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Prof. Marcos Leal Brioschi, de arts die al ons beeldmateriaal interpreteert, doet erg veel aan onderzoek met betrekking tot de mogelijkheden van medische thermografie. Vele van zijn studies zijn gepubliceerd. Hij houdt zich full time bezig met medische thermografie.

Onderstaand artikelen van researchprojecten met betrekking tot medische thermografie.

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POSTURAL THERMOGRAPHY ASSESSMENT

POSTURAL THERMOGRAPHY ASSESSMENT

Marcos Leal Brioschi MD, Manoel Jacobsen Teixeira MD Clinical Thermology and Thermography Postgraduate Specialty Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil.

The term ideal posture can be defined as upright position adopted by the human being in perfect equilibrium with gravity action and spending as less energy as possible. This lowenergetic expenditure is due to a low joint overload, which in turn determines a less intense muscle activity. Postural deviations results in thermal imbalance. Thermal imbalance can cause serious damage combined with misguided physical activity and inappropriate intensity. Thermal imbalances can guide the type of exercise that may or may not to do. Thermal asymmetric patterns (difference between sides) can results from dysfunctions, injuries or pathologies that may be related, and been cause or effect postural changes. Thermography can be implemented for evaluation of biomechanics and muscle overloads during patient treatments, also to identify mechanical overload, to assess muscle fatigue and injury prevention by thermographic biomechanical analysis (TBA). The authors proposed a thermography method to assess posture by anterior, posterior and lateral full body high definition thermal mapping.

Postural thermography assessment.

Postural thermography assessment.

The analysis involves these three thermography elements: anatomic deviations (horizontal, vertical and spine alignments) and functional overloads and deficits (78 ROI´s delta T measurements of muscles and joints segments). It is also done a biomechanical vector analysis by spot marking of the ROI, a paired plantar surface study with pedothermography and a detailed paraspinal thermography. The TBA or simply Postural Thermography enables to make a quick, accurate and reliable postural diagnosis based on static image as photography. Therefore, it should not replace clinical judgment, but complement it.

THE ROLE OF THERMOGRAPHY IN EVALUATION OF THE SYMPATHETIC NERVOUS SYSTEM.

THE ROLE OF THERMOGRAPHY IN EVALUATION OF THE SYMPATHETIC NERVOUS SYSTEM.

Andrea Pereira Augusto MD, Marcos Leal Brioschi MD, Manoel Jacobsen Teixeira MD. Clinical Thermology and Thermography Postgraduate Specialty Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil.

A.M.C., male, 50 years old, occupation: electrical technician. Main Complaint: Pain in the right posterior cervical region. The patient referred pain in the right posterior cervical region, radiating from the back side of the right shoulder, side and rear face of the right upper limb until the thumb, which refers paresthesia. A cold stress test was performed, and the right thumb kept the hyper-radiation in the region where the patient complains of paresthesia. Other regions of both hands responded with hyporadiation. Radiography of cervical spine showed normal bone density, osteophytes and reduced intervertebral spaces between C5 and C6. The diagnosis of this patient could have been based on clinical examination and radiography. However, the confirmation of the sympathetic nervous system involvement was only possible with thermography.

Reference
Brioschi ML, Silva FMRM, França GV, Teixeira MJ. Termografia no diagnóstico da dor. In: Onofre Alves Neto, Carlos Maurício de Castro Costa, José Tadeu T. de Siqueira, Manoel Jacobsen Teixeira (SBED), organizadores. Dor: princípios e prática. Porto Alegre: Artmed; 2009, v. 1, p. 1338-57.
Balbinot LF, Robinson CC, Achaval M, Zaro MA, Brioschi ML. Repeatability of infrared plantar thermography in diabetes patients: a pilot study. J Diabetes Sci Technol. 2013 Sep 1;7(5):1130-7.

CUTANEOUS INFRARED THERMOMETRY IN AID TO DIFFERENTIAL DIAGNOSIS OF CHRONIC PAIN AND NEUROGENIC PAIN - CASE REPORT

CUTANEOUS INFRARED THERMOMETRY IN AID TO DIFFERENTIAL DIAGNOSIS OF CHRONIC PAIN AND NEUROGENIC PAIN – CASE REPORT

Carlos Dalmaso Neto MD, Marcos Leal Brioschi MD, Manoel Jacobsen Teixeira MD Clinical Thermology and Thermography Postgraduate Specialty Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil.

