Intake summary:
The intake session was conducted via Zoom on 10/6/23, 8:00-10:15 AM. LIS is a 58-year-old Caucasian female of Jewish ancestry and a professional violinist who tutors students remotely from home. She lives in Austin, Texas, with her husband and two kittens acquired recently after they had lost previous pets. She was referred to me by a yoga teacher, Charles McInerny, in Texas.

LIS described her stress level as high for numerous reasons, including changes in her community due to the city's rapid growth, political climate, aging, and, most of all, not being able to exercise as much due to the diagnosis of osteoporosis (OP) received in 2017. Treatment with Bisphosphonates was recommended, which she decided not to pursue because of possible side effects. Out of a fear of spinal fractures due to OP, she has stopped working out and has gained almost 40 lbs. She feels "depressed being fat and old,” describing that her life “has gotten much smaller since the pandemic." She also has insomnia and mood swings and describes her emotional state as "there’s a war going on inside of me: between feeling energetic, inspired, and wanting to do things at times and then feeling stuck and sad." Her coping mechanism is to keep herself busy with activities such as entertainment and socializing. LIS recounted that when growing up, she was treated unfavorably and “emotionally abused” by her mother, who passed away four years ago.

More recently, she injured her neck/upper back, and the pain has made her even less active and depressed. Baseline measurements for physical pain were 4 out of 6 for the right side of the neck and the left side of the upper back. (MYMOP2 assessment tool was used for measurement for this case study. 6 is “as bad as it could be”) She also experiences pain in the left rib cage, for which she has been working with a chiropractor. She evaluates her sleep quality as 4 out of 6, having difficulty falling asleep and not feeling refreshed the next day. Current medical conditions also include acid reflux (since 2014), tendonitis in the wrist (since 2014), macular pucker in the eyes (since 2022), TMJ, ocular migraines, and neuroma in the right foot. Her HA1C level is above normal. Her general sense of well-being is low.

Her primary objective for participating in yoga therapy sessions is to reduce and manage stress. She has done various therapeutic modalities in her life and wanted to try a new approach. She has some familiarity with yoga philosophy and occasionally practices guided meditation. She had a positive experience with somatic experiencing therapy for reducing stress.

Assessment:
LIS has withdrawn from a physically active lifestyle after receiving the diagnosis of osteoporosis seven years ago, creating stagnation and imbalance in the physical and energetic body (Annamaya and Pranamaya Kosha). Progression of OP and fear of bone fracture are impacting the integrity of Manomaya Kosha.

Strong attachment to her old self suggests klesha’s coloring over Manomaya and Vijnanamaya Kosha, dislike of change and impermanence (raga), and aversion to addressing the root cause of stress and opting for distractions (dvesha). Misidentification with the outer layer obstructs her from identifying with her True Self as avidya clouds the connection with Anandamaya Kosha. Such afflictions can be addressed via witness practice, svadhyaya, and meditation.

Her mood swings and inner struggle suggest she is tossed between desires and depression, going back and forth between an over-functioning mind and an under-functioning body, or rajas and tamas, from the aspect of gunas. Depression, weakness, and fear point to derangement of apana vayu, which also often manifests in bone issues as it obstructs the absorption and retention of minerals.

Her childhood trauma may also be a contributing factor to anxiety and fear. Yoga’s intentional movements can support her in building the mind-body connection, releasing emotions and stress trapped in negativity, and bringing more profound healing without exposing her to re-traumatization. Also, teaching aparigraha may loosen a grip of attachments, help free her from resentments, negative thought patterns, and expectations, and guide her toward recognizing and making peace with impermanence.

During the physical assessment, she reported pinching pain in her left shoulder in arm abduction/adduction and discomfort in the right foot when bearing weight in Tree Pose. Lateral spinal flexion appeared effective in alleviating tightness in the left scalene. She was talkative throughout the session and had views and opinions that were presented with inflexibility.

