Infrared thermography and shoulder pain in wheelchair users ...

Universidad Politécnica de Madrid

Facultad de Ciencias de la Actividad Física y el Deporte (INEF)

Termografía infrarroja y dolor de hombro en usuarios

de sillas de ruedas

Infrared thermography and shoulder pain in wheelchair

users

Tesis Doctoral con Mención Internacional / International PhD Thesis

Isabel Rossignoli Fernández

Licenciada y Máster en Ciencias de la Actividad Física y del Deporte

Master of Science in Adapted Physical Activity

Madrid, 2015

Isabel Rossignoli 2015

II

Isabel Rossignoli, 2015

Título: Termografía infrarroja y dolor de hombro en usuarios de sillas de ruedas. Infrared

thermography and shoulder pain in wheelchair users

Universidad Politécnica de Madrid 2015

Editorial: FUNDACIÓN GENERAL DE LA U.P.M.

www.fgupm.es

ISBN: 978-84 608-4845-5

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DEPARTAMENTO DE SALUD Y RENDIMIENTO HUMANO

FACULTAD DE CIENCIAS DE LA ACTIVIDAD FÍSICA Y DEL DEPORTE (INEF)

Termografía infrarroja y dolor de hombro en usuarios

de sillas de ruedas

Infrared thermography and shoulder pain in wheelchair

users


Licenciada y Máster en Ciencias de la Actividad Física y el Deporte

Master of Science in Adapted Physical Activity

DIRECTORES DE TESIS

Pedro José Benito Peinado

PhD

Prof. Titular de Universidad

Universidad Politécnica de

Madrid

Azael Juan Herrero Alonso

PhD

Prof. Titular de Universidad

Universidad Europea Miguel de

Cervantes

Madrid, 2015


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MIEMBROS DEL TRIBUNAL

Tribunal nombrado por el Magfco. y Excmo. Sr. Rector de la Universidad

Politécnica de Madrid, el día ____________________________________________________________

Presidente D. _____________________________________________________________________________

Vocal D. ___________________________________________________________________________________

Vocal D. ___________________________________________________________________________________

Vocal D. ___________________________________________________________________________________

Secretario D. _____________________________________________________________________________

MIEMBROS DEL TRIBUNAL SUPLENTES

Vocal D. ___________________________________________________________________________________

Vocal D. ___________________________________________________________________________________

Realizado el acto de defensa y lectura de Tesis el día _________________________________

en _________________________________________________________________________________________

Calificación: ______________________________________________________________________________

EL PRESIDENTE LOS VOCALES

EL SECRETARIO


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A mi abuela ‘grande’

“El futuro tiene muchos nombres: para el débil es lo inalcanzable, para el miedoso lo desconocido. Para el valiente, la oportunidad”

(Víctor Hugo)

"Valiente no es el que no tiene miedo, sino el que lucha y se enfrenta a sus miedos" (Isabel Rossignoli)


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AGRADECIMIENTOS

Winston Churchill, político británico y premio novel Laureate, afirmó “success is the ability

to go from one failure to another with no loss of enthusiasm”. Allí donde el entusiasmo falla,

las fuerzas flaquean, o las zancadillas aparecen, es el punto de encuentro con muchas

personas, que intencional o fortuitamente me han echado una mano o directamente no han

dudado en sostenerme entre sus brazos. Al final de una tesis empieza una nueva etapa.

Espero compartirla de nuevo con vosotros.

Mi director, pero sobretodo mi amigo, Pedro J. Benito. Lo que no aparece en tu curriculum

es justo lo que más valor tiene, me quedo con tu ejemplo de honestidad, honradez y

perseverancia. Eres un referente para alumnos y profesores, pero sobretodo eres un modelo

como persona. Te estaré siempre agradecida por todo el apoyo recibido cuando más lo he

necesitado, por tu comprensión cuando perdía la serenidad, y por tus consejos humanos y

profesionales (me quedo con tu sabiamente repetida frase ante cualquier problema:

“seamos pragmáticos”).

Azael J. Herrero, muchísimas gracias por confiar en mí, sin conocerme me abriste las puertas

del CIDIF, me ofreciste todo tu equipo, y me aconsejaste en numerosas ocasiones. Gracias

también por presentarme a los compañeros del CIDIF, Juancho Martín, Héctor Alegre, Pedro

Marín, que me recibieron con los brazos abiertos y me brindaron todos sus conocimientos y

apoyo. Nunca disfruté y aprendí tanto en una toma de datos como esos intensos 5 meses en

Valladolid. Mi agradecimiento se extiende a todos los 55 sujetos que participaron

voluntariamente en la aventura de someterse a 11 test, ¡algunos hasta 2 veces! Tanto los

jugadores del MUPLI y de la Fundación Grupo Norte, como los residentes de ASPAYM

Castilla y León, gracias por vuestra generosidad y todas las conversaciones compartidas.

Manuel Sillero Quintana, el terremoto del INEF. Siempre dejando huella por donde pasas.

¿Cuántas personas habrán recibido tu ayuda en el INEF? Incontables. Incansable trabajador,

abierto a dar y recibir conocimiento de quien fuese. Muchísimas gracias por compartir tu

entusiasmo, energía, y por brindarme tu ayuda en numerosas ocasiones.

Aplicando el refrán, “dime con quién andas y te diré quién eres”, puedo enorgullecerme de

“andar” con lo mejorcito del INEF, y es que todos sus rincones me han regalado personas

fantásticas. Empezando por mi equipo de fabulosas y empollonas: Ana Paz Bermúdez, Ana

Belén Peinado, Cristina Vintaned, Marta Rodelgo y Rosa Mª Valera. Hemos compartido todas

las clases, prácticas, estudios, dudas, y cuando ya no quedaban años de clases, seguimos

compartiendo historias de novios, hijos, oposiciones, viajes… Os llevo con mucho cariño en

mi maleta. Rocío Cupeiro y Helena la chula, mis coaches particulares. Cada encuentro es una

charla de crecimiento, es un sincero abrir el corazón. Sin duda habéis caminado de la mano

de esta tesis y no sería igual sin vosotras. Mi rincón favorito del INEF, la biblioteca, donde

Minerva siempre me guarda un rato para una charla cariñosa y Gloria me pasaba los

artículos y compartía sueños de escaladas pirenaicas. El INEF tiene mucho que ofrecer no

solo en las clases, también en sus laboratorios, y he tenido la suerte de pasar mucho tiempo


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en varios. El laboratorio de Fisiología del Esfuerzo, donde Irma Lorenzo, Mercedes Galindo y

Javier Calderón transformaron las pruebas de esfuerzo en el más emocionante de los tests

deportes. Gracias por vuestras enseñanzas, amor a la ciencia y momentos compartidos.

Javier Brutragueño, tus palabras el día de tu defensa realmente me hicieron cambiar el chip

para conseguir disfrutar esta última etapa afrontando con alegría el estrés. El laboratorio de

termografía, antes pemaGroup y ahora ThermoHuman; Manolo me invitó a entrar y allí me

atraparon las risas, compañerismo y hospitalidad de Miguel ‘miarma’, Ismael Fernández,

Peter Gómez, Sergio ‘canicas’ Piñonosa y Javier Arnaiz. Empezamos de cero y el sueño

continua, gracias Javier por resucitarlo. Gracias Miguel por hacer el INEF un poco más

divertido y humano. Gracias Isma por tus palabras de ánimo y todo tu apoyo en esta última

etapa. Gracias Peter por tu ejemplo de liderazgo, por tus consejos, pero sobre todo, por tus

bromas. Clemens Ley y María Rato me inspirasteis en mis comienzos del doctorado siendo

modelo de solidaridad, esfuerzo, rigurosidad, e impulso para realizar los voluntariados en

deporte adaptado en Guatemala y Argentina. Gracias por presentarme al grupo DIM. Me

llevo con cariño las enseñanzas y el tiempo compartido con muchos profesores: Javier

Durán, Carlos Cordente, Alberto García, Jose Antonio García de Mingo, Javier Rojo,

Guadalupe Garrido, Alfonso López, Enrique López, José Aparicio, Vicente Gómez, Cristina

López, Isabel Rico, Isabel Martín, Mª José Gómez… Mil gracias Andrés desde secretaría por

salvar el pellejo de los alumnos todos los días. Gracias Gador, que has ejercido de madre en

el INEF empujándome a terminar pronto la tesis.

La tesis empezó en Madrid y decidió viajar. En el Erasmus Mundus Master in Adapted

Physical Activity aprendí de la mano de grandes profesores y científicos a nivel internacional,

sus enseñanzas y trabajos fueron fuente de inspiración para esta tesis. In particular, Sean

Tweedy thanks for trusting me and for supervising the master’s thesis in Australia, you

taught me to dream high and to see the international perspective of the Paralympic

Movement, many thanks for your teaching in the data collection of Kenya. Thanks Alice

Niewbouer for your patience, empathy and feedback to the master’s thesis. Viajar es el

mejor de los aprendizajes, el máster me regaló la oportunidad de recorrer varios países.

Empezando por Bélgica, donde tuve la suerte de tener por compañeras y buenas amigas a

Erika Ermacora, Andreea Dragos y Julie Jayapal, gracias por vuestra dulzura y cuidados;

Noruega me abrió un mundo de posibilidades en la utilización del deporte como medio de

rehabilitación, me permitió aplicar los conocimientos adquiridos, tratar a bellísimas

personas con diversidad de discapacidades que me dejaron “experimentar” a través del

deporte adaptado, y convivir con geniales compañeras que me ayudaron a progresar

profesionalmente: gracias Lieke de Vries, Kate Goble, Maud Rubinstein, y especialmente

Rinske de Jong, me llevo el mejor de los recuerdos. De las prácticas en Noruega salté a la

investigación aplicada en Australia. Thousand thanks Hedda Giorgi (Brooks) for the time

spent together in Brisbane, for taking care of my in the distance, for your advices and your

example as a researcher, let’s toast for future trips and projects together. After all your

feedback this thesis is also yours. Gracias Coni Galleguillos y Eva Madrid por vuestra especial

amistad, hicisteis Nueva Zelanda mucho más hogareña, sin duda me ayudó a trabajar en la

tesis.

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Muchas más personas me apoyaron de alguna manera o fueron fuente de inspiración,

durante el máster de EMMAPA, el máster del INEF o en Magisterio de EF, así como durante

las clases en la UCJC y en la ENE. Me faltan palabras en estos agradecimientos y temo

dejarme a alguien en el tintero (que no en el corazón). Gracias Pablo González, Antonio Cala,

Rafita Blanco, Raúl Reina, Jorge Couceiro, Lola Moreno, Mª Jesús Perea, Margarita Alcaide,

Juan Camilo, César Uribe, Marga Gual, Rossina Colista, Javi Argüelles, Johanna P, Rebecca

Deuble, Virginia Zamorano, cada uno pusisteis un granito de esta tesis de muy diversas

formas.

Una tesis no se puede llevar a cabo sin la comprensión y apoyo de los más cercanos. La

personalidad, los valores, las virtudes y vicios de cada investigador dan también carácter a

alguna pieza del puzle que es la tesis. Muchas de las características personales se forman a

base de conversaciones con amigos grandes que te hace crecer. Porque “el viaje más largo

es el que se hace hacia el interior de uno mismo”, gracias por todas las charlas y tiempo

compartido Javier Martín de Villa, Eugenio Amor, Roberto Sayalero, Ero Silva, os debo parte

de lo que soy. Gracias a los que quedándose en España y desde la distancia, me habéis

enviado cariño y mimos vía Skype: Ana Alonso, Magda Trzpis, Kike Cantos, Floren Cano. Si el

Judo me hizo luchadora, la escalada me enseña que la vida comienza fuera de tu zona de

confort. Sin duda tengo que agradecer a este deporte el darme la oportunidad de

enfrentarme a mis límites. Gracias a mis amigos escaladores que me han acompañado en mi

mejor y mi peor faceta, y por saber comprender que tenía que aparcar la roca un tiempo

para poder terminar la tesis, pronto volveremos a compartir y acumular buenos ratos: Félix,

Marta, Vari, Hilá, Edu, Raph, Gerar, Bea, Pablo, Nuria, Itzi, Elena, Carlos, Juanan, Eli, Jorge,

Nick, Ryan, Tania, y todos los forestales: Jorge, Cris, Eva, Sergio, Asun, Luisa, Ibone, Maribel,

Sara… Especialmente gracias a Fred, que pacientemente ha escuchado la presentación de la

tesis.

Mi fuente de inspiración, la razón de por qué sigo investigando en el mundo del deporte

adaptado, son los propios atletas. Gracias por todo lo que enseñáis al mundo: Urko

Carmona, Pipo, Paula de la Calle, Juan Antonio Bellido, Simone Salvagnin, Francesca

Porcellato, Gema Hassen-bey, Raphael Nishimura, Ronnie Dickson, Bethany Hamilton…

Dentro de este grupo de excelentes deportistas, no puedo olvidar al equipo Fundosa ONCE,

quienes me ofrecieron su tiempo y esfuerzo para realizar los tests del estudio del DEA.

Argentina: donde me llamó el amor. Allí me encerré analizando termogramas durante

meses. Mis suegros, Liliana y Raúl, no dudaron ofrecerme su casa y hacer más fácil mi

estancia para poder analizar los datos en el mejor ambiente posible. Gracias por vuestra

comprensión y paciencia, sobretodo este verano. Me llevo en mi maleta bonaerense un

montón de buenos aprendizajes con los chicos de la Casa Ceferino, a quienes la vida les

golpeó en la calle y ellos le devuelven alegría. Buenos Aires está para siempre asociada a

facturas con dulce de leche, mate entre boulders, infinitas horas de subte…, pero sobre todo

tiene cara de amistad: Negro, Pauli, Gastón, Lu, William, Mateico, Pablo, Nati, Mamo,

Nobile, Richard, Marisa… nos vemos pronto.


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Mi casa durante dos años y medio tiene nombre alemán, Bonn. Trabajando como

responsable de investigación en el Comité Paralímpico Internacional (IPC) aprendí lo que los

libros no muestran ni las clases enseñan. Si la tesis tuvo que ser aparcada temporalmente,

fue para participar en otras numerosas investigaciones dentro del movimiento paralímpico.