CAAS, female, 31 year old. Asked to performThermography for chronic pain and suspected of fibromyalgia syndrome. She complained of lower back pain with radiation to the lower limbs and pain relief at rest. After 3 years she evolved with generalized weakness and pain. After one more year of progress she had dystonia in the extremities, generalized pain persisted, worsening by exposing herself to heat. Lumbar CT showed incipient lumbar spondyloarthrosis, mild diffuse bulging of L3-L4 intervertebral disc, small disc protrusions L4-L5 and L5-S1, atrophic pattern of paraspinal musculature on the right and a discrete anterolystesis in L4. Electromyography was normal in upper limb, except for an irregular tremor of the limbs surveyed by 20Hz. Thermography showed a complete asymmetry of the whole body with sympathetic vasomotor instability of the hands after cold stress test and also an asymmetric pattern in medial canthus eyes (territory of internal carotid artery terminal branches), suggesting a neurogenic central dysfunction.

Reference
Brioschi ML, Silva FMRM, França GV, Teixeira MJ. Termografia no diagnóstico da dor. In: Onofre Alves Neto, Carlos Maurício de Castro Costa, José Tadeu T. de Siqueira, Manoel Jacobsen Teixeira (SBED), organizadores. Dor: princípios e prática. Porto Alegre: Artmed; 2009, pp. 1338-57.
Ammer K. Thermal imaging: a diagnostic aid for fibromyalgia? Thermology International 18(2):45-50, 2008.

CHRONIC PAIN IN LEFT HAND AFTER TRAUMA IDENTIFIED BY THERMOGRAPHY

CHRONIC PAIN IN LEFT HAND AFTER TRAUMA IDENTIFIED BY THERMOGRAPHY

Paulo Roberto Fochesato MD, Marcos Leal Brioschi MD, Manoel Jacobsen Teixeira MD Clinical Thermology and Thermography Postgraduate Specialty Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil.

December 2012 a 19 years old woman had work related accident caused by gripping the left hand between mechanical structures in a fridge industry, with fracture of 5th finger distal phalanx. She was managed with an uneventfully conservative treatment. Later the resignation, eight months after the accident, she filed a labor indemnity claim and was attended by an expert examination in November 2013 with intermittent pain complaints of the left hand, referring swelling and difficulty for bending the fingers. The medical expert physical examination didn´t identify any functional limitations.Thermographic imageswere taken in ideal condition for examination and identified hyporadiants thermal images on the left hand suggesting a possible sequel to the accident. The infrared imaging identified anomalies that justified the complaints of pain she had alleged during the medical expert examination.

Reference
Brioschi ML, Teixeira MJ, Silva FMRM, Colman D. Medical thermography textbook: principles and applications. Sao Paulo, Brazil:Ed. Andreoli; 2010.p.1-280.
Hubbard JE, Hoyt C. Pain evaluation in 805 studies by infrared imaging. Thermology. 1986;1:161-6.
Brioschi ML, Okimoto ML, Vargas JV. The utilization of infrared imaging for occupational disease study in industrial work. Work. 2012 Jan 1;41(0):503-9.
Brioschi ML, Cherem AJ, Ruiz RC, Sardá Júnior JJ, Silva FMRM. The use of infrared thermography in evaluating returns to work in an extended rehabilitation program (PRA). Acta Fisiatr 2009; 16(2): 87-92.

CASE REPORT: MYOFASCIAL PAIN SYNDROME IN PATIENT WITH NEUROMUSCULAR SCOLIOSIS - USE OF THERMOGRAPHY IN DIAGNOSTIC AND THERAPY EVALUATION

CASE REPORT: MYOFASCIAL PAIN SYNDROME IN PATIENT WITH NEUROMUSCULAR SCOLIOSIS – USE OF THERMOGRAPHY IN DIAGNOSTIC AND THERAPY EVALUATION

Luis Paulo de Oliveira Pereira, MD, Sidney Benedito Silva DPT, Marcos Leal Brioschi MD, Manoel Jacobsen Teixeira MD Clinical Thermology and Thermography Postgraduate Specialty Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil.

Myofascial pain syndrome is one of the most common causes of pain. Usually related to trauma, recurrent microtrauma or postural overload is a highly prevalent pathology, leading to high social and economic impact. Despite its prevalence, it is frequently not recognized, since the diagnosis depends on a detailed medical history and precise physical examination. Even when suspected, differential diagnosis and the precise location of the injured tissues may be difficult, compromising treatment efficacy. The use of Thermography, associated to a careful physical examination, provides better diagnosis and therapy directions. We report a case of a young patient, with neuromuscular scoliosis related to myelomeningocele, in chronic cervical, lumbar and leg pain, besides headache.We performed a Thermographic evaluation, identifying myofascial compromised areas related to postural overload. Based on images and clinical information, patient was treated and showed great pain and posture improvement.

Reference
Brioschi ML, Teixeira MJ, Silva FMRM, Colman D. Medical thermography textbook: principles and applications. Sao Paulo, Brazil:Ed. Andreoli; 2010.p.1-280.

THERMOGRAPHY CASE REPORT: NEUROPATHIC CENTRAL PAIN

THERMOGRAPHY CASE REPORT: NEUROPATHIC CENTRAL PAIN

Rosa Maria Papaléo MD, Marcos Leal Brioschi MD, Manoel Jacobsen Teixeira MD Clinical Thermology and Thermography Postgraduate Specialty Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil.

E.C.L. 68 years old with right neck pain and hoarseness for about 20 years. At clinical exam was foundmyofascial trigger points in the right upper trapezius. The aphonia started after the end of her marriage. The patient was previously singer and wants to continue their vocal classes. The full body thermography helped to additional clinical diagnoses as right shoulder perintendinitis, contracture of the left posterior cervical muscles (osteoarthropathy), dysfunction of temporomandibular joint, L4 and C5 right radiculopathy and sleep disorders (periocular hot spot). But especially two finds were essential in this case: signs of vascular insufficiency in the internal carotid in the face territory (delta T 0.5o C) associated with a noteworthy asymmetry of the whole body compatible with neurogenic central pattern. After thermographic examination, the patient went to the neurologist who indicated a brain MRI. Despite the absence of a significant finding in MRI an ENT doctor found asymmetric vocal cords. Today she is taking the gabapentin 300mg a day, doing therapy with a speech therapist and singing. Her voice is better and there is a considerable improvement after the thermography identification of her neurologic problem.

Reference
Brioschi ML, Yeng LT, Pastor EMH, Colman D, Silva FMRM, Teixeira MJ. Documentation of myofascial pain syndrome with infrared imaging. Acta Fisiatr 2007; 14(1): 41-8.
Brioschi ML, Silva FMRM, França GV, Teixeira MJ. Termografia no diagnóstico da dor. In: Onofre Alves Neto, Carlos Maurício de Castro Costa, José Tadeu T. de Siqueira, Manoel Jacobsen Teixeira (SBED), organizadores. Dor: princípios e prática. Porto Alegre: Artmed; 2009, v. 1, p. 1338-57.

THERMOGUIDED TRIGEMINAL NEURALGIA SURGERY

THERMOGUIDED TRIGEMINAL NEURALGIA SURGERY

Robson Prudêncio Silva Lima MD, Marcos Leal Brioschi MD, Manoel Jacobsen Teixeira MD Clinical Thermology and Thermography Postgraduate Specialty Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil.

BACKGROUND: Trigeminal neuralgia is a neuropathic disorder of the trigeminal nerve with paroxysmal attacks of severe pain lasting from a fraction of a second to minutes, affecting one or more divisions of the trigeminal nerve, and the maxillary branch V2 is the most frequent reached. Pain has at least one of the following: intense, sudden, superficial, precipitated by factors trigger or trigger areas as a light touch or small movements, talking, drinking, brushing teeth, shaving, chewing. Infrared thermography is an examination without contrast or radiation with a thermal camera that features high sensitivity sensors which allows obtaining high resolution images that are studied using specific software and identifying possible changes in temperature characteristics of neurovascular disorders.

OBJECTIVES: To demonstrate the use of thermography as a tool for diagnosis of Trigeminal Neuralgia and surgical monitoring parameters for analysis result of retrogasserian compression by balloon pre, intra and postoperative complementary to clinical symptoms.

METHOD: Female patient 78 years with severe pain (VAS 8-10) in the right maxillary region, began three months ago with a gradual worsening crises and recurrent shocks triggered by the act of mastication, direct contact and cold on the face. She underwent retrogasserian compression by balloon due persistence of pain and adverse reactions to medications and the phases of treatment were evaluated by thermography.

RESULTS: Preoperative thermography showed temperature difference (Delta-dt) of 1.1oC in the affected right face area compared with the opposite non painful side. Intraoperative examination have revealed an increase of 0.6oC after compression of the Gasserian ganglion in its area of referred pain and hyper-radiation in the territory of V1 and V2 (predominant) which signaled to the surgeon that he had achieved its objective, the neuropraxis of maxillary branch of trigeminal nerve. Reassessment of the patient on the 10th postoperative day confirmed the clinical improvement (VAS=0) and showed symmetrical thermographic pattern of the face without temperature difference in the analyzed areas.

CONCLUSION: Thermography is a harmless test that can be used to establish the Trigeminal Neuralgia, to assist the surgical procedure and to control the postoperative response because it determines the temperature variation due neurovascular reaction.

Reference
Brioschi ML, MalafaiaO, Costa AFCB, Vargas JVC. Surgery by infrared vision. Engenharia Térmica, v. 5, p. 33-35, 2004.
Brioschi ML, Silva FMRM, França GV, Teixeira MJ. Termografia no diagnóstico da dor. In: Onofre Alves Neto, Carlos Maurício de Castro Costa, José Tadeu T. de Siqueira, Manoel Jacobsen Teixeira (SBED), organizadores. Dor: princípios e prática. Porto Alegre: Artmed; 2009, v. 1, p. 1338-57.
Drummond PD, Gonski A, Lance JW. Facial flushing after thermocoagulation of the Gasserian ganglion. J Neurol Neurosurg Psychiatry. 1983 Jul;46(7):611-6.

THERMOGRAPHY CASE REPORT: NEUROPATHIC CENTRAL PAIN

THERMOGRAPHY CASE REPORT: NEUROPATHIC CENTRAL PAIN

Rosa Maria Papaléo MD, Marcos Leal Brioschi MD, Manoel Jacobsen Teixeira MD Clinical Thermology and Thermography Postgraduate Specialty Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil.

E.C.L. 68 years old with right neck pain and hoarseness for about 20 years. At clinical exam was foundmyofascial trigger points in the right upper trapezius. The aphonia started after the end of her marriage. The patient was previously singer and wants to continue their vocal classes. The full body thermography helped to additional clinical diagnoses as right shoulder perintendinitis, contracture of the left posterior cervical muscles (osteoarthropathy), dysfunction of temporomandibular joint, L4 and C5 right radiculopathy and sleep disorders (periocular hot spot). But especially two finds were essential in this case: signs of vascular insufficiency in the internal carotid in the face territory (delta T 0.5o C) associated with a noteworthy asymmetry of the whole body compatible with neurogenic central pattern. After thermographic examination, the patient went to the neurologist who indicated a brain MRI. Despite the absence of a significant finding in MRI an ENT doctor found asymmetric vocal cords. Today she is taking the gabapentin 300mg a day, doing therapy with a speech therapist and singing. Her voice is better and there is a considerable improvement after the thermography identification of her neurologic problem.

Reference
Brioschi ML, Yeng LT, Pastor EMH, Colman D, Silva FMRM, Teixeira MJ. Documentation of myofascial pain syndrome with infrared imaging. Acta Fisiatr 2007; 14(1): 41-8.
Brioschi ML, Silva FMRM, França GV, Teixeira MJ. Termografia no diagnóstico da dor. In: Onofre Alves Neto, Carlos Maurício de Castro Costa, José Tadeu T. de Siqueira, Manoel Jacobsen Teixeira (SBED), organizadores. Dor: princípios e prática. Porto Alegre: Artmed; 2009, v. 1, p. 1338-57.

THERMOGRAPHY AND OCULAR UVEITIS

THERMOGRAPHY AND OCULAR UVEITIS

Alberto Rafael Ferreira Neto MD, Marcos Leal Brioschi MD, Manoel Jacobsen Teixeira, MD Clinical Thermology and Thermography Postgraduate Specialty Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil.

E.C.D.O. 42y looked for medical care as there was days suffering hyperemia and photophobia in the right eye, which progressed with low visual acuity.He reported uveitis in the right eye at past, but during the ophthalmologist consult nothing was identified. He consulted another medical doctor who decided to do a complementary thermographic exam. It was confirmed an ocular uveitis by infrared imaging that allowed the initial diagnosis and treatment for this patient. Thermography can be a remarkable tool in ophthalmology field and help to the diagnosis of inflammatory eyes diseases.

INFRARED THERMOGRAPHY IN THE PREOPERATIVE PLANNING OF ANTEROLATERAL THIGH PERFORATOR FREE FLAP

INFRARED THERMOGRAPHY IN THE PREOPERATIVE PLANNING OF ANTEROLATERAL THIGH PERFORATOR FREE FLAP.