How yoga therapy can help the client:
• Releases tension in the overall body through gentle and slow movements, especially neck and upper back, while taking great cautions in the major joints susceptive to osteoporotic fracture, e.g., Femur/hip, radius/wrist, and spine (L10-12). Asanas strengthen balance and stimulate bone regeneration through isometric contraction. Safely flex and rotate the spine without triggering a fear of injury. (Annamaya)
• Increases pranic flow via physical movements and unclog apana vayu, activating down and out movements of pranic flow to eliminate negativities and attachments. Pranayama balances the autonomic nervous system and promotes the constitution towards sattva dosha. Asanas and pranayama together address the mind-body imbalance. (Annamaya and Pranamaya)
• Facilitates access to the root cause of stress and emotional pain. Provides stress reduction tools to support self-regulation. (Manomaya)
• Takes a non-judgmental approach to self-inquiry that can help my client become aware of current and past attachments, creating more space for the pranic energy to flow for healing. (Pranamaya, Manomaya and Vijnanamaya)
• Develop regular practices to build resilience to internal and external influence and cultivate a connection with the True Self (Anandamaya)

Note: Most of the asanas requiring spinal rotation were removed from the care plan per the client’s request

Agreed-Upon Goals:
Short-term: Address stress and emotional pain by utilizing yogic tools to release stagnant energy and physical tension. The approach of physical practice should be gentle and slow while taking great care of the major joints susceptive to osteoporotic fracture and pain in the neck/upper back/rib cage
Long-term: Bring balance in Body & Mind and connect with the True Self to experience profound peace

Care plans:

I. Asana will be given to balance Annamaya, Pranamaya, and Manomaya by:
a. Releasing tension in the overall body through gentle sand slow movements for stretching and strengthening. The interventions include:
• Joint exercises
• Cat & Cow and variations
• Sun salutation with a chair (Yoga for Arthritis by Dr. Steffanie Moonaz) [Removed after the Follow-up Session 2] https://www.youtube.com/watch?v=oVtnVwdIvkY
• + Half Sun salutation Swan dive with Ardha Uttanasana w/mantra (also Bhakti)
• Supine Hamstring Stretch
• Supine Resting Pigeon Pose with wall
b. Strengthening balance
• Mountain Pose
• Tree Pose
• Stoke Pose
• Triangle Pose w/chair [Removed per request]
c. Stimulating bone regeneration via isometric contraction
• Prayer Press
• Hand Pull
• Static Quad/Glutes
• Standing High Lunge pressing a wall
• Chair Pose with thigh contraction against a wall
d. Safely flexing the spine
• Half Forward Fold (Hands are on chair seat)
• Balasana w/ a chair (2 blankets)
• Bananasana for lateral flexion
e. Safely rotating the spine [Removed]
• Spinal Twist in supine position [Removed]
• Supported Spinal Twist [Removed]
f. Restorative pose
• Savasana

II. Pranayama and other energy work will be given to balance Annamaya, Pranamaya, and Manomaya by:
a. Bringing balance into the autonomic nervous system and promoting the constitution towards sattva. The interventions include:
• Deep Abdominal Breathing
• 3-Part Breathing
• Ujjayi Breathing
• Kapalabhati
• Alternate Nostril Breathing
b. Increasing pranic flow and unclogging apana vayu
• Alternate Nostril Breathing with extended exhalation
• Mulabandha
• Jnana Mudra
• Prana Mudra

III. Meditation and other mindfulness techniques will be given to balance Pranamaya, Manomaya, Vijnanamaya, and Anandamaya via:
a. Stress reduction techniques for self-regulation
• Breath Meditation
• Imagery Meditation to Cope with Problems
b. Contemplative practices to direct mental activities
• Witness Practice
• Yoga Nidra
• Moving meditation with breath
• + So Hum contemplation meditation (also Bhakti)

IV. Other yogic tools will be given to balance Pranamaya, Manomaya, Vijnanamaya, and Anandamaya via:

a. Svadhyaya that facilitates access to the root cause of stress and emotional pain, e.g., attachment
• Ahimsa, Aparigraha, Satya
• Aparigraha Journaling
b. Sutra studies on regulating our internal state and connection with the True Self
• Sutra 1.2, 1.3, 1.4 (also Raja &Jnana yoga)
• Introduction to Panchamaya kosha
• Journaling on Higher Self-Perception (Ishwarapranidharna)
• Sutra 2.33 Pratipaksha Bhavana

