Intake summary:
The intake session was conducted on 8/27/23 via Zoom. ALK is a 28-year-old white female who teaches English at an inner-city public high school from which she is taking a leave of absence for a month due to health conditions. She is single and shares a house with a roommate. She is 5'5" and weighs 123 lbs., 10-12 lbs. lower than her regular weight but not underweight per BMI; she has a boyfriend and is sexually active.

Her primary objective for seeking yoga therapy is to improve her lower back pain related to ulcerative colitis ("UC"). She also hopes yoga therapy can help with posture to alleviate her middle back pain due to herniated discs (T11-12), which can be exacerbated by sitting for an extended period.

ALK was diagnosed with UC in 2020 and is under treatment. It is active with inflammation; symptoms include diarrhea and pain in the sacrum. She recently developed lichen planus ("LP") that causes vaginal burning.* This new diagnosis of an idiopathic condition severely impacted her QoL, and the health trajectory worries her. Before the diagnosis of UC, ALK enjoyed an active lifestyle—taking intense workouts and Ashtanga yoga classes, going out with friends, and dancing until late at night, which are no longer possible as she gets quickly exhausted, resulting in flare-ups. Pain intensity scores for UC-induced lower back pain are 7/10 (10 as the worst pain imaginable) for bad days and 3-4/10 for good days; burning sensation from LP are 9/10 and 3-4/10, respectively. She stopped smoking recreational drugs and maintains a controlled diet.

She receives AMMR and TMS therapy for anxiety and depression, which she has suffered since her teenage, although she is no longer on antidepressants. Subtle signs of UC flare-ups wake her in the middle of the night, making her anxious and preventing her from falling back to sleep. To cope with stress, she keeps up with less intense exercises, including qi going and gentle yoga using exercise apps and a 15-20 min daily walk while taking caution not overdoing.

ALK reports the diagnoses of UC and LP "have shifted who I am," who used to be "outgoing, social, fun, silly, and physically active." She enjoys creative activities like drawing and writing and socializing with close friends.

*ALK received a biopsy result later in the sessions and was re-diagnosed for vulvodynia.

Assessment:
A disturbance in the enteric nervous system, a.k.a. brain-gut connection, is suspected in this case, impacting across the koshas.
The health of Annamaya is significantly affected by physical pain and dehydration due to diarrhea; Pranamaya is impacted by digestive and inflammatory issues in the gut, as well as fatigue and stress. Imbalance in Manomaya Kosha is manifested as anxiety/depression and mood swings, all of which are known psychological symptoms in people with inflammatory bowel dysfunction. Her overreacting to the signs of flare-ups triggers anxiety and sleep disturbance.

Such emotions exacerbate her UC symptoms, causing her to create negative conditioned patterns in the brain-gut pathway and cloud the clarity of Vijnanamaya. Imbalance in Apana Vayu is also suspected, affecting Pranamaya kosha's vitality; when prana's flow is blocked along the current, it can manifest as depression, which can be considered the inability to eliminate negative thoughts and emotions.

The Kleshas, namely Avidya (Ignorance), Asmita (Ego), and Raga (Attachment), play a role in her sadness and depression: loss of her self-image that identifies with youthfulness and being active. She may be attached to the esteem of peers at work for being an effective teacher. Misidentification of who she truly is has become an impediment to her experiencing happiness.

Physical assessment revealed instability in the pelvic girdle and minor knock knees. Tightness in hamstrings and erector spinae and limited ROM in both FAj are visible in postures that require hip flexion. The overall energy level is weak, presenting tiredness.

Contraindications and Cautions:
- Avoid over-exhaustion
- Avoid practicing activation asanas (Brahama) later in the day
- Caution in spinal flexion and rotation for herniated discs (T11-12) and possible arthritic issues in the sacrum, e.g., spondylosis
- Her hyperextended elbows need to be taken caution in asanas such as Downward Facing Dog

Agreed-Upon Goals:
Short-term: Learn how to release tension in the lower and middle back through gentle stretching, strengthen the posterior structures, and +build endurance while taking care of ulcerative colitis flare-ups. Improve energetic flow and activate relaxation response to address anxiety and depression via breathwork and other yogic techniques.
Long-term: Cultivate the ability to navigate the ups and downs of life with greater ease and equanimity

Note: + denotes an update to the initial goals

*How yoga therapy can help the client:

