Abstract
BACKGROUND:
Infrared thermography is recognized as a viable method for evaluation of subjects with myofascial pain.
OBJECTIVE:
The aim of the present study was to assess the intra- and inter-rater reliability of infrared image analysis of myofascial trigger points in the upper trapezius muscle.
METHOD:
A reliability study was conducted with 24 volunteers of both genders (23 females) between 18 and 30 years of age (22.12±2.54), all having cervical pain and presence of active myofascial trigger point in the upper trapezius muscle. Two trained examiners performed analysis of point, line, and area of the infrared images at two different periods with a 1-week interval. The intra-class correlation coefficient (ICC2,1) was used to assess the intra- and inter-rater reliability.
RESULTS:
With regard to the intra-rater reliability, ICC values were between 0.591 and 0.993, with temperatures between 0.13 and 1.57 °C for values of standard error of measurement (SEM) and between 0.36 and 4.35 °C for the minimal detectable change (MDC). For the inter-rater reliability, ICC ranged from 0.615 to 0.918, with temperatures between 0.43 and 1.22 °C for the SEM and between 1.19 and 3.38 °C for the MDC.
CONCLUSION:
The methods of infrared image analyses of myofascial trigger points in the upper trapezius muscle employed in the present study are suitable for clinical and research practices.
myofascial pain syndromes; thermography; skin temperature; physical therapy
Introduction
Myofascial trigger points are structures found in skeletal muscles that present with
some type of dysfunction. Conceptually, they are nodules hypersensitive to palpation due
to pain, change in muscular activity, limitation in joint mobility, and autonomic
manifestations11. Ge HY, Arendt-Nielsen L. Latent myofascial trigger points. Curr Pain
Headache Rep. 2011;15(5):386-92.http://dx.doi.org/10.1007/s11916-011-0210-6.
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. In addition, the literature
suggests that the physiopathological mechanism of myofascial trigger points is related
to changes in muscular activity and the repercussions for blood circulation and local
metabolism22. Bron C, Dommerholt JD. Etiology of myofascial trigger points. Curr
Pain Headache Rep. 2012;16(5):439-44.http://dx.doi.org/10.1007/s11916-012-0289-4.
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,
33. Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial
trigger points using in vivo microdialysis: an application of muscle pain concepts to
myofascial pain syndrome. J Bodyw Mov Ther.
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.
Myofascial trigger points may present as active or latent. The active points are
hypersensitive points that trigger pain recognized as familiar by the patient during the
application of compressive force; in turn, latent points are clinically quiescent with
respect to spontaneous pain, generating unfamiliar pain22. Bron C, Dommerholt JD. Etiology of myofascial trigger points. Curr
Pain Headache Rep. 2012;16(5):439-44.http://dx.doi.org/10.1007/s11916-012-0289-4.
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. The active myofascial trigger points also differ by the presence of
different algesic substances, such as bradykinin, substance P, and serotonin33. Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial
trigger points using in vivo microdialysis: an application of muscle pain concepts to
myofascial pain syndrome. J Bodyw Mov Ther.
2008;12(4):371-84.http://dx.doi.org/10.1016/j.jbmt.2008.06.006.
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.
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have used the criteria set by Simons et
al.77. Simons DG, Travell J, Simons LS. Myofascial pain and dysfunction: the
trigger point manual. 2nd ed. Baltimore: Lippincott Williams & Wilkins;
1999. for the correct diagnosis of myofascial
trigger points based on muscle palpation. However, other authors highlight that
palpation requires a combination of skill, training, and critical clinical practice88. Thomas K, Shankar H. Targeting myofascial taut bands by ultrasound.
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. In addition, other instruments may be applied for
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vascular environment of myofascial trigger points using ultrasonic imaging and
computational modeling. Conf Proc IEEE Eng Med Biol Soc.
2010;2010:5302-5., sonoelastography1010. Ballyns JJ, Shah JP, Hammond J, Gebreab T, Gerber LH, Sikdar S.
Objective sonographic measures for characterizing myofascial trigger points
associated with cervical pain. J Ultrasound Med. 2011;30(10):1331-40.
PMid:21968483., and electromyography1111. Ibarra JM, Ge HY, Wang C, Martínez Vizcaíno V, Graven-Nielsen T,
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antagonistic muscle activity during agonist muscle contraction. J Pain.
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. However,
despite advances in diagnostic technology, physical examination remains the most
accepted method of evaluation of myofascial trigger points due to the limited clinical
applicability of the new instruments.
Within this context and considering both autonomic and metabolic repercussions resulting
from the presence of myofascial trigger points22. Bron C, Dommerholt JD. Etiology of myofascial trigger points. Curr
Pain Headache Rep. 2012;16(5):439-44.http://dx.doi.org/10.1007/s11916-012-0289-4.
PMid:22836591
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,
infrared thermography is recognized as another viable method for the evaluation of
subjects with myofascial pain, according to studies conducted by Hakgüder et al.1212. Hakgüder A, Birtane M, Gürcan S, Kokino S, Turan FN. Efficacy of low
level laser therapy in myofascial pain syndrome: an algometric and thermographic
evaluation. Lasers Surg Med. 2003;33(5):339-43.http://dx.doi.org/10.1002/lsm.10241.
PMid:14677161
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and Haddad et al.1313. Haddad DS, Brioschi ML, Arita ES. Thermographic and clinical
correlation of myofascial trigger points in the masticatory muscles. Dentomaxillofac
Radiol. 2012;41(8):621-9.http://dx.doi.org/10.1259/dmfr/98504520.
PMid:23166359
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. This is a non-invasive method for evaluating the behavior of body skin
temperature1414. Szentkuti A, Kavanagh HS, Grazio S. Infrared thermography and image
analysis for biomedical use. Period Biol. 2011;113:385-92., which is dependent on
microcirculatory, metabolic, and autonomic activities1515. Brioschi ML, Macedo JF, Macedo RAC. Skin thermometry: new concepts.
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,
1616. Holey LA, Dixon J, Selfe J. An exploratory thermographic
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.
In general, infrared images can be evaluated in two ways: qualitatively, in which an
experienced examiner gives an opinion based on the visual analysis of the image1717. Gratt BM, Sickles EA, Ross JB, Wexler CE, Gornbein JA. Thermographic
assessment of craniomandibular disorders: diagnostic interpretation versus
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,
1818. Kontos M, Wilson R, Fentiman I. Digital infrared thermal imaging
(DITI) of breast lesions: sensitivity and specificity of detection of primary breast
cancers. Clin Radiol. 2011;66(6):536-9.http://dx.doi.org/10.1016/j.crad.2011.01.009.
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; and quantitatively, in which body skin
regions of interest are measured by means of specific software. According to the
literature, the latter is the most used form1313. Haddad DS, Brioschi ML, Arita ES. Thermographic and clinical
correlation of myofascial trigger points in the masticatory muscles. Dentomaxillofac
Radiol. 2012;41(8):621-9.http://dx.doi.org/10.1259/dmfr/98504520.
PMid:23166359
http://dx.doi.org/10.1259/dmfr/98504520...
,
1919. Dibai Filho AV, Packer AC, Costa AC, Berni-Schwarzenbeck KC,
Rodrigues-Bigaton D. Assessment of the upper trapezius muscle temperature in women
with and without neck pain. J Manipulative Physiol Ther.
2012;35(5):413-7.http://dx.doi.org/10.1016/j.jmpt.2012.04.006.
PMid:22608286
http://dx.doi.org/10.1016/j.jmpt.2012.04...
20. Dibai-Filho AV, Costa AC, Packer AC, Rodrigues-Bigaton D.
Correlation between skin surface temperature over masticatory muscles and pain
intensity in women with myogenous temporomandibular disorder. J Back Musculoskelet
Rehabil. 2013;26(3):323-8. PMid:23893148.
-
2121. Costa AC, Dibai Filho AV, Packer AC, Rodrigues-Bigaton D. Intra and
inter-rater reliability of infrared image analysis of masticatory and upper trapezius
muscles in women with and without temporomandibular disorder. Braz J Phys Ther.
2013;17(1):24-31.http://dx.doi.org/10.1590/S1413-35552012005000058.
PMid:23117649
http://dx.doi.org/10.1590/S1413-35552012...
. However, despite the studies using infrared
thermography in subjects with myofascial pain, there is a lack of standardization in the
method of infrared image analysis, as reported by Costa et al.2121. Costa AC, Dibai Filho AV, Packer AC, Rodrigues-Bigaton D. Intra and
inter-rater reliability of infrared image analysis of masticatory and upper trapezius
muscles in women with and without temporomandibular disorder. Braz J Phys Ther.
2013;17(1):24-31.http://dx.doi.org/10.1590/S1413-35552012005000058.
PMid:23117649
http://dx.doi.org/10.1590/S1413-35552012...
.
In light of this, the objective of the present study was to assess the intra- and inter-rater reliability of infrared image analyses of myofascial trigger points in the upper trapezius muscle. The hypothesis tested herein is that the methodologies for the analysis of infrared images show reliability that endorses its use in clinical practice and research.
Method
Sample
A sample size calculation was performed with a confidence coefficient of 0.95 and a
range of the confidence interval (CI) for the intraclass correlation coefficient
(ICC) of 0.30. Fleiss's2222. Fleiss J. The design and analysis of clinical experiments. New York:
Wiley; 1986. coefficients were
also calculated to detect substantial reliability (ICC=0.76)2222. Fleiss J. The design and analysis of clinical experiments. New York:
Wiley; 1986.. Therefore, a sample size of 24 volunteers was estimated. The
sample size calculation was based on the study conducted by Bonett2323. Bonett DG. Sample size requirements for estimating intraclass
correlations with desired precision. Stat Med.
2002;21(9):1331-5.http://dx.doi.org/10.1002/sim.1108. PMid:12111881
http://dx.doi.org/10.1002/sim.1108...
.
The target population of this study was recruited from the university community of
Ribeirão Preto, SP, Brazil, by means of verbal invitation and posters. The inclusion
criteria were the following: age group between 18 and 30 years old; both genders;
presence of neck pain2424. Muñoz-Muñoz S, Muñoz-García MT, Alburquerque-Sendín F,
Arroyo-Morales M, Fernández-de-las-Peñas C. Myofascial trigger points, pain,
disability, and sleep quality in individuals with mechanical neck pain. J
Manipulative Physiol Ther.
2012;35(8):608-13.http://dx.doi.org/10.1016/j.jmpt.2012.09.003.
PMid:23158466
http://dx.doi.org/10.1016/j.jmpt.2012.09...
, anatomically defined
as pain within the region limited by the superior nuchal line, the lateral margins of
the cervical vertebrae and an imaginary transverse line immediately above the first
thoracic spinous process2525. Bogduk N. The anatomy and pathophysiology of neck pain. Phys Med
Rehabil Clin N Am. 2003;14(3):455-72,
v.http://dx.doi.org/10.1016/S1047-9651(03)00041-X. PMid:12948338
http://dx.doi.org/10.1016/S1047-9651(03)...
, which was
identified by a Neck Disability Index (NDI) score ≥5 points2626. Cook C, Richardson JK, Braga L, Menezes A, Soler X, Kume P, et al.
Cross-cultural adaptation and validation of the Brazilian Portuguese version of the
Neck Disability Index and Neck Pain and Disability Scale. Spine (Phila Pa 1976).
2006;31(14):1621-7.http://dx.doi.org/10.1097/01.brs.0000221989.53069.16.
PMid:16778699
http://dx.doi.org/10.1097/01.brs.0000221...
,
2727. Vernon H, Mior S. The Neck Disability Index: a study of reliability
and validity. J Manipulative Physiol Ther. 1991;14(7):409-15.
PMid:1834753 and a score ≥3 points according to the
Numeric Pain Rating Scale2828. Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP. Validity of four
pain intensity rating scales. Pain.
2011;152(10):2399-404.http://dx.doi.org/10.1016/j.pain.2011.07.005.
PMid:21856077
http://dx.doi.org/10.1016/j.pain.2011.07...
; use of computer
for at least 2 hours daily2929. Oliveira-Campelo NM, de Melo CA, Alburquerque-Sendín F, Machado JP.
Short- and medium-term effects of manual therapy on cervical active range of motion
and pressure pain sensitivity in latent myofascial pain of the upper trapezius
muscle: a randomized controlled trial. J Manipulative Physiol Ther.
2013;36(5):300-9.http://dx.doi.org/10.1016/j.jmpt.2013.04.008.
PMid:23769263
http://dx.doi.org/10.1016/j.jmpt.2013.04...
; and the presence
of active myofascial trigger point, unilateral and of central location3030. Ziaeifar M, Arab AM, Karimi N, Nourbakhsh MR. The effect of dry
needling on pain, pressure pain threshold and disability in patients with a
myofascial trigger point in the upper trapezius muscle. J Bodyw Mov Ther.
2014;18(2):298-305.http://dx.doi.org/10.1016/j.jbmt.2013.11.004.
PMid:24725800
http://dx.doi.org/10.1016/j.jbmt.2013.11...
in the upper trapezius muscle on the same side
of the dominance of the upper limb.
The diagnosis of the myofascial trigger point was performed only once according to
the criteria established by Simons et al.77. Simons DG, Travell J, Simons LS. Myofascial pain and dysfunction: the
trigger point manual. 2nd ed. Baltimore: Lippincott Williams & Wilkins;
1999. and
Gerwin et al.3131. Gerwin RD, Shannon S, Hong CZ, Hubbard D, Gevirtz R. Interrater
reliability in myofascial trigger point examination. Pain.
1997;69(1-2):65-73.http://dx.doi.org/10.1016/S0304-3959(96)03248-4.
PMid:9060014
http://dx.doi.org/10.1016/S0304-3959(96)...
: 1) presence of a palpable
taut band in a skeletal muscle, 2) presence of a hypersensitive tender spot within
the taut band, 3) local twitch response elicited by the snapping palpation of the
taut band, and 4) reproduction of referred pain in response to myofascial trigger
point compression. These criteria were found to have good levels of inter-rater
reliability3131. Gerwin RD, Shannon S, Hong CZ, Hubbard D, Gevirtz R. Interrater
reliability in myofascial trigger point examination. Pain.
1997;69(1-2):65-73.http://dx.doi.org/10.1016/S0304-3959(96)03248-4.
PMid:9060014
http://dx.doi.org/10.1016/S0304-3959(96)...
. Myofascial trigger point was
considered active if local and spontaneous pain evoked by digital compression was
recognized as familiar pain by the volunteer3232. Alburquerque-Sendín F, Camargo PR, Vieira A, Salvini TF. Bilateral
myofascial trigger points and pressure pain thresholds in the shoulder muscles in
patients with unilateral shoulder impingement syndrome: a blinded, controlled study.
Clin J Pain. 2013;29(6):478-86.http://dx.doi.org/10.1097/AJP.0b013e3182652d65.
PMid:23328323
http://dx.doi.org/10.1097/AJP.0b013e3182...
.
The exclusion criteria were the following: volunteers with history of cervical
trauma; surgery of the head, face or neck; cervical disc disease; degenerative
diseases of the spine; physical therapeutic treatment in the past 3 months; use of
analgesics, anti-inflammatories or muscle relaxants in the past week; presence of
systemic diseases; diagnosis of fibromyalgia; body mass index (BMI) greater than 25
kg/m22. Bron C, Dommerholt JD. Etiology of myofascial trigger points. Curr
Pain Headache Rep. 2012;16(5):439-44.http://dx.doi.org/10.1007/s11916-012-0289-4.
PMid:22836591
http://dx.doi.org/10.1007/s11916-012-028...
.
The procedures of the present study were approved by the Research Ethics Committee of Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil, according to protocol number 030643/2013. Each volunteer signed a consent form.
Infrared thermography
Myofascial trigger points do not show a pattern of identification when analyzed by
infrared imaging. Therefore, to ensure that the skin temperature was measured
precisely on the myofascial trigger points, we initially performed palpation and
identification of the myofascial trigger point centrally located3030. Ziaeifar M, Arab AM, Karimi N, Nourbakhsh MR. The effect of dry
needling on pain, pressure pain threshold and disability in patients with a
myofascial trigger point in the upper trapezius muscle. J Bodyw Mov Ther.
2014;18(2):298-305.http://dx.doi.org/10.1016/j.jbmt.2013.11.004.
PMid:24725800
http://dx.doi.org/10.1016/j.jbmt.2013.11...
in the upper trapezius muscle according to the diagnostic
criteria of Simons et al.77. Simons DG, Travell J, Simons LS. Myofascial pain and dysfunction: the
trigger point manual. 2nd ed. Baltimore: Lippincott Williams & Wilkins;
1999. and Gerwin et
al.3131. Gerwin RD, Shannon S, Hong CZ, Hubbard D, Gevirtz R. Interrater
reliability in myofascial trigger point examination. Pain.
1997;69(1-2):65-73.http://dx.doi.org/10.1016/S0304-3959(96)03248-4.
PMid:9060014
http://dx.doi.org/10.1016/S0304-3959(96)...
; next, four Styrofoam markers
measuring 8 mm in diameter were used because of their isolating characteristic,
positioned equidistantly at a distance of 25 mm from the center of the myofascial
trigger point (Figure 1); after these
procedures, the volunteers remained seated and at rest for 15 minutes in a room with
controlled environment at a temperature of 22°±2°C and humidity of 50%, as
established by Roy et al.3333. Roy RA, Boucher JP, Comtois AS. Digitized infrared segmental
thermometry: time requirements for stable recordings. J Manipulative Physiol Ther.
2006;29(6):468.e1-10.http://dx.doi.org/10.1016/j.jmpt.2006.06.007.
PMid:16904493
e1-10.http://dx.doi.org/10.1016/j.jmpt.2...
; and finally,
three infrared images were sequentially captured at a distance of 100 cm from the
subject and perpendicular to the myofascial trigger point1212. Hakgüder A, Birtane M, Gürcan S, Kokino S, Turan FN. Efficacy of low
level laser therapy in myofascial pain syndrome: an algometric and thermographic
evaluation. Lasers Surg Med. 2003;33(5):339-43.http://dx.doi.org/10.1002/lsm.10241.
PMid:14677161
http://dx.doi.org/10.1002/lsm.10241...
,
2121. Costa AC, Dibai Filho AV, Packer AC, Rodrigues-Bigaton D. Intra and
inter-rater reliability of infrared image analysis of masticatory and upper trapezius
muscles in women with and without temporomandibular disorder. Braz J Phys Ther.
2013;17(1):24-31.http://dx.doi.org/10.1590/S1413-35552012005000058.
PMid:23117649
http://dx.doi.org/10.1590/S1413-35552012...
, thus allowing the muscle to be framed.
Styrofoam markers used to delineate the myofascial trigger point in the upper trapezius muscle.
The room used for the thermographic examination was lit with fluorescent lamps,
without the presence of electrical equipment generating heat and no incidence of
sunlight or airflow on the volunteer3333. Roy RA, Boucher JP, Comtois AS. Digitized infrared segmental
thermometry: time requirements for stable recordings. J Manipulative Physiol Ther.
2006;29(6):468.e1-10.http://dx.doi.org/10.1016/j.jmpt.2006.06.007.
PMid:16904493
e1-10.http://dx.doi.org/10.1016/j.jmpt.2...
. The
subjects were instructed to avoid taking a hot bath or shower, using topical agents
such as creams or talc, practicing physical exercises, and ingesting stimulating
substances such as caffeine, nicotine or chocolate during the two hours before data
collection1919. Dibai Filho AV, Packer AC, Costa AC, Berni-Schwarzenbeck KC,
Rodrigues-Bigaton D. Assessment of the upper trapezius muscle temperature in women
with and without neck pain. J Manipulative Physiol Ther.
2012;35(5):413-7.http://dx.doi.org/10.1016/j.jmpt.2012.04.006.
PMid:22608286
http://dx.doi.org/10.1016/j.jmpt.2012.04...
,
2121. Costa AC, Dibai Filho AV, Packer AC, Rodrigues-Bigaton D. Intra and
inter-rater reliability of infrared image analysis of masticatory and upper trapezius
muscles in women with and without temporomandibular disorder. Braz J Phys Ther.
2013;17(1):24-31.http://dx.doi.org/10.1590/S1413-35552012005000058.
PMid:23117649
http://dx.doi.org/10.1590/S1413-35552012...
.
During the collection procedures, the volunteers remained seated on a bench, with their trunk erect, hands on the thighs, and staring ahead. They were asked to let the region of the muscle being evaluated free of clothes or personal items, such as earrings or necklaces, in addition to keeping their hair tied up.
A thermal camera (T300, FLIR Systems, Wilsonville, OR, USA) was used to capture infrared images, operating with precision of up to 0.05 °C, emissivity of 0.98. The device was stabilized for 10 min prior to the reading.
Analysis of infrared images
All analyses were conducted by using the QuickReport software, version 1.2 (FLIR Systems). Two examiners, who had previously received training with infrared thermography, performed the measurements of the images twice with a 1-week interval3434. Van Maanen CJ, Zonnenberg AJ, Elvers JW, Oostendorp RA. Intra/interrater reliability of measurements on body posture photographs. Cranio. 1996;14(4):326-31. PMid:9110628., thus making it possible to assess the intra- and inter-rater reliability of the infrared image analyses.
Based on the analysis features of the software used in the present study, three forms of measurement of the skin temperature were performed over the myofascial trigger point: point analysis, in which the temperature of the central point of the area delimited by the markers was measured (Figure 2A); line analysis, in which a straight-line linking two markers was drawn across the region where the trigger point was located (Figure 2B); and area analysis, in which the area delimited by the four markers was established (Figure 2C). Initially, the mean values of skin temperature for the three analyses were calculated. Next, minimum and maximum values were considered for line and area analyses.
Analyses for point (A), line (B), and area (C) of the myofascial trigger point in the upper trapezius muscle.
Statistical analysis
Intraclass correlation coefficient (ICC2,1) was used to determine the
intra- and inter-rater reliability, with its respective 95% confidence interval (CI
95%) , standard error of measurement (SEM), and minimum detectable change (MDC)3535. Tucci H, Martins J, Sposito G, Camarini P, Oliveira A. Closed
Kinetic Chain Upper Extremity Stability test (CKCUES test): a reliability study in
persons with and without shoulder impingement syndrome. BMC Musculoskelet Disord.
2014;15(1):1.http://dx.doi.org/10.1186/1471-2474-15-1. PMid:24387196
http://dx.doi.org/10.1186/1471-2474-15-1...
. Interpretation of ICC values was based on
that suggested by Fleiss2222. Fleiss J. The design and analysis of clinical experiments. New York:
Wiley; 1986.. For values less
than 0.40, the reliability was considered low; between 0.40 to 0.75, moderate;
between 0.75 to 0.90, substantial; and finally, values greater than 0.90, excellent.
All statistical analyses were performed using the SPSS software, version 17.0
(Chicago, IL, USA).
Results
According to the eligibility criteria, twenty-eight volunteers were recruited from the
university community. However, four volunteers were excluded from the study due to an
NDI score of less than 5 points, thus resulting in a final sample of 24 subjects of both
genders (23 females), 22 right-handed, mean age of 22.12 (SD=2.54) years, mean BMI of
21.04 (SD=1.95) kg/cm22. Bron C, Dommerholt JD. Etiology of myofascial trigger points. Curr
Pain Headache Rep. 2012;16(5):439-44.http://dx.doi.org/10.1007/s11916-012-0289-4.
PMid:22836591
http://dx.doi.org/10.1007/s11916-012-028...
, mean NDI score of 10.41
(SD=3.18) points, mean pain intensity of 5.00 (SD=1.66) points, and mean duration of
cervical pain of 39.33 (SD=33.26) weeks.
Table 1 lists the values of intra-rater reliability, showing excellent reliability for point analysis (mean value), line analysis (mean and maximum values), and area analysis (mean, minimum, and maximum values), with ICC values ranging between 0.943 and 0.993. In addition, there was a moderate reliability for line analysis (minimum value), with ICC value equal to 0.591, and substantial reliability for area analysis (minimum value), with ICC value equal to 0.821. With respect to the SEM, there was variation in values between 0.13 and 1.57 °C. In turn, the MDC values ranged from 0.36 to 4.35 °C.