+ denotes an update to the initial care plan

1. Osteoporosis and Yoga:
a. Clinical Study
Lu YH, Rosner B, Chang G, Fishman LM. Twelve-Minute Daily Yoga Regimen Reverses Osteoporotic Bone Loss. Top Geriatr Rehabil. 2016;32(2):81-87. doi:10.1097/TGR.0000000000000085“What is suggested by this study's results is that yoga can reverse bone loss that has reached the stages of osteopenia and osteoporosis.”
b. Articles:
i. Yoga and Osteoporosis: The Do’s and Don’ts https://yogainternational.com/article/view/yoga-and-osteoporosis-the-dos-and-donts/
ii. How to work with students diagnosed with osteoporosis, SequeceWiz

c. Interventions cited in the studies and articles that informed the care plans:
i. Yoga for Osteoporosis, L Fishman, et al.
ii. Yoga Sequence for Osteoporosis https://yogainternational.com/article/view/yoga-sequence-for-osteoporosis/

2. Neuroma
• Morton’s Neuroma: What It Is, Symptoms & Treatment, Cleveland Clinic
“A neuroma occurs after a nerve is partially or completely disrupted by an injury — either due to a cut, a crush, or an excessive stretch. The neuroma is a ball-shaped mass at the site of the injury, which can be painful or cause a tingling sensation if tapped or if pressure is applied.”

3. Ocular Migraine
• Ocular Migraine: What It Is, Symptoms & Treatment, Cleveland Clinic
“Migraine with aura: a wave of activity in the brain traveling through the brain. The location of the wave of activity in the brain determines the type of aura. The most common type of aura is a visual aura. About 90% of people who have migraine with aura have this type. It's thought that auras are usually visual because such a large portion of the brain processes visual information.”

4. Macular Pucker
• Macular Pucker: What It Is, Symptoms & Treatment, Cleveland Clinic
“a rare eye condition that can make your vision wavy or distorted. Most of the time, experts don't know what causes it. Many people who have macular pucker have mild symptoms — and most people don't need any treatment”

5. Stress and Anxiety
a. Yoga Therapy for Stress & Anxiety, R Butera, et al
b. Integral Yoga Stress Management Teacher Training Manual

6. Sutras
a. Aparigraha, The Yamas & Niyamas by Debrah Adele
b. Aparigraha, simple yoga article
c. Emotional regulation and resilience (Sutra 1.2-1.4). Inspired by A Seeker’s Guide to the Yoga Sutras by Ram Bhakt, 31-days Yoga Sutras, Seattle YogaNews
d. “Higher Self-perception Exercise” Yoga Therapy for Stress & Anxiety, R Butera, et al.

7. Pranas and Vayus
a. Understanding Prana by David Frawley
b. 5 Currents of Vital Energy (Pancha Vayu Model), www.sequencewiz.com

• Yes

Date: 10/12/2023 Time: 8:30-10 AM Location: Virtual via Zoom

Activities:
1. Check-in. Follow-up questions from the intake. Discussion to co-create specific therapy goals.
2. Pranayama: Deep Breathing/Dirgaswasm/Ujjayi
3. Witness Practice (Body, breath, emotions, energy, thoughts)
4. Discussion on Yamas & Niyamas with visual aid, focusing on Ahimsa and Aparigraha
5. Asanas
a. Warm-up
i. Joint exercises
ii. Cat & Cow and variations
iii. Half Forward Fold (hands on chair seat)
b. Isometric Contraction
i. Prayer Press
ii. Hand Pull
c. Sun salutation breakdown - Yoga for Arthritis sequence. “Sun salutation as moving meditation" with breath
d. Spinal flexion
i. Balasana with a chair (2 blankets)
e. Posterior Stretch
i. Windshield wiper
ii. Supine Hamstring Stretch w/strap*
f. Lateral Stretch　
i. ”Bananasana”
6. Imagery Meditation to Cope with Problems
7. Review Home Practice. Readiness assessment and the SMART goal setting. Accountability and Progress Tracking Sheet

Weekly assignments, resources, and handouts were shared with LIS in a GoogleDoc

1. Witness Practice
2. Asana practice
a) Warm-up
i) Joint exercises (page 2, upper body, spine only)
ii) Cat & Cow and variations
iii) Half Forward Fold (with hands on chair seat)
b) Isometric Contraction
i) Prayer Press
ii) Hand Pull
c) Sun salutation w/chair - Yoga for Arthritis sequence with breath
d) Spinal flexion
i) Balasana w/chair
e) Posterior Stretch in the supine position
i) Windshield wiper w/knees bent
ii) Supine Hamstring Stretch w/strap
f) Lateral Stretch in the supine position
i) Bananasana
3. Pranayama → Meditation
a) Deep Breathing/Dirga Swasam/Ujjayi
b) 3-mins of meditation focusing on breath
4. Journaling on Aparigraha (Yamas & Niyamas) with prompts

Resources and Handouts:
Practice:
1. Sun Salutation Yoga for Arthritis Sequence
2. Yoga Sequence for Osteoporosis, Yoga Journal article

Reading and worksheet:
How to Build Regular Home Yoga Practice, sequencewiz.com

The conflict in the Middle East has added stress for LIS, as she has relatives in Israel. “Meditation practice has been calming.” Upon follow-up to her no longer going to local meditation group meetings, she attributed it to her discomfort being around people and difficulty trusting people in general. She started practicing Dirgaswasm last week and noticed it has become easier to relax the abdomen, with better breath control. Using breathing as a good example, aparigraha was introduced, discussing the art of letting go and how to create more space.

The SMART goal-setting activity was conducted. LIS found the short and long-term goals relevant. Her response was ambivalent about readiness for change; she sounded uncommitted –“See what I can do.” Nevertheless, she expressed willingness to put aside one hour for yoga practice each day, and her husband can be the accountability partner. We will closely monitor the progress and adjust the volume of weekly assignments as needed.

Pranayama and Witness Practice were given as preparation for the asanas, effectively soothing her nervousness. Asana interventions were tolerated except for the lateral spinal flexion in the tabletop position, which caused a cramp in the left side of her buttocks. Yoga for Arthritis version of chair-assisted Sun Salutation was performed without difficulty, and she “felt good overall.” In the supine position, she particularly enjoyed the hamstring stretch and the lateral spinal flexion called “Bananasana.” Balasana was adapted and well supported with a chair and blankets to make spinal flexion safe and accessible.

She responded favorably to the imagery meditation with a theme of a leaf carrying away troubles or worry. Returning to meditation sangha in the care plan has been removed in response to her comment. The care plan will be focused on meditation practice at home.

Positive asana experiences today hopefully motivate her to comply with prescribed practice. A complex relationship with her mother might be a reason for her sensitivity to people’s judgment, as observed in her resistance to rejoining a meditation group when the suggestion was made. LIS appears to be a strong writer, as observed from her meticulous notes in the intake form. Prompted journaling assignments on aparigraha will provide her with the opportunity for self-inquiry and reflection, where she can start working on raga klesha including negative attachment.

The next session is scheduled for two weeks from today. She will continue to build up pranayama for stress reduction and explore the sutra 1.2-1.4 to work further on self-regulation.

• Yes

Date: 10/26/2023 Time: 8:30-10:15 AM Location: Virtual via Zoom

Activities:
1. Check-in. Progress on the home practice
2. Witness Practice (Body, breath, emotions, energy, thoughts)
3. Breath Awareness Practice for stress management
4. Asanas
a. Warm-up
i. Joint exercises –> Cat & Cow
b. Spinal flexion/posterior stretch
i. Half Forward Fold with chair
ii. Half Salutation with Ardha Uttanasana
c. Isometric Contraction
i. Standing High Lunge pressing a wall -> Supported Downward Facing Dog
ii. Chair Pose with thigh contraction against a wall
d. Restorative
i. Savasana
5. Pranayama. Alt. nostril breathing w/ext. exhalation
6. Sutra study. Sutra 1.2, 1.3, 1.4 Discussion about regulating our internal states

Weekly assignments, resources, and handouts were shared with LIS in a GoogleDoc

1. Breath Awareness Practice
2. Asana practice
a) Warm-up
i) Joint exercises (page 2, upper body, spine only)
ii) Cat & Cow and variations
iii) Half Forward Fold (hands on chair seat)
b) Isometric Contraction
i) Prayer Press
ii) Hand Pull
c) Vinyasa/Flow: Half Sun Salutation (with Ardha Uttanasana) x3
d) Spinal flexion
i) Balasana w/chair
e) Posterior Stretch in the supine position
i) Windshield wiper w/knees bent
ii) Supine Hamstring Stretch w/strap
f) Lateral Stretch in the supine position
i) Bananasana
3. Pranayama -> Meditation
a) Deep Breathing/Dirga Swasam ->Alt. nostril breathing with extended exhalation
b) Meditation focusing on breath (10 mins)
4. Journaling with prompts: Cultivate emotional regulation and resilience (Sutra 1.2-1.4).

Resources and Handouts:
Practice: Breath Awareness Practice Audio File

Upon follow-up to the progress at home, LIS reported she dedicated one hour each day for seven to eight days since we met two weeks ago. The amount of work was manageable for her. Yoga for Arthritis version of Sun Salutation “didn’t feel safe” to her, so she stopped after trying once at home and spent more time “working out” by dancing via YouTube. She followed the entire Joint Freeing series despite only being assigned to do the first page (upper extremities and spine). Her neck “feels sometimes good and sometimes not” after the joint exercise. She sustains six minutes of daily meditation.

She completed the journaling assignment for the Week 1 and 2 and showed me how much she wrote in her notebook on aparigraha. She “wrote constantly for eight days,” filling all the spaces on the page. Last week coincided with her late mother’s birthday, so she reflected on her and their relationship. She found the prompts “helpful for reflection and release” but opted out of sharing the details.

She noted fear and stress concerning the war in Israel and Gaza have affected her breathing and body. Breath Awareness practice was added to today’s activities, in which she was instructed to explore where she is holding tension and where she can release it if it’s ready. Breathing practice enabled her to notice the tight spots and “breathe deeper and fully into them.” The audio recording was provided for home practice.

Asked to elaborate on her negative response to Sun Salutation, LIS cited the following: it was awkward and difficult, felt a chair as a barrier, was hard to maneuver, and took a lot of effort to judge space. We refined the activity plans, removed a chair, and replaced it with high lunge vinyasa, which “didn’t feel good” to her either. She noted the lower back felt “tight and twisty,” and the knees were “unhappy” during lunge. We then tried Half Salutation with Ardha Uttanasana, to which she responded favorably. Standing asanas with a wall for isometric contraction were also well tolerated. The care plan will be updated accordingly.

It was unexpected to hear that the chair version of Sun Salutation did not serve her well. We discussed distinguishing pain vs. “mild discomfort” felt through muscle engaging and stretching. She appears to strongly believe in her comfort level, which needs to be respected and accommodated. The aparigraha journaling assignment effectively supported her healing through a creative outlet.

Meditation will be increased to 10 minutes daily since her steady progress. We will take extra care with asana interventions and keep it within a warm-up and gentle stretching; a balancing asana may be added for bone health as long as she is comfortable. To accommodate her physical limitations and preferences, emphasis will be placed on pranayama and mudra to improve the movements of prana. So Hum chanting with breath will be given for somatic experience to enhance the understanding of the sutra 1.2-1.4 introduced today.

• Yes

Date: 11/2/2023 Time: 8:30-10:15 AM Location: Virtual via Zoom

Activities:
1. Check-in. Progress on the home practice
2. Progress assessment
3. Witness Practice
4. Pranayama (1 of 2)
a. Kapalabhati
b. Kapalabhati with Mulahandha
5. Asanas
a. Cat & Cow variation
a. Half Sun-Salutation
b. Chair Pose variation
c. Stork Pose variation for balance
d. Isometric contraction
e. Staff Pose variation
f. Leg lifts
g. Posterior stretch in the supine position - Resting pigeon
h. Spinal rotation - Windshield wiper with head movements
6. So Hum contemplation meditation with Jnana mudra in a supine position
7. Pranayama (2 of 2). Alternate nostril breathing with Pratipaksha Bhavana
8. Prana mudra meditation
9. Discuss home practice assignments. Journaling with prompts: Pratipaksha Bhavana
10. Wrap-up

Weekly assignments, resources, and handouts were shared with LIS in a GoogleDoc

1. Breath Awareness Practice
2. Asana practice
a) Warm-up
i) Joint exercises (page 1&2)
ii) Cat & Cow and variations
iii) Half Forward Fold (hands on chair seat)
b) Standing asanas for strengthening lower body and balance
i) Chair pose
ii) Stork pose
c) Isometric contraction for the bone health and alignment
i) Staff Pose* (leaning back)
ii) Leg Lifts*

**Please refer to the Yoga Sequence for Osteoporosis handout

d) Vinyasa/Flow: Half Sun Salutation (with Ardha Uttanasana) x3
e) Spinal flexion
i) Balasana w/chair
f) Posterior stretch in the supine position
i) Windshield wiper w/knees bent
ii) Supine Hamstring Stretch w/strap
g) Lateral stretch in the supine position
i) Bananasana
3. Pranayama -> Meditation
a) Deep Breathing/Dirga Swasam
b) Mulabhanda (Kumbhaka Pranayama) 20 expulsions x2
c) Alt. nostril breathing -> Pratipaksha Bhavana 2-3 mins
d) Followed by 10 minutes of meditation

4. Self-Study (Svadhyaya)
1. Journaling on Pratipaksha Bhavana with prompt
2. Higher-Self Perception Journaling Exercise (from Week 2)

LIS has been practicing asanas in 15-minute intervals to accommodate her stamina. The prescribed asanas with weekly chiropractic visits have helped alleviate pain and stiffness. She “started feeling good” after joint exercise (x3/week) while avoiding cervical rotation. She didn’t do much journaling, stating she would try it again this week. She was pleased with the recent lab results, where her HA1C level returned to normal (5.4)

We reviewed the progress against the baseline measurements. Three weeks of yoga therapy sessions didn’t improve the neck and upper back pain, which she “did not expect to improve in any way.” She immediately related to the benefits of weekly pranayama, meditation, and journaling assignments prescribed to her. They have improved anxiety and stress, as have the body's overall energy levels. Witness Practice has been helping her with reactivity; she is “able not to get so freaked out by things.”

LIS will have lunch with her Israeli cousin today, which makes her anxious, assuming that it will involve political conversation. “I want to be there for her just to listen to what she needs to say,” and “don’t want to say anything to upset her,” referring to LIS’ political view. We strategized to keep her reactivity under control, such as making a card for herself to remind her of good intentions during the meeting.

Several pranayama techniques were introduced to stimulate prana vayu and apana vayu and as preparation for meditation. Stoke Pose was practiced against a wall and well tolerated. So Hum contemplation meditation was practiced supine while performing jnana mudra for open awareness.

Her progress assessment was positive in general. Even though the interventions did not help her much with physical pain, her feedback underscores the effectiveness of pranayama and other subtle practices on her stress and anxiety, which had been her primary objective.

It was observable from the beginning that LIS has a strong personality and opinions and needs to know the whys of what she was given or asked to do. With that in mind, I spent more time explaining what she was prescribed than any other clients I have worked with. I answered questions and ensured she felt she was an active participant in the experience. Although it necessitated simplifying the rest of the activities, it was an effective approach for this client.

As noted in the progress summary above, she demonstrated improved agency to manage stress and anxiety by revitalizing pranayama, meditation, and journaling practices and incorporating them into her daily life. Her excellent work builds resilience against them, improving the integrity of the Pranayama and Manomaya Kosha. Pranayama and Manomaya also benefited from a tailored approach to working with her physical body/Annamaya, as the asanas increased the fluidity of the prana. The improved health of Vijnanamaya and Manomaya is evident as she began to employ witnessing techniques to not react to external stimuli or emotional fluctuations.

LIS was highly cautious about the asana interventions. At times, I wanted to persuade her to get out of her comfort zone a little to overcome fear; however, it could have been counterproductive. My mantra has been, “I meet where they are,” which was a particularly apt and important reminder for this case study! And my effort was recognized and appreciated. In her post-session feedback survey, she acknowledged I have been respectful of her willingness and unwillingness to try things and was willing to work on solutions and come up with modifications to something she didn’t feel safe doing. She also noted I did an excellent job “being patient and kind” with her and her “limitations and occasional stubbornness.”

The yoga therapy sessions exposed her to the philosophical aspects of yoga. The journaling on aparigraha supported her in working with raga klesha, reflecting on attachments that can be the root causes of stress, fear, and unhappiness. I also hope the knowledge of yoga sutra 1.2-1.4 imbued her with a renewed sense of agency and resilience to outside influences to navigate her life more easefully toward peace.

The four-week yoga therapy program for LIS has concluded with no subsequent sessions scheduled. She will review her weekly assignments and continue home practice on her own.