Kim (00:02.047)
Okay, this is one of the most anticipated episodes, I think, both for myself and my audience. I am excited to have you both, Dr. Jessica Propes, Dr. Imran Siddiqui. I will use your first names for the rest of the episode, but welcome to you both. I'm really excited about this conversation.
Jessica Probst (00:18.035)
Thank you so much. We're so excited to be here.
Imran James Siddiqui (00:20.05)
Yeah, thank you for having us. Very excited to be here.
Kim (00:23.317)
So how I was connected with you both, I'm gonna just tell that little plant that seed and then I would like to get you to introduce yourselves with your bios and backgrounds. I long story short, after 14 years after giving birth found out, well, I was suspected that I had partial avulsion tear, levator avulsion tear. Somebody had pointed me in the direction of Dr. Schoberry who is in Washington DC.
I had interviewed him on the podcast. I was in a few different Facebook groups with people dealing with this birth injury and somewhere within one of those groups, I don't even remember which one it was, it was mentioned that there was this team of a regenerative medicine doctor and a pelvic floor physical therapist who were aligning and helping people with this injury with kind of alternative, if I will say healing modalities, non-surgical.
And so of course I had my interest peak this one person happened to also be a Canadian which I'm from Canada. I reached out to her privately she shared her story I then got connected with you. I went through the whole process I came to see you twice and this is really an opportunity for us to talk about my experience but also learn more about what it is that you two are doing together.
Jessica, let's start with you. If you can tell us a little bit about your background as a pelvic PT, what brought you to the world of pelvic health? Well, first of all, physical therapy, then pelvic health, and then I'll hand it over to Imran.
Jessica Probst (01:53.108)
Thank you. I always know that I love to interact with people and to help people and I'm really passionate about that. And I knew I wanted to do something with my hands for work and I knew that I wanted to do something that could really make positive impacts in people's lives. So physical therapy seemed like a perfect match for me. I got really, really lucky and I've been a physical therapist for over 20 years and I...
Part of what really gets me excited is to figure out what the next pieces I can do to help people more. I get people a certain amount better, but I want to help them get further better. What else am I missing? So that's led me to continually do different continuing education and to figure out other ways to help people at a deeper and deeper level and figure out what spots were missing. So when I came to the world of the pelvic floor, it was a huge aha moment for me for so many people who had
pelvic girdle pain, hip pain, back pain, even thoracic pain, all these pieces. And the even more exciting part for me is it's an opportunity to help people in really, really meaningful ways, whose lives are extremely disrupted, and then to be able to show compassion, caring, tie the pieces together, really focus on what each individual's goal is in, and then affect their lives in a positive way. So I've been doing pelvic floor work for over 15 years,
I'm very passionate about it. have a pelvic rehabilitation practitioner certification designating me as a specialist in pelvic floor rehab. I've been involved in teaching many, many courses. As a teaching assistant, I've written and taught courses, and I provide a lot of mentorship for my colleagues at an advanced level, because I love the idea of bringing us all up to be able to help people more and more. It's really my passion.
Kim (03:37.749)
Yeah, very cool. Yeah. And I hear that a lot with pelvic PTs that they were in physical therapy and they just, something's missing. And then as soon as they get that pelvic health piece, it's that aha moment. So yeah, awesome. Thank you for your work. Imran, I'll pass it off to you if you can give us a quick little intro.
Jessica Probst (03:46.826)
Yes.
Imran James Siddiqui (03:56.912)
Yeah, absolutely. So my path to how I got into pelvic floor regenerative treatments or pelvic floor medicine was not as straightforward. I originally went to medical school for sports medicine.
Jessica Probst (04:07.701)
you
Imran James Siddiqui (04:14.306)
I had multiple, I played sports through college, had multiple injuries, spent a lot of time dealing with my own injuries and talking to others about their injuries. And so my passion originally was to help people get through those injuries, mainly non-surgically, and help them get back to doing what they love doing. In my personal life, my wife and I, we have six children. And so while I was developing my sports medicine practice,
A big part of what I developed was diagnostic muscle skull ultrasound, trying to become an expert in that. And I feel like I was able to accomplish that. I teach muscle skull ultrasound at different courses throughout the country. I'm certified in muscle skull ultrasound and also help write some of the questions for some of the board certification as well. But watching my wife and helping my wife get through six pregnancies and deliveries,
and the recovery from those deliveries, I saw a huge kind of black hole in medicine. We learned nothing about pelvic floor health in medical school or residency or any of my rotations. Actually, how I started learning about pelvic health was through physical therapists like Dr. Probst. And so a lot of the physical therapists in the musculoskeletal world
Some of them also did pelvic floor health and that's how I started learning about it and over time started learning more about how the pelvic floor can, how it relates to overall musculoskeletal health, especially with hip injuries, back injuries, but even beyond that. And then watching my wife go through the recovery and how if she was an athlete in college, she was a two sport athlete in college as well and watching her.
have to go through what you had to go through and struggle to get back to athletics and seeing how there was almost other than these wonderful physical therapists. in as far as like medicine is concerned, just nothing there for them, or almost nothing. So started thinking about, okay, you know, swaps, seeing how regenerative therapies have healed tendon, ligaments, injuries, and joint injuries in the muscle, skeletal world with shoulders, knees, hips.
Imran James Siddiqui (06:41.686)
thinking started thinking about okay, how could we apply this to the pelvic floor and then just coincidentally Jessica and I we had a you know, we had a mutual patient She thought that they could really benefit from a regenerative treatment And so we got it started, you know, I started learning from her About the pelvic floor anatomy. We started ultrasound in it together and and figuring out
where these injuries are in people and started helping them. So it's been a very rewarding experience.
Kim (07:14.153)
Yeah, that's so I love hearing the origin story. And I love hearing how people start to collaborate and think outside the box. I will say we're thinking inside the box when we talk about pelvic floor. But I'm glad you two came together. So to kind of very high level summarize the experience I had, I first of all, booked in Jessica with you at your clinic, and you sort of did the your team or you did the coordination then with Imran to then also book
time there and I think that eventually that will become streamlined as you sort of fine-tune this process. But right now it's you're I wouldn't say you're necessarily in the quote-unquote testing phase but you're sort of you're creating something new that has not been done anywhere and so I came I booked an initial assessment I showed up in the morning we did an assessment a couple of hours later I walked down the street literally a block maybe two blocks to Dr. Siddiqi's office.
Jessica Probst (07:45.658)
Yes.
Kim (08:12.313)
I had the initial kind of intake blood draw, waited for, I think it was about 45 minutes to an hour, and then the treatment began. You then, Jessica, you came down to Imran's office, you and one of your teaching, your therapist partners, you were both in there, which you had done the evaluation, the physical examination with me. You were now in the room with me, with Imran, who was now using ultrasound.
Jessica Probst (08:24.018)
Mm-hmm.
Jessica Probst (08:30.439)
you
Kim (08:41.429)
He could see with the ultrasound. He could make his observations. You then also were verbally saying, and I felt something here. And so while he was using the ultrasound, you also would insert your finger and find the spot so he could see it. Like it was the, it was the epitome of collaboration. And I just felt so supported and also really like, this was really cool. Like I filmed the whole thing.
Jessica Probst (08:50.695)
Mm-hmm.
Kim (09:09.345)
because I wanted to it just found it so awesome what what was being identified and highlighted and so then then the blood draw so the this is using the p there's a different terminology which i'm going to get into but prp or prf so it's basically a blood draw it gets put into a centrifuge it creates platelet rich plasma that is then reinjected into me so it's my own my own
stuff that's being reinjected into my body in targeted locations in and around. And this was the other part that for me in my mind, I'm thinking it's a I have, well, you found many different tears in many different locations within my pelvic floor. But you were also in by my pubic symphysis joint for my rectus, you were in my SI joint, like I hadn't really thought of it, even though I know that that's all part of the pelvis. I didn't think about the injections being placed elsewhere.
Jessica Probst (09:51.635)
Ha ha.
Kim (10:07.561)
So that then was kind of high level. It's pretty uncomfortable. You're uncomfortable for a few days afterwards. And then we'll talk about the changes after, but that's kind of high level what the experience was for me. I then came back and we repeated that a second time. to start out with, Imran, if you can explain what is PRP,
Jessica Probst (10:20.863)
Thank
Imran James Siddiqui (10:34.3)
Mm-hmm.
Kim (10:34.625)
PRF, PRGF, like there's different terminology that's being used. So if you can help decipher what it is, but also what the different terms mean.
Imran James Siddiqui (10:43.494)
Got it. So platelet-rich plasma in general is a concentration of one's own platelets in their plasma. Our basic blood fluid is plasma. And so if you take all the cells out of your blood, you're left with plasma. And so what we do to make platelet-rich plasma is we take all the cells out pretty much except for
platelets. There's some stem cells floating around your blood that end up in there as well. Some white blood cells get in there. Maybe a few red cells stay in there, but for the most part, it's mostly platelets in your plasma. And what platelets do is so anytime you injure an area, say you cut your skin, you bleed into that area. That bleeding is actually very important because you have platelets in your bloodstream. When platelets touch damaged tissues, they actually have
receptors for damaged tissue on their cell walls. And so when they touch that damaged tissue, your platelets activate and release growth hormones. And these growth hormones will float into your bloodstream more regionally, and that will attract other healing cells, fibroblasts, microphages, other stem cells to that area to start and maintain a healing response.
And so that's kind of, that's how our body heals naturally. And so what platelet-rich plasma does, what we're doing is, is we're using it in areas that don't heal very well on their own. Most of the time it's tendons and ligaments and joint cartilage, but muscles too can get injuries that don't heal very well on their own either. And these areas don't heal well because they don't have good blood supply. Our skin has great blood supply, so a lot of platelets can get there when you cut it or injure it.
but these other areas don't have the blood supply so the platelets can't get there. So we get around it by drawing your blood, concentrating those platelets, making platelet-rich plasma, and then injecting them directly into the injured tissue, and we do it directly under ultrasound guidance to make sure it's very precise. And to be a good treatment for it to work well, has to be very precise. Regional treatments don't really work. It has to be very precise. As far as...
Imran James Siddiqui (13:00.816)
the different iterations of platelet-rich plasma. Platelet-rich plasma is the general term. There's different iterations. There's PRF, there's platelet lysate, there's plasma rich in growth factors, or PRGF. And then there's also, for PRP, there's leukocyte rich and leukocyte poor. These are different formulations. I don't know if I want to get into all the details. It's kind of more basic science stuff. But the different formulations will keep.
different proportions of the white blood cells versus the platelets. And some might have higher concentrations of platelets and lower concentrations of platelets. Some may still have some more red blood cells in it and not. But in general, what we see is that if we look at the research on platelet-rich plasma in more detail and the clinical efficacy of platelet-rich plasma, it's being used in everything from joint and in ligament health, which is what I use it for, to hair restoration and...
and facials for collagen restoration in the face, wound healing as well. But in all those cases, what we're finding is that it's dose dependent. The more platelets you get, the better results you have. So we try and concentrate our platelets to about 10 times the normal body's concentration. But you'll find the issue that we have in this field is that there's a wide variety, a wide range of quality of products.
It's kind of a sexy place in medicine, regenerative medicine. And so there are lot of companies trying to make kits and make products to sell to providers to be able to perform platelet-rich perch plasma procedures on people. But it's not all equal. So there are some kits that will make a two times concentration, which is not very effective. And there some that will create a 10 to 12 times, which is we try and do.
and which can be very effective and then anywhere in between. So for people listening who are potentially interested, it is very important that you ask whatever provider you're considering this from what kit they use or how they create their platelet-rich plasma, what's the concentration of the platelet-rich plasma and what type of platelet-rich plasma they use.
Kim (15:21.035)
Wouldn't it be dependent on the person? Like if it's being drawn from me, what is, like when you say kit, what actually makes it a higher concentration or a lower concentration? And could somebody, dependent on how much I drank, like hydration wise or food I ate, would that influence my plasma?
Jessica Probst (15:36.762)
Mm-hmm.
