Professional Writings by Medical Practitioners, Max Super Speciality Hospital, Saket

7Utility of Cardiac Magnetic Resonance Imaging

4 TIPS - Transjugular Intrahepatic Portosystemic Shunt

INSIDE

6Laparoscopic Surgery in

Emergency

8Effect of Heat - Stretching &

Dry Needling

Dwarfism may be due to several musculoskeletal and hormonal growth disorders. The most common cause is considered to be achondroplasia, a condition due to a mutation affecting the Fibroblast Growth Factor Receptor (FGFR) gene 3. Achondroplasia occurs with equal frequency in males and females. It is inherited

[1]in an autosomal dominant manner. At least 80% of cases result from a random new mutation. In sporadic cases, a paternal age older than 36 years is common. Most parents are of average size and have no family history of a dwarfing condition. The risk of the parents producing a second affected child is almost

[2] [7]negligible. These patients' sitting height is within normal range.

Despite an estimated prevalence is 1:25,000 in the general population, there is little literature concerning the diagnostic and treatment challenges faced by doctors dealing with CAD in such patients requiring myocardial revascularization.

CASE REPORTA 46 -year-old Iraqi male with achondroplasia presented with intermittent rest angina & dyspnoea for last 1-2 months relieved by sublingual nitrate. His height was 85 cm, his weight was 70 kg, and he had severely atrophic limbs with kyphoscoliosis (Figure 1). He was having hypertension and hyperlipidemia as risk factors. The electrocardiogram showed Q wave in inferior leads with T wave inversion (Figure 2). Echocardiogram revealed LV ejection fraction of 45-50% with RWMA.

CAG was planned via radial artery route in view of femoral artery access issues and to avoid local bleeding complication. Left radial artery access was taken as preferred route in view of anticipated tortuosity. There was severe tortuosity in brachial artery (Figure 3) and great difficulty was encountered in tracking diagnostic catheter. Angiography revealed TVD with critical disease in LAD, major diagonal, major OM and RCA proximal which was 100% occluded (Figures 4 & 5). Surgical revascularization was the initial plan. Heart team was involved. CABG required multiple grafts but in view of severe musculoskeletal deformity, surgeons were not optimistic of suitable grafts. So PTCA was planned after taking informed consent. Patient was preloaded with Ticagrelor 180 mg, aspirin 325 mg and atorvastatin 80 mg. Unfractionated heparin was used as the anticoagulant. PTCA

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Vol.6 (October 2014)

Dr. Viveka Kumar

Director – Cath Lab Sr. Consultant – Interventional Cardiology & ElectrophysiologyMax Hospital, Saket

A Case of Multivessel PTCA in Achondroplasia Patient

+S with DES were done to RCA, LCX-OM2 and MID LAD, POBA to proximal PLB and diagonal arteries.

PTCA was done via right femoral artery access using 7Fr femoral sheath. Ultrasound guided femoral artery puncture was done. The RCA was cannulated with 7 Fr, 3.5 curve Judkins right guiding catheter with the catheter tracked over an amplatzer super stiff wire because of the severe iliac artery and abdominal aortic tortuosity (Figure 6). Lesion was crossed with 0.014˝ whisper guidewire with the support of a 1.25 x15 mm balloon. A 3.5 x 36 mm DES was deployed across the lesion in RCA at 14 atm after pre-dilatation. After dilating proximal 100% RCA lesion, another critical lesion was evident in proximal segment of a very large PLB. Prolonged low pressure dilation to proximal PLB lesion was done with 2.5 X 10 semi-compliant balloon at 6atm. Distal TIMI 3 flow was achieved at the end of the procedure (Figure 7 & 8).

Then LCA was cannulated with 7 Fr, 3.5 curves EBU guiding catheter. A 0.014˝ whisper guidewire was then used to cross the OM2 lesion. A 2.5 x 14 mm DES was deployed across the lesion from LCX-OM at 14 atm after pre-dilatation. Post-dilatation distal TIMI 3 flow was achieved (Figure 9 & 13).

Then whisper wire was crossed across diagonal lesion and 0.014” BMW wire was crossed across LAD lesion. Balloon dilatation was done to proximal diagonal lesion with 2.5 x 10 semi-compliant balloon at 8 atm . A 2.5 x 33 mm DES was deployed across the mid LAD lesion at 14 atm after pre-dilatation. Postdilatation distal TIMI 3 flow was achieved (Figure 11 & 12). Right femoral artery puncture was closed with Proglide PERCLOSETM femoral closure device after completion of the procedure. Later course in the hospital was uneventful and he was discharged in a stable condition on day 3 of hospitalization. After discharge, the patient was placed on aspirin, ticagrelor, statin, beta-blocker and ACE inhibitor.

