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Braz. J. Phys. Ther. vol.17 no.1 São Carlos enero/feb. 2013 Epub 02-Nov-2012
Confiabilidade intra e interexaminador da análise de imagens infravermelhas dos músculos mastigatórios e trapézio superior em mulheres com e sem disfunção temporomandibular
Ana C. S. Costa; Almir V. Dibai Filho; Amanda C. Packer; Delaine Rodrigues-Bigaton
Laboratory of Therapeutic Resources, Postgraduate Program in Physical Therapy, Universidade Metodista de Piracicaba (UNIMEP), Piracicaba, SP, Brazil
BACKGROUND: Infrared thermography is an aid tool that can be used to evaluate several pathologies given its efficiency in analyzing the distribution of skin surface temperature.
OBJECTIVES: To propose two forms of infrared image analysis of the masticatory and upper trapezius muscles, and to determine the intra and inter-rater reliability of both forms of analysis.
METHOD: Infrared images of masticatory and upper trapezius muscles of 64 female volunteers with and without temporomandibular disorder (TMD) were collected. Two raters performed the infrared image analysis, which occurred in two ways: temperature measurement of the muscle length and in central portion of the muscle. The Intraclass Correlation Coefficient (ICC) was used to determine the intra and inter-rater reliability.
RESULTS: The ICC showed excellent intra and inter-rater values for both measurements: temperature measurement of the muscle length (TMD group, intra-rater, ICC ranged from 0.996 to 0.999, inter-rater, ICC ranged from 0.992 to 0.999; control group, intra-rater, ICC ranged from 0.993 to 0.998, inter-rater, ICC ranged from 0.990 to 0.998), and temperature measurement of the central portion of the muscle (TMD group, intra-rater, ICC ranged from 0.981 to 0.998, inter-rater, ICC ranged from 0.971 to 0.998; control group, intra-rater, ICC ranged from 0.887 to 0.996, inter-rater, ICC ranged from 0.852 to 0.996).
CONCLUSION: The results indicated that temperature measurements of the masticatory and upper trapezius muscles carried out by the analysis of the muscle length and central portion yielded excellent intra and inter-rater reliability.
Keywords: physical therapy; temporomandibular joint disorder; reliability; thermography; skin temperature.
CONTEXTUALIZAÇÃO: A termografia infravermelha vem sendo utilizada como instrumento auxiliar na avaliação de patologias diversas, dada a sua eficiência na investigação da distribuição da temperatura superficial cutânea.
OBJETIVOS: Propor duas formas de análise das imagens infravermelhas dos músculos mastigatórios e trapézio superior e determinar a confiabilidade intra e interexaminador dessas duas formas de análise.
MÉTODO: Foram coletadas imagens infravermelhas dos músculos mastigatórios e trapézio superior de 64 voluntárias do gênero feminino, com e sem disfunção temporomandibular (DTM). A análise das imagens infravermelhas ocorreu de duas formas: mensuração da temperatura da extensão do músculo e do centro do músculo, sendo realizada por dois examinadores. A confiabilidade intra e interexaminador foi verificada por meio do Coeficiente de Correlação Intraclasse (CCI).
RESULTADOS: Os valores do CCI intra e interexaminador foram considerados excelentes em ambas as avaliações: análises da extensão do músculo (grupo DTM, intraexaminador, CCI variou de 0,996 a 0,999, interexaminador, CCI variou de 0,992 a 0,999; grupo controle, intraexaminador, CCI variou de 0,993 a 0,998, interexaminador, CCI variou de 0,990 a 0,998) e análise do centro do músculo (grupo DTM, intraexaminador, CCI variou de 0,981 a 0,998, interexaminador, CCI variou de 0,971 a 0,998; grupo controle, intraexaminador, CCI variou de 0,887 a 0,996, interexaminador, CCI variou de 0,852 a 0,996).
CONCLUSÃO: O estudo evidenciou que a mensuração da temperatura dos músculos mastigatórios e trapézio superior, realizada por meio da análise da extensão e do centro do músculo, apresentou excelente confiabilidade intra e interexaminador.
Palavras-chave: fisioterapia; transtornos da articulação temporomandibular; reprodutibilidade dos testes; termografia; temperatura cutânea.
Blood flow towards the skeletal muscles is directly related to the contraction or relaxation state of the muscle supplying oxygen and nutrients to the muscles so it can function perfectly1. Most of the energy supplied to the muscles generates heat. Therefore, with a rigid central control, the body temperature remains at approximately 37º C, and consequently, chemical reactions are processed and homeostasis is maintained2.
The measurement of the central body temperature is one of the methods commonly used in clinical practice for the diagnosis and monitoring of feverish states3. To measure the peripheral temperature, the infrared thermography is applied. It is based on the emission of body infrared radiation with a temperature above absolute zero, used as an effective tool for the diagnosis of various diseases, given its efficiency in analyzing the distribution of skin surface temperature4.
The infrared thermography can be used to measure the skin surface temperature of masticatory muscles and temporomandibular joint in individuals with temporomandibular disorder (TMD)5-9, which is defined as a multifactor pathology, difficult to diagnose and characterized by an alteration of the masticatory muscles, limitation of the jaw movement, pain, joint noises and other symptoms10-12. In individuals with TMD, the temperature is altered when the blood flow decreases in the masticatory muscles due to a mechanical compression of blood vessels as a result of the muscular hyperactivity9,10. It is important to evaluate various aspects of the masticatory muscles, such as temperature, due to the high prevalence of involvement of this component of the stomatognathic system in subjects with TMD13.
Some studies6,14-18 were carried out to assess the temperature of masticatory and upper trapezius muscles. In these investigations, a high level of subjectivity was observed in the infrared image analysis, even with the delimitation of specific areas to register the temperature. Therefore, new methods should be developed to allow a more objective analysis of such areas.
McCoy et al.19 performed a study with 100 healthy subjects, whose paravertebral muscles were submitted to thermography, using an infrared scanner. The authors observed that the paraspinal thermal scanning presented excellent reliability. In another study conducted by Hart et al.20, three examiners evaluated 30 healthy individuals using a paraspinal thermal scanning to evaluate three methods of computer-aided thermal pattern analysis. The authors observed that the results of the intra and inter-rater analyses for all methods were acceptable, which ensured the reliability of the three analyzed software. Varjú et al.21 evaluated 91 individuals with hand osteoarthritis and correlated the thermogram, x-ray and digital photograph images, which presented high reliability. In a similar study, Spalding et al.22 analyzed the thermal and three-dimensional images of 17 individuals with hand arthritis and concluded that both images presented reliable measures, which showed that these technologies can be used to better quantify the disease diagnosis. Based on these studies, the hypothesis is that the infrared thermography is a reliable instrument to be used as an assessment method.
Although some studies have observed excellent reliability in the use of infrared thermography19,21-23, the literature on the reliability of infrared thermography in the evaluation of masticatory and upper trapezius muscles is scarce. Therefore, for the infrared thermography to be properly used, both in clinical and research practices, as an aid resource to assist in the diagnosis of TMD and to evaluate the effect of different therapeutic resources, it is necessary to evaluate the levels of intra and inter-rater reliability.
Therefore, the aim of the present study was to propose two forms of analyses of infrared images of masticatory and upper trapezius muscles, and to determine the intra and inter-rater reliability of both forms of analyses.
The sample comprised of 64 female volunteers recruited through a verbal invitation in the university community of the city of Piracicaba, São Paulo, Brazil, being 32 with TMD (TMD group), average age of 25.63 (SD=3.85) years, mean body mass index (BMI) of 21.60 (SD=2.45) kg/m2, and 32 without TMD (control group), average age of 22.18 (SD=2.95) years, mean BMI of 21.18 (SD=2.14) kg/m2.
The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD)24 was used to select the volunteers without and with TMD (myofascial pain, Ia or Ib diagnosis).
The exclusion criteria were: women with BMI over 25 kg/m2, in orthodontic treatment, using painkillers, anti-inflammatory or muscle relaxers. Volunteers with systemic disease, history of facial or cervical spine trauma, cervical discopathy and those diagnosed with TMD (IIIb or IIIc) through RDC/TMD criteria were also excluded.
The study procedures were approved by the Research Ethics Committee of the Universidade Medodista de Piracicaba (UNIMEP), Piracicaba, SP, Brazil, under protocol number 15/11. Each volunteer signed a consent form.
To evaluate the temperature of the right (RMA) and left masseter (LMA), right (RAT) and left anterior temporalis (LAT), right (RUT) and left upper trapezius (LUT) and supra-hyoid (SHY) muscles was used a thermal camera T360 model, FLIR Systems® (Stockholm, Sweden). The following parameters were considered: an emissivity of 0.98 and image captured at a 100 cm distance from the individual25. The instrument was stabilized for 10 minutes before the exam.
For the examination, the volunteers stayed in an acclimatized room (approximately 22ºC) for 20 minutes, without the presence of electric heat generators and equipment without incidence of air or sunlight. Fluorescent bulbs lighted the place.
Two hours before data collection, the participants were asked to avoid hot showers or baths, to use of topical agents, creams or powders or nasal decongestants, to not practice vigorous exercise, or to intake stimulants such as caffeine.
During data collection, the volunteers sat in a chair, with the trunk erect, feet on the ground and hands resting on the thighs, following the Frankfurt plane parallel to the ground. The region of the muscles to be assessed had to be free from clothes and personal items, such as earrings and necklaces; the hair had to be tied, whenever necessary.
Styrofoam markers were used due to their insulating characteristics, with the purpose of delimiting the origins and insertions of the evaluated muscles, enabling their further analysis in the infrared image.
For the anterior temporalis muscle, one marker was placed on the frontal bone, immediately above the muscle belly, and another near the eyelid lateral commissure; for the masseter muscle, one marker was positioned into the zygomatic arch and another in the lateral surface of the angle of mandible; for the supra-hyoid muscles, one marker was positioned on the ment and another on the hyoid bone; and for the upper trapezius muscle, one marker was positioned on the C7 spinous process and another on the acromion.
The infrared imaging analysis was performed in two ways: temperature measurement of the muscle length and central portion. All analyses were performed by two raters using the QuickReport software, version 1.1, FLIR® Systems (Stockholm, Sweden).
Analysis of muscle length temperature
For this analysis, the "line" tool of the software was used with a line being drawn between the markers along the entire length of the delimited muscle, generating the average temperature of the entire line extension (Figure 1).
Temperature analysis of the muscle central portion
The "point" tool of the software determined the temperature value. Thus, a point on an average distance was set up between the markers and the central portion of the muscle was established (Figure 2).
Two trained raters evaluated three infrared images from each muscle, totaling 672 measurements for each type of analysis (muscle length and center portion).
To evaluate the intra-rater reliability, a single rater analyzed the images in two different occasions separated by a one-week interval26. For the inter-rater reliability, two independent examiners analyzed the same images.
In addition, a reliability evaluation was carried out between the analyses: for the intra-rater, an examiner measured the infrared image temperature by analyzing the muscle length and the center portion of the muscle; for the inter-rater, an examiner measured the temperature by analyzing the muscle length, while the other measured it by analyzing the center portion of the muscle.
The Intraclass Correlation Coefficient (ICC) was used to determine the intra and inter-rater reliability, with its respective 95% confidence interval. Interpretation of ICC values was based on that suggested by Weir27. For values ranging from 1.0 to 0.81, the reliability was considered excellent; from 0.80 to 0.61, very good; from 0.60 to 0.41, good; from 0.40 to 0.21, reasonable and, finally, from 0.20 to 0.00, poor. The statistical analysis was performed using the SPSS® software, version 13.0 (Chicago, USA).
For the TMD group, in the analysis of muscle length, we found the following mean values (95% confidence interval) of skin surface temperature for each muscle evaluated: LMA, 32.84 (32.60 to 33.08); RMA, 32.99 (32.77 to 33.21); LTA, 34.09 (33.88 to 34.30); RTA, 34.29 (34.10 to 34.49); SHY, 32.99 (32.72 to 33.25); LUT, 32.60 (32.03 to 33.16); RUT, 32.67 (32.16 to 33.18). Furthermore, in the analysis of the muscle central portion, it was observed the following values: LMA, 32.99 (32.74 to 33.24); RMA, 33.03 (32.80 to 33.26); LTA, 34.08 (33.86 to 34.30); RTA, 34.32 (34.13 to 34.51); SHY, 33.05 (32.76 to 33.34); LUT, 33.00 (32.54 to 33.91); RUT, 32.85 (31.95 to 33.55).
For the control group, in the analysis of muscle length, the mean values (95% confidence interval) of skin surface temperature for each muscle evaluated were: LMA, 32.67 (32.52 to 32.82); RMA, 32.65 (32.49 to 32.81); LTA, 34.22 (34.09 to 34.35); RTA, 34.21 (34.08 to 34.34); SHY, 33.02 (32.88 to 33.17); LUT, 32.59 (32.44 to 32.75); RUT, 32.57 (32.42 to 32.72). In the analysis of the muscle central portion, it was observed the following values: LMA, 32.77 (32.61 to 32.93); RMA, 32.69 (32.53 to 32.85); LTA, 34.31 (34.18 to 34.44); RTA, 34.17 (34.02 to 34.32); SHY, 33.17 (33.01 to 33.33); LUT, 32.94 (32.79 to 33.10); RUT, 32.91 (32.76 to 33.05).
The intra and inter-rater ICC values of the infrared image analysis of the muscle length and central portion are shown in Tables 1 and 2. The reliability was considered excellent in all analyses. The intra and inter-rater ICC values between the two types of infrared image analysis, muscle length and central portion, are shown in Table 3.
The present study showed that the two types of infrared image analysis of masticatory and upper trapezius muscles showed excellent intra and inter-rater reliability. These results agreed with those by Owens et al.23, whose objective was to evaluate the paraspinal region by contact thermography. Other study19 obtained similar results to previous research23, providing evidence that the paraspinal thermal imaging is a reliable diagnostic test. The present study is not in agreement with previous ones in terms of the tool used to capture the images, which had no contact with the region being analyzed, keeping a 100 cm distance from the volunteers, while in the aforementioned studies19,23 the images were captured with the contact technique.
It is worthwhile to mention that in most studies the infrared image analysis is subjective, that is, the location for the evaluation of the muscle temperature is randomly determined6,8,14,16,28, while others studies make no reference to the way the analysis was carried out5,29,30. Furthermore, no standardization of specific areas for image analysis was found in other studies that measure facial temperature31,32. With that regard, in the present study, the infrared image analysis was performed in two ways, muscle length and the central portion of the muscle, by using markers to delimit the muscle insertions and origins for further analysis. The reliability was considered excellent in all the analyses performed.
Therefore, considering the results found in this study, we recommend the use of infrared thermography as an aid tool in assessing TMD, mainly when the objective is to determine the effect of different therapeutic resources used for the TMD treatment, such as electrotherapy33,34, laser therapy35,36 and manual therapy37,38.
The literature emphasizes the importance of using infrared thermography for the assessment and documentation of many pathologies39-42. However, for the adequate use of infrared thermography in TMD diagnosis, further studies should be carried out to evaluate the instrument accuracy.
The evaluation by the infrared thermography has some limitations, as the amount of subcutaneous fat, since this interferes in the skin surface temperature43. Furthermore, it is an indirect measure of the blood flow44 and of the activity of the autonomic nervous system45. Thus, in this study, to ensure the quality of thermographic evaluation, women with BMI over 25 kg/m2 were excluded, and remained for 20 minutes at 22º C to ensure thermal equilibrium body.
Given the above, the limitation of this study referred to the non-evaluation of the variability of the measurements of temperature at different times of day, in different emotional states, and in different phases of the menstrual cycle.
The intra and inter-rater reliability of the temperature measures of the masseter, anterior temporalis, supra-hyoid and upper trapezius muscles analyzed by muscle length and central portion were considered excellent.
The Reginaldo Teixeira Coelho, Laboratory for Manufacturing Process Optimization, Engineering School of São Carlos, Universidade de São Paulo (USP), São Carlos, SP, Brazil.
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Almir Vieira Dibai Filho
Rua São João, 1529, Ed. Saint Michael, Apto 62, Bairro Alto
CEP: 13416-585, Piracicaba, SP, Brasil