MJB has a history of osteoarthritis (total hip arthroplasty, left side,1989,1998), and knee tendinitis. She demonstrates an imbalance in her physical body which is presented as: reduced hip mobility with limited flexion and extension, decreased external rotation and abduction of the right hip, accompanied by discomfort and pain in the right groin area during internal rotation of the right hip, and intermittent pain in both knees when climbing stairs.

MJM can transition from a seated position to standing comfortably with the left foot forward; however, she exhibits visible difficulty when the right foot is positioned forward. Muscle strength in both the leg and hip regions appears decreasd on right side, particularly in the quadriceps, hamstrings, and gluteal muscles; the left leg appears shorter.

MJM can accurately describe her physical sensations: notices asymmetries in various postures while seated, standing and lying down, indicating good proprioceptive awareness. She is conscious of pain in terms of intensity, quality, and location, reflecting strong interoceptive awareness; she presents with flatfooted posture, loading through the knees when walking up the stairs while using a railing; climbs up fast; short gait pattern; walks with rigid trunk. MJM is comfortable moving to and from the floor.

MJB exhibits an imbalance in her energetic body. She reports feeling energized “all day long”; however, during the assessment, her energy seemed diminished, and her breathing appeared shallow with minimal movement in the abdomen, chest, and rib cage.

Throughout the seated, standing, and supine assessments, MJB instinctively placed her hands behind her head and engaged in a backbend stretch (Anuvittasana), suggesting a desire to invigorate her body. When asked about the stetch she said that "it feels good." It appeared that her breathing and movement patterns were not synchronized, with movements occurring ahead of her breath, as if in a state of alertness, and reduced body awareness.

MJB is curious about her breathing patterns. When asked to describe the sensations of her breath, she reported experiencing airflow in her throat. During the final relaxation in savasana, her breathing pattern appeared to be low and slow.

MJB exhibits an imbalance between the sympathetic (overactive) and parasympathetic (protective) nervous systems, which manifests in the physical body as an irregular heart rhythm (atrial fibrillation and premature atrial contractions).

MJB has imbalances in her emotional body which present as excessive stress and worry about caring for her spouse (reports feeling responsible for husband’s health, managing bills, helping with dressing, bathing, lifting from wheelchair), worries about meeting those demands, particularly when no support is available: “If no nurse is available, I just do it by myself,” and denying her own needs for selfcare: “I am fine.”

These imbalances further present as an underlying fear of loss, change, and death: MJB reports feeling sad that she no longer shares a life with her husband outside of his care facility; she teared up when talking about having to live without her husband: “what am I going to do without having him to lean on?”

MJB is concerned about the potential decline in her physical health, specifically the functioning of her twice-replaced hip due to “wear and tear,” and has worries about her ability to breathe, given her history of arrhythmia. MJB reports that she has a family history of Alzheimer’s disease and that she is concerned about the decline of her mental health, that she may develop the disease as well, and will have to leave her home. Expressed a history of childhood trauma, stating: “I was so severely controlled by everybody.”

Imbalances present as a strong attachments and aversions to certain beliefs (regarding new scientific perspectives on pain, formal excercise), and self-perceptions (her roles as wife and caretaker), which may limit her ability to adapt to new experiences or perspectives and result in a fear of change and/ or a reluctance to explore other aspects of her identity.

As part of her coping strategy, MJB carries an oximeter throughout the day to monitor her pulse as a source of feedback and reassurance. At night, she uses magnesium to alleviate knee pain and manage her irregular heart rhythm. Additionally, she incorporates walking and climbing stairs into her routine as a form of exercise. She has expressed a reluctance to take prescription medications, suggesting that she views this as a form of avoidance: “This would be cheating, wouldn’t it?”

MGB is oriented towards animals and nature, as well as values such as love and resilience. She emphasizes her spiritual orientation, stating that she prioritizes her spiritual needs in her daily life and feels a continuous connection to a higher power: “I am always with GOD.” She states that she experiences this connection by fostering relationships with others and by embracing their love.

Initially, MGB indicated that spiritual considerations were not necessary. However, during the practical portion of the assessment, she expressed an appreciation for chanting OM and requested that this practice, along with any relevant practices for addressing her knee pain, be incorporated into future sessions.

MJB follows a spiritual practice that involves the study and application of metaphysical concepts, which she describes as foundational to her understanding of the world. “It underpins absolutely everything.”

She has a regular, night-time, meditation (visualization) practice to manage stress. She reports that she incorporates into her daily life mindfulness and present moment awareness to enhance her connection with herself, others, and the broader universe. She has an evening ritual to replenish her energy (prana): “So every evening I stand in front of the bug windows and open my heart and drink in the fading rays of sun until they are gone.”

She reports that she has been seeking spiritual advice throughout her life: “A spiritual intuitive once told me: You are the kind of person who, if you have to go to the gym to exercise, by the time you get there, it will be too late”— meaning that I would have found another way to get the job done before I even get to the gym,” suggesting that she intuitively finds alternative ways to accomplish her goals.

MJB is intellectually curious and values the intellect. She reports that has liberated herself from the expectation of her “controlling family,” and that she was able to think for herself independently “for the first time” after their death; she says that she is “at peace” with herself now.

MJB’s sense of self is deeply intertwined with her husband and the joy they find in their shared well-being: “all life together for us is play,” and her role as a wife and caretaker.

Philosophy/ wisdom reserach reference:
Nischala Joy Devi, The Secret Power of Yoga: A Woman's Guide to the Heart and Spirit of the Yoga Sutras (New York, Three Rivers Press, 2007; Healing Relationships TT Manual, 2020.

Realization of the True Self in Yoga
1.2 Yoga is the uniting of consciousness of the heart
1.3 United in the heart, consciousness is steadied; then we abide in our true nature – joy
1.4 At other times, we identify with the rays of consciousness, which fluctuate and encourage our perceived suffering.

MJB is new to yoga philosophy. I selected sutras 1.2, 1.3,1.4. because they provide foundational insights into understanding the essence of yoga. MJB is intellectually curious and is continually seeking knowledge. Yet, I also sense a deep desire and readiness in her to speak from the heart, especially when talking about end-of-life issues, her spirituality and her own mortality. NJD writes that the heart “responds more readily to tenderness, and gentle, caring treatment of your consciousness is the best way to liberate it.” MJB’s also shared that she is worried about her heart health, and that she connects with herself, those around her and the Divine through her heart. This translation may resonate with her and nourish her heart.

I also chose a wisdom teaching from Jnana Yoga to nourish MJB's intellect (which is also a practice of Pradibakshe Bhavana)

“In the present moment, I am consciously aware of events around me, and of the sensations and emotions arising within me. From this vantage point of awareness, I can make conscious choices. I can see my existence is unchanging, while life is an ever-changing adventure.” © 2009 Swami Ramananda and Swami Vidyanananda

MJB caries a lot on her shoulders and this Jnana Yoga practice may allow her to use her intellect to alter her reaction to stress. It may also allow her to nourish her intellect, which appears to be very important to her (in addition to her heart).

1. Akella K, Kanuri SH, Murtaza G, et al. Impact of Yoga on Cardiac Autonomic Function and Arrhythmias. J Atr Fibrillation. 2020;13(1):2408. Published 2020 Jun 30. doi:10.4022/jafib.2408
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533135/
Research shows that yoga may help balance the sympathetic and the parasympathetic nervous systems (by increasing the vagal tone), decease inflammation and oxidative stress and contribute to deceasing the occurrence and duration of A-Fib.
I plan to share table 6 which depicts the potential impact of yoga on the body and arrythmia (via the HPA axis) and explain how the tools of yoga may help with stress reduction, autonomic function, pain management. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533135/figure/F6/

2. https://www.heartmath.org/resources/heartmath-tools/quick-coherence-technique-for-adults/
Research indicates that the Quick Coherence technique can support adults in attaining a state of heart coherence (alignment of heart, mind, emotions), enhance emotional regulation, and improve overall well-being. I plan to incorporate this technique into the Hatha Yoga practice as part of the centering process, and as an optional homework practice.

GUIDELINES: gentle, progressive movements, with awareness on body, breath, and mind, gentle asanas, easy pranayama exercises, build up slowly over time, no straining and/ or competition, include meditation and relaxation. Nadi Shodhana: alternate nostril breathing; Savitri: controlled, slow, deep breathing; Pranava: deep, meditative, slow breathing; Pranava: deep, meditative, slow breathing. CONTRAINDICATIONS: inversions, intense backbends, locking knees, arms overhead; coming up to standing from the floor quickly. WHY? Increases heart rate and load on the heart; rapid breathing can feed back into brain and amplify fear; breath holds can increase stress on heart (Akella K, Kanuri SH, Murtaza G, et al, 2020; McCall, 2007; Psych & Mental Health TT, 2021)

I have more general and specific research on excercise guidelines/ and contraindications but there was no space here and so I just focused on breathing, but there is more.
If I understand the guidelines correctly, the excercise guidelines etc will also be put into the plan, and with citations? Did I get this right.
Do I copy my breathing guidelines that I have in this window into the plan?
OMMMMM

• Check in, centering, balanced hatha yoga set considering contraindications, relaxation (with imagery as appropriate),
• Balanced pranayama considering contraindications, meditation/centering.
• Include at least one suggestion from Karma, Bhakti, Raja, or Jnana Yoga tailored for this client.