DISCUSSIONMortality in general in these individuals for all age groups is 2.27 times more than that of the general population, cardiovascular problems being the most frequent causes of

[8]death in persons aged 25-54 years. Apart from the traditional risk factors, there seems to be other occult genetic or other unknown factors responsible for this increased risk. No large cohort studies have

been done to delineate these additional factors till date. There is dearth of literature regarding the technical aspects of coronary intervention in this group of individuals. There are a few reports of coronary artery

[9, 10] bypass surgery in these patients, and a single report on PCI to RCA as rescue PCI

[11]post thrombolysis . Option of CABG in the setting of multivessel CAD in an achondroplastic patient may be ruled out because of non-availability of adequate grafts as in our case. However there is a report of successful CABG after a phlebography of the limbs revealed

[10]adequate saphenous veins , but the patient had a height of 137 cm height, in our case patient's height was 85 cm only. So in such short patients with multi-vessel CAD multivessel PTCA may be the only option to achieve myocardial revascularization. To our knowledge, this is the first case report of mutivessel PTCA in an achondroplastic patient. Radial intervention may prove to be particularly challenging in such cases, but with proper hardware and adequate skills it may still be feasible to do non-complex PTCA. Local bleeding complications were minimized by using USG guided femoral artery puncture and post procedure use of Per-close femoral artery closure device. Our case demonstrates that patients with achondroplasia can safely undergo multivessel coronary angioplasty without additional risk.

CONCLUSION Achondroplastic patient having multivessel CAD pose a great challenge for myocardial revascularization. CABG as an option may be limited by non-availability of normal saphenous vein grafts in such patients having severely dysmorphic limbs. Multivessel PTCA can be safely performed in pat ients wi th dwarf i sm due to achondroplasia with the available technical knowhow and hardware. Further studies need to be done to look into the increased risk of CAD in such population.

REFERENCES1. Scott CI Jr. Medical and social adaptation in

dwarfing conditions. Birth Defects Original Article Ser. 1977; 13(3C):29-43.

2. Baitner AC, Maurer SG, et al. The genetic basis of the osteochondrodysplasias. J Pediatr Orthop. Sep-Oct 2000; 20(5):594-605.

3. J . M . P a r r o t . L e s m a l f o r m a t i o n s achondrodysplasiques. In: Bulletins de la Société d'anthropologie de Paris, 1878. 1878.

4. Bailey JA 2nd. Orthopaedic aspects of

achondroplasia. J Bone Joint Surg Am. Oct 1970;52(7):1285-301.

5. Nelson MA. Orthopaedic aspects of the chondrodystrophies. The dwarf and his orthopaedic problems. Ann R Coll Surg Engl. Oct 1970; 47(4):185-210.

6. Horton WA, Hall JG, Hecht JT. Achondroplasia. Lancet. Jul 14 2007; 370(9582):162-72.

7. Laederich MB, Horton WA. Achondroplasia: pathogenesis and implications for future treatment. Curr Opin Pediatr. Aug 2010; 22(4):516-23.

8. Wynn J, King TM, Gambello MJ, Waller DK, Hecht JT. Mortality in achondroplasia study: A 42-year follow-up. Am J Med Genet A. Nov 1 2007; 143(21):2502-11.

9. Balaquer JM, Perry D, et al. Coronary artery bypass grafting in an achondroplastic dwarf. Tex Heart Inst J. 1995;22(3):258-260.

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Figure 2: ECG

Figure 1

3

Figure 4: RCA proximal 100% occluded

Figure 5: Critical disease in LAD, major diagonal and major OM

Figure 6: Right femoral artery access with Iliac artery tortuosity

Figure 7: RCA after predilatation 2.5 x 10 mm balloon at 6atm

Figure 8: RCA after stent deployment and dilatation to proximal PLB

Figure 9: Predilation to OM with the 2.5 x 10 mm balloon at 14atm

Figure 10: Whisper wire in D1 and BMW wire in LAD

Figure 11: 2.5 x 33 mm DES was deployedin the mid LAD lesion at 14 atm

Figure 12: LAD after post-dilatation with 2.5 x 10 mm balloon at 14-16atm

Figure 13: 2.5 x 14 mm DES deployed in LCX-OM, after post-dilatation

Figure 3: Tortuosity in Brachial artery

Transjugular Intrahepatic Portosystemic (TIPS) Shunt - Salvage Therapy for Refractory Variceal Bleed

CASE HISTORYMr. H, a 61 year old male, is a known case of is a known case of alcoholic liver disease with cirrhosis with portal hypertension diagnosed on the basis of biochemistry (Hb – 9.1 gm/dL, INR – 1.68, Total bilirubin 3.3 mg/dL, Total Protein 7.1g/dL and platelet count 150,000) and USG findings (evidence of cirrhosis with portal hypertension with splenomegaly with ascites).