Lo mejor sin duda fue conocer y aprender de atletas paralímpicos, entrenadores,

clasificadores, investigadores y muy especialmente de los miembros del Classification

Committee del IPC. It is impossible to mention everybody, but I would like to particularly

express my gratitude to my collagues from the Medical & Scientific Department: Peter Van

de Vliet, Greg Vice, Cris Gomes, Julia Rauw, Vanessa Webb, Bee O Callaghan. Thanks for your

unconditional friendship Heike, living in Bonn would be much more complicated without

you, thanks for making the complex German bureaucracy a little bit more understandable

and for your blind faith in myself. Alba Roldán, o el comienzo de una gran amistad,

espontaneidad y humildad, trabajadora como nadie, te mereces de lo bueno lo mejor. Anna

Sagarra, siempre dispuesta a echar un cable, gracias por rescatarme la noche anterior a mi

boda. Jose Gigante, mil gracias por tu hospitalidad y calurosa acogida. Gracias María

Carballeira por cada conversación compartida que me hizo crecer como persona. The best of

traveling is that you meet amazing people. Many of them have supported this thesis in a

direct or indirect way. Sash Ramírez-Hughes, thanks for teaching me a bit of your crappy

English and for your corrections. Steph La Hoz Theuer, a quién admiro por tu inteligencia y

tus ganas incansables de aprender. Chitro Chaudhuri, you’ll always be the strongest Indian in

Germany, thanks for your constant smile. Thanks all for your friendship: Vasily Kuznetsov,

Christopher Reeder, Nathan, Moremi, Jessica, Li, Lana, Pishum, Tina, Simon, Ulla, Roman,

Rosario, Sven, Vivien, y Sana. Thanks for your support when I have difficulties to combine my

job with my PhD work.

Después de mucho trotar, llenando la maleta de experiencias inolvidables y aprendizajes

que han hecho posible que hoy pueda defender esta tesis, por fin vuelvo a casa, donde están

aquellos a los que más tengo que agradecer, mi familia que siempre me espera. Gracias a

mis hermanos, Tomás, Javier, Susana, Pablo y Alberto, y a mis padres, por estar a mi lado

incluso (y sobretodo) en la distancia, por creer y confiar en mí. Gracias mamá por ser tan

luchadora y por aceptar que estos pies inquietos siempre quisiesen viajar. Gracias papá, por

recodarme que las personas van antes que todo lo demás, por tu bondad y comprensión,

gracias por nunca cortar mis alas.

Guille mi roca, todo paciencia y dulzura, no hay palabras para agradecer todo lo que has

hecho por mí, y como no te gustan las palabras, te lo agradeceré dedicándote todo el

tiempo que esta tesis nos ha robado.

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Dr. PEDRO JOSÉ BENITO PEINADO

Profesor Titular de Universidad

Departamento de Salud y Rendimiento Humano

Facultad de Ciencias de la Actividad Física y del Deporte

Universidad Politécnica de Madrid

PEDRO JOSÉ BENITO PEINADO, PROFESOR TITULAR DE LA UNIVERSIDAD

POLITÉCNICA DE MADRID, FACULTAD DE CIENCIAS DE LA ACTIVIDAD FÍSICA Y

DEL DEPORTE

CERTIFICA:

Que la Tesis Doctoral titulada “Termografía infrarroja y dolor de hombro en

usuarios de sillas de ruedas. Infrared thermography and shoulder pain in

wheelchair users” que presenta Dña. ISABEL ROSSIGNOLI FERNÁNDEZ al

superior juicio del Tribunal que designe la Universidad Politécnica de Madrid, ha

sido realizada bajo mi dirección durante los años 2009-2015, siendo expresión

de la capacidad técnica e interpretativa de su autora en condiciones tan

aventajadas que le hacen merecedora del Título de Doctor con Mención

Internacional, siempre y cuando así lo considere el citado Tribunal.

Fdo. Pedro José Benito Peinado

En Madrid, a 5 de Octubre de 2015


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Dr. AZAEL JUAN HERRERO

Profesor Titular de Universidad

Laboratorio de Fisiología

Facultad de Ciencias de la Salud

Universidad Europea Miguel de Cervantes

AZAEL JUAN HERRERO, PROFESOR TITULAR DE LA UNIVERSIDAD EUROPEA

MIGUEL DE CERVANTES, FACULTAD DE CIENCIAS DE LA SALUD

CERTIFICA:

Que la Tesis Doctoral titulada “Termografía infrarroja y dolor de hombro en

usuarios de sillas de ruedas. Infrared thermography and shoulder pain in

wheelchair users” que presenta Dña. ISABEL ROSSIGNOLI FERNÁNDEZ al

superior juicio del Tribunal que designe la Universidad Politécnica de Madrid, ha

sido realizada bajo mi dirección durante los años 2009-2015, siendo expresión

de la capacidad técnica e interpretativa de su autora en condiciones tan

aventajadas que le hacen merecedora del Título de Doctor con Mención

Internacional, siempre y cuando así lo considere el citado Tribunal.

Fdo. Azael Juan Herrero

En Madrid, a 5 de Octubre de 2015


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TABLE OF CONTENTS

LIST OF TABLES .............................................................................................................. XIX

LIST OF FIGURES ............................................................................................................ XXI

LIST OF ABBREVIATIONS ......................................................................................... XXIII

LIST OF PUBLICATIONS ............................................................................................. XXIV

RESUMEN ......................................................................................................................... XXV

ABSTRACT .................................................................................................................... XXVII

1 INTRODUCTION ............................................................................................................ 1

1.1 WHEELCHAIR USER’S SHOULDER ........................................................................................... 2 1.1.1 Shoulder joint mobility and scapular stability ........................................................... 2 1.1.2 Pathologies related to wheelchair propulsion ............................................................ 3 1.1.3 Prevalence of shoulder pain in wheelchair users ...................................................... 5 1.1.4 Etiology of shoulder pain in wheelchair users ........................................................... 7

1.1.4.1 Wheelchair ambulation ................................................................................................................. 7 1.1.4.2 Wheelchair transfers ................................................................................................................... 14 1.1.4.3 Musculoskeletal causes of shoulder pain and excessive load ................................... 15

1.2 TOOLS FOR SHOULDER PAIN EVALUATION .................................................................... 18 1.3 INFRARED THERMOGRAPHY ................................................................................................. 20

1.3.1 Concept and types ............................................................................................................... 20 1.3.2 Infrared thermography applications ........................................................................... 24 1.3.3 Factors influencing the application of infrared thermography in humans.. 30

1.3.3.1 Specific factors influencing the application of infrared thermography in people with disabilities ................................................................................................................................................. 32

1.3.4 Technique and protocol .................................................................................................... 33 1.3.5 Corporal symmetry and infrared thermography .................................................... 36

1.4 THERMOREGULATION .............................................................................................................. 39 1.4.1 Thermoregulation and exercise ..................................................................................... 40 1.4.2 Thermoregulation in people with spinal cord injury during exercise ........... 42

1.5 PHYSICAL ACTIVITY IN WHEELCHAIR USERS ................................................................ 47 1.6 OUTLINE OF THE PRESENT THESIS .................................................................................... 50

2 OBJECTIVES ................................................................................................................. 53

2.1 STUDY 1 ............................................................................................................................................ 53 2.2 STUDY 2 ............................................................................................................................................ 53 2.3 STUDY 3 ............................................................................................................................................ 53

3 MATERIAL AND METHODS .................................................................................... 54

3.1 STUDY DESIGN .............................................................................................................................. 54 3.2 SAMPLE ............................................................................................................................................ 54

3.2.1 Ethics norms followed in this study ............................................................................. 55 3.2.2 Inclusion and exclusion criteria ..................................................................................... 56 3.2.3 Demographic data of the studies 1 and 2 ................................................................... 56 3.2.4 Demographic data of the study 3 .................................................................................. 57

3.3 EQUIPMENT ................................................................................................................................... 57 3.3.1 Material for the thermographic evaluation ............................................................... 57 3.3.2 Material for the shoulder pain evaluation ................................................................. 58 3.3.3 Material for the register of the kinematic variables .............................................. 59

3.4 RESEARCH PERSONNEL ............................................................................................................ 61


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3.5 PROCEDURES ................................................................................................................................. 62 3.5.1 Study 1: Infrared Thermal Imaging .............................................................................. 62 3.5.2 Study 2: Infrared Thermal Imaging and The Wheelchair User Shoulder Pain Index…….. ................................................................................................................................................ 65 3.5.3 Study 3: Infrared Thermal Imaging, The Wheelchair User Shoulder Pain Index and the wheelchair propulsion test T-CIDIF ............................................................... 66

3.6 VARIABLES ..................................................................................................................................... 68 3.7 STATISTICAL ANALYSIS ............................................................................................................ 69

3.7.1 Study 1 ...................................................................................................................................... 69 3.7.2 Study 2 ...................................................................................................................................... 69 3.7.3 Study 3 ...................................................................................................................................... 70

4 RESULTS ....................................................................................................................... 71

4.1 STUDY 1: Reliability of infrared thermography in skin temperature evaluation of wheelchair users .................................................................................................................................. 71

4.1.1 Reliability of measurements ........................................................................................... 71 4.2 STUDY 2: Relationship between perceived shoulder pain and infrared thermography in wheelchair athletes and nonathletes ........................................................... 76

4.2.1 Comparison of thermography values in nonathletic and athletic subjects . 76 4.2.2 Comparison of shoulder pain in athletic and nonathletic subjects ................. 80 4.2.3 Relationship between thermography and shoulder pain ................................... 80

4.3 STUDY 3: Relationship between shoulder pain and skin temperature measured by infrared thermography in a wheelchair propulsion test ................................................... 81

5 DISCUSSION ................................................................................................................. 88

5.1 STUDY 1: Reliability of infrared thermography in skin temperature evaluation of wheelchair users .................................................................................................................................. 88 5.2 STUDY 2: Relationship between perceived shoulder pain and infrared thermography in wheelchair athletes and nonathletes ........................................................... 92 5.3 STUDY 3: Relationship between shoulder pain and skin temperature measured by infrared thermography in a wheelchair propulsion test ................................................. 100

6 CONCLUSIONS ........................................................................................................... 105

6.1 Conclusions study 1 ................................................................................................................... 105 6.2 Conclusions study 2 ................................................................................................................... 105 6.3 Conclusions study 3 ................................................................................................................... 106

7 LIMITATIONS ............................................................................................................ 108

8 FUTURE RESEARCH LINES .................................................................................... 111

9 REFERENCES ............................................................................................................. 113

10 APPENDIXES ............................................................................................................. 146

10.1 APPENDIX 1. Example of informed consent form ...................................................... 146 10.2 APPENDIX 2. Example of thermographic report ........................................................ 148 10.3 APPENDIX 4. Data collection information sheet for the subjects ........................ 150 10.4 APPENDIX 4. WUSPI test in English ................................................................................. 152 10.5 APPENDIX 5. WUSPI test in Spanish ................................................................................ 153

11 SUMMARIZED CV / CURRICULUM VITAE ABREVIADO ............................... 155

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LIST OF TABLES

Table 1. Prevalence of current SP and SP since wheelchair ambulation ................... 6

Table 2. Number of subjects per group ................................................................................. 55

Table 3. Group subject characteristics from studies 1 and 2 expressed by mean±Standard Deviation............................................................................................................ 56

Table 4. General characteristics of the weather station, model BAR-908-HG® (Oregon Scientific, Portland, Oregon) ..................................................................................... 58

Table 5. Rolling resistance to overcome depending on the subject's mass ........... 61

Table 6. Variables and their values ......................................................................................... 68

Table 7. Descriptive maximum values of the skin temperature profile on day 1, day 2 and between both the assessments of the analyzed area .................................. 72

Table 8. Descriptive average values of the temperature profile on day 1, day 2 and between both the assessments for each analyzed area .......................................... 74

Table 9. Interrater-reliability measures in terms of ICC and CV organized by general areas ...................................................................................................................................... 75

Table 10. Mean maximal values of regional skin temperature °C (±) standard deviations and absolute values of the side-to-side differences (ΔTsk) for the different skin areas of the study subjects. Results of Student’s t-test for the two measures .............................................................................................................................................. 75

Table 11. Results of unpaired t-test in nonathletic and athletic subjects. Mean °C (±) Standard Deviation of the maximum basal values registered in ROIs. It is showed the values of each body side (right vs. left) for each ROI .............................. 76

Table 12. Results of unpaired t-test in nonathletic and athletic subjects. Mean °C (±) Standard Deviation of the average basal values registered in the ROI. It is showed the values of each body side (right vs. left) for each ROI .............................. 77

Table 13. Results of unpaired t-test in nonathletic and athletic subjects. Mean °C (±) Standard Deviation of the side-to-side differences (ΔTsk) of maximum values between bilateral body areas in nonathletic and athletic subjects ............................ 79

Table 14. Results of unpaired t-test in nonathletic and athletic subjects. Mean °C (±) Standard Deviation of the side-to-side differences (ΔTsk) of average values between bilateral body areas in nonathletic and athletic subjects ............................ 79

Table 15. Descriptive values of the skin temperature (°C) of 22 ROIs in wheelchair athletes; repeated measures ANOVA correlation ...................................... 82

Table 16. Descriptive values of the side-to side differences (°C) of the 26 measured ROIs in wheelchair athletes; repeated measures ANOVA correlation 83

Table 17. Spearman Rho correlations between bilateral ΔTsk and shoulder pain…. .................................................................................................................................................... 84

Table 18. Descriptive values of the kinematic variables; Spearman Rho correlations between kinematic variables and shoulder pain ..................................... 86


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LIST OF FIGURES

Figure 1. Shoulder anatomy. From Morphopedics (272) ................................................. 3

Figure 2. Supraspinatus tendon rupture (left) and supraspinatus impingement and rotator cuff tendonitis (right). Adapted from ePainAssist (106) .......................... 4

Figure 3. Wheelchair propulsion technique parameters. The dots represent the trayectory of the hand. EA = end angle (°); HC = hand contact; HR = hand release; PA = push angle; SA = start angle. From Vanlandewijck et al. (422) ............................ 8

Figure 4. Mean muscle forces (only forces larger than 10 N) during the push phase (left) and recovery phase (right). From Veeger et al. (427) ................................ 9

Figure 5. The relationship between force direction and calculated net joint torques around shoulder and elbow. From Veeger et al. (432). .................................. 13

Figure 6. Sliding board (left) and sitting pivot transfer (right) for individuals with spinal cord injury. From Gagnon (129) ....................................................................... 14

Figure 7. The first medical thermographic device developed by Schwamm and Reeh in 1952, from Berz et al. (39) (above), and a modern high resolution thermographic camera VarioCAM®, from Jenoptik (193) (below) ........................... 22

Figure 8. Thermogram of a patient with allergic rhinitis detected with an early IRT camera, from Georgevici (136) (left), and a thermogram of a patient with hypothyroidism and inflamed carotid artery detected with a modern IRT camera, from Möhrke (271) (right) ........................................................................................................... 23

Figure 9. Thermograms with TotalVision™ Anatomy Software. From Möhrke (271) ...................................................................................................................................................... 23

Figure 10. Classification of IRT-related factors in humans by Fernández (113) 30

Figure 11. Physiologic thermoregulation in humans. A, Increases in internal and/or skin temperatures are identified by the preoptic/anterior hypothalamus (PO/AH) and result in increased heat dissipation via cutaneous vasodilation and sweating, which then corrects an increase in temperature. B, Decreased skin or internal temperature causes reflex decreases in heat dissipation (cutaneous vasoconstriction) and increased heat generation (through shivering) to correct a decrease in temperature. CNS = central nervous system. From Charkoudian (60)… ..................................................................................................................................................... 40

Figure 12. Thigh, Calf, Forearm, and Upper Arm skin temperatures for able-bodied (AB), paraplegic (PA), and tetraplegic (TP) athletes during prolonged exercise and recovery in warm conditions. From Price (317) ..................................... 46

Figure 13. IRT camera T335 (FLIR® Systems, Sweden) ............................................... 57

Figure 14. Elite wheelchair athlete ready to perform the wheelchair propulsion test (T-CIDIF) ..................................................................................................................................... 60

Figure 15. T-CIDIF. Left: detail of the linear position transducers integrated with the fitness pulley. Right: detail of the gloves fixed to the forearm. ............................ 61

Figure 16. Thermographic analysis of an athlete (left) and a nonathlete (right)62


XXII

Figure 17. A total of 16 areas on the front body were studied in the study 1. Example from a wheelchair athlete ......................................................................................... 63

Figure 18. A total of 20 areas on the rear body were studied in the study 1. Example from a wheelchair athlete ......................................................................................... 64

Figure 19. Measurements of the study 3. Pre-test, thermographic evaluation before the wheelchair exercise test; Post-test, thermographic evaluation one minute after completing the wheelchair exercise test; Post-10, thermographic evaluation ten minutes after completing the wheelchair exercise test .................... 67

Figure 20. Day-to-day analysis of the reliability in all body areas measured ...... 73

Figure 21. Mean and standard deviation of the average and maximum basal skin temperature (Tsk) values .............................................................................................................. 78

Figure 22. Mean and standard deviation of the average and maximum basal side-to-side skin temperature (ΔTsk) values ........................................................................ 78

Figure 23. Manual drawing of the regions of interest ................................................. 108

Figure 24. The impact of different backrest on the thermal image. Backrest size is dependent upon the impairment of the subject .......................................................... 110

PhD thesis

XXIII

LIST OF ABBREVIATIONS

BMI Body Mass Index

CRT Circuit resistance-training

CV Coefficient of Variation

FES Functional electrical stimulation

ICC Interclass Correlation Coefficient

IRT Infrared Thermography

°C Degrees Celsius

Pre-test Thermographic evaluation before the wheelchair

exercise test

Post-test Thermographic evaluation one minute after

completing the wheelchair exercise test

Post-10 Thermographic evaluation ten minutes after

completing the wheelchair exercise test

ROI Region of Interest

SCI

SD

Spinal Cord Injury

Standard Deviation

SP Shoulder pain

Tsk Skin Temperature

WCUs Wheelchair Users

WUSPI Wheelchair Users Shoulder Pain Index

∆Tsk Side-to-side skin temperature difference


XXIV

LIST OF PUBLICATIONS

The content of this thesis is included in the following articles:

I - Rossignoli I, Benito PJ, Herrero AJ. Reliability of infrared thermography in skin

temperature evaluation of wheelchair users. Spinal Cord. 2014;53:243-8.

II - Rossignoli I, Herrero AJ, Menéndez H, Sillero M, Benito PJ. Relationship

between perceived shoulder pain and infrared thermography in wheelchair

athletes and nonathletes. Disability and Health Journal. (Submitted)

III - Rossignoli I, Fernández-Cuevas I, Benito PJ, Herrero AJ. Relationship

between shoulder pain and skin temperature measured by infrared

thermography in a wheelchair propulsion test. Infrared Physics and Technology.

(Submitted)

PhD thesis

XXV

RESUMEN

Las personas que usan la silla de ruedas como su forma de movilidad prioritaria

presentan una elevada incidencia (73%) de dolor de hombro debido al sobreuso

y al movimiento repetitivo de la propulsión. Existen numerosos métodos de

diagnóstico para la detección de las patologías del hombro, sin embargo la

literatura reclama la necesidad de un test no invasivo y fiable, y sugiere la

termografía como una técnica adecuada para evaluar el dolor articular. La

termografía infrarroja (IRT) proporciona información acerca de los procesos

fisiológicos a través del estudio de las distribuciones de la temperatura de la piel.

Debido a la alta correlación entre ambos lados corporales, las asimetrías

térmicas entre flancos contralaterales son una buena indicación de patologías o

disfunciones físicas subyacentes. La fiabilidad de la IRT ha sido estudiada con

anterioridad en sujetos sanos, pero nunca en usuarios de sillas de ruedas. Las

características especiales de la población con discapacidad (problemas de

sudoración y termorregulación, distribución sanguínea o medicación), hacen

necesario estudiar los factores que afectan a la aplicación de la IRT en usuarios

de sillas de ruedas.

La bibliografía discrepa en cuanto a los beneficios o daños resultantes de la

práctica de la actividad física en las lesiones de hombro por sobreuso en usuarios

de sillas de ruedas. Recientes resultados apuntan a un aumento del riesgo de

rotura del manguito rotador en personas con paraplejia que practican deportes

con elevación del brazo por encima de la cabeza. Debido a esta falta de acuerdo

en la literatura, surge la necesidad de analizar el perfil termográfico en usuarios

de sillas de ruedas sedentarios y deportistas y su relación con el dolor de

hombro. Hasta la fecha sólo se han publicado estudios termográficos durante el

ejercicio en sujetos sanos. Un mayor entendimiento de la respuesta termográfica

al ejercicio en silla de ruedas en relación al dolor de hombro clarificará su

aparición y desarrollo y permitirá una apropiada intervención.

El primer estudio demuestra que la fiabilidad de la IRT en usuarios de sillas de

ruedas varía dependiendo de las zonas analizadas, y corrobora que la IRT es una


XXVI

técnica no invasiva, de no contacto, que permite medir la temperatura de la piel,

y con la cual avanzar en la investigación en usuarios de sillas de ruedas.

El segundo estudio proporciona un perfil de temperatura para usuarios de sillas

de ruedas. Los sujetos no deportistas presentaron mayores asimetrías entre

lados corporales que los sedentarios, y ambos obtuvieron superiores asimetrías

que los sujetos sin discapacidad reportados en la literatura. Los no deportistas

también presentaron resultados más elevados en el cuestionario de dolor de

hombro. El área con mayores asimetrías térmicas fue hombro. En deportistas,

algunas regiones de interés (ROIs) se relacionaron con el dolor de hombro. Estos

resultados ayudan a entender el mapa térmico en usuarios de sillas de ruedas.

El último estudio referente a la evaluación de la temperatura de la piel en

usuarios de sillas de ruedas en ejercicio, reportó diferencias significativas entre

la temperatura de la piel antes del test y 10 minutos después del test de

propulsión de silla de ruedas, en 12 ROIs; y entre el post-test y 10 minutos

después del test en la mayoría de las ROIs. Estas diferencias se vieron atenuadas

cuando se compararon las asimetrías antes y después del test. La temperatura de

la piel tendió a disminuir inmediatamente después completar el ejercicio, e

incrementar significativamente 10 minutos después. El análisis de las asimetrías

vs dolor de hombro reveló relaciones significativas negativas en 5 de las 26 ROIs.

No se encontraron correlaciones significativas entre las variables de propulsión

y el cuestionario de dolor de hombro. Todas las variables cinemáticas

correlacionaron significativamente con las asimetrías en múltiples ROIs. Estos

resultados indican que los deportistas en sillas de ruedas exhiben una capacidad

similar de producir calor que los deportistas sin discapacidad; no obstante, su

patrón térmico es más característico de ejercicios prolongados que de esfuerzos

breves. Este trabajo contribuye al conocimiento de la termorregulación en

usuarios de sillas de ruedas durante el ejercicio, y aporta información relevante

para programas deportivos y de rehabilitación.

Palabras clave: extremidad superior; deportistas; discapacidad; temperatura de

la piel; dolor de hombro; deporte; termografía infrarroja.

PhD thesis

XXVII

ABSTRACT

Individuals who use wheelchairs as their main means of mobility have a high

incidence (73%) of shoulder pain (SP) owing to overuse and repetitive

propulsion movement. There are numerous diagnostic methods for the detection

of shoulder pathologies, however the literature claims that a noninvasive

accurate test to properly assess shoulder pain would be necessary, and suggests

thermography as a suitable technique for joint pain evaluation. Infrared

thermography (IRT) provides information about physiological processes by

studying the skin temperature (Tsk) distributions. Due to the high correlation of

skin temperature between both sides of the body, thermal asymmetries between

contralateral flanks are an indicator of underlying pathologies or physical

dysfunctions.

The reliability of infrared thermography has been studied in healthy subjects but

there are no studies that have analyzed the reliability of IRT in wheelchair users

(WCUs). The special characteristics of people with disabilities (sweating and

thermoregulation problems, or blood distribution) make it necessary to study

the factors affecting the application of IRT in WCUs.

Discrepant reports exist on the benefits of, or damage resulting from, physical

exercise and the relationship to shoulder overuse injuries in WCUs. Recent

findings have found that overhead sports increase the risk of rotator cuff tears in

wheelchair patients with paraplegia. Since there is no agreement in the

literature, the thermographic profile of wheelchair athletes and nonathletes and

its relation with shoulder pain should also be analysed. Infrared thermographic

studies during exercise have been carried out only with able-bodied population

at present. The understanding of the thermographic response to wheelchair

exercise in relation to shoulder pain will offer an insight into the development of

shoulder pain, which is necessary for appropriate interventions.

The first study presented in this thesis demonstrates that the reliability of IRT in

WCUs varies depending on the areas of the body that are analyzed. Moreover, it


XXVIII

corroborates that IRT is a noninvasive and noncontact technique that allows the

measurement of Tsk, which will allow for advances to be made in research

concerned with WCUs.

The second study provides a thermal profile of WCUs. Nonathletic subjects

presented higher side-to-side skin temperature differences (ΔTsk) than athletes,

and both had greater ΔTsk than the able-bodied results that have been published

in the literature. Nonathletes also revealed larger Wheelchair Users Shoulder Pain

Index (WUSPI) score than athletes. The shoulder region of interest (ROI) was the

area with the highest ΔTsk of the regions measured. The analysis of the athletes’

Tsk showed that some ROIs are related to shoulder pain. These findings help to

understand the thermal map in WCUs.

Finally, the third study evaluated the thermal response of WCUs in exercise.

There were significant differences in Tsk between the pre-test and the post-10

min in 12 ROIs, and between the post-test and the post-10 in most of the ROIs.

These differences were attenuated when the ΔTsk was compared before and after

exercise. Skin temperature tended to initially decrease immediately after the

test, followed by a significant increase at 10 minutes after completing the

exercise. The ΔTsk versus shoulder pain analysis yielded significant inverse

relationships in 5 of the 26 ROIs. No significant correlations between propulsion

variables and the results of the WUSPI questionnaire were found. All kinematic

variables were significantly correlated with the temperature asymmetries in

multiple ROIs. These results present indications that high performance

wheelchair athletes exhibit similar capacity of heat production to able-bodied

population; however, they presented a thermal pattern more characteristic of a

prolonged exercise rather than brief exercise. This work contributes to improve

the understanding about temperature changes in wheelchair athletes during

exercise and provides implications to the sports and rehabilitation programs.

Key words: upper extremity; athletes; disability; skin temperature; shoulder

pain; exercise; sports; infrared thermography.

Introduction

1

1 INTRODUCTION After London 2012, best Paralympic Games hitherto (187), adaptive sports and

attitudes towards people with impairment around the world changed forever.

Famous para-athletes are starring in multiple leading brand advertisements, and

wheelchair rugby chairs or running blades are seen merely as another type of

sports equipment. This proliferation of media commercials and mainstream

acceptance has meant a development in para-sports at all levels. Some

consequences have been an increase in para-sports participation by people with

disabilities, an improvement in accessibility, the diversification of sporting

disciplines and an increase in the number of scientific studies related to para-

sports.

The shift to a more active lifestyle for people with disabilities should imply an

enhancement of the quality of life (18, 98, 395), since exercise prevents other

secondary impairments (loss of cardiorespiratory, and muscular function,

metabolic alterations and systemic dysfunctions) and diminishes loss of mobility,

physical dependence and poor social integration (288). Nonetheless, the

particularities of some impairments can lead to overload injuries. More

concretely, upper extremity injuries are a limiting factor for the mobility and

independence of wheelchair users (WCUs). The repetitive and continuous

movement of wheelchair propulsion, added to the mechanical strain of lifting

tasks and transfers, compromise the upper body musculoskeletal system of this

population. Moroever, wheelchair-confinement forces WCUs to sedentarism – a

well-known metabolic risk factor, and while increasing the physical capacity

seems particularly necessary for WCUs, physical activity for this population is

inherently related to upper-body work. Thus, physical activity for WCUs will

likely further contribute to complications in the upper extremities. There is no

agreement in the literature about whether the exercise implies an additional

overload on the already burdened upper body or, on the contrary, trained joints

will be well protected with developed musculature.


2

In the following review of the literature, an overview will be given of the

wheelchair ambulation implications on shoulder problems in WCUs. The most

commonly used tools for shoulder evaluation will then be introduced, with

special focus on the non-contact infrared thermography technique. Furthermore,

the specific characteristics of the thermoregulation of people with spinal cord

injury (SCI) will be described.

1.1 WHEELCHAIR USER’S SHOULDER

1.1.1 Shoulder joint mobility and scapular stability The complex structure, limited muscle mass and wide movement possibilities of

the shoulder make for a joint that has a propensity to overuse injuries (32). The

tendons of the rotator cuff muscles (supraspinatus, subscapularis, infraspinatus,

and teres minor) are primarily responsible for glenohumeral joint stabilization

(41, 142), and together with the deltoid and long head of the biceps brachii

muscles, are the stabilizing components of the shoulder (Figure 1). External

rotators also decelerate the arm during various activities through eccentric

contraction (12). Since the shoulder’s mobility relies on its stability, this joint is

particularly exposed to the development of muscle imbalances (142). Individuals

who use wheelchairs as their main means of mobility have a high incidence of

shoulder pain due to the overuse of the shoulder stabilizing and the repetitive

propulsion movement (32).

Introduction

3

Figure 1. Shoulder anatomy. From Morphopedics (272)

1.1.2 Pathologies related to wheelchair propulsion Nichols et al. assigned the name ‘wheelchair user’s shoulder’ to the shoulder

problems experienced by individuals who utilize manual wheelchairs for their

primary means of locomotion (284). In a study of 94 paraplegic individuals, a

third presented with shoulder pain, a condition that Nichols et al. designated ‘the

weight-bearing shoulder’ (32). Both names make reference to the same problem

in this joint, which is designed, in evolutionary terms, for mobility and not for

loading.

During the propulsive phase of the wheelchair propulsion, the active muscles

(internal shoulder rotators, adductors and flexors (275)) become stronger, while

muscles involved in the recovery phase remain at the same strength (12). With

years of wheelchair propulsion, this leads to an imbalance in the shoulder

muscles, characterized by stronger internal rotators than external rotators and

weaker shoulder adductor muscles (12, 53). It is the internal-external rotators

strength ratio that is primarily considered indicative of shoulder instability and

impingement (12).


4

Many movements for WCUs occur at or above shoulder height, strengthening

shoulder abductors and flexors. This imbalance heightens the risk of

supraspinatus tendon impingement (because abductors pull the humeral head

upward within the glenoid cavity and into the subacromial space), which leads to

the development of inflammation and pain, and may prompt rotator cuff tears

(142) (Figure 2). Supraspinatus impingement syndrome with subacromial

bursitis is the most common cause (74%) of shoulder pain in this population (32,

303, 367). The soft tissues involved can suffer other disorders such as rotator

cuff tendinitis and tears (32, 108), supraspinatus tendinitis (100), bicipital

tendinitis (134, 366), myalgias and myofascial pain syndromes (100),

subacromial bursitis (32, 366), adhesive capsulitis (366), instability (100),

undiagnosed upper limb fractures (100), osteonecrosis of the humeral head,

osteolysis of the distal clavicle (100), osteoporosis and osteoarthritis of the

acromioclavicular and glenohumeral joints (366), and acromioclavicular joint

space narrowing and calcifications (30). Nerve entrapment causing median

nerve dysfunction at the carpal tunnel and ulnar neuropathy were the most

common entrapment of the wrist and forearm segments (55, 134). Degenerative

arthritis resulting from overuse injuries is less common, but has been also

reported in the literature, for example osteonecrosis of the head of the humerus

(31, 32) and glenohumeral joint degeneration (450).

Figure 2. Supraspinatus tendon rupture (left) and supraspinatus impingement and rotator cuff tendonitis (right). Adapted from ePainAssist (106)

Introduction

5

1.1.3 Prevalence of shoulder pain in wheelchair users

The prevalence of shoulder pain in wheelchair users (WCUs) has been reported

to be from 26% to 71.2% in those who currently experiences shoulder pain and

from 30% to 85% in those who have experienced shoulder pain since becoming

a WCU (7, 30, 32, 50, 53, 80, 100, 120, 225, 284, 346, 366). The heterogeneity of

age, duration of injury, neurologic level and severity of injury among the

participants involved in these studies explain the wide variability in the

prevalence of current and previous shoulder pain (100). Shoulder pain entails

functional loss and a reduction in mobility, quality of life and social participation

(100, 154, 210).

Nichols et al. reported shoulder pain in 51.4% of 517 individuals with spinal

cord injury (SCI) (284), while Bayley et al. reported 31% of 94 individuals in a

more recent study (32). This percentage of upper extremity pain increased to

55% and 64% for a sample of individuals with tetraplegia and paraplegia,

respectively (366). From 451 interviewed individuals with SCI, Subbarao et al.

found that 68% suffered shoulder pain or wrist pain (389). A later review of the

literature reported a range of 30-73% of shoulder pain (100). An extension of

this review revealed a similar range with 26-71.2% reporting shoulder pain at

the present time, and 30-85% reported experiencing shoulder pain since

beginning to use the wheelchair (Table 1).


6

Table 1. Prevalence of current SP and SP since wheelchair ambulation

Year Author Current SP (%) SP since WCUs (%) Notes

1979 Nichols 51.4 51.4 (idem)

1987 Bayley 30.8 32.9

1988 Gellman a) 34.5, b) 67.8 a) SP, b) UE

1988 Wylie 36.36 a) 18, b) 45 a) Athletes b) Nonathletes

1991 Pentland 73 Women

1991 Waring 75 TP

1991 Silfverskiold a) 78 TP, 35 PP b) 33 TP, 35 PP

a) 6 months after SCI b) 18 months after SCI

1992 Sie a) 55 TP, 64 PP b) 46 TP, 36 PP

a) UE, b) SP

1993 Burnham 26 PP Athletes

1994 Pentland 39 PP 58 PP

1995 Subbarao a) 35.6, b) 57.8 a) Only SP b) SP and wrist pain

1996 Campbell a) 11, b) 13 All sample with SP a) Acute SP b) Chronic SP

1997 Escobedo 69.56 PP

1999 Curtis 59 TP, 42 PP 78 TP, 59 PP

1999 Curtis 52 72 Female athletes

1999 Curtis 75 Female and male

1999 Dalyan a) 32 b) 76 (31.57, 68.42)

a) SP b) UE (athletes, nonathletes)

2000 Ballinger 30

2001 Boninger 32 PP 36

2001 Russell 47 72

2003 Salisbury a) 54, b) 85, c) 54 TP a) SP before rehab b) During rehab c) After rehab

2003 Fullerton 48, a) 66, b) 39 a) Nonathletes b) Athletes

2004 Finley 29 61.55

2004 Samuelsson 37.5

2008 Alm 40 67

2008 Brose 67 24.5 untreated SP

2010 Jain 35.4

2010 Akbar 67

2011 Akbar 71.2

Note: SP, shoulder pain; UE, upper extremity; TP, tetraplegic; PP, paraplegic.

Introduction

7

Shoulder pain has been reported to be higher in people with tetraplegia than

paraplegia (80, 107, 313, 346, 347), greater in higher levels of paraplegia

compared to lower SCI levels (372), and higher in women than in men (100, 154,

159, 191, 302), despite similar levels of physical activity between women and

men (154). There exists controversy in the literature regarding the incidence of

shoulder pain in inactive compared to active wheelchair users, which will be

discussed in section 1.5. Interestingly, Fullerton et al. argued that there are more

sedentary individuals with tetraplegia than paraplegia, because the tetraplegic

group tends to avoid physical activity due to shoulder pain and they have fewer

sporting opportunities (128).

The normal process of aging may accelerate the degeneration of the shoulder

joint and aggravate the pain (11, 191). In addition to age, other factors that

correlate with shoulder pain include time since injury (134, 191, 284), years or

hours per week of wheelchair usage (80), and body mass index (BMI) (47, 100).

In contrast to most studies, Subbarao et al. did not find statistical significances by

age, neurologic level or time since injury (389).

1.1.4 Etiology of shoulder pain in wheelchair users

Woude et al. highlighted propulsion technique, transfers, wheelchair design and

excessive load as the main causes of shoulder injuries in wheelchair ambulation,

and pointed to training protocols and wheelchair design as the preventive

measures on which to focus (414). Ambrosio et al. recommended that clinicians

implement two types of rehabilitation strategies: 1) stretching and strengthening

shoulder muscles to maintain the glenohumeral alignment and to augment the

resistance to fatigue of the shoulder; and 2) teaching proper wheelchair

propulsion techniques (12) such as the one described in the following section.

1.1.4.1 Wheelchair ambulation There are two wheelchair propulsion phases (Figure 3): the push and the

recovery. The muscles acting during the push phase are the anterior deltoid,

pectoralis major, supraspinatus, infraspinatus, subscapularis, serratus anterior,


8

lower trapezius, rhomboid major and long head of biceps brachii (276) (Figure

4). For tetraplegic individuals, some of these muscles may have a slightly delayed

onset or may have greater recruitment than in paraplegics. The muscles involved

in the recovery include the middle and posterior deltoid, supraspinatus, upper

and middle trapezius and subscapularis (276).

Figure 3. Wheelchair propulsion technique parameters. The dots represent the trayectory of the hand. EA = end angle (°); HC = hand contact; HR = hand release;

PA = push angle; SA = start angle. From Vanlandewijck et al. (422)

It is interesting to note that supraspinatus is active in both the push and

recovery phases. Moreover, subscapularis is employed by paraplegics during

recovery, but is actually utilised for the push phase in WCUs with tetraplegia, and

while tetraplegics use latissimus dorsi for push work, its activation in the push

and recovery phases is inconsistent in paraplegics. Finally, the activity of the

infraspinatus is lower in WCUs with tetraplegia than paraplegia (276). Mulroy et

al. (275) indicated that the muscles most vulnerable to fatigue in paraplegics

were pectoralis major, supraspinatus and the recovery muscles, and that the

push phase is the most intense period of muscle activity.

Introduction

9

Figure 4. Mean muscle forces (only forces larger than 10 N) during the push phase (left) and recovery phase (right). From Veeger et al. (427)

The repetitive and continuous activity of wheelchair ambulation is the main

stressor that leads to the development of activity-related musculoskeletal

problems in WCUs. The fact that wheelchair propulsion leads to upper-body

musculoskeletal disorders necessitates an ergonomic and integrative approach

to all of the components involved in this task (414, 431). There are three factors

that play an important role in the efficiency of wheelchair propulsion: the

wheelchair design, the wheelchair user and the wheelchair-user interaction.

Wheelchair design There has been an evolution of the hand-rim wheelchairs from chromium-plated

wheelchairs used in the sixties to the high-tech, task-specific and self-tuned

wheelchairs of the present day. This progression reflects improvements in the

durability and safety of the wheelchairs and health of the WCUs. The rolling

resistance, air drag, and internal friction of the wheelchair (416, 418), its weight


10

(47, 414), the rear wheel position (349), the effect of camber (249), the seat

position and angle (139, 220, 349, 373), the rim radius or gear ratio (121, 416)

and the material and deformation of the frame are some of the mechanical

components that must be considered for improving wheelchair ergonomics and

attaining the best wheeling conditions, and thus avoiding shoulder pain in WCUs.

For example, changes in seat position or handrim diameter will have an effect on

the elbow angle, subsequently impacting the constrained movement of the arms

during the push phase (428). A higher seat position is associated with upper-

extremity pathologies (250), and handrim size is recommended depending on

the functional capacity and preferences of the users (430).

Wheelchair weight, rear wheel location and wheelchair width were designed

prior to the 1980s in such a way that individuals had to push using a pattern of

shoulder abduction, internal rotation and extension. Additionally, wheelchair

seats that were parallel to the floor with tall backrests forced a spinal flexion

posture with forward head and shoulder positions (158). Configuration has

changed over the years resulting in different propulsion techniques, and people

using old wheelchair designs have been shown to present better shoulder pain

scores 15 years after injury due to changes in configuration (158).

Wheelchair user

Factors associated with the user including overweight (43, 47), duration of

disability (55) and time spent in the wheelchair per week (55) contribute to the

incidence of upper-extremity injuries in WCUs. Furthermore, the physical work

capacity, training status and propulsion technique should be addressed (414) in

order to achieve the optimal functioning of the musculoskeletal system. Strength

training should be specific for manual wheelchair propulsion, but shoulder

strength itself does not guarantee an improvement of the wheelchair ambulation

(12). A study of the electromyographic activity of shoulder muscles during

wheelchair propulsion recommended endurance training to prevent the fatigue

of the pectoralis major, supraspinatus and muscles involved in the recovery

phase (275). Fatigue in these muscles has been associated with a shift in joint

power from the shoulder to the elbow and wrist (339), increasing the risk of

Introduction

11

overload injuries in these distal joints. Therefore, the implications for joint injury

could be different for endurance-trained WCUs.

The alignment of the trunk and its stabilization are important factors for

shoulder function (456) and can be achieved through changes in the wheelchair

configuration. Hastings et al. highlighted postural alignment as a good

prevention of shoulder pain based on the authors’ experience. An optimal

balance must be found between stabilization possible mobility, as usually one

works to the detriment of the other. A more stable posture, such as one that

includes a posterior pelvic tilt and flexed spine, for example, will not allow great

mobility (158). In individuals with paraplegia, the absence of innervated trunk

musculature means that the external support system (the wheelchair) together

with the forces of gravity dictate the posture of the trunk (158). It has been

shown that in individuals with a SCI without trunk control presented a higher

intensity of shoulder pain than in those with trunk control (456), because of an

increased biomechanical stress on the upper limbs, which are also required for

stabilization to avoid falling and also collapsing into a “C” spinal sitting posture

(158).

In people with tetraplegia, the shoulder is not fully innervated, which

accentuates the shoulder muscle imbalance. For example, people with a C6 level

SCI have innervated rotator cuff muscles, rhomboids and deltoid, but pectorals

major and dorsal are not fully innervated resulting in a shoulder muscle

imbalance (158). In addition, tetraplegics are not able to properly grip with their

hands, so they must provide an extra-internal rotation force to provide some

friction on the wheel to move it. A lack of sternal pectoralis major innervation

precipitates an increase of the use of humeral depressors to reduce the risk of

impingement in the shoulder, and the anterior deltoid and serratus anterior

must perform additional work to compensate the smaller clavicular pectoralis

major in high SCI (276). A reliance on smaller or weaker muscles for shoulder

movements typically achieved (in able-bodied persons) by muscles that do not

receive full innervation in people with SCI can lead to shoulder injuries.


12

Generally, the higher the level of injury the higher the prevalence of shoulder

disorders (372).

The wheelchair-user interaction The most effective propulsion technique involves pushing on the wheel with a

greater push angle and spending a longer period of time on the pushrim,

allowing for a decreased pushing cadence (12, 46). It is important to reduce the

cadence since increased movement repetition is related to an increased

predisposition for median nerve injury (43). The hand is held below the pushrim

during the recovery phase of the propulsion stroke. This technique is called the

semicircular pattern. The literature recommends that WCUs are trained to let

their hand drift down naturally when letting go of the pushrim to achieve the

semicircular motion (46). Sport propulsion techniques, such as the butterfly

technique (64, 148, 423), have rarely been the subject of scientific studies, and

bilateral symmetry during wheelchair propulsion has been identified as another

important aspect that requires further research (148, 183, 377).

Finally, the appropriate wheelchair-user interface determines the efficiency of

power transfer from the user to the wheelchair. This interaction depends on the

combined adjustment of movement pattern of the arm and trunk, timing

parameters (such as number of pushes, duration of the hand-to-rim contact,

push range or angle, work per cycle), force generation (75, 234, 427), muscle

activation of arms and shoulders (412), wheelchair configuration (rim size

(429), gear ratio (254), rim tube diameter (181), seat height and position (415)),

type and position of the propulsion mechanism (levers, rims, arm-cranks or hub-

cranks) (413, 416, 417), as well as individual characteristics (138, 235, 273, 284,

416). Propulsion technique varies between WCUs depending on the type of

wheelchair used, activity (daily propulsion, type of wheelchair sport), the

individual functional capacity of the user, level of expertise and how well suited

the wheelchair is to the user (90, 91, 414, 416). Veeger et al concluded that the

combination of lower handrim velocity and larger propulsive torque was

beneficial to the efficiency of wheelchair propulsion (429). In addition, they

Introduction

13

affirmed that the most efficient direction of force application was tangential to

the rims (Figure 5).

Figure 5. The relationship between force direction and calculated net joint torques around shoulder and elbow. From Veeger et al. (432).

In summary, the most efficient wheelchair propulsion entails a combination of a

proper and individualised wheelchair design that reduces rolling resistance and

fits the user; a good level of physical fitness to counteract the forced physically

inactive lifestyle; and an ergonomic manner of propulsion that neutralises the

low mechanical efficiency of handrim wheelchair propulsion (431), which is the

product of the discontinuous movement, the particular muscles used (430) with

their low muscle mass, the position of the arms and the synchronicity of the arm


14

movements (140). An overview of the three factors that determine the efficiency

of wheelchair propulsion (wheelchair design, user and wheelchair-user

interaction) has been given, nevertheless, other individual (posture, fitness,

physical characteristics), environmental (exposure to cold, vibration, overhead

reaching) and work (transfers, pressure reliefs, driving, upper body dressing,

ramps or inclines) factors should be considered to reduce the risk of shoulder

injury and to allow the WCU to carry out activities of daily living, exercises

during physical therapy and physical training safely and with the correct

technique.

1.1.4.2 Wheelchair transfers We have included a specific section for transfers since transferring to and from

the wheelchair has been reported as the second most painful activity for the

upper limbs of WCUs after wheelchair propulsion (32, 78, 158). The technique of

transfers has evolved from an overhead trapeze bar to techniques such as pivot

transfers or devices such as sliding boards or poles (Figure 6). Trapeze transfers

demand shoulder flexion, abduction and internal rotation placing the shoulder in

an impingement-prone position (158). This activity generates an intra-articular

pressure in the shoulder that exceeds the arterial pressure by two and a half

times, which, combined with the abnormal distribution of stress transmitted

across the subacromial area during the transfer, contributes to the high

prevalence of shoulder pain (32).

Figure 6. Sliding board (left) and sitting pivot transfer (right) for individuals with spinal cord injury. From Gagnon (129)

Introduction

15

There is a lack of documentation of transfer technique in the literature. It is

necessary to have a clear definition of the correct technique before

biomechanical analyses of the various transfer techniques may be performed.

Transfer techniques will differ depending on the lesion level. For example,

tetraplegic individuals, who do not have innervation to their triceps muscles,

must lift themselves using flexion and adduction of the shoulder (157). Shoulder

pain can also be modified by the technique of the transfers; in a study with 23

WCUs, the 13 subjects with shoulder impingement performed transfers with

reduced thoracic flexion and increased scapular and humeral internal rotation

(119). This study also compared transfers towards the involved or dominant

side (lead limb transfer) to transfers towards the instrumented or non-dominant

side (trail limb transfer). The instrumented limb transfer showed reduced

upward scapular rotation and posterior tip and lower trapezius and serratus

anterior muscle activity than in the lead limb transfer (119). Ultimately, and in

support of the benefits of exercise in WCUs, the residual musculature should be

maintained to be able to do the transfers.

1.1.4.3 Musculoskeletal causes of shoulder pain and excessive load

The main shoulder pathologies of WCUs – subacromial impingement and rotator

cuff disorders – have, to this point, been discussed. These pathologies are

primarily caused by a narrowing of the impingement zone, that is, the space

through which the supraspinatus tendon passes. Some reasons for these

pathologies in WCUs have also been reviewed, including wheelchair ambulation

and transfers, however the most common causes of shoulder pain are due to

musculoskeletal disorders. Shoulder pain in WCUs may originate both from

structures intrinsic and also extrinsic to the shoulder joint complex. Other causes

of shoulder pain, impingement syndrome and rotator cuff pathologies, reported

by the literature, include:

Overuse (19, 32, 284, 313)

Repetitive overhead activities, such as reaching from a wheelchair

position (6, 8, 19, 108, 225, 389)


16

Time since injury (134)

Reflex neurovascular disorders of the shoulder, arm and hand, known as

‘shoulder-hand syndrome’ (294)

Weakness of abductors and/or muscle strength imbalance of abductors-

adductors (53, 100, 269)

Weakness of rotator cuff (specifically external rotators) and axial

musculature that influences humeral head depression (53, 269)

Level of the spinal lesion (269)

Referred pain from the neck (19, 366) or degenerative changes at the

cervical spine (100)

Orthopedic origin (366)

Mechanical impingement, which is responsible for the rotator cuff

disease (32, 273)

Acute trauma when the humeral head is forced against the acromion,

such as when the arm is used to brace a fall (19)

Calcification of the coracoacromial ligament with subsequent

impingement and acromioclavicular joint arthritis (19)

Ligamentous laxity (100)

Nerve root entrapment (100)

Complex regional pain syndrome type II (100)

Frozen shoulder (19)

Joing instability (19)

Infection (19)

Myocardial infarction (19)

Syringomyelia (101)

Heterotopic ossification (101)

Spasticity (100)

It is generally accepted that the musculotendinous-type overuse injuries are the

most common cause of rotator cuff injuries (100). Excessive shoulder joint

loading through the support of body weight has been related to pushrim forces

and median nerve function (43); weight loss may probably prevent this injury in

manual WCUs (75). In support of this, several authors found that BMI may play a

Introduction

17

roll in shoulder injuries in WCUs because of its direct relation to the amount of

physical strain experienced during transfers and propulsive work done during

wheelchair propulsion (43, 47, 100, 192).

A number of causes of shoulder pain exist, therefore, in addition to factors

related specifically to wheelchair ambulation and transfers. Many of these have

musculoskeletal origins and are related to the high mechanical load on the upper

limbs, during handrim wheelchair propulsion, as a result of the repetitive and

continuous nature of this activity, the relatively small muscle mass involved, the

relatively large peak force required and the specific direction of force application

involved, and finally the complexity of the shoulder joint, particularly with

regard to stabilizing the glenohumeral joint.


18

1.2 TOOLS FOR SHOULDER PAIN EVALUATION

Assessment of the specific location or cause of shoulder pain in WCUs is

complicated, and treatment may be inappropriate without an accurate

evaluation. Arthrography (32, 57), radiography (5, 7, 30, 47, 57, 152, 229, 447,

450), imaging and arthrographic magnetic resonance (6, 7, 44, 47, 108, 312) or

computed tomography (152, 435) are considered accurate and reliable

techniques to diagnose the causes of shoulder pain. Nevertheless, these

assessments are expensive and usually not available to many researchers (152,

396). Particularly, magnetic resonance arthrography is an invasive technique

and the required intraarticular injections for this technique pose a risk to the

joint (451). Moreover, the effectiveness of these evaluative tools are dependent

on the experience of the radiologist (152), and some techniques are better suited

to specific types of shoulder injury (152, 160). For example, arthrography is not

helpful in detecting partial tears of the tendons (211). Other evaluation

implements, that are cheaper and less time-consuming for assessing shoulder

pain in WCUs, are: physical examination (47, 50, 57, 229, 312), specifically the

Physical Examination of the Shoulder Scale (50, 400); inclinometer (27, 202,

388); dynamometer (16, 44, 266, 330, 388) – the hand-held dynamometer

(HHD) is the most frequently used; electromyography (EMG) (37, 119, 266, 274-

276); ultrasound (50, 152, 419); and questionnaires (49, 81).

It has been reported that self-report questionnaires are the most frequently

employed, non-imaging evaluation tool for shoulder pain (49). Of all of these

tools, the most commonly used in the assessment of shoulder pain in WCUs is the

questionnaire (49, 59, 226, 284, 300), with the Wheelchair Users Shoulder Pain

Index (WUSPI) (23, 78, 80-83, 354, 372) and Shoulder Pain and Disability Index

(17, 40, 52, 105, 170, 241, 337, 446) being the two most popular. Other shoulder

pain questionnaires include the ShoulderQ, designed for hemiplegic shoulder

pain (405), the Shoulder Disability Questionnaire (285) and the visual analog

scale for pain (7, 285). The WUSPI test is the one used in this thesis and will be

explained in section 3.4.2.

Introduction

19

Thurston et al. (400) claimed the need for a noninvasive, but accurate test to

appropriately evaluate shoulder pain. They pointed to thermography as a well-

established technique used for the evaluation of the back, neck and shoulder

pain (38, 400). This technique will be described in the following section.


20

1.3 INFRARED THERMOGRAPHY

1.3.1 Concept and types

Infrared Thermography (IRT) is a noninvasive method that detects and records

the infrared radiation in the long-infrared range of the electromagnetic spectrum

emitted by any body, and allows the interpretation of the distribution of surface

temperature (77, 216). The amount of radiation emitted by an object increases

with temperature, hence, thermography enables the assessment of variations in

temperature. In humans, this technique provides information about

physiological processes related to blood perfusion, through the examination of

skin temperature (Tsk) distributions (167, 204). The maximum flux of blackbody

radiation at human skin temperature (30-36°C) is in the infrared part of the

spectrum (9–10 µm). Accordingly, clinical thermography must use detection

systems sensitive to that range of the infrared spectrum (15). In contrast to other

regions of the infrared spectrum, skin is >98% emissive in the 9-10µm range.

When skin is partly reflective, as it is below 8 µm, the detected infrared emission

may represent the infrared radiation originating from other sources in the

environment (15). Because of this low energy and intensity of the Tsk infrared

radiation, telethermometry was not available for clinical usage until the advent

of more sensitive and precise (<1% precision) detectors of infrared radiation

such as the photon or quantum detectors (15). Another requirement of the

application of thermal imaging to Tsk is a spatial resolution that allows the

distinction between two points less than 1 mm apart and differing in

temperature by 0.1°C. Factors that determine the temperature distributions on

body surface must be considered, including the temperature of internal organs,

heat conductivity of muscular and adipose tissue and heat emissivity of the skin.

Thus, the temperature on the surface of the skin is dependant on the

temperature of internal organs and the heat properties of the tissues that lie

between the organs and the body surface. It must be remembered that IRT only

measures heat convections at a depth of 0.5 cm.

Introduction

21

The methods of measuring infrared radiation utilize either contact and

noncontact devices. Contact devices are characterized by liquid crystal

thermography or LCT, where cholesteric crystals are embedded in rubber sheets

and the layers of crystals are mounted in a frame. Those crystals selectively

reflect polarized light in a narrow region of wavelength; therefore they change

their colour when applied to the surface of the body (216). The colour

distribution represents the Tsk distribution that is photographed to have a hard

copy of the image or thermogram (15). Other contact devices for measuring

temperature include thermometers, thermistors, and thermocouples.

The advent of the quantum physics allowed the development of noncontact

infrared equipment. There are a number of the different contact-free

thermography techniques, including infrared or electronic thermography (IRT),

computer-assisted image analysis, area telethermometry, infrared

telethermography (ITT), and digital infrared telethermographic imaging (DITI)

(15). Electronic thermography involves scanning mirrors that reflect the infrared

radiation on an infrared transducer, and the infrared pattern is displayed on a

cathode ray tube from which it can be photographed (216). Telethermometry, or

radiation thermometry, measures Tsk at a single spot, remotely, and

telethermography, or area telethermometry, provides quantitative information

on the Tsk of a large area (15). Dynamic area telethermometry (DAT) measures

the time dependence of Tsk, that is, the modulation of the temperature when the

Tsk changes non-uniformly over the surface.

Because a thermal imaging camera allows for the distinction between warm

objects against cooler backgrounds, it is possible to use this type of camera to

monitor Tsk. Thermographic cameras provide a thermal map of the skin surface

measuring the heat radiation emitted, however the literature recommended not

comparing Tsk results that have been measured with different types of

thermographic cameras (conducted vs. infrared) (36, 96). Thermographic

cameras produce a visual display of the radiation called a thermal image or

thermogram. Early models of infrared cameras had low thermal and geometric

resolutions, stability issues and low reproducibility or accuracy, as well as a high


22

cost. Due to these limitations, IRT was rapidly substituted by other more precise

diagnostic techniques (39). Currently, with the advent of modern infrared

cameras (Figure 7) and improved data acquisition and processing techniques, it

is now possible to have real-time high-resolution thermographic images (198,

227, 381, 411) (Figure 8). Such high-speed images with high thermal and spatial

resolutions can be rapidly processed with modern software and standardized

protocols (see Figure 9, for example).

Figure 7. The first medical thermographic device developed by Schwamm and Reeh in 1952, from Berz et al. (39) (above), and a modern high resolution

thermographic camera VarioCAM®, from Jenoptik (193) (below)

Introduction

23

Figure 8. Thermogram of a patient with allergic rhinitis detected with an early IRT camera, from Georgevici (136) (left), and a thermogram of a patient with

hypothyroidism and inflamed carotid artery detected with a modern IRT camera, from Möhrke (271) (right)

Some advantages to using thermal imaging cameras include immediacy of

results, mobility and adaptability, easy comparison of images, rapidity in the

millisecond range facilitating measuring of moving targets, and there is the

option to record a thermal video as well. Moreover, given that thermal imaging

cameras are noninvasive and contact-free, they allow for the measurement of

dangerous or physically inaccessible bodies and the risk of contamination to be

avoided, there is no interference with and no energy lost from the target, and

there is no mechanical effect on the surface of the object (145, 208).

Figure 9. Thermograms with TotalVision™ Anatomy Software. From Möhrke (271)


24

1.3.2 Infrared thermography applications

Fernández divided the main areas in which IRT is applied into two groups: IRT

for objects and IRT for living beings (112). The first group includes diverse

domains, such as engineering, construction, the military, industry, the

environment andastronomy, that which a long history of the use of, and strong

market for, IRT. The application of IRT in these domains include, for example, the

location of the base of a fire through the smoke by firefighters, the detection of

building fissures in historic structures and diagnosis of buildings safety; non-

destructive testing of structures; the positioning of overheating joints and

sections of power lines; the location of gas and heat leaks in defective thermal

insulation to improve the efficiency of heating and air-conditioning units; the

inspection procedures for and optimization of the experimental set-up in the

aerospace industry; mapping of surface temperature in temperature-dependent

manufacturing processes; night vision, missile guidance and surveillance

cameras in the military industry; surface crack detection on concrete surface and

masonry bridges; the control the process, cost reduction and safety

improvements in steel industry and high voltage facilities; the protection of

flowers and trees; or monitoring and water pollution (26, 29, 71, 89, 110, 150,

208, 240, 244, 262, 287, 359, 402, 436).

Infrared thermography also has many direct applications in humans and

animals. The majority of studies of IRT in veterinary medicine are focused on its

utility as a diagnostic tool in equine health to detect locomotion injuries (e.g.

quantify inflammatory process) and to monitor the health status of horses (252,

324, 375, 382, 386). Moreover, in recent years, IRT has been directed to the

exercise training and thermoregulation of racehorses (135, 168, 371, 379, 454)

and animal behavior (208). The main source of error in IRT animal studies is due

to variation in emissivity, evaporative cooling and radiative heating of an

animal’s coat. Their hairy skin hinders the measures and it makes necessary to

wait for the seasonal shedding of fur (252). Another methodological limit is the

skin thickness. The literature on thermography in equine medicine recommends

that the examination be performed when the horse is at rest and before training

Introduction

25

to avoid the changes in body heat balance and blood circulation related to

working muscles (379). Horses are the most studied animal with respect to IRT,

however birds, foxes, bats, rats, marine mammals, cattle, sheep, dogs and wolves

have also benefited from this technology (126, 228, 255, 256, 301, 382).

From all the usages of IRT, we are obviously more interested in human

applications. The utilization of IRT in the clinical field in humans dates back to

the 1960s, although it started to become more accessible in the 1970s with the

development of computerized processing that allowed the storage and

quantification of images (332). Some physiological changes in human beings can

be monitored with IRT during clinical diagnostics testing. Kobrossi et al. affirmed

that this is an ideal technique for diagnosis because of its noninvasive and safe

nature and because it can be frequently applied (216) (other imaging techniques

cannot be used so frequently because of their potential to be harmful to

humans). However, these authors limited thermographic evaluation to

cutaneous circulation and pathological conditions that influence the superficial

blood flow, and confined its use for soft tissue injuries assessment (216). In spite

of IRT limitations as a diagnostic tool, Bertmaring et al. also recommends the use

of IRT to evaluate and identify injuries and musculoskeletal disorders (38). Some

of the most representative applications, in the medical and physiological

environment, where thermography is being used successfully are (39, 151, 203,

227, 267, 332):

Anaesthesia:

- Pain management: neuropathic pain due to perivascular

microcirculatory sympathetic dysfunction, radicular pain

syndromes, reflex sympathetic dystrophy, complex regional

syndrome, myofascial pain, and nociceptive pain (99, 125, 163-

165, 169, 172-174, 184, 222, 223, 230, 328, 361, 401).

Neurology:

- Neuromusculoskeletal disorders (4, 24, 35, 74, 308, 343, 400, 408,

420, 458, 460).

Traumatology:

- Detection of entrapment of peripheral nerves (196, 197, 311);


26

- Rehabilitation medicine, pain detection and location of the

neurological level of paralysis in individuals with SCI (92, 179, 180,

188, 189, 340, 342, 361, 362, 463, 464);

- Musculoligamentous injuries (332) of the spine (207), shoulder

(270, 299, 394), trapezius (310) and forearm (360), including

arthritis, bursitis and tendinitis (92, 151, 364, 399).

Evaluation of vascular disorders and measurement of the skin blood

perfusion (96):

- Evaluation of patients at high risk for lower extremity peripheral

arterial disease (176);

- Detection of deep vein thrombosis (194);

- Detection of entrapment of blood vessels, and vascular occlusion

predictive of CVA (206);

- Histamine skin test evaluation (409);

- Detection of tissue death in instances of frostbite, diabetic ulcers,

and burns (309).

Oncology (133, 162, 267, 449), especially breast cancer screening (22, 39,

215, 246, 282, 295).

Neonatal physiology (65, 156).

Surgery: appendicitis diagnosis (104), shoulder surgery (217, 296, 455),

flap tissue viability (239, 397), breast reconstruction (444), location of

perforator vessels (296), plastic surgery (267).

Dermatological disorders (70, 95, 268):

- Diagnosis of skin tumours: hyperthermic detection of cutaneous

melanoma;

- Cosmetic field: evaluation of aging skin to prevent photo-aging.

Microangiopathies:

- Study of skin circulation in systemic diseases such as progressive

systemic sclerosis, diabetes (127, 357, 380, 390, 461) and arterial

hypertension;

- Locoregional diseases such as occupational radiodermitis and

occupational Raynaud’s syndrome (332).

Assessment of the effectiveness of different therapies:

Introduction

27

- Ice burn and cryotherapy (358);

- Whiplash injury treatment (232);

- Trigger point treatment (74, 242, 393);

- Anterior cruciate ligament therapy (305);

- Coccygodynia therapy (448).

Diagnosis of thyroid gland disease (161).

Facial IRT applied in dentistry (15, 149).

Gynaecology (224).

Allergy detection (267)

Tuberculosis (123)

Effects of vasoactive drugs (corticosteroids) (332)

Others: kidney transplantation, heart, rheumatic diseases, orthopaedics,

fever screening for swine flu detection in airports (42, 62), and brain

imaging.

The use of IRT by VU University Medical Center in Amsterdam was presented in

at the XIII European Association of Thermology Congress: “Thermology in

Medicine: Clinical Thermometry and Thermal imaging”, in 2015. In this clinic,

IRT is widely used to monitor vital functions (heart rate, breathing, perfusion,

oxygenation and temperature), to discriminate diseased from healthy tissue

(pre-cancerous tissue, inflammation and tissue damage such as eczemas), and

for treatment monitoring of dermatology allergy testing (even allergic reactions

not recognized by visual inspection). Several of the clinic’s research studies were

introduced at the congress that exemplify the diverse application of IRT,

including the assessment of stress recovery by thermography, the oxygenation of

the fetal brain in the final stage of childbirth, the quantification of inflammation

in Graves’ orbitopathy, the examination for hypothermia in high altitude and the

study of Temporomandibular disorders, along with many other interesting

applications in the sport field: thermographic evaluation of swimming

techniques, different thermal models of warm-up for decathlon athletes, for

aerobic and anaerobic training and analysis of the hamstring muscles during

static stretching.


28

The most common areas of research regarding IRT and people with disabilities

are:

The improvement of communication with people unable to speak, IR

thermal video detects the movements of the mouth, and therefore IRT

substitutes conventional less hygienic devices that require the mouth to

direct objects (258-260);

The design of cushions for avoiding pressure-ulcers (116, 117);

The Tsk responses in lower limbs in children with cerebral palsy (466);

The Tsk inside prostheses as rest does not provide thermal relief (214);

The study of the autonomous nervous system with skin vasomotor

responses to cold stimuli in individuals with severe motor and intellectual

disabilities (392);

The study of postural adjustment in leg length differences (1);

The evaluation of autonomic function in animals and humans with SCI

(99, 186, 228, 439, 464);

The detection of the neurological level of paralysis in SCI people, which is

useful in emergency diagnosis and therapy for accident victims (340).

Moreover, the principal areas of interest in IRT application in the sport sciences

include:

Sport injury prevention and monitoring (33, 34, 114, 130, 131, 146, 167,

168, 368), specifically in knee injuries, epicondylitis, ankle sprain, tibial

shin splints and stress fractures (151), patellofemoral syndrome, Osgood

Schlatter’s disease, bicipital tendonitis, entrapment neuropathies, spinal

injuries, and reflex sympathetic dysfunction;

Monitoring thermoregulation during exercise and recovery (2, 264, 265,

298, 351, 378, 442);

Evaluation of mechanical load on the muscles of upper limb during

wheelchair driving (248, 251, 365);

The effectiveness of compression stockings in running (322).

Early detection of overuses injuries and minor trauma in athletes is crucial to

avoiding injuries, thus the application of IRT in sport injury prevention has been

suggested as one of the most beneficial and promising applications (167, 168).

Introduction

29

This demands the investigation of different thermal patterns by group i.e., sport

and discipline, and by injury, particularly with regard to the evolution of the

injury. The stage of injury development will be reflected as hyperthermia in

acute injuries, inflammatory processes that result in higher skin blood flow such

as in infections, tendinitis, bursitis, bone fractures, arthritis, tennis elbow,

compartment syndrome and ankle sprain; and a hypothermic pattern in chronic,

compression, poor perfusion and degenerative injuries including nerve damage,

reflex sympathetic dystrophy, Raynaud’s phenomenon, avascular tissues and

vein occlusion (113, 130). A proper diagnostic procedure should accompany the

thermographic analysis of an injury, in which information about previous

injuries, diseases and surgeries is obtained for a correct interpretation of the

thermograms. The application of IRT in prevention of injuries is based on the

concept of corporal symmetry, which will be described in the section 1.3.5.

IRT and pain

Of all the applications of the thermography, the interaction with pain

management in connection to sport injury prevention is particularly interesting.

Wheelchair users may experience pain in their muscles joints, bones, ligaments,

and nerves, and in some cases an individual may feel pain in areas distant from

the injury, which is called ‘referred pain’. The zones of the referred pain are a

somatocutaneous sympathetic response, which is usually presented with

hyperthermia due to decreased sympathetic function. That response can be

located with thermography (34). BenEliyahu (1990) showed that IRT findings

correlated with the painful areas reported by their subjects, and although

thermography is not a picture of pain, it is a picture of autonomic dysfunction that

correlates well with pain (34). The literature is in agreement with this

relationship between thermography and pain or tisular damage (10, 455), and

suggests that IR imaging could be a valid technique for detecting soreness.


30

1.3.3 Factors influencing the application of infrared thermography in humans

An extensive review of the factors that influence the application of IRT on the

human body was conducted by Fernández et al. (113). They classified these

factors in the following groups (see Figure 10):

1. Environmental factors, including room size, ambient temperature,

relative humidity, atmospheric pressure, and source radiation (297, 363);

2. Technical factors, such as validity, reliability, protocol, camera features,

ROI selection, software, and statistical analysis;

3. Individual factors:

a. Intrinsic factors, for example, sex, age, anthropometry, circadian

rhythm, hair density, skin emissivity, medical history, metabolic

rate, skin blood flow and genetic and emotional influences;

b. Extrinsic factors, such as intake factors (substancies that are

ingested), application (topical creams and oilments), therapies and

physical activity (137, 174, 308, 332).

Figure 10. Classification of IRT-related factors in humans by Fernández (113)

Introduction

31

Alternatively, the factors that must be considered in the evaluation of the human

body using IRT can alternately be classified as natural, artificial and sports-

related. In the group of natural factors, atmospheric pressure, relative humidity

and air temperature, as well as reflectivity or reflected radiation of surrounding

objects, must be controlled for during IRT measurements (297, 363).

Furthermore, it is recommended that artificial factors such as the ingest of

medications that affect the cardio-vascular system are avoided, and likewise,

nicotine (137, 308) and alcohol, large meals and the consumption of tea, coffee

and sugar should be avoided (174). It is also recommended that creams and

ointments are not applied prior to the IRT analysis being done (36), and that the

skin is not exposed to sunlight for prolonged periods or treatment with

ultraviolet rays. Sweat can also change the skin surface temperature (36, 459).

Electrotherapy, ultrasound, thermotherapy, cryotherapy, massage and

hydrotherapy treatments must be avoided because their thermal effects can last

from 4 to 6 hours (332). Moreover, circadian rhythm affects Tsk due to the loss of

heat through the limbs (270); circadian effect can be avoided by testing each

subject at the same time as their previous test. The temperature variation of

female breast, which is affected by individual development of the mammary

gland, the distribution of veins in the breast and the period of catamenia (65),

should be considered if the pectoral region of women is to be evaluated. Physical

exercise should not be performed within 4-6 hours before IRT analysis, as a

number of sports-related factors may influence the results, including the type of

sport, playing position, dominant side use, state of rest or fatigue (and the

specific activity in the most recent session), composition of muscle fibres, density

of capillary nets, thickness of skin and body fat, nutrition, sex (menstrual period)

and clinical history (e.g., injuries, lipid profile and infectious processes) (38, 113,

143, 369, 370, 462).

We will not enter in more detail since the literature extensively explains them.

Though, we will review the studies that applied IRT in people with disabilities,

and we will propose a few recommendations.


32

1.3.3.1 Specific factors influencing the application of infrared thermography in people with disabilities

There are a number of disability-specific characteristics that can influence the

efficacy of IRT in people with those disabilities. For example, a steady body

posture must be maintained during IRT evaluation. Persons with cerebral palsy

or with SCI may present involuntary muscle contractions and these spasms may

start or increase with changes of posture. Emergence of these movements can be

avoided with muscle relaxant drugs (although the effect of anti-spasticity

medicaments in IRT evaluation is yet unknown), by minimising or avoiding

posture changes altogether or slowing the speed of changes to body posture.

Calancie reported that spasmic contractions did not occur unless the hips and

knees were extended, such as when the subjects were supine (56).

Multiple sclerosis is a chronic and progressive neurological disease

characterized by inflammation and demyelination of nerve cells (87, 304). The

lesions of multiple sclerosis are restricted to the central nervous system and

hence they arise from disruption of central sudomotor pathways (290) and can

result in autonomic dysfunction (304). Subjects with multiple sclerosis may

present abnormal thermoregulatory sweating resulting from a lesion in the

central or preganglionic sympathetic nervous system (290, 410). A case reported

by Ueno et al. found a high-intensity lesion involving the left hypothalamus with

a consequent over-activity in the sweat glands of the right forehead and shoulder

(410). Although the literature reports cases of hyperhidrosis, a more common

response is decreased sweating and regional anhydrosis, or total anhydrosis in

the most advanced cases of multiple sclerosis (177, 304). These abnormalities in

thermoregulatory sweating may impact the effectiveness of IRT. Furthermore,

during exercise, people with multiple sclerosis may present impairments in the

autonomic control of cardiovascular (reduced elevations in blood pressure) and

thermoregulatory function. Moreover, 80% of subjects with multiple sclerosis

developed a variety of neurological signs (e.g., amblyopia) during hyperthermia,

60% of which had not been previously experienced (153). Heat also increases

weakness and spasticity in 62% vs. 14% of deterioration after cold exposure

(153). It is recommended to do physical exercise in early morning or after sunset

Introduction

33

to minimize heat exposure; it is also suggested to precool the head and neck

(304).

Scar tissue can influence Tsk (174, 203, 335, 363), which may be particularly

pertinent when using IRT in individuals with amputations or SCI due to

accidents who may have significant scarring located in specific part of the spinal

column. Moreover, some people with disabilities may experience problems with

the peripheral circulation in the distal parts of the body (459), as a consequence

of obliterating artery disease, malignancies, varicose veins or inflammatory

processes. This local change in blood flow can affect the Tsk (441) and

subsequently, the results of IRT. Finally, and of particular interest to this thesis,

people with SCI also present thermoregulation problems that can influence the

success of IRT techniques (319). These will be discussed in further detail in

section 1.4.2.

1.3.4 Technique and protocol

Thermography requires standardized protocols and careful interpretation of

thermograms (173, 204). According to Ring and Ammer, the thermographic

evaluation should follow these steps (332):

1. Ensure that the location, the assessment room, is of a satisfactory (or

particular) temperature, equipment for the image processing and the

cubicle for the participant;

2. Image system: infrared cameras, reference temperatures, image

monitoring, installation of the cameras and processing of the

thermograms;

3. Participant: previous information, balance and positioning of the

image and vision field;

4. Report generation: colour and temperature scales, processing and

archiving of the thermograms.


34

In addition to the recommendations from Ring and Ammer (332), other

internationally recognized guidelines for thermographic evaluation include the

“Thermology Guidelines. Standards and protocols in Clinical Thermography

Imaging” from the International Academy of Clinical Thermology (185) and “The

Glamorgan Protocol for recording and evaluation of thermal images of the

human body” by Ammer (2008) (13).

For the optimization and reliability of the assessments, all tests must be

conducted in an air-conditioned room that is free of drafts, with a recommended

dimension of minimum 2x3 m (332). The literature advocates a temperature

range of between 18 and 25°C (332), 22.5°C (38), and between 23 and 26°C

(407), oscillating one or two degrees depending on the weather. Importantly, the

highest degree of emissivity in humans is achieved at 21°C. It is interesting to

know that inflammatory injuries are more visible in cold environments (20°C),

but for the evaluation of the limbs, a warm environment has been suggested, i.e.,

around 22-24°C (332). In any case, the Tsk is more homogeneous under warm

conditions (96). Humidity was recommended to be between 45 and 60% (407).

The use of thermography requires that the skin is free of clothing and jewelry for

10-15 minutes prior to the measurement, and the subject must be at rest to

acclimatize the skin and the blood pressure. Moreover, the participant should

avoid tight clothing and bending the arms or legs during this period. If this

resting time is extended to 30 minutes, some body temperature changes will be

observed as a result of thermal asymmetries in the two sides of the body (332)

due to vasoconstriction, for example, specially in subjects with SCI (see 1.4.2).

The selected body position for the measurement has to be consistent when inter-

and intra-individual comparisons are to be made, otherwise the body surface

area exposed to ambient temperature might differ, i.e., two thermograms taken

in different positions - standing up, sitting down or lying down - cannot be

compared.

Participants should abstain from smoking (137, 332) prior to thermographic

images being taken, as well as from drinking coffee, tea or alcohol, which will

Introduction

35

increase Tsk due to skin vasodilatation (109, 248, 257). Taking medication (216)

should also be avoided, as certain drugs may influence the cardio-vascular

system and affect the Tsk (332). Eating heavy meals on the day of the

examination (86) and participating in physical activity within 8 hours before the

IRT evaluation (113, 201) can affect the results and so participants should

refrain from these. Wearing cosmetics or ointments can change the emissivity of

the skin (332, 384) and so should be avoided prior to testing, as should

treatments such as electrotherapy, ultrasound, heat treatment, cryotherapy,

massages and hydrotherapy, since the thermal effects on the Tsk will last for up

to 6 hours (216, 332). Some studies exclude subjects with a body fat content

greater than the 50 percentile, because of the insulating effect of adipose tissue

in the thermal data (38, 353). Larger variations of Tsk distributions have been

found as body fat mass increases (238). Finally, it is necessary to know a

person’s clinical history since some surgeries, scars and pathologies leave

permanent changes to the skin that can incorrectly modify the skin temperature

distribution.

External light over the camera lens can alter the thermograms, which should be

considered when calculating the angle between the camera and subject, and can

be avoided with curtains or reflectors. The proximity of the infrared camera with

respect to the subject depends on the area of study or region of interest (ROI).

Bertmaring et al. positioned the camera 0.5 m from the shoulder when

investigating this joint specifically (38), but other ROIs require 2 m to include the

trunk and upper limbs. Furthermore, it is recommended that the distance be

fixed when replicating the test in future registrations, as a change in the field of

view of the same subject could lead to false Tsk data. To avoid an angle of

inclination of the camera above horizontal, and hence ensure reliable and valid

measurement, it is recommended that a tripod with vertical adjustment be used;

one with wheels, for fast changes in position, may also be beneficial (332).

Moreover, the temperature behind the subject should be controlled using a white

or black background that will provide a uniform temperature. With regard to the

image system itself, the new generation of infrared cameras use new techniques

of data processing that can quantify the thermograms. Most thermal imaging


36

cameras have an internal reference temperature and perform auto-calibrations;

hence the technician does not need to do external calibration (336).

1.3.5 Corporal symmetry and infrared thermography

There is a direct relation between the increment of temperature and the

emission of infrared radiation. Furthermore, there is a direct relation between

the increment of temperature from a body part that has been overloaded

because of training or competition and the risk of injury (167). Infrared

thermography can measure this increase of temperature, and bilateral, localised

Tsk differences can be identified by monitoring the evolution of the temperature

changes in the thermograms (comparing one side of the body with its

contralateral) and used to detect the presence of pathologies (28, 111, 167, 350).

Jones et al. indicated that changes of a few degrees Celsius in core body

temperature is a sign of physical dysfunction (204). A normal thermogram of the

limbs should show a symmetrical heat emission (216). In healthy subjects, the

cutaneous temperature difference between the sides of the body (ΔTsk) was

reported to be only 0.24±0.073°C (406). On the contrary, a temperature

difference of at least 1°C between the right and left sides of the body for more

than 25% of a specific body region is classified as asymmetrical or an

abnormality (4, 38, 111, 361, 400, 406, 460). With the improvement in the

thermal imaging cameras’ accuracy, the limit for left-to-right-side asymmetries

has been reduced to 0.5°C for clinical significance for healthy normalised ΔTsk

(28, 286, 407, 426). Subsequent studies of athletes saw a reduction in the normal

ΔTsk to 0.4±0.37°C (54), 0.4±0.22°C (459), and 0.3±0.61°C (167). This limit was

reduced even further in a recent study (424) in which the ΔTsk was equal to

0.19±0.2°C. The standard deviation providesve information about the presence

of abnormalities; it has been proposed that a ΔTsk exceeding 3 SD from the mean

is not normal (286).

Thermographic data of healthy subjects are scarce, notwithstanding a database

of normal Tsk patterns distribution is under construction (333). Many efforts

have been made to develop this database using data from different people of

Introduction

37

various ethnic backgrounds, including healthy Brazilians (245), Chinese (462),

Finnish (459), Taiwanese (286), Mexican children (218), and Portuguese (425).

Thermal references allow for the evaluation of normal Tsk and ΔTsk in different

ROIs. Therefore, it would also be interesting to include data from studies

regarding the ΔTsk in people with specific impairments or pathologies. An

example of one such study is that of Sherman et al. in which skin temperature

was compared between an area with normal sensations and an area without

sensation or with abnormal sensations in subjects with complete and incomplete

SCI. The differences were 1.5±0.62°C and 0.58±0.29°C for the participants with

complete and incomplete SCI, respectively (362). Since some nociceptive and

most neuropathic pain pathologies are associated with an alteration of the

thermal distribution (173), a more recent study on the assessment of pain

through IRT proposed statistical computations and distance measures between

comparable regions to assess the degree of asymmetry between contralateral

ROIs (165). In another example with patients with peripheral nerve injury, the

Tsk in the area innervated by the damaged nerve deviated an average of 1.55°C

from the undamaged areas (406). There are many other examples of ΔTsk

description in pathology samples (51, 293, 345, 406, 441). Some of these

asymmetries may remain for long periods, for example, for the first 90 days of an

injury in the peripheral nerves the Tsk of the affected side is elevated, and

following this, a reduction in the Tsk appears, which may last for years (38).

Varicose veins may also present long-term alterations of the Tsk (227). Cold

stress, common in northern countries, can increase the ΔTsk (459).

The effect of left- and right-side dominance, and factors associated with it, on

skin temperature is unclear. The literature reported no consistent relative

hyperthermia in the dominant extremity, no definitive thermal asymmetries and

no systematic pattern related to handedness (111, 151, 459). Gross et al. added

that asymmetrical temperature distribution patterns are caused by unilateral

pathologies rather than dominance (151). Smith et al. indicated there are no

significant differences between the dominant and the non-dominant limb on the

patterns of temperature distribution (374). They explained the presence of ΔTsk

in healthy subjects is because of better vascularization in the dominant side as a


38

consequence of physiological adaptations resulting from repetitive unilateral

activities performed in some sports or occupations (374), and not because of an

increased muscular mass in the dominant side. However, other studies suggested

that hyperthermia in the dominant side is caused by greater vascularity, strength

and muscle fiber composition (38). Further, Sillero et al. suggested that

differences found on the dominant leg might be due to a different contraction

pattern (369). Nevertheless, regardless of the precise mechanism, it is generally

agreed that temperature comparisons between bilateral body areas can be

employed to detect symptomatology and abnormal patterns in Tsk distribution

(407).

Introduction

39

1.4 THERMOREGULATION

The body’s thermoregulatory system acts maintaining the normal body

temperature during challenges to thermal homeostasis. The thermoregulatory

system is under the command of the hypothalamus, which prevents overheating

or overcooling by detecting changes to different central and peripheral stimuli,

such as blood temperature, blood pressure and level of metabolic activity, and

regulating blood flow (61). The sympathetic function of the hypothalamus is

responsible for thermal emission and thermal microcirculation. Reflex

sympathetic innervation of the circulation of the skin incorporates the

sympathetic noradrenergic vasoconstrictor system and the non-noradrenergic

active vasodilator system. Cutaneous sympathetic vasoconstrictor and

vasodilator systems also participate in the baroreflex control of blood pressure.

The constant vasomotor tone of the peripheral arterioles and precapillary

sphincters and the consequent vasoconstricted state of the dermal vessels allows

inhibits excess heat loss from the core (34). Figure 11 summarizes the

thermoregulation process.


40

Figure 11. Physiologic thermoregulation in humans. A, Increases in internal and/or skin temperatures are identified by the preoptic/anterior hypothalamus (PO/AH) and result in increased heat dissipation via cutaneous vasodilation and sweating, which then corrects an increase in temperature. B, Decreased skin or

internal temperature causes reflex decreases in heat dissipation (cutaneous vasoconstriction) and increased heat generation (through shivering) to correct a decrease in temperature. CNS = central nervous system. From Charkoudian (60).

1.4.1 Thermoregulation and exercise

During heat stress and exercise, a large percentage of cardiac output is directed

to the skin and the active vasodilator system is initiated (61). Increased blood

flow to the skin plays an essential roll in preventing overheating. It facilitates

perspiration to cool the skin by evaporation and allows for a reduction in body

heat and blood heat by convection, when the air is colder than the skin (61).

Therefore, the two thermoregulatory mechanisms that are employed in response

to an elevated core body temperature during exercise are cutaneous

vasodilatation and active sweat secretion (200, 209). Fernández presented a

overview of studies that analyzed the influence of exercise on Tsk before, during

and after exercise using IRT (112).

Introduction

41

Of the total metabolic energy generated only 30% is converted to mechanical

energy and the rest should be dissipated to the environment through the skin

(233). At the beginning of exercise, the blood flow of the muscles increases

causing reflex vasoconstriction in the skin and metabolically inactive areas and

vasodilatation in the working muscles (61, 199). Heat transfer between the body

and the external environment occurs bi-directionally through convection,

conduction and radiation, whereby the transfer of heat is driven by the

temperature gradient between the skin and the environment. Heat is also

transferred uni-directionally through evaporation - heat is dissipated only from

the skin to the environment. Evaporation is the primary (>80%) means of heat

removal from the body (233).

The literature reports different skin temperature reactions subsequent to the

initial reactions described above depending on the type and duration of the

exercise (72, 168, 212, 265, 465). Increments in exercise load usually imply

increases of Tsk, quantitative and qualitative changes in the Tsk distribution and

homogenization of the Tsk during the recovery (73). Prolonged exercise at a

constant load raises the core temperature and this heat must be transferred to

the skin to be dissipated ouside the body, therefore an initial decrease of Tsk is

followed by an increase of the Tsk due to the reflex neurogenic skin vasodilation

(72, 118, 168, 171, 182, 237, 411, 437, 457). At some point during prolonged

exercises sweating ceases and the core temperature increases considerably.

Brief and intense, graded, intermittent or maximal exercises experiment this

initial decrease that is maintained across the full exercise while the working

muscles demand blood. This is due to an increase in catecholamine and

vasoconstrictor hormones as exercise intensity increases (212). Therefore, tests

of a short duration result in decreased Tsk caused by the blood redistribution

(264, 265, 404). The higher the intensity of the exercise, the more delayed the

onset of cutaneous vasodilation (61). Coh et al. concluded that IRT is an

important method for monitoring loading conditions resulting from different

training means or exercise intensities (73).


42

When measuring the Tsk it should be considered that sweat changes the radiant

heat characteristics of the skin and can influence measurements and

underestimating the Tsk results. For this reason, some authors avoid using IRT

during exercises of longer duration because of the increased interference from

sweat (28). It is noteworthy to indicate that in cooler conditions (23 and 28°C)

such as the settings selected during IRT evaluations, the only reason for an onset

of sweating is related to a positive rate of oesophageal temperature variation,

while the Tsk level remains low and stable (243). This is in contrast to the

response following exercise in warm conditions (36.5 to 50°C), where the onset

of sweating is related to Tsk (243).

The literature reports some differences between the thermoregulation in trained

versus untrained individuals. For example, trained individuals have improved

skin thermal control, better vasoconstriction capability during the initial phase

of muscle work and a superior heat dissipation capability via the skin, because

the onset of vasodilation occurs at lower core temperatures and demonstrates

greater sensitivity to changes in temperature (264, 338). While it has been

reported that trained people have a more efficient thermoregulatory system

corresponding to greater levels of skin blood flow and sweating (61), the relation

between muscular effort and Tsk is still unknown. Interestingly, a very recent

study that assessed the relationship between neuromuscular activation and Tsk

during incremental cycle exercise found that participants with larger changes in

neuromuscular activation in the vastus lateralis muscle presented with a better

adaptive response of their thermoregulatory system, observed by smaller

increases in Tsk after exercise (321). This finding is supported by previous

studies that also showed a decrease in Tsk after the onset of the muscle work in

trained individuals (2) and a larger increase in Tsk after a prolonged exercise in

fit players (66).

1.4.2 Thermoregulation in people with spinal cord injury during exercise

People with SCI exhibit bradycardia, orthostatic hypotension, autonomic

dysreflexia, thermo-dysregulation and sweating disturbances as a result of

Introduction

43

impaired autonomic nervous system (221). All of these present important

applications for this population, however of particular importance to the

application of IRT are 1) the interruption of the neural transmission of

thermoregulatory signals; 2) the loss of autonomic nervous control for

vasomotor and sudomotor responses that leads to an inability to vasodilate and

sweat in regions below the level of the spinal cord lesion (175, 355); and 3) a

reduced thermoregulatory effector response for a given core temperature (314,

355). The three main phenomena linked with thermal dysregulation in SCI are:

poikilothermia, acute hyperthermia and exercise-induced hyperthermia (186).

Due to their poikilothermic behaviour, or the inability to regulate body

temperature in ambient conditions (453), people with SCIs show a lower core

temperature in the cold and a higher core temperature in the heat when

compared with able-bodied people (25), because of the lack of peripheral

circulation control (453). Consequently, people with SCI have a reduced ability to

tolerate thermal extremes (355), a greater heat storage within the lower body

(314) and a tendency to sweat less (314, 317). The acute hyperthermia related to

SCI, when it is not associated with infections or other such recognizable causes,

is called ‘quad fever’ and appears in the first weeks of months following the SCI

(186).

During exercise, the decreased sensitivity for thermoregulation as a result of SCI

translates to a greater increase in Tsk and skin blood flow in comparison with

healthy people (248). Circulatory responses during heat exposure, and also fluid

losses during exercise and heat retention during passive recovery from exercise

are related to lesion level (314, 453). This insufficiency in temperature

regulation makes Tsk very changeable from one day to another. Moreover, some

cardiovascular responses to exercise, for example, the increase of blood flow to

active muscles and vasoconstriction in inactive tissues, may be distorted (141).

Finally, the absence of a venous muscle pump, which limits the venous return

(140) must not be disregarded.

All of the complications described above are amplified in individuals with

tetraplegia compared to paraplegics (314) due to the alteration of sweating


44

capacity. Although people with a low level of SCI can have up to a 50% reduction

in perspiration capacity compared to able-bodied individuals, being this

reduction proportional to their skin area available for sweating (178, 314).

Thijssen et al. found a significant disturbance of the circadian variation in core

temperature in tetraplegics, whereas paraplegics presented a comparable

circardian variation to their able-bodied counterparts (398). It has been

reported that people with tetraplegia have higher risk of hypo- and

hyperthermia than individuals with a thoracic-level injury (48, 213), and they

also have little to no sweating response as the injury level is above the

sympathetic outflow (155, 443). A study of the sympathetic sudomotor skin

activity in SCIs found that the manifestation or not of sympathetic skin responses

after stimulation at the palmar and dorsal wrist skin was dependent on the level

of the lesion and the location of the stimulation (327).

It has been suggested that the sixth thoracic vertebrae is the limit above which

individuals with SCIs experience a greater thermal strain (155). Gass et al. found

greater increase in the calf Tsk of subjects with T12-T11 injury level in

comparison with higher lesions indicating that the neural pathway responsible

for vasodilation may be located at or below T10 (132). Despite the increase in

thermal strain, it is interesting to note that Yaggie et al. observed a compensation

for the decreased sweating in regions affected below the level of the SCI by way

of greater perspiration in regions innervated above the injury level (452). In

general, people with tetraplegia have a much greater difficulty regulating

temperature (319). Michael J Price, one of the main contributors to the field of

thermoregulation in SCI explained that “A relationship between the available

muscle mass for heat production and sweating capacity appears evident for the

maintenance of thermal balance. During recovery from exercise, decreases in aural

temperature, Tsk and heat storage were greatest for the able-bodied athletes with

the greatest capacity for heat loss and lowest for the tetraplegic athlete with the

smallest capacity for heat loss” (317).

It is encouraging to note that despite impaired thermoregulation in people who

have SCIs, exercise training has been shown to alleviate the complications. In

Introduction

45

fact, the literature reports a greater capacity for the dissipation of heat in the

trained individuals with SCI (88, 122) compared to those who are not trained.

Moreover, similar increases in core temperature in cool and warm conditions

have been reported in trained low-level paraplegics and able-bodied people

(317), and similar decreases in Tsk from resting values followed by a plateau in

trained paraplegic and able-bodied individuals (88).

Lastly, it is important to highlight the regional Tsk responses experienced by

individuals with SCIs (Figure 12). This population is characterized by cold and

blue lower limbs with cooler thigh and calf Tsk than the rest of the body at rest

(175, 315). Conversely, there are almost no differences in Tsk values between

able-bodied and SCI subjects. Another interesting response observed in people

who have a SCI and associated disrupted sympathetic nervous system is the

increase in calf Tsk during prolonged arm exercise (132, 315-317). This

phenomenon has been attributed to heat storage within the lower body (315-

318), and for this reason Price et al. concluded that cooling the lower body

during arm exercise in hot conditions is more effective in reducing physiological

and thermal strain than cooling the upper body (320). The greater heat storage

in the lower body results in a reduced ability to lower the core temperature of

SCI during recovery periods (434), however this increase in thigh and calf Tsk is

necessary to stabilize the active upper body. These observations should be

considered when evaluating Tsk in SCI subjects with IRT.


46

Figure 12. Thigh, Calf, Forearm, and Upper Arm skin temperatures for able-bodied (AB), paraplegic (PA), and tetraplegic (TP) athletes during prolonged exercise and

recovery in warm conditions. From Price (317)

Introduction

47

1.5 PHYSICAL ACTIVITY IN WHEELCHAIR USERS

The literature generally agrees on the positive influence of physical exercise on

WCUs, specifically in people with SCI (115, 279). Amongst this population,

individuals actively involved in sports have higher employment rates than those

who are physically inactive, and physical activity has been identified as the

principal determinant of quality of life (18, 385). Recreational and therapeutic

exercise has been found to improve the physical and emotional wellbeing of

participants with SCI (279). Moreover, quality of life is closely related with

independent living, and it is a crucial outcome when evaluating the success of

rehabilitation (288). In a 9-month randomized control trial study, exercisers

reported greater quality of life and less stress and pain than non-exercisers; the

study highlighted the need to continue exercise adherence to maintain these

positive effects (98). Another study with paraplegics revealed the positive effects

of an exercise programme using a seated double-poling ergometer in reducing

musculoskeletal and neuropathic pain (291).

Pain is the first indication of an overload injury and, as it increases, the WCU

reduces their performance of daily life activities, resulting in a reduction of their

physical capacity and a subsequent increment of the overloading risk (348).

Therefore, it seems obvious to prescribe exercise to wheelchair-dependent

individuals. In a cross-sectional and longitudinal survey, it was found that the

shoulder was the most frequently reported site of pain (195). More recent

studies have indicated that lower quality of life and physical activity scores are

significantly related to higher levels of shoulder pain (154) and vice versa (63,

210). The majority of studies concur in indicating that the longer the duration of

injury and the older the wheelchair users are, the higher the shoulder pain.

Quadriplegics are also reported to have more shoulder pain than people with

paraplegia, as are women compared to men.

The literature is, to this point, inconclusive regarding the effect of physical

activity on shoulder pain. Some authors assert that the shoulder pain does not

increase or decrease with sports (120), while other authors argue that shoulder


48

pain decreases with exercise (83, 85, 128, 277, 395, 450), and one study found

slightly higher shoulder pain in those using a powered-wheelchair than those in

manual-wheelchairs (190). On the other hand, some studies support the ‘overuse

theory’ described by Wing et al. (447), where a greater number of injuries have

been associated with an increase in sports participation, particularly overhead

sports (8); a larger number of training hours per week (79); a higher level of

wheelchair activity (225, 229); and musculoskeletal overuse (32, 284). One

study reported simply that wheelchair sports generate shoulder pain (389).

There are a number of studies that have addressed the incidence of shoulder

pain and/or shoulder injuries with various modes of physical activity. An

investigation of wheelchair rugby players (mostly quadriplegics) found an

adductor strength deficit linked to shoulder pain, probably due to the level of the

SCI, in contrast to the common weak abductors in able-bodied athletes (269). An

interesting study analyzed five wheelchair-based circuit resistance-training

(CRT) exercises (overhead press, lat pull-down, chest press, row and rickshaw)

and how they placed the shoulder at risk for subacromial mechanical

impingement. The rickshaw was shown to be the most dangerous exercise with

respect to this type of injury (329). Similarly, Nash et al. examined the effects of a

CRT on muscle strength, endurance, anaerobic power, and shoulder pain in

middle-aged men with paraplegia. They concluded that CRT improves muscle

strength, endurance, and anaerobic power of the paraplegia sample while

significantly reducing their shoulder pain (280). Conversely, a primary fitness

program using arm crank ergometry had no effect on shoulder pain in 23 SCI

WCUs (102), possibly because of the less harmful type of wheelchair exercise.

Hettinga et al. presented functional electrical stimulation (FES) as an alternative

to increase the upper body muscle mass to avoid the risk of shoulder overuse

injury. In this review, the benefits of three FES modalities were shown, including

FES-assisted cycling, FES-cycling combined with arm cranking (FES-hybrid

exercise) and FES-rowing; all have been suggested as candidates for

cardiovascular training in SCI (166). Burnham et al. compared paraplegic

athletes, 26% of whom had rotator cuff impingement syndrome, whith healthy

athletes. Stronger shoulders in all directions were shown for the paraplegic

Introduction

49

group, as well as a higher strength ratio of shoulder abduction:adduction (53).

Shoulder pain intensity was inversely related to physical activity in a study with

80 WCUs with shoulder pain (154). In this study, women reported higher levels

of shoulder pain, but men and women had similar levels of physical activity. The

same inverse correlation was found by Fullerton et al. (128). While Wylie et al.

reported that moderate joint activity protected shoulders from degeneration

after finding 45% of inactive paraplegics with degenerative changes in

comparison with 18% of the actives; an interview to 88 individuals with thoracic

SCI found shoulder pain in 47% of the wheelchair athletes compared to 33% of

the sedentary WCUs (11). Taken together, these studies show that, according to

literature, the effect of exercise in WCUs is yet unclear. The comparison of results

between the studies is difficult due to a lack of standardization and consensus

with respect to the technologies and methodologies applied. Added to this are

relatively small sample sizes and large inter-individual variations that limit the

application of the results.


50

1.6 OUTLINE OF THE PRESENT THESIS

This review of literature identified that injuries to the shoulder are particularly

prevalent in people who use wheelchairs. The propulsion activity for ambulation

in handrim wheelchair activity itself causes muscle imbalances and

complications due to overloading of the upper limbs. However, it is not clear

whether sedentariness prevents shoulder injuries or whether shoulder pain

impