Thoracic Spine Rehabilitation and Regenerative Medicine

How does platelet rich plasma (PRP) therapy work?

The patient's blood is centrifuged to make a concentrated formula with a 3-5x higher amount of platelets

Platelets contain growth factors that can promote tissue healing, growth, and remodeling

How often does someone have to receive PRP? How long does it take to see improvements?

May require multiple injections 1-2 weeks apart

Usually will see improvements in 4-6 weeks, but can take up to 3 months

Limitations of PRP

Lack of standardized protocols

Variable insurance coverage

Mixed outcomes

Is PRP easily covered by insurance? How much does it cost out of pocket?

Not really. In special cases yes

1-8 injections can cost between $5,000-$8,000

In what cases does insurance cover PRP?

Tricare may cover PRP for mild to moderate knee OA or lateral epicondylitis

Medicare may cover PRP for chronic, non-healing, non-regenerative, diabetic, pressure, or venous wounds

What orthopedic conditions hold the most promise for PRP therapy?

Tendinopathies and hamstring strains

How to load tendon for optimal recovery

Eccentric loading, heavy-slow resistance

How to load cartilage for optimal recovery

Progressive weightbearing, cycling, aquatic loading

How to load muscle for optimal recovery

Gradual concentric/eccentric loading, avoid early overstretch

How to load ligament for optimal recovery

Proprioceptive training, bracing early if needed

What are the four different types of interventions for an osteochondral defect?

Osteochondral autograft transfer (OAT)

Osteochondral allograft transfer (OCA)

Autologous chondrocyte implantation (ACI)

Microfracture

Osteochondral autograft transfer (OAT)

Used to treat osteochondral defect

Graft comes from within the same person

Used for small lesions and hyaline cartilage

Pt will have limited WB for at least 8 weeks afterwards

Osteochondral allograft transfer (OCA)

Used to treat osteochondral defect

Graft comes from a cadaver

Used for larger lesions

Autologous chondrocyte implantation (ACI)

Used to treat osteochondral defect

Healthy cartilage cells are harvested from within the same person, from a non-weightbearing area

Used to treat large lesions and hyaline-like cartilage

Microfracture

Used to treat osteochondral defect

Small lesions (holes) made in bone in damaged cartilage area

Used for fibrocartilage lesions

Common in younger patients

In the thoracic spine, if thoracic pain is above T6, what else should you include in your examination?

Full cervical spine exam + shoulder girdle exam

What two things must you consider to decide whether thoracic pain is truly an orthopedic lesion?

MSK exam is positive, visceral exam is negative

Causes of posterior MSK related pain in thoracic spine

Disc injury

Facet dysfunction/pain

Vertebral or rib fracture

Rib subluxation

Scoliosis

Kyphosis

Flattened T-spine

Scheuermann's disease

Causes of posterior non-MSK related pain in thoracic spine

Kidney infection

Spinal tumor

Myocardial infarction

GERD

Causes of anterior MSK related pain in thoracic spine

Costochondritis

Arthritis

Muscle spasm

Rib contusion

Rib fracture

Rib subluxation

Causes of anterior non-MSK related pain in thoracic spine

Stable angina

Unstable angina

Pericarditis

Pneumonia

Pulmonary embolus

Pneumothorax

Myocardial infarction

GERD

What are the structural implications of a flat T-spine?

Could potentially see hypermobility, since the kyphotic curve is what provides strength to the thoracic spine

Components of thoracic exam in standing

Posture

Breathing

Neck flexion (if it reproduces global pain, it is a neural stretch; if it reproduces localized pain, it is a hypomobile segment)

Scap squeeze (looking for gross weakness)

Gross shoulder clearing

Gross trunk AROM + overpressure

Resisted side flexion

Components of thoracic exam in sitting

T-spine ROM + overpressure

MMTs

LE neuro exam

Stability testing

C-spine AROM and shoulder clearing (if upper T-spine involvement)

Breathing

Components of thoracic exam in prone

Tenderness/ease of movement

Muscle tone/tenderness

Bony symmetry

Spring testing of spinous processes, transverse processes, and ribs

Components of thoracic exam in supine (if indicated)

1st rib assessment

Spring testing of ribs, sternum, and clavicle

Abdominal muscle strength

Organ palpation

Capsular pattern of restriction for thoracic spine

Equal loss of sidebend and rotation, then extension

Capsular pattern of restriction for lumbar spine

Equal loss of sidebend and rotation, then extension or extension + sidebend + rotation

Capsular pattern of restriction for cervical spine

Equal loss of sidebend and rotation, then extension

Description of pain caused by intervertebral facet joints

Unilateral paravertebral pain

Felt deeply and locally, but does not go further than the medial edge of the scapula

Description of pain caused by disc

Deep, central ache with pain piercing through chest

Pain runs posterior to anterior along rib with sudden shooting pain (if nerve root involved)

Description of pain caused by ankylosing spondylitis

Pain spreads vertically, starting in lumbar spine

How does the shoulder abduction sign (Bakody's sign) differentiate between thoracic outlet syndrome and cervical radiculopathy?

If hand on head relieves radicular symptoms, it indicates cervical radiculopathy because the neural tension is removed

If hand on head does not relieve radicular symptoms or worsens them, could be thoracic outlet syndrome or a shoulder issue

Ankylosing spondylitis - signs and symptoms

Kyphotic posture

Inflammation in other joints and eyes

Weight loss

Lower back and/or hip pain and stiffness, worsening with rest or inactivity

Ankylosing spondylitis - risk factors and prevalence

Commonly onsets <30 years of age

Risk factors: male, Crohn's disease, ulcerative colitis, psoriasis

Ankylosing spondylitis - treatment

Movement and exercise to improve pain

Scheuermann's disease - charateristics

Form of juvenile osteochondritis

Found mostly in teens and presents with significantly worse deformity than simple postural kyphosis

Cannot correct posture

Wedging and Schmorl's nodes present on x-ray

Scheuermann's disease - treatment

Management

Gentle mobility and stability

Costochondritis/Tietze's syndrome - characteristics

Inflammation of cartilage connecting a rib to the sternum

Symptoms: sharp, localized chest pain to a defined area of costal cartilage/joint articulation, pain with coughing/deep breathing, pain with end-range stretch, pain with direct pressure

Costochondritis/Tietze's syndrome - treatment

Ice

Rest

Gentle stretching

Tape/bracing

Breathing exercises

Rib fracture - clinical presentation

Sharp, localized pain at site of fracture that sharply increases with breathing and trunk motions (inspiration, laughing, coughing, sneezing)

May have swelling or bruising over fracture

Rib fracture - treatment

Ice

Rest

Gentle stretching

Tape/bracing

When fracture is closed, do gentle progressive mobility exercises

Characteristics of traumatic T-spine fractures (vertebral or rib)

Severe central pain to be expected for 2-6 weeks

For first week, there is often girdle pain

If uncomplicated, spontaneous cure to be expected within 12 weeks

Treated with pain meds, rest, gradually progressing flexion/impact/compression activities, and back brace

Characteristics of compression fractures in T-spine

Risk factors: Caucasian, female, smoking, early menopause, thin, sedentary lifestyle, steroid treatment, excessive consumption of caffeine

Signs: moderate decrease in trunk ROM with pain, pain w/ palpation over spinous process

Tend to occur around T10-T12, rarely occur above T7

Prevalent in over 50% of people >80 years

Conservative treatment of a fracture

Relative rest

Positioning

Pain-relieving modalities

Decrease risk of falls

Strengthen trunk muscles

Improve postural alignment

Avoid exercises involving too much forward flexion, sidebending, or twisting

Avoid water or endurance exercises, since they have been shown to negatively affect bone density

Unavoidable risks for osteoporosis

Female

Small frame

Advanced age

Hormone levels

Genetics

Predisposing medical conditions

Avoidable risks for osteoporosis

Cigarette smoking

Excessive alcohol intake

Inactive lifestyle

Excessive caffeine intake

Lack of weightbearing exercise

Drugs, such as steroids or heparin

Poor health

Low weight

Calcium-poor diet

Low vitamin D levels

Weightbearing exercises and resistance exercises to use to prevent osteoporosis

Dancing

Jogging (if bone density is higher than -3.0)

Racquet sports

Heel drops

Stomping

Weightlifting

Use of exercise bands

Exercises done against gravity

Exercises that reduce or stabilize kyphosis

Balance exercises

Important questions to ask if you suspect cancer/metastatic cancer

Prior history of cancer within last 5 years

Family history of cancer

Important questions to ask if you suspect GI involvement

Presence of abdominal pain

Symptom response to eating

Changes in digestion

Meds like prolonged NSAID use

Important questions to ask if you suspect pulmonary involvement

Medical history

Vitals

Medications

Response to activity

Pain with breathing

Important questions to ask if you suspect cardiac involvement

Medical history

Vitals

Medications

Response to activity

Pancoast tumor - characteristics

Tumor on lungs

Pain can be directed to cutaneous portion of intercostal nerves and will follow a distribution

Can present with arm/shoulder pain and hand numbness/tingling/weakness

Screening for gallbladder involvement

Symptoms related to eating timing/contents, or after eating

Chronic symptoms: acid reflux, gas, diarrhea, stoll abnormality, discolored urine, mid-low back pain in addition to right upper quadrant pain

Acute symptoms: nausea, vomiting, fever, chills, jaundice

Screening for uterine fibroids

Heavy menstrual bleeding

Menstrual periods lasting more than a week

Screening for prostate involvement

Sciatica (most common type of referred pain in advanced prostate cancer)

Advanced prostate cancer: dull deep pain/stiffness in pelvis, lower back, ribs, or upper thighs in addition to genital pain

Pain when peeing, needing to pee frequently (esp. at night), problems starting or stop-start peeing, urgency, blood in urine