Patient had hematemesis on Aug 19th, 2014s back in his hometown for which he came to Max Hospital, Saket, 3 days later. Upper Gastro Intestinal Endoscopy (UGIE) was done which revealed Grade-II oesophageal varices and a large gastric varix. No evidence of bleeding could be ascertained.

He again presented on Aug 27th, 2014 with complaints of sudden onset of hematemesis. Initial investigations revealed an Hb of 6.9 g/dL, INR of 1.82, Platelet count of 105,000, Ammonia was 213 and TLC of 6.8.

UGIE done on Aug 27th, revealed evidence of Grade-II oesophageal varices and a large gastric varix with cherry red spot suggestive of recent bleeding. Endoscopically, glue was inserted into the gastric varix. Patient remained stable for 2 days, when he had another bout of hematemesis. Repeat endoscopy was performed which revealed a large clot in the stomach secondary to the bleeding gastric varix. A repeat injection of glue was performed which was unable to stem the flow of blood. Subsequently, the patient was intubated and a Sengstaken – Blackmore tube was introduced and the gastric balloon was inflated in an effort to stop the bleed. At this point, placement of a TIPS shunt was considered for reducing the pressure in the portal system. After detailed discussion with the patient’s relatives a TIPS shunt was placed connecting the branches of the right hepatic vein and right portal vein. Also a large gastric varix was identified which was obliterated by gelfoam injection through the TIPS shunt. Post placement of the TIPS shunt, the portosystemic gradient fell from 20 to 14 mm Hg. The TIPS shunt was successful and the patient remained hemodynamically stable (Hb stabilized at 9.0

gm/dL) and there was no hematemesis or malena. The Sengstaken tube was deflated after 72 hrs and monitoring was done to watch for signs of upper GI bleeding and hepatic encephalopathy.

USG was done on a periodic basis to ascertain patency of the shunt. Ammonia levels were carefully monitored to assess for hepatic encephalopathy. No fresh upper GI bleed has been was observed since then and patient has remained hemodynamically stable. Patient is now being worked up for hepatic transplant.

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNTTransjugular Intrahepatic Portosystemic Shunt (TIPS) is the percutaneous formation of a tract between the hepatic vein and the intrahepatic segment of the portal vein in order to reduce the portal venous pressure. The blood is shunted away from the liver parenchymal sinusoids, thus reducing the portal pressure. TIPS, therefore, represents a first-line treatment for complications of portal hypertension, typically in patients with decompensated liver cirrhosis.

HEMODYNAMICSPortal blood pressure is normally low resistance as compared to systemic arterial pressure because the blood has already passed through the high resistance capillary beds of the more proximal organ. As a result, the organ which receives the portal blood i.e liver should offer less resistance for onward blood flow. This is achieved by the livers unique architecture which allows blood to pass through sinusoids and not capillaries. In liver cirrhosis, there is a distortion of the liver architecture due to fibrosis causing a high resistance system to develop. This causes portal back pressure changes and hypertension which eventually lead to increased blood flow in the portosystemic collaterals. Some of these abnormally enlarged tortuous collaterals especially in the gastroesophageal region may rupture leading to upper GI bleed. TIPS shunt diverts blood away from the liver and

creates an alternative low resistance pathway to the portal blood flow, thereby reducing the pressure in the portal system. This helps in controlling the variceal bleed

PROCEDUREAccess is usually gained through the right Internal Jugular Vein. The right hepatic vein is accessed using a wire catheter technique. Subsequently, a direct puncture is done through the liver parenchyma to access a branch of the portal vein and after dilatation of the tract a metallic stent is placed in this tract from the right hepatic vein to the portal vein.

INDICATIONS1. Acute and Uncontrolled variceal

hemorrhage from esophageal, gastric, and intestinal varices that do not respond to endoscopic and medical management

2. Prevention of recurrent gastro-esophageal bleed unresponsive to medical therapy

3. Refractory ascites4. Refractory hepqtic hydrothorax5. Budd-Chiari syndrome6. Bridge to transplantation 7. Hepatorenal syndrome (HRS)

CONTRAINDICATIONSAbsolute1. Severe and progressive liver failure

(Based on Childs-Pugh Score - Scores A and B have a better outcome than C)

2. Severe encephalopathy3. Polycystic liver disease4. Uncontrolled systemic infection or

sepsis5. Severe right heart failure6. Unrelieved biliary obstruction

Relative1. Portal and hepatic vein thrombosis2. Pulmonary hypertension3. Hepatopulmonary syndrome4. Active infection5. Tumor within expected path of shunt

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Dr. Vivek Saxena

a b aDr. Vivek Saxena , Dr. Vivan Talwar , Dr. Bharat Aggarwal aDepartment of Radiology, Max Hospital, SaketbDepartment of Gastroenterology, Max Hospital, Saket

COMPLICATIONS1. Hepatic encephalopathy2. Liver dysfunction3. Sepsis

PROCEDURE RELATED1. Transcapsular rupture of liver2. Bleeding – Intraperitoneal/hemobilia3. Stent malposition / occlusion4. Morbdity and mortality (2 %)

TIPS AS A BRIDGE TO TRANSPLANTThe definitive treatment of liver cirrhosis is liver transplant. Unlike surgical shunts, a TIPS shunt does not interfere with subsequent liver transplantation. Pretransplantation TIPS shunt placement has shown to improve the general condition and nutritional status of the patient, reduce operative blood loss and procedure time and decrease hospital stay.

REFERENCES1. Transjugular intra-hepatic portosystemic

shunt for refractory variceal bleeding: Bizollon T, Dumortier J et al; Eur J Gastroenterol Hepatol. 2001 Apr;13(4):369-75

2. Transjugular Intrahepatic portosystemic shunt: Efficacy for the treatment of portal h y p e r t e n s i o n a n d i m p a c t o n l i v e r transplantation: Cosenza CA , Hoffman AL et al: Am Surgeon1996;62:835

3. Tips for controlling portal hypertension complications: efficacy, predictors of outcome and technical variations: Radiol Bras vol.39 no.6 São Paulo Nov./Dec. 2006

4. S a l v a g e t r a n s j u g u l a r i n t r a h e p a t i c portosystemic shunt followed by early transplantation in patients with Child C14-15 cirrhosis and refractory variceal bleeding:a strategy improving survival: Transplant International Volume 26 Issue 6; March,2013

5. Urgent transjugular intrahepatic portosystemic shunt for control of acute variceal bleeding: Banares R , Casado M et al: Am J Gastroenterol. 1998 Jan;93(1):75-9

6. Comparison of transjugular and surgical portosystmic shunts on the outcome to liver transplantation; Menegaux F, Keeffe E B et al; Arch Surg1994;129:1018

7. Use of transjugular intrahepatic portosystemic shunt as a bridge to liver transplantation in a patient with severe hepatopulmonary syndrome: Lasch H M, Fried M W et al; 2001 Feb;7(2):147-9.

8. Role of TIPS as a Bridge to Hepatic Transplantation in Budd-Chiari Syndrome: Robert K Ryu, Jannett Durham et al;,Journal of Vascular and Interventional Radiology;Volume 10, Issue 6, Pages 799–805, June 1999

9. Vascular and Interventional Radiology by Karim Valji 2nd Edition

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Figure 1: Accessing the right hepatic vein

Figure 2: Portal puncture of right 2nd order branch of portal vein

Figure 3: Dilatation of the hepatoportal tract

Figure 6: Flow through the TIPS stent

Figure 7: Gastric varices

Figure 8: Gastric varices – post embolisation

Figure 4: Insertion of the TIPS stent

Figure 5: Ballooning of the TIPS stent

Figure 9: Doppler of blood flow through the TIPS stent after 1 week

Figure 10: Colour Doppler of blood flow through the TIPS stent after 10 days

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Laparoscopic Surgery in Emergency: Gastric Volvulous with Hiatus Hernia

ABSTRACTMesenteroaxial Volvulous with Hiatal Hernia is an uncommon problem and is caused by rotation at the transverse axis of the stomach. This can lead to ulceration, strangulation and necrosis of the strangulated segment. This can present in a variety of ways ranging from dysphagia and upper abdominal pain to acute abdomen in emergency. We present a case of 54 year old male who presented with dysphagia . He was investigated and found to have Mesentero axial volvulous with hiatus hernia which was delt laparoscopically with reduction of the hernia with Nissen's fundoplication and mesh repair.

CASE REPORT45 year old male presented in emergency with acute onset dysphagia. There was no past history of dysphagia, weight loss of odynophagia. Abdomen was soft. X-ray plain picture abdomen showed a large air pocket in chest with air fluid level. Contrast enhanced CT confirmed the findings of x-ray and a diagnosis of mesenteroaxial gastric volvulous with hiatal hernia was made. After resuscitation in emergency, he was prepared for Surgery. It was found that a large hiatal hernia was present which had a mesetroaxial volvulous in it. The gastric contents in the thoracic cavity were reduced Laparoscopically. He underwent Laparoscopic Nissens Fundoplication to correct the hiatal hernia and the hiatal defect was reinforced with composite mesh. Stomach was fixed to avoid the recurrence of volvulous.

Post operative period was uneventful and patient was discharged on the 3rd day. His dysphagia which improved in the late post operative period resolved completely in 2 weeks.

DISCUSSIONMost of the patients of hiatal hernia do not have any symptoms. Two type of gastric volvulous are identified, organoaxial and mesenteroaxial. Intrathoracic mesenteroaxial volvulous is an uncommon condition. It can be repaired with gastropexy along with repair of the defect in the hiatus.

The recurrence rate after hiatal hernia repair can 1be reduced after application of mesh . Repair

can be done transthoracic or transabdominally. The gastroesophageal junction should be infradiapragmatic post-operat ively. Fundoplication treats GERD and prevents future

2intrathoracic migration of stomach .

CONCLUSIONRepair of the hiatus hernia with gastric volvulous can be done laproscopically. Nissen's fundoplication with mesh hiatus hernia repair along with gastropexy give satisfactory results.

REFERENCES1. Hiatal Hernia. Waqar A Qureshi, Julian Katz.

Medscape

2. Laparoscopic repair of chronic intratoracic gastric volvulous. Namir K, Eli M, Kranthi A et al, Science Direct. Vol 128, Issue 5:Nov 2000 pg 784-90

Dr. Ashish Vashistha

Dr. Ashish Vashistha, Dr. Amar Bajaj, Dr. Nitin SardanaDepartment of General Surgery, Max Hospital, Saket

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Utility of Cardiac Magnetic Resonance Imaging in Evaluating Left Ventricular Aneurysm

BACKGROUNDLeft ventricular aneurysm (LVA) is defined as circumscribed, thin-walled, non-contractile

(1)out-pouching of the ventricle . True aneurysm of left ventricle (LV) develops after completed myocardial infarction resulting in the out-pouching of thinned and scarred myocardium which becomes dyskinetic in systole. LV aneurysms predispose to thrombo-embolism, congestive cardiac

(2)failure, and ventricular arrhythmias .

CASEThe patient is a 65 years old man admitted to the hospital with past history of myocardial infarction treated with PTCA and now having chest pain. Echocardiography showed a large aneurysm arisingfrom the posterior-lateral wall of left ventricle measuring (70 X 65 mm) with evidence of alarge thrombus within it. (Figure1)

morphology of the aneurysm and adjacent myocardium. Furthermore, it demonstrates the continuity of the myocardial wall, thus differentiating between a real and a pseudo- aneurysm. If surgical repair is being considered, the identification of viable myocardium is important and tissue characterization by MRI delivers additional key information not available with other techniques. Furthermore, the dynamic nature of MRI scanning and its ability to quantify LV ejection fraction, LV volumes, and mitral regurgitation allow operative p l a n n i n g a n d a p p r o p r i a t e r i s k

(2)stratification .

Management of aneurysm largely depends on presenting symptoms and nature of aneurysm i .e . true aneurysm or pseudoaneurysm. Perceived high risk of spontaneous rupture associated with pseudoaneurysm and its catastrophic consequences dictate urgent surgical repair whereas true LV aneurysm can be managed both surgically and medically. Medical management focuses on reducing the risk of embolism and treating underlying congestive cardiac failure. The aim of surgical therapy is restoration of LV geometry, LV volume reduction, and the relief of ischemia by CABG in the presence of concomitant coronary artery disease in viable myocardial territory (4).

REFERENCES1. Hamer DH, Lindsay J, Jr. Redefining true

ventr icular aneurysm. Am J Cardiol 1989;64:1192-4.

2. Heatlie GJ, Mohiaddin R. Left ventricular aneurysm: comprehensive assessment of morphology, structure and thrombus using cardiovascular magnetic resonance. Clin Radiol 2005;60:687-92.

3. Haddadian B, Jan MF, Paterick TE, Khandheria BK, Tajik AJ. Multimodality imaging of left ventricular aneurysm: tools of the trade. Eur Heart J Cardiovasc Imaging;13:629.

4. Toker ME, Onk OA, Alsalehi S, et al. Posterobasal left ventricular aneurysms: surgical treatment and long-term outcomes. Tex Heart Inst J; 40:424-7.

Cardiac MRI (CMRI) showed a well-defined large thin walled aneurysm arising from posterior-lateral wall of left ventricle measuring 70x64 mm size with a large thrombus in it (Figure 2 & 3).The aneurysm showed paradoxical movement. There was delay in contrast delivery in the aneurysmal wall as seen in resting perfusion. Delayed contrast MRI showed trans-mural enhancement of the aneurysmal wall (Figure 4). Rest of the myocardium showed no delay enhancement consistent with viable myocardium.

Large thin walled aneurysm arising from posterior-lateral wall of left ventricle with a large thrombus in it. The aneurysm showed paradoxical movement. Delayed contrast MRI showed trans-mural enhancement of the fibrotic aneurysmal wall. Rest of the myocardium was viable.

DISCUSSIONTransthoracic echocardiography plays an important role and provides assessment of LV structure and function, however, inferior wall aneurysm can be difficult to visualize particularly in patients with sub-optimal image quality. In patients with poor acoustic windows, contrast echocardiography is useful in identifying presence of aneurysm. Transoesophageal echocardiography has a limited role due to its semi-invasive nature and the availability of superior non-invasive imaging modalities like cardiac MRI and CT (3).

Cardiac CT offers complementing information regarding the anatomy of aneurysm as well as that of coronary arteries, though at an expense of ionizing radiation. Cardiac MRI provides a comprehensive assessment of the

Dr. Reena Anand Dr. Raj Kumar Dr. Bharat Aggarwal

a b aDr. Reena Anand , Dr. Raj Kumar , Dr. Bharat Aggarwal aDepartment of Radiology, Max Hospital, SaketbDepartment of Cardiology, Max Hospital, Saket

Figure 4: Delayed contrast MRI 4 chamber image showing trans-mural enhancement of the aneurysmal wall and no enhancement inrest of the myocardium

Figure (2 and 3): Two & four chamber image showing Left ventricle large aneurysm arising from its posterio-

lateral wall. A large clot is noted in the aneurysm

Figure 1: Echocardiography showing large LV aneurysm

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Effect of Heat - Stretching & Dry Needling in Upper Crossed Syndrome

INTRODUCTIONUpper Crossed SyndromeUpper crossed syndrome (UCS), characterized by the facilitation of upper trapezius, levator, sternocleidomastoid and pectoralis muscle, as well as the inhibition of the deep cervical flexors, lower trapezius and serratus anterior. Janda noted that these changes in muscular tone create a muscle imbalance, which leads to

1movement dysfunction . Upper crossed syndrome can have detrimental effects on anyone from an everyday blue collar worker to a professional athlete as it is characterized by hypersensitive points called trigger points found in one or more

2muscles and/or connective tissues. An active trigger point is defined as a hyperirritable spot in skeletal muscle that is

3associated with a hypersensitive palpable nodule in a taut band. They are tender on compression and may give rise to referred pain, motor dysfunction and autonomic responses. Muscles with active trigger points appear hypertonic, weak and are also

4sensitive to stretch. Physical therapy modalities such as hot packs, Interferential Therapy and ultrasound along with exercises and dry needling are used in the treatment of this frequently

5encountered disease.

Dry Needling Over the years, dry needling has become a popular treatment technique in manual physical therapy. Although various dry needling approaches exist, the more common and best supported

6approach targets myofascial trigger points. Contemporary schools approach dry needling from a broad pain sciences perspective. Dr. Yun Tao Ma, PhD, educator, researcher, founder of the American Dry Needling Institute, is an internationally recognised and highly respected authority in the field of Rehabilitation. Ma has developed a dry needling approach based on clinical applications of pain sciences and he maintains that his 'integrative systemic dry needling' is required to restore and maintain normal physiology of soft tissues and to reduce

7systemic stress to improve homeostasis.

The 'intramuscular stimulation' dry needling approach developed by Gunn is one of the first medical dry needling approaches. Gunn considers myofascial pain to be secondary to neuropathy. A few studies demonstrated the efficacy of intramuscular stimulation. Dommerholt and Huijbregts focused on dry needling of trigger points, which occasionally has been interpreted erroneously as a more 'local' approach. Trigger point dry needling has local and widespread effects and influences remote parts of the body. A superficial and a deep technique have been developed, whereby proponents of superficial needling suggest that the intervention targets primarily peripheral sensory afferents, while deep trigger point dry needling targets mostly

6dysfunctional motor units.