Table 2 lists the values of inter-rater reliability, showing excellent reliability for point and line analysis (mean value), with ICC values equal to 0.908 and 0.918, respectively. For the other measures, there was moderate to substantial reliability, with ICC values ranging from 0.615 to 0.894. With respect to the SEM, there was variation in values between 0.43 and 1.22 °C. In turn, the MDC values ranged from 1.19 to 3.38 °C.
Discussion
In the present study, the intra- and inter-rater reliability of infrared image analyses by using point, line, and area approaches had substantial to excellent ICC values, except the minimum value for line analysis, as moderate ICC values were observed for intra- and inter-rate analyses.
The results of the present study are in partial accordance with those reported by Costa
et al.2121. Costa AC, Dibai Filho AV, Packer AC, Rodrigues-Bigaton D. Intra and
inter-rater reliability of infrared image analysis of masticatory and upper trapezius
muscles in women with and without temporomandibular disorder. Braz J Phys Ther.
2013;17(1):24-31.http://dx.doi.org/10.1590/S1413-35552012005000058.
PMid:23117649
http://dx.doi.org/10.1590/S1413-35552012...
, who found excellent intra- and
inter-rater reliability for point and line analyses regarding the masseter, temporalis
anterior, suprahyoid, and upper trapezius muscles in individuals with or without
temporomandibular disorder. However, it should be pointed out that these authors were
not assessing myofascial trigger points in the skeletal muscles in question as their aim
was to investigate skin temperature on the muscle belly.
Point analysis was also employed by Rodrigues-Bigaton et al.3636. Rodrigues-Bigaton D, Dibai Filho AV, Costa AC, Packer AC, de Castro
EM. Accuracy and reliability of infrared thermography in the diagnosis of arthralgia
in women with temporomandibular disorder. J Manipulative Physiol Ther.
2013;36(4):253-8.http://dx.doi.org/10.1016/j.jmpt.2013.04.006.
PMid:23719519
http://dx.doi.org/10.1016/j.jmpt.2013.04...
for assessment of skin temperature in the temporomandibular joint
of individuals with and without arthralgia, with ICC values ranging from 0.841 to 0.874.
Rodrigues-Bigaton et al.3737. Rodrigues-Bigaton D, Dibai-Filho AV, Packer AC, Costa AC, de Castro
EM. Accuracy of two forms of infrared image analysis of the masticatory muscles in
the diagnosis of myogenous temporomandibular disorder. J Bodyw Mov Ther.
2014;18(1):49-55.http://dx.doi.org/10.1016/j.jbmt.2013.05.005.
PMid:24411149
http://dx.doi.org/10.1016/j.jbmt.2013.05...
also used area
analysis of the masseter and temporalis anterior muscle belly in both individuals with
temporomandibular disorder and controls, reporting ICC values ranging from 0.945 to
0.998.
Some studies assessed the reliability of the infrared thermography in other clinical
conditions, reporting results similar to those found in the present study. In the
analysis of skin temperature regarding the paraspinal region, McCoy et al.3838. McCoy M, Campbell I, Stone P, Fedorchuk C, Wijayawardana S, Easley
K. Intra-examiner and inter-examiner reproducibility of paraspinal thermography. PLoS
One. 2011;6(2):e16535.http://dx.doi.org/10.1371/journal.pone.0016535.
PMid:21347290
http://dx.doi.org/10.1371/journal.pone.0...
found excellent intra- and inter-rater
reliability. Choi et al.3939. Choi E, Lee PB, Nahm FS. Interexaminer reliability of infrared
thermography for the diagnosis of complex regional pain syndrome. Skin Res Technol.
2013;19(2):189-93.http://dx.doi.org/10.1111/srt.12032. PMid:23331254
http://dx.doi.org/10.1111/srt.12032...
observed a high
inter-rater reliability in the assessment of individuals with complex regional pain
syndrome. In addition to these studies, Zaproudina et al.4040. Zaproudina N, Varmavuo V, Airaksinen O, Närhi M. Reproducibility of
infrared thermography measurements in healthy individuals. Physiol Meas.
2008;29(4):515-24.http://dx.doi.org/10.1088/0967-3334/29/4/007.
PMid:18401069
http://dx.doi.org/10.1088/0967-3334/29/4...
found high ICC values for inter-rater reliability in healthy subjects,
however these authors identified reasonable ICC values when considering the temperature
of the extremities on different days.
The studies conducted by Costa et al.2121. Costa AC, Dibai Filho AV, Packer AC, Rodrigues-Bigaton D. Intra and
inter-rater reliability of infrared image analysis of masticatory and upper trapezius
muscles in women with and without temporomandibular disorder. Braz J Phys Ther.
2013;17(1):24-31.http://dx.doi.org/10.1590/S1413-35552012005000058.
PMid:23117649
http://dx.doi.org/10.1590/S1413-35552012...
,
Rodrigues-Bigaton et al.3636. Rodrigues-Bigaton D, Dibai Filho AV, Costa AC, Packer AC, de Castro
EM. Accuracy and reliability of infrared thermography in the diagnosis of arthralgia
in women with temporomandibular disorder. J Manipulative Physiol Ther.
2013;36(4):253-8.http://dx.doi.org/10.1016/j.jmpt.2013.04.006.
PMid:23719519
http://dx.doi.org/10.1016/j.jmpt.2013.04...
, and Rodrigues-Bigaton
et al.3737. Rodrigues-Bigaton D, Dibai-Filho AV, Packer AC, Costa AC, de Castro
EM. Accuracy of two forms of infrared image analysis of the masticatory muscles in
the diagnosis of myogenous temporomandibular disorder. J Bodyw Mov Ther.
2014;18(1):49-55.http://dx.doi.org/10.1016/j.jbmt.2013.05.005.
PMid:24411149
http://dx.doi.org/10.1016/j.jbmt.2013.05...
were based on the mean value of analyses
performed for measurement of the skin temperature. Within this context, Klamann et
al.4141. Klamann MK, Maier AK, Gonnermann J, Klein JP, Pleyer U. Measurement
of dynamic ocular surface temperature in healthy subjects using a new thermography
device. Curr Eye Res.
2012;37(8):678-83.http://dx.doi.org/10.3109/02713683.2012.674610.
PMid:22559822
http://dx.doi.org/10.3109/02713683.2012....
assessed the intra-rater reliability of
the temperature analysis of ocular surface, reporting ICC values of 0.947, 0.949, and
0.955 for minimum, maximum, and mean values, respectively. In the present study, not
only the mean value was used but also minimum and maximum values of line and area
analyses.
Regarding the values of SEM and MDC, published studies that evaluated the reliability of
infrared thermography showed no such statistical measures2121. Costa AC, Dibai Filho AV, Packer AC, Rodrigues-Bigaton D. Intra and
inter-rater reliability of infrared image analysis of masticatory and upper trapezius
muscles in women with and without temporomandibular disorder. Braz J Phys Ther.
2013;17(1):24-31.http://dx.doi.org/10.1590/S1413-35552012005000058.
PMid:23117649
http://dx.doi.org/10.1590/S1413-35552012...
,
3737. Rodrigues-Bigaton D, Dibai-Filho AV, Packer AC, Costa AC, de Castro
EM. Accuracy of two forms of infrared image analysis of the masticatory muscles in
the diagnosis of myogenous temporomandibular disorder. J Bodyw Mov Ther.
2014;18(1):49-55.http://dx.doi.org/10.1016/j.jbmt.2013.05.005.
PMid:24411149
http://dx.doi.org/10.1016/j.jbmt.2013.05...
38. McCoy M, Campbell I, Stone P, Fedorchuk C, Wijayawardana S, Easley
K. Intra-examiner and inter-examiner reproducibility of paraspinal thermography. PLoS
One. 2011;6(2):e16535.http://dx.doi.org/10.1371/journal.pone.0016535.
PMid:21347290
http://dx.doi.org/10.1371/journal.pone.0...
39. Choi E, Lee PB, Nahm FS. Interexaminer reliability of infrared
thermography for the diagnosis of complex regional pain syndrome. Skin Res Technol.
2013;19(2):189-93.http://dx.doi.org/10.1111/srt.12032. PMid:23331254
http://dx.doi.org/10.1111/srt.12032...
-
4040. Zaproudina N, Varmavuo V, Airaksinen O, Närhi M. Reproducibility of
infrared thermography measurements in healthy individuals. Physiol Meas.
2008;29(4):515-24.http://dx.doi.org/10.1088/0967-3334/29/4/007.
PMid:18401069
http://dx.doi.org/10.1088/0967-3334/29/4...
. In the present study, when considering the
intra-rater reliability, higher SEM and MDC were observed for the minimum value of line
(1.57 and 4.35 °C) and area (0.66 and 1.83) analyses. For inter-rater reliability,
similar results were found, with higher SEM and MDC for the minimum value of the line
(1.22 and 3.38 °C) and area (0.62 and 1.72 °C) analyses.
Thus, in general, mean (point, line, and area analyses) and maximum (line and area analyses) measures are the most reliable (intra-rater, ICC between 0.943 and 0.993; inter-rater, ICC between 0.851 and 0.918) and with less error (intra-rater, SEM between 0.13 and 0.34 °C, and MDC between 0.36 and 0.94 °C; inter-rater, SEM between 0.43 and 0.52 °C, and MDC between 1.19 and 1.44 °C). Moreover, in a more rigorous analysis of ICC values, considering the lower limit of the CI 95% and excepting the minimum values of the area and line analyzes, excellent intra-rater reliability (ICC values between 0.909 and 0.989) and substantial inter-rater reliability (ICC values between 0.762 and 0.869) were observed. These results give more robustness to the applicability of the methods of analyses (mean and maximum values) of the infrared images.
