Unconstipating Kids: A Whole-Body Approach to Pediatric Pelvic Health with Dr. Caitlin Keller

• Learn more about Level 1 Functional Pelvic Health Practitioner program
• Get certified in pelvic health from the OT lens here
• Grab your free AOTA approved Pelvic Health CEU course here.

More about my guest:

Dr. Caitlin Keller is a pediatric physical therapist with a deep passion for helping children overcome bowel and bladder challenges. After earning her Doctorate in Physical Therapy from Springfield College, she specialized in pediatrics and, in 2015, began focusing on pediatric pelvic health. In 2020, she founded Unconstipated Kids—a practice dedicated to compassionate, whole-body care for children with toileting difficulties.

At Unconstipated Kids, we take a holistic, collaborative approach, recognizing that toileting success isn’t just about the pelvic floor—it’s about the whole child. Our team of occupational and physical therapists works together to address muscle coordination, sensory processing, posture, reflexes, and emotional well-being. By tailoring treatment to each child's unique needs, we empower families with practical strategies for lasting success.

Beyond her work, Dr. Caitlin finds joy in family life with her husband and children, along with a wide array of hobbies—from dancing and hiking to baking and crocheting. She is endlessly grateful for the opportunity to serve families, guided by faith, love, and a deep appreciation for the work she feels called to do.

She also offers a provider mentorship group with her business partner through LittleLearning Lav. It’s perfect for anyone looking to start or continue their pediatric pelvic health approach. Find it here.

____________________________________________________________________________________________
Pelvic OTPs United - Lindsey's off-line interactive community for $39 a month!
Inside Pelvic OTPs United you'll find:​

• Weekly group mentoring calls with Lindsey. She's doing this exclusively inside this community. These aren't your boring old Zoom calls where she is a talking head. We interact, we coach, we learn from each other.
  ​
• Highly curated forums. The worst is when you post a question on FB just to have it drowned out with 10 other questions that follow it. So, she's got dedicated forums on different populations, different diagnosis, different topics (including business). Hop it, post your specific question, and get the expert advice you need.

More info here. Lindsey would love support you in this quiet corner off social media!

Transcript

Lindsey Vestal (00:00):

My guest today is Dr. Caitlin Keller, who's a pediatric physical therapist with a deep passion for helping children overcome bowel and bladder changes. After earning her doctorate in physical therapy from Springfield College, she specialized in pediatrics, and then in 2015 began focusing on pediatric pelvic health. In 2020, she founded Unconstipated Kids, a private practice dedicated to compassionate whole body care for children with toileting difficulties. Her team of occupational and physical therapists work together to address muscle coordination, sensory processing, posture, reflexes, and emotional wellbeing. Beyond her work, Dr. Caitlin finds joy in family life with her husband and children, along with a wide array of hobbies from dancing and hiking to baking and crocheting. She's endlessly grateful for the opportunity to serve families, guided by faith, love, and a deep appreciation for the work she feels called to do. New and seasoned OTs are finding their calling in pelvic health. After all, what's more a DL than sex peeing and poop? But here's the question. What does it take to become a successful, fulfilled, and thriving OT in pelvic health? How do you go from beginner to seasons and everything in between? Those are the questions, and this podcast will give you the answers. We are inspired OTs. We are out of the box OTs. We are pelvic Health OTs. I'm your host, Lindsay Vestal, and welcome to the OTs and Pelvic Health Podcast.

(01:43):

Caitlin, I am so excited about our conversation today. Thanks for making the time to be on the podcast with me.

Dr. Caitlin Keller (01:49):

Thanks for making this a possibility and having conversations with lots of different people and providers.

Lindsey Vestal (01:55):

Yeah. Oh, it's the best part of my job. Well, let's kick it off with, I was so inspired by your journey and your holistic approach to the care that you provide, and so what really inspired you to pursue the career that you have and how did you develop your holistic approach to client care?

