Year 4 of Diastasis Rectus Abdominis

When I started practicing pelvic health, I didn't realize how terrified women were of the dreaded "diastasis." Diastasis rectus abdominis is something that is most commonly seen after pregnancy and is the separation of the abdominal muscles in the middle of the belly, along that line that sometimes turns dark during pregnancy. After a few women came in to the clinic to be evaluated "just in case" with looks of terror in their eyes I realized that this was a big deal to new moms (and some not-so-new moms as well). Much of the time these women didn't even have a separation, but the horror stories on the internet freaked them out enough to want confirmation from an actual human rather than WebMD. They were scared of the idea of a hernia, a surgery, or "making it worse" while they exercised. Seems like a legitimate worry of course. After all it can be scary to feel your belly and feel like there's a big hole.

My non-pregnant belly four years after my last pregnancy. 

For me, it was something that hadn't ever really crossed my mind. I was a healthy person when I got pregnant with my son and while I carried him full term I didn't stop to think about my core for a while. The postpartum depression, nursing, and sleeplessness took precedence over my abs at that time. When I got pregnant with my twins I was too overwhelmed about, well, twins, that again I wasn't worried about it. They were born via Cesarean birth at 38 weeks and I didn't have two seconds to even think about my body. I nursed and pumped for a full year with them, so it wasn't until about 3 years ago when my body became my own again. I have my own body image issues like most women out there, but because I didn't have any pain or problems I just sort of moved past my post-baby belly. I tried to just be grateful for what my body had done for me and stop focusing on how different I looked. 

Mile 7ish of my last marathon -
March 2018

It's only been the past few months that I am experiencing the issues that an abdominal separation can create in the body. The thing is, when I check my separation, it's only 1 fingertip that can fit down in there. (There are about a million videos that "teach" you how to check for it, some are right, some are "eh").  In the world of PT, 1-2 centimeters (about 1-2 finger widths) is considered normal. It's the 3-4 finger separations that are typically more concerning. My problem is actually not the width of the separation, but the depth. It's deep y'all. And the longer I practice Pelvic Health, the more classes I take and books I read the more I realize that it's so complicated. I don't look that bad from the outside but my body is screaming otherwise. The tissues that hold muscles together, that run between muscles and connect things, my fascia, is stretched. And it's not going to just tighten back up. Over the past three years, my body has slowly started to suffer from the fact that my abdominal muscles can't work effectively and my poor pelvis isn't very stable. Up until this year it's done pretty well trying to fake it. Your body does NOT have to be perfect to work well, and up until this year my body was working just fine for the most part. I trained for two marathons (both of them after my babies were born) without any problems. But this time it was different. My body couldn't work overtime just to keep me stable anymore and I had pain every time I ran for months while training for this most recent race, my third marathon. It was a beast. I had pelvic pain and butt pain and back pain and then hamstring pain by the end. Rough. It took me three days to recover. 

Retired marathon shoes

My point here is that now I sort of understand the fear. I didn't before, partly because I felt like "but I'm a pelvic health PT, I will never have that!" I had read articles about it and books about it and learned in classes about it. I figured that since research can't find a big connection between separation and major dysfunction and since I only had about a finger width between the muscles that I was good. However, for me, I am beginning to feel the effects of my abdominal weakness. My body is done trying to compensate for it. I couldn't run another marathon like this. Marathons aren't necessarily my main fitness goal, but I know I'll want do do another one in the future and currently my body isn't going to let me. I am taking things back to basics, trying to teach my body to be strong despite the weakened fascia so that I can safely do things like run. I'll get there, and if I don't I'll look to the next step. I am lucky that I know enough to retrain myself, but probably dumb for not paying more attention to things a couple of years ago. 

Belly taped up to bring the fascia closer to the middle so my abdominals can work better. Sadly this tape doesn't stay on for 26.2 miles. 

