1
Infrared thermography
Infrared thermography is a non-invasive method of diagnostics and monitoring of a
patient, which is based on remote registration of thermal radiation of the human body.
Thermography simultaneously represents anatomical, topographical and functional
changes, as the only method capable of giving a visible form of patient’s pain. Changes of
local temperature are caused by microcirculation changes associated with inflammatory
processes
(http://www.icim.ie/articles/medicalthermography.htm,
http://mt.chinapapers.com/2/?p=8871).
Thermography is a method of functional diagnostics. Normally, distribution and
intensity of thermal radiation is determined by the peculiarity of physiological processes in
the body (vascular responses, the nature of general and local metabolic processes, and
the functional state of relevant organs). Normally, the temperature distribution on a body’s
surface is symmetrical and the difference between symmetrical areas normally does not
exceed 0.2°-0.4°C. Proximal and distant temperature gradient can be observed: the
temperature decreases from the head to the extremities, as well as from the proximal to
the distal extremities. A slight hyperthermia in the projection of superficial blood vessels is
possible, especially in lean people.
Each area of the human body has a characteristic thermographic picture. James
B.Mercer (Northern Norwegian Centre for Medical Thermography) has described normal
distribution of temperature on a human body (Mercer J.B. Thermal Symmetry –
http://www.medimaging.org/). Healthy people usually have stable thermographic patterns
(Zaproudina N., Varmavuo V., Airaksinen J. and Närhi M. Reproducibility of infrared
thermography measurements in healthy individuals // PHYSIOLOGICAL MEASUREMENT.
- №29, 2008. – Р. 515–524). The change of this picture is a clear sign of a pathological
process. Various pathological processes are characterized by the presence of thermal
asymmetry. They are also characterized by the presence of temperature gradient between
the zone of high or low radiation and the surrounding skin or reference point, which is
reflected on the thermographic picture. Therefore, a quantitative assessment is based on
the comparison of skin temperature in the problem area with the symmetric parts of the
body or with surrounding areas. Many pathologic processes (inflammation, tumor,
degenerative processes, and circulation disturbances) change the normal distribution of
temperature on the surface of the body. These changes are more evident if the
pathological center is situated near to the skin surface. In many cases, local changes in
temperature appear before other clinical manifestations, which is very important for early
diagnosis and timely treatment.
Thermography is a highly sensitive method with relatively low specificity.
Thermography with the use of standard type thermographs did not gain a wide popularity
as a method of diagnostics because of insufficient specificity. At the same time, the
method does not have contraindications for repeated use because of its absolute safety.
Therefore, thermography is suitable not only for screening and diagnostic purposes, as a
part of a comprehensive survey, so, it is an optimal method for monitoring and evaluating
the effectiveness of treatment of a wide spectrum of diseases with inflammatory genesis
(Ring F., Jung A., Zuber J. New opportunities for infrared thermography in medicine // Acta
Bio-Optica et Informatica Medica. – 1/2009, vol.15. – P.28-30.; KANAI SHIGEYUKI,
TANIGUCHI NORIMASA, SUSUKI RYUTARO Evaluation of Osteoarthropathy of Knee
Monitored with Thermography // Orthopedics & Traumatology. – VOL.48; NO.1;
PAGE.348-350(1999); David BenEliyahu Infrared Thermography and the Sports Injury
Practice // Dynamic Chiropractic – March 27, 1992, Vol. 10, Issue 07). High sensitivity of
examination method is especially important, because the diagnosis is already set, and the
patient needs to detect exacerbations on early stages and monitor the results of the
treatment.
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Infrared thermography is used in medicine for over 50 years. The first publication
came out in 1956 (Lawson R.N. Implications of surface temperatures in the diagnosis of
breast cancers // Can Med Ass J 1956, 75:309-310. 1972 – Registration of the European
Association of Thermography in Strassbourg (http://www.europeanthermology.com). Since
than, application areas of thermography have significantly widened (Ring EFJ, Jung A.,
Zuber J. New opportunities for infrared thermography in medicine // Acta Bio-Optica et
Informatica Medica. – 1/2009, vol.15. – P.28-30).
The first European Congress on Thermography was held in 1974 (Thermography.
Proceedings of the first European Congress of Thermography. Amsterdam 1974,
Bibliotheca Radiologica No.6, Karger, Basel, 1975). Thermography as an outcome
measure had the highest number of papers dedicated, equipment, breast thermography,
rheumatology, thermophysiology and microwave detection were the next in rank. The 11th
European Association of Thermology European Congress of Medical Thermology took
place in Mannheim, Germany from 17th - 20th September 2009. Similar as the scientific
literature on thermology, the history of the European Congress of Thermology reflects the
peaks and troughs of this discipline.
BERZ R., SAUER H. The Medical Use of Infrared-Thermography History and Recent
Applications // Thermografie-Kolloquium 2007 – Vortrag 04. – Р.1-12.
The medical use of infrared thermography started shortly after 1950 in Germany, where
long time before Prof. Czerny in Frankfurt am Main presented the first infrared image of a
human subject (1928). In the beginning, single IR detectors have been used. Due to the
development of other thermographic devices like contact thermography by electronic
thermometers and by LC (liquid crystal) plates they were integrated in medical diagnostic
systems. Early infrared imaging cameras derived from military systems suffered for a long
time from a poor resolution (thermal as well as spatial) and extremely high prices.
Additionally there was a lack of computer hardware and software. Better technology
suitable for medical purposes was available since about 1980 and then used worldwide,
mostly LN2 cooled MCT (HgCdTe) scanners. Since 2000 uncooled microbolometer FPA
systems got more affordable and were, despite some methodological problems leading to
medical misinterpretation, frequently used in medicine. In 2007 the first medical infrared
imaging systems (MammoVision, ReguVision and FlexiVision by InfraMedic) have
received a CE certification allowing to be used as thermal measuring medical devices
(Category 1) and matching the European Medical Directive legislation. Other devices
without medical CE certification are limited to be used as imagers only without
measurement functions and without temperature reading. Qualified medical infrared
imaging covers a broad field of applications: female breast, rheumatology and orthopedics,
neurology, vascular imaging (arterial and venous), occupational (vibration related
vasospastic syndrome), forensic, surgery, and full body screening including thermal stress
response examinations (IRI – Infrared Regulation Imaging). Medical infrared imaging can
only be applied by physicians who have been educated and trained intensively and have
received a medical certificate (either by the German Society for Thermography and
Regulation Medicine, the European Association of Thermology, or the University of
Glamorgan, Wales).
Thermography devices are categorized by the U.S. Food and Drug Administration
(FDA) as Class I medical devices under the 510(k) process. Under this process, the
manufacturer is not required to supply to the FDA evidence of the effectiveness of the
device prior to marketing it. According to FDA labeling, thermal imaging is a noninvasive
diagnostic technique that allows a practitioner to quantify and visualize skin surface
temperature changes. The device allows the user to map body temperature graphically
and display the image on a monitor. Images can be captured and stored on a computer.
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Thermography may be used as an aid for diagnosis, as well as follow-up therapy in such
areas as orthopedics, pain management, neurology and diabetic foot care.
In an advisory statement, the American Academy of Orthopedic Surgeons (AAOS,
2005) states that a “review of the literature indicates a lack of specificity, reliability, and
reproducibility for this technique in the diagnosis of specific musculoskeletal conditions and
neural injuries or disease states” and that “the use of thermography as a clinically useful
diagnostic or prognostic test in orthopedic surgery cannot at this time be scientifically
justified.” Therefore, monitoring and evaluation of treatment efficiency is the main focus for
the use of infrared thermography.
Infrared thermography, non-contact, noninvasive technique is widely accepted as a
medical diagnostic tool. An IR camera captures heat variations from the skin and maps
into thermographs. Thermographs are acquired for the whole body or the region of
interest. Thermographs either gray scale or pseudo color are processed for abnormality
detection and quantification. However temperature variations are not normally visible to
naked eye. Hence it is necessary to develop and analyze the feature extraction algorithms
for abnormality detection [Selvarasu N., Alamelu Nachiappan and Nandhitha N.M.
Euclidean Distance Based Color Image Segmentation of Abnormality Detection from
Pseudo Color Thermographs // International Journal of Computer Theory and Engineering,
Vol. 2, No. 4, August, 2010. Р. 1793-8201].
Thermal imaging is now increasingly used for imaging different physiological
reactions induced by non-drug treatments such as massage (Bonnett et al 2006, Sefton et
al 2010, Holey et al 2011, Wu et al 2009) or manual therapy (Mori et al 2004, Roy et al
2010). Temperature distribution of the skin during and after physical exercise has been
reported (Zontak et al 1998, Ferreira et al 2008, Merla et al 2010). The effects of
thermotherapy were recorded with means of thermal imaging (Ammer 2004) and water
filtered infrared A-irradiation monitored by thermography (Mercer et al 2008, Notter et al
2011). Various modalities for cryotherapy have been evaluated with thermal imaging (Selfe
et al 2009, Schnell and Zaspel 2008). Recent studies have also used thermography as an
outcome measure in trials investigating low level laser treatment for myofascial pain
(Hakg¨uder et al 2003) or knee osteoarthritis (Puzder et al 2010). Hence, IR-thermography
method is very convenient and useful for thermo monitoring of diseases’development and
treatment’s effectiveness, when the diagnosis is already established (Fig. 1).
Fig. 1. The picture is taken from www.drdawn.net/services/thermography/
Infrared thermography is informative and absolutely safe for a user. However,
modern infrared cameras can not be used at home without participation of a medical
specialist due to complexity and expensiveness of infrared cameras, as well as due to
inability of correct automatic analysis of thermograms. Roback K. considers that «...there
is also a future for cheaper, uncomplicated devices intended for at homecare. The selfcare
alternative will be even more important as public healthcare budgets probably cannot
match the increasing costs of the technologic development and higher healthcare need
owing to demographic factors» (Roback K. An overview of temperature monitoring devices
for early detection of diabetic foot disorders // Expert Rev. Med. Devices 7(5), 711–718
(2010)).
4
Operating principle of IR-thermographs and IR-thermometers
In general, IR radiation covers wavelengths that range from 0.75 µm to 1000 µm,
among which the human body emissions that are traditionally measured for diagnostic
purposes only occupy a narrow band at wavelengths of 8 µm to 12 µm [J. Whale. An
introduction to dynamic radiometric thermal diagnostics and dielectric resonance
management procedures. Positive Health.], sometimes, diapason from 3 µm to 14 µm is
captured
(https://www.google.com/search?q=wavelength+in+medical+imagers&oq=wavelength+in+medical
+imagers&). This region is also referred to as the long-wave IR (LWIR) or body infrared
rays. Infrared thermographs, intended for medical diagnostic purposes and monitoring
(medical thermographs) register IR radiation from skin surface. They work in the diapason
3-14 µm, at that, irrespective of the width of infrared radiation diapason, obtained
thermograms are roughly equal and they equally successful allow detecting hyperthermic
centers, for example, in case of inflammation (Fig. 2).
Fig. 2 The picture is taken from the article of Ring E. F. J., Thomas R. A., Howell K. J.
SENSORS FOR MEDICAL THERMOGRAPHY AND INFRARED RADIATION
MEASUREMENTS // Jones D.P. Biomedical Sensors. - Momentum Press, 2010. – 320 р.
Medical Infrared Imaging. Edited by Nicholas A. Diakides, Joseph D. Bronzino. 2008.
P.96.
–
http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&v
ed=0CD4QFjAB&url=http%3A%2F%2Fbooks.google.com%2Fbooks%2Fabout%2FMedica
l_Infrared_Imaging.html%3Fid%3Dz-EsDmgyF4YC&ei=FkxfU4nIKfS4QT4xIDAAg&usg=AFQjCNHTwNiVoJeVAYpGjvkEO52BkEzBjA&bvm=bv.65397613,
d.bGE
Infrared thermography provides a thermal map of the skin surface area by measuring the
radiant heat that is emitted. Current IR-thermography machines provide accurate skin
surface temperatures (<0.05◦C) that are noninvasive, noncontact measurements through
the use of stable detectors. These systems produce high speed–high resolution images
from which thermal data can be pictorially and quantitatively stored and analyzed. While
IR-radiation begins at wavelengths of 0.7 μm, current IR-thermographic imagers are
operating at either the mid-range (3–5 μm) or long range (8–14 μm) wavelengths [Jones
B.F. and Plassmann P. Digital infrared thermal imaging of human skin. IEEE Eng. Med.
5
Biol. 21, 41–48, 2002.; Otsuka K., Okada S., Hassan M., and Togawa T. Imaging of skin
thermal properties with estimation of ambient radiation temperature. IEEE Eng. Med. Biol.
21, 65–71, 2002; Head J.F. and Elliott R.L. Infrared imaging: making progress in fulfilling
its medical promise. IEEE Eng. Med. Biol. 21, 80–85, 2002.]. At these wavelengths the
skin’s ability to emit the radiant heat is 0.98 on a scale of 1.0 for a perfect radiator,
blackbody surface [Flesch, U. Physics of skin-surface temperature. In Thermology
Methods. Engel J.M., Flesch U., and Stüttgen G. (eds), translated by Biederman-Thorson
M.A. Federal Republic of GermanyWeinheim, pp. 21–37, 1985].
Medical Thermal Imaging Cameras (http://www.infraredcamerasinc.com/ThermalCameras/FDA-Medical-Thermal-Cameras/FDA_Cleared_Medical_Thermal_Imagers.html)
FDA has cleared all thermal imaging cameras by ICI with designation S (Scientific) or P
(Professional) series as medical thermal imaging cameras. These cameras can be used
for a variety of medical diagnostics, monitoring, etc. Below is a list of our medical thermal
imaging cameras.
The examples of Medical Thermal Imaging Cameras Recommended For Doctors,
Physicians, & Veterinarians, having 510(k) Number:
 ICI ETI 7320 Pro Fix-mounted Sensitivity <27 mK, Resolution: 320 x 240, 7 -14 µm
 ICI 7320 Scientific Fix-mounted Sensitivity:<38 mK, Resolution: 320 x 240
 ICI 7320 Pro Fix-mounted, Sensitivity: <38 mK, Resolution:320 x 240, 7 to 14
microns








ICI Prodigy Pro Handheld, Sensitivity: <38 mK, Resolution: 320 x 240
ICI 7640 Pro Sensitivity:<50 mK, Resolution: 640 x 480
Mirage Pro Fix-mounted, Sensitivity:<14 mK, Resolution: 320 x 256, 3-5 µm
ICI IR Monitor Pro Fix-mounted, Sensitivity:<80 mK, Resolution: 320 x 240, 7 -14
µm
ICI Centurion Pro Fix-mounted, Sensitivity:<65 mK, Resolution:320 x 240
DuraCam 320 Pro Handheld, Sensitivity:<80 mK, Resolution: 320 x 240
ToughCam Pro Handheld, Sensitivity: <60 mK, Resolution:160 x 120
ToughCam Scientific Handheld, Sensitivity:<120 mK, Resolution:160 x 120
The examples of Medical Infrared Thermometers, having 510(k) Number:
 Derma Temp 1001, Exergen
 AMPLIFE Digital Infrared Ear Thermometer, Model El 00, Microlife
 Infrared Thermometer FDIR-Vl, FAMIDOC TECHNOLOGY CO., LTD.
 Braun Thermoscan® IRT 2000, infrared ear thermometer, Braun GmbH
 Infrared Thermometer ThermoFlash LX-26, JXB Co, LTD Guangzhou
 AViTA Radar Thermo IR Thermometer, NT1 Series , NT 152, AViTA Corporation
 Infrared
Thermometer
Model:
DT-8806H/DT-8806/DT-886,
SHENZHEN
EVERBEST MACHINERY INDUSTRY CO.,LTD
 Valeo VT-601 Series ZR Thermometer, Model no.: VT-601D, VT-601E, VT-601F,
VALEO Corporation
 Infrared Thermometer (FT-Fl 1, FT-F21, FT-F31, FT-F41), Fudakang Industrial Co.,
Ltd.
 InnoTherm lCT-l00, INNOCHIPS TECHNOLOGY Co., Ltd
 INFRARED FOREHEAD THERMOMETER, MODEL FS-300&301(K1 01912),
HUBDIC CO., LTD
 Non-contact Infrared Thermometer-JXB 182, Jinxinbao Electronic Co., Ltd
 Non-contact Infrared Thermometer JPD-FR100, Shenzhen Jumper Medical
Equipment Co., Ltd.
 No Touch + Forehead Thermometer, NTF3OOO, KAZ USA, Inc.
6
Analysis of thermograms obtained with infrared thermographs has showed that
increased heat emission in the pathological center is projected on skin surface in the form
of thermal anomalies, linear dimensions of which are larger than 1 cm (Beloshenko V.A.,
Doroshev V. D., Karnachev A. S., Prihodchenko V. V. Equipment complex (thermomammograph) for early diagnostics oncology diseases of mammary gland with contact
digital thermography method - http://www.mederbis.com.ua/node/130).
In other study, it has shown that the choice of optimal scanning pitch when
measuring temperature gradients on the surface with a purpose of obtaining the desired
accuracy and resolution as well as reduction of examination time is possible at the
determination pitch of 5 cm, if the pathological center is located at a depth of 1 to 5 cm
(which corresponds to the average sizes of structures of knee and wrist joints) (S.V.
Miheev, Metrologic ensuring temperature measurements in medical technology of
diagnostic contact thermography, Moscow, Medical physics 2011 №1.). Analysis of typical
thermograms in case of oncologic diseases of bones [Thermo vision method of study in
oncology practice. Thermo semiotics of malignant and non-malignant growths. Atlas of
thermograms // Leningrad, 1976, 72 p.] has shown that the sizes of thermal anomalies
reach 2–3 cm and more.
Fig. 3.
Denoble A.E., Hall N., Pieper C.F., Kraus V.B. have used the mark (silver sticker) of
the size of 2 cm for thermo vision studies. Thermogram shows that the zone of
hyperthermia of red-and-orange color at arthritis is significantly larger than the size of the
mark (Fig.3). (Denoble A.E., Hall N., Pieper C.F., Kraus V.B. Patellar Skin Surface
Temperature by Thermography Reflects Knee Osteoarthritis Severity // Clin Med Insights
7
Arthritis
Musculoskelet
Disord.
2010;
3:
69–75.
–
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998980/).
Hand joints have small sizes and, accordingly, the centers of hyperthermia have
small area: from 1 cm to several square centimeters. In the article of Spalding S.J. et al.
(Spalding S.J., Kwoh C.K., Boudreau R., Enama J., Lunich J., Huber D., Denes L., Hirsch
R. Three-dimensional and thermal surface imaging produces reliable measures of joint
shape and temperature: a potential tool for quantifying arthritis // Arthritis Research &
Therapy 2008, 10:R10 – http://arthritis-research.com/content/10/1/R10) the authors have
described plotting of volumetric models of hand joints with distinguishing of hyperthermia
centers (Fig. 4). These hyperthermia centers are situated exactly in the projection of
metacarpophalangeal and interphalangeal joints.
Fig. 4.
The Smart ThermoGraph
Development of new devices for thermo diagnostics and monitoring proceeds in two
directions:
- Increase of temperature’s measurement accuracy up to thousands of a degree, which
naturally leads to a significant increase in the price of thermographs. For medical
purposes, such accuracy is not needed, as temperature changes starting from 0.4ºC and
more in the projection of the pathological focus are considered to be significant
(pathological).
- Simplification and cost reduction of the equipment with the required accuracy of
measurement, the creation of portable devices that can be used both in hospitals and at
home.
Prominent representative of the second group of new devices is a Smart
ThermoGraph. It is a hardware-software complex, which includes a device (infrared
thermometer) that transmits information to a computer and the program that draws
thermograms according to the results of measurements of skin temperature.
For thermogram plotting, the program uses the same generally accepted Colour
and Temperature Scale that is described in the article of Ring EFJ, Ammer K. (Ring EFJ,
Ammer K. The Technique of Infra red Imaging in Medicine // Thermology international 10/1
(2000) – Р. 7-14.): «Every image or block of images must carry the indication of
temperature range, with color code/temperature scale. The color scale itself should be
standardized. The so-called rainbow or spectral order of colors is more widely recognized,
especially by colleagues who are not used to the other color scales used by engineers. А
false color finely graded scale is also possible, this can be ranged from dark blue at the
cold end through green to red, and will convey a similar degree of image contrast to a
monochrome black and white picture».
The Smart ThermoGraph device has an infrared sensor that receives thermal
(infrared) radiation in the same wavelength range as the other thermal imagers: from 5 to
14 microns (5-14 µm), which is analogical to IR-thermographs recommended by FDA for
medical purposes (see above). Temperature resolution of IR-sensor is ≤ 0.2ºС.
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It measures the intensity of thermal radiation only in specific locations, the area of
which corresponds to the working surface of the device (diameter is 0.5 cm, diameter with
a nozzle is 1.3 cm).
Fig. 5. Grid with maximum amount of points for temperature measurement, and example
demonstrating how to place it on the photographic image of the knee-joint.
Fig. 6. Thermograms in case of osteoarthritis of knee joint
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The computer program “Smart ThermoGraph”, linked with the Smart ThermoGraph
device, offers to the user several patterns of rectangular-shaped grid of points (from 2x2 to
6x6) with the possibility of changing the number of points and the distance between them
in such a way that the final grid does not extend beyond the area of interest but covers it in
maximum way. The grid of points for temperature measurement with the Smart
ThermoGraph must be plotted with taking into consideration well-known sizes and
localization of hyperthermia centers for example at inflammatory diseases (Fig.5). Points
for temperature measurement in the area of interest should be situated at the distance of
2-2.5 cm from each other, which ensures plotting of sufficiently detailed thermogram with
clearly (probability is close to 100%) visible centers of hyperthermia (Fig.6).
The computer program processes temperature data from measurements and draws
thermograms basing on the data. Thus, the device Smart ThermoGraph produces results
similar to medical imagers, provided the user observes the standard conditions for
implementing the medical thermography set forth later. The Smart ThermoGraph can be
used at home not for primary/differential diagnostics, but for monitoring chronic diseases.
The computer program Smart ThermoGraph generates automatic conclusions
about the main temperature parameters (the maximal temperature value, the average
temperature value), and its changes.
There are several mathematical methods of modeling and processing of the results
of skin temperature measurements (Titova A.Y. Specialized computer system of
processing of thermo-mammographic images // Informational control systems and
technologies and computer monitoring (IUS and KM 2012). – p. 544-548), major of which
are used in the computer program of the Smart ThermoGraph:
interpolation and averaging of temperatures;
detection of edges of anomalous zones;
identification of gradients, confidence intervals of temperature distribution;
plotting of histograms and isotherms;
smoothing filtration, contrasting, framing, and others.
Generally known methods of processing of temperature data are used in Smart
ThermoGraph program:
- thermogram is plotted by interpolation method,
- average temperature in the area of examination is calculated,
- maximum temperature in the area of examination is calculated.
All calculated values are compared with the respective values received in the
previous session of self-examination. According to the results of such comparison, the
user is given the conclusion that includes the calculated values and the result of their
comparison with previous values, for example:
- T maximum = 30.8ºС, increased for 0.6ºС,
- T average = 29.4ºС, increased for 0.2ºС.
Through application of the Smart ThermoGraph device in combination with the
computer program “Smart ThermoGraph”, and observing at the same time the standard
conditions of examination by means of the medical thermography, the user may carry out
thermal monitoring of vast range of diseases.
Inflammation diseases and thermosigns
Inflammation (Latin, īnflammō, "I ignite, set alight") is part of the complex biological
response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or
irritants. Inflammatory diseases account for about 80% of all human diseases.
Inflammation plays a fundamental role in host defenses and the progression of immunemediated diseases. The inflammatory response is initiated in response to tissue injury
10
(e.g., trauma, ischemia, and foreign particles) and infection by a complex cascade of
events, including chemical mediators (e.g., cytokines and prostaglandins) and
inflammatory cells (e.g., leukocytes). The inflammatory response is characterized by
increased blood flow, increased capillary permeability, and the accumulate of phagocytic
cells at the site of injury. These events result in swelling, redness, warmth (altered heat
patterns), and pus formation at the site of injury.
Parakrama Chandrasoma, Clive R. Taylor. Concise Pathology, 3e, Los Angeles,
Appleton & Lange, 1998.
Acute inflammation is the early (almost immediate) response of a tissue to injury. It is
nonspecific and may be evoked by any injury short of one that is immediately lethal. Acute
inflammation may be regarded as the first line of defense against injury and is
characterized by changes in the microcirculation: exudation of fluid and emigration of
leukocytes from blood vessels to the area of injury. Acute inflammation is typically of short
duration, occurring before the immune response becomes established, and it is aimed
primarily at removing the injurious agent.
Clinically, acute inflammation is characterized by 5 cardinal signs: rubor (redness), calor
(increased heat), tumor (swelling), dolor (pain), and functio laesa (loss of function).
Redness and heat are due to increased blood flow to the inflamed area; swelling is due to
accumulation of fluid; pain is due to release of chemicals that stimulate nerve endings; and
loss of function is due to a combination of factors. These signs are manifested when
acute inflammation occurs on the surface of the body, but not all of them will be
apparent in acute inflammation of internal organs. The increased heat of inflamed
skin is due to the entry of a large amount of blood at body core temperature into the
normally cooler skin. When inflammation occurs internally—where tissue is
normally at body core temperature—no increase in heat is apparent. Cardinal signs
of acute inflammation. Note swelling and redness of the skin around an infected
burn. Marked tenderness, increased local temperature, and loss of function were
also present.
The Editors of Encyclopædia Britannica. http://global.britannica.com/EBchecked/topic/287677/inflammation
The inflammatory response is a defense mechanism that evolved in higher organisms to
protect them from infection and injury. Its purpose is to localize and eliminate the injurious
agent and to remove damaged tissue components so that the body can begin to heal. The
response consists of changes in blood flow, an increase in permeability of blood vessels,
and the migration of fluid, proteins, and white blood cells (leukocytes) from the circulation
to the site of tissue damage.
An inflammatory response that lasts only a few days is called acute inflammation. Acute
inflammation usually of sudden onset, marked by the classical signs, in which vascular
and exudative processes predominate.
Chronic inflammation prolonged and persistent inflammation marked chiefly by new
connective tissue formation; it may be a continuation of an acute form or a prolonged lowgrade form.
Quanten P. The Inflammation Process. http://freespace.virgin.net/ahcare.qua/literature/medical/inflammationprocess.html
Increasing levels of prostaglandin E2 in the brain induce an area called the hypothalamus
to turn up the body's thermostat a notch. Suddenly, the same external temperature feels
colder, and various means are employed to restore the subjective impression of warmth.
