Yoga and Pelvic Health - A Guest Post by Ashley Chandler PT, DPT

Today I am excited to feature a guest post by Dr. Ashley Chandler PT, DPT on Yoga and Pelvic Health PT. Ashley works at Advanced Physical Therapy Solutions with me and has begun to work in the pelvic health field more and more over the past few years. I am very thankful to have her help in writing about why yoga is an important part of pelvic health PT as well as jumping on the pelvic bandwagon with me! 

Pelvic floor dysfunction and yoga. They have such a great relationship with each other, the more I learn about both the more I think this.

Let's rewind.

I first met Lacy Kells at Duke University in 2006 when we both started our journey towards our doctorate in physical therapy. We became immediate friends and helped pull each other through the rigorous process that is PT school.

Lacy Kells, Ashley Chandler, and our dear friends from Duke
enjoying our reunion weekend in Charleston in 2017. 

  As we were winding down the academic portion of our schooling, we had to choose what elective we wanted to take. Lacy, without hesitation, knew that she would take the women's health elective. I wanted NOTHING to do with vaginas and decided to take the prosthetics and orthotics elective, about as far away from women's health as I could get. I felt no need to know what the pelvic floor was or did, thank-you-very-much.

Fast forward to 2015. Pregnant with my first baby and still mostly uninterested in working with pelvic floor patients. I gave birth in January 2016 with a lovely tear of my perineum. I had sensations of something "extra" in my vagina in the first few weeks following delivery, leading to a panicked text message in which Lacy told me to let myself heal and we'll figure it out when and if we need to. Luckily I have a pelvic health PT as my best friend, because my 6 week check with my delivering MD included a cursory look and a leading question of "everything is going well, right?" Yup, super fantastic (dripping with sarcasm). I'm still weak as can be but thank goodness the prolapse sensations had resolved for the most part.

This lit a fire under my butt to be able to offer other women better care than what I had received. It is ridiculous that my physician didn't complete a more careful examination. It wouldn't have taken long to ask me about leaking or tell me things to watch for and what to do about them (like go visit your friendly, local pelvic health PT for example). So I took matters into my own hands and decided to attend Hermann and Wallace's Level 1 course. Here we go, a weekend filled with giving and receiving internal exams. I don't think many professionals get this level of intimate encounters in their continuing education.

Around this time, Lacy came back into the clinic for more patient care and began seeing almost all pelvic health patients. I became her "assistant" or maybe apprentice is a better way to put it.

I have a background in chronic pain and happen to be a yoga instructor and had found a great relationship between the two, and I soon found that the same can be said of pelvic health and yoga.

To waaaaay oversimplify, the patients Lacy sent to me seemed to be either people who needed to relax the pelvic floor (usually those who are more pain driving and have pain with intercourse, pain with sitting, sometimes accompanied by leaking) and those who needed strengthening because of incontinence. Again, I way oversimplifying the many things that can be going on with a woman but it helped me make sense of things as I eased myself into the specialty.

I did a lot of research, began following a ton of people more experienced than me on social medial and began to find the connection between breathing and the pelvic floor. There is this beautiful dance that happens between the anterior abdominal wall, diaphragm and the pelvic floor. It happens with every breath we take and with pelvic patients I almost always found this to be altered. Luckily, I have been teaching yoga for years and yoga is very much about the breath.

Most fitness or functional cues I use have a yoga twist to them and I already started almost all my treatment sessions or plans of care by watching my patient or client breathe, so I was already very comfortable with this. Combining this with new knowledge of how the pelvic floor and the breathe work together and you get a naturally amazing relationship between pelvic floor dysfunction and yoga. Everything in yoga is tied to the breath and all movement in yoga uses your own body weight as resistance; both things we need to master for our body to work at its greatest potential. There is a component of relaxation, utilization of the parasympathetic nervous system (our relax and digest side) in every class taught which is paramount to happy pelvic floors. Yoga also builds strength, stability, and power. I have always used it in my PT practice, but now that I am becoming more and more involved in pelvic health, I am finding it even more essential. Yoga and pelvic PT definitely go hand in hand, in my totally biased opinion!