• Releases tension in the posterior complex via asanas supported by Langhana-based asanas poses. +Strengthen core structures and improve endurance to address fatigue and depression via a well-curated Brahmana-based sequence while avoiding UC flare-ups. (Annamaya)
• Improves the energetic movement of Apana Vayu, promoting digestive health and countering depression. Activates relaxation response to reduce anxiety via breath work that improves brain-gut connection, i.e., respond to discomfort by staying calm and breathing into the area without overreacting. Opens the abdominal area and promotes deep rest and healing through restorative yoga. +Invigorating pranayama will elevate mood. (Annamaya, Pranamaya, Manomaya & Vijnanamaya)
• Repatterns conditioning to break the negative brain-gut cycle. + Engage in creative/contemplative activities to quiet the chatter in the mind (Manomaya & Vijnanamaya)
• Cultivate the ability to navigate the ups and downs of life with greater ease and stay positive by connecting with the True Self. (Anandamaya)

Note: + denotes an update to the initial care plan

*Asana will be given to balance Annamaya, Pranamaya, and Manomaya by:
a. Releasing lower and middle back tension via posterior and lateral complex stretching (erector spinae, lats, hamstrings, glutes, QL, obliques, etc.). The interventions include:
i. Cat & Cow and variations
ii. Gate Pose
iii. + Ardha Uttanasana
iv. Hamstring stretches, Happy Baby, Resting Pigeon w/wall, Spinal Twist in a supine position
v. + Supported Downward Facing Dog Pose for posterior stretch (short hold, with a blanket log under heels)
vi. Seated Spinal Twist ("Stay in a tight spot and breathe" can be applied to anxious feelings in other situations)

b. Strengthening core structures and improving endurance ("The AM practice"). The interventions include:
i. Tadasana-Swan Dive-Uttanasana-Ardha Uttanasana-Reverse Swan Dive
ii. Downward Facing Dog Pose for posterior stretch
iii. Warrior I vinyasa-style with intention
iv. Pelvic Rock to Gentle Bridge

c. + Gentle inversion for improving sleep reducing anxiety and depression. The interventions include:
i. Viparitakarani (“The PM practice”)

d. Restorative yoga to open up the abdominal area and promotes deep rest and healing. The interventions include:
i. Supported Spinal Twist (focus on Manipura Chakra for the digestive issue)
ii. Supported Reclining Pose (focus on Anahatha, to open heart, acceptance)
iii. Supported Bridge for IBS

*Pranayama and other energy work will be given to balance Annamaya, Pranamaya, and Manomaya via:
a. Pranayama to release blockage in Apana Vayu. The interventions include:
i. Deep Breathing/Dirgaswasm
ii. Kapalabhati with Mulabandha (Promote digestive health and counter depression)

b. Pranayama that engages relaxation response to reduce anxiety and improve brain-gut connection. The interventions include:
i. Breath awareness
ii. Alt. nostril breathing w/ ext. exhalation
iii. Alt. nostril breathing w/Pratipaksha Bhavana (Also Bhakti)
iv. Brahmari
c. Manipura Chakra activation to promote digestive health. The interventions include:
i. Focal point during asanas
ii. Vocalization "RAM" (also Japa/Bhakti)
iii. Guided meditation with imagery during restorative yoga (also Japa/Bhakti)

d. Anahatha Chakra activation to learn to let go and accept the current-self. The interventions include:
i. Setting a focal point at the heart chakra during asanas and restorative yoga

e. Mantra to elevate mood and energy (also Japa/Bhakti)
i. OM
ii. OM Shanti
iii. RAM
iv. "I am" affirmation/mantra

*Meditation and other mindfulness techniques will be given to balance Pranamaya, Manomaya, Vijnanamaya, and Anandamaya:
a. Cultivate the Buddhi mind/discriminating faculty to help repattern conditioning and build the resilience to bounce back from setbacks and challenges. Become able to observe and accept "what is" with self-compassion. The interventions include:
i. Witness Practice (also Jnana yoga)
ii. Practice Pratyahara via a body scan
b. + Quiet the mental chatter through contemplative activities and positive self-expression, e.g., artwork and writing

*Other yogic tools will be given to balance Pranamaya, Manomaya, Vijnanamaya, and Anandamaya by:
a. Self-inquiry for connecting with her True Self. The interventions include:
i. "I am [adjective]" mantra journaling
ii. "Who am I" journaling
iii. Pratipaksha Bhavana journaling with prompts