These include involuntary processes such as shivering, which generates heat by
11
movement, and voluntary behaviour such as putting on more clothes, finding a warm
radiator to sit next to, and so on.
Like pain and swelling, fever plays a vital part in defending the body against infection.
Many bacteria reproduce most effectively at normal body temperature. So by raising body
temperature the rate at which the bacteria can divide is slowed down. Fever has the
opposite effect on most immune cells, causing them to divide more quickly. So fever both
slows down the spread of the infection and accelerates the counterattack by the immune
system.
All injuries and infections, as stated above, cause a fever. This might only manifest
itself in a localised heat, and does not always produce an overall increase of the
body temperature.
Vinay Kumar, Abul K. Abbas, and Jon C. Aster. Robbins Basic Pathology, Ninth Edition.
– 2013.
Stimuli for Acute Inflammation:
• Infections (bacterial, viral, fungal, parasitic) & microbial toxins
• Tissue necrosis: ischemia, trauma, physical or chemical injury (e.g., thermal injury;
irradiation; some environmental chemicals)
• Foreign bodies (splinters, dirt, sutures)
• Immune reactions (aka hypersensitivity reactions)
Cardinal signs of inflammation:
• Heat (calor)
• Redness (rubor)
• Swelling (tumor)
• Pain (dolor) – Celsus, De Medicina, Roman encyclopedia of medicine, >2000 years ago
• Loss of function – Rudolf Virchow (“father of modern pathology”), Late 19th century
Vasodilation - Change in vessel flow:
– NO, histamine  vascular smooth muscle  vasodilatione  increased blood flow
 heat & redness.
– Stasis: slowed blood flow, hyperviscosity.
– Margination of circulating leukocytes & endothelial activation.
Causes of chronic inflammation:
• Persistent injury or infection (Ulcer, tuberculosis)
• Prolonged exposure to a toxic agent (Pulmonary silicosis (silica in the lung))
• Autoimmune disease—self-perpetuating immune reaction that results in tissue damage
and inflammation (Rheumatoid arthritis, Systemic lupus erythematosus, Multiple sclerosis)
Features of chronic inflammation:
• Chronic inflammation = long duration
• Components:
– Lymphocyte, plasma cell, macrophage (mononuclear cell) infiltration
– Tissue destruction by inflammatory cells
– Repair with fibrosis and angiogenesis (new vessel formation)



In connection with the above signs of inflammation following group of inflammatory
diseases are listed according to the International Statistical Classification of Diseases
and Related Health Problems 10th Revision:
Chapter IV Endocrine, nutritional and metabolic diseases
E10-E14 Diabetes mellitus
Chapter VII Diseases of the eye and adnexa
H00-H06 Disorders of eyelid, lacrimal system and orbit
H10-H13 Disorders of conjunctiva
H15-H22 Disorders of sclera, cornea, iris and ciliary body
12
H30-H36 Disorders of choroid and retina
Chapter VIII Diseases of the ear and mastoid process
H60 Otitis externa
H65 Nonsuppurative otitis media
H66 Suppurative otitis media
H70 Mastoiditis and related conditions
Chapter IX Diseases of the circulatory system
I80 Phlebitis and thrombophlebitis
I88 Nonspecific lymphadenitis
I89 Other noninfective disorders of lymphatic vessels and lymph nodes
Chapter X Diseases of the respiratory system
J01 Acute sinusitis
J02 Acute pharyngitis
J03 Acute tonsillitis
J04 Acute laryngitis and tracheitis
J32 Chronic sinusitis
J35 Chronic diseases of tonsils and adenoids
J37 Chronic laryngitis and laryngotracheitis
Chapter XI Diseases of the digestive system
K04 Diseases of pulp and periapical tissues
K05 Gingivitis and periodontal diseases
K10 Other diseases of jaws
K11 Diseases of salivary glands
Chapter XII Diseases of the skin and subcutaneous tissue
L02 Cutaneous abscess, furuncle and carbuncle
L03 Cellulitis
L04 Acute lymphadenitis
L08 Other local infections of skin and subcutaneous tissue
L20-L30 Dermatitis and eczema
Chapter XIII Diseases of the musculoskeletal system and connective tissue
M00-M03 Infectious arthropathies
M05-M14 Inflammatory polyarthropathies
M15-M19 Arthrosis
М20-М25 Other joint diseases
M65-M68 Disorders of synovium and tendon
M70-M79 Other soft tissue disorders
Chapter XIV Diseases of the genitourinary system
N41 Inflammatory diseases of prostate
N45 Orchitis and epididymitis
N49 Inflammatory disorders of male genital organs, not elsewhere classified
N61 Inflammatory disorders of breast
Chapter XV Pregnancy, childbirth and the puerperium
O91 Infections of breast associated with childbirth
Chapter XIX Injury, poisoning and certain other consequences of external causes
S00-S09 Injuries to the head
S10-S19 Injuries to the neck
S20-S29 Injuries to the thorax
S30-S39 Injuries to the abdomen, lower back, lumbar spine and pelvis
S40-S49 Injuries to the shoulder and upper arm
S50-S59 Injuries to the elbow and forearm
S60-S69 Injuries to the wrist and hand
S70-S79 Injuries to the hip and thigh
13
S80-S89 Injuries to the knee and lower leg
S90-S99 Injuries to the ankle and foot
T00-T07 Injuries involving multiple body regions
T08-T14 Injuries to unspecified part of trunk, limb or body region
For each of the above listed group of diseases, below you may find short abstracts
of major medical publications concerning capabilities of the thermography for treatment of
these diseases.
Publications, devoted to use of IR-thermography for different inflammation diseases
Abstracts and quotations from the articles devoted to the results of thermographic
studies for different diseases are presented below. IR-thermography can be successfully
used for diagnostics as well as for monitoring of treatment process, as publication reviews
indicate regarding to possibilities of IR-thermography.
Chapter IV Endocrine, nutritional and metabolic diseases
E10-E14 Diabetes mellitus
The International Diabetes Federation (IDF) has estimated the World diabetes
prevalence at 6% in the adult population (aged 20–79 years). Consequently, there are
currently approximately 30 million people with diabetes in the EU-27 countries [The
International Working Group on the Diabetic Foot and The International Diabetes
Federation. Available from http://www.iwgdf.org/. Accessed 3 February 2009; Eurostat.
Available from http://epp.eurostat.ec.europa.eu. Accessed 19 March 2009.]. Recent
statistics by the American Diabetic Association suggest that the prevalence of diabetes in
the United States is 18 million and the onset of type 2 diabetes mellitus preceded its
diagnosis by a mean 7 years [O’Brien J, Patrick A, Caro J. Estimates of direct medical
costs for microvascular and macrovascular complications resulting from type 2 diabetes
mellitus in the United States in 2000. Clin Ther 2003;25:1017-38.]. The diabetic foot is a
major long-term complication of type 2 diabetes mellitus [Armstrong D, Lavery L,
Wunderlich R, Boulton A. Skin temperatures as a one-time screening tool do not predict
future diabetic foot complications. J Am Podiatr Med Assoc 2003;93:443-7.].
The risk of hospital admission for PVD, neuropathy, and ulceration is greater for
patients with diabetes [Currie C, Morgan C, Peters J. The epidemiology and cost of
inpatient care for peripheral vascular disease, infection, neuropathy and ulceration in
diabetes. Diabetes Care 1998;21:42-8.]. The annual incidence of foot ulceration among
people with diabetes is approximately 2% and approximately 15% of these will lead to a
lower-limb amputation [Prompers L, Huijberts M, Schaper N, et al. Resource utilisation and
costs associated with the treatment of diabetic foot ulcers. Prospective data from the
Eurodiale Study. Diabetologia. 51(10), 1826-1834 (2008); Apelqvist J, Ragnarson Tennvall
G. Counting the costs of the diabetic foot. Diabetes Voice. 50(Special Issue), 8-10
(2005).]. This would imply that 600,000 diabetic foot ulcers occur each year in the EU-27
countries, of which 90,000 will require an amputation. Foot ulcers are the main cause of
lower extremity amputation in patients with diabetes, resulting in a huge economic burden
for health services [Morbach S, Lutale J, Viswanathan V, Mollenberg J, Ochs H,
Rajashekar S, et al. Regional differences in risk factors and clinical presentation of diabetic
foot lesions. Diabet Med 2004;21:91-5.].
Studies show that there is a relationship between increased temperature and foot
complications in diabetes [Sun PC, Lin HD, Jao SH, Ku YC, Chan RC, Cheng CK.
Relationship of skin temperature to sympathetic dysfunction in diabetic at-risk feet.
Diabetes Res. Clin. Pract. 73(1), 41-46 (2006).]. Increased temperature may be present
14
up to a week before a foot ulcer occurs [Armstrong DG, Holtz-Neiderer K, Wendel C,
Mohler MJ, Kimbriel HR, Lavery LA. Skin temperature monitoring reduces the risk for
diabetic foot ulceration in high-risk patients. Am. J. Med.. 120(12), 1042-1046 (2007).]. In
this early stage of the disease, patients seldom feel pain because of neuropathic sensory
loss, which indicates that increased temperature can be a useful predictive sign of foot
ulceration and sub-clinical inflammation of the feet. Consequently, monitoring of foot
temperature could be used for preventive purposes. Studies of at-home monitoring of foot
temperature show that the incidence of foot ulcers in a risk group may be reduced by more
than 60% [Lavery LA, Higgins KR, Lanctot DR, et al. Preventing diabetic foot ulcer
recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool.
Diabetes Care. 30(1),14-20 (2007); Lavery LA, Higgins KR, Lanctot DR, et al. Home
monitoring of foot skin temperatures to prevent ulceration. Diabetes Care. 27(11), 26422647 (2004).]. The concept of measuring body weight and foot temperature simultaneously
can easily make the procedure into a daily routine, and thereby lead to better compliance
with selfcare advice. Temperature monitoring could be a complementary therapy in the
prevention of major foot complications but cannot replace any of the current steps in
modern diabetes care. Adoption of temperature monitoring in standard care may lead to a
more frequent referral of patients from primary care to specialists as further imaging
studies will be needed to determine the cause of an increased temperature. Early
diagnosis and early treatment is crucial for the healing of diabetic foot lesions, and
resources for early interventions must therefore be available to take care of a higher
number of suspected foot complications.
Arad Y, Fonseca V, Peters A, Vinik A. Beyond the Monofilament for the Insensate Diabetic
Foot: A systematic review of randomized trials to prevent the occurrence of plantar foot
ulcers in patients with diabetes // Diabetes Care 34 (4) (2011): 1041–6.
Lavery et al. reported an RCT of 85 subjects at high risk for foot ulceration (neuropathy
and foot deformity or a history of ulceration or partial foot amputation). Standard therapy
consisted of therapeutic footwear, diabetic foot education, and regular foot evaluation by a
podiatrist. Enhanced therapy included the addition of infrared skin thermometer to
measure temperature at six locations on the sole of the feet twice per day. When a
difference of >4°F between the same locations of the two feet was noted, subjects were
instructed to contact the nurse and reduce activity of the involved foot (higher temperature)
until the temperature gradient decreased to <4°F. During a 6-month period, new
complications were found in 20% of the standard therapy group (seven ulcers and two
Charcot fractures) versus 2% (one ulcer) in the intervention group (odds ratio 10.3, CI 1.2–
85.3, P = 0.01). The study was single blinded (physicians). Relevant baseline values were
not well described. It is possible that temperature monitoring led to more intense
interaction with caretakers and thus better monitoring and therapy. Otherwise, the study
was well designed with a score of.
A similar but larger study was subsequently reported by the same group. This was also
physician blinded and a multicenter study of 173 individuals at high risk for foot ulcers.
Randomization was computer-generated. To account for the possibility that effect of
temperature monitoring may be due to more intense interaction with caregivers, the study
was divided into three groups: 1) standard therapy; 2) structured foot examination twice
daily by the patients using a mirror and a log book (The patient was instructed to call the
nurse if any abnormality was noted.); and 3) enhanced therapy group consisting of the
addition of temperature measurements to standard therapy. If temperature increased by
4°F compared with the corresponding site on the other foot, patients were instructed to call
the nurse and decrease activity until the gradient decreased to <4°F. After 15 months, the
incidence of foot ulcer decreased from 30% in the first two groups to 8.5% in the plantar
foot temperature-guided avoidance therapy. The study was well conducted and scored.
15
The study by Armstrong et al. randomized 225 patients to two groups. Both groups
received diabetic foot education and therapeutic footwear, and daily structured foot
examinations were performed as described above. The intervention group also performed
temperature-guided avoidance therapy as described above, although the patient’s
physician was blinded to the randomization compliance and dropout rates were not
described. Furthermore, it is not clear whether the analysis was based on intent to treat.
Overall incidence of subsequent foot ulceration was lower than in other studies (total of
8.4%). Nonetheless, the incidence of ulcers decreased by 62% (from 12.2 to 4.7%) in the
group using temperature monitoring. The study scored.
David G Armstrong, Lawrence A Lavery, Paul J Liswood, William F Todd and Jeffrey A
Tredwell. Infrared Dermal Thermometry for the High-Risk Diabetic Foot // Physical
Therapy . Volume 77 . Number 2 . February 1997. – Р. 169-175.
Background and Purpose. The purpose of this study was to compare skin temperatures in
patients with asymptomatic peripheral sensory neuropathy, patients with neuropathic
ulcers, and patients with Charcot's arthropathy using the contralateral limb as a control.
Subiects. On a retrospective basis, patients with diabetes (N=143) were divided into three
groups: patients with asymptomatic sensory neuropathy (n = 78), patients with neuropathic
foot ulcers (n= 44), and patients with neuropathic fractures (Charcot's arthropathy) (n=21).
Methods. We evaluated the subjects' skin temperatures with a portable handheld infrared
skin temperature probe at the time pathology was initially identified and at subsequent
clinical visits for an average of 22.1 months (SD=6.4). Skin temperatures of the
contralateral foot were measured as a control.
Results. There were differences in skin temperature between the affected foot and the
contralateral (ie, nonaffected) foot among the patients with Charcot's arthropathy (8.3" F)
and the patients with neuropathic ulcers (5.6"F), with no difference identified among the
patients with asymptomatic sensory neuropathy. Five patients with neuropathic ulcers
experienced reulceration a mean of 12.2 months (SD=6.4) after initial healing, with a
corresponding increase in skin temperature (89.6°F±1.2°F versus 82.5°F±2.9°F) at the
clinic visit immediately preceding reinjuiy.
Conclusion and Discussion. The data suggest that monitoring of the corresponding
contralateral foot site may provide clinical information before other clinical signs of injury
can be identified. [Armstrong DG, Laveiy LA, Liswood PJ, et al. Infrared dermal
thermometry for the high-risk diabetic foot. Phvs Ther. 1997;77:169-177.].
Bharara M., Schoess J., Armstrong D.G. Coming events cast their shadows before:
detecting inflammation in the acute diabetic foot and the foot in remission // Diabetes
Metab Res Rev 2012; 28(Suppl 1): 15–20.
The incidence of diabetic foot complications, most notably wounds, is increasing
worldwide. Most people who present for care of a foot wound will become infected.
Globally, this results in one major amputation every 30 seconds with over 2500 limbs lost
per day. Presently, clinicians assess circulation, neuropathy and plantar pressures to
identify the risk of foot ulceration. Several studies have suggested prevention of foot ulcers
by identifying individuals at high risk and treating for lower extremity complications. Our
group has proposed several diagnostics as well as prevention strategies, especially
thermography and thermometry for management of patients with diabetic foot
complications. These strategies employ non-invasive assessment of inflammation for
acute as well as chronic care for the foot, with the intent to prevent ulceration/re-ulceration
and subsequent traumatic amputations. The authors’ review some important clinical
studies and ongoing research in this area, with the long-term goal to further the role of
thermography and thermometry in clinical care for the diabetic foot.
16
Bagavathiappan S., Philip J., Jayakumar T., Raj B. et al. Correlation between Plantar Foot
Temperature and Diabetic Neuropathy: A Case Study by Using an Infrared // Journal of
Diabetes Science and Technology. - Volume 4, Issue 6, November 2010.
Background: Diabetic neuropathy consists of multiple clinical manifestations of which loss
of sensation is most prominent. ТHigh temperatures under the foot coupled with reduced
or complete loss of sensation can predispose the patient to foot ulceration. The aim of this
study was to look at the correlation between plantar foot temperature and diabetic
neuropathy using a noninvasive infrared thermal imaging technique.
Methods: Infrared thermal imaging, a remote and noncontact experimental tool, was used
to study the plantar foot temperatures of 112 subjects with type 2 diabetes selected from a
tertiary diabetes centre in South India.
Results: Patients with diabetic neuropathy (defined as vibration perception threshold (VPT)
values on biothesiometry greater than 20 V) had a higher foot temperature (32–35 °C)
compared to patients (27–30 °C). Diabetic subjects with neuropathy also had higher mean
foot temperature (MFT) (p = .001) compared to non-neuropathic subjects. MFT also
showed a positive correlation with right great toe (r = 0.301, p = .001) and left great toe
VPT values (r = 0.292, p = .002). However, there was no correlation between glycated
hemoglobin and MFT.
Conclusion: Infrared thermal imaging may be used as an additional tool for evaluation of
high risk diabetic feet.
Kaabouch N., Wen-Chen Hu, Yi Chen. Alternative Technique to Asymmetry AnalysisBased Overlapping for Foot Ulcer Examination: Scalable Scanning // J Diabetes Metab
2011, S:5.
Asymmetry analysis based on the overlapping of thermal images proved able to detect
inflammation and, predict foot ulceration. This technique involves three main steps:
segmentation, geometric transformation, and overlapping. However, the overlapping
technique, which consists of subtracting the intensity levels of the right foot from those of
the left foot, can also detect false abnormal areas if the projections of the left and right feet
are not the same. In this paper, we present an alternative technique to asymmetry
analysis-based overlapping. The proposed technique, scalable scanning, allows for an
effective comparison even if the shapes and sizes of the feet projections appear differently
in the image. The tested results show that asymmetry analysis- based scalable scanning
provides fewer false abnormal areas than does asymmetry analysis -based overlapping.
The experimental results show that the proposed technique gives fewer false abnormal
areas and hence is more reliable to use to identify inflammation. In the future, our research
objectives will include 1) studying the decay rates of temperature distributions over time for
successive images that correspond to the same feet, and 2) combining temperature and
pressure distributions to predict foot ulceration.
Makoto Oe, Rie Roselyne Yotsu, Hiromi Sanada,Takashi Nagase, and Takeshi Tamaki.
Screening for Osteomyelitis Using Thermography in Patients with Diabetic Foot. – Ulcers.
- Volume 2013, Article ID 284294, 6 pages.
One of the most serious complications of diabetic foot (DF) is osteomyelitis, and early
detection is important. To assess the validity of thermography to screen for osteomyelitis,
we investigated thermographic findings in patients with both DF and osteomyelitis. The
subjects were 18 diabetic patients with 20 occurrences of DF who visited a dermatology
department at a hospital in Tokyo and underwent evaluation by magnetic resonance
imaging (MRI) and thermography between June 2010 and July 2012. Osteomyelitis was
identified by MRI. Thermographs were taken of the wounds and legs after bed rest of more
than 15 minutes. Two wound management researchers evaluated the range of increased
skin temperature. There were three types of distribution of increased skin temperature: the
17
periwound, ankle, and knee patterns. Fisher’s exact test revealed that the ankle pattern
was significantlymore common in the group with osteomyelitis than in the group without
osteomyelitis (𝑃 = 0.011). The positive predictive value was 100%, and the negative
predictive value was 71.4%. Our results suggest that an area of increased skin
temperature extending to the ankle can be a sign of osteomyelitis.Thermography might
therefore be useful for screening for osteomyelitis in patients with DF.
Roback K. An overview of temperature monitoring devices for early detection of diabetic
foot disorders // Expert Rev. Med. Devices 7(5), 711–718 (2010).
Diabetic foot complications are associated with substantial costs and loss of quality of life.
This article gives an overview of available and emerging devices for the monitoring of foot
temperature as a means of early detection of foot disorders in diabetes. The aim is to
describe the technologies and to summarize experiences from experimental use. Studies
show that regular monitoring of foot temperature may limit the incidence of disabling
conditions such as foot ulcers and lower limb amputations. Infrared thermometry and liquid
crystal thermography were identified as the leading technologies in use today. Both
technologies are feasible for temperature monitoring of the feet and could be used as a
complement to current practices for foot examinations in diabetes.
• Increased temperature may be detected as an early warning for foot complications in
diabetes. This occurs at a reversible stage of the disease.
• At home monitoring of foot temperature may reduce the incidence of foot ulcers by more
than 60%.
• There are currently three types of devices available for monitoring of foot temperature: a
specially designed infrared thermometer, the Liquid Crystal Thermography (LCT) indicator
plates and a body weighing scale with built-in thermistors.
• The technologies may be used either for at-homecare or for screening in hospital
scheduled diabetes care.
• Scanning of foot temperature with an infrared thermometer is relatively time consuming,
while the LCT technology offers rapid temperature imaging. However, the thermographs
may sometimes be difficult to interpret.
• The temperature-sensing weighing scale has a potential of making foot temperature
monitoring into a daily routine but must be developed further.
• Temperature monitoring could be a complement in the prevention of major foot
complications but cannot replace any of the current steps in diabetes care.
• Adoption of temperature monitoring in standard care may lead to a more frequent referral
of patients from primary care to specialists but prevention of serious foot complication has
a potential to save costs owing to avoided amputations and in-hospital
care.
• Early diagnosis and early treatment is crucial for the healing of diabetic foot lesions. The
healthcare system must therefore be prepared to take care of a higher number of
suspected foot complications.
Veikutis V., Verkauskiene R., Jakuboniene N., Marciulionyte D., Morkunaite K., Raisutis
R., Monstvilas E., Stankevicius E. Clinical identification of early „diabetic foot„ by infrared
imaging // Conference “Biomedical Engineering“
Diabetic foot disease can occur in various stages of diabetes mellitus and consist from
peripheral angiopathy, neuropathy, which in presence of infection and some other factors
can lead to ulceration and in 15 % of cases to lower limb amputation. Early detection of
ulceration risk is essential clinical and prognostic test for successful diabetic foot
development control. The aim of the study was to determine optimal characteristics and
clinical possibilities of thermography for early detection of lower leg peripheral vascular
function changes. Therefore we tried evaluate foot temperature differences between
18
controls and diabetic patients. According to our studies, temperature monitoring could be a
complementary therapy in the early prevention of mayor diabetic foot complications.
Chapter VII Diseases of the eye and adnexa
Kawali AA. Thermography in ocular inflammation. Indian J Radiol Imaging 2013;23:2813.
Background and Objectives: The purpose of this study was to evaluate ocular
inflammatory and non-inflammatory conditions using commercially available thermal
camera.
Materials and Methods: A non-contact thermographic camera (FLIR P 620) was used to
take thermal pictures of seven cases of ocular inflammation, two cases of noninflammatory ocular pathology, and one healthy subject with mild refractive error only.
Ocular inflammatory cases included five cases of scleritis, one case of postoperative
anterior uveitis, and a case of meibomian gland dysfunction with keratitis (MGD-keratitis).
Non-inflammatory conditions included a case of conjunctival benign reactive lymphoid
hyperplasia (BRLH) and a case of central serous chorio-retinopathy. Thermal and nonthermal photographs were taken, and using analyzing software, the ocular surface
temperature was calculated.
Results: Patient with fresh episode of scleritis revealed high temperature. Eyes with MGDkeratitis depicted lower temperature in clinically more affected eye. Conjunctival BRLH
showed a cold lesion on thermography at the site of involvement, in contrast to cases of
scleritis with similar clinical presentation.
The eye of the patient with a fresh episode of scleritis, which was not on treatment,
showed hot colors on thermography indicating higher temperature in right eye compared to
fellow healthy eye. Eyes with scleritis on treatment showed slightly higher temperature
compared to the fellow eye. A case of resolved necrotizing scleritis showed lower
temperature at the site of the necrosis surrounded by normal tissue temperature. Eye with
postoperative anterior uveitis also revealed increased temperature, but paradoxically, eyes
with MGD-keratitis depicted lower temperature in clinically more affected right eye (OD).
Eye with conjunctival BRLH showed lower temperature at the site of the lesion. Eyes with
only refractive error but no other pathology showed no temperature difference between
both the eyes. is the temperature scale ranged between 31.5°C to 38.5°C.
Discussion: Ocular thermography is a relatively newer imaging modality. Attempts to
calculate normal eye temperature were made way back in 1950s using contact
thermometry. In 1968, R. Mapstone introduced infrared thermometry using bolometer, a
non-contact method of ocular thermometry. [Mapstone R. Determinants of corneal
temperature. Br J Ophthalmol. 1968; 52: 729–41.] The normal corneal temperature
measured by thermography ranges from 35.4±0.1°C [Stefanie PetrouBinder.
Thermography shows enormous promise for diagnosis and treatment of eye diseases.
Eurotimes.
[Last
accessed
on
2003
Mar].
Available
from:http://www.escrs.org/eurotimes/march2003/thermo.asp] to 34.01 ± 0.64°C, [Tan JH,
Ng EY, Acharya UR. An efficient automated algorithm to detect ocular surface temperature
on sequence of thermograms using snake and target tracing function. J Med Syst. 2011;
35: 949–58.] and the mean inter-ocular difference of OST in normal individuals was found
to be 0.21 ± 0.18°C.[Tan JH, Ng EY, Acharya UR. An efficient automated algorithm to
detect ocular surface temperature on sequence of thermograms using snake and target
tracing function. J Med Syst.2011;35:949–58.] Our first patient, a fresh case of scleritis
who was not on any treatment, had higher OST difference ( t) between the two eyes as
compared to the eyes on treatment for more than a week. This may suggest that ocular
temperature rapidly decreases with anti-inflammatory treatment and has a positive
correlation with the signs and symptoms. In this study, the case of MGD-keratitis (case 6)
19
paradoxically showed low temperature in clinically more affected eye (OD). Rolando et al.
also noted similar finding in dry eye and suggested that the ocular surface would be
0.10°C lesser in dry eyes due to the increased rate of evaporation.[ Rolando M, Refojo
MF, Kenyon KR. Increased tear evaporation in eyes with keratoconjunctivitis sicca. Arch
Ophthalmol. 1983;101:557–8. ] Hence, applying the same logic, it is clear that in case 6 in
the present study, due to decreased tear film lipids owing to MGD, the worse eye (OD)
was subjected to rapid evaporation of the tear film which resulted in a relatively colder eye
on thermography.
Thermography can also be used to distinguish between a cold lesion of non-inflammatory
condition from a hot lesion of ocular inflammation. Conjunctival BRLH is a poorly
vascularized tumor, and hence, case 8 in the present study showed low temperature at the
site of the lesion. In contrast case 1 who came with similar clinical presentation showed
high temperature, suggestive of inflammation due to scleritis. Our cases of posterior
scleritis had “minimal” increase in temperature as compared to the non-affected eye, as
they were on treatment. This may suggest that posterior segment inflammation can also
cause increase in OST, which can be picked up on thermography when posterior segment
examination is difficult as in the case of mature cataract or when it is normal as in the case
of mild posterior scleritis.
Conclusion: Ocular thermal imaging is an underutilized diagnostic tool which can be used
to distinguish inflammatory ocular conditions from non-inflammatory conditions. It can also
be utilized in the evaluation of tear film in dry eye syndrome. Its applications should be
further explored in uveitis and other ocular disorders. Dedicated "ocular thermographic"
camera is today's need of the hour.
Morgan Philip B, Tullo Andrew B, Efron N. Infrared thermography of the tear film in dry
eye. – Eye (1995) 9, 615–618.
Infrared ocular thermograms were recorded for a group of 36 dry eye patients and for 27
age- and sex-matched controls. Mean ocular surface temperature was greater in the dry
eye group (32.38 ± 0.69°C) compared with the control group (31.94 ± 0.54°C; P<0.01). In
addition, there was a greater variation of temperatures across the ocular surface in the dry
eye group, illustrated by the difference in temperature between the limbus and the centre
of the cornea (0.64 ± 0.20 °C in dry eye patients compared with 0.41 ± 0.20°C in the
control group; p<0.001). This parameter was also shown to be greater in dry eye patients
who displayed either a fast tear break-up time or a poor Schirmer's test result. Infrared
thermography is a non-invasive and objective technique that may prove a useful research
tool for study of the tear film, its deficiencies and its various treatment modalities.
Morgan, P. B. Ocular thermography in health and disease. - Thesis (Ph.D.). - The
University of Manchester, 1994. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.507520#sthash.ulqVkAMV.dpuf
There has been interest in ocular temperature for over a century, with the publication of a
limited amount of literature over that time. This thesis reports on the development and
utilisation of a system for the measurement of ocular surface temperature based on an
advanced infrared detector. The development of a suitable protocol for the infrared
imaging and temperature measurement of the eye was established. Results from the
analysis of the ocular temperature of 98 normal subjects indicated that the temperature at
the centre of the cornea was 31.68 ± 0.60°C (mean ± SD), and the mean ocular surface
temperature (MOST) was 32.10 ± 0.53°C. This value rose with increasing room and oral
temperature (both p< 0.0001) and decreased with corneal thickness (p< 0.05) and age (p<
0.01). Ninety five per cent of the subjects had an inter-ocular difference in MOST within
0.53°C. There was a positive relationship between the variation in temperature across the
ocular surface and the distance between the corneal apex and a coronal plane through the
20
limbus (p< 0.001). The effect on eye temperature of changes in the ocular blood, nerve
and tear supplies was studied. Three of nine patients (33%) with unilateral inflammatory
disease had ocular temperature outside the established normal limits. For the group of
patients as a whole, the temperature of the affected eye was warmer than the fellow
(32.40 ± 0.81°C compared with 32.10 ± 0.70°C; p< 0.05). In the examination of two
patients with Horner's syndrome, one demonstrated a difference in eye temperature
(0.61°C) outside normal limits (0.53°C), with the affected eye being warmer.
Tkáčová M., Živčák J., Foffová P. A Reference for Human Eye Surface Temperature
Measurements in Diagnostic Process of Ophthalmologic Diseases. - MEASUREMENT
2011, Proceedings of the 8th International Conference, Smolenice, Slovakia.
Introduction
For many years temperature is the first measurement of a physical property for
determination of diagnosis in the medicine. From electromagnetic theory it is a form of
infrared energy being emitted from the first molecular surface of a body (skin). Infrared
imaging is the detection and conversion of energy from a section of the infrared spectrum,
into the visible spectrum. Surface energy levels are affected by the environment,
operational conditions, heat transfer processes of a human body and the surface
characteristics.
Thermography is a non-invasive, contactless temperature measurement technique used to
produce a colored visualization of thermal energy emitted by the measured surface. Each
pixel in the image depicts the radiance falling on the focal plane array/ microbolometer–
type detector used in an IR camera.
Current applications infrared thermography in ophthalmology include:
 diagnosis of glaucoma, an eye disorder in which the optic nerve suffers damage,
permanently impacting vision in the affected eye(s) and progressing to complete
blindness if untreated. It is often, but not always, associated with increased
pressure of the fluid in the eye;
 monitoring surface temperature of a healthy eye;
 thermographic monitoring of tear ocular film;
 thermography and comparison of normal, ischemic and hyperaemic eye;
 the impact of contact lenses for the eye surface temperature and other.
Our study is based on monitoring the temperature of the healthy eye to get the reference
database for diagnostic process support of ophthalmologic diseases.
Subject and Methods
Skin temperature on human eyes from our database (n= 28) were measured with an
infrared camera (ThermaCam Fluke Ti55/20, Fluke, USA) with 10,5 mm lens (10,5 mm
F/0,8; 8-14 μm). The thermal sensitivity of the camera is 0.05°C at 30°C of a blackbody.
Camera works in the spectral range from 8 to 14 μm (human body infrared radiation is
highest in the spectral range around 9,66 μm) and the calibrated temperature range from 20 to 100 °C. Emissivity of the skin was set in the camera software to 0,98, the ambient
temperature was measured by handheld thermometer (Testo 810). Before each recording
the camera was calibrated using the system's internal calibration process. All thermograms
(n=28) were processed by SmartView 2.1 software.
Object of our measurements were volunteers, their average age was 24 years.
Discussion
Studies published worldwide indicate that thermography is a valuable diagnostic method in
ophthalmology, in order to objective detection of some ophthalmologic diseases and
conditions (monitoring of tear ocular film, ischemic and hyperaemic eye, diagnosis of
glaucoma, etc.). The database of healthy eye surfaces temperature is important to
differentiate the healthy eye and pathological condition of the eye in specific
ophthalmologic diseases.
21
Conclusions
In the study a methodology of thermographic measurements was assessed. After the
processing of the thermograms, the average temperatures of the cornea in all measured
subjects were calculated . Results show, that a total average temperature in the cornea of
the eye in markers T1, T2 a T3 is 34,51 ± 0,82 oC. The minimum temperature of the
cornea eye was 33,82 ± 1,10 oC and maximum temperature 35,41 ± 0,73 oC. Theresults
show that the overall average temperature of the eye surface is 34,51 ± 0,82 oC. The
bigger statistically significant group is planned to get the significant reference values.
Chapter VIII Diseases of the ear and mastoid process
Merkulov V.G. Comprehensive thermography diagnostics of some ear-nose-throat related
diseases. // Russian otorhinolaringolagy. – 2000. – №3. – Pages 163-168.
The research demonstrated sufficiently high specific of the infrared thermography:
91.4% during examination of the middle ear. The analysis of the results of
thermography performed for the unilateral inflammatory pathology of the middle ear
demonstrates that such diseases as mastoiditis (including the non-perforative middle
otitis), chronic pus middle otitis with cholesteatoma are optimal and practically important
factors for its application. For the mastoiditis the thermography’s diagnostic
sensitivity is equal to 81.3%, for the chronic pus middle otitis with choleastoma –
79.6%.
Jolin S.W., Howell J.M., Milzman D.P., Stair T.O., Butzin C.A. Infrared emission detection
tympanic thermometry May be useful in diagnosing acute otitis media // American
Journal of Emergency Medicine Volume 13, Issue 1, Pages 6-8, January 1995.
To determine the utility of infrared emission detection (IRED) tympanic thermometry in
diagnosing acute suppurative otitis media (ASOM), a prospective, nonblinded sampling of
ear temperatures was performed. Children between the ages of 6 months and 6 years
presenting to an urban emergency department were included in the study. Tympanic
temperatures were determied in all subjects. Clinical data, tympanic audiometry, and
telephone follow-up were used to define ASOM. Temperature differences were
determined for children with unilateral ASOM and those without ear infection. Data from
48 patients were analyzed. The mean temperature difference in the control group, 0.23° ±
0.15°C (95% confidence interval [Cl], 0.17° to 0.29°C) differed from those with ASOM:
0.39° ± 0.29°C (95% Cl, 0.25° to 0.53° C, P = .047). Logistic regression was used to
describe the predictive relationship between temperature difference and probability of
ASOM. We conclude that IRED tympanic thermometry may be useful in diagnosing ASOM
when used with other clinical data.
Chapter IX Diseases of the circulatory system
In his research Popov V.A. (1997) has defined the yearly and late emergent signs of
thermal images of the acute vein thrombosis of legs. The research justified application of
the thermal imaging for patients suffering from non-occlusive thrombosis in the inferior
vena cava. For diagnostics of acute phlebothtombosis by the thermography the high
sensitivity (98%), specificity (90%), and diagnostic accuracy (85%) was established.
Also, the thermal-imaging signs for the congenital angiodysplasia of extremities were
identified. Arteriovenous fistulas are characterized through local increase of irradiation
intensity of the dysplastic area with the thermal asymmetry not exceeding 1°С. The
thermal-imaging syndrome of the venous form of the congenital angiodysplasia is
characterized through decrease of the skin temperature by 1°С, and more dysplastic area
as compared to the unchanged surounding tissues.
22
Kelechi T.J., Michel Y. A Descriptive Study of Skin Temperature, Tissue Perfusion, and
Tissue Oxygen in Patients With Chronic Venous Disease // Biol Res Nurs 2007 9: 70-80.
Chronic inflammation and microcirculatory disturbances of the skin have been implicated
as causative factors of complications associated with chronic venous disease (CVD). The
purpose of this study is to describe the mean differences between and correlations among
three measures of microcirculation: skin temperature (Tsk), tissue perfusion/blood flow
(BF), and tissue oxygen (tcPO2) of CVD-inflamed skin compared to normal controls. In a
convenience sample of 55 patients with CVD (n = 31) and without CVD (n = 24), Tsk was
measured with an infrared thermometer, BF with a laser Doppler flowmeter, and tcPO2
with a transcutaneous oximeter across three measurements periods 1 week apart (Times
1, 2, and 3) at the medial aspect of both lower legs. Tsk was higher (1.2°C) across all
measurement periods (p < .05), BF was higher at Times 1 and 3 (p = .002 and .012,
respectively), and tcPO2 was lower at Times 1 and 3 (p = .013 and .050, respectively) in
the CVD group as compared to the non-CVD group. BF and Tsk were positively correlated
at Times 1 and 2 (r = .516, p < .005; r = 0.278, p = .04) but not at Time 3 (r = 0.235, p >
.05). No consistently significant correlations were found between tcPO2 and BF or tcPO2
and Tsk (p > .05). Tsk and BF were higher in the skin of lower legs affected by CVD than
in those not affected. Pathological processes in the skin produce heat detectable by an
infrared thermometer. Measurement and monitoring of Tsk can augment clinical findings
and guide treatment when localized inflammation is suspected. Future studies of Tsk
should be directed toward the usefulness of infrared technology to develop a CVD leg
ulcer prediction model.
Steri N.A. Capabilities of the combined thermography for diagnostics of the varicose vein
disease of lower extremities. – Abstract of thesis…Ph.D. (medical sciences) – Volgograd,
2008.
The varicose disease is still one of the most common vascular diseases of the lower
extremities. The report of the international compromissary committee for treatment of
chronical vein diseases of lower extremities (1999 year) has stated, that the varicosity
prevalence rate for the adult polulation of western countries is equal to 25-33% for women,
and 10-20% for men. It is mentioned in the report, that 1% of population is suffering from
open or cicatrized ulcers of the vein aetiology. Only half of total number of ulcers is
cicatrized within 4 months, yet majority of ulcers are subject to recurrence at least once in
a year. Such statistics convert the varicous disease from a purely medicinal issue to a
severe social and economic problem.
The modern diagnostics of vein diseases and control of treatment are based on noninvasive examination technologies, of which the ultrasonography is the main method.
However, the ultrasonic examination does not allow evaluating to full extent the condition
of the soft tissues of the lower extremities, as it examines mainly the blood circulation in
the main vessels. It is not possible to examine the state of microcirculation of the shank’s
lower part, which is the principal area of maximum disturbances of venous outflow of
patients suffering from the leg varicous diseases.
The author has developed the non-invasive evaluation technique of the condition of leg
venous system by of multi-point combined thermography for diagnostics of vein
pathologies. This technique may be used independently or in combination with the
ultrasonography. The obtaind data allow evaluating efficiency of conservative or chirurgical
treatment of patients with leg varicous disease.
For obtaining the thermal images of the lower extermities it is possible to use the
technique involving multi-point human shank thermal examination by means of 12 points
on the shank’s reverse surface. For detection of pathological thermographic signs it is
23
necessary to compare two significantly different thermograms, one of a sound extremity
and a thermogram of leg with varicous disease.
It was established that when conducting the examination the patient’s posture (standing or
lying) does not significantly impact on the thermal image.
Thermal-imaging signs of the leg varicous disease include: detection of shank’s thermal
disturbances from a normal value, detection of shank’s thermal assymetric arears,
presence of an axial thermal gradient (temperature difference relatively an extremity’s
axis), availability of a lateral-medial gradient (temperature difference from the outer to the
inner shank surface).
The thermogram’s sensitivity and specificity of the patients with leg varicous
disease of the category С1-3 is equal to 63.6% and 76.4%, accordingly, for the С4-6
the sensitivity is 89%, the specificity is 91.5%, thus allowing to integrate and elaborate
the varicous disease diagnostics, and to substantiate optimization of treatment in the preand after operational period.
KHVOROSTUKHIN V.S. SIGNIFICANCE OF VALVE INSUFFICENCY OF
PERFORATING VEINS, AND MINIMALLY INVASIVE SURGICAL TECHNIQUES FOR
ITS TREATMENT FOR THE PATIENTS SUFFERING FROM THE LOWER
EXTREMITIES VARICOUS DISEASE. – Abstract of thesis. …Ph.D. (medical sciences) –
Saratov, 2006.
Using the thermograph ТВ-03К with the temperature range of 25-40°С and sensitibity of
0.1°С, thermography of the lower extremities of 112 patients (49.6%) was conducted. The
control group was composed of 15 apparently healthy persons without clinical implications
of the chronical venous insufficiency of the lower extremities.
For all the examined patients (100%) the thermography has discovered convolute linear
focuses of hyperthermia in the projection of varicousities over their whole length with a
uniform temperature increase of 0.8–1.8С (the average value is 1.4±0,1С) as compared
to the surrounding tissues. Detection and localization of incapable perforating veins was
performed by means of detection in the projection of superficial veins of warmer sections
of various shapes with better manifesting hyperthermia focus in this area. The dimensions
of these sections considerably exceeded diameters of the corresponding veins. The
temperature gradient, as compared to the projection of other various veins, was in the
range of 0.6 – 1.1С (averagely – 8.7±0.5С), in comparision with the surrounding tissues
in the range of 1.0 – 2.4С (averagely – 1.8±0.5С). The sensitivity of the thermography
study with respect to detection of incapable perforating veins was equal to 64.6%.
When conducting the control thermography following the medical treatment, in the
projection of remote varicous veins were detected linear sections of hyperthermia with the
temperature gradients in the range of 0.4 – 0.8С (averagely – 0.6±0.2С), the
varicousities were not identified. After the catheter and puncture scleral obliteration at the
varicosities, 7 days following the treatment the isothermical sections and centers of
insignificant temperature increase with the gradient of 0.3С were identified. In case of
acute ssuperficial thrombophlebitis, the thermograms demonstrate for their projections
wide centers of huperthermia involving the surrounding tissues into this process with the
temperature rise in the range of 1.5 – 3.1С (averagely – 2.5±0.6С). Following the
treatment the area of hyperthermia decreased significantly.The trophic ulcers were marked
by availability in the ulcer’s projection of a cold zone of round geometry (the gradient in the
range of 0.8 – 1.1С, averagely – 0.9±0.1С) with hyperthermia of the surrounding tissues
of 1.1 – 1.3С (averagely – 1.2±0.1С), as compared to the symmetrical section of a sound
extremity. Following the ulcer healing its projection retains a hyperthermia focus with
gradient in the range 0.4 – 0.8С, averagely – 0.6±0.2С (the area of trophic
abnormalities); the zone of hyperthermia was not identified.
24
This way, it appears expedient to apply the thermography for evaluating efficiency of the
performed treatment, and dynamics of manifestation of the chronic venous insufficiency.
Wild W.; Schütte S., Große M. Тhermal imaging as a non invasive application in the field
of diagnostics and treatment of varicosis and succeeding symptoms // 6th
INTERNATIONAL CONFERENCE ON QUANTITATIVE INFRARED THERMOGRAPHY
QIRT
2002,
DUBROVNIK,
September
24-27,
2002
(www.fsb.unizg.hr/Qirt2002/abstract/60.doc)
Introduction. Varicosis with all its succeeding symptoms is a serious and broad spread
illness our civilization has to face. Nowadays approved diagnostic methods include non
invasive duplex sonography and invasive angiography. This study evaluates the
possibilities of thermal imaging as a new or supporting tool in the process of diagnostics
and monitoring of treatment of varicosis and should raise information for a succeeding
more detailed study.
Patients and Methods. First of all 11 randomly chosen patients (7 female, 4 male) with a
proven diagnostic suffering from varicosis and succeeding symptoms like postthrombotic
symptom, Ulcus Cruris and phlebitis underwent thermal imaging at their regions of interest.
The images were taken under equal circumstances with a FLIR / AGEMA Thermovision
550 infrared camera. For comparison to this, pictures of the same regions were taken with
a commercial digital camera. The evaluation of the thermographic images was conducted
with the Software ThermaCam Reporter 2000.
Results. No technical problems occurred during the course of image reception. Infrared
Imaging and the camera system itself prove to be an easy to handle and quick to apply
recording installation. Thermal images show high detail and contrast with blood vessels
located close below the skin. Resolution of skin temperature between the single outer
extremities – fingers and toes, appears to be acceptable and correlates to the proven
diagnosis. Problems of image detail resolution occur especially with male leghair coating
and deeper position of the blood vessels below the skin because of bodyfat.
Conclusion. The data collected during the study seem to be promising that thermal
imaging may be suited as an additional and supporting non-invasive method of diagnosis
in the field of varicosis and post symptoms. The succeeding study may also be spread out
to general blood flow insufficiency symptoms like arteriosclerosis.
Chapter X Diseases of the respiratory system
Gauthier E., Marin T., Bodnar J-L. and Stubbe L. Assessment of the pertinence of
infrared thermography as a diagnostic tool in sinusitis - Cases study // The 12th
International Quantitative InfraRed Thermography Conference, At Bordeaux, FRANCE.
Sinusitis is a frequent otorhinolaryngologic disease, often misdiagnosed. None of the usual
imaging equipment is specific, quick or efficient enough for sinusitis diagnosis.
Misdiagnosis induces unnecessary health expenditures as well as a risk of antibiotic
resistant strain development. Our study (with one healthy control subject, two pathological
subjects) shows that infrared thermography could be an efficient, low-cost and noninvasive diagnostic tool for clinical purposes. A cohort study is necessary to establish
threshold values for systematic reliable diagnosis.
Sinusitis is an otorhinolaryngologic disease that affects people of every age, with millions
of consultations per year [Benson V, Marano MA. Current estimates from the National
Health Interview Survey. 1995. Vital Health Stat. 1998;199:1-428.]; it is fifth in ranking for
antibiotics prescription [Fagnan LJ. Acute sinusitis: a cost-effective approach to diagnosis
and treatment. Am Fam Physician. 1998;58:1795-802,805-6., McCaig LF, Hughes JM.
Trends in antimicrobial drug prescribing among office-based physicians in the Unites
States. JAMA. 1995;273:214-9.]. Sinusitis is an inflammation of the mucous membrane of
25
one or several of the sinus cavities of the face, sometimes accompanied by suppuration. It
is a common affliction, although its prevalence is difficult to assess; according to an
american study, it affects 14% of the American population, adults and children combined
[Poole MD. A focus on acute sinusitis in adults: changes in disease management. Am J
Med. 1999;106:38S-47S.].
In this pathology, inflammation is materialized by a sinus temperature increase [Prasał M,
Sawicka KM, Wysokiński A. Thermography in cardiology. Kardiol Pol. 2010;68(9):1052-6.].
In humans, a calorific exchange happens between the skin and the atmosphere through
infrared, either emitted or absorbed. Previous studies have shown that human
inflammation can be detected through thermography: infrared cameras allow for a noninvasive estimation of infrared radiation, which are the external manifestation of an internal
process [Ring EFJ, Ammer K. Infrared thermal imaging in medicine. Physiological
Measurement. 2012;33(3):R33., Lange KHW, Jansen T, Asghar S, Kristensen PL,
Skjønnemand M, Nørgaard P. Skin temperature measured by infrared thermography after
specific ultrasound-guided blocking of the musculocutaneous, radial, ulnar, and median
nerves in the upper extremity. British journal of anaesthesia. 2011;106(6):887-95.].
The objective of this study is to assess the pertinence of infrared thermography as an
efficient diagnostic tool for sinusitis. This study will only evaluate the anterior sinuses
network: it is less deep than the other sinuses of the face and thus more pertinent for
thermographic evaluation. Also, 90% of sinusitis affect the anterior sinuses network
[Institut Français de Chirurgie du Nez et des Sinus. http://www.institutnez.fr/sinusite/sinusite-chronique-19.html. Dernière mise à jour le 26/04/2011.].
Infrared thermography seems to be an efficient, reliable, non-invasive and immediate
diagnostic tool for sinusitis; it could be used with any patient, including children, pregnant
women or immunodepressed people. Many thermal cameras are light, easy to use and
inexpensive (under 1000€). For research purposes, a wider study is required to establish
threshold values to precise the analysis protocol. Visual analysis crossed with clinical
symptoms could be sufficient for clinical diagnosis.
Merkulov V.G. Comprehensive thermography diagnostics of some ear-nose-throat related
diseases. // Russian otorhinolaringolagy. – 2000. – №3. – Pages 163-168.
The research demonstrated sufficiently high specific of the infrared thermography:
94.5% during examination of the paranasal sinus. The diagnostic sensitivity of
thermography for the maxillary sinusitis is equal to 91.5%.
Murawski P., Jung A., Kalicki B., Rustecki B. USEFULNESS OF LINEAR PREDICTIVE
CODING COEFFICIENTS FOR THE QUALIFICATION HEALTHY PEOPLE AND
PATIENTS WITH SINUSITIS BASED ON FACIAL THERMOGRAMS // 17th Congress of
the Polish Association of Thermology and Certifying course: "Practical application of
thermography in medical diagnostics" - Thermology international 23/2 (2013).
1.Application of LPC covariates in signals analysis marked from facial thermograms,
allows qualification of patient to proper group healthy or sick.
2.Values of proper qualification probability are dependent on number of covariates and
they are acceptable when nLPC _14.
Plouzhnikov M. S., Ryabova M. A. Thermography: clinical significance in rhinology //
SP1E Vol. 2106 Iconics and Thermovision Systems.
1. Thermographic picture in patients with operated sinuses during remission period
essentially differs from those in normal patients with acute sinusitis.
2. Thermography may be helpful to differentiate the cause of different types of prosopalgia.
26
Torossian F, Giard A, Cereja F. Digital thermography for the evaluation of the effect of
betamethasone in the treatment of acute sinusitis. Preliminary study // Presse Med. 1997
Oct 18;26(31):1482-7.
OBJECTIVES: Heat emitted during the process of inflammation can be visualized by
means of dynamic telethermography (DDT). In the case of sinusitis, it is possible to verify
the efficacy of an anti-inflammatory treatment such as betamethasone.
PATIENTS AND METHODS: Ten adult ambulatory patients with sinusitis were treated with
2 tablets of betamethasone (Celestene) 2 mg daily for 10 days without concomitant
medications. DDT images were obtained on day 0, day 2, day 3, day 5 and day 10. A color
chart indicated differences in temperature according to the selected sensitivity. Computer
analysis of the images was then obtained. Clinical assessment of symptoms and tolerance
were recorded at the same time-points as the DDt images.
RESULTS: The effect of treatment was beneficial in all patients since cure of sinusitis was
achieved in 5, with marked improvement in 4 others and fair improvement in 1. Pain was
significantly reduced on day 10 compared with day 0 (Friedman's test p < 0.0001). There
was a simultaneous reduction of sinusitis associated signs: rhinorrhea, lacrimation,
photophobia and cutaneous hyperesthesia as well as of general signs. On the DDT
images, right-sinus to right-side and left-sinus to left-side ratios both showed a significant
decrease between day 0 and day 10 from 41.00 +/- 14.07 to 7.90 +/- 7.22 (ANOVA p <
0.0001) and from 30.70 +/- 5.20 +/- 6.49 (ANOVA p < 0.0001) respectively.
DISCUSSION: Whereas in animal pharmacology inflammation can be evaluated by any
number of objective methods, only a very few are applicable to clinical situations. Powerful
computer image analysis may prove useful in establishing nature and severity based
inflammation reduction standards.
CONCLUSION: These preliminary findings demonstrated that in most cases single agent
therapy provides adequate and rapid control of clinical and thermographic signs of acute
sinusitis. Computer analysis corraborates clinical findings and thermogram interpretations.
Wojaczyñska-Stanek K., Marszal E., Krzemieñ-Gabriel A., Mniszek J., Sitek-Gola M.
Biostimulating Laser Treatment of Chronic Sinusitis in Children – Monitoring by Thermal
Imaging // Thermology international 2005, 15: 140-145.
Chronic inflammation of the paranasal sinuses is defined as a persistent process in the
mucous skin of the nose and and the sinus that continues for at least 12 weeks despite
appropriate treatment. Thermographic examination of the sinus area has become a
recognized diagnostic method. Thermographic images of children presenting with sinusitis
reveal warmer areas in the maxillar projection of the sinus and often higher temperatures
in the periorbital region. The experimental group consisted of 20 children treated with
biostomulating laser (10 laser therapy sessions) and 15 children who received a long term
antibiotic treatment (14 days of antibiotic administration) for chronic sinusitis. A control
group consisted of 20 healthy children. Thermographic examination was made under
standard condition sbefore and at the end of the course of therapy using a THERMACAM
PM595. After laser treatment 16 of 20 patients achieved normal temperature distribution in
their thermal images, and after the prolonged antibiotic therapy 12 of 15 patients showed
normal thermograms. Subjective improvement related to nasal congestion and headache
was evaluated. In one patient, the thermographic image of the sinus indicated persistent
inflammation and the patient required another antibiotic treatment. Thermography can be
used to monitor the effects of both pharmacological treatment and biostimulating laser
therapy. Biostimulating laser treatment appears to be an effective adjunct to long term
pharmacological therapy in children with chronic sinusitis.
Berman S.Z., Mathison D.A., Stevenson D.D., Usselman J.A., Shore S. Maxillary sinusitis
and bronchial asthma: Correlation of roentgenograms, cultures, and thermograms //
27
Journal of Allergy and Clinical Immunology. – Volume 53, Issue 5, May 1974, Pages
311–317. Eng M. Tan.
Chapter XI Diseases of the digestive system
Biagioni P A, McGimpsey J G & Lamey P J. Electronic infrared thermography as a dental
research technique. - British Dental Journal 180, 226 - 230 (1996).
Electronic infrared thermography is an imaging modality for the accurate quantification of
surface temperature. It has been used in medicine since the 1960s but its use in dentistry
has been limited. Its use in dentistry could, however, be very useful, for example in
objectively quantifying post-surgical inflammation and studying the effects of treatment
with agents such as analgesics and anti-inflammatory drugs.
Christensen J, Matzen LH, Vaeth M, Schou S, Wenzel A. Thermography as a
quantitative imaging method for assessing postoperative inflammation. - Dentomaxillofac
Radiol. Sep 2012; 41(6): 494–499.
Objective
To assess differences in skin temperature between the operated and control side of the
face after mandibular third molar surgery using thermography.
Methods
127 patients had 1 mandibular third molar removed. Before the surgery, standardized
thermograms were taken of both sides of the patient's face using a Flir ThermaCam™
E320 (Precisions Teknik AB, Halmstad, Sweden). The imaging procedure was repeated 2
days and 7 days after surgery. A region of interest including the third molar region was
marked on each image. The mean temperature within each region of interest was
calculated. The difference between sides and over time were assessed using paired ttests.
Results
No significant difference was found between the operated side and the control side either
before or 7 days after surgery (p > 0.3). The temperature of the operated side (mean:
32.39 °C, range: 28.9–35.3 °C) was higher than that of the control side (mean: 32.06 °C,
range: 28.5–35.0 °C) 2 days after surgery [0.33 °C, 95% confidence interval (CI): 0.22–
0.44 °C, p < 0.001]. No significant difference was found between the pre-operative and the
7-day post-operative temperature (p > 0.1). After 2 days, the operated side was not
significantly different from the temperature pre-operatively (p = 0.12), whereas the control
side had a lower temperature (0.57 °C, 95% CI: 0.29–0.86 °C, p < 0.001).
Conclusions
Thermography seems useful for quantitative assessment of inflammation between the
intervention side and the control side after surgical removal of mandibular third molars.
However, thermography cannot be used to assess absolute temperature changes due to
normal variations in skin temperature over time.
Mostovoy A. Thermography and Oral Pathology. - This paper was presented in
September of 2012 at the European Asociation of Thermography (EAT) in Porto, Portugal.
- http://www.thermographyclinic.com/thermography/dental-oral
Introduction: The purpose of this study is to illustrate the clinical use of thermography in
identifying asymptomatic dental (oral) pathology. A common cause of dental (oral)
infection and inflammation found in this study is in fact due to a common dental procedure,
a root canal. Unless the region becomes abscessed, usually over a longer period of time,
we are completely unaware that there is an issue.
28
For years, a debate has brewed between those, who are proponents of root canals, and
those, who see root canals as a potential health threat. Current convention is to save a
tooth at any cost. Despite multiple research studies that link root-canal treated teeth to
cancer and other chronic disease, the majority of people, even health care professionals,
do not pay enough attention to dental health. With thermographic imaging, we can identify
areas of suspected inflammation and infection because they present with heat. Once an
area of concern is identified, it needs further investigation and resolution.
Materials and Methods: Study population consisted of 20 patients (2 males and 18
females, aged from 42 to 63 years) that visited Thermography Clinic in Toronto, Ontario,
Canada with variable complaints. All patients were evaluated with IR imaging and followed
up with dental examination that included x-ray and examination of the oral cavity. Patients
were followed up with additional dental examinations for up to one year.
Patients were evaluated with FLIR A-320 Infra Red camera, with examination guidelines
followed, as set 1-2 detected spots, six subjects (42.9%) had confirmed results. Five out of
six subjects (83.3%) with 3-4 spots received such confirmation. During the second followup dental exam, thermographic findings were confirmed in all 10 subjects evaluated.
Notably, in 7 of these subjects results of the first dental evaluations were not confirmatory.
When both first and second dental evaluations are take into account, thermographic
findings when confirmed at least once in 18 our 20 subjects. The high confirmation rate
(90%) indicates strong correlation between thermographic and dental exams.
Discussion: Pain acts as a warning system that something is wrong. Unless the region
becomes abscessed, usually over a longer period of time, we are completely unaware that
something is going on. When a patient has no symptoms of pain or discomfort, the
assumption is that all is well. If an infection in the area does develop, we have no way of
knowing this, as the pain receptors in that area have been removed as in case of root
canal treated teeth. If an abscess develops, it will be taken care of – usually as an
emergency – but by then, infection could have been setting in for many years and could
have already contributed to the development of other health issues. Chronic inflammation
has been accepted as “the silent killer” that leads to chronic disease, heart disease, and
cancer. Root canals are inherently susceptible to infection and inflammation.
Over the years at our clinic, we have imaged thousands of women using infrared
thermography. In many cases, we have clearly seen cases of inflammation in the dental
area using this heat sensing technology. Many of forth by the International Academy of
Clinical Thermology. The IR imaging finding results were summarized. Quantitative
variables were described using summary statistics (means, medians, and standard
deviations, minimum and maximum values). Categorical variables were summarized by
giving frequency distributions. Percent of patients with at least one IR imaging finding
confirmed by subsequent dental evaluations was the primary endpoint in this study.
Results: Twenty patients with age ranging from 42 to 63 years (mean age ± SD is 52.4 ±
6.7 y.o.} participated in this study. Eighteen (90%) patients were females. Two patients
(10%) had total body scan performed; thirteen patients (65%) had both breast and facial
scans, and 5 patients (25%) had a facial scan only. Fourteen patients (70%) did not have
any symptoms related to dental pathology. The number of oral cavity findings (“spots”) per
patient ranged from 1 to 4 (mean ± SD is 2.1 ± 1.1}. Most of patients had 1 (40%) or 2
(30%) dental cavity findings. Following the thermography evaluations, eight subjects (40%)
had a dental follow-up exam in less than a month, 12 subjects (40%) had such an exam in
29
1-2 months. Ten subjects (50%) subsequently had another dental exam; seven of these
subjects saw the dentist within the following 6 months. In eleven subjects, (55%),
thermographic findings were confirmed during the first follow-up dental exam. In fourteen
subjects with these cases are caused by a low-grade infection and inflammation and have,
through further testing, been attributed to dental or oral issues, such as issues related to
root-canal treated teeth. Invariably, some cases are very subtle, even asymptomatic for
many years, but these cases slowly and continuously affect peoples’ health. With
thermographic imaging, we can identify areas of suspected inflammation and infection
because they present with heat. Once an area of concern is identified, it needs further
investigation and resolution. People living with a chronic source of infection and
inflammation will eventually find that their immunity is affected. In some cases, this chronic
inflammation and infection will actually promote the growth of malignancy. The natural
defense mechanism to fight malignant development is impaired since their immune system
is busy dealing with inflammation that has no chance of resolving on its own. The only way
this problem can be resolved is by identifying and removing the cause. The infected area
has to be properly dealt with before the body can be restored to health.
Conclusion: The IR imaging procedure provided enormous information about the
physiological processes through examining the temperature of the facial area that can be
related to the internal process of inflammation or irritation. The early signs provided by the
IR imaging can be used as a prognostic indicator in detecting oral and or dental pathology.
The merits of a non-invasive IR imaging modality are important in identifying early stages
of inflammation not visible by other imaging modalities. The high confirmation rate (90%)
indicates strong correlation between thermographic and dental exams.
Sarbani Deb Sikdar, Anshul Kjanddelwal, Savita Ghom, Rajkumar Diwan, FM Debta.
Thermography: a new Diagnostic tool in Dentistry // Journal of Indian Academy of Oral
Medicine and Radiology. – 2010; 22 (4): 206-210.
30
Sudhakar S., Bina kayshap, Sridhar reddy P. Thermography in dentistry-revisited // Int J
Biol Med Res. 2011; 2(1): 461-465.
Thermography is a method of measurement of skin temperature distribution on the body
over a given period of time. For the past four decades, various devices have been used to
measure the amount of heat dissipated by the body. The principle behind such application
was built on the fact that, as the amount of blood circulation at different layers of the skin
varies, the temperature also changes accordingly. Consequently, disorders that affect the
blood flow too results in abnormalities in temperature distribution and these when
evaluated will provide valid diagnostic informations. Thermography since its inception has
provided numerous dental applications; however, its usage has been abridged when
compared with other diagnostic modalities. This article highlights the basics of
thermography and its role in dentistry.
Additional applications of telethermography:
- Evaluation of craniomandibular disorders.
- Quantification of the effects of post-surgical inflammation.
- Quantification of the effects of analgesics, anti-inflammatory drugs, etc.
- In the diagnosis of myofacial symptoms.
Thermography aids in the assessment and staging of various dysfunctions of the head and
neck region. The unique significance of thermography is both qualitative and quantitative
assessment which helps in estimation of progression of the disease in a systematic
manner. With the innovation of novel equipments and the state of the art facility,
thermography in the near future will certainly re-emerge as a unique research tool in
dentistry.
Durnovo Е.А., Potekhina Y.P., Marochkina M.S., Yanova N.А., Sahakyan М.Yu.,
Ryzhevsky D.V. Diagnostic Capabilities of Infrared Thermography in the Examination of
Patients with Diseases of Maxillofacial Area // Modern Technologies in Medicine – N2,
2014. – P. 61-67.
The aim of the investigation was to evaluate the possibility to apply infrared
thermography for the diagnosis of pathological maxillofacial conditions.
Materials and Methods. 250 patients with different maxillofacial pathological conditions
underwent an examination, thermographic analysis and comprehensive treatment. All
patients were divided into three groups: group 1 (n=114) — patients with inflammatory
diseases of maxillofacial area; group 2 (n=40) — patients with traumatic maxillofacial
31
injuries; group 3 (n=96) — patients with benign (n=54) and malignant (n=42) neoplasms of
the maxillofacial area.
Results. Local temperature indices of the maxillofacial area were found to change
significantly in inflammatory diseases. The decrease of temperature indices was revealed
in the centre of radicular cysts (by 0.1–0.3°С), in central and peripheral (by 1.3–2.3°С)
points over chronic osteomyelitis, in acute purulent periostitis (by 1.2–1.9°С), in acute
osteomyelitis (by 1.5–1.9°С), in acute grandular abscess (by 2.0–2.3°С), in odontogenic
phlegmon of maxillofacial area (by 1.4–3.0°С), and odontogenic abscess (by 1.8–2.4°С).
We found significant increase of temperature indices in traumatic injuries: in lower type
LeFort fractures (by 1.3–1.5°С), in medial type LeFort fractures (by 1.2–1.6°С), in
mandibular fractures (by 0.2–0.6°С). Significant increase of temperature indices was
observed over malignant neoplasms — in the range of 2.8–3.6°С, while temperature
indices over benign tumors and tumor-like masses did not exceed 1.4°C.
Conclusion. Infrared thermography is a reliable, highly informative, non-invasive and safe
method, requiring no trained staff. It can be used for diagnosis, differential diagnosis and
prognostic studies in various diseases of maxillofacial area.
Chapter XII Diseases of the skin and subcutaneous tissue
Juhee Park, Woo Sun Jang, Kui Young Park, Kapsok Li, Seong Jun Seo, Chang Kwun
Hong, Jong Beum Lee. Тhermography as a predictor of postherpetic neuralgia in acute
herpes zoster patients: a preliminary study // Skin Research and Technology. Volume
18, Issue 1, pages 88–93, February 2012.
Background/purpose: Infrared thermal images in patients suffering from herpes zoster
(HZ) may exhibit thermal asymmetry due to the unilateral distribution of HZ lesions. This
study examined the usefulness of infrared thermography in acute HZ as a predictor for the
development of postherpetic neuralgia (PHN).
Methods: The authors collected demographic and clinical data including age, sex, onset of
skin lesion, pain intensity by a visual analogue scale (VAS) and the development of PHN
from a total of 55 patients diagnosed with HZ. We evaluated the body surface
thermographic parameters between the lesion and contralateral normal skin: maximal
difference in the temperature (ΔT) and the size of the body surface area (BSA) showing
thermal asymmetry.
Results: Temperatures of the lesions were found to be warmer than the control side in
most patients with acute HZ. We compared the patient group who developed PHN with
those who did not. In univariate analysis, patients with PHN were older (P=0.004), had a
higher VAS score for pain (P<0.001), higher ΔT (P<0.001) and larger BSA (P=0.001). In
logistic regression analysis to identify independent risk factors of PHN, older age (>60
years old) and ΔT more than 0.5 °C were found to be statistically significant.
Barton M. Gratt. Electronic thermography for the assessment of mild and moderate
temporomandibular joint dysfunction. - Oral Surgery, Oral Medicine, Oral Pathology, Oral
Radiology, and Endodontology. - Volume 79, Issue 6, June 1995, Pages 778–786.
Today facial heat emission patterns may be rapidly obtained and quantified with the use of
advanced electronic thermography units that have the promise of being a nonionizing,
noninvasive, low-cost diagnostic alternative for the evaluation of temporomandibular joint
disorders. This study design measured the use of electronic thermography as a tool to
select between asymptomatic (control) subjects and a patient group with mild to moderate
temporomandibular joint disorders. Study populations consisted of 24 asymptomatic
(control) subjects and 20 patients with (1) either locked or unlocked temporomandibular
joints, (2) varying degrees of limitation of mouth opening, (3) mild to moderate muscle
pain, and (4) mild to moderate temporomandibular joint arthralgia.
32
The results indicated that the control group demonstrated a high level of thermal symmetry
over the temporomandibular joint region. The patient group demonstrated a low level of
thermal symmetry with a T value of 0.4°C. The control group was selected from the patient
group with 85% sensitivity (17 of 20), and 92% specificity (22 of 24), and 89% overall
accuracy (39 of 44), when selecting among the 44 subjects used in this study. The
conclusion therefore is that electronic thermography shows promise as a method of
diagnosing mild to moderate temporomandibular joint disorders.
Lamey P.-J. Thermography as a method of measuring viral activity in a herpes labialis
infection. - United States Patent 5666962. - Filing date: Apr 13, 1995. Issue date: Sep 16,
1997.
Disclosed is a non-invasive method of measuring the progress of viral activity in a
mammalian herpes labialis episode, the method comprising the step of measuring the
temperature of the symptomatic area of the herpes labialis episode during the episode.
Also disclosed is a non-invasive method of preventing the clinical effects of a herpes
labialis episode, the method comprising the steps of: measuring the temperature of the
symptomatic area during the herpes labialis episode; and treating the herpes labialis
episode with an effective amount of an antiviral agent sufficient to prevent a herpetic
lesion. Further disclosed is a non-invasive method of confirming the efficacy of an antiviral
agent in the treatment of a herpes labialis episode, the method comprising the steps of:
standardizing a subject having a herpes labialis episode; measuring the temperature of the
symptomatic area during the herpes labialis episode; treating the herpes labialis episode
with an effective amount of an antiviral agent sufficient to prevent a herpetic lesion; and
remeasuring the temperature of the previously symptomatic area of the subject after
treatment with the antiviral agent. Still further described is a kit for preventing the
progression of a herpes labialis episode to a herpetic lesion, the kit comprising: a
thermographic sensing device; and an antiviral medication. The kit comprises a
thermographic sensing devise and an antiviral medication.
Mikulska D, Maleszka R, Parafiniuk M. THE USEFULNESS OF THERMOGRAPHY AS A
DIAGNOSTIC METHOD IN DERMATOLOGY ON THE BASIS OF CLINICAL TRIALS IN
2001-2005. Ann Acad Med Stetin. 2006;52(3):91-97.
INTRODUCTION: Thermal imaging is a powerful tool for the study of temperature of the
human body. Even though the skin lies superficially and as such is an ideal object for
thermography, the method has not gained widespread acceptance as a diagnostic
modality in dermatology. The aim of this study was to describe the methodology of
thermography for applications in dermatology and to develop a method for computer
processing ofthermograms. In addition, we searched for skin factors, which could be
responsible for false results in thermography and errors during interpretation of thermal
images.
MATERIAL AND METHODS: Clinical trials were performed in 2001-2005. We enrolled 230
patients, including 70 who were hospitalized at the Department of Dermatology and
Venereal Diseases, Pomeranian Medical University in Szczecin, and 160 who were
referred from the Outpatient Dermatology Clinic. The control group consisted of 20 healthy
volunteers. The skin was examined to disclose primary and secondary skin lesions.
Thermography was performed according to recommendations of the European Association
of Thermology. Therma CAM SC500 infrared camera was used and the thermograms
were analyzed with Therma CAM 200 Professional software.
RESULTS: 1. Areas of the skin with inflammatory reactions resulting from allergy, infection
or other process causing local hyperthermia could be visualized. 2. Primary eruptions
(papules, nodules) and secondary eruptions (scales) presenting as hypothermia in
thermography were found in the skin of the patients and some individuals from the control
33
group. 3. Interpretation of thermograms in dermatoses can be done using various colour
scales, like "rain", "iron", "medical", "grey", "greyred" and the threedimensional scale.
CONCLUSIONS:
1. Thermography is a useful diagnostic method in dermatology.
2. The normal thermogram, as well as thermograms specific for various dermatoses need
to be described.
3. Compliance is indispensable with rules and principles concerning the examination itself,
as well as analysis and clinical interpretation of the results.
4. The person performing the examination and interpreting the thermograms should take
part in history-taking and physical examination of the patient and should be familiar with
photographic documentation of the examined regions of the skin.
Nakagami G, Sanada H, Iizaka S, et al.Predicting delayed pressure ulcer healing using
thermography: a prospective cohort study.// J Wound Care. 2010 Nov;19(11):465-6, 468,
470 passim.
Nakagami et al. (2010) investigated whether thermography can be used to detect latent
inflammation in pressure ulcers and predict pressure ulcer prognosis in a clinical setting.
Thirtyfive patients with stage II-IV pressure ulcers on the torso, who underwent
thermographic assessment on discovery of their pressure ulcer were included in the study.
The patients were followed up for at least 3 weeks. Thermography was performed
immediately after dressing removal. Pressure ulcers were classified into two groups
depending on whether or not the wound site temperature was lower or higher than the
periwound skin: the low temperature group and the high temperature group respectively.
The relative risk for delayed healing in high temperature cases was 2.25. Sensitivity was
0.56, specificity was 0.82, positive predictive value was 0.75, and negative predictive
value was 0.67. The investigators concluded that the results indicate that using
thermography to classify pressure ulcers according to temperature could be a useful
predictor of healing at 3 weeks, even though wound appearances may not differ at the
point of thermographical assessment. The higher temperature in the wound site, when
compared with periwound skin, may imply the presence of critical colonization, or other
factors which disturb the wound healing.
Chapter XIII Diseases of the musculoskeletal system and connective tissue
Diseases of joints (arthritis, osteoarthritis, etc.) are widely spread amongst people
all over the world. Osteoarthritis (osteoarthrosis) is the most common disease of joints that
develops with age. 10% of all adults have this disease and more than half of people after
60 are diagnosed with it, which is a problem of health care systems around the world.
Osteoarthritis is a degenerative disease of joints; it can be primary and secondary.
Secondary osteoarthritis develops after trauma, infection arthritis, gout, and pseudo-gout,
osteochondropathy, and epiphyseal separation of whirlbone (Murtagh J. General Practice,
5th Edition.-John Murtagh & Jill Rosenblatt McGraw Hill: 2010. – 1430 pp.).
Disability of elderly is caused by diseases of joints in 25% of all the cases. Arthritis
is the leading cause of physical disability in the United States. Arthritis comprises over 100
different disease and conditions. The most common types are osteoarthritis, rheumatoid
arthritis, fibromyalgia, and gout. Arthritis is estimated to cost $51 billion in medical costs
and $86 billion in total costs. Arthritis limits everyday activities for 8 million Americans.
According to CDC’s Behavioral Risk Factor Surveillance System, which provides the main
source of state arthritis data, 49 million American adults reported doctor-diagnosed arthritis
and another 21 million reported chronic joint symptoms (CJS) in 2001. The number of
people age 65 and older who have arthritis or chronic joint symptoms is projected to nearly
double from 21.4 million in 2001 to 41.4 million in 2030 as the population ages. Adults 65
34
years of age or older have the highest risk of arthritis (58.8 percent), but two-thirds of all
people
with
arthritis
are
younger
than
age
65
(http://www.newsmedical.net/news/2004/05/15/1586.aspx).
Knee joints suffer the most, especially if there is a problem of excessive body
weight. Prevalence of knee joint’s osteoarthritis in Western Europe is 18-25% for men and
24-40% for women at the age of 60 to 79 years (van Saase JL, van Romunde LK, Cats A,
Vandenbroucke JP, Valkenburg HA. Epidemiology of osteoarthritis: Zoetermeer survey).
100 million people with osteoarthritis live in European Union. Direct costs associated with
this disease have reached 1.64 billion Euro in France in 2001 (Le Pen C, Reygrobellet C,
Gerentes I. Financial cost of osteoarthritis in France. The "COART" France Study. Joint
Bone Spine 2005;72:567—70.).
Even though arthritis is not as widely spread in Africa and Asia as in Europe, the
number of people with this disease is growing on these continents (Akhter E, Bilal S,
Haque U. Prevalence of arthritis in India and Pakistan: a review. –
http://www.ncbi.nlm.nih.gov/pubmed/21331574).
Because of such prevalence of arthritis, World Health Organization has announced
the period from 2000 to 2010 as “Decade for fighting bone and joint diseases). However,
the number of people with such diseases has not decreased yet.
Woolf A.D., Pfleger B. Burden of major musculoskeletal conditions // Bulletin of the World
Health Organization 2003, 81 (9). – Р. 646-656.
Musculoskeletal conditions are a major burden on individuals, health systems, and social
care systems, with indirect costs being predominant. This burden has been recognized by
the United Nations and WHO, by endorsing the Bone and Joint Decade 2000–2010. This
paper describes the burden of four major musculoskeletal conditions: osteoarthritis,
rheumatoid arthritis, osteoporosis, and low back pain. Osteoarthritis, which is
characterized by loss of joint cartilage that leads to pain and loss of function primarily in
the knees and hips, affects 9.6% of men and 18% of women aged >60 years. Increases in
life expectancy and ageing populations are expected to make osteoarthritis the fourth
leading cause of disability by the year 2020. Joint replacement surgery, where available,
provides effective relief. Rheumatoid arthritis is an inflammatory condition that usually
affects multiple joints. It affects 0.3–1.0% of the general population and is more prevalent
among women and in developed countries. Persistent inflammation leads to joint
destruction, but the disease can be controlled with drugs. The incidence may be on the
decline, but the increase in the number of older people in some regions makes it difficult to
estimate future prevalence. Osteoporosis, which is characterized by low bone mass and
microarchitectural deterioration, is a major risk factor for fractures of the hip, vertebrae,
and distal forearm. Hip fracture is the most detrimental fracture, being associated with 20%
mortality and 50% permanent loss in function. Low back pain is the most prevalent of
musculoskeletal conditions; it affects nearly everyone at some point in time and about 4–
33% of the population at any given point. Cultural factors greatly influence the prevalence
and prognosis of low back pain.
Joint diseases, as a rule, are chronic diseases that have phases of exacerbation
and remission. As a result, patients frequently have to go to the doctor, their capacity for
work and quality of life reduce. In these circumstances, is necessary to develop simple and
safe methods of monitoring and controlling the effectiveness of treatment, which could be
used not only doctors but also by patients at home. The use of these devices enables the
development of telemedicine services.
For example, in the USA, CDC currently funds 36 states to implement programs to
improve the quality of life of people that have arthritis. Arthritis programs in funded state
health departments are working with their state Arthritis Foundation partners to expand the
35
availability
of:
- Arthritis Self Help Course, a program to help people with arthritis better manage their
condition.
- People with Arthritis Can Exercise (PACE), a program that teaches people with arthritis
how to safely increase their level of physical activity. (http://www.newsmedical.net/news/2004/05/15/1586.aspx).
As non-invasive method of diagnostics, infra-red thermography is highly suitable for
diagnostics and monitoring of joint conditions. It is shown that thermography data reflects
the severity of the inflammatory process. (A.E. Denoble, N.Hall, C.F. Pieper and V.B.
Kraus. Patellar Skin Surface Temperature by Thermography Reflects Knee Osteoarthritis
Severity // Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders - 2010:3; рр.
69-75).
This method allows giving objective characteristic of such subjective symptom as
pain, including the diseases of knee joint. Median temperature difference between pain
localization and localizations without pain was 0.7°C and ranged from 0.1°C to 1.7°C.
In the receiver operating characteristic (ROC) analysis the sensitivity of this method
was 1.0 and specificity was 0.917. The evidence of a significant increase in skin
temperature on the painful sites opens up the possibility to localize and assess pain more
precisely in patients with joint prosthesis. We consider this novel, rapid, inexpensive and
non-invasive technology to posses the potential to become a useful and objective tool for
diagnosis of pain and inflammation and to generate digital data that can be stored and
analyzed in clinical practice (M Glehr et al. Thermal Imaging as a Noninvasive Diagnostic
Tool for Anterior Knee Pain Following Implantation of Artificial Knee Joints // International
Journal of Thermodynamics (IJoT). - Vol. 14 (No. 2), pp. 71-78, 2011).
The use of thermography for examination of the joints is particularly informative,
since fatty tissue does not prevent from obtaining the infra-red temperature. Joints
generally have less fatty tissue on them. Thermography can detect signs of inflammation
in the early stages of joint damage, when the temperature difference between healthy joint
and the involved joint is at the beginning of rising. The method is particularly valuable in
subclinical or latent form of joint damage, in cases of absence of cutaneous
manifestations. In case of chronic arthritis it is possible to control the temperature in the
projection of the joints, and timely start the treatment if the temperature rises.