Ashley on her wedding day in 2008 in the midst of PT school with our three best friends from Duke, back
when she was totally sure she would NEVER treat vaginas.
#neversaynever 

Ashley Chandler is a certified lymphedema therapist in Fayetteville, NC who leads the oncology rehabilitation program at Advanced Physical Therapy Solutions.  She is also manual therapy certified and uses hands on care every day as she makes movement better for her patients. She has practiced yoga since 2002 and has been a yoga teacher for nearly 9 years and uses this daily in her clinical practice.  In her free time she enjoys the outdoors, traveling with her family, and baking the most delicious treats you've ever tasted. 

You can follow her on instagram @ashleychandleryoga, facebook at Ashley Chandler PT, DPT, CLT. Best of all she has a youtube channel with lots of short yoga flows that you know are safe since she's a Doctor of Physical Therapy AND a yoga instructor. 



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

Book Club, Sand Dollars, and What They Have To Do With Pelvic Pain

My book club recently read a book called Present Over Perfect. The gist of it is about allowing yourself to be present in whatever season of life you are in rather than constantly striving for perfection in all things. I have actually finished the entire book but did appreciate the overall point. It has definitely helped me pause to enjoy more moments with my kids instead of obsessing over the cleanliness of my house and overflowing laundry hampers. I definitely need those reminders on a regular basis thanks to my type A personality and my anxiety (see my blog post on what anxiety does to your body here).

Present Over Perfect 
by Shauna Niequist with a glass
of wine and some chocolate

When I treat patients with pain, be it pelvic or pain elsewhere, they often have perfection in their heads. I get it, I have been there. If you need proof that I actually do get it, check out my blogs about my own pelvic pain journey HERE and HERE. It's easy to assume that your body is supposed to be perfect to work correctly. When you experience years of painful intercourse, it often takes an eternity to get it diagnosed. Over time, you start to fear that you'll never be fixed and that your body is getting worse and worse. I mean, let's be real, oftentimes it IS getting worse. When one area hurts your entire body can start to move differently. With chronic pain you get actual changes in your brain chemistry that makes you hurt even worse. It's a pretty awful cycle. Pelvic pain gets into your head and makes you question everything from your health to your marriage to your fertility. There is a big component of shame and embarrassment to pelvic pain with a desperate need to hide it. It's a different beast than when you hurt your ankle running. Again, I know this, I run marathons and I've had pelvic pain, and trust me when I say that for most people, pelvic pain is something entirely worse.

My husband and my imperfect self
 on a family road trip, almost
9 years since my pelvic pain
was healed! 

But here is what I tell people: Your body does not have to be perfect to work well. Let's repeat that one more time. You don't have to be perfect to work well, to be whole. In fact, our bodies were not meant to be perfect. If you look closely at your face in the mirror you'll notice asymmetries, little things that aren't quite perfect from one side of your face to the other. Guess what, that is NORMAL. It's what makes us beautiful and unique. Your body isn't made to be perfect symmetrical. Still, we get people in the clinic all the time who have been told that their "hips are off" or that "one shoulder is lower" and that that is what is causing their problems. Here's the thing though - that's how your body was made. It's meant to be a bit like that in most cases. Look at any elite athlete and watch them move. They are always going to have a side with more arm swing when they run, a dominant arm for shooting free throws, a leg that lets them do a few more pirouettes because they can balance better on it. It's normal. The problem is that in their heads "being off" means that they aren't working correctly. Look, sometimes that may be true. Sometimes the little things that are "off" are causing some problems, but most of us that's just how the body is made. You are not meant to be perfect.

Even so, when people come in to see me, they are terrified of their own bodies because they think their body has failed them in some way. They feel broken. I have felt that, it's so true. You end up feeling like even if the pain gets better your body still won't do what it is supposed to do and that you're doomed to a sexless marriage. Or if you think that maybe one day you'll get to have sex you but won't be able to run or exercise because your body is a failure. Or maybe you'll be able to exercise but definitely never ride a bike or sit through your kids' ballgame on the hard bleachers. There are lots of "buts" involved. (No pun intended there.) These thoughts and feelings are completely legitimate, pelvic pain is so scary because no one talks about it. However, there is so much hope.  Before you had pain your body functioned just fine. What needs to happen is not getting everything magically perfect, but instead re-teaching your body how it worked before. How to function well in all its imperfection. And you WILL function well again. It takes a lot of attention, specific training, tweaking of how you move, but it'll get better. It also helps once the ideal of perfection is officially out of your head. Because guess what, your body is going to work well without perfection.