Alexandre Aldred MD, Bernardo Nogueira Batista MD, Marcos Leal Brioschi MD, Manoel Jacobsen Teixeira MD. Clinical Thermology and Thermography Postgraduate Specialty Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil.

BACKGROUND: The anterolateral thigh free flap is vascularized by one or several perforating arteries arising from the descending branch of the lateral circumflex femoral artery. This flap is large, thin and very versatile and is commonly used for reconstruction of head and neck defects (1). Infrared thermography is an effective tool for the study of cutaneous perfusion and its application in preoperative planning was tested on abdominal perforator flaps for breast reconstruction. (2,3). We briefly describe the use of infrared imaging in the preoperative planning of anterolateral thigh perforator free flap

METHODS: One patient scheduled for anterolateral thigh free flap was selected and kept for thirty minutes in controlled environment (23oC) lay in the bed, with legs exposed. Proceeded anatomical mark of the area of interest and start cooling the area with cotton swab soaked in 70% alcohol for 5 minutes. The perforator was identified by the location of a hot spot on the thermal image during the rewarming of the skin after the cold challenge. The hot spot location was marked and compared with intraoperative findings.

RESULTS: The hot spot observed in the right thigh of the patient corresponded to a perforator identified during the dissection phase.

CONCLUSION: Infrared imaging can be helpful in mapping suitable perforators in preoperative planning of anterolateral thigh perforator free flap.

References
1.Wei F-C, Jain V, Celik N, Chen H-c, Chuang DC-C, Lin C-h. HaveWe Found an Ideal Soft-Tissue Flap? An Experience with 672 Anterolateral Thigh Flaps. Plastic and Reconstructive Surgery. 2002;109(7):2219-26.
2.de Weerd L, Weum S, Mercer JB. The value of dynamic infrared thermography (DIRT) in perforatorselection and planning of free DIEP flaps. Ann Plast Surg. 2009 Sep;63(3):274-9.
3.de Weerd L, Weum S, Mercer JB. Locating Perforator Vessels Using Dynamic Infrared Thermography. Ann Plast Surg. 2012 Dec 13. [Epub ahead of print]

AN INFRARED IMAGING CASE STUDY: FACIAL PAIN CAUSED BY PULPITIS

AN INFRARED IMAGING CASE STUDY: FACIAL PAIN CAUSED BY PULPITIS

Maristela Zoboli Pezzucchi MD, Marcos Leal Brioschi MD, Manoel Jacobsen Teixeira MD Clinical Thermology and Thermography Postgraduate Specialty Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil.

INTRODUCTION: Orofacial pain has odontogenic source as one of the most frequent causes. It is common to use X-ray examinations that emits high energetic, ionizing radiation. Thermographic devices do not emit radiation and direct contact with the affected area is no longer required.

CASE DESCRIPTION: BFA, male, 34 years old, complains of pain in the right anterior hemiface for 3 years. He mentions having undergone dental treatment for an abscess with a fistula in his upper right first molar. Therewas a period without pain but later the symptoms returned. Thermographic image was captured from the front face incidence, as preliminary procedure. The image showed the asymmetry of the face with standard thermal hyper-radiation in the zygomatic region. The patientwas referred to the dentist who confirmed the diagnosis of pulpitis and the new therapeutic approach was settled.

DISCUSSION: The hyper-radiation identified in the thermographic image reveals an area with metabolically active and significant change (measured delta T:0.8 °C, by 0.25 °C higher than the normal value ). Due to this thermographic examination, the patient was spared from exposure to harmful electromagnetic radiations, was preserved from tests that could worsen painful symptoms, assessed the patient’s pain, helped in the treatment decisions and helped to prevent the development of complications in pulpitis.

CONCLUSION:Thermography is a non-invasive, non- traumatic examination that is decisive for the diagnosis, therapeutic management and good prognosis in orofacial pain.

Reference
Brioschi ML, Silva FMRM, França GV, Teixeira MJ. Termografia no diagnóstico da dor. In: Onofre Alves Neto, Carlos Maurício de Castro Costa, José Tadeu T. de Siqueira, Manoel Jacobsen Teixeira (SBED), organizadores. Dor: princípios e prática. Porto Alegre: Artmed; 2009, v. 1, p. 1338-57.
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.

