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

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

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"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

From Pelvic Pain to Passion for Pelvic Health

I am Lacy. I am a wife, a mother, a daughter, a sister, a physical therapist. I graduated from a great high school, 
attended college at a Top 25 university, and got my Doctorate degree from Duke. My plan was to become a Doctor, 
marry my High School sweetheart, move back to our hometown, have babies, and have a

successful career as a mom and a Physical Therapist. I had it all figured out and I had worked super hard to  

make the most of the opportunities I was blessed with. Okay, okay, I realize how this sounds, I am making you

want to smack me a little bit. Just give me a minute here, I have a point and I'm seriously not as stuck up as I 
sound. My point is that in the midst of all my plans, I ended up adding in a four year journey through pelvic pain.

Somewhere in the middle of of all of my young adult life, I had sex for the first time. From this very first time
I felt excruciating pain. Like, not discomfort or just a little pain, I am talking a knife scraping the walls of my 
vagina pain. Pain that I couldn’t just endure by taking a Tylenol or having a glass of wine. Suddenly I was 
faced with the thought that I wouldn’t ever be able to enjoy sex with the love of my life, the person who made 
me better, happy, and safe. The problem with pelvic pain is that NO ONE TALKS ABOUT IT so no one knows 
what to tell you when you mention how much sex hurts to them. You get things like “Oh, keep at it, it should 
get better” or “That stinks, I don’t know what to tell you, that never happens to me.” Even my gynecologist 
had NO idea what to say to me. She told me that everything looked fine. She referred me to a sex therapist.

Here’s the thing, I am so fortunate to have no major issues with my childhood. I was not abused, I had a 
totally normal relationship with my parents (specifically with the men in my life), so I knew that my problem 
was not predominantly psychological. I knew it was a physical problem. It took me a full year before I had 
the guts to call the number on the card and make an appointment with this therapist. When I showed up at 
her office I had no idea what to expect. Eventually during that hour session, she decided that my pain was, 
in fact, due to something physically wrong and she referred me to the UNC Pelvic Pain Clinic in Chapel Hill, NC.

At this point there were two people other than myself who knew about what I was dealing with. My fiance 
(now husband), and my BFF of forever. I carried this around with me all the time, every day. When you have 
pelvic pain you assume you are alone because again, NO ONE TALKS ABOUT IT. I was so ashamed not to 
be a normally functioning woman who couldn’t provide something so basic for the person I loved. I was terrified 
that this was going to forever be my normal. I felt like a failure as a woman.

I made an appointment at UNC and went alone the first time, I have no idea why I thought that was a good idea. 
I think I was keeping this secret so close to my heart that I didn’t even want my fiance to feel like he needed to 
help me carry this burden. I sat on the table and my doctor listened to my history quietly. The next thing I knew 
she was telling me exactly what was wrong and that she could fix it. Without even touching me, she knew exactly 
what it was that was causing my pain for the past two years. Her whole world revolved around pelvic pain and 
researching the causes and treatments. I immediately burst into tears as she showed so much empathy, as she 
talked about how emotional and devastating it is for her patients. Yep. Exactly. Clearly this was a woman who 
WAS talking about it! I left with a prescription for a medication, a cream, some instructions on exercises. 
For some reason between her office and my car my brain responded by totally shutting down. I think hearing a
diagnosis out loud just freaked me out. I did absolutely nothing she asked me to. I was the quintessential 
noncompliant patient. But, about 6 months later I had my follow up with her and this time, I was ready. I had 
processed it, I had come to terms with it, I was ready to deal with it head on. It wasn’t scary to me anymore. 
I widened my circle of trust and told three of my best friends from PT school but besides that I kept this circle 
small. That is until I scheduled my surgery. Conservative treatments didn’t work and I was ready to move on. 
I told my family, my brand new boss (I had just started working as a PT only a few months early), all my brand 
new coworkers, and my friends. I can tell you first hand that nothing freaks your new boss out quite the 
way that saying “Hey Boss, I need vagina surgery” does. When I got out of that surgery, I felt like a new person. 
I was liberated, I was free. I had no more pain with intercourse and I had no more shame over what I went through. 
It wasn’t my fault. From four years of shame and pain came a passion for using this to help other
woman (and men) in my shoes. To be a voice and advocate for those people dealing with the “unspoken”
problems that lead to isolation, dysfunction, embarrassment.

My "circle of trust" in PT school on the night before our graduation, Duke PT 2009

Today, I am married with three healthy children after conceiving them naturally thanks to UNC (another reason 
I have remained a Carolina fan even after attending Duke grad school). I have the most beautiful son and 
incredible twin daughters. I work at an amazing PT clinic (Advanced Physical Therapy Solutions) with 
exceptional therapists and an owner who lets me pursue my passion. I specialize in Pelvic Health PT and 
make it my purpose to help people with pelvic pain, sexual dysfunction, prolapse, abdominal separation, 
bowel and bladder dysfunction, constipation, incontinence, pregnancy related pain, and more. Admittedly 
it’s somewhat of a strange thing to be passionate about but I have a vested interest in getting people better. 
I hope if you recognize any of these as being something you or someone you know is dealing with you will 
seek help. For goodness sake, let’s start TALKING about pelvic health so that people don’t have to feel so 
alone. Help is out there.

Our wedding in 2006 while I was still in the middle of my quest to find answers to my pain. 

Lacy Kells PT, DPT

Fayetteville's Down Low Physio

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 aptsnc.com