*Ulcerative Colitis:
https://www.mayoclinic.org/diseases-conditions/ulcerative-colitis/symptoms-causes/syc-20353326

*Yoga and UC
a. Studies:
1. The Effect of Breathing, Movement, and Meditation on Psychological and Physical Symptoms and Inflammatory Biomarkers in Inflammatory Bowel Disease: A Randomized Controlled Trial.
Gerbarg PL, Jacob VE, Stevens L, Bosworth BP, Chabouni F, DeFilippis EM, Warren R, Trivellas M, Patel PV, Webb CD, Harbus MD, Christos PJ, Brown RP, Scherl EJ. Inflamm Bowel Dis. 2015 Dec. Clinical Trial.
"Conclusions: In patients with IBD, participation in the BBMW [Breath-Movement-Meditation Workshop] was associated with significant improvements in psychological and physical symptoms, quality of life, and C-reactive protein. Mind-body interventions, such as BBMW, which emphasize Voluntarily Regulated Breathing Practices, may have significant long-lasting benefits for IBD symptoms, anxiety, depression, quality of life, and inflammation."
"
2. The mediating effect of psychological resilience on the level of mindfulness and general well-being in patients with inflammatory bowel disease.
Wang M, Lu X, Liu M.Ann Palliat Med. 2021 Aug
"Conclusions: We concluded that psychological resilience in IBD patients has a partially mediating effect between mindfulness level and overall well-being."

b. Articles:
1. Brain-gut connection explains why integrative treatments can help relieve digestive ailments, Harvard Health Blog July 2023
2. Crohn’s & Colitis Foundation https://www.crohnscolitisfoundation.org/

• Management of UC: Mind-Body Therapy
• Stress
• Diet and nutrition

c. Studies and articles that informed the care plan formulation:
1. Randomised clinical trial: yoga vs written self-care advice for ulcerative colitis. Cramer H, Schäfer M, Schöls M, et al. Aliment Pharmacol Ther. 2017;45(11):1379-1389. doi:10.1111/apt.14062
2. Yoga in Patients With Inflammatory Bowel Disease: A Narrative Review. Kaur S, D'Silva A, Shaheen AA, Raman M. Crohn's Colitis 360. 2022;4(2):otac014. Published 2022 Apr 14. doi:10.1093/crocol/otac014
3. 5 Yoga Poses for IBS (Yoga International Article) https://yogainternational.com/article/view/5-yoga-poses-for-ibs-irritable-bowel-syndrome/

*Lichen Planus:
https://my.clevelandclinic.org/health/diseases/17723-lichen-planus#:~:text=Lichen%20planus%20is%20a%20condition,alleviate%20related%20symptoms%2C%20including%20itching.

*Vulvodynia:
Vulvodynia, Disease & Conditions, Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/vulvodynia/diagnosis-treatment/drc-20353427
"Stress tends to make vulvodynia worse. And having vulvodynia can cause you to have stress. Activities that can help ease stress include yoga and mindfulness meditation."

*Depression:
a. Yoga as Medicine, Timothy M Call, M.D. Depression pp.261-280
b. 3 Yoga Inversion Postures for Mental Health & Mood Stabilization, UC Irvine Susan Samueli Integrative Health Institute, April 2020
https://ssihi.uci.edu/news-and-media/blog/3-yoga-inversion-postures-for-mental-health-mood-stabilization/#:~:text=Yoga%20inversion%20asanas%20(postures)%20have,the%20pineal%20and%20pituitary%20glands.

"Yoga inversion asanas (postures) have been used for centuries for mood stabilization and to support mental health. Inversion postures can be helpful in relieving headaches, improving sleep, reducing anxiety & depression, and helping to regulate hormones by increasing blood flow to the pineal and pituitary glands."