Imran James Siddiqui (15:38.642)
Correct. So when we talk about the concentration, we talk about how much more concentrated is it compared to your specific baseline. So most people have their platelet counts like 250 million per microliter somewhere around there. So we can take that and we'll concentrate it about 10 to 12 times.
Other people may come in and some people who have low platelet counts or are over hydrated, their platelet count may be 200 million or might be 150 million. And so we'll still concentrate that to 10 to 12 times, but they will have a lower total count than someone with a normal count. And so we do test for that in certain situations if there's someone who
we're concerned that they might have low platelet counts. It's always good to get maybe a baseline CBC from your primary care to know what your baseline platelet count is. if it is low, and we do it on people where it is low, we can draw more blood to get a higher count.
Kim (16:50.379)
Got it. Okay. Jessica, can you remember the patient that connected the two of you? Okay. And so what was the challenge that person was facing and what I guess the result of the two of you working together, what was the outcome for that person?
Jessica Probst (16:57.627)
I absolutely can.
Jessica Probst (17:06.352)
Mm-hmm.
So this person was a fairly elite distance runner. when I was, when I inserted my finger vaginally and was feeling what was happening in her pelvic floor, it was very clear that there was injury to her muscles that I was able to feel, especially the levator anion, that large group of muscles that provide a lot of support to pelvic organs and help control continents. And also they're really useful for activities such as running, walking, moving, standing. I mean, there's a lot of factors.
commonly under regarded area. But I could feel in terms of, I could feel these defects in the muscle, these places where they were not lined up, where there was like little divots in the muscle almost. And I felt these in other areas in the human body. And I've worked, I've worked for many years with Dr. Siddiqui and his colleagues. I think they're fantastic, which is why I gave him a call. said, this feels like, if this was in a hamstring,
I would send this person to you because I would do all my standard rehab. A lot of times that works great, but some folks, if they have a hamstring tear and then they just slip just the wrong way, it is a game changer for them to have PRP where things are able to really heal more fully. And I know that's the right step for those people that aren't able to respond all the way to a conservative care of a partial hamstring tear.
and I send them over to my friends. And this felt so similar in some ways in terms of with a tour when I tore my own calf muscle doing martial arts and I went over and Dr. Siddiqui and his colleagues treated me and it was outstanding and I could feel the same problems on a much smaller scale that I felt in my own calf when I tore, partially tore that that I did for this levator, anion, other pelvic floor muscles.
Jessica Probst (18:58.751)
So, and some folks that we see are so, have such amazing body awareness, they can really tell this side is sort of activating, this side isn't doing anything. It used to do all these things and now I feel open, hangy, I feel when I'm moving it doesn't feel like it's firing and doing things right. And then certainly some people will have, you know, feelings of heaviness, a variety of different problems, irritation, pain, problems with continents, et cetera.
So with our patient, that's when I reached out to Dr. Siddiqui and I said, hey, you know, can we, this feels like a partial tear of the levator anus. Could we just treat it like a, all it is is a skeletal muscle, just like our biceps. Could we treat it just like a skeletal muscle, just like the biceps? So when he said, well, there's not, I looked, there's not imaging courses on how to do this. How are you supposed to do an ultrasound image of this when there's no, and I looked also and not surprisingly he's,
his research was thorough, there is not a way to learn these things. And I said, well, I can take care of that. I've spent years training other people in the details of it. with part of what I've done through our work together is I've developed a systematic approach to evaluating the pelvis and pelvic floor that I call precision pelvic mapping.
Imran James Siddiqui (19:58.93)
Thanks.
Jessica Probst (20:15.657)
where I look at all these factors that will tie in throughout, especially throughout the pelvis and the pelvic floor, in areas where are likely to be injured by birth traumas. And I do a meticulous evaluation of exactly what is happening with each of the specific muscle, and I muscle test within different parts of the same muscle, the inside versus outside part of the muscle, this whole very, very in-depth check to see what's happening in terms of with strength ability to activate. And also if I'm feeling like there's a muscle defect, like something's wrong.
So the patient, our patient who's just was super excited, wonderful, she's a fantastic patient. go there and then through her and her adventurous nature and generous use of her time, we were able to find, when I inserted my finger vaginally and Dr. Siddiqui came with his ultrasound, which we have down to a pretty nice science here where we don't get in each other's way.
Kim (21:12.737)
Mm-hmm.
Jessica Probst (21:15.278)
And we were, Ava said, it feels like there's a partial tear here. And he's looking and I wiggle my finger and he moves it around and he says, well, it feels like there's a partial tear there because there's a partial tear in that muscle. You know, since we agree there's the linear defects and the correlation that we have is really exciting where we both get to learn every time we're together, which is, you know, for me, it's, you know, it's a dream. So now I get better at telling this is a partial tear versus this is what I would, you know, where I can expect because I get to go see the outcomes of these things.
Kim (21:43.681)
Yeah, yeah.
Jessica Probst (21:44.536)
So our patient we addressed, she went from having muscle, she was not able to fire well to being able to fire muscles really noticeably differently. A lot of her issues were around her being able to return to her previous level of activity. And I believe, Amarana Vekerev, I believe she's setting new PRs, is that right?
Imran James Siddiqui (22:07.452)
She's setting new PRs and marathons and she's back to her old self and she went from not being able to run at all to back to running marathons and PRs. She's a sub three hour marathon runner and she's doing it. It's so rewarding. It's so wonderful to be able to... Because her only other answer was some surgeries with mesh.
Kim (22:13.139)
Wow.
Kim (22:21.942)
Wow.
Imran James Siddiqui (22:37.266)
outcomes aren't great and so being able to help something like that is just wonderful.
Kim (22:44.885)
That's really cool.
Jessica Probst (22:44.944)
I'm worried those other things would have caused her more problems, would have laid in more scar tissue and created more dysfunction.
Imran James Siddiqui (22:49.798)
Yeah. Yeah.
