if we could have a shorter session today so she wouldn’t have to put pressure on her wrists on the mat, not realizing that we could have a chair practice today and keep the movements low-key. I told her that she could be the guide on progression of movement to keep the session pain free.

Since this was our last meeting, I really wanted to offer more practices that could help her manage her stress and bring more awareness to her breath throughout the day. I also wanted to provide tools she could use to increase circulation as well as relieve stiffness for her feet, due to the substantial pain she experienced in the course of the day.

This session also included a good deal of meaningful dialog to convey knowledge for moving forward. I was happy to answer the many clarifying questions the client asked about the practices we did. In addition, I introduced the concept of awareness of her own energy reserves so that she wouldn’t use more than she had available and deplete herself. This would then require prioritizing the most important tasks of the day and pacing herself accordingly. We also brainstormed possibilities for her to practice yoga nidra without constant interruption from the kids. That quiet time of deep relaxation and connection would be so crucial for her ability to heal.

We met for 1 intake and 3 sessions.

Working with this client felt really impactful for me because we were able to make such a big difference in her pain level through education and the consistent practice of simple yogic tools. As a stay-at-home parent who homeschooled her three young children, her family always came first. Having someone outside of her circle allowed a perspective that gave her permission to prioritize her health and self-care, not as a selfish act, but as a way to be more present for her family. She developed an understanding that it was important to take the time to practice what she learned consistently and often, and that over time what she gained in her health would be reflected in what she could offer for others. I was happy to be able to offer a safe place to hold space for her during many of our discussions. (Raja, Manomaya)

She found the physical practices helpful to release tension and ease stiffness in her body. Due to a change in the client’s priorities, we were not able to spend as much time on the strengthening aspects, but she gained great benefit from the stretching and mobility work, especially in the neck and smaller joints. (Annamaya, Hatha) The most significant results were with the subtle practices. She was able to reduce the effects of stress with breathwork and yoga nidra practices. (Pranayama, Manomaya) The yoga nidra practice was especially instrumental in changing her relationship to pain and reminding her mind and body how to let go. Her sleep improved, fatigue decreased, and the pain seemed less intense after doing these practices consistently over even this short time.

I would not change what I did. The client’s priorities were the guide for how we moved forward. It was good to experience the reshuffling and to witness which concerns became more or less important as the client experienced the practices over time.

We discussed some strategies the client could do to take care of herself as well as give her space to grow intellectually and with purpose.