Dr. Caitlin Keller (02:17):

Ooh, we're just getting right into it. So I kind of envisioned where I was going to be and what I was going to do in a different way, and then just was thrust into what I'm doing now. So I started out in outpatient pediatrics, meandered my way over to inpatient pediatrics. They had a women's pavilion, and so I really had an interest in graduate school of pelvic health. And so I thought, okay, let me kind of see if I can get into that part of the therapy world in that hospital-based setting, working with peds, but also the mamas who have the babies. And I didn't realize how saturated pelvic health can be. And so our managers offered this opportunity to start a pediatric pelvic health program where I was at. And so me and another therapist grew this program from the ground up and it wasn't what I thought I wanted to do, but it was this perfect mesh of pelvic health and pediatrics.

(03:27):

And so I had already had that developmental background, like the whole body approach with kids, and I truly think that that's what brought me into the holistic whole body approach from in the pelvic health world because pediatric pelvic health right now is very zoomed in on the pelvis. There's a lot of biofeedback being used, and I think that there's this approach that's kind of being missed. There's this approach that people are taking the adult literature that we have and the evidence that we have and applying it to kids and that doesn't work. And so I think having that background really led me to see, oh, we have this biofeedback machine. It's cumbersome. It takes a lot of time. It can make kids feel very vulnerable. And so I found that through just a developmental approach, whole body approach, really zooming out of the pelvis that we saw great if not better success outside of using a biofeedback machine. And that kind of thrusts me into this, well wait a minute, this is kind of what I was told from these foundational pediatric pelvic health courses. What else can I maybe challenge in terms of the thinking and the approach and the methodology? And so that's kind of how I got to where I am today, which is a very different place than in 2013. I have my own practice and have never purchased a biofeedback machine, which I think is a little bit telling of where I started and where I'm at now.

Lindsey Vestal (05:05):

Wow. So much of what you said really resonates with me not to throw shade at all to biofeedback. I really do think it has a time and a place, and I have so much respect for people that use it and for my mentors that really introduced it to me. But I have to admit that while I don't work with kids, I also have found a lot of reasons very similar to yours as to why biofeedback hasn't been a great tool for a lot of my clients. And again, that's very much my individual practice and my approach. And I have to say that a couple things that you said really resonate with me. Number one, this idea of adult literature being applied to kids, it just doesn't make sense. And I understand there's limitations to studying kids directly, but that doesn't necessarily mean that that's the route we should go.

(05:58):

And so I haven't heard anyone say it quite that clearly. And so I really want to point that out. The second thing that I really love Caitlin, is this idea of zooming out of the pelvis. That very much is akin to my belief system working with adults as well. I also really love this idea that you said, what else can I challenge? That is definitely so authentic with me. My course is called UTI Pioneers for a reason. I'm a little bit of a rebel, and I think that this idea, that is where I was when I first learned internal exams, I was kind of like, why is this the gold standard and why do we start there? And so fast forward also, just thinking about my own journey as you're reflecting on yours is now I've come up with, and what I teach in my level one programs and in my certification programs is like this menu of options that starts with the client completely dressed to them choosing option four, which would be that gold, not that gold, which would be that internal exam. And there's so much we can play with between option one and option four. And so I definitely sat through those initial courses thinking, what can I challenge here? This isn't feeling quite right. So already we're hitting the ground running and I feel like such a kinship to you. So I'm really excited about this conversation. Yeah. So my next question for you is can you share a little bit about your personal journey and how it shaped your passion for advocating for OTs within our profession?

Dr. Caitlin Keller (07:35):

So when I was at the pediatric hospital, hospital-based therapy, there is this built in collaboration between speech, OT and pt. That's a very strong relationship that we had. We were all physically in the same office. We could communicate very easily. There was a lot of collaboration, and that's where I started. And so when I ventured out into the private practice world, it can feel very, or it's easy to isolate yourself, it's easy to just dive into, okay, I'm in pt, I'm in my private practice. I'm going to market myself as a pt. And this whole area that a child, in our case in the Pete's world needs, they need the sensory regulation, they need the primitive reflex integration. And if we don't acknowledge those things, then our treatment will likely fail for many patients because every child is individual. So the, I'm going to say the maybe ratio that a child needs help with in the sensory perspective, from the primitive reflex integration perspective, that might be a larger ratio for one child, but a smaller ratio for another.