Thermographic study reveals the increase of local temperature in the projection of the
affected joint, which usually occurs before other clinical manifestations and remains for a
long time. When diagnosing one-sided affection (for example, right knee joint), thermal
asymmetry of 0,6º C in comparison with the opposite area (left knee joint) has diagnostic
value. Re-examination of the local temperature can objectively assess the results of
treatment. With proper treatment temperature in the inflamed joint should be reduced.
Thermography has been used worldwide for diagnosing, monitoring and evaluating of the
effectiveness of treatment for diseases of joints.
From early times physicians have used the cardinal signs of inflammation, i.e. pain,
swelling, heat, redness and loss of function. When a joint is acutely inflamed, the increase
in heat can be readily detected by touch. However, subtle changes in joint surface
temperature occur, and increase and decrease in temperature can have a direct
expression of reduction or exacerbation of inflammation. This means that changes
due to treatment, whether pharmaceutical, physical or surgical, can be objectively
measured [Ring E F J., Ammer K. Infrared thermal imaging in medicine // Physiol. Meas.
33 (2012) R33–R46].
Recently, a pilot study from the United States found a high coincidence between
high temperature and swelling of finger joints detected by three-dimensional images. The
authors created a heat distribution index which had a diagnostic of specificity 67% and
a sensitivity of 100% for arthritic swelling (Spalding S J, Kwoh C K, Boudreau R,
36
Enama J, Lunich J, Huber D, Denes L and Hirsch R 2008 Three-dimensional and thermal
surface imaging produces reliable measures of joint shape and temperature: a potential
tool for quantifying arthritis // Arthritis Res. Ther. 10 R10).
Lahiri B.B., Bagavathiappan S., Jayakumar T., Philip J. Medical applications of infrared
thermography: A review // Infrared Physics & Technology 55 (2012) 221–235.
IRT has been successfully used in the diagnosis and assessment of recovery after
treatment in gout [M. Schiavenato, R.G. Thiele, Thermography detects subclinical
inflammation in chronic tophaceous gout, Journal of Rheumatology 39 (2012) 182–183.]
and arthritis [N.J. McHugh, D.M. Elvins, E.F.J. Ring, Elevated Anticardiolipin Antib Odies in
a patient with vibration white-finger, valvular heart disease and psoriatic arthritis, Clinical
Rheumatology 12 (1993) 70–73., E.F.J. Ring, A.J. Collins, P.A. Bacon, J.A. Cosh,
Quantitation of thermography in arthritis using multi-isothermal analysis II. Effect of
nonsteroidal anti-inflammatory therapy on the thermographic index, Annals of the
Rheumatic Diseases 33 (1974) 353–356]. Arnold et al. reported that, IRT is an excellent
technique for measurement of skin temperature over different joints [M.H. Arnold, S.J.L.
Preston, E.M. Beller, W.W. Buchanan, Infra-red surface thermography. Evaluation of a
new radiometry instrument for measuring skin temperature over joints, Clinical
Rheumatology 8 (1989) 225–230]. Ring demonstrated that, the subjects suffering from
rheumatoid arthritis, juvenile arthritis, osteoarthrosis, gout, etc. show abnormal
temperature distributions over joints [E. Ring, Thermography and rheumatic diseases,
Bibliotheca Radiologica 6 (1975) 97–106.]. Collins et al. developed a thermographic index
based methodology for quantification of joint inflammation in human subjects [A. Collins, E.
Ring, J. Cosh, P. Bacon, Quantitation of thermography in arthritis using multi-isothermal
analysis. I. The thermographic index, Annals of the Rheumatic Diseases 33 (1974) 113–
115.]. Ring et al. have demonstrated the use of IRT to quantify the effects of non-steroidal
anti-inflammatory drugs (aspirin, indomethacin and benorylate) in subjects with rheumatoid
arthritis and gout [E.F.J. Ring, A.J. Collins, P.A. Bacon, J.A. Cosh, Quantitation of
thermography in arthritis using multi-isothermal analysis II. Effect of nonsteroidal antiinflammatory therapy on the thermographic index, Annals of the Rheumatic Diseases 33
(1974) 353–356]. Based on their studies it has been concluded that, IRT is a suitable tool
for assessment of the response to the anti-inflammatory treatment. Paterson et al. used
IRT for assessment of rheumatoid inflammation in the knee joint, while using antiinflammatory steroid therapy [J. Paterson, W.S. Watson, E. Teasdale, A.L. Evans, P.
Newman, W.B. James, D.A. Pitkeathly, Assessment of rheumatoid inflammation in the
knee joint, Annals of the Rheumatic Diseases 37 (1978) 48–52.]. Frize et al. used IRT for
diagnosis of rheumatoid arthritis in human subjects and found that, metacarpal phalangeal
joints of the index, middle fingers and knee are the most suitable locations for IRT based
studies [M. Frize, C. Adea, P. Payeur, G.D. Primio, J. Karsh, A. Ogungbemile, Detection of
rheumatoid arthritis using infrared imaging, in: Proc. of SPIE, 7962 (2011) 9620M-9621–
79620M-79611.]. Wu et al. reported that, local skin temperature near the coccyx region
decreases significantly after conservative therapy in subjects suffering from coccygodynia
[C.L. Wu, K.L. Yu, H.Y. Chuang, M.H. Huang, T.W. Chen, C.H. Chen, The application of
infrared thermography in the assessment of patients with coccygodynia before and after
manual therapy combined with diathermy, Journal of Manipulative and Physiological
Therapeutics 32 (2009) 287–293.]. Their studies concluded that IRT is as an effective tool
for assessment of pain intensity after treatment of coccygodynia. Thermographic results
were compared with other clinical findings and this study confirmed that, the decreased
range of motion and hypothermic temperature patterns are correlated. Thomas et al.
investigated unilateral and bilateral cases of tennis elbow using IRT and observed that in
94% unilateral and 100% bilateral cases, hot spots could be detected [D. Thomas, G.
37
Siahamis, M. Marion, C. Boyle, Computerised infrared thermography and isotopic bone
scanning in tennis elbow, Annals of the Rheumatic Diseases 51 (1992) 103–107].
With the advent of newer generation infrared detectors, infrared thermal imaging is
becoming a more accurate alternate medical diagnostic tool for abnormal temperature
pattern measurements. Besides, better temperature sensitivity, spatial resolution and
noncontact nature, IRT is an absolutely harmless imaging methodology. Thermal images
can be stored digitally and post-processed using various software packages to obtain
insight into the thermal pattern. Interpretation of pseudo-color coded thermograms is
comparatively easier and faster.
Bacon P.A., Ring E.F.J., Collins A.J. Thermography in the assessment of anti rheumatic
agents Rheumatoid Arthritis ed. J L Gordon and B L Hazleman 1977 (Amsterdam:
Elsevier/North Holland Biomedical Press) 105.
This study found that small joints such as fingers and metacarpal joints increased in
temperature quite rapidly while paracetamol (analgesic) treatment was given, even if pain
was still suppressed. Larger joints, such as knees and ankles required more than 1 week
off active anti-inflammatory treatment to register the same effect. Nevertheless, the
commonly accepted protocol was to switch from analgesic to the new test antiinflammatory treatment after 1 week of washout therapy. In every case if the dose was
ineffective the joint temperature was not reduced. At an effective dose, a fall in
temperature was observed, first in the small joints, then later in the larger joints. Statistical
studies were able to show an objective decrease in joint temperature by infrared imaging
as a result of a new and successful treatment.
BOROJEVIC N., KOLARIC D., GRAZIO S., GRUBIC F., ANTONINI S., NOLA I.A.,
HERCEG E. Thermography hand temperature distribution in rheumatoid arthritis and
osteoarthritis // PERIODICUM BIOLOGORUM UDC 57:61 VOL. 113, No 4, 445–448,
2011.
Background and Purpose: Earliest written medical text from ancient Egypt mentioned
temperature as an indicator of a disease. Although already known, thermal imaging has
not been routinely used in medicine. Inflammation of peripheral joints, close to skin
surface, is the dominant type of presentation of rheumatoid arthritis and due to that, those
joints are suitable for infrared thermal scanning. Considering the changes of the bones in
the affected joints, as a control group, apart from healthy subjects, study was conducted
on patients with osteoarthritis as well. Purpose of this paper was to investigate thermal
images of the hands of patients with rheumatoid arthritis and osteoarthritis and analyze
temperature distribution.
Materials and Methods: Thermographic images of both hands of healthy subjects, patients
with rheumatoid arthritis and patients with osteoarthritis were made. On thermal images
obtained, temperature distribution of certain regionswas analyzed. Basic statistical
analyses (minimum, maximum, standard deviation, mean, and variance) were performed.
Results: There is a statistically significant difference in finger andmetacarpophalangeal
joint mean temperature values on ventral and dorsal sides for both healthy patients and
patients with rheumatoid arthritis and osteoarthritis. Mean surface skin temperature has
also shown a statistically significant difference between the observed groups so that it was
the highest in patients with rheumatoid arthritis, lower in patients with osteoarthritis and
lowest among the healthy subjects (Fig. 8). Also, there is a statistically significant
difference of mean temperature values between the aforementioned patient groups.
Temperature distribution curves of patients with osteoarthritis have been narrower than
those of subjects with rheumatoid arthritis and normal subjects. Temperature distribution
curves of patients with rheumatoid arthritis have been shifted towards higher temperatures
than those of subjects with osteoartritis and normal subjects.
38
Thermographic image of the dorsal side of the
right hand of a healthy subject with marked
areas for mean surface temperature
measurements of the fingers I–V (labels 1–5)
and metacarpophalangeal region (label 6).
Thermographic image of the dorsal side of the
right hand of a subject suffering from
osteoarthritis with marked areas for mean
surface temperature measurements of the
fingers I–V (labels 1–5) and
metacarpophalangeal region (label 6).
Fig. 8.
Conclusion: From the results obtained it was concluded that heat distribution over the skin
surface apart from depending on the affected joint and on the intensity of the disease and
given drug therapy also differs between the patients with rheumatoid arthritis and
osteoarthritis, making the use of thermography a possible method of differentiating normal
subjects and rheumatoid arthritis subjects and osteoarthritis subjects from each other.
Brenner M, Braun C, Oster M, Gulko PS. THERMAL SIGNATURE ANALYSIS AS A
NOVEL METHOD FOR EVALUATING INFLAMMATORY ARTHRITIS ACTIVITY // Ann
Rheum Dis. 2006 Mar;65(3):306-11.
OBJECTIVE: To examine the potential usefulness of a novel thermal imaging technique to
evaluate and monitor inflammatory arthritis activity in small joints using rat models, and to
determine whether thermal changes can be used to detect preclinical stages of synovitis.
METHODS: Three different rat strains were studied in a model of inflammatory arthritis of
the ankle induced by an intra-articular (IA) injection of complete Freund's adjuvant (CFA),
compared with the contralateral ankle injected with normal saline. Arthritis activity and
severity scores, ankle diameters, pain related posture scores, and thermal images were
obtained at 10 different times between 0 h (before induction) and day 7. The pristane
induced arthritis (PIA) model was used to study preclinical synovitis. Thermal images were
obtained at each time point using the TSA ImagIR system and were digitally analysed.
RESULTS: Rats developed similar ankle arthritis detected six hours after the IA injection of
CFA, which persisted for seven days. All ankle clinical indices, including arthritis activity
and severity scores, correlated significantly with ankle thermal imaging changes in the
monoarthritis model (p<0.003). No thermal imaging changes were detected in preclinical
stages of PIA. However, PIA onset coincided with increased ankle thermal signature.
CONCLUSIONS: Thermal measurements correlated significantly with arthritis activity and
severity indices. The technique was highly sensitive and could measure directly two
cardinal signs of inflammation (warmth and oedema, based on ankle diameter) in an area
(ankle) that is less than half the size of an h umaninterphalangeal joint, suggesting a
potential use in drug trials or clinical practice.
39
Brioschi, M.L., Yeng, L.T., Pastor, E.M.H., Teixeira, M.J. Infrared imaging use in
rheumatology // Revista Brasileira de Reumatologia. - Volume 47, Issue 1, 2007, Pages
42-51.
Infrared thermography is unique objective imaging procedure for the quantitative
assessment of local inflammatory reactions in parts of the locomotor system. For
differential diagnosis the thermographic results should be evaluated in conjuction with
clinical examination and other technical procedures. As a means of monitoring the
course of the local inflammatory activity, however, quantitative infrared
thermography is a useful tool in itself, particularly during the application of local
and systemic anti-inflammatory therapy.
COLLINS A. J., RING E. F. J., COSH J. A., BACON P. A. Quantitation of thermography in
arthritis using multi-isothermal analysis (1. The thermographic index) // Ann. rheum. Dis.
(1974), 33, 113-115.
Thermography can be used for the assessment of joint involvement in inflammatory
arthritis. The effect of anti-inflammatory compounds on joint inflammation in animals has
been quantitated using radiometry (Collins and Ring, 1972). Thermography provides more
information about the distribution of temperature. We wish to report a method for the
quantitative measurement of joint inflammation in man, using thermography.
PATIENTS: Patients with classical or definite rheumatoid arthritis, with current acute
inflammation in one knee joint, were studied. Eight patients were studied before and after
a single intra-articular injection of 100 mg. methyl prednisolone triacetate (Ultracortenol,
Ciba). Four patients were followed by serial thermograms on four to eight occasions, for up
to 20 days. Four other patients were thermogrammed at 7 days only. Data on the
thermographic patterns of normal knees were obtained from 32 healthy male and female
volunteers in the age range 20 to 56 years.
Results: It can be appreciated from the analysis, that the inflamed knee shows a wide
range of temperature zones, which contracts markedly after treatment. Also, the peak
temperature of 32.5°C before treatment, which only occupies a small area, falls to
30.0°C after treatment. The thermographic index, which reflects both the range and the
peak of temperature, falls with treatment. Initially, nine isotherms were present, but after
treatment these were reduced to five, with nearly 50 per cent. of the area at 28.5°C.
Discussion: This report has been confined to the demonstration of a method of
quantitation of anti-inflammatory activity. Local steroid injection was chosen as an
accepted potent anti-inflammatory against which to test the methodology. In our
experience, the effect of oral non-steroidal anti-inflammatory agents can also be
demonstrated with the thermographic index and this can be correlated with other clinical
measurements. This will be the subject of a separate communication.
Summary: A method for the quantitative measurement of joint inflammation in man is
described. Multi-isothermal scans of joints are obtained by thermography. By analysis of
the isothermal areas, a thermographic index is produced. This index is demonstrated by
following the course of intra-articular steroid therapy.
Frize Monique, Adéa Cynthia, Payeur Pierre, Di Primio Gina, Karsh Jacob, Ogungbemile
Abiola. Detection of rheumatoid arthritis using infrared imaging. - Medical Imaging 2011:
Image Processing, edited by Benoit M. Dawant, David R. Haynor, Proc. of SPIE Vol. 7962,
79620M
Rheumatoid arthritis (RA) is an inflammatory disease causing pain, swelling, stiffness, and
loss of function in joints; it is difficult to diagnose in early stages. An early diagnosis and
treatment can delay the onset of severe disability. Infrared (IR) imaging offers a potential
approach to detect changes in degree of inflammation. In 18 normal subjects and 13
patients diagnosed with Rheumatoid Arthritis (RA), thermal images were collected from
40
joints of hands, wrists, palms, and knees. Regions of interest (ROIs) were manually
selected from all subjects and all parts imaged. For each subject, values were calculated
from the temperature measurements: Mode/Max, Median/Max, Min/Max, Variance, MaxMin, (Mode-Mean)2, and Mean/Min. The data sets did not have a normal distribution,
therefore non parametric tests (Kruskal-Wallis and Ranksum) were applied to assess if the
data from the control group and the patient group were significantly different. Results
indicate that: (i) thermal images can be detected on patients with the disease; (ii) the best
joints to image are the metacarpophalangeal joints of the 2nd and 3rd fingers and the
knees; the difference between the two groups was significant at the 0.05 level; (iii) the best
calculations to differentiate between normal subjects and patients with RA are the
Mode/Max, Variance, and Max-Min. We concluded that it is possible to reliably detect RA
in patients using IR imaging. Future work will include a prospective study of normal
subjects and patients that will compare IR results with Magnetic Resonance (MR) analysis.
Denoble A., Hall N., Pieper C.F., Kraus V.B. Patellar Skin Surface Temperature by
Thermography Reflects Knee Osteoarthritis Severity // Clinical Medicine Insights:
Arthritis and Musculoskeletal Disorders - 2010:3; рр. 69-75.
Digital infrared thermal imaging is a means of measuring the heat radiated from the skin
surface. Our goal was to develop and assess the reproducibility of serial infrared
measurements of the knee and to assess the association of knee temperature by region of
interest with radiographic severity of knee Osteoarthritis (rOA).
A total of 30 women (15 Cases with symptomatic knee OA and 15 age-matched Controls
without knee pain or knee OA) participated in this study. Infrared imaging was performed
with a Meditherm Med2000™ Pro infrared camera. The reproducibility of infrared imaging
of the knee was evaluated through determination of intraclass correlation coefficients
(ICCs) for temperature measurements from two images performed 6 months apart in
Controls whose knee status was not expected to change. The average cutaneous
temperature for each of five knee regions of interest was extracted using WinTes software.
Knee x-rays were scored for severity of rOA based on the global Kellgren-Lawrence
grading scale. The knee infrared thermal imaging procedure used here demonstrated longterm reproducibility with high ICCs (0.50–0.72 for the various regions of interest) in
Controls. Cutaneous temperature of the patella (knee cap) yielded a significant correlation
with severity of knee rOA (R = 0.594, P = 0.02). The skin temperature of the patellar region
correlated with x-ray severity of knee OA. This method of infrared knee imaging is reliable
and as an objective measure of a sign of inflammation, temperature, indicates an
interrelationship of inflammation and structural knee rOA damage.
DEVEREAUX M. D., PARR G. R., LACHMANN S. M., PAGE THOMAS D. P., HAZLEMAN
B. L. THERMOGRAPHIC DIAGNOSIS IN ATHLETES WITH PATELLOFEMORAL
ARTHRALGIA // THE JOURNAL OF BONE AND JOINT SURGERY – No. I, JANUARY
1986.
Pain in front of the knee is common in athletes and is often called patellofemoral arthralgia,
but it is difficult to prove that the pain arises in that joint. Thermograms of 30 athletes
clinically considered to have patellofemoral arthralgia were compared with those of a
similar number of unaffected athletes matched for age and sex. A comparison was also
made with thermograms of two older groups of 30 patients with knee involvement from
either rheumatoid arthritis or osteoarthritis. Twenty-eight of the athletes with patellofemoral
arthralgia had a diagnostic pattern on thermography.
The anterior knee view showed a rise in temperature on the medial side of the patella and
the medial knee view showed that this temperature rise radiated from the patellar insertion
of the vastus medialis into the muscle itself. The possible aetiological role ofquadriceps
muscle imbalance in athletes with patellofemoral arthralgia.
41
DEVEREAUX M.D., PARR G.R., PAGE THOMAS D.P., HAZLEMAN B.L. Disease activity
indexes in rheumatoid arthritis; a prospective, comparative study with thermography //
Annals of the Rheumatic Diseases, 1985, 44, 434-437.
There are many difficulties associated with the assessment of disease activity in
rheumatoid arthritis. Infrared thermography has been used to quantify joint inflammation.
The heat distribution index (HDI) is reproducible, sensitive, quantifiable, and not subject to
circadian variation or interobserver error. In this study the HDIs for both elbows, wrists,
knees, and ankles were summated and compared with other parameters of disease
activity. There were 167 sets of observations in 20 patients with classical, seropositive,
rheumatoid arthritis followed up over 12 months. There was a significant correlation
(p<0.001) for thermography with the Ritchie articular index, Mallya score, grip strength,
morning stiffness, erythrocyte sedimentation rate, and pain score. Significant correlations
(p<0.05) for thermography with these parameters were found in individual patients. The
summated HDI is a suitable, objective method for the assessment of response to therapy
in patients with rheumatoid arthritis.
Thermographic assessment is objective, reproducible, accurate, and non-invasive.
Thermography is non-stressful for the patient and appears to improve compliance during
drug studies. The thermographic method is extremely suitable for the assessment of
response to therapy in patients with rheumatoid arthritis.
Edwards A.; Selvanayagam J.N.; Beach J.; Homik J.; Francisca dos Santos M.; Yacyshyn
E. ASSESSMENT OF PATIENTS WITH INFLAMMATORY ARTHRITIS USING
THERMOGRAPHY
//
http://rheum.ca/images/documents/Elaine_Yacyshyn_%282010_Grant_Competition%29.p
df
OBJECTIVE: Thermography is a novel and potentially useful tool for evaluating patients
with inflammatory arthritis. As tender and swollen joint counts are liable to inter-observer
variation, thermography may assist in the detection of active disease. Our objective was to
determine the reliability of thermography measurements of patients with inflammatory
arthritis and compare to clinical examination.
METHODS:
EQUIPMENT
- Thermography camera “FLIR T300 Shortwave Thermovision System” (Figure 1)
- Subjects rested for 15 minute acclimation period
- Camera was maintained at fixed distance (0.5m)
- Subjects used a resting hand splint (Figure 2)
PARTICIPANTS
- Control patients: healthy volunteers from University of Alberta
- With no history of inflammatory or symptomatic joint disease
- Inflammatory arthritis patients: recruited from Rheumatology outpatient clinic at University
of Alberta
- Patients taking vascular medications or with co-existing vascular disease excluded.
RESULTS: In total, 2038 joints were analyzed in 29 control patients and 49 patients with
inflammatory arthritis. Inflammatory arthritis patients have a mean temperature 1.58ºC
warmer than controls of both area and spot temperatures (p ≤ 0.0001). During the patient
assessments, overtly swollen joints did not show an increased temperature. Tender joints,
however were colder on average, by 0.3ºC (p≤0.008). A secondary measure was to
determine validity of thermography by correlating findings to other outcome measures.
- For each unit increase (by 1 unit) of the DAS 28, the temperature reduced by 0.47ºC
- For each unit increase (by 1 unit) of the clinHAQ, the temperature reduced by 0.67ºC.
42
CONCLUSIONS: This study established the ability to assess surface temperatures of MCP
and PIP joints in control and inflammatory arthritis patients. It produced reliable,
quantifiable measures of joint temperature to assist in the assessment of disease activity
in arthritis. Further study would include prospective analysis of individual patients, as the
thermography camera may be useful in longitudinal patient assessment.
Edrich J, Smyth CJ. Arthritis inflammation monitored by subcutaneous millimeter wave
thermography // J Rheumatol. – 1978 Spring; 5(1):59-67.
A new technique for remote, noninvasive mapping of temperature elevations of the human
joints is described; it uses the mm wave radiation emitted by the human body. A solid state
switched scanner for 68 GHz is described which overcomes the depth limitations of
conventional, infrared thermographs and can measure to subcutaneous depths of several
mm with a temperature resolution of 0.25 degrees C. Measurements on rheumatoid
arthritic knee joints are presented which show little correlation with simultaneously
measured skin temperatures. Significant longterm thermographic changes induced by
steroid injection indicate a potential for objective patient monitoring and development of
new treatment methods.
Engel JM. Quantitative thermography of the knee joint // Z Rheumatol. 1978 JulAug;37(7-8):242-53.
Computer-assisted evaluation of thermography of the knee joints allows diagnosis and
quantitation of inflammatory processes. This needs an adequate thermography camera,
registration standards and a thermographic index. With the aid of this index normal knee
joints and those with inflammatory changes can clearly be differentiated: an index of less
than 3.5 is normal, values above 5.0 indicate an inflammation. The author proposes to
correct the thermographic index with reference to actual rectal temperature in order to
improve inter- and intra-individual comparability of thermograms. Apart from the
thermographic index, the formal analysis of the line-scan over the joint space and the
maximal temperature of the joint can be used as further diagnostic criteria.
Gratt BM, Sickles EA, Ross JB, Wexler CE, Gornbein JA. Thermographic assessment
of craniomandibular disorders: diagnostic interpretation versus temperature measurement
analysis.- J Orofac Pain. 1994 Summer;8(3):278-88.
This study assessed electronic thermography as a diagnostic alternative for evaluation of
temporomandibular disorders. The study populations consisted of 50 temporomandibular
joint patients having internal derangement or osteoarthrosis and 30 normal
temporomandibular joint subjects. An Agema 870 thermovision unit was used for analysis.
Diagnostic evaluations by expert interpreters were made using standard procedures.
Thermography measurements included mean absolute temperature measurements and
right-left temperature differences for five anatomic zones and four spot areas. Statistical
analysis of data included both linear discriminant analysis and classification-tree analysis.
Results indicated that when differentiating between "abnormal" and "normal"
temporomandibular joints using classification-tree analysis, correct classifications were
made in 89% of the cases and observer diagnostic accuracy was 84%. When evaluating
for specific diagnoses (eg, osteoarthrosis, internal derangement, or normal
temporomandibular joint), correct classifications using classification-tree analysis were
made in 73% of the cases and observer evaluation was correct in 59%. The three best
temperature measures found were: (1) delta T of the zone immediately overlying the
temporomandibular joint; (2) the zone temperature of the half-face; and (3) the spot
43
temperature anterior to the external auditory meatus. Additional studies are needed before
thermographic diagnosis of craniomandibular disorders is accepted clinically.
Hegedűs B., Viharos L., Gervain M., Gálfi M. The Effect of Low-Level Laser in Knee
Osteoarthritis: A Double-Blind, Randomized, Placebo-Controlled Trial // Photomedicine
and Laser Surgery. - August 2009, 27(4): 577-584.
Low-level laser therapy (LLLT) is thought to have an analgesic effect as well as a
biomodulatory effect on microcirculation. This study was designed to examine the painrelieving effect of LLLT and possible microcirculatory changes measured by thermography
in patients with knee osteoarthritis (KOA). Patients with mild or moderate KOA were
randomized to receive either LLLT or placebo LLLT. Treatments were delivered twice a
week over a period of 4 wk with a diode laser (wavelength 830 nm, continuous wave,
power 50 mW) in skin contact at a dose of 6 J/point. The placebo control group was treated
with an ineffective probe (power 0.5 mW) of the same appearance. Before examinations
and immediately, 2 wk, and 2 mo after completing the therapy, thermography was
performed (bilateral comparative thermograph by AGA infrared camera); joint flexion,
circumference, and pressure sensitivity were measured; and the visual analogue scale
was recorded. In the group treated with active LLLT, a significant improvement was found
in pain (before treatment [BT]: 5.75; 2 mo after treatment: 1.18); circumference (BT: 40.45;
AT: 39.86); pressure sensitivity (BT: 2.33; AT: 0.77); and flexion (BT: 105.83; AT: 122.94).
In the placebo group, changes in joint flexion and pain were not significant. Thermographic
measurements showed at least a 0.5°C increase in temperature—and thus an
improvement in circulation compared to the initial values. In the placebo group, these
changes did not occur. Our results show that LLLT reduces pain in KOA and improves
microcirculation in the irradiated area.
Kang TG, Kim HJ, Sim HS, Kim SM, Youn DK, Park YK, Chang JA, Cho KH, Hong MH,
Kim YC, Choi GH. Practicality of thermography in evaluation of osteoarthritis of knee joint.
http://www.koreamed.org/SearchBasic.php?QY=%22J+Korean+Acad+Fam+
Med%22+%5BJTI%5D&DisplaySearchResult=1.
About 80 percent of the Korean population over 55 years old show radiographic signs of
osteoarthritis. Hence, osteoarthritis has become one of the most important public health
problem among the old age. Despite the importance of this disease, proper methods for
evaluation and diagnosis of osteoarthritis have not been developed. Authors have
investigated the sensitivity and specificity of thermography in diagnosing osteoarthritis.
KAVANAGH H.S., DUBRAVIС A., LIPIС T., SOVIС I., GRAZIO S. Computer supported
thermography monitoring of hand strength evaluation by electronic dynamometer in
rheumatoid arthritis – a pilot study // PERIODICUM BIOLOGORUM VOL. 113, No 4, 433–
437, 2011.
This paper describes the implementation of a new dynamometer system with
thermography monitoring of heat dissipation, and the implications of this new system in
physiatry, rheumatology and neurology. The system includes a single data processing
algorithm and the concept of motor hand function evaluation involving the determination of
quantitative indicators.
In rehabilitation medicine, muscle function is assessed during the physical examination of
a patient. Although a simple computer- supported approved dynamometer instrument
improves the assessment of static strength, it is rarely used in clinical practice where
dynamic measurements are preferred.
A computer-assisted electronic dynamometer has been developed to enable a clinician to
measure dynamic muscle function in standardized manner. Dynamometer comprises a
44
force transducer and a movement transducer interfaced to a personal computer. In the
study, dynamic measurement protocols were used that are based on biomechanical
analysis.
During the execution of test exercise used the method of thermographic recording of heat
dissipation using dedicated software for analysis of characteristic parameters. The results
obtained showed the possibility of objectification biomechanical properties and heat
dissipative characteristics of the hand. The results of data analysis from calculated
characteristic parameters show the correlationwith patients’ clinical status, i.e. the motor
status of the hand and efficiency of temperature monitoring (standard deviation 0.92.).
From the results of this pilot-study it can be concluded that computer supported
dynamometer might be suitable for use in diagnostics in physical and rehabilitation
medicine, possibily in conjuction with thermography. Further studies on larger numbers of
participants are needed to evaluate these preliminary results.
Kawano W1, Kawazoe T, Tanaka M, Hikida Y. Deep thermometry of temporomandibular
joint and masticatory muscle regions. - J Prosthet Dent. 1993 Feb;69(2):216-21.
A study was designed to measure noninvasively the deep temperature of the
temporomandibular joint (TMJ) region and corresponding regions of the masticatory
muscles at rest. With a transcutaneous probe, the deep thermometry of the right and left
anterior (Ta) and the posterior portion (Tp) of the temporal muscles, the mid-portion of the
superficial belly of the masseter muscles (Mm), and the TMJ regions were measured. In
20 normal male subjects, the deep temperature of the Ta region (mean 36.342 degrees
C), the Tp region (mean 36.345 degrees C), and the TMJ region (mean 36.06 degrees C)
was higher than that of the Mm region (mean 35.897 degrees C) at rest. In addition, no
differences in the deep temperature were observed between the right and left Ta, Tp, Mm,
and TMJ regions at rest. All of the normal subjects showed differences between the right
and left TMJ region of less than 0.3 degrees C. In 10 patients with craniomandibular
disorders, however, eight patients showed differences of more than 0.3 degrees C
between the asymptomatic and asymptomatic TMJ region. Because of high sensitivity and
specificity, the deep thermometry measurements can provide useful non-invasive
information.
MANGINE R.E., SIQUELAND K.A., NOYES F.R. The Use of Thermography for the
Diagnosis and Management of Patellar Tendinitis // THE JOURNAL OF ORTHOPAEDIC
AND SPORTS PHYSICAL THERAPY. - October 1987, Vol. 9, No. 4. – P. 132-140.
Computerized thermography was used to evaluate 17 patients diagnosed with patellar
tendinitis. The intent of this study was to determine if a specific patellar tendinitis thermal
pattern could be distinguished using infrared thermography. A specific thermal abnormality
was found over the patellar tendon in 14 subjects (78%). Twelve subjects showed focal
"hot" spots, while two showed focal "cold" spots. The thermal abnormalities appeared as
specific focal areas directly overlaying the patellar tendon, without disruption to the thermal
pattern of the remaining peripatellar regions. The thermal gradient slope over the patellar
tendon was greater in symptomatic knees. Five subjects returned 2-4 weeks later for
follow-up thermographic examination. Among the follow-up subject group, changes in
thermal asymmetry correlated with changes in symptoms 80% of the time. Computerized
thermography appears useful as a noninvasive, objective method of detecting
inflammation of the soft tissues about the patellar tendon, and also helps to differentiate
this disorder from other knee pathologies.
Oblinger W, Engel JM, Franke M. Thermographic diagnosis of arthritis in peripheral joints
// Z Rheumatol. - 1985 Mar-Apr;44(2):77-81.
45
The measurement of absolute temperatures on the surface of the human body using
quantitative thermography allows this technique to be used in rheumatology, for the
diagnosis and monitoring the course of inflammatory diseases of the locomotor system.
The patient is exposed to a room temperature of 18 degrees C and the skin temperature
measured over the joint for a defined area (region of interest). Inflamed joints show
distinctly higher absolute temperatures than normal ones within the observation time of 40
minutes. Moreover, the skin over healthy joints cools faster and to a greater extent than
skin over inflamed joints, whose temperatures remain the same or even rise minimally in
more acute cases. Using two measurements, the determination of the absolute
temperatures (static thermography), and the changes in these temperatures within a
definite time interval (dynamic thermography) it is thus possible to establish a diagnosis of
arthritis in the regions of the peripheral joints with the help of standardised nomograms
with an accuracy of more than 90%, and to follow the course of the disease more exactly.
Puzder A., Gworys K. Trial of thermal imaging in the evaluation of low level laser therapy
effectiveness in patients with knee joint pain syndrome // Medicina Sportiva. - N3. –
2010.
Aim of the study: The article presents trial of using thermal imagines parameters in
monitoring gonarthrosis and low level laser therapy to alleviate the pain symptoms.
Material and methods: The double-blind research involved 69 patients among whom 53
with confirmed gonarthrosis were treated. Group A n=24 knee joints, contact laser
irradiations were applied with a semiconductor laser (400mW, wave length 810nm). Total
surface energy density on therapeutic point consisted of fractionated doses of energy
(9.5J/cm2 +4.8J/cm2) with 30 min. interval between the 6J dose and 3J dose application.
One series of 10 procedures was performed, five times per week. Group B (n=84 knee
joints) with placebo therapy was accomplished. Group C (n=32 knee joints) had no pain
syndrome and any treatment, only thermal images were conducted. The intensity of the
pain in group A and B were evaluated on the Visual Analogue Scale and a modified
version of the Laitinen questionnaire. Thermal imaging parameters Knee-Leg Temperature
Index (TI) were conducted in all patients.
Results: There was statistically significant reduction in pain by VAS and Laitinen
questionnaire after laser therapy. In group B there was no statistically significant changes
in pain disorders and TI index.
Conclusions: Pain reduction (VAS and Laitinen questionnaire) has been evaluated after
laser fractionated doses of energy in patients with knee osteoarthrosis. There were not
significant statistical changes in pain reduction and thermal imaging parameters in placebo
group. A tendency to temperature indicators stabilization was observed in the treatment
group. It is necessary to perform further investigations with the use of various radiation and
thermal imaging modes in a more numerous groups of patients.
Rusch D, Follmann M, Boss B, Neeck G. Dynamic thermography of the knee joints in
rheumatoid arthritis (RA) in the course of the first therapy of the patient with
methylprednisolone // Zeitschrift fur Rheumatologie (2000). – Volume: 59 Suppl 2,
Pages: II/131-135.
Thermography in rheumatology is most often used in a static manner: after having fulfilled
the conditions of standardized preparation of the patient in a cold examination room one or
more thermograms are taken in standard positions for the respective joints. In our hospital
the thermograms are more or less supplementary. The main examination result is a
rewarming curve of the skin over the knee joints. The rewarming is provoked by dry
cooling of the skin for one minute. Calculation of the slope of the rewarming curve and
plotting the slope on a logarithmic scale shows two different rewarming processes in the
skin overlying inflamed joints. The faster one is the rewarming by the arterial blood flow in
46
the skin and the slower one is an additional rewarming by a pathological venous skin blood
flow originating from deeper tissues under the skin. One has to suppose that the
occurrence of excessive nitric oxide production in inflamed tissues is responsible for this
pathological venous skin blood flow. Until now only nine patients receiving for the first time
methylprednisolone could be included in a therapy study. Therefore only slight indications
can be seen in the results. Whereas the erythrocyte sedimentation rate (ESR mm/h
becomes more homogeneous (lower confidence interval CI 95) over the course of the
treatment with decreasing drug dose, the thermal signs of inflammatory activity as
measured by dynamic thermography have greater CI 95 values at the end than at the
beginning of the treatment under study. This indicates that not all patients had sufficient
antiinflammatory medication with the final 6 mg/d of methylprednisolone as measured by
dynamic thermography but not by ESR or CRP.
RYOICHI K. Osteoarthritis of the knee and nearby disease. III. Image analysis. 3.
thermography. Disease state of the osteoarthritis of the knee from the viewpoint of the
thermography. // Orthopedic Surgery. - VOL.; NO.42; PAGE.90-96(2002).
We analyzed the thermographic finding of the leg mainly on the knee, and examined the
disease state of the osteoarthritis of the knee. In diseased side and non-diseased side of
osteoarthritis patient of 60 cases 120 knees, we displayed the distribution according to the
grade of the temperature pattern of 6 regions, and it was compared with the normal
person. Each grade was made into the score, and the tendency in the mean value was
examined. The front of the knee showed the high temperature. Next, 10 hydrarthrosis
cases with the high temperature were treated by centesis and drainage, or centesis and
drainage combined with injection of steroid and hyaluronic acid. We measured the
crosswise difference of skin temperature before and after the treatment, and examined the
significance and the effect. The inflammation exists for the symptom stage of the
osteoarthritis, and this shows the activity. We indicated that the low-temperature tendency
of thigh and lower leg occurs by the effect of the osteoarthritis on the muscle.
Samokhin A.V., Buryanov O.A., Kotiuk V.V., Karnauh Y.V. Quantitative Assessment of
Thermal Images of the Hand Joints in Psoriatic Arthritis Patients // Radiation
Diagnostics, Radiation Therapy, #1 / 2011.
The detection of hyperthermia by the hand of the doctor has long been the standard of
diagnosing the inflammatory changes in joints along with detection of other four signs of
inflammation. The situation dramatically changed after the development of thermography.
Exact localization of hyperthermic region in the hand is important to differentiate between
arthritis, tendovaginitis, enthesitis and felon. It is of particular significance in psoriatic
arthritis patients as far as enthesitis is a rather specific feature of the disease and may be
utilized for the differential diagnosis. Hyperthermia in standard points of the hand in
psoriatic arthritis patients with hand joints involvement was expectable. But hyperthermia
was noted more or less markedly in all the hand joints, not only those with clinical
manifestation. This may give evidence to the spread of the pathologic process on the
majority of the hand joints, to the relevance of diagnosing psoriatic arthritis with hand joints
involvement even if only few joints are clinically affected and in preclinical stages of the
disease. Detection of hyperthermia of the nail plates in the presence of other symptoms of
the disease also may indicate the presence of inflammation at the tendons insertions to
the distal phalanges (enthesitis) which is a distinctive feature of psoriatic arthritis.
Hyperthermia of the hand joints may be one of the additional confirmations of psoriatic
arthritis in the lack or equivocality of the clinical symptoms and changes of laboratory
values when it is necessary to confirm documentarily the diagnosis in early preradiological
stages (particularly in conscripts or in the case of examination of working ability) or in
persons that can’t be examined radiologically (pregnant women). The benefits of thermal
47
imaging are exceeding: relatively low cost, absence of ionizing radiation and
electromagnetic fields, absolute noninvasiveness and safety, absence of contraindications,
ability to diagnose and to objectify patients’ complaints at the early stages of the disease,
before radiological and ultrasonographical changes appear.
SALISBURY R.S., PARR G., DE SILVA M., HAZLEMAN B.L., PAGE-THOMAS D.P. Heat
distribution over normal and abnormal joints: thermal pattern and quantification // Annals
of the Rheumatic Diseases, 1983, 42, 494-499.
We have identified regular thermal patterns over normal knee, ankle, and elbow joints and
demonstrate how synovitis affecting these joints may be identified by alteration or loss of
the thermal pattern. Sixty healthy volunteers were thermographed on a total of 190
occasions, and 614 out of 618 joints conformed to the normal thermal pattern. Eight-five
patients with synovitis of at least one of the specified joints were thermographed on a total
of 339 occasions, and 322 out of 1362 thermograms were abnormal. No joint with clinical
evidence of synovitis had a normal thermal pattern. As temperature-based parameters
have been found to show marked dermal variation and relative frequency distributions do
not have this drawback, we suggest that quantification of synovitis by thermography
should in future be based on abnormalities of thermal pattern rather than absolute skin
temperature values.
Sanchez BM, Lesch M, Brammer D, Bove SE, Thiel M, Kilgore KS. USE OF A PORTABLE
THERMAL IMAGING UNIT AS A RAPID, QUANTITATIVE METHOD OF EVALUATING
INFLAMMATION AND EXPERIMENTAL ARTHRITIS // J Pharmacol Toxicol Methods.
2008 May-Jun;57(3):169-75.
INTRODUCTION: Thermal imaging has been utilized, both preclinically and clinically, as a
tool for assessing inflammation and arthritis. However, previous studies have employed
large, relatively im mobile devises to obtain the thermal signature of the tissue of interest.
The present study describes the characterization of a hand-held thermal imaging device in
a preclinical model of general inflammation and a model of rheumatoid arthritis (RA).
METHODS: A hand-held ThermoView Ti30 portable thermal imager was utilized to detect
the temporal changes in thermal signatures in rat model of carrageenan-induced paw
edema (CFE) and a model of collagen-induced arthritis (CIA). In both in vivo models, the
kinetics of the thermal changes were correlated to footpad swelling. In addition, the CFE
model was utilized to examine the ability of this technology to delineate pharmacodynamic
changes in thermal signature in response to the non-steroidal anti-inflammatory drug
indomethacin (10 mg/kg; p.o.).
RESULTS: Thermal analysis of rat paws in the CFE model demonstrated a significant
increase in the mean temperature difference between the inflamed and contralateral
control paw by two hours postcarrageenan (8.3 +/-0.5 degrees F). Indomethacin
significantly decreased the mean temperature difference in treated animals as compared
to vehicle. In the rat CIA model, increases in footpad temperature, as determined by
thermal imaging, were significantly elevated by Day 11 and remained elevated throughout
the duration of the 28 day protocol. Thermal changes were also found to precede
increases in footpad edema (swelling).
DISCUSSION: The results of this study demonstrate that the hand-held thermal imaging
technology represents a rapid, highly-reproducible method by which to quantitate the
degree of inflammation in rat models of general inflammation and rheumatoid arthritis. The
ability to detect pharmacodynamic responses in paw temperature suggests that this
technology may be a useful tool for the development of pharmacologic interventions for the
treatment inflammation-related pathologies.
48
SHIGEYUKI K., NORIMASA T., RYUTARO S. Evaluation of Osteoarthropathy of Knee
Monitored with Thermography // Orthopedics & Traumatology. - VOL.48;
NO.1;PAGE.348-350(1999).
Osteoarthropathy (OA) of the Knee occurs in the elderly and requires long term treatment.
We investigated the degree of severity by X-ray and surface temperature using
thermography for knee. The surface temperature of knees in the moderate severity group
showed low temperatures compared with the normal group. The results of this study
indicate the usefulness of thermography according to the degree of OA in patients with
knee pain.
Schiavenato M, Thiele RG. Thermography detects subclinical inflammation in chronic
tophaceous gout. J Rheumatol. 2012 Jan; 39(1):182-3.
Thermographic imaging is a noninvasive diagnostic tool used to document the
inflammatory process in many species and may be useful in the detection of subclinical
bumblefoot and other inflammatory diseases. Bumblefoot is a chronic inflammation of the
plantar metatarsal or digital pads of the foot (pododermatitis), or both. It is one of the major
health problems in birds including chickens and is responsible for significant economic
losses in commercial poultry operations. Early diagnosis of bumblefoot is essential for the
prevention of economical loss and the improvement of animal well-being. The object of this
study was to determine the suitability of thermography for the identification of subclinical
bumblefoot in chickens. Experiment 1 was designed to validate thermography as a tool for
screening avian populations for bumblefoot. The plantar surface of the feet of 150
randomly selected hens was imaged using a thermal camera. The thermal images were
identified as suspect, positive, or negative for bumblefoot based on thermal patterns of the
plantar surface. Visual inspection of the feet identified as suspect followed 14 d later. A
visual score of clinical, mildly clinical, or negative for bumblefoot was assigned, based on
gross pathological changes in the plantar surface. A correlation between initial thermal
images identified as suspect for bumblefoot and a visual score of positive 14 d later
was 83% (P< 0.01). In experiment 2, hens whose feet were free of lesions were inoculated
in the metatarsal foot pad with Staphylococcus aureus. Thermal images and visual clinical
scores were taken, prechallenge and 1, 2, 3, 4, and 7 d postchallenge. The correlation
between thermal images classified as clinical and a visual score of clinical for
bumblefoot was 86.7% (P < 0.001). However, the correlation between the thermal
images classified as mild (subclinical) and a visual score of mild was only 26.7%,
suggesting that thermography is a more sensitive indicator of subclinical infection
than visual appraisal. Thermography may thus provide a useful tool for screening avian
populations for signs of bumblefoot, early in the course of the disease, which will improve
recovery percentages and bird well-being.
Shu-wang C., Cong-cong W. STUDY ON PATHOLOGICAL AREA OF KNEE BY
INFRARED IMAGING // Optics in Health Care and Biomedical Optics IV, edited by
Qingming Luo, Ying Gu, Xingde Li, Proc. of SPIE Vol. 7845, 784531 © 2010 (Downloaded
from SPIE Digital Library on 17 Jun 2011 to 85.143.5.214. Terms of Use:
http://spiedl.org/terms)
The application of infrared imaging in biomedical fields has been very broad, but the
research results of the lesion of knee by using of infrared imaging have seldom been
reported at present. On the basis of infrared images research, we present the exploring
image analysis and relate the programming optimum entropy algorithm about infrared
imaging analysis. The paper demonstrates the comparative study on the infrared images
contrast between the pathological knee and the reference normal group through the
optimum entropy algorithm. The rule of variation between the normal image and
pathological changes of level about knee lesion in patients is gained. The research results
49
provide a kind of methods for the clinical diagnosis of the pathological knee and also
discuss the value of application about the optimum entropy algorithm in infrared imaging
analysis. Contrasting the MRI or CT, the infrared imaging is cheap and harmless. So the
method can be used in health care and prophylactic detection.
Spalding S.J., Kwoh C.K., Boudreau R., Enama J., Lunich J., Huber D., Denes L., Hirsch
R. Three-dimensional and thermal surface imaging produces reliable measures of joint
shape and temperature: a potential tool for quantifying arthritis // Arthritis Research &
Therapy 2008, 10:R10 - http://arthritis-research.com/content/10/1/R10
Introduction: The assessment of joints with active arthritis is a core component of widely
used outcome measures. However, substantial variability exists within and across
examiners in assessment of these active joint counts. Swelling and temperature changes,
two qualities estimated during active joint counts, are amenable to quantification using
noncontact digital imaging technologies. We sought to explore the ability of three
dimensional (3D) and thermal imaging to reliably measure joint shape and temperature.
Methods: A Minolta 910 Vivid non-contact 3D laser scanner and a Meditherm med2000
Pro Infrared camera were used to create digital representations of wrist and
metacarpalphalangeal (MCP) joints. Specialized software generated 3 quantitative
measures for each joint region: 1) Volume; 2) Surface Distribution Index (SDI), a marker of
joint shape representing the standard deviation of vertical distances from points on the
skin surface to a fixed reference plane; 3) Heat Distribution Index (HDI), representing the
standard error of temperatures. Seven wrists and 6 MCP regions from 5 subjects with
arthritis were used to develop and validate 3D image acquisition and processing
techniques. HDI values from 18 wrist and 9 MCP regions were obtained from 17 patients
with active arthritis and compared to data from 10 wrist and MCP regions from 5 controls.
Standard deviation (SD), coefficient of variation (CV), and intraclass correlation
coefficients (ICC) were calculated for each quantitative measure to establish their
reliability. CVs for volume and SDI were <1.3% and ICCs were greater than 0.99.
Results: Thermal measures were less reliable than 3D measures. However, significant
differences were observed between control and arthritis HDI values. Two case studies of
arthritic joints demonstrated quantifiable changes in swelling and temperature
corresponding with changes in symptoms and physical exam findings.
Thermal imaging differentiates patients with active arthritis from normal controls:
To determine the reliability of thermal imaging of the wrist and MCP, 6 normal adult wrists
and hands from 3 controls were imaged on 3 separate days. Three thermal scans were
obtained at each session and the HDI was calculated for each ROI. Intra-session (that is,
same day and time) HDIs were very similar, with SDs less than 0.05°C (data not shown).
Pooled inter-session (that is, day-to-day) SD of wrist HDIs was 0.2°C (Figure 3a) whereas
MCP HDI performed less well, with an inter-session SD of 0.4°C (Figure 3b). Pooled intersession CVs were 22.1% for the wrist and 29.7% for the MCP, indicating relatively large
day-to-day variation. This was also reflected in the low HDI ICC [1,3] values for wrists
(0.146) and MCPs (-0.295). However, no control wrist or MCP HDI exceeded 1.3°C,
suggesting that an HDI above 1.3°C might be indicative of the presence of arthritis. To
explore this further, we compared HDI values of 10 control wrists and 10 control MCPs to
18 wrists with active arthritis and 9 MCPs with active arthritis. As shown in Figure 3c, an
HDI cutoff of 1.3°C discriminated well between controls and patients with active arthritis.
The mean ± SD HDI in control joints was 1.0°C ±0.2°C compared with 1.7°C ± 0.6°C in
joints with active arthritis (p < 0.0001). By ROC analysis, an HDI value of 1.3°C yielded
a sensitivity of 67% and a specificity of 100%. The area under the ROC curve was
0.823. No significant differences in HDI were seen between control adults and children or
between arthritic adults and children. Using thermal imaging, we determined that an HDI of
greater than 1.3°C correlated with physician-assessed active arthritis (r = 0.68, p < 0.0001)
50
and displayed a specificity of 100% and a sensitivity of 67% when compared with normal
controls. The poorer performance of the MCP HDI is likely a consequence of
uncontrollable physiologic factors (metabolic rate, caloric intake, and so on) within each
subject, suggesting that absolute changes in HDI may not be a reliable longitudinal
measure of change in arthritis activity. However, the HDI could be employed in a
dichotomous fashion to classify joints as active or inactive, which could simplify and
improve the reproducibility of active joint counts.
Conclusion: 3D and thermal imaging provide reliable measures of joint volume, shape, and
thermal patterns. Further refinement may lead to the use of these technologies to improve
the assessment of disease activity in arthritis.
Trafarski A., Rózanski L., Straburzynska -Lupa A., Korman P. The Quality of Diagnosis
by IR Thermography as a Function of Thermal Stimulation in Chosen Medical Applications
// 9th International Conference on Quantitative InfraRed Thermography. - July 2-5, 2008,
Krakow – Poland.
The working of many physical procedures used in medical science is connected to
changes in the temperature of tissue. A research has been carried out into the possibility
of using the thermographic technique in evaluating the effectiveness of local cryotherapy
procedure (local cryostimulation) in patients with rheumatoid arthritis. The aim of the
research was to determine the degree of thermal stimulation intensity during the local
cryotherapy procedure and duration of response of the organism to the applied stimulation.
The research was based on comparison of temperature distribution on the surface of the
hand prior to, immediately after, and at certain intervals after the procedure of local blast of
liquid nitrogen vapours or cool air on the hand. All people taking part in the study suffered
from rheumatoid arthritis, accompanying illnesses occurring in some of them. The study
allowed optimizing thermal stimulation procedures used in rheumatology and cosmetology.
The carried out research demonstrated that thermography is a measurement technique
useful in analyzing thermal reaction of the organism connected with local cryostimulation,
and monitoring and evaluating the progress of treatment. It was revealed that the stimulus
produced by liquid nitrate vapours is a much stronger thermal stimulation for the patient
than the stimulus produced by cool air. Duration of response to the stimulation in patients
ill only with RA was longer in the case of stimulation with liquid nitrate vapours. A faster
and bigger temperature rise, as well as longer duration of organism response to
stimulation with cool air was observed in patients ill with RA and AH. Further research
should be carried out which would be directed at discovering the proper diversification and
adequate optimization of testing cryotherapy procedures applied in various morbid cases
accompanying RA, as well as in various stages of progression of RA.
Varjú G, Pieper CF, Renner JB, Kraus VB. Assessment of hand osteoarthritis: correlation
between thermographic and radiographic methods // Rheumatology (Oxford). - 2004
Jul;43(7):915-9.
OBJECTIVE: Anatomical stages of digital osteoarthritis (OA) have been characterized
radiographically as progressing through sequential phases from normal to osteophyte
formation, progressive loss of joint space, joint erosion and joint remodelling. Our study
was designed to evaluate a physiological parameter, joint surface temperature, measured
with computerized digital infrared thermal imaging, and its association with sequential
stages of radiographic OA (rOA).