Kim (22:50.559)
Yeah, yeah. And that's part of the kind of the message and mission that I have too, is there's, as you have both noticed as well, there is just an under awareness, under appreciation of the pelvic floor and how much it influences so many aspects of our lives. People suffer for a long time when they finally do go get help, they're often offered a surgical path, which surgery can be a great option for many people. However, they are still not they're not getting to the root cause they're not provided any
You prehab rehab guidelines and so they end up often with either different or the same problem down the road because they haven't really addressed part of the issue. But. But that's like there there's no exploration of all of the other that I wouldn't necessarily consider what you're doing super conservative, but all the other non surgical options, I guess I would say. So I just again I love the collaboration and the power of the.
brains and the expertise coming together to help these people. So this person has gone back to running marathons, you know, PRs for herself. And hers was levator injuries. And some other okay. And that was so part of mine was partial levator, but there was other stuff there as well. So what are some of the and could this be
Jessica Probst (24:05.68)
She had some other entries as well, but the largest was the elevator.
Imran James Siddiqui (24:06.842)
name
Kim (24:18.613)
from people who've never given birth before? Could some of these tissue defects result from other injuries or could it be from hormones? Could it be like what are other ways that somebody may have a tissue defect that's not childbirth related? Either of you can answer that one.
Imran James Siddiqui (24:37.158)
Jess, don't you go ahead.
Jessica Probst (24:38.609)
All right, we both want to. So in general, with the things that we do and we find with the injuries, the most straightforward situations are when there has been some element of trauma to the area. When we're talking about, terms of which childbirth is the most straightforward of those, sometimes there are surgeries that will tie in and there will be trauma to the area for that. And now there can be other pieces also, like for example,
If you think of any other skeletal muscle, there's ways that you could irritate and cause problems with skeletal muscles in other ways. So for, there's a lot of people where that's really useful to check on. It's important also, it's a particularly useful time when we do really the collaborative effort. So when I go in and get the history and find out exactly what I'm feeling through here, then I'm able to.
correlate with, here's your symptoms and this defect that I found I think is relevant and pertinent a big deal and sometimes especially in people whose symptoms are not from childbirth, they can have a defect from the baby they had 20 years ago, but it doesn't mean that that's necessarily what's causing their current symptoms. So we want to make sure that we're really getting at the things which are most important for people most related to their current symptoms. But we certainly see applicability outside the childbearing.
Kim (25:56.758)
Got it.
Jessica Probst (26:02.114)
population, we just want to just really double check to make sure because as we know, pelvic health is an, or pelvic pain rather, is an abnormally complex area. So want to make sure that we're really putting all the brains together and to get real clarity so we're treating the things that are the most directly related to the person's symptoms.
Imran James Siddiqui (26:03.279)
Yeah.
Imran James Siddiqui (26:19.792)
Yeah. And then other areas where we've seen some injuries, brought up, post-surgical for if you've had other surgeries to either colorectal surgery or pelvic surgery, you know, dealing with scar tissue or areas that didn't fully heal from the surgery. That's one. Another one is, you know, more more common, which is I love, which is women getting into weightlifting. But
Jessica Probst (26:32.657)
Mm-hmm. yeah.
Imran James Siddiqui (26:48.47)
you can develop pelvic floor injuries from weightlifting. A lot of them will actually present with more musculoskeletal like hip issues, but their pelvic floor will also have injuries to them as well. And so the wonderful thing about working with someone like Jess and me also being kind of a sports medicine doctor at heart is we're able to comprehensively and treat.
you know, the SI joints, the pubic symphysis, the adductors, the hamstrings, the labrum tears, all that other stuff that can coincide with this. And then the third area actually where we're seeing issues is people after taking certain antibiotics, especially ciprofloxacin and levoquin, they're called fluoroquinolones, they weaken tendons and muscles. And I've had multiple patients who have been in this cycle where they
Jessica Probst (27:20.147)
Mm-hmm.
Kim (27:22.497)
Yeah.
Jessica Probst (27:27.123)
Bye.
Imran James Siddiqui (27:42.864)
maybe had a UTI to begin with or something. And Cipro is a very common antibiotic treatment for a UTI, but it is a black box warning that it can cause tendon and ligament injuries. And I've seen now a handful of people who took Cipro and then their pelvic symptoms got worse. And then also they were getting more of this dysuria or cystitis symptoms that they were
and feeling like they had more bladder infections, they kept, whenever they were testing it, it would not show up as a bladder infection, but they would get treated recurrently for bladder infections. So take more antibiotics. And actually what was happening is they were getting damaged to the ligaments and tendons around the pelvic floor and around the urethra. And so that's what was causing the dysuria and cystitis symptoms. And then it just snowballed and they had.
Jessica Probst (28:16.608)
Mm-hmm.
Kim (28:26.891)
Yeah.
Imran James Siddiqui (28:40.796)
picked up multiple, multiple injuries without even, with just doing kind of normal daily activity and some exercise. So that's a big one for everyone out there is be very cautious about using Cipro. You know, I talked to all my clinicians that I work with, OBs, primary care to counsel their patients on it. And if you do have to take it, try your best to take something else. But if you have to take it, do not exercise while you're on it.
Kim (28:47.947)
Mm-hmm.
Kim (29:10.849)
crazy. So then, I get, can you talk a little bit about, I mean, this involves needles, which, I mean, it's not not, it's not pleasant. But how like, tell me a little bit about obviously, I've experienced it. But from your perspective, you're you're using the plasma, you also used a pain relief.
was sort of the initial part of the injection delivered the pain relief first and then there was the PRP that that went in. Can you talk a little bit about sort of that that you know the precision mapping that Jess is using the ultrasound that you're using you pinpoint the exact location and then walk us through what you do from there like how deep does the needle go how long is it in this I can tell my story but you're better at it.
Imran James Siddiqui (29:57.83)
Yeah. So first off, Kim, you being one of the pioneers in this, being one the first dozen patients to do this, definitely were not optimizing the analgesic and... Apology for that.
Jessica Probst (30:01.15)
Thank you.
Jessica Probst (30:05.619)
Mm hmm.
Jessica Probst (30:15.799)
Apologies for that.
Imran James Siddiqui (30:25.852)
But you trooped through it and you did wonderfully. But we have now fine-tuned it and we have a much better algorithm. Now we offer both a sublingual benzodiazepine with some ketamine in it, which helps. And so it keeps you conscious. We don't have to put anybody asleep. But it definitely helps with the pain significantly. And then on top of that, either on top of that,
or in replacement of, we also have nitrous oxide or laughing gas available to patients. And I think before when you were there, we had these, but we were like, eh, you can use it if you want. And now we're saying, should really, yeah, please use it. So that's definitely made a vast improvement in the overall experience of the procedure. But to your question in terms of
Kim (31:11.499)
Please use it. Yeah.
Jessica Probst (31:12.536)
in.
Imran James Siddiqui (31:24.038)
kind of what we do. So after Jess does her thing, she maps the pelvic floor with her manual exam. She'll point out the precise areas where she thinks are most affecting the patient, both from how it feels in terms of the muscle defect and also how that particular area ties into the patient's overall functioning. So she's very talented in that. So she'll pick those out, ultrasound those specific areas and find
whatever injuries, sometimes we don't find an injury, but most of the time we find an injury there. And then we also have a standard protocol of areas that, musculoskeletal areas like the pubic symphysis and tendons and ligaments that attach there to the pelvic girdle. And then also the pelvic floor, including urethra, external anal sphincter, all the muscles of the pelvic floor that Jess has.
so wonderfully taught me how to find an ultrasound and taught me where they are in anatomy. So thank you for that. so then once we identify the areas, and it's usually a fair amount of areas because these, there's a lot of structures and they play off each other. So if you injured one, two years ago, there's a chance that if you've kept trying to exercise and do stuff, you've injured others because they're trying to pick up the slack. And so a lot of the times we do find a lot of injuries. then.
Kim (32:24.362)
You
Jessica Probst (32:27.52)
Thank
Imran James Siddiqui (32:48.828)
We'll look at how much plasma we have. We'll divvy it up and say, okay, we can do two milliliters here, one milliliter here, and kind of plan out how we're gonna use the plasma. And then we do the injections. We do an anesthetic injection first. yeah, so we do, it is an injection, but it's an anesthetic injection. The anesthetic takes about five to 10 seconds to kick in. So that first five seconds are where you're gonna feel your discomfort.
more so pain than discomfort, but where you feel it. And then, yeah, let's keep it on here. So you'll feel the pain and then it should numb up. And the way we do it is rather than doing a bunch of numbing injections and then a bunch of plasma injections, we do it where I do a numbing injection and just unscrew the anesthetic, put on the PRP and.
Kim (33:21.119)
Yeah. Let's be honest.
Jessica Probst (33:24.919)
you
Imran James Siddiqui (33:46.876)
complete the injection right there and then just walk around the different spots. I think also important for everyone to know all of our, none of our injections are internal. They're all external. They're trans perineal and translabial injections. My ultrasound is also not internal. It is transpare meal and translabial. And actually the main reason for that is the quality of the image that we get with a linear ultrasound, not a trans vaginal or trans rectal ultrasound.
is a much higher quality and higher definition. And so we can see tears and injuries that otherwise are missed on transvaginal ultrasound where the image quality is just not as good and you just can't see it. It's no fault of any practitioners, just the technology is just not there yet.
Kim (34:35.359)
Yeah. I want to talk. So I'm to start with you, and then come back to you, Jess. But the the second time that I came, the other cool part I found was you you have the images from the first time and then you're now looking at the images from this repeat visit and you can see the change as well. So what does that what do you see? What changes on that image to show you that there has been some change to that tissue? Is it the color like
I'm not asking you to read an ultrasound, just what are you generally seeing?
Imran James Siddiqui (35:07.378)
Yeah, so generally each tissue in our body has a specific, what we call echo texture in ultrasound. It's basically a specific image that it should look like. Muscle has a specific type that it looks like. Tendon, ligament, joint. And so that's how I was more easily able to get into the pelvic floor despite not understanding the anatomy very well when I started.
was that I knew what normal muscle and normal tendon and normal ligament was supposed to look like, and I knew what injured muscle, tendon, and ligament looked like. So I was able to pick up these injuries. And so you can see those areas. You can see defects in muscles. You can see tears. You can see fraying of tendons. You can see swelling of ligaments. You can see arthritis or degeneration of cartilage. You can see bone spurs.
You can see swelling of nerves so there you can see scar tissue so we can see all that and we take images of each area that looks abnormal and Then when you come back we'll take images again to see how it's improved if it has and so we will be able to see if the tear has filled in or Partially or fully we can see if the swelling in the ligament has improved we can see if if the swelling in the joint or the the arthritis has improved so
So we can easily compare before and after to see if you're responding or not.
Kim (36:34.495)
Now the time between when I came the first time and the second, I believe it was about three-ish months or so. So it's not that I didn't have a follow-up visit, you know, three weeks or four weeks later with Jess, it was several months, but maybe some of your other local people you might see quicker than that. But go back to that first patient, the now marathon runner, how soon afterwards, Jess, did you do a follow-up internal? Could you palpably feel the change that was also visible on the ultrasound?
Jessica Probst (37:05.002)
So I'd like to use a different patient example only because at this point we've done enough people that I'm not going to be able to answer that question accurately enough. There's one patient that actually we're in the process of publishing a case study on who after giving birth had problems throughout her pelvic floor, but especially problems with fecal continence, which is of course a massive life changing debilitating problem.
Kim (37:11.658)
Yeah, yeah.
Jessica Probst (37:33.844)
And I could feel when evaluating her external anal sphincter, I was evaluating rectally, I could feel defects in areas where she was not able to fire. And then we went in and did the ultrasound and you could see the shape of it. It was sort of an oblong pulled over shape of her anal sphincter. was not a nice little circle the way that we would hope and expect for it to be. And she was having these symptoms.
Then when she came back, I believe that we did a check-in, I would say about eight weeks later, if I'm not mistaken. And there was a notable difference in terms of she still had a divot, but it was definitely, we went from having a super thin area, her extra anal sphincter had gained a significant amount of bulk to it. It was able to contract not perfectly, but definitely better than before. And her symptoms were somewhat.
were definitely less than before, much less incontinence, still some gas incontinence and other issues, but definitely doing better. And then Amron was able to see once again, it was not quite, it wasn't as adlong. And I believe it was, what we're using with the paper, I believe, is following the second round of PRP, where you can see, all of her, in terms of all of her fecal incontinence and the fecal urgency, was pretty much gone.
Kim (38:55.518)
Wow.
Jessica Probst (38:55.936)
She would every now and have a little bit of problems with urgency, for the most part these things she was fully continent and she had in the picture again, which will be you know in our publication maybe we can post the thing here was a nice beautiful round. If someone points, if you have had one arrow and everyone who is listening or watching would easily be able to see wow yeah that was off and funky and there was a black thing there and then now it's this nice round circle. So to see
Kim (39:08.779)
Mm-hmm.
Jessica Probst (39:24.372)
to feel the differences in how the muscles are able to activate and the quality of the muscles, for me to feel them with my finger, to see them with an ultrasound, but most beautifully, of course, is to see the functional improvements and that dramatic improvement in the person's quality of life.
Kim (39:34.987)
Mm-hmm.
Kim (39:38.987)
That's so cool. what is actually, back to when you were describing, Imran, what PRP is, what actually is happening? Does the ligaments and tendons and muscle, is it regrowing muscle? Is it reattaching the ligament? What's actually happening that's making that change?
Imran James Siddiqui (39:58.226)
Yeah, so it's going through a natural healing process. So if we're looking at, a ligament that has a partial tear in it, what we're doing is we're putting the platelet-rich plasma both a little bit in the tear, but mostly around the tear. And so when you, I don't want to get too granular with this, when we look at like a wound and how it heals,
The healing comes from the surrounding area around the tear. And so we want to stimulate that area with platelet-rich plasma. And so when you put the platelets there, they're going to release their growth hormones. It's going to stimulate that natural area of healing to shoot the metabolism through the roof, bring extra cells there to help heal, and just really boost that.
a natural healing response. It's the body's natural healing response. We're just kind of guiding it to where it goes and stimulating it to work harder and stronger. And so that's how it's working. Now, if there are areas where the tendon or the ligament is completely pulled off the bone, putting PRP there is not gonna fix that, okay? And there are definitely, there's research papers about...
using transvaginal ultrasound to diagnose levator A &I tears and they call them evulsions. An evulsion in true terms of what we talk about in the orthopedic muscle skeletal sports medicine world is where the tendon pulls off the bone. Somehow the nomenclature got a little bit funky when OV started writing about this stuff and they called any injury
to the pelvic floor muscles and avulsion. So if you do have a true avulsion, then PRP is not gonna help, because the tendon's pulled off the bone, there's a gap between them, you can pour all the PRP you want there, it's not gonna make it come together. Now if it's a partial tear like this, you put PRP in here, it'll close up like that. But some research studies have also shown that these avulsions that were...
Imran James Siddiqui (42:16.658)
diagnosed on transvaginal ultrasound that 90 % or so are actually partial tears. so the vast majority of them are not true evulsions. And so the vast majority, 92%, are amenable to PRP.
Kim (42:34.847)
Got it. Sorry. Yeah, please.
Jessica Probst (42:35.968)
And think that's an important, if it's okay for me to jump in, I think that that's an important factor for folks to know because being told that they have an evulsion is often devastating, devastating news for them. And a lot of times, again, with what we find, there are definitely true evulsions and that there is an again, that would not be, we would not be able to help with.
Kim (42:48.598)
Mm-hmm.
Jessica Probst (42:59.232)
But a lot of people, we see a lot of people who have been devastated to hear that they have a levator of ulcer. And again, with looking with this different technology with ultrasounds that shows such detailed clarity, then we're able to see attached, you know, he's able to see these areas, which again shows that it's not. So I think that can hopefully provide a lot of hope for a lot of people who have been told that something's of ulcer, which is, well, maybe come and check it out with some different additional technology and some different providers, because a lot of times there's things that
that can be done. And we're also really straight shooters. So if there's things occasionally, there'll be more damage to a certain area. And we're really straightforward about we think that this is going to progress in this way. And we're expecting that these we think we can get there. And sometimes I will think that there's a, you know, there might be a little bit of a residual weakness in a certain muscle, but it's entirely different than than being a voles. We like to be really straightforward and transparent, and also provide
for people.
Kim (43:59.519)
Yeah, okay. The recommendation afterwards moving into the healing phase now. So after the treatment, I flew in. So I would basically, I went home to my Airbnb and I flew out the next day and no exercise, no sex, no nothing really for a couple of weeks. Like obviously you're walking around the house, that kind of thing. But what's the reason why there is no exercise and no movement? Why would that be more favorable than
I feel in my mind movement would activate and make things spread around and do their work, but I guess you're kind of trying to keep it more concentrated. Is that like layman's term way to describe it?
Imran James Siddiqui (44:43.972)
So, so, so when we are trying to get, say you have a muscle that is supposed to be attached to the bone like this, and then you have split tears like this, which is, we see this commonly, okay? If you, if we are trying to get these tears to heal together, if the muscle continues to contract, it's pulling on these tears. So what we want to do is try and...
in the first two weeks it's most important. The first two weeks is when the platelets kind of make their, it's almost, it's a scab basically. Like that scab that you get on your skin, it's made of platelets and other healing cells. So we want that to adhere to the tissue and stay in the tissue. And if you get to that two week mark, it'll stay. But within that two week mark,
if we found through our orthopedics and sports medicine treatments that if you activate those areas too much too often with too much stress in that first two week period, you don't get as good at outcomes. So that's where that comes into play.
Kim (45:56.213)
Got it. You talked about arthritis and other joint degeneration. a lot of, like when you think of the pelvis, the number of hip replacements that are happening and also the ties to incontinence. So Jess, I'm going to come back over to you here. could this potentially, this is for both of you really, I guess, but for people who are having, who have arthritis in their hips, who need a hip replacement, who have had a hip replacement, could this
come in and play a role as well, like just when there's been such degeneration in the actual joint itself.
Imran James Siddiqui (46:33.286)
So it depends. usually, now getting into the orthopedic world, there's grades of arthritis. It's pretty simple, zero through four, right? Zero nor arthritis, one is mild, two is mild to moderate, three moderate to severe, and four is severe bone on bone, right? So in general, platelet-rich plasma works very well for grade two, one to two works.
okay for grade three, anything above that, it's not gonna work. Now we do also stem cell treatments either from bone marrow or micronized adipose. Those are cellular-based treatments. Now those can treat the grade three and fours more readily. But yes, there is a limit. If the arthritis is too bad, it's not gonna work, mainly because of...
Kim (47:05.899)
gonna happen.
Imran James Siddiqui (47:29.286)
bony changes within the joint, bone spurs grow and you can regenerate all the cartilage you want, but if you have bone spurs that are hitting each other, there's nothing we can do other than surgery. However, a lot of people, and I see a lot of people believe it or not post hip replacement in my orthopedic clinic because often they had, in addition to their arthritis, had tendon injuries and ligament injuries due to...
just poor hip mechanics that led to their arthritis. The same thing led to soft sister injuries. So they get the hip replacement and they feel better, but they still have pain in certain areas and we ultrasound them and we find tendon injuries and ligament injuries. So even despite them getting a hip replacement and having bad hip arthritis, we're still able to help them get more function to heal by healing their tendon and ligament injuries.
Kim (48:25.553)
So Jess, if somebody had like, I'm just trying to think of the incontinence symptoms, you've talked about the fecal incontinence, urgency, fecal urgency, prolapse. this is not like, it's not magically going to come in and fix your prolapse, like resuspend, put your bladder right where it's supposed to be, but it could potentially mitigate symptoms by improving the muscles that are then providing the support. Was that an accurate statement?
Jessica Probst (48:31.642)
Mm-hmm.
Mm-hmm. Mm-hmm.
Jessica Probst (48:54.744)
Yeah, you did great. We'd like to under promise and over deliver. With prolapse, of course, having to do with many layers of support, you can have prolapse, which is very much tied in with muscular layers that we can affect. And then you can have other prolapse, which is tied in with ligaments with a whole lot of vasculature where we're going to be less able, we're not going to be able to visualize and address.
So a lot of people, so we like to, we don't want people to expect to come in with a visible large prolapse and then think that that is going to head back up. With that said, we've been doing, a lot of people are having, depending on the details of their particular prolapse, a lot of people are having a lot of symptomatic improvements. A lot of people think that they're, that,
It is prolapse which is causing that heavy dragging sensation and while prolapse certainly can do that, a lot of times what we're finding is actually other supportive layers of muscles in the pelvic floor, both the levator anus and that layer one muscles actually have significant injury and damage to them. So things really are sagging down. And when we address those muscles, some of our patients no longer have that heavy sagging feeling which they thought was tied in with a prolapse.
Kim (50:14.304)
Yep.
Jessica Probst (50:14.356)
The other thing that we've been doing is we've been addressing the periorithal tissues and are now starting to address tears when we can find them at the base of the bladder. It has a slightly different feel to it, which now, thanks to Dr. Siddiqi, I can identify and say, this feels this way. What's going on here?
Kim (50:30.785)
hehe
Jessica Probst (50:30.976)
And that now we know in terms of when there's sort of more of a full body feeling, a more of mushy body feeling of the peri-arethral tissues, then that has been consistent with tears that he's able to see in the peri-arethral tissues and all the way up to the level of the base of the bladder. So we're not, he's not doing injections in the actual bladder, but in these tissues, these supportive tissues around it, we're continuing, this is part of what we've been doing is about continuing to push the boundary up.
Is there any way we could see this? And then we play around with it and we figure it out together and then continue to find other ways. Of course, keeping safety top of mind. They're very, very, very specific and targeted. So we've been able to help with symptoms also tied in with that. So we're never going to say that we're going to fix your prolapse, but a good number of our patients, symptoms that they thought really were tied in with prolapse, and some of them were and maybe some of them not as much, can.
Kim (51:03.043)
You
Jessica Probst (51:28.764)
feel lot better, depending on the case.
Kim (51:31.753)
So when we're nearing the end here, my mind is also going to many people who have prolapse, many people who have urgency, many people who have incontinence will often have tension, tightness, guarding, other muscles coming in to try to save the day and do some work. So Imran, have you noticed when you're, somebody has, maybe that's part of...
what Jess has identified as a contributing factor. Do you notice any difference in the results or the efficacy of the treatment? Could it play a in helping that?
Imran James Siddiqui (52:08.862)
Yeah, so that reminds me of another case that...
we've had is so this was a patient whose primary symptom was pelvic floor spasticity or tension in their pelvic floor. Couldn't do anything insertional with the vagina because the tension was so bad. They were actually getting Botox injections to the pelvic floor and they were helping, not 100 % that they helped her function in her daily life, but had to get them
Jessica Probst (52:22.889)
Thank you.
Imran James Siddiqui (52:44.66)
every three months or so. then, so when I saw her, I took a step back and went through her whole history of her pelvic floor. And actually this all had started after she had had a surgery for a separate condition around the rectal area. so I didn't look at, I didn't start, I looked at her pelvic floor, but I started actually around that area and saw that there was scar tissue and
areas that didn't fully heal in that area. actually, her, she was...
She was not postpartum. She hadn't had any pregnancies. And so actually her pelvic floor muscles looked fine to me. Their tendons, ligaments, all that looked fine. So we actually treated her scar tissue around her rectal area and all her pelvic floor tension went away. So it was actually the scar tissue from the rectal area tugging on everything. And then, you know, what we see both in the general muscle
musculoskeletal area and also the pelvic floor is that if an area is being pulled or in a certain area, it's going to try and counteract that. The body wants balance, right? So it's gonna spasm, those muscles are gonna spasm to pull everything back into alignment and then they just stay in spasm. And so we were able to release that scar tissue, heal some of those injuries in scar tissue and she has back to being able to have a functioning pelvis.
So that goes right along with what you're describing in terms of treating one area and allowing other areas to relax.
Kim (54:30.987)
That's really cool.
Jessica Probst (54:31.198)
Another part with pelvic tension is if there's tension in a certain part of a muscle, it's going to inhibit the muscle's use, especially if there's something underlying piecing like scar tissue. So we do, and it's really useful, again, this is part of why we're with this wonderful partnership with the advanced manual work with the pelvic floor therapist and the wonderful work that Dr. Siddiqi does. It goes really nicely together because sometimes just even when there's patients also that I would take into him,
with tension post childbirth that I couldn't feel a defect, but there's something going on in this spot here. And I've done a whole bunch of different manual techniques, but there's something that I can't get at. And I...
There's a patient I'm remembering first one of these I bought to him where I said I think there's I think I can't feel a defect But I think that there's something in here Which is I think that there's something that I can't feel some scar tissue problems that I can't feel because this is not Responding the way that it should be responding usually I don't you know It's not usual problem here unless there's another underlying piece and he's looked he's been able to say yeah and find problems find scar tissue deep inside of muscles
free that up and then la, voila, the manual therapy actually works because the underlying damage there that the muscle is bracing, compensating around and then causes inhibition through those areas is addressed. So that's been just really hugely helpful.
Kim (56:03.805)
Amazing. We're very glad we've even gone over time. I'm so grateful for your time for both of you. is there anything Imran is there anything that I haven't asked? There's a lot more. I have so many more questions, but it just high level. Is there anything that you want to add that we haven't talked about?
Imran James Siddiqui (56:19.442)
Well, just one thing for you, Kim. I want to thank you for having us, but also for having this podcast and doing what you're doing. Like I got into this because I saw that there there's just this huge void in pelvic health care. And the fact that you're doing such an amazing job of trying to promote pelvic health care, trying to get the word out. We just need to, we just need to talk about it more. That's the problem.
There's this whole, like no one wants to talk about it. OBs don't even want to talk about it. Like no one, like medicine, they don't want to talk about it. And it needs to be talked about because it's, you know, than 50 % of our population is women and vast majority of them are going to have children at some point in their life or have a pelvic floor injury. And this has to be talked about. It has to be addressed. We have to have people, you know, addressing these issues and helping so many people that problems with this. So thank you very much for having us and also thank you very much for doing this.
Kim (56:46.475)
Yeah.
Jessica Probst (56:47.521)
You
Imran James Siddiqui (57:13.692)
from doing this, you're gonna be helping a lot of people.
Kim (57:16.289)
Thank you, I appreciate it. Jess, anything that you want to, any final words?
Jessica Probst (57:20.635)
I just will plug in here also that I know this is between two lips, but we will also see men with pelvic floor problems. So we collaborate also with men. So for anyone, and again, that's the public an area where there's a desert. So we've been able to really help also men who have pelvic floor problems as well. So I'll put that plug in, but I think that this is wonderful. It's really exciting. I think that some of the work that we're doing might really lay some foundation for
how I'm hoping we can move forward in the field to really help people at a much, much deeper level with a lot less side effects than some of the options we have right now.
Kim (58:02.283)
Yeah, well, I of course want you to have an amazing practice. I also want you to teach other practitioners. So this will be something that that expands throughout the world. Where can people find like, what is the process I guess right now? Is it changed from when I was there? Do you is there a separate website or first of all, Jessica, where can we find you just in your general pelvic health practice? And then we'll hand it over to Imran to share his as well.
Jessica Probst (58:09.7)
Yes.
Jessica Probst (58:27.578)
Sure. So the practice I created is called Thrive Again Physical Therapy and Wellness and you can find a lot more online at thriveagainpt.com and we're also happy, we do free brief phone consultations or paid longer phone consultations and also we're happy to email with people just to find out just a little bit about the case because at this point we have a good gauge it can pick up
about people who might be good candidates for this here and if I suddenly want to try. And we're happy to see local people and we're also happy to see people from different places, people flying from different places in the world and we're delighted to see them and take care of them too.
Kim (59:11.073)
Yeah, and that's, I forgot that piece of it. I did do a phone consultation or Zoom consultation with you as well prior to coming down there just so you could kind of gauge like is, should you come down and will this be helpful? Yeah.
Jessica Probst (59:16.213)
Yeah.
Jessica Probst (59:21.81)
So these days, as we've continued to progress and gotten more and more data, we've seen more and more people. Usually people don't even need as long consultations as I was doing originally because we see more and more people. I'm likely to say, odds are good, we can help with this, this, this.
Kim (59:35.093)
Mm-hmm.
Jessica Probst (59:43.729)
I'm not guaranteeing anything about your prolapse and this other symptom here is probably not, we can give it a try, but if these symptoms that you have are important to you, those are areas where we regularly can help most people with. So we can usually give information without even needing as long of a virtual intake.
Kim (01:00:02.849)
Awesome. And Imran, where can people find you?
Imran James Siddiqui (01:00:05.274)
So the name of our practice that we started earlier this year, we kind of, I was at regenerative orthopedics and sports medicine. That's our sports medicine practice, but kind of branched off, started a regenerative pelvic Institute. Our website is rpiclinic.com. You can, you can find us there. It is, it is very bare bones right now, but it has some basic information, how to get in contact with us.
And then so you can go either way. can contact our office first and then we can send your information over with your permission to Dr. Probst team or you can contact Dr. Probst first and she'll get us your information. And so either way works. And so we still have some more kinks to work out, but it's a better process than when we start.
Jessica Probst (01:00:58.653)
yeah, we're getting there. Yeah, and we do encourage people, especially with out of town, it's especially important for them to make sure that they don't miss coming to see me first so I can do my fair evaluation. Then I come in and I tell you, we rock and roll. We'll walk down together and then I can clearly, concisely present the case, get things targeted, and then can work as magic. So again, the collaboration's super important.
Kim (01:01:24.319)
Yeah, yeah, it was amazing. It was an amazing experience. I'm so grateful for both of you for the work that you do and that you've come together and you're collaborating. You're gonna help so many people. And yeah, thank you so much for sharing your time here as well. I know that this is gonna be a very well listened to episode and I suspect you'll have several patients coming your way. So thank you so much.
Imran James Siddiqui (01:01:45.104)
Well, thank you for having us. We really appreciate it. Wonderful to be here.
Jessica Probst (01:01:45.247)
Thank you.