FIBROMYALGIA EVALUATION BY THERMOLOGY

FIBROMYALGIA EVALUATION BY THERMOLOGY

Kátia H. Nakamura1,2, Marcos Brioschi2, Manoel Jacobsen Teixeira2
1. Hospital Metropolitano de Sarandi-PR 2. Clinical Thermology and Thermography Pos Graduate Specialty – Hospital das Clínicas – School of Medicine – University of São Paulo

INTRODUCTION: The fibromyalgia diagnosis is often given to the individuals with diffuse chronic pain which intensity range over the time. The morning stiffness and limb or articulation edema are often associated to abnormality cognitive and the humor, persistent fatigue and besides them the sleep disorder. It is also reported the gastrointestinal symptom and bladder disorder. There is an agreement of its heterogeneous physiopathology with characteristic and variable therapeutic response. Evidences show the main component of the pain in the fibromyalgia is related to the central sensitization with symptom amplification. The prevalence in the adult population is 2 to 5% and it predominates in women on the proportion of 8 to 9 women / 1 man, age range: 35 to 60 years. There are no laboratorial abnormalities evidences or exams such as radiography, ultrasonography, computerized tomography or even nuclear magnetic resonance. The infrared imaging exam fulfill this large diagnostic opening that can detect physiological changings and the metabolic processes at the same time, and helping in the diagnostic confirmation and the fibromyalgic patients follow up.

PROCEDURE: The patient must be 15 minutes undressed to equalize its temperature with the climatized environment at the 23°C degree, air humidity in 60%, air conditioning with air current <0,2m/s, thermic isolation environment and the distance between the camera and the patient must be 4m with the whole body filming. The fibromyalgic patient presents a heated image on the trunk region of a mantle shape caused by thermo-regulation disorder associated to the cold extremes by the periferic vasoconstriction and the eyelid heating, known as owl eye due to the sleep disorder. CONCLUSIONS: The infrared imaging is a non ionizing diagnostic method, painless without radiological contrast and it can be applied at all ages, also pregnant. It can be applied for the chronic pain understanding such as fibromyalgia.

REFERENCES
1. Bennett R, Nelson D. Cognitive behavioral therapy for fibromyalgia. Nat Clin Pract Rheumatology 2006; 2:416-24.
2. Brioschi ML, Colman D, Kosikov A et al. Terapia de pontosgatilhos guiada por termografia infravermelha. Rev Dor 2004; 5(3):9.
3. Biasi G, Fioravanti A, Franci A, Marcolongo R. The role computerized telethermography in the diagnosis of fibromyalgia syndrome. Minerva Med. 1994; 85(9):451-4.
4. Brioschi ML, Abramavicus S, Correa FC. Valor da imagem infravermelha na avaliação da dor. Rev Dor 2005; 6(1):514-524

MEDICAL THERMOGRAPHY FOR THE DIAGNOSISOF FIBROMYALGIA SYNDROME AND EXCLUSION OF OTHER WIDESPREAD PAIN DISORDERS.

MEDICAL THERMOGRAPHY FOR THE DIAGNOSISOF FIBROMYALGIA SYNDROME AND EXCLUSION OF OTHER WIDESPREAD PAIN DISORDERS.

Haroldo Garcia Barbosa MD, Marcos Leal Brioschi MD, Manoel Jacobsen Teixeira MD Clinical Thermology and Thermography Postgraduate Specialty Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil.

Currently there are no laboratory tests available for diagnosing fibromyalgia (FM). Doctors must rely on patient histories, selfreported symptoms, a physical examination and an accurate manual tender point examination. This exam is based on the standardized American College of Rheumatology (ACR) criteria. To be used as a complementary diagnosis of FM syndrome, thermography must exclude other widespread pain disorders. The authors present a FM case report to discuss it.

PROCEDURE: Initially the patient stayed standing and undressed for 15 minutes to equalize full body temperature in a conditioned environment at 23°Cand air humidity below60%.

RESULT: The FMpatient showed a well-defined warmer image on the trunk area like a mantle shape caused by thermo- regulation disorder simultaneous with cold extremities triggered by peripheral vasoconstriction and also periocular heating, known as “owl eye” essentially due to related sleep disorders.

DISCUSSION: It is estimated that it takes an average of five years for an FM patient to get an accurate diagnosis. Many doctors are still not adequately informed or educated about FM. Laboratory tests often prove negative and many FM symptoms overlap with those of other conditions, thus leading to extensive investigative costs and frustration for both the doctor and patient. Another essential point that must be considered is that the presence of other diseases, such as rheumatoid arthritis or lupus, does not rule out an FM diagnosis. FM is rich of neurovegetative symptoms and impairments that are not related to other widespread pain disorders. FM is not a diagnosis of exclusion and must be diagnosed by its own characteristic features, especially by the neurovegetative impairments that can be documented by thermography. FM test must be focus on these neurovegetative disturbances.

CONCLUSION: If associated with clinical assessment thermography can be effective in further documentation diagnosis of fibromyalgia syndrome, and also for the exclusion diagnosis of other widespread pain disorders.

References
1. Bennett R, Nelson D. Cognitive behavioral therapy for fibromyalgia. Nat Clin Pract Rheumatology 2006; 2:416-24.
2. Brioschi ML, Colman D, Kosikov A et al. Terapia de pontos-gatilhos guiada por termografia infravermelha. Rev Dor 2004; 5(3):9.
3. Biasi G, Fioravanti A, Franci A, Marcolongo R. The role computerized telethermography in the diagnosis of fibromyalgia syndrome. Minerva Med. 1994; 85(9):451-4.
4. Brioschi ML, Abramavicus S, Correa FC. Valor da imagem infravermelha na avaliação da dor. Rev Dor 2005; 6(1):514-524.
5. Ammer K. Thermal imaging: a diagnostic aid for fibromyalgia? Thermology International 18(2):45-50, 2008.
6. Brioschi ML, Abreu GF, Balbinot L et al. Identificação clínica, termográfica e ultrassonográfica de pontos-gatilho em pacientes com fibromialgia (OR015). XXIII Congresso Brasileiro de Medicina Física e Reabilitação, São Paulo, 2012.

THE “MANTLE SIGN”: HOW THERMOGRAPHY CAN HELP TO SUPPORT THE CLINICAL DIAGNOSIS OF FIBROMYALGIA SYNDROME?

THE “MANTLE SIGN”: HOW THERMOGRAPHY CAN HELP TO SUPPORT THE CLINICAL DIAGNOSIS OF FIBROMYALGIA SYNDROME?

Marcos Leal Brioschi MD, Manoel Jacobsen Teixeira MD
Clinical Thermology and Thermography Postgraduate Specialty Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil.

Fibromyalgia (FM) syndrome is a chronic condition characterized by musculoskeletal pain that persists for many years and is unresponsive to anti-inflammatory and analgesic compounds. There is an overlap between thermoregulation and the modulation of nociception that are consistent with the symptoms of FM (Larson et al, 2013):
1. Cold intolerance.
2. Decreased body temperature (low metabolic rate).
3. Distribution of brown adipose tissue (BAT) resembles that of tender points (TP) (Jeschonneck, 2000).
4. BAT activity at rest and the incidence of FM are each relatively greater in females than males (whereas adaptive thermogenesis is greater in males than females).
5. Stress and cold each stimulate thermogenesis and aggravate symptoms of FM (whereas warmth suspends thermogenesis and temporarily relieves the symptoms of FM).
6. Regulation of thermogenesis and pain share several areas in the brain where they may influence each other.
7. Sensitive to sympatholytic maneuvers: injections of a local anesthetic into stellate ganglia (sympathetic projections to subclavicular BAT) reduce pain in patients with FM (Bengtsson, 1988).
8. Rekindles upon injection with norepinephrine.
9. Polymorphisms in catechol-o-methyl transferase have been linked toFM(faulty degradation of catecholamines increases the risk of developing FM)
10. Extended programs of exercise relieve symptoms of FM (improve thermoregulation, decrease adrenergic activity, and inhibit recruitment of BAT).

Nerves projecting to BAT are located near regions surrounding tender points (TP), primarily in the supraclavicular region, and also in supra axial, perirenal, and subcutaneous areas. Eighteen TP distributed symmetrically on the trunk and proximal regions of limbs rather than areas that are usually more sensitive to tactile stimulation in healthy individuals, such as hands, feet, genitals, and mouth were defined by the American College of RheuRheumatology. This anatomic overlap provides collateral innervation of tissue adjacent to BAT, for example, skin and muscle, by sympathetic and primary afferent nerves. Thermogenic activity is increased by the same conditions that exacerbate the symptoms of FM, that is, cold and mild daily stress. BAT undergoes “recruitment” (increased mass) in response to repeated cold, repeated stress and overfeeding with diets chronically high in calories. Consistent with this, when BAT is activated by injections of adrenaline in rats, muscles surrounding interscapular BAT have greater blood flow than in muscles of the anterior limbs indicating that adjacent tissues operate in synergy with BAT (Sbarbati, 2006). Sympathetic activity that induces thermogenesis is poised to induce hyperalgesia in tissues surrounding BAT by referred pain.

One model of FM based on repeated exposures of rodents to cold depends on spinal substance P activity for hyperalgesia (Nishiyori, 2008). Substance P, released from primary afferent C-fibers transmitting pain or temperature, causes vasodilation in skin to dissipate heat and induces hyperalgesia. Thus pain can result from the combined effect of substance P along nociceptive pathways together with sympathetically mediated hyperalgesia in skin and muscle surrounding BAT, similar to the pain of angina.

Interscapular brown fat can be readily seen using IR thermography in young rats during cold exposure, in bats during arousal from torpor, in human infants and in human adults (Jackson et al, 2000).

Recently Symonds et al (2012) demonstrated using IR thermography a consistent, and highly localized, increase in local temperature within the supraclavicular region that directly corresponds to the main site of BAT, previously established from PET/CT scans and biopsy studies (Lee et al, 2011).

This is compatible with rapid activation of the sympathetic nervous system, concomitant unmasking of guanodine diphosphate binding sites within uncoupling protein and the stimulatory effect of catecholamines on heat production both in the newborn and in adults. Only a modest standard cool challenge (by placement of the participant’s feet or hand inwater at 20o C) is required to cause a local temperature increase within this supraclavicular region.

In awell-controlled ambient temperature lab Brioschi et al (2007) described in FM patients a consistent pattern called “mantle sign” that correspond of an exacerbated increase in temperature within the supraclavicular region that can extend to neck and trunk, observed by Biasi et al (1994) as a nonspecific hyperthermic pattern, corresponding to painful muscular areas. The authors also related a direct clinical correspondence of these findings with visual analog pain scale during the full body IR thermography of 226 patients and after validated with more 542 evaluations. Most of times, this finding was associated with symmetrical cold hands and periocular hyper radiation. Based on the count of hot spots, 74.2% of 252 subjects have been correctly diagnosed by Ammer et al (2011) described a high consistency of hot spots correlated with TP on upper body with 74.2% of precision in FM patients.

The supraclavicular “mantle sign” observed by IRthermography can be related to the vascular convection that carries in FM patients the overstimulated BAT heat to adjacent vital organs, such as the thoracocervical regions of the spinal cord, heart, and other thoracic organs. Although it is not a definitive diagnosis, the phenomenon of mantle sign can support the clinical dia. gnosis and play an important role in the following of FM patients.

thermal imaging


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COMPARISON CLINICAL ULTRASOUNDANDTHERMOGRAPHY POINTS IN IDENTIFYING MYOFASCIAL TRIGGERS IN PATIENTS WITH FIBROMYALGIA

COMPARISON CLINICAL ULTRASOUNDANDTHERMOGRAPHY POINTS IN IDENTIFYING MYOFASCIAL TRIGGERS IN PATIENTS WITH FIBROMYALGIA

Marcos Leal Brioschi, Manoel Jacobsen Teixeira, Lin Tchia Yeng, Giovanna Abreu Franco, Joaci Oliveira Araújo, Mônica Lourdes de Andrade Lima, Adolfo Marcondes, Paulo Freitas, Juliana Badaró. Pain Center of the Hospital of the University of São Paulo (HCFMUSP)

The myofascial pain syndrome and fibromyalgia syndrome are common painful musculoskeletal conditions that often coexist in the same patient.

OBJECTIVE: This study aimed to evaluate the parameters of sensitivity (S) and specificity (E) Thermography and Clinical palpation in the diagnosis of myofascial trigger points in patients with fibromyalgia syndrome.

METHODS: Sensitivity (S) is the probability that a test result is positive when the disease and specificity (E) is likely to give a test negative in the absence of disease. We examined 40 patients with trigger points in myofascial pain syndrome associated with fibromyalgia by three different methods: clinical palpation, thermography and ultrasound as reference. For thermography, one of the criteria for positive diagnosis was a difference of 1° C from the contralateral region.

RESULTS: Thermography showed S=E=79.31% and 50.00%. Already presented clinical palpation S = 65.52%, E = 18.18% when ultrasound was taken as reference. Joining thermography with palpation sensitivity was 93.1%.

CONCLUSION: Clinical assessment when integrated thermography showed higher diagnostic sensitivity in screening trigger points in patients with fibromyalgia, but not replace ultrasound confirmation. However ultrasound does not identify trigger points alone without guidance of palpation and thermography.