Considering the relevance of SEM and MDC in reliability studies, Tucci et al.3535. Tucci H, Martins J, Sposito G, Camarini P, Oliveira A. Closed
Kinetic Chain Upper Extremity Stability test (CKCUES test): a reliability study in
persons with and without shoulder impingement syndrome. BMC Musculoskelet Disord.
2014;15(1):1.http://dx.doi.org/10.1186/1471-2474-15-1. PMid:24387196
http://dx.doi.org/10.1186/1471-2474-15-1...
evaluated a specific test for identification of
shoulder impingement syndrome and also found that previously published studies in the
same subject did not consider these statistical measures in reliability analysis. In
addition, these authors emphasize the importance of knowing the values for SEM and MDC
as these numbers give a good indication of the minimal score difference between
evaluations that could be considered as real improvement.
Finally, infrared thermography has been employed for the evaluation of different
musculoskeletal conditions4242. Dibai Filho AV, Packer AC, Costa AC, Rodrigues-Bigaton D. Accuracy
of infrared thermography of the masticatory muscles for the diagnosis of myogenous
temporomandibular disorder. J Manipulative Physiol Ther.
2013;36(4):245-52.http://dx.doi.org/10.1016/j.jmpt.2013.04.007.
PMid:23706912
http://dx.doi.org/10.1016/j.jmpt.2013.04...
43. Zaproudina N, Airaksinen O, Närhi M. Are the infrared thermography
findings skin temperature-dependent? a study on neck pain patients. Skin Res Technol.
2013;19(1):e537-44.http://dx.doi.org/10.1111/srt.12007.
PMid:23020845
http://dx.doi.org/10.1111/srt.12007...
-
4444. Roy RA, Boucher JP, Comtois AS. Comparison of paraspinal cutaneous
temperature measurements between subjects with and without chronic low back pain. J
Manipulative Physiol Ther.
2013;36(1):44-50.http://dx.doi.org/10.1016/j.jmpt.2012.12.002.
PMid:23380213
http://dx.doi.org/10.1016/j.jmpt.2012.12...
. Therefore, the aim of the present study was
to standardize the infrared image analyses of myofascial trigger points, thus making it
possible to support the use of infrared thermography in clinical practice and research
for either mapping the skin temperature of a given site or even for assessing the
effects of therapeutic resources in musculoskeletal dysfunctions44. Montañez-Aguilera FJ, Valtueña-Gimeno N, Pecos-Martín D,
Arnau-Masanet R, Barrios-Pitarque C, Bosch-Morell F. Changes in a patient with neck
pain after application of ischemic compression as a trigger point therapy. J Back
Musculoskelet Rehabil. 2010;23(2):101-4. PMid:20555123.
,
66. Tekin L, Akarsu S, Durmuş O, Cakar E, Dinçer U, Kıralp MZ. The effect
of dry needling in the treatment of myofascial pain syndrome: a randomized
double-blinded placebo-controlled trial. Clin Rheumatol.
2013;32(3):309-15.http://dx.doi.org/10.1007/s10067-012-2112-3.
PMid:23138883
http://dx.doi.org/10.1007/s10067-012-211...
,
1212. Hakgüder A, Birtane M, Gürcan S, Kokino S, Turan FN. Efficacy of low
level laser therapy in myofascial pain syndrome: an algometric and thermographic
evaluation. Lasers Surg Med. 2003;33(5):339-43.http://dx.doi.org/10.1002/lsm.10241.
PMid:14677161
http://dx.doi.org/10.1002/lsm.10241...
.
The present study had the limitation of not including volunteers with latent myofascial
trigger points, since these differ from the active ones due to the presence of algesic
substances, among other features33. Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial
trigger points using in vivo microdialysis: an application of muscle pain concepts to
myofascial pain syndrome. J Bodyw Mov Ther.
2008;12(4):371-84.http://dx.doi.org/10.1016/j.jbmt.2008.06.006.
PMid:19083696
http://dx.doi.org/10.1016/j.jbmt.2008.06...
. Moreover, we
suggest that future studies assess the reliability of the entire procedure of collecting
thermographic data: patient preparation, instrumentation, recording, and analysis of the
infrared images.
Conclusion
The methods of infrared image analysis of myofascial trigger points in the upper trapezius muscle proposed by the present study showed acceptable intra- and inter-rater reliability values, which supports the use of these methodologies in clinical and research practices.
Acknowledgements
To Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP, grants 2013/19368-8 and 2013/09753-1) and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil, for their financial support of this study.
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Publication Dates
-
Publication in this collection
27 Apr 2015 -
Date of issue
Mar-Apr 2015
History
-
Received
21 May 2014 -
Reviewed
18 July 2014 -
Accepted
02 Oct 2014