With my friend Tracey after finishing my third marathon with
a ton of imperfections, my weak abs for one because of my
pregnancies.

Imperfect but whole and beautiful. 

On the beach this weekend I found some sand dollars. For me, sand dollars have a special meaning. Last summer I was in a very dark place and I was desperate for a sign of comfort. I had lost someone beloved to me and I was devastated. My blog isn't about religion, but I'll share that I believe in God and while running down the beach alone I started praying for a sign. I asked specifically a sand dollar because I had never in 35 years found one on the beach, ever. I knew it was wrong to pray for that but I did, like I said I was desperate. As I reached the end of the beach a perfectly formed sand dollar was lying in my direct path. For me, I knew it was my reminder that my loved one was okay. I know some people wouldn't agree, but it's my blog so I get the last word. Kidding. But technically I do. Anyway, this past weekend, 7 months after I found that first ever sand dollar I was running again on the same beach and found five sand dollars. It's that time of year for them to wash up I guess. But I chose to think of it as a sign of peace. However, this time, they weren't perfect. Not one of them was. But they were all whole. Let's read this once more - they were imperfect but whole. (Another but y'all.) Like me, like you. Like those of us suffering from pain. We will never be perfect, but our bodies are whole and our bodies will work well. Perfection is not attainable. Our hips aren't going to be perfectly symmetrical, our pelvic floor muscles aren't going to work the exact same on both sides. There may always be certain positions during intercourse that aren't the best for our bodies. But there will be others that are. There are ways to use our bodies that allow them to work well. Without being perfect.


My job is so amazing. I get to teach people how to be present in their imperfect bodies and accomplish the goals that are important to them. I get to take life lessons that I have learned from books, pain, and loss and use them for good. My past has had times of difficult, but those times get to be beautiful now because I have learned from them. All of these lessons translate into healing pelvic pain. Healing pelvic pain is complicated, it's challenging, it's lots of imperfection. BUT, it's not impossible. Every person deserves to learn how amazing their body is and learn to use it without pain. To see how beautiful it is in all its imperfection. To learn to be present over perfect.

Dr. Lacy Kells PT, DPT

The Physio Down Low

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

Kegel Confusion: Reasons to Kegel and when it's not right for you

One month ago I ran my third marathon. It was my first one completed without leaking urine during the race. Woohoo!! That was no small feat considering how my first two marathons went. I will be honest and say that I am a terrible patient when it comes to fixing my own incontinence because I am so good at coming up with excuses not to do my homework. However, with the strength training I did this time around (core strengthening with some Kegels thrown in there when I wasn't lazy) I had enough endurance built up down there to hold things in. Thanks levator ani muscles! I'm so proud. Here's the thing though - Kegels aren't for everyone. There's a right time to do them and there are many times that you should not be "Kegeling."

Kegel exercises are named for Dr. Arnold Kegel, a gynecologist who had his patients doing pelvic floor contractions after childbirth to try and decrease incontinence. He did not "invent" the pelvic floor contraction, but in the US his name is the one we refer back to when we talk about strengthening the pelvic floor since we have named this exercise after him. I have found that there are many people who are well aware of these Kegel exercises (either from their physicians, friends, or just their own online research) and there are just as many who are not. Often I hear the whole "I've heard of that but have no idea what it is" response. Just as often I hear the "Yeah, I know I'm supposed to be doing those but have no idea how." I always reassure my patients that all of these answers are okay because honestly, we don't know yet if you need to be Kegeling until we sit and chat and go through an examination. So stop beating yourself up over not doing your Kegels. You may not even be ready for them and if you are, chances are you aren't doing them in the best way anyway.

Here's how your it works: If you come in to see me for urine leaking, there are generally (by generally I mean no one fits into a perfect mold) two overall reasons. Either your pelvic floor is (1) weak because it's just weak or your pelvic floor is (2) weak because it's actually tight. Now, admittedly these aren't super scientific explanations, but that's the gist of it. You can have that typical weakness that sometimes comes with pregnancy, childbirth, aging, high impact activities, lack of physical activity, etc. but you can also have weakness that is actually a result of a tight pelvic floor. See, your muscles have a "happy place." The little fibers that make up a muscle like to rest at just the right spot. They overlap each other in a way that lets them contract with strength but also stretch a bit when they need to. If the muscle fibers are resting in such a way that they overlap too much, then the entire muscle won't work well. So when you go to use the muscle, it won't have nearly as much strength as it needs to work right. Weak muscles can't compress the urethra (where your urine comes out) so when you go do sneeze, stand, cough, laugh, jump, shop, try and hold your pee as your key turns the lock, they can't work enough to keep you from leaking.

If your muscles are "just" weak, meaning they aren't tight but are just lacking enough strength to keep you from leaking, then you could definitely benefit from Kegel exercises. As Pelvic PT's we are trained to develop a personalized program just for you to get your pelvic muscles working well again. We are, after all, experts in exercise and movement science. Your home program is tailored to where you are starting now, so we work on exactly what you need. The best way to work on the pelvic floor is through long holds (which strengthen what I call the marathon muscle fibers) and also on the quick flicks (which work on the sprinter muscle fibers). For my marathon, I needed both. I needed the endurance fibers to be able to stay turned on for 5.5 hours but I also needed my sprinter fibers to turn on when I sneezed (#allergies) or "jumped down from a curb while crossing a street" (#gracefullystumble). We need both to get the most benefit. These are things I go over in a session and always write down on a sheet for homework. We then progress things as your body gets stronger over time and move from lying down to sitting to standing to even jumping or running depending on your desires.

The other side of the story are the patients who come in with leaking but also seem to have other problems as well. These often include constipation, pain with intercourse, trouble or pain with tampon use, history of trauma, history of abuse, or general pain in the pelvic region. These are usually signs that Kegels are going to take a backseat to pelvic relaxation. If you have tightened muscles in the pelvis, strengthening them won't be effective until we get the muscle fibers to their "happy place." You could Kegel all day long everyday and not see improvement. In fact, you could make things worse. So, we have to teach the muscles to relax, get them to their neutral starting point where they prefer to be before we can build up their strength. Sometimes, once the pelvic floor learns to relax again patients will notice less urgency to pee through the day or that they are better able to keep themselves from leaking when they sneeze. That's because the muscles are finally happier and can automatically work better even without training them to be stronger. Over time, once the muscles have found their happy spot, we begin the Kegels and can take care of the leaking. This tends to be a longer process than "just plain weakness" but more often than not, while fixing your incontinence you'll also fix some of the other issues like pain with sex or excessive straining to poop. So you are almost getting more bang for your buck! You can tell your levator ani muscles thank you for that little bonus.

Don't forget that peeing on yourself is NEVER NORMAL. It's not. It's not something that happens "because you are pregnant" or "because you've had babies" or "because you are getting older." Nope. Don't let anyone tell you that. It's not true. We don't have to live this way. We can go without Depends or extra large pads just so you can do your Christmas shopping. There's a better way, and that is retraining your pelvic floor muscles. Retraining can be a few sessions where you learn how to activate your pelvic floor and learn how to progress yourself through a home program or it can be weeks of pelvic relaxation and learning to get to the bottom of your tightness so you can start strengthening, but either way there is help and hope. You too can be like me, a three time marathoner with a goal of not peeing on yourself! Yippee!! Doesn't that sound awesome?? No? You're probably right. I should find a better hobby. But this last time I got pajama pants just for running 26.2 miles and it seemed like a great deal.

Anyway, back to the point here. It's time for us to DEMAND BETTER. Let's demand better from our physicians or healthcare providers. Tell them you will not accept leaking as part of your life and insist a referral to a Pelvic PT. PT's are experts in exercise prescription. Pelvic PT's get to take it to another level and teach you how to be an expert in your own pelvic floor so you can put the pads behind you. We can do better y'all. Spread the word and get the help you deserve. Your body is amazing and with some education and special attention it can work beautifully - even when you are pregnant, postpartum, a high intensity athlete, struggling to get back into exercise, or aging. (And for the men out there the same goes for you - even post prostatectomy). With all the money you'll save on pads or laundry detergent you could register for your first marathon... Or at least buy yourself a cute pair of "running shoes." You know, just in case. It won't hurt if they look cute with your yoga pants.

Dr Lacy Kells PT, DPT

The Physio Down Low

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