METHODS: Thermograms, radiographs and digital photographs were taken of both hands
of 91 subjects with nodal hand OA. Temperature measurements were made on digits 2-5
at distal interphalangeal (DIP) joints, proximal interphalangeal (PIP) joints and
metacarpophalangeal (MCP) joints (2184 joints in total). We fitted a repeated measures
51
ANCOVA model to analyse the effects of rOA on temperature, with handedness, joint
group, digit and NSAID use as covariates.
RESULTS: The reliability of the thermoscanning procedure was high (generalizability
coefficient 0.899 for two scans performed 3 h apart). The mean joint temperature
decreased with increasing rOA severity, defined by the Kellgren-Lawrence (KL) scale.
The mean temperature of KL0 joints was significantly different from that of each of
the other KL grades (P </= 0.002). After adjustment for the other covariates, there was a
strong association of rOA with joint surface temperature (P<0.001). The earliest
discernible radiographic disease (KL1) was associated with a higher surface temperature
than KL0 joints (P = 0.01) and a higher surface temperature than any other KL grade.
Joint erosions were not associated with a change in joint temperature.
CONCLUSION: Joint surface temperature varied with the severity of rOA. Joints were
warmer than normal at the onset of OA. As the severity of rOA worsened, joint surface
temperature declined. These data support the supposition that digital OA progresses in
phases initiated by an inflammatory process. The cooler surface temperatures in later
stages of the disease may in part explain the paucity of symptoms reported by patients
with hand OA.
Vujcic M, Nedeljkovic R. Thermography in the detection and follow up of chondromalacia
patellae // Annals of the Rheumatic Diseases. - 1991; 50: 921-925.
Although diagnostic criteria for chondromalacia patellae exist, the disease is often
accompanied by physical signs which are limited or non-diagnostic. Thermographic
examination was performed in 157 patients with clinical diagnosis of chondromalacia
pateliae in 86 patients after surgical treatment for chondromalacia, and in 308 controls.
Thermography can help the clinicians in establishing the diagnosis of chondromalacia
patellae, but by itselfis not sufficiently specific. The specificity of thermography was
dependent on age, ranging from 90% for the 15-24 year age group to 65% for the 45-54
year age group. Sensitivity of the method was 68%. Thermography can disclose other
knee disorders which imitate chondromalacia pateliae.
Warashina H, Hasegawa Y, Tsuchiya H, Kitamura S, Yamauchi K-I, Torii Y, Kawasaki M,
Sakano S. Clinical, radiographic, and thermographic assessment of osteoarthritis in the
knee joints // Annals of the Rheumatic Diseases.- 2002;61:852–854
In this study we evaluated the correlation between radiographic and clinical findings and
skin temperature measured by thermography for the assessment of osteoarthritis in the
knee joints in the Comprehensive Health Examination Programme at Y-town, Japan in
1999. The assessments were performed on 974 knees of 169 men and 318 women who
had a mean (SD) age of 57.6 (4.3). In this study, thermography provided objective data of
skin temperature that was compared with other physical parameters, showing a correlation
between skin temperature and clinical and radiological evidence of OA in the knee joints.
Cheung PP et al. Reliability of patient self-evaluation of swollen and tender joints in
rheumatoid arthritis: A comparison study with ultrasonography, physician and nurse
assessments. Arthritis Care Res 2010 Aug; 62(8): 1112-1119.
Esselinckx W. Bacon P A, Ring E F, Crooke D, Collins A J, and Demottaz D. A
thermographic assessment of three intra-articular prednisolone analogues given in
rheumatoid synovitis. Br J Clin Pharmacol 1978 May; 5(5): 447-451.
1 Three intra-articular prednisolone analogues have been studied in a group of forty-six
rheumatoid arthritic subjects. Each compound was tested at 50 mg and 100 mg dose over
3 weeks. 2 The anti-inflammatory effect was assessed by quantitative thermography.
Systemic escape of the drug was monitored by plasma prednisolone and cortisol levels. 3
52
Both the systemic escape from the joint and the duration of effect on injected and
uninjected knees were related to drug solubility. 4 Depression of plasma cortisol occurred
with all three preparations and was most prolonged with the long-acting preparation. 5
Increasing the dose from 50 mg to 100 mg increased the antiflammatory effect only with
the soluble acetate preparation.
Spalding SJ et al. Three-dimensional and thermal surface imaging produces reliable
measures of joint shape and temperature: a potential tool for quantifying arthritis. Arthritis
Res Ther 2008; 10(1): R10.
Schiavenato M, Thiele RG. Thermograph detects subclinical inflammation in chronic
tophaceous gout. J Rheumatol. 2012 Jan; 39(1):182-3.
Disorders of synovium and tendon and оther soft tissue disorders
Muscle action is the most important source of increased metabolic heat. Therefore,
contracting muscles contribute to the temperature distribution at the body’s surface of
athletes (Tauchmannova et al 1993, Smith et al 1986). Pathological conditions such as
muscle spasms or myofascial trigger points may become visible as regions of increased
temperature (Fischer and Chang 1986). An anatomic study from Israel proposed that in
the case of the levator scapulae muscle, the frequently seen hot spot on thermograms of
the tender tendon insertion on the medial angle of the scapula could be caused by
inflamed bursae and not by a taut band of muscle fibres (Menachem et al 1993).
Acute muscle injuries may also be recognized by areas of increased temperature
(Schmitt and Guillot 1984) due to inflammation in the early state of trauma. However, long
lasting injuries and also scars appear as hypothermic areas caused by reduced muscle
contraction, and therefore reduced heat production. Similar areas of decreased
temperature have been found adjacent to peripheral joints with reduced range of motion
due to inflammation or pain (Ammer 1995a). Muscle overuse or repetitive strain may lead
to painful tendon insertions, or where the tendons are shielded by the tendon sheath or
adjacent to bursae, with painful swelling. It has been shown that tendovaginitis in the hand
was sucessfully diagnosed by skin temperature measurement (Graber 1980). Painful
muscle insertion of the extensor muscles at the elbow is associated with hot areas on a
thermogram (Binder et al 1983). Thermal imaging can detect persistent tendon insertion
problems of the elbow region in a similar way as isotope bone scanning (Thomas and
Savage 1989). Hot spots at the elbow have also been described as having a high
association with a low threshold for pain on pressure (Ammer 1995b). Such hot areas
have been sucessfully used as outcome measure for monitoring treatment (Devereaux et
al 1985, Meknas et al 2008). In patients suffering from fibromyalgia, bilateral hot spots at
the elbows are a common finding (Ammer et al 1995).
Fibromyalgia. There are two terms used by physicians in the examination of
muscular pain: tender points (important for the diagnosis of fibromyalgia) and trigger points
(main feature of the myofascial pain syndrome). Tender points and trigger points may give
a similar image on the thermogram. If this is true, patients suffering from fibromyalgia may
present with a high number of hot spots in typical regions of the body. A study from Italy
did not find different patterns of heat distribution in patients suffering from fibromyalgia and
patients with osteoarthritis of the spine (Biasi et al 1994). However, they reported a
correspondence of non-specific hyperthermic pattterns with painful muscle areas in both
groups of patients. In an Austrian study, thermographic investigations in fibromyalgia
revealed a diagnostic accuracy of 60% of hot spots for tender points (Ammer et al 1995).
The number of hot spots found was greatest in fibromyalgia patients and least in healthy
subjects. It was therefore concluded that more than seven hot spots could be predictive for
53
tenderness in 11 or more of 18 specific sites (Ammer K. Thermal imaging: a diagnostic aid
for fibromyalgia? // Thermol. Int. 2008. 18 45–50). Based on the count of hot spots, 74.2%
of 252 subjects (161 fibromyalgia, 71 with widespread pain, but less than 11 tender
sites out of 18, and 20 healthy controls) were correctly diagnosed.
Al-Nakhli, H.H., Petrofsky, J.S., Laymon, M.S., Berk, L.S. The Use of Thermal Infra-Red
Imaging to Detect Delayed Onset Muscle Soreness. J. Vis. Exp. (59), e3551, DOI:
10.3791/3551 (2012).
Delayed onset muscle soreness (DOMS), also known as exercise induced muscle damage
(EIMD), is commonly experienced in individuals who have been physically inactive for
prolonged periods of time, and begin with an unexpected bout of exercise1-4, but can also
occur in athletes who exercise beyond their normal limits of training5. The symptoms
associated with this painful phenomenon can range from slight muscle tenderness, to
severe debilitating pain1, 3, 5. The intensity of these symptoms and the related discomfort
increases within the first 24 hours following the termination of the exercise, and peaks
between 24 to 72 hours post exercise1, 3. For this reason, DOMS is one of the most
common recurrent forms of sports injury that can affect an individual’s performance, and
become intimidating for many1, 4.
For the last 3 decades, the DOMS phenomenon has gained a considerable amount of
interest amongst researchers and specialists in exercise physiology, sports, and
rehabilitation fields6. There has been a variety of published studies investigating this
painful occurrence in regards to its underlying mechanisms, treatment interventions, and
preventive strategies1-5, 7-12. However, it is evident from the literature that DOMS is not
an easy pathology to quantify, as there is a wide amount of variability between the
measurement tools and methods used to quantify this condition.
It is obvious that no agreement has been made on one best evaluation measure for
DOMS, which makes it difficult to verify whether a specific intervention really helps in
decreasing the symptoms associated with this type of soreness or not. Thus, DOMS can
be seen as somewhat ambiguous, because many studies depend on measuring soreness
using a visual analog scale (VAS) 10, 13-15, which is a subjective rather than an objective
measure. Even though needle biopsies of the muscle, and blood levels of myofibre
proteins might be considered a gold standard to some6, large variations in some of these
blood proteins have been documented 6, 16, in addition to the high risks sometimes
associated with invasive techniques.
Therefore, in the current investigation, we tested a thermal infra-red (IR) imaging
technique of the skin above the exercised muscle to detect the associated muscle
soreness. Infra-red thermography has been used, and found to be successful in detecting
different types of diseases and infections since the 1950’s17. But surprisingly, near to
nothing has been done on DOMS and changes in skin temperature. The main purpose of
this investigation was to examine changes in DOMS using this safe and non-invasive
technique.
Selfe James, Hardaker Natalie, Whitaker Jonathan, Hayes Colin. Thermal imaging of an
ice burn over the patella following clinically relevant cryotherapy application during a
clinical research study // Physical Therapy in sport. – Volume 8, Issue 3, August 2007,
Pages 153–158.
The use of cryotherapy in soft tissue injury is still largely based on anecdotal rather than
empirical evidence. The objective of this case report is to present thermal imaging data
from a mild ice burn sustained during a clinical research project.
Design
Case report.
Case description
54
A 43-year-old male participant recruited to take part in an ongoing cryotherapy research
project sustained a mild ice burn, resulting in visible blanching of the skin over the affected
area and a transient burning sensation. The burn occurred unexpectedly during a tightly
controlled experimental procedure, employing protocol from current clinical practice. Three
participants had already successfully completed the study with no adverse reactions when
the ice burn occurred.
Outcome measures
Outcome measures were; patella skin-fold, modality temperature pre and post application,
baseline thermal image, and thermal imaging data over the knee at a rate of 1 image min−1
during a 25-min re-warming period.
Results
The participant recorded a patella skin-fold of just 7 mm. Baseline skin surface
temperature was 29.4 C. Skin surface temperature (Tsk) decreased by 17.9 C following
cold application. During the 25-min re-warming period Tsk increased 11.8 C.
Conclusions
Twenty minutes of cryotherapy application may be too long over an anatomically bony
area. Clinicians should consider thermal gradient as part of their clinical decision making
process, which would be influenced by increased ambient temperature, pathology, and
also lower modality temperature.
Chapter XIV Diseases of the genitourinary system
Daneliia EV, Gotsadze DT. Infrared telethermography in the diagnosis of testicular tumors.
– Urol Nefrol (Mosk). 1995 Nov-Dec;(6):38-40.
Diagnostic potential of infrared extracorporeal thermography (IET) was studied in 334
males: 167 with testicular tumors, 42 with acute or chronic epididimitis, 33 with orchitis, 17
with hydrocele and 75 controls.
Gotsadze DT, Sepiashvili AO, Daneliia EV. Thermography in inflammatory and neoplastic
diseases of the testis. – Vopr Onkol. 1990;36(4):476-9.
Thermographic examination of the scrotum was performed in 55 healthy males, 64
patients with nonspecific inflammatory lesions of the testicles and 44 cases of testicular
tumor. In thermograms of the normal scrotum, cold zones provided the background for
homogeneous isothermic images corresponding to the testicles. Inflammatory lesions
showed atypical diffuse zones of increased thermogenic activity which were in some cases
associated with hyperthermic stem foci in the inguinal-scrotal area.
Helen Potter , Robin Horne, Kristy Le May, John Seah. The sensitivity of thermography to
temperature changes in breast tissue. - Australian Journal of Physiotherapy. - Volume
43, Issue 3, 1997, Pages 205–210.
This study evaluates the ability of thermography to i) detect temperature changes in a
lactating breast in response to the application of therapeutic ultrasound; ii) identify an area
of raised temperature in a breast affected by mastitis; and iii) detect temperature changes
in the affected area in response to the application of ultrasound.
An area of raised temperature (38 degrees C), corresponding with the area of
inflammation, was identified in a mastitic breast. Eighty-seveen per cent of this area had
returned to normal resting breast temperature (33 degrees C) within 30 minutes of
application of pulsed ultrasound. The use of thermography to evaluate temperature
changes in mastitic breast tissue before and after the application of ultrasound is
supported.
55
Jang H A, Kim T, Yoon S, Kim W, Lee S. THE CLINICAL APPLICATION OF SCROTAL
INFRARED THERMOGRAPHY IN NORMAL AND PATIENTS WITH ACUTE
EPIDIDYMITIS OR EPIDIDYMO-ORCHITIS. www.ics.org/Abstracts/Publish/180/000726.pdf
Hypothesis / aims of study
We evaluate the finding of scrotal infrared thermography in normal and patients with acute
epididymitis/epididymo-orchitis, and try to assess its capability through the comparison
with clinical parameters.
Study design, materials and methods
We performed the digital infrared thermography of scrotum in 15 normal male and 23
patients with acute epididymitis, and assessed the thermographic characteristics in normal
male. Both thermographic patterns and thermal differences between normal and affected
scrotum in acute epididymitis patients were retrospectively analyzed. Also we compared it
with clinical parameters such as fever, pyuria and findings of doppler ultrasound.
Interpretation of results
In 15 normal male, thermal differences between bilateral hemiscrotums were average 0.30
± 0.16 ℃, and they did not show statistical significance. By ROC curve analysis, diagnostic
cut-off value, sensitivity and specificity were 0.6℃, 69.6%, 100% respectively. Sixteen of
twenty-three patients presented significant thermal differences over 0.6℃. Also, the
thermal differences of hot spot of patients were significantly increased comparing with that
of normal scrotum. Thermography revealed that the temperature of affected hemiscrotum
in patient with acute epididymitis was statistically higher than that of normal hemiscrotum
as well.
Concluding message
Scrotal thermography had the capability as a diagnostic tool of acute epididymitis through
both the comparison of thermal difference between normal and affected scrotum in patient,
and ROC analysis. However, currently it was uncertain whether thermography could
differentiate acute epididymitis from other intrascrotal disease. In the future, the
advancement of thermographic device and more data accumulation may improve the
clinical value of thermography.
Novikova E.E. Possibilities of thermography in diagnostics of diseases of mammary
gland: thesis. – Saratov, 1996.
The following women were carefully examined: 800 healthy women and 1357 patients
(726 women with dishormonal hyperplasia, 581 women with malignant tumors, 150 women
with purulent and inflammatory processes). Thermographic symptoms for all diseases of
the breast were the same type, but the degree of hyperthermia, area, shape and its
location were different for various pathological processes.
Purulent and septic diseases of mammary gland: expressed hyperthermic fibrotic folds
along the vessels and channels, and centers of heating corresponding to projections of the
affected areas were observed at serous form of mastitis. The difference of temperatures
was from 1.0 to 1.5°С. Positive dynamics with subsequent normalization in three to four
weeks was observed after the treatment course.
The difference of temperature for patients with infiltrative and purulent-infiltrative mastitis
was 3.0-5.0°С. The difference of temperatures of more than 5 degrees was observed for
patients with obliterating mastitis.
Tiktinskiĭ OL, Mel'nikova VP, Moshkalov AA, Novikov IF. The role of thermography in the
diagnosis of testicular diseases. - Urologii͡a i nefrologii͡a:1 pg 23-6. http://www.unboundmedicine.com/medline/citation/2718279/[The_role_of_thermography_i
n_the_diagnosis_of_testicular_diseases]_
56
Combined clinical and thermovision investigation was carried out in 104 patients with
various scrotal diseases. Acute epididymitis and orchidoepididymitis (42 patients) were
associated with the following thermographic signs: thermo-asymmetric intensity of infrared
emission with hyperthermia (0.6 to 2 degrees C) on the affected side, a greater glow area,
as compared to actual anatomical size of the organ, "truncal" inguino-iliac hyperthermia in
cases of ascending lymphangitis. Asymmetry of heat pattern diminished or disappeared
altogether in cases of successful treatment. Hydrocele (32 patients) was associated with
enlarged heat outlines on the affected side of the scrotum, without any apparent heat
pattern asymmetry. Malignant testicular tumors (30 patients) were associated with
enlarged outline of the affected scrotal side with a temperature difference of 1.2 degrees C
and more, as compared to the normal side, persistent hyperthermia at repeated
examinations, small- and medium-sized hyperthermic foci over the projected liver, lungs,
mediastinum, meso- and hypogastrium, lumbar region and in the area of lateral neck
surface in cases of metastatic growth. A clear-cut homogeneous hyperthermia over the
anterior abdominal wall and in the lumbar region is registered as a post-gamma
teletherapy condition. Thermovision is an effective instrument for the diagnosis of benign
and malignant scrotal diseases; it makes possible early detection of complications
(lymphangitis, lymphadenitis, metastases) providing for an objective assessment of
treatment efficiency. The accuracy of thermovision diagnosis was 100% in cases of
hydrocele and acute orchidoepididymitis, and 89.6% in cases of testicular tumors.
YuHongKai. Infrared heat map for the diagnosis of chronic prostatitis clinical research. Master's thesis, 2004. - http://www.dissertationtopic.net/doc/839669
The chronic prostatitis research purposes is one of the most common diseases in the
male. American Urological Andrology clinic patients, accounting for 9% to 14% of patients
with chronic prostatitis. There are also a report chronic prostatitis accounted for 25% of
urology, andrology outpatient, like a recent MI, unstable angina, active Crohn's disease,
the impact of the disease on the quality of life is significant, and the psychological damage
and even more serious than severe diabetes or chronic heart failure. Secretory dysfunction
accompanied by chronic prostatitis, from adverse effect on sperm, resulting in reduced
fertility. Chronic prostatitis is a serious impact on a disease of male physical and mental
health, urology, andrology research focuses on diseases.
Prostatitis diagnosis: prostate massage fluid examination, four cups positioning method,
polymerase chain reaction technology (PCR), antibody detection, Determination of
cytokines (IL-6, TNF-α), voiding pressure - flow rate - EMG measurement, cystoscopy, B
ultrasound, voiding the bladder and urethra contrast, prostate tissue biopsy. These
methods have their own advantages, but there are shortcomings. For example: prostate
massage fluid examination with four cup positioning method requires digital rectal
diagnosed prostate massage extracting solution, the patient is often very painful, and even
refused to check; And often the extract failed. Chronic prostatitis often local glandular
inflammation, prostate massage extracting solution is not necessarily the prostatic fluid
extrusion glandular inflammation can cause check false negative. Voiding pressure - flow
rate - EMG measurement, cystoscopy, the excretory bladder urethrography, prostate
tissue biopsy are invasive or inspection fees, and is not suitable for general clinical
examination. Medical infrared thermal imaging (infrared thermography, IRT) technology is
an emerging hi-tech, human radiation source, the use of state-of-the-art infrared scanning
technology to detect infrared radiation, after a series of signal processing, not visible The
surface temperature changes into visibility and quantitative infrared heat map. Chronic
prostatitis pathological manifestations of the same general inflammation, mainly to the
posterior urethra, prostate tube and surrounding interstitial tissue congestion, edema, local
temperature. High temperature parts of the deep, and its surface temperature is also
higher. Based on the above principles, the study by medical infrared camera detection
57
around the male external genitalia infrared heat map to explore the diagnostic value of the
infrared image of chronic prostatitis.
Methods: This study selected Dongzhimen Hospital Urology chronic prostatitis outpatients,
30, normal subjects 30; symptom score table designed in accordance with the Beijing
University Hospital, and 30 patients with chronic prostatitis improved symptom scores.
Application DW-9100 medical infrared camera, temperature 20 ~ 24 ℃, 60% humidity
environment, to ensure that no wall the reflection, indoor airflow, direct sunlight lens and
subjects, the subjects undressing imaging pants shot five minutes later. Imaging method:
subjects face the camera standing at 1.2 meters in front of the lens of the camera, at the
same time exposed to the lower abdomen (below the navel) and thigh upper third start
shooting system, adjust the focus to the screen image clarity, the image Save and analysis
and inspection.
Observed: (1) around the external genitalia of infrared heat map form. (2) the ambient
temperature of the external genitalia hotter regions close to the region of the temperature
difference. The results of the findings show that the the normal infrared image
performance: the ambient temperature of the external genitalia basically equal on both
sides of the basic symmetry, the temperature difference is less than 2°C. The infrared
image showed chronic prostatitis patients: around the external genitalia (scrotum on both
sides of the lower abdomen near the base of the penis) visible strip, sheet or groups like
the hot zone of 2.5 to 4°C, and the immediate area of the temperature difference. The
hotter the ambient temperature of the external genitalia of the normal subjects and patients
with chronic prostatitis District and close to the region of the temperature difference
between the existence of significant differences (P lt; 0.0001). Hotter regions around the
external genitalia of the patient group close to the area of the temperature difference
between its symptoms grading no correlation. Around the external genitalia of the patient
group compared with the lt; WP = 4 gt; Chinese Abstract hot zone close to the area of the
temperature difference between its duration of disease.
Conclusion around the male external genitalia (scrotum on both sides of the lower
abdomen near the base of the penis), infrared thermal images can be used as a census of
the men with chronic prostatitis and auxiliary diagnostic one. Infrared thermal images can
not be used to determine chronic prostatitis severity;, and the course of disease.
Chapter XV Pregnancy, childbirth and the puerperium
Mastitis is the inflammation of breast tissue.[1] S. aureus is the most common etiological
organism responsible, but S. epidermidis and streptococci are occasionally isolated as
well. Mastitis can be classified as milk stasis, non-infectious or infectious inflammation and
abscess. It is impossible to correlate this classification with clinical symptoms. In particular,
milk stasis, non-infectious and infectious inflammation can be distinguished only by
leukocyte count and bacteria culturing. Symptoms like fever, intensity of pain, erythema or
rapid onset of symptoms can not be used to distinguish these. Early stages of mastitis can
present with local pain, redness, swelling, and warmth. Later stages also present with
systemic symptoms like fever and flu-like symptoms and in rare cases an abscess can
develop. However it is pretty common that symptoms develop very quickly without any
warning [http://en.wikipedia.org/wiki/Mastitis].
58
Anita Batista dos Santos Heberle, Marcos Antônio Muniz de Moura, Mauren Abreu de
Souza, Percy Nohama. Assessment of techniques of massage and pumping in the
treatment of breast engorgement by thermography. - Rev. Latino-Am. Enfermagem. vol.22, no.2. Ribeirão Preto. - Mar./Apr. 2014. - http://dx.doi.org/10.1590/01041169.3238.2413
Mammary engorgement, in the breastfeeding process, is the first symptom encountered by
the mother in the self-regulation of the physiology of lactation. Sometimes, the breasts
produce a quantity of milk secretion greater than the demand of the child, becoming so full
and taut they are called "gable chest" [Almeida JAG. Amamentação: um híbrido naturezacultura. Rio de Janeiro: Fiocruz; 1999.], one of the factors of interruption of the exclusive
breast feeding (EBF) in children under four months of life [Carvalhaes MABL, Parada
CMGL, Costa MP. Fatores associados à condição do aleitamento materno exclusivo em
crianças menores de 4 meses, em Botucatu, SP. Rev. Latino-Am. Enfermagem.
2007;15:62-9.]. Breast engorgement arises from the increased vascularity and
accumulation of milk and, secondarily, by lymphatic and vascular congestion [Giugliani
ERJ. Problemas comuns na lactação e seu manejo. J Pediatr. 2004;80(5) suppl: 147-54.].
Signals arise such as pain, interstitial edema, increase in the volume of the breasts [Book
OR, Guralnik L, Keidar Z, Gaitini DE, Engel A. Pitfalls of the lactating breast on computed
tomography. J Comput Assist Tomogr. 2004;28(5):647-9.], shiny skin, flattened nipples,
with or without accompanying diffuse and reddened areas [Giugliani ERJ. Problemas
comuns na lactação e seu manejo. J Pediatr. 2004;80(5) suppl: 147-54.], elevation of the
body temperature including a febrile state. After the breasts are emptied [Shimo AKK.
Mama Puerperal: aspectos preventivos e curativos do ingurgitamento mamário.
[dissertação]. Ribeirão Preto: Escola de Enfermagem de Ribeirão Preto da Universidade
de São Paulo; 1983. 163 p.], a reduction in temperature occurs.
In the research literature, temperature changes in breasts of pregnant women have been
observed [Birnbaum SJ. Breast temperature as a test for pregnancy. Obstet Gynecol.
1966;27(3): 378-80.], and hormone dosage in lactating women with engorged breasts, in
which it was found that systems with high sensitivity could provide early diagnosis, both of
postpartum breast discomfort as well as the evolution of breast engorgement (BE)
[Menczer J, Eskin BA. Evaluation of post-partum breast by thermography. Obstet Gynecol.
1969;33(2):260-3.].
OBJECTIVE: to evaluate techniques of massage and pumping in the treatment of
postpartum breast engorgement through thermography.
METHOD: the study was conducted in the Human Milk Bank of a hospital in Curitiba,
Brazil. We randomly selected 16 lactating women with engorgement with the classification
lobar, ampullary and glandular, moderate and intense. We compared the differential
patterns of temperature, before and after the treatment by means of massage and
pumping.
RESULTS: we found a negative gradient of 0.3°C of temperature between the pre- and
post-treatment in the experimental group. Breasts with intense engorgement were 0.7°C
warmer when compared with moderate engorgement. It was verified that the breasts
with moderate engorgement had a mean temperature of 34.8°C versus 35.5°C for
those with intense engorgement. It was found that, at the 5% level of significance, there
was a significant difference between the temperature variations between the pre and post
treatment in the experimental group. In the control group, there was no significant
difference.
CONCLUSION: massage and electromechanical pumping were superior to manual
methods when evaluated by thermography.
59
Chapter XIX Injury, poisoning and certain other consequences of external causes
Arfaoui A., Polidori G., Taiar R., Popa C. Infrared Thermography in Sports Activity //
Infrared Thermography Edited by Dr. Raghu V Prakash 236 pages.
Due to its non-intrusive feature, infrared thermography (IRT) is a powerful investigation
tool to be applied as well in sports performance diagnostic (due to the relationship
between muscular energy and thermoregulation process) as in sports pathology
diagnostic. It is well known that sports activity induces a complex thermoregulation
process where part of heat is given off by the skin of athletes. As not all the heat produced
can be entirely given off, this follows a muscular heating resulting in an increase in the
cutaneous temperature. For example, in sports activity, we have presented the usability of
infrared thermography in swimming for the purpose of quantifying the influence of the
swimming style on the cartographies of cutaneous temperatures of a swimmer similar
analysis has concerned cycling activity. In particular, the IRT method will enable, in the
long term, to quantify the heat loss according to the swimming style, and to consider the
muscular and energy outputs during the stroke. In the field of pathology diagnostic, applied
to sports activity, the application of infrared thermography (IRT) has a long history in
musculoskeletal trauma. Infrared thermography is a diagnostic method providing
information on the normal and abnormal sensory and nervous systems, trauma, or local
and global inflammation. Infrared thermography shows physiological changes rather than
anatomical changes and could be a new diagnostic tool to detect the pathology of the
knee. For example, IRT appears to be a reliable diagnostic tool to detect quantifiable
patterns of skin temperatures in participants with knee osteoarthritis.
BenEliyahu D. Infrared Thermography and the Sports Injury Practice // Dynamic
Chiropractic – March 27, 1992, Vol. 10, Issue 07.
Infrared thermal imaging can be very useful to the sports injury practice. Infrared
Thermography (IRT) measures cutaneous surface temperature which is reflective of the
underlying sympathetics and local chemical mediators. Previous studies have shown that
skin temperature from right to left sides only differ within a few tenths of a degree for
homologous parts. In the case of the anterior calves, the normal mean temperature
differential is 0.31 degrees C. Other studies have shown that temperature
differentials over 0.65-0.80 degrees C are indicative of underlying pathology. IRT has
been found to be useful by both the AMA Council on Scientific Affairs and the ACA Council
on Diagnostic Imaging, which has its own American Chiropractic College of Thermology.
IRT has been documented in the world scientific literature as an efficacious diagnostic tool,
prognostic and treatment assessment tool. IRT has been shown to be useful for stress
fractures, tibial stress syndromes (shin splints), patellofemoral disorders, shoulder
impingement, reflex sympathetic dystrophy, Osgood Schlatter’s disease, epicondylitis,
nerve entrapments, ankle injuries, foot disorders, and myofascial pain syndromes. In a
study published by Goodman, et al., IRT was found to be a useful test to distinguish stress
fractures and shin splints in a prospective blind study of runners. The athletes with
hyperthermic calves had a poorer prognosis as opposed to those with a hypothermic/cold
pattern. In a study by this author that was presented at the 17th Annual Symposium of the
American College of Sports Medicine, and to be published in the JMPT, IRT was found to
have a high sensitivity and specificity for patellofemoral pain syndrome (PFPS).
PFPS will image as a global patellar hypothermia that will usually affect the patella region
only.
IRT is also helpful in the following conditions:
1. Shoulder impingement syndrome – focal hyperthermia of shoulder.
2. Achilles’ tendinitis – focal hyperthermia at Achilles’ tendon.
3. Morton’s neuroma/metatarsalgia – focal hyperthermia at plantar foot.
60
4. Tarsal tunnel syndrome – hypothermia at heel and big toe.
5. Osgood Schlatter’s disease – focal hyperthermia at tibial tubercle.
6. Myofascial pain syndrome – focal hyperthermia overlying involved muscle.
7. Facet syndrome – focal hyperthermia overlying involved facet.
8. Ankle sprains – typically hyperthermic
9. Tennis leg – hyperthermia over head of involved gastrocnemius as opposed to diffuse
hyperthermia in phlebitis.
IRT is also useful as a prescan team assessment tool, to determine areas of thermal
asymmetry that may represent subclinical problems predisposing the athlete to injury. For
example, in a study done by this author, it was found that 70 percent of a high school
football team showed patellar thermal asymmetry. IRT can be used with follow-up studies
to follow treatment response and as a prognostic indicator of when to best return the
athlete to practice and/or competition.
Conclusion. Infrared thermography has many applications in a sports injury practice and is
valuable for diagnostic, prognostic, and treatment assessment purposes. Thermography
should be utilized whenever possible by sports medicine doctors.
Hildebrandt C., Raschner C., Ammer K. An Overview of Recent Application of Medical
Infrared Thermography in Sports Medicine in Austria // Sensors 2010, 10, 4700-4715.
Medical infrared thermography (MIT) is used for analyzing physiological functions related
to skin temperature. Technological advances have made MIT a reliable medical
measurement tool. This paper provides an overview of MIT´s technical requirements and
usefulness in sports medicine, with a special focus on overuse and traumatic knee injuries.
Case studies are used to illustrate the clinical applicability and limitations of MIT. It is
concluded that MIT is a non-invasive, non-radiating, low cost detection tool which should
be applied for pre-scanning athletes in sports medicine.
A common problem in alpine skiing is the occurrence of overuse injuries such as patellae
tendinopathy, which is characterized by swelling, pain and tenderness above the tibial
tuberosity. This regional problem becomes apparent in the form of a hyperthermic pattern,
as can be seen in Figure 4 in which the right knee is affected. The preseason training
program includes excessive jumps, leading to mechanical strain and overuse of the patella
tendon. In this study, a total of seven athletes showed symptoms of regional overuse
reactions. The symptomatic athletes had a mean side temperature differences of
1.4°C. The normal temperature range of the eight non-injured athletes showed a
side-to-side variation of 0.3°C.
Thermal imaging in medicine is not new, but early investigation with old and insufficient
techniques has led to work with dubious results. Recent work with modern 21st century
technology has demonstrated the value of MIT in medical application when used as an
auxiliary tool. Knowledge about thermoregulation, anatomy, physiology, morphology and
pathophysiological processes is important to counteract inaccurate diagnoses. The aim of
this technique is not to be a substitute for clinical examination but to enhance it. Further
research and follow-up studies are warranted to create databases for clinical
measurements and further determine its viability in real-world medical settings. Empirical
evidence of correlation between pathology and infrared imaging is essential to further
predict the value of MIR. It should be used as a multidisciplinary assessment tool by
experts from different fields. Based on the advantages of MIT as a non-invasive, nonradiating, low cost first-line detection modality, it should be applied in the field of sports
medicine as a pre-scan team assessment tool. The extension of sport specific databases
may further contribute to the detection of high risk athletes and help them to start early
intervention.
61
Nica AS, Mologhianu G, Murgu A, Mitoiu B, Lili M, Moise M. THERMOGRAPHIC
EVALUATION OF A YOUNG PATIENT WITH POSTTRAUMATIC SEQUELAE OF
LOWER LIMB.// Thermology international 22/2 (2012).
A patient suffered from an injury by falling (during a football game)) on October 15, 2011
resulting in double fracture of the right ankle. He was admittted to the orthopaedic
department, where fixation and osteosynthesis of the fractured medial and the lateral
malleolus were performed the course of recovery from the injury was favourable due the
surgical intervention and under the complex pharmacological treatment (antibiotic, anti inflammatory, anticoagulant.)The patientwas referred to the rehabilitation department one
month after surgery. Patient, with a posttraumatic and post surgical history, was evaluated
at the rehabilitation ward clinically from a functional point of view. The results of clinical
and functional assessment have been completed with imaging investigations: such as
ultrasound of the anterior-lateral right leg, radiographs of both legs including the ankle-foot
complex, and thermography to detect changes of the peripheral temperature distribution.
The patient underwent a comprehensive rehabilitation programme including electrotherapy
for pain reduction andmuscle stimulation and adapted exercise therapy. Thermography
was performed daily, before and after treatment, recording changes in thermal skin
reaction possibly inducedb y the rehabilitative interventions. The dynamics of thermal
activity were recorded and graphically and statistically analysed.
Sands A. W., McNeal R. J., Stone H.M. THERMAL IMAGING AND GYMNASTICS
INJURIES // Science of Gymnastics Journal. - Vol. 3 Issue 2: 5 – 12
Gymnasts have a relatively high injury rate and severity with highly qualified gymnasts
suffering the most. One of the common injuries in gymnastics is the overuse-type that
often remains latent until near the decisive moments of competition when the injury rises to
the level of incapacitation. Is there a technology and methodology available to monitor
gymnasts during development that can identify latent injuries and thus alert medical
personnel to potential performance-limiting problems at the earliest possible time? Imaging
consists of the use of a thermal camera to identify inflamed areas and asymmetric
temperature patterns. Thermal asymmetries are determined via thermal image and pain is
assessed with palpation, history, and subject identification. Video recordings are made of
the involved areas and recorded electronically for transfer to physicians, physical
therapists, and athletic trainers for further investigation and remediation. This is an
ongoing descriptive study of the use of thermal imaging on inflammation and injury in
gymnasts. Thermal differentiation of tissue areas is performed by visual inspection and
bilateral comparison of the thermal images. Thermal images show bilateral and tissue area
thermal differentials by differences in gray scale. This information discriminates injuries,
inflammation, and other conditions without invasive procedures. The ability to identify and
thus treat injuries while they are minor is a significant improvement over waiting until the
injuries become increasingly symptomatic and performancelimiting.
Thermal imaging has become a mainstay of our laboratory in assisting young athletes in
remaining injury free, making return-to-activity decisions, and collaborating with medical
personnel to identify, prevent and treat injuries and other conditions.
Seok Won Kim, Seung Myung Lee, Seong Heon Jeong. Validation of Thermography in the
Diagnosis of Acute Cervical Sprain // J Korean Neurosurg Soc 36: 297-301, 2004.
Objective: The diagnosis of acute cervical sprain was done based on rigidity in the cervical
area on X-ray and the symptoms reported by the patient so that it was difficult to
differentiate those patients who complain of cervical sprain for a secondary gain. Thus, the
present study is done for differential diagnosis of those fake patients who want the
diagnosis of cervical sprain for the purposes of financial gain using the thermography,
62
which is effective for objectifying pain by detecting the change in body temperature in the
area of pain.
Methods: This study was done in 327 patients who were admitted to the neurosurgery
department at Chosun University Hospital between January 1, 2001 to January 31, 2002,
mainly complaining of cervical pain from traffic accidents. According to the previous
methods of diagnosis, the presence of rigidity in the cervical region was determined on Xray and this result was compared with the result from thermal imaging.
Results: When the verbal numerical rating scale of patient's subjective pain was classified
into severe, moderate and mild, cold spot and disruption of normal thermographic shape
increased significantly on thermal imaging as the severity of pain increases.
Conclusion: Thermal imaging is not only effective for differentiating the presence or
absence of cervical pain but also for determining the pain severity, fake patients, and pain
recovery.
Postoperation monitoring
Thermal imaging was used to monitor patients after knee endoprosthesis (Lambiris
and Stoboy 1981, Mayr 1995, Glehr et al 2011, Romano et al 2011). Lambiris et al claimed
a high increase of temperature in case of infection after knee surgery and that the
temporary elevation of temperatures returns to normal values within 4 to 6 weeks
(Lambiris and Stoboy 1981). Mayr reported that the time to achieve normal temperatures
after knee surgery is at minimum 120 days, but thermal symmetry over the knee joints was
not achieved even after 10 months in some patients (Mayr 1995). A study from Italy
observed identical anterior knee temperature 90 days after total knee replacement (Glehr
et al 2011). Romano et al investigated patients with anterior knee pain which had
developed after implantation of an artificial knee joint 1–9 years previously (Romano C L,
Romano D, DellO´ ro F, Loguluso N and Drago L. Healing of surgical site after total hip
and knee replacements show similar thermographic patterns // J. Orthop. Traumatol.
2011. 12 81–6). The study participants had to walk 3 km prior to acclimatization to a room
temperature of 20ºC for 20 min. On the thermal image a reference temperature over the
patella was compared with the temperature readings at the painful knee site. Mean
temperature differences between painful and non-painful sites ranged between 0.8
and 0.9ºC. The authors claimed a diagnostic sensitivity of 100% and a specificity of
91.7% for painful sites at cut-off point of temperature difference between painful and nonpainful sites.
Glehr M, Stibor A, Sadoghi P, Schuster C, Quehenberger F, Gruber G, Leithner A,
Windhager R. Thermal Imaging as a Noninvasive Diagnostic Tool for Anterior Knee Pain
Following Implantation of Artificial Knee Joints // International Journal of
Thermodynamics. - Vol. 14 (No. 2), pp. 71-78, 2011.
In this article we present for the first time a direct correlation between an increase in skin
temperature and existent frontal (anterior) knee pain after implantation of artificial knee
joints measured with thermography. In a standardised way 26 knees were analysed.
Temperatures in locations with pain were significantly higher compared to the reference
field in inner location (median 0.95°C, p=0.0043), as well as in outer location (median
0.5°C, p=0.032). Median temperature difference between pain localization and
localizations without pain was 0.7°C and ranged from 0.1°C to 1.7°C. In the receiver
operating characteristic (ROC) analysis the sensitivity of this method was 1.0 and
specificity was 0.917. The evidence of a significant increase in skin temperature on the
painful sites opens up the possibility to localize and assess pain more precisely in patients
with joint prosthesis. We consider this novel, rapid, inexpensive and non-invasive
technology to posses the potential to become a useful and objective tool for diagnosis of
63
pain and inflammation and to generate digital data that can be stored and analysed in
clinical practice.
Haidar S.G., Charity R.M., Bassi R.S., Nicolai P., Singh B.K. Knee skin temperature
following uncomplicated total knee replacement // The Knee. - Volume 13, Issue 6,
December 2006, Pages 422–426. (http://www.sciencedirect.com/science/article/pii/
S0968016006001384).
This prospective study aimed to establish the pattern of knee skin temperature following
uncomplicated primary total knee replacement. Thirty-two patients were included. The skin
temperature of operated and contralateral knees was measured preoperatively and daily
during the first 6 weeks postoperatively. Measurements were also taken at 3, 6, 12 and
24 months following surgery. The difference in temperature between the two knees had a
mean value of +2.9°C at 7 days. This mean value decreased to +1.6°C at 6 weeks, +1.3°C
at 3 months, +0.9°C at 6 months +0.3°C at 12 months and +0.0°C at 24 months. Following
uncomplicated total knee replacement, the operated knee skin temperature increases
compared to the contralateral knee. The difference decreases gradually but remains
statistically significant up to at least 6 months following surgery. In the absence of other
features of infection, local knee warmth should not cause concern.
Honsawek S., Deepaisarnsakul B., Tanavalee A., Sakdinakiattikoon M., Ngarmukos S.,
Preativatanyou K., Bumrungpanichthaworn P. Relationship of serum IL-6, C-reactive
protein, erythrocyte sedimentation rate, and knee skin temperature after total knee
arthroplasty: a prospective study // International Orthopaedics (SICOT) (2011) 35:31–35.
Knee osteoarthritis is a common cause of severe pain and functional limitation. Total knee
arthroplasty is an effective procedure to relieve pain, restore knee function, and improve
quality of life for patients with end stage knee arthritis. The aim of this study was to
investigate the inflammatory process in patients with primary knee osteoarthritis before
surgery and in subsequent periods following total knee arthroplasty. A prospective study of
49 patients undergoing primary total knee replacements was conducted. The patients were
evaluated by monitoring serum interleukin-6 (IL-6), C-reactive protein (CRP), erythrocyte
sedimentation rate (ESR), knee skin temperature, and clinical status. Measurements were
carried out preoperatively and postoperatively on day one and at two, six, 14, and 26
weeks during follow-up review in the knee clinic. The serum IL-6 and CRP were elevated
on the first postoperative day but fell to preoperative values at two weeks postoperatively.
Both returned to within the normal range by six weeks postoperatively. In addition, the
postoperative ESR showed a slow rise with a peak two weeks after surgery and returned
to the preoperative level at 26 weeks postoperatively. The difference in skin temperature
between operated and contralateral knees had a mean value of +4.5°C at two weeks. The
mean value decreased to +3.5°C at six weeks, +2.5°C at 14 weeks, and +1.0°C at 26
weeks. The difference in skin temperature decreased gradually and eventually there was
no statistically significant difference at 26 weeks after surgery. A sustained elevation in
serum IL-6, CRP, ESR and skin temperature must raise the concern of early complication
and may suggest the development of postoperative complication such as haematoma
and/or infection.
Mehra A., Langkamer V.G., Day A., Harris S., Spencer R.F. C reactive protein and skin
temperature post total kneereplacement // The Knee. – Volume 12, Issue 4, August 2005,
Pages
297–300.
(http://www.sciencedirect.com/science/article/pii/
S0968016004001954#SECX1)
We prospectively assessed 20 patients following uncomplicated total knee replacement
(TKR). Clinical status, skin temperature and C-reactive protein (CRP) were measured
preoperatively and at intervals up to 18 weeks. The CRP rose postoperatively up to 5–7
64
days but returned to normal values by 6 weeks. The skin temperature remained elevated
up to 18 weeks. We concluded that in uncomplicated cases, the CRP should be within
normal limits by 6 weeks after operation, but skin temperature may remain elevated up to
18 weeks. Highly statistically significant differences were found across the category means
of both knee (F(1,18)=40.06; p<0.001) and time (F(3,54)=11.94; p<0.001). In addition, a
highly significant interaction effect was also found between knee and time (F(3,54)=31.65;
p<0.001), indicating a different pattern of change in knee temperature over time for the
operated knee compared with the control knee. A sustained rise in these values may
indicate the development of a complication such as infection and the patient must be
closely monitored.
Piñonosa S., Sillero-Quintana M., Milanović L., Coterón J., Sampedro J. THERMAL
EVOLUTION OF LOWER LIMBS DURING A REHABILITATION PROCESS AFTER
ANTERIOR CRUCIATE LIGAMENT SURGERY. - Kinesiology 45(2013) 1:121-129.
Infrared thermography (IRT) is a safe and non-invasive tool used for examining
physiological functions based on skin temperature (Tsk) control. The aim of this paper was
to establish the probable thermal difference between the beginning and the end of the
anterior cruciate ligament (ACL) rehabilitation process after surgery. For this purpose
thermograms from 25 ACL surgically operated patients (2 women, 23 men) were taken on
the first and last day of a six-week rehabilitation program. A FLIR infrared camera
according to the protocol established by the International Academy of Clinical Thermology
(IACT). The results showed significant temperature increases in the posterior thigh area
between the first and the last week of the rehabilitation process probably due to a
compensatory mechanism. According to this, we can conclude that temperature of the
posterior area of the injured and non-injured leg has increased from the first to the last day
of the rehabilitation process.
Romanò CL, Logoluso N, Dell'oro F, Elia A, Drago L. Telethermographic findings after
uncomplicated and septic total knee replacement. // The Knee. – 2011 Mar 25.
Thermal imaging with infrared thermography is a noninvasive approach to monitoring
surgical site healing and detecting septic complications. The aim of this study was to set
reference values for telethermographic patterns of wound healing after total knee
replacement (TKR) not complicated by infection and to compare them against
thermograms from patients with knee prosthesis infection. Forty consecutive patients
operated for TKR underwent telethermography of the operated and the contralateral knee
before and up to 12 months after uncomplicated surgery. The imaging data sets were then
compared against those obtained starting 8months after TKR in 15 other patients with
diagnosed periprosthetic infection. Presurgical assessment thermograms showed no
difference between the affected and the healthy knees. At assessment 3days
postoperative, the temperature of the operated knee had increased markedly, with a peak
differential temperature (operated minus non-operated knee joint temperature) of
3.4±0.7°C; measurement at 90 days after surgery showed a return to baseline knee joint
temperature in the patients with uncomplicated surgery. In the patients with septic
complications, the mean differential temperature was 1.6±0.6°C (range, 1.1-2.5°C).
Thermal imaging showed a measurable, reproducible telethermographic pattern of surgical
site healing in patients with uncomplicated TKR and an elevated mean differential
temperature >1.0°C in those with persistent prosthesis infection.
65
Thermo-monitoring conditions
In the article, Ring E.F.J and Ammer K. (Ring EFJ, Ammer K. The Technique of
Infra red Imaging in Medicine // Thermology international 10/1 (2000) – Р. 7-14.) describe
the conditions that should be followed at thermovision examination.
1) A camera stand which provides vertical height adjustment is very important for
medical thermography. Photographic tripod stands are inconvenient for frequent
adjustment and often result in tilting the camera at an undefined angle to the patient. This
is difficult to reproduce, and unless the patient is positioned so that the surface scanned is
aligned at 90º to the camera lens, distortion of the image is unavoidable.
Solution of the problem is point by point measurements, which can be realized with
the Smart ThermoGraph device (Fig. 9).
Fig. 9.
2) Human skin temperature is the product of heat dissipated from the vessels and
organs within the body, and the effect of the environmental factors on heat loss or gain.
There are a number of further influences which are controllable, such as cosmetics (Engel
J-M. Physical and Physiological Influence of Medical Ointments of Infrared thermography.
In: Ring EFJ Phillips B, editors, Recent Advances In Medical Thermology. New York.;
Plenum Press,. 1984. p.177-184), alcohol intake (Mannara G; Salvatori GC; Pizzuti GP.
Ethyl alcohol induced skin temperature changes evaluated by thermography. Preliminary
results. Boll Soc Ital Biol Sper 1993 69/10:587-94) and smoking (Usuki K; Kanekura T;
Aradono K; Kanzaki T Effects of nicotine on peripheral cutaneous blood flow and skin
temperature. J Dermatol Sci 1998; 16/3:173-81). These should form part of the request
made to the patient when calling him or her for examination. In general terms the patient
attending for examination should be advised to avoid all topical applications such as
ointments (Hejazi S, M.Anbar. Effects of topical skin treatment and of ambient light in
infrared thermal images. Biomedical Thermology 1993, 12: 300-305) and cosmetics on the
day of examination to all the relevant areas of the body. Large meals and above average
intake of tea or coffee should also be excluded, although studies supporting this
66
recommendation are hard to find and the results are not conclusive (34,35,36). Patients
should be asked to avoid tight fitting clothing, and to keep physical exertion to a minimum.
This particularly applies to methods of physiotherapy such as electrotherapy (Mayr H, Thür
H., Ammer K. Electrical Stimulation of the Stellate Ganglia. In: Ammer K., Ring EFJ,
editors, : The Thermal Image in Medicine and Biology, Wien Uhlen, Verlag, 1995, p.206209.), ultrasound (40), heat treatment (Rathkolb O, Ammer K. Skin Temperature of the
Fingers after Different Methods of Heating using aWaxBath. Thermol Österr 1996, 6: 125129), cryotherapy (Dachs E, Schartelmüller T, Ammer K: Temperatur zur Kryotherapie und
Veränderungen der Hauttemperatur am Kniegelenk nach Kaltluftbehandlung. Thermol
Österr 1991; 1: 9-14), massage (Eisenschenk A, Stoboy H: Thermographische Kontrolle
physikalisch-therapeutischer Methoden. Krankengymnastik 1985; 37: 294) and
hydrotherapy (Ring EFJ, Barker JR, HarrisonRAThermal Effects of Pool Therapy on the
Lower Limbs. Thermology. 1989;3:127-131) because thermal effects from such treatment
can last for 4-6 hours under certain conditions . Heat production by muscular exercise is a
well documented phenomenon (Ammer K. Low muscular acitivity of the lower leg in
patients with a painful ankle Thermol Österr 1995, 5: 103-107). Drug treatment can also
affect the skin temperature. This phenomenon was used to evaluate the therapeutic
effects of medicaments (Ring EFJ, Engel JM, Page -Thomas DP Thermologic methods in
Clinical Pharmacology – Skin Temperature Measurement in Drug Trials, Int. J Clinical
Pharmacol Therapy & Toxicology 1984; 22: 20-24.). Drugs affecting the cardiovascular
system (Natsuda H; Shibui Y; Yuhara T; Akama T; Suzuki H, Yamane K; Kashiwagi H.
Nitroglycerin tape for Raynaud’s phenomenon of rheumatic disease patients—an
evaluation of skin temperature by thermography. Ryumachi 1994;34(5):849-53) must be
reported to the thermographer, in order that the correct interpretation of thermal images
will be given. On arrival at the department, the patient should be informed of the
examination procedure, instructed to remove appropriate clothing and jewellery, and asked
to sit or rest in the preparation cubicle for a fixed time. The time required to achieve
adequate stability in blood pressure and skin temperature is generally considered to be 15
minutes, with 10 minutes as a minimum (Ring EFJ. Computerized thermography for osteoarticular diseases. Acta thermographica 1976, 1:166-173). A range of temperatures from
18°C to 25°C should be attainable. Good technique is essential with infra-red imaging,
which is a physiological procedure. Attention to details as described will improve
physicians ability to use the technique as a diagnostic aid and for monitoring change from
treatment or from the natural course of the disease.
Recommendations for the use of the Smart ThermoGraph device include all these
facts, and the following minimal mandatory conditions of self-examination are listed for the
user:
 The room temperature is from 20 to 24°C
 There are no air drafts in the room
 Air conditioner and/or heater are turned off or situated far enough and are not
directed at me
 The examined area of the body has been freed from clothes or bandages for at
least 10 minutes
 I'm in a comfortable and relaxed position
 I did not touch the examined area of the body with hands during the past 10 minutes
The major problem with thermography is the requirement of a temperature
controlled room for the 15 minutes patient cooling period (thermo-adaptation period)
(DEVEREAUX M.D., PARR G.R., PAGE THOMAS D.P., HAZLEMAN B.L. Disease activity
indexes in rheumatoid arthritis; a prospective, comparative study with thermography //
Annals of the Rheumatic Diseases, 1985, 44, 434-437.). In home conditions, these
requirements are met simpler than in the conditions of medical facility, especially if the
67
user conducts temperature measurements in the morning, before taking medications,
application of ointments, and other.
Conclusion
Thus, the aggregate of collected and analyzed information makes it obvious that
methods of using of the Smart ThermoGraph device with the Smart ThermoGraph
software are based on previously known studies published in open sources (peer-reviewed
medical journals). Therefore, there is no need for the additional medical tests of the Smart
ThermoGraph device with the Smart ThermoGraph software.