*Mantra:
Nine mantras for anxiety that experts use themselves. hhuffpost.com
https://www.huffpost.com/entry/mantras-for-anxiety_n_5b8570c0e4b0162f471cdfda

*Reading: Golden Present by Swami Satchidananda. "Life without turmoil is not real peace" "(from September 11 reading)

*Sutras:
a. Yoga Sutra of Patanjali I. 2-4
b. Yoga Sutra of Patanjali II. 2-7 (Kleshas), II. 6 Removal of Asmita to reveal the True Self
c. Pratipaksha Bhavana
Yoga Sutra of Patanjali II.33 "When disturbed by negative thoughts, opposite ones should be thought of. This is Pratipaksha Bhavana.” Inside the Yoga Sutras by Rev. Jaganath Carrera

*Training Manuals and Notes:
Integral Yoga Therapy Training Modules:
Human Body Ease and Dis-ease, Stress Management Teacher Training, Raja Yoga Teacher Training

• Yes

Session Date: 8/31/23 Time: 4-5:30 PM Location: In-person at client's home
Activities:
1. Check-in. Shared assessment summary. Goal setting.
2. Asanas: Warm-up in all 4s, Cat & Cow, etc. Gate Pose, Apanasana/Happy Baby, Hamstring stretches in a supine position
3. Bandha: Pelvic Rock with pelvic floor contraction (Mulabandha) Gentle Bridge
4. Restorative yoga with pranayama
a. Supported Reclining Pose
i. Breath awareness
b. Supported Spinal Twist
i. Deep Breathing "Breathing into a tight spot"
ii. Extended exhalation
5. Mantra: OM chanting. Call and response "I am [adjective]" mantra. "I am peaceful,” etc.
6. Review this week's home practice. Feedback.

Weekly assignments and resources/handouts are shared in a Google Doc
1. Asana practice
a. Cat & Cow→Side-to-side
b. Gate
c. Pelvic Rock with Mulabandha (contract pelvic floor muscle as you round the back)
d. Gentle Bridge. Flowy movement first, then hold the Bridge for 5 breaths
e. Apanasana→Happy Baby
f. Restorative yoga: Reclining abdominal twist
2. Pranayama (Breathwork)
a. Deep Belly Breathing with extended exhalation
3. OM mantra x3, “I am” mantra x3, observe silence
4. Journaling "I am [any adjective of your choosing]" to enhance positive feeling
5. [Updated] Spend more time doing what you love, e.g., drawing and connecting with loved ones

Resources and Handouts:
1. Practice aid:
a. 5 Yoga Poses for IBS (Yoga International Article)
b. AUM/OM Mantra audio
2. Article:
Brain-gut connection explains why integrative treatments can help relieve digestive ailments, Harvard Health Blog July 2023

Baseline measurements were taken for fatigue and sleep hygiene for the past seven days using the PROMIS-43 scale. ALK reported she feels fatigued very much (5/5), and she has trouble starting things. The quality of sleep was "fair," except she woke up in the middle of the night twice this week due to feeling "a warning sign of flares, like it's coming," the indication of having diarrhea the following day. She reports that diarrhea could have been precipitated by eating asparagus or walking up a hill during the day.

I handed ALK an article by Harvard Health regarding brain-gut connection and explained how inflammation in the GI tract and emotions are intimately interconnected via the enteric nervous system. She embraced my care plans' integrative “mind-body” approach and responded positively to the overall goals presented. She requested that we add "increase stamina" to the short-term goals.

Today's focus was improving the flow of Apana Vayu, and the emphasis in the asana and pranayama was stretching and relaxation. Overall, she responded to the program well, including chanting and pranayama, which are new to her. During the "I am" Practice, she used adjectives such as peaceful and calm, reflecting the state of Manomaya.

The lateral flexion in the Gate Pose suggests limited ROM on the left side of the body; thus, slow extended exhalation was instructed. Supported Reclining Pose was supplemented with an extra blanket in her lower back to alleviate discomfort.

ALK stated she is ready for more strengthening practices to improve her stamina. We will adjust the strategies to incorporate Brahmana-type practice to address a deficiency in the pranic flow while monitoring her energy and internal physiological balance, including UC flare-ups. Depending on how she felt after today's session, some standing asanas and more energizing pranayama will be introduced to activate the system: vinyasa-style movements with steady breath and Supported Downward-Facing Dog Pose, Kapalabhati, etc. We may incorporate Mulabandha into Kapalabhati, which she learned today via the Kegel exercise. Those activation practices may be appropriate for the next session as it is scheduled for the morning hours.

After the session, she showed me the drawing she had been working on—an abstract intricate maze. The activity could have had a calming effect on her, and she should be encouraged to spend more time on it.

I researched the correlation between UC and pain/heat in the sacrum. Information on the Crohn's & Colitis Foundation website suggests her lower back pain can be arthritic: "Axial Arthritis is also known as spondylitis or spondyloarthropathy. Axial arthritis produces pain and stiffness in the lower spine and at the bottom of the back (sacroiliac joints)."
"https://www.crohnscolitisfoundation.org/emr/emr-ibd-education-tool/arthritis

I felt responsible for sharing this information with ALK and suggested she tell her doctor about lower back pain. I am aware that diagnosing someone is out of my scope of practice, and I chose the words carefully when delivering what could be bad news to her. She appreciated it and said she would. We may not know if that is the case before we conclude the four-week session, but regardless, I need to take extra caution when bringing her to axial flexion or extension.

The next session is scheduled for 9/10/23. ALK will let me know if she had a flare from today’s session. We will work together to find her threshold capacity by adjusting the intensity and duration of various asanas and pranayama. Adaptive inversion may be introduced to address fatigue, insomnia, and depression.

• Yes

Session Date: 9/10/23 Time: 4:30-6:00 PM Location: In-person at client's home
Activities:
1. Check-in. Review Home Practice
2. OM chant
3. Witness practice
4. Intro to Chakra. Manipura Chakra. "RAM"
5. Asanas
a. Warm-ups. Cat & Cow, Side-side [Leg crunch removed]
b. + Supported Downward-facing Dog Pose for posterior stretch + inversion (Use a blanket log under heels)
c. + Ardha Uttanasana
d. Happy Baby, Resting Pigeon w/wall
e. + Viparita karani for insomnia
f. Janisirasana w/a strap, Paschimotanasana w/strap
g. Ardha Matsyandrasana (seated position)
h. Restorative yoga: Supported Bridge
6. Meditation on Manipura Chakra ("RAM" & visualization)
7. Pranayama
i. [Kapalabhati with Mulabandha removed]
j. Alt. nostril breathing w /ext. exhalation
8. OM Shanti chant

Weekly assignments and resources/handouts are shared in a Google Doc

1. Witness practice (Observe body, breath, emotions, energy level, and thoughts, as they are, w/o judgment)

2. Asana practice
a. Cat & Cow→Side-to-side→Sunbird Balance (see the image below)
b. Gate
c. Pelvic Rock with Mulabandha (contract pelvic floor muscle as you round the back)
d. Gentle Bridge. Flowy movement first, then hold the Bridge for 5 breaths
e. Apanasana→Happy Baby
f. Reclining OR Seated abdominal twist
g. Figure 4 using a wall
h. Restorative Yoga
i. Viparita Karani – Legs up on a wall (evening practice)
ii. Supported Bridge - with a folded blanket under the sacrum

3. Pranayama (Breathwork)
• Nadi Suddhi/Alternate Nostril Breathing with extended exhalation
4. OM mantra x3 RAM mantra focusing on Manipura Chakra
5. Journaling "I am [a noun]" e.g., a woman, a daughter, a teacher… Keep going!
6. Spend more time drawing as a form of contemplative practice

Resources and Handouts:
Research studies on UC + Yoga and yogic techniques used in the care plans:
1. Randomised clinical trial: yoga vs written self-care advice for ulcerative colitis. Cramer H, Schäfer M, Schöls M, et al. Aliment Pharmacol Ther. 2017;45(11):1379-1389. doi:10.1111/apt.14062

2. Yoga in Patients With Inflammatory Bowel Disease: A Narrative Review. Kaur S, D'Silva A, Shaheen AA, Raman M. Crohn's Colitis 360. 2022;4(2):otac014. Published 2022 Apr 14. doi:10.1093/crocol/otac014

3. 5 Yoga Poses for IBS (Yoga International Article) https://yogainternational.com/article/view/5-yoga-poses-for-ibs-irritable-bowel-syndrome/ Note: You can find asanas assigned for the home practice

ALK stated she was not ready to push herself today because spending a day with friends outdoors depleted her energy. Biopsy results came back; she learned that she has vulvodynia. Gabapentin prescribed also exacerbates her fatigue. In the past seven days, she had one episode of UC flare with diarrhea and a burning pain in the sacrum region (pain intensity 7.5/10).

She had some upsetting episodes with her boyfriend. She "needs to spend more time drawing," as “it is helpful to clear the mind”; I encouraged her to continue drawing as a form of meditation and added it to the home practice list.

As today’s session was rescheduled to late afternoon and her low energy state, we adjusted the activities to keep asana shorter and gentler. (Removed from the activity plans include Kapalabhati with Mulabandha and Sunbird Balance to tabletop crunch). Axial flexion was instructed with caution.

During the witness practice, while she noticed "discomfort" in the physical body and "anxiety" in the emotional body, she was able to experience "peacefulness and feeling calm" at the end of the practice. Her efforts to maintain calmness and stability were also demonstrated in her asana practice. For example, she presented instability with slight wobbling in her muscles during Supported Downward Dog and Ardha Matsyendrasana; then, by employing slow, deep breaths, she gained stability and ease.

ALK tolerated supported inversions without difficulties: its benefits for depression and insomnia and correlations with pituitary and pineal glands were explained.

As we were experimenting with hand positions for meditation, she reported "feeling vulnerable" when her palms were turned upward. I asked if she could find any "positive" adjectives, to which she said, "more open." It opened the opportunity to introduce Pratipaksha Bhavana, which was initially planned for the subsequent session.

ALK did well with the home practice (“70%”), evident from improved interoceptive awareness and acquired skills to use the breath to stay calm and steady. The recent diagnosis of vulvodynia was difficult for her and seemed to affect her mood. We focused on stress reduction to support her mental health and relaxation today. It was recognizable she slowly regained physical stamina by the end of the session, as the interventions might have unblocked stagnant pranic energy.

Having a backup plan for the activities saved the day! It was an excellent opportunity to put the idea of "meeting the person where they are" into practice. Working in an in-person setting helped as I could closely monitor her energy level to adjust the plans on the spot.

We scheduled the next session in the morning hour. Provided ALK has enough endurance, more active asanas and pranayama with Mulabandha will be introduced, per her request. Anahata Chakra activation will be given to learn to let go and accept herself and to enhance positive energy.

• Yes

Date: 9/17/23 Time: 10:15-11:45 AM Location: Client’s home

Activities:
1. OM chant
2. Check-in. Review Home Practice. Progress assessment on Anxiety, Sleep, and Pain
3. Pranayama "Morning Practice" for activation
a. Kalapabhathi with Mulabandha
4. Asana "Morning Practice" for activation
a. Cat & Cow. Sunbird Balance to Tabletop Crunch
b. Downward Facing Dog Pose for posterior stretch
c. Tadasana-Swan dive-Uttanasana-Ardha Uttanasana-Reverse swan dive High Lunge
d. Warrior I vinyasa with affirmation +Anahata Chakra activation for learning to "let go" and "accept myself"
e. "Warrior II vinyasa with affirmation +Anahata Chakra activation for learning to "let go" and "accept myself"
f. Back Bend – Half/Full Locust
g. Forward Bend – Head-to-knee pose
h. Seated Spinal Twist

5. Restorative Yoga: Supported Reclining Pose with Anahatha chakra meditation to open heart and acceptance.
6. Pranayama for relaxation:
• Alt. nostril breathing w/Pratipaksha Bhavana
7. Reviewed Home Practice. Pratipaksha Bhavana journaling with prompts
8. Wrap-up. Yoga practice going forward

Weekly assignment is shared with CT in a GoogleDoc
*Regimen for Morning Practice
1. OM
2. Witness practice (Observe body, breath, emotions, energy level, and thoughts, as they are, w/o judgment)
3. Morning Practice (Activation-focused)
1) Asanas:
a. Cat & Cow. Sunbird Balance to Tabletop Crunch
b. Downward Facing Dog for posterior stretch
c. Tadasana-Namaste-Reach out and up, bend back - Swan Dive-Uttanasana (Foward Fold)-Ardha Uttanasana (Half Forward Fold/Upside L shape) - Uttanasana-Reverse Swan Dive-Reach out and up, bend back- Tadasana
d. Warrior I vinyasa with affirmation + Anahata/Heart Chakra activation for learning to "let go" "and "accept myself."
e. Warrior II vinyasa with affirmation + Anahata Chakra activation
f. Half locust pose (Tuck the arms under the body, extend one leg, Inhale, lift it up. Keep the chin on the floor)
g. Full Locust (Raise both legs)
h. Head to Knee Pose using a strap (Gently, take care of your disk)
i. Seated abdominal twist (Gently, take care of your disk)

2) Pranayama (Breathwork):
• Kapalabhati with Mulabhandha (Root lock at inhalation and retain for a few seconds)
• Nadi Suddhi/Alternate Nostril Breathing with Pratipaksha Bhavana

4. OM mantra x3 RAM mantra focusing on Manipura Chakra at solar plexus
5. Journaling homework - Pratipaksha Bhavana with suggested prompts

Resources and Handouts:
Integral Yoga Institute of San Francisco

• Noon meditation M-F (both in-person and online)
• Early AM meditation on Thursdays (online only)
• Many classes and workshops

ALK had a good week and didn't have any UC flares last week, including the day after the evening she went out to celebrate her birthday. She stated she felt her mood uplifted by connecting with people, which was one of her weekly assignments. She didn't do "I" am…" journaling but reported she did most of the assignments, including spending quiet time drawing.

Assessment of the progress was conducted using a self-reported PROMIS score. Improvement in anxiety and sleep disturbance were most notable; compared to the baseline taken on 8/27, her score of feeling fearful and nervous and rumination about anxiety decreased from "often" "to "sometimes." The frequency of waking up in the middle of the night also decreased from x2 weeks to none in the past seven days. Fatigue and pain intensity from UC and vulvodynia showed no significant changes. However, she reports that the pain and discomfort no longer hold her back from socializing with friends as much, demonstrating she is regaining her positive attitude. It appeared that Annahatha/heart Chakra meditation especially resonated with her today, contributing to the health of Pranamaya, Manomaya, and Anandamayakosha.

She states the mantra practice (OM and RAM) has been particularly enjoyable and helpful "for emotional release." Her relationship with her boyfriend has been unsteady; however, "when I catch myself feeling sad or anxious, I try not to be reactive, and remember to breathe deeply." Her statement demonstrates her gained awareness and skills for self-regulation, bringing more balance to Vijnanamaya and Manomaya kosha. We both agreed the yoga therapy sessions were successful in that regard, even though it didn't help her physical pain to make a noticeable difference.

The active practice was well tolerated today. I took extra caution in the seated forward fold and seated twist for her herniated disk. I found that a lesson by Swami Satchidananda was appropriate to share with her at this final session, "Peace without turmoil is not real peace. Real peace is to stay calm in the midst of turmoil."

This case study deepened my understanding of the strong connection between mind and body and how they can impact/color each kosha. Being an IBS sufferer myself, it was not hard to connect two dots— bouts of anxiety/depression and her UC flare-ups. Working with ALK, the Panchamaya Kosha model provided a solid framework for working with her ailments holistically and guided me on which tools to apply.

To a young single woman, a diagnosis of chronic illness such as ulcerative colitis is not only physically debilitating, but it can also threaten the self-image of “young, active, and sexy.” Supporting her through the lens of Kleshas, I identified the root cause of her sadness and depression, which is the attachment to the identity she had created. I have her work on the afflictions through “I am” practice. The mantra practices and contemplative activity (drawing) unleashed her yearning to express and release emotions, lifting the veils over Pranamaya and Manomaya to get her closer to connecting with the Bliss body.

As we assessed the progress at the last session and compared it with the baseline, we agreed that the four-week therapy sessions made some impact in improving her QoL—reduced anxiety and the frequency of waking up in the middle of the night ruminating for hours and helped regain a positive attitude to get out and spend time with loved ones, contributing to the health of each kosha. However, it showed no measurable improvement in her lower back pain and discomfort, which was her primary objective for participating in the practicum. It was disappointing for both of us, but it is understandable because of the nature of chronic illness, pain, and energy level changes depending on the day. Still, she appreciated stretches and strengthening practices, which helped her feel better. At the conclusion of the sessions, she became more attuned to the brain-gut connection and equipped with newly acquired skills in utilizing discernment and breathing techniques to respond skillfully, not merely react, to otherwise triggering situations.

Our four-week in-person program has concluded with no subsequent sessions scheduled. ALK will review the assignments and choose either a gentle version (Week 1 and 2) or an active version (Week 3), depending on her energy level. I instructed that she conduct Witness Practice before coming onto the mat to determine what type of practice would be appropriate. A link to the IYISF website is shared in the Google Doc for reference, as she expressed interest in attending in-person meditation sessions, which are convenient from her home.