Outcome Measures8

Ÿ Numeric pain rating scale (NPRS)

Ÿ Neck disability index: Neck Disability Index (NDI) was used to evaluate the extent of disability in the activities of daily living. The NDI which is a 10-item questionnaire that measures a patient's self-reported neck pain related disability was found to

9be 9. (Figure 1)

Patient: __________________________________________

File#: ___________________ Date: ____________________

PLEASE READ INSTRUCTIONS:This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only ONE box which applies to you. We realize you may consider that two of the statements in any section relate to you, but just make the box which most closely describes your problem.

Dr. Tanvi Gupta (PT), Dr. Surabhi Bassin (PT), Dr. Alakananda Banerjee (PT)Department of Physiotherapy & Rehabilitation, Max Hospital, Saket

Dr. Tanvi Gupta Dr. Surabhi Bassin Dr. Alakananda Banerjee

9

PAIN SCALE:Rate the severity of your pain by checking one box on the following scale.

0 1 2 3 4 5 6 7 8 9 10

No Pain Excruciatin

Neck Disability IndexŸ Craniovertebral (CV) angle: Previous studies have found an

association among forward head posture (FHP), neck pain and disability. The studies found that subjects with head, neck, and shoulder discomfort are more likely to have a smaller CV angle

10that indicates a FHP than that of asymptomatic individuals. To assess the severity of forward head posture, CV angle is measured by drawing a horizontal line through the spinous process of C7 vertebra with the tragus of the ear on a still

11photograph from lateral view with patient in sitting position.

Ÿ Manual muscle testing

Ÿ Range of motion

Ÿ Muscle tightness

CASE REPORTA 32 year old male patient working as an IT professional complained of pain in the nape of neck for the past few days. He

also complained of inability to rotate neck on either side and work on the computer for long durations. There was no complaint of numbness, tingling or radiating pain in the arms. Patient has had similar episodes in the past. The patient scored his pain as 6/10 on NPRS which he reported would be aggravated while working on computers for a long time and rotating the head to terminal ranges of neck movement. The pain decreased with rest and hot water fomentation. On observing closely, the patient had a forward head posture and protracted shoulders. The CV angle of the patient was 22.27 degrees.

Examination revealed restricted ranges of motion in neck rotations and side flexion. Muscle strength was decreased in lower and middle trapezius, serratus anterior, rhomboids, deep neck flexors and scaleni. Muscle tightness was observed in Pectoralis major, upper trapezius, levator scapulae, sternocleidomastoid muscles. Trigger points were palpated in the bilateral upper fibres of trapezius.

TREATMENT PROTOCOLThe treatment protocol used for the patient was hot packs on upper back covering the nape of the neck for 15 minutes. This was followed by stretching of the Pectoralis major, upper trapezius, levator scapulae and sternocleidomastoid muscles.

12Each stretch was held for 30 seconds and was repeated thrice. The trigger points that were palpable in bilateral upper fibres of trapezius, sternocleidomastoid (SCM) and scalene were addressed with dry needling. Standard acupuncture (0.25mmX 25mm) needles were inserted into the skin over trigger points (Fig. 2-4) to a depth of approximately 20 mm. usually during dry needling there is an initial twitching of muscles or a feeling of dull pain which was noted in this patient too. The needle was kept inserted

13for 10 minutes. Hot packs and stretching exercises were continued for a week and dry needling was done twice a week.

RESULTSAfter seven days, the outcome measures were reassessed. The NPRS was 2/10 and pain was only felt during long driving hours. The CV angle was measured to be 27.41 degrees and the NDI score was 2 and the neck range of motion was full and pain free.

Figure. 4 Dry needling of upper trapezius

Figure. 3 Dry needling of Scalene

Figure 2: Dry needling of SCM

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DISCUSSIONThe patient who complained of pain while working on computer for long hours had decreased pain after seven days of treatment. As per previous studies, long working hours on computer leads to prolonged flexion at cervical spine with consequent higher activity in the cervical erector spinae and upper trapezius muscles, with a posture in which the trunk is slightly inclined backward. This forward head posture reduces the average length of muscle fibres, which contributes to extensor torque at the atlanto-occipital joint, and it is possible that this shortening reduces the

14tension generating capabilities of muscles. The reason for discomfort during driving could be because of sustained postures adopted during those long hours. Prolonged sitting (static posture) or muscular inactivity can exert tension (load) on the musculoskeletal structures, thus leading to musculoskeletal discomfort. A relationship between longer duration of driving and

15, 16musculoskeletal discomfort is supported by various studies.

The outcome of decreased pain and improved ranges was seen as NDI decreased from 9 to 2 as in Figure 5. The intervention of hot water fomentation, stretching and dry needling for seven days was given. The hot packs given during the session helped in relaxing and then releasing the tight muscles. The stretching exercises helped stretch the tight muscles to their optimal length thus, rectifying the muscle imbalance. The dry needling helped in proper muscles activation which was earlier not in optimal use due to weakness. And also it led to release of trigger points which limit full excursion of the muscles and are also a source of pain. 5, 6 & 13 from a pain science perspective, trigger points are constant sources of peripheral nociceptive input leading to peripheral and central sensitization. Dry needling cannot only reverse some aspects of central sensitization, it also reduces local and referred pain, improves range of motion and muscle activation pattern and alters the chemical environment of trigger points. The advantages of dry needling are increasingly documented and include an immediate reduction in local, referred, and widespread pain, restoration of range of motion and muscle activation patterns, and a normalization of the immediate chemical environment of active myofascial trigger points. Dry

17, 18needling can reduce peripheral and central sensitization.

FUTURE SCOPESStudies with large sample size should be conducted to see the effect of Dry needling in patients with Upper crossed syndrome.

CONCLUSIONThe use of dry needling and muscle stretching exercises may be beneficial in the treatment of upper crossed syndrome.

REFERENCES1. Leon Chaitow, Muscle Energy Techniques, second edition 2001, Churchill

Livingstone, London.

2. Simons DG, Mense S, Understanding and measurement of muscle tone as related to clinical muscle pain. J. Pain, 1998, 1-17

3. Sciotti et al. Clinical presentation of myofascial trigger point location in the trapezius muscle. J.pain. 2001;259-266

4. Ilbuldu E. Comparison of laser, dry needling and placebo laser treatments in myofascial pain syndromes: photomed laser surgery, 2004;306-11

5. Tough EA. Acupuncture and dry needling in the management of

myofascial trigger point pain: a systemic review and meta-analysis of randomised controlled. European Journal of Pain, 2009;3-10

6. Dommerholt J, Mayoral del Moral O, Grobli C. Trigger point dry needling. Journal of manual manipulative therapy, 2006E 70-87

7. Affaitati G, Costantini R, Fabrizio A, Lapenna D, Tafuri E, Giamberardino MA. Effects of treatment of peripheral pain generators in fibromyalgia patients. European journal of pain, 2011; 61-69

8. Lori A. Michener, Alison R. Snyder, and Brian G. Leggin, Responsiveness of the Numeric PainRating Scale in Patients With Shoulder Pain and the Effect of Surgical Status, Journal of Sport Rehabilitation, 2011, 20, 115-128

9. Vermon H, Mior S. The Neck Disability Index: a study of reliability and validity. Journal of Manipulative and Physiological Therapeutics, 1991, 409-415.

10. Watson DH, Trott PH. Cervical headache: an investigation of normal head posture and upper cervical flexor muscle performance. Cephalagia 1993;272-284.

11. Herman Mun Cheung Lau. Measurement of craniovertebral angle with electronic head posture instrument: criterion validity. Journal of Rehabilitation Research and Development, 2010 vol 47.

12. K.Kotteeswaran1, K.Rekha1, VaiyapuriAnandh.Effect of Stretching and Strengthening Shoulder Muscles in Protracted Shoulder in Healthy Individuals. International journal of computer application, 2012, vol 2

13. Tsai CT Remote effects of dry needling on the irritability of myofascial trigger points in the upper trapezius muscle. American journal of physical medicine and rehabilitation, February 2010.

14. Fernandez-Carnero J, La Touche R, Ortega-Santiago R, Galan-del-Rio F, Pesquera J, Ge HY, et al. Short-term effects of dry needling of active myofascial trigger points in the masseter muscle in patients with temporomandibular disorders. J Orofac Pain2010;24:106–12.

15. J.M. Porter, D.E. Gyi, The prevalence of musculoskeletal troubles among car drivers, occupational medicine,2002 vol. 52, no.1,pp.4-12

16. J.Abledu, E.Offei, G.Abledu, Occupational and personal determinants of musculoskeletal disorders among urban taxi drivers in Ghana, International scholarly research notices, 2014, vol.2014, article ID 517259.

17. Hsieh YL, Kao MJ, Kuan TS, Chen SM, Chen JT, Hong CZ. Dry needling to a key myofascial trigger point may reduce the irritability of satellite MTrPs. Am J Phys Med Rehabil 2007; 86:397–403.

18. Lewit K. The needle effect in the relief of myofascial pain. Pain 1979; 6:83.

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