(08:53):

And so if I isolate myself in the PT world and only take my approach, then I'm going to set myself up for failure because many kids have a larger ratio, all kids have some, right? We all have a sensory system that needs support, just kind of depends on how much that's playing into the pelvic health symptoms that a child is having. And so I don't think it's really shaped me, but I think having that foundational communication with other providers and other disciplines really had it set the standard for me that that's kind of what we need to be able to successfully help children.

Lindsey Vestal (09:40):

Yeah, that's awesome. That's incredible. I want to reference something you said with my very first question with you, which is that you don't own biofeedback. You don't use biofeedback. So I'm curious, how do you integrate various modalities to promote overall wellbeing? Let's go a little bit more into what you are using.

Dr. Caitlin Keller (10:00):

That's a great question, and I agree with you. I'm not throwing shade at biofeedback, and I'm not saying that that's the wrong choice because it's a different choice, it's a different approach. And literature shows that it does have positive outcomes and that needs to be honored. I think the thing that I'm challenging is, is there a way that we can do it for the kids that are aversive to it? For the kids that are not ready for it age appropriate or cognitively, they're not ready for that kind of assessment and intervention. And so it doesn't have a place in our approach. So what we are doing is we're doing a lot of developmental screens from the beginning. Our intake form has a lot of questions. Even if I'm working with a 12-year-old, what did infancy look like? What did transition to solids look like? What did your overall, so this is for the family to think about what was your overall experience through the developmental milestones?

(11:04):

Were you constantly feeling like your child was having to catch up? Were you having to do all these supplementary things to help them catch up? What was potty training like? And then a lot of questions about when your child is at home, where are they in the house, what are they doing? Are they sitting on the floor? Are they sitting at the table? Are they on video games a lot? Are they outside? Talk to us about what your child is doing with their body on a regular basis. And then we do that same assessment in the room. And so as we're doing evaluations, I sometimes have to say to the family member, like you and I talking right now, is giving your child an opportunity to play and use their body how they organically want to. And so you see me looking at you and talking with you, and maybe your perception is that we're wasting time and all of these oral questions, but out of the corner of my eye, I'm watching your child tuck their toes underneath their bottom.

(11:57):

I'm watching them sit in a very asymmetrical position 100% of the time with their right knee up against their chest. I'm seeing them w sit a lot. I'm seeing how they stand up from the floor. I'm hearing how they speak with you and how much they're holding their breath. And holy moly, what information I can get from just watching a child organically play for 15 minutes as I go through some oral stuff with the family is so full of information about what we can do, and it's really the biggest impact we can have. If I took that child and they walked in the door and I had the intake form and I said, okay, we're going to sit down and we're going to get going and hop on the table, what would I miss if I didn't do that? And what an opportunity to be able to help shape the child and how they're using their body on a regular basis.

(12:44):

The biofeedback machine is just this minute point in time, and yes, it can help bring awareness very quickly for the child to their pelvic floor if we can get there, if they feel safe enough to be able to have their brain perceive that sensation, they need to have those prerequisites, but so much happens and just how a child moves their body. And then we shape that and then that starts to support the pelvis to function in a biomechanically appropriate way to help support their sensory system to be able to perceive what's happening in their pelvis. And I want to highlight, I want to make shirts that save rainbow smiles because we do a ton of rainbow smiles in our clinic and it's the cat cow yoga move that everybody knows, right? X amount of years ago I was in outpatient peds and I'm like, how do I explain to this kiddo? Which one's cat? Which one's cow? I don't know which one's which.

(13:40):

So it's very indicative for a child to think about a rainbow and think about a smile and how they should arch and move their back to do that movement. And one thing that I talk to families about is what is that doing for their brain to be able to think about their pelvis? So yeah, it's not in a toileting environment, but we are helping to connect their brain and their pelvis to be able to communicate in that bi-directional way that it needs to, and that gives so much awareness to their pelvic region that can then apply maybe organically to toileting. Maybe we don't have to do any actual toileting intervention, but just bringing those two parts of the body, the brain and the pelvis together through movement, through exercise, setting it up in a better structural position so that the neurological system can work better. So yeah, that's a big nutshell, but that's kind of our nutshell of our approach.

Lindsey Vestal (14:33):

Oh, I love it. I absolutely love it. And there's one thing in particular that I would love to let you know that really resonated with me, and I really appreciate so much how you point out to the parent, I'm watching your child organically play right now, and these are the things that I'm finding. And the reason I like that is it's kind of calling out the elephant in the room, if you will, and you're letting the client in the parent in sort of on your clinical reasoning and how you work and how you function. And I think that immediately differentiates you. And I think that while a lot of us listening to this podcast do that, I want to say a call to action here, is there a way today? Is there a way tomorrow that you as a listener listening to our conversation right now, can also do that, can also incorporate that whether you're working with kids or not. There is something about letting the client into that process that differentiates us from a lot of other care providers that I think is really exceptional. So that was cool. That was really cool.

Dr. Caitlin Keller (15:39):

I appreciate that. That's a great question for your listeners too. I think that's amazing.

Lindsey Vestal (15:43):

Yeah. Awesome. So as an advocate for occupational therapists, what do you think is an important aspect of collaboration between OTs and PTs?

Dr. Caitlin Keller (16:00):

I think we all have this perception that we, not perception belief that what we do is amazing. It's moving for a family to experience quality of life changes, and we are motivated by that and every profession, but specifically therapy professions, we want to help people get better. And so we believe that our methodology and our approach is the thing that's going to help. And I think one thing that collaboration can maybe change is this idea that as a provider to constantly, maybe not constantly, but have it as my back pocket question, is what I'm doing the best thing for this patient? Is what I'm doing getting to the root cause or the priorities that this patient presents with? Because I might, from a PT perspective, help a child and I can see some impairment areas, but I also need to be able to screen them for the other approaches that are not my strengths so that maybe an occupational therapist can take the priorities and get some forward momentum with those, get some resolution with those for the child so that then my approach can be more effective because it's not so hindered by these other things that aren't being worked on, that there's no resolution happening yet.

(17:36):

And so it's almost like this prerequisite thing. I might be able to help a child, but is there something else that someone else could do that's in their wheelhouse that could be more effective before I lay hands on this? And we have a lot of conversations with families about that. We do the evaluation, we say, I think that this is going to be great. I think we need to pause and work on these other things first and then circle back with me and we'll do the final touches if there's anything remaining left. And so I think one thing that brings us together is honestly the acknowledgement that there is another approach that might be better timed. The priorities call for it, but just to have the humility to say, this child needs somebody else right now, and that's okay. So I think that's what brings us together is hearing out that we each have different strengths and there's beauty in that. The acknowledgement is what I think will bring those two professions together.

Lindsey Vestal (18:43):

I think you hit the nail on the head there with the word humility. I think another word that comes to mind is an abundance mindset that sometimes what the client needs, what I can do best for the client in front of me may not be in skillset that I have. And so that is where I think a practice that has an OT and a PT working together is best because also from a business standpoint, it's obviously not sustainable to be sending clients out the door. And so let's be practical while also looking at outcomes that would best serve the client. So this is where I do think a practice where there are multiple disciplines working together at the end of the day is really best. And I don't know about you, but professionally I am so excited when I'm around people who have different thoughts and are analyzing it differently than I am because it challenges my assumptions.

(19:40):

I'm growing as an individual. I think we get into rehab, we get into these fields because we are lifelong learners, and I think sometimes when burnout happens or we're stuck in the status quo, the same interventions, that is a call to us to go, what can I do to shake things up? Sometimes that's a CEU course. Most times I find it's surrounding yourself with people that really inspire you. It could be day in and day out professionally. It could be starting a study group in your community that allows you to get together monthly, whatever that may be. I think surrounding yourselves with people outside of your discipline or your initial thought processes is just such an incredible way to go. Thank you for sharing those thoughts. Do you actually have any specific examples or case studies where an OTPT collaboration did go ahead and prove those client outcomes?

Dr. Caitlin Keller (20:36):

That's a difficult question because I feel like it happens so often in our clinic. I feel like there's this strong collaboration between the and the PTs at Unsated kids that we're constantly talking with each other and there's constantly this sharing and flip-flop of patients back and forth. And so that's a really hard question for me to answer because for us, that's our norm. For us, the collaboration between OTs and PTs is what we do on a regular basis. I feel confident saying a hundred percent of the time that we're constantly keeping each other in check, making sure that we're not missing anything. So I don't have any specific examples, but I think that's a really interesting but wonderful perspective that I'm just so used to it. I'm just so accustomed to being able to talk with occupational therapists.

Lindsey Vestal (21:43):

That's great. I love that answer. It was not one I was expecting, but I love it. I happen to know firsthand through an OT that is in my OTs for pelvic health Facebook group that you have been such a great mentor to many people in pelvic health. And I'm curious to hear from you, Caitlin, what do you think makes an effective mentor and how do you build trust with mentees?

Dr. Caitlin Keller (22:12):

I appreciate that. That's really kind. I love teaching, and so I get really passionate about it. I think that a relationship between a mentor and a mentee is really built on the ability of the mentor to listen and shape the mentee's thoughts, their ideas. Because if it's a relationship of I'm going to tell you X, Y, and Z, and you're going to listen to me and I'm going to fill your head with this information, well, we kind of all know that learning by doing is one great way to help solidify something in your brain, in your body, in your mind. And so if I'm just telling you something that you then have to carry out, well, what learning is involved in that? And so I think as a listener, you then are able to hear someone's ideas, hear where they're coming from, and then say, okay, well, I'm going to challenge you to think about this.

(23:12):

And have you considered maybe this perspective? I think I'm surprised all the time Right now I'm onboarding a new physical therapist in our clinic, and I'm surprised all the time when I hear her approach and her thoughts as we're working through that clinical reasoning. And it's not what I had in the forefront of my brain, but it's what she has as her first thought. And no, there's nothing wrong with that. Tell me more about why that's your thought. Tell me more about where you're going to go next. Tell me more about why you think that that's your priority for this child. And then it might be a great way, a different way than my way. And that challenges me to make sure that I'm not saying that there's only one way to do something. So I really think the communication, the ability to listen, even though I might be mentoring somebody that doesn't make me a better therapist, that does not make me a better person, that just puts me in a position of I'm shaping this conversation based on my experience, and I've been doing this for a while.

(24:25):

So I think I have some things to offer to you that might help you move through that process that we all move through of. Ooh, if I could go back and help all the patients again that I helped in 2013 when I was a new grad, I would do things very differently. Not that what I was doing then was wrong, but would I have more effective ways? Would I have more better communication with the families and my ability to educate and help them understand so that they are then more motivated to work on their home program instead of me just saying, these are the things you're going to work on and have fun. Good luck with your four other children and how you're going to incorporate this in your afterschool routine rhythm that you have that can be a little chaotic. So yeah, I think it's just about communication. We listen to each other, we shape each other. I think that's the best thing anybody in a teaching position can do with the people they're educating.

Lindsey Vestal (25:22):

I wholeheartedly agree. You touched on something that got me curious, which was the home exercise program. And it sounds like, and I'm not surprised you've put a lot of thought into that and how to more easefully help support your clients in what the home exercise program could be. Could you just tell us a little bit about that process for you?

Dr. Caitlin Keller (25:46):

Yeah, thanks for expanding on that because I think in the pediatric world, that's a really big piece that maybe a lot of therapists can forget about because it's the part that we don't see. We don't see their follow through at home and what they're doing on a regular basis. But it's what matters because how much time are you spending in the clinic versus at home? We all know that ratio means that home exercise follow through really needs to be high so that we can get the outcomes that we're hoping for. So we have a conversation with the family about what does your day look like? And one thing that we often recommend is this four-step process that we call reflex loops for things that can help initiate a bowel movement in a child or initiate the body's desire to have a bowel movement. So sitting, eating, warm beverage, belly massage, belly breathing, and so we'll say, does this feel like a reasonable 30 minutes that you can invest?

(26:53):

And then the follow-up question is often, well, when do I need to do this? And I say, well, right now your child's body is like at max capacity, they're constipated. There's stool retention, and we want to help them evacuate more on a regular basis. And because they're at that full capacity, if you use these reflux loops at any point during the day, their body has a good chance of responding just because they're so full. So why don't we start with when you feel like you can implement it, integrate it into your rhythm, your daily rhythm most easily. We want you to feel calm and really intentional. We want your child to feel good. So maybe doing it in the morning before you're leaving for school has maybe not the time that we do it because that feels like the opposite of that whole parasympathetic relaxation safety environment that we're going for.

(27:45):

And so that's one way we talk about where are we going to implement that 30 ish minute reflex loop process. The other thing that I really love, what we do is we, in our after visit summaries, we have a list of exercises that we maybe did in the evaluation that we think are good for them to try. And in that summary, we have a daily therapy homework and reflux loops is often number one. Number two might be some kind of positional change that we're offering. So challenge your child to sit with their feet in front every time you see them, do a WIP position, that kind of thing. Then the third thing might be choose one of the exercises from below to do every day. And so we're not saying do all seven, all 12, all four exercises every day, choose one. Try to make it different every day.

(28:40):

If you have extra time, great, but if you don't, just choose one. Let your child choose. There's the autonomy that's built into that that feels really fun. You can make little cards and we can choose. They can visually choose what they're going to do on every day and make a little schedule for the week. But I think having the family feel like, okay, I learned a lot in this evaluation. There's a lot that we need to work on. You brought my attention to a lot of things that are kind of pouring into this toileting challenge that my child has. Resolution can feel really intimidating. But if I break it down and I say, do these three things, do it when you feel equipped to do so. That is also empowering for the parent, for the family to be able to say, okay, this is not going to be this huge hurdle and this feels really realistic. And oh my gosh, I have an action plan versus years and years of a provider saying, use MiraLax and then come back and we'll see if it's better and maybe we need to up the MiraLax. This feels different, this feels good. And that really starts the process in a really great way. Instead of them feeling intimidated, they feel empowered and excited, and it's a really great start to our therapy family relationship.

Lindsey Vestal (30:02):

Absolutely fantastic. I love that approach. I love what you guys are doing. It's so thoughtful and always puts the client in the forefront. So that was genius. I could talk for hours. I'm going to restrain myself and ask you one last question, which is if you could go back and advise your younger self just starting off in the field, what are some thoughts that you would share with her?

Dr. Caitlin Keller (30:33):

I think a lot of my challenges in life have really been rooted in the ultimate search of finding that perfect balance. So I love what I do and I love being a therapist, and so when I'm at work, I'm a hundred percent all in and then time can sag into what was supposed to be my transition home time. And the opposite is true too. When I'm home with my kids, I'm supposed to work during nap time or at night after everybody goes to the bed. And sometimes that just doesn't happen because I'm home and I'm feeling rejuvenated and rested and spending time with my family in the evenings. And so that has been a constant challenge for me my whole life. And I think that honoring that we need that balance and what can come from the thing that we think is not as necessary or I don't have a home to-do list, so let me focus on my work to-do list.

(31:48):

Being able to rest and have time with my family and time with myself right now is not necessarily a season that I get a whole lot of those things in. I have three kids under five. But I think what happens and what grows from the time and space to be able to have that rest, that's where creativity blooms from, and that's where we get these bursts of energy that propel us in the things that we're working on. And so I think that being thankful for the time and honoring the time and trying our best to give that time a hundred percent of ourselves, no matter how small it is during our week or our day, there's beauty in that. And there's, I say the word productivity, but productivity in that there's productivity in rest. I didn't know that that's a concept that flies around sometimes, but that's what I would tell my new grad self is that that needs to be honored. And don't shame yourself for feeling like that balance is off and we all always have things that we're trying to do better. And patience to allow for that balance is really the biggest gift I could have given myself in 2013.

Lindsey Vestal (33:13):

Phenomenal. This has been such an honor and a pleasure. I'm so glad that we had this time together today. Really appreciate all that you're putting out in the world, not only professionally, but also your clients are just incredibly lucky to have you. Caitlin, thank you again for being a guest today.

Dr. Caitlin Keller (33:29):

What kind words? Thank you so much. I appreciate the time to be able to just chat.

Lindsey Vestal (33:34):

Thanks for listening to another episode of OTs and Pelvic Health. If you haven't already, hop onto Facebook and join my group OTs for Pelvic Health, where we have thousands of OTs at all stages of their pelvic health career journey. This is such an incredibly supportive community where I go live each and every week. If you love this episode, please take a screenshot of this episode on your phone and post it to ig, Facebook, wherever you post your stuff. And be sure to tag me and let me know why you like this episode. This will help me to create in the future what you want to hear more of. Thanks again for listening to the OTs and Public Health Podcast.