Regardless of whether you have a really large separation or just a small little valley, if you are having pain, trouble lifting, urine leaking (no, even when you exercise it's not normal), find a PT to check you out and get you back to functioning correctly. Don't be like me and ignore it and hope for the best, at least not if you have high hopes for staying active in the years to come.  I'm starting over and showing my body the love it deserves after growing three amazing people inside of it. It's frustrating to me that I wasn't more careful and respectful with my body after my babies, but I am fortunate to be an exercise specialist, it's what we PT's do, we make movement better. So I will work on my back, my buttocks, my core, and my pelvic floor carefully, thoughtfully, and with love. If you need help with this, find a PT to help you. You owe it to your amazing body! 

Dr Lacy Kells PT, DPT

Fayetteville's "Physio Down Low"

lacykells@gmail.com
Find me on Facebook at Lacy Kells PT, DPT or on instagram at lacykellspt

For more info about our clinic please visit Advanced Physical Therapy Solutions at aptsnc.com 

Anxiety, pain, and that time I drove around with only one lens in my sunglasses

The past few weeks have been exceptionally stressful around our house. My husband has had work deadlines, I have been busy with work both in the clinic and at home, I was gone for four days to Boston for a continuing education class last weekend, the kids have had a cold, we had a random showing for our house pop up, and I have a marathon coming up this weekend. We thankfully have a lot of help from our parents and a great friend group for support, but still, it's felt like a lot this month. Anxiety is NOT new to me by any means, just check out my other blogs for a little insight here and here, but even so, it continues to be something that I struggle with during particularly stressful times. I have come a long way over the years and now I am rarely disabled from it, but it is something that I have learned can be a big contributor to physical pain.

This is anxiety y'all- being so worked up in your own brain that you DO NOT NOTICE that you are wearing sunglasses with ONLY ONE LENS. This was after twins but before I went back on my anxiety meds, and clearly I need them. Because I definitely walked through the grocery store parking lot wearing these, and back to my car.

Mental health, like pelvic health, is not discussed a whole lot. Like pelvic health, there is a shame that goes along with things like depression, addiction, anxiety. It's not talked about and when it is, there's a heaviness and an embarrassment that goes with it. It's the opposite of what you need when struggling with a mental health issue. Part of the reason I started a blog was to start normalizing pelvic pain, incontinence, prolapse, sexual dysfunction. All the things that make you uncomfortable to hear me talk about. Those are the things I want to throw out and rub in everyone's face until it becomes as normal as low back pain. Because seriously, who does not know someone with back pain? I'm willing to bet there is no one out there who doesn't. Well guess what, that means you most likely know someone with pelvic floor dysfunction or a mental health disorder like depression or anxiety. In fact, pelvic pain usually comes along with stress, anxiety, depression, so you may know someone with both.

Here's how it works: Pain is meant to be a built-in alarm system for our bodies to keep us safe. So, if you touch a hot stove or cut yourself cooking dinner, you want to feel pain to tell your hand to move away. It's an awesome evolutionary tool that has allowed us humans to survive all these years. Once you have this initial injury, you'll often feel the acute pain as the tissues heal over the next few days or weeks. The nerves at the site of the injury are stimulated which remind the brain that it hurts, and your brain sends chemicals and cells to the area to help things heal. This is all normal and good. 

The problem is that many of us end up with chronic and often seemingly unexplainable pain and often, there's a link with our mental state. For now let's talk about pelvic pain because that's my jam. Chronic, unexplained pain is usually happening even after the tissues have healed, so pain without any damage. It feels like something is damaged, but with chronic pain (3 months or more of pain) the tissues are usually no longer damaged. This kind of pain occurs because your nervous system is a little too excited. It wants to warn us of threats and dangers, but at this point those are gone. With chronic pain, our nervous system becomes overly sensitive, so the nerves in the body may turn on faster or stay on longer which tells the brain that your body is in danger. 

When you have anxiety, your brain can assume that your body is in danger, so it naturally sends chemicals throughout your body that tend to make things more sensitive. You become even more stressed from the pain and this makes your brain even more paranoid about everything that moves or gets touched. The mental stress over the pain you feel causes your brain to release even more stress chemicals that can cause inflammation, sensitivity and pain. It's a vicious cycle. It can be extremely debilitating. It is rough. It's hard on the person who hurts and it's hard on their caregivers and loved ones. It's kind of a nightmare. Many of the patients who walk through my door are at their wits end, they are depressed and they have lost hope. It's easy to see how you could get that way after not knowing how to break the cycle. Pain makes you exhausted, sad, sometimes angry. It takes over everything. 

But, the wonderful thing is that there is definitely hope and help. The first thing that PTs often do is some pain education. Sometimes I have patients watch this video and we talk about the brain, the nerves and the nervous system. I tell them that their anxiety and tension is causing part of their nervous system to be turned on practically all the time (the sympathetic nervous system). The thing is, unless a bear is chasing you down the street, you don't need your sympathetic nervous system quite so excited all day long. Back in the day if, I don't know, a wooly mammoth or something was chasing you down, you'd want that sympathetic nervous system to kick in so you can run like for your life, literally. However, sitting in your office on a normal ho-hum workday is not the time for it to be needed. In my case, the sympathetic nervous system was turned on practically all the time. My husband could tell me that we were out of milk and it would literally send me into a tailspin of anxiety and panic which would then make my neck hurt and of course my pelvic floor as well. It's not a fun way to live. 

The way to make it better is to use our "rest and digest" nervous system, the parasympathetic branch. It keeps us calm, it tells the brain not to be so sensitive, to stop letting out all of these crazy chemicals that circulate through our bodies and make us hurt. Learning how pain works, how to turn on the parasympathetic nervous system is often the beginning of the end of chronic pain. 

For me, I got into yoga, I started running, I learned to breath correctly (that's for another blog but you can check out this quick video for an intro), and I ended up going on an oral medication that helps keep my brain chemistry more regulated. Now, I don't have pain in my neck or my vagina. (I have pain everywhere else at the moment but that's thanks to my upcoming marathon and all the running. So. Much. Running.) I have seen first hand how my patients' stress increases their pain, which usually makes them anxious and perpetuates that pain cycle. When we work on breathing, calming down the brain and the nervous system, talking about things that make them laugh, their pain is often immediately reduced. It's awesome. Yes, there's a lot more that goes into the full healing process, but the brain is a huge part of it. Your body is NOT BROKEN. You are not broken. Your body does not have to be perfect to work well. Sometimes you just need to break the cycle. 

When your best friend is a yoga teacher you learn to be really good at using your breath to calm down. Also you have access to a free yoga teacher who is also an awesome physical therapist and just happens to be the BEST baker I know. Not a bad deal I've got going on here. This is her teaching a workshop, helping so many people to learn to manage their own anxiety through activating their parasympathetic nervous systems. 

Living with anxiety is hard and it can wreak havoc on your body, but it's not forever. We got through the crazy week. The house is super clean thanks to the house showing, my marathon is only a couple of days away and I get to celebrate with my family and one of my best friends from college, my husband's deadlines have been met and/or pushed back, and my kids aren't sick anymore. My pelvic pain is under control and I get to have amazing conversations with incredible men and women at work while getting to share my passion. Don't let your pain get the better of you. There's a PT who can help, and you don't even necessarily have to show them your vagina y'all. Let us help you heal. 

My de-stressors: peace and quiet, chocolate, a book (this one I am reading for book club just happens to be about being Present, not Perfect which was needed after this week), and a little red wine, you know, for my heart obviously. 

Dr. Lacy Kells PT, DPT
The Physio Down Low
Advanced Physical Therapy Solutions

Follow me on Facebook at Lacy Kells PT, DPT
and Instagram @lacykellspt

"Look! She bleeds from her vestibule!"

If you have read my first blog post (if not you can find it here), you know that I have a history of pelvic pain that inspired me to first dabble in Pelvic Health Physical Therapy and then dive in head first. I didn't go into detail about my condition because I didn't initially think hearing about the details was that important to my story. I realize, however, that it actually seems more scary with me glossing over those details in a way and I want to break through the wall of fear and shame and let people instead feel hopeful and informed. So here we go.

I told you that the first time I had sex, it was excruciating. Here's what it felt like to me - from the instant that there was any penetration, it felt like I was being stabbed with a knife in my vagina. It was a very specific, localized, sharp pain. It burned like someone was holding a match to me. It did not get better as sex went on, instead it got worse and more times than not I was not able to tolerate it. If we tried two nights in a row, it was always worse the next night. It never changed for the better, no matter how long we waited in between bouts of intimacy, no matter how much foreplay there was, no matter what lube we tried, no matter how much wine I drank, no matter what. It was an obvious physical problem.

My husband and me in front of our first house in Fayetteville in 2009, shortly before my surgery. #itwasnotactuallyacrimescene #myhusbandisanengineer

My MD at student health had absolutely no idea what to look for when I told her sex hurt. She didn't even look at the area of my pain. She brushed it off as a likely psychological issue and probably assumed that my husband abused me and that was why sex was painful. That is a legitimate concern and I don't ever want to minimize the impact abuse can have on a person's sexual health. However, for me, that was not the case. She gave me no hope, she made me even more confused and scared and ashamed. My poor best friend had no idea what to tell me. She told me that maybe I should keep practicing and it would get better. I did, and it didn't. It's not her fault, because no one talks about pelvic pain, so no one knew what to say to me.

Anyway I digress. My doctor at UNC, Dr. Denniz Zolnoun was my angel. I described my pain and she told me I had vestibulitis without even touching me. She told me that I was most likely a type A personality with lots of anxiety who never stopped worrying and that for that reason I had inflammation that just happened to manifest in my pelvic floor. (Yep, nailed it.) She told me that some people got migraines, others fibromyalgia, but for me, for some reason, I was lucky enough to have pelvic pain. Hurray. Unlike my doctor at student health, however, her first comment after diagnosing me was "We will fix it, don't worry." Umm, wait what? That's amazing, because up until now I feel like all of this was just me being crazy. Which, in a way it sort of was, after all my brain chemistry was out of whack and did make me a little crazy at times. But the thing was, it wasn't my fault!! I knew it!!

She examined me and for the first time ever, actually looked at my pelvic floor. Don't get me wrong, gynecologists and obstetricians are great at their job, but I do think there is sometimes a bit of a gap when someone comes in complaining of pain. Their job is to look at the organs, to rule out all kinds of medical issues like cancer, endometriosis, pregnancy, etc. Obviously that is number one and absolutely has to be done, I can't do that as a PT and I'm so grateful for what they do. To do that, though, often they don't get a chance to look at the tissues, the muscles, the quality of the skin. Dr. Zolnoun did a very thorough and very different exam than I'd ever had. To be honest, I wish I had been practicing pelvic health PT at the time because I feel like it is very similar to what we do with our patients. She looked at the muscles, the sensation, the skin of the vagina. Then she pulled out her Q-tip and touched my vestibule.

To clarify, the vestibule is basically the opening of the vagina. It's sort of where the outside skin transitions to the inside skin, to over simplify it. When she touched this skin with a Q-tip, it was so raw that it bled. The woman was so shocked that she actually acted slightly excited (I mean, she's a researcher so I totally didn't judge her because I'd have been excited too). She began exclaiming "You bleed from your vestibule! You bleed from your vestibule!" Here I am laying there on my back half naked just looking at her like she's crazy now yet also completely digging her enthusiasm for my delicate vagina. She then told me to wait there (sure, no problem, not going anywhere with this paper drape, no worries lady) and went to get a colleague to come in and have a look. "Look, she bleeds from her vestibule!" Good times.

The normal treatment plan was using estrogen cream to try and change the skin integrity a bit, use a vibrator to stretch and desensitize the tissue, and to go on oral medication to try and calm down my hyperactive central nervous system (aka my brain that likes to release way too many bad chemicals all over my body). Well, as I said in my initial blog post, none of it worked. The cream was annoying and not effective despite me being compliant with using it, the vibrator did nothing other than to make me feel even more ashamed (shout out to my AMAZING hubby who went to the sex store to buy it for me because I couldn't handle doing it myself, it was way too emotionally charged). The meds didn't help either and I still felt as anxious as ever. The best thing to come out of my time attempting to treat this conservatively was me being brave enough to ask for a different medication for my anxiety. She put me on a second medication and after two weeks I felt like a new (and better) person. I still take it, though I went off of it for years during my pregnancies, and it still works for my anxiety. I love it. It was the best thing I ever did. For my brain, not my vagina.

Anyway, eventually, two years later, I was done with all of it. I needed to be done. I wanted a family, I wanted to have sex with my husband, I wanted to be able to forget this had ever happened. Clearly that won't be happening after this blog, but that's okay. I told them to cut the skin off. It was our last resort. Somehow I ended up seeing a different physician along the way, I think Dr. Zolnoun was out or something so Dr. Steege, who was basically in charge of the program at that time, ended up finishing my care. He had a fellow working with him (I feel terrible that I can't remember his name, Matthew something??) and together they agreed to perform a vestibulectomy. They would go in, cut off the inflamed tissue, and pull healthy vaginal tissue down in it's place. My mom, mother in law, and husband drove me up there, my husband almost passed out watching me get my IV (not the best foreshadowing for my future C-section with twins but that's another story), and I went on back to the OR. I woke up with my cousin's face in my face being saying hello as I was wheeled to my room. My husband slept in the hospital with me and held my hand the entire night. Like literally, he slept on some little cot next to my bed and held his arm up in the arm so I could hold his hand. Those nurses probably though we were super annoying. After three weeks of recovery, I was cured. I don't remember when we had sex for the first time after it but it did not hurt. For the first time ever, I had pain free sex.

I got pregnant some time later, carried my son to full term and had a vaginal delivery with a pretty gnarly tear, but even so I have not had pain with sex since my surgery. The whole healing from a ripped vagina after childbirth is another story, but again, for another time.

I was lucky. Honestly, most women with pelvic pain have it worse. They hurt all the time, they hurt when sitting, when standing, they have to quit their jobs. If they have vestibulitis like I had they also have horrible muscle spasms in their pelvic floor. They are bounced from one physician to another, they have multiple surgeries that don't change their pain, they are so much more debilitated than I ever was. I was actually emailing a friend about this and I told her that part of me feels guilty for sharing my story because it's nothing compared to some I hear in the clinic. However, I also know that if mine were more challenging, I may not be here today writing a pelvic health blog. I'd be in a very different place. I may not have my babies, I may not be working as a PT, it's a very physical job after all. I certainly wouldn't be here sharing this with the internet.

My reasons for sharing these intimate details of my past are so that the next time your best friend, your spouse, your child, your coworker says to you "Something doesn't seem right with me, it hurts when I have sex," you'll tell them there's hope. You'll tell them they aren't crazy and that there are people who specialize in making this better. There are physical therapists just for this, there are physicians who do this every day. There's help and there is hope. Painful intercourse is not ever normal. It's not. Don't let anyone tell you it is. Get help. The right kind. The kind that makes you feel like you're going to be okay, not the kind that makes you feel ashamed. There's nothing to be ashamed about. Trust me, I know.

Here we are in 2016 in Plymouth, MA on an epic 10 day road trip with our three children. We all shared a hotel room so no sex but still, we could have if we had wanted to, which for me is pretty darn exciting even now. 

Dr. Lacy Kells PT, DPT
The Physio Down Low

Advanced Physical Therapy Solutions

Follow me on Facebook at Lacy Kells PT, DPT
and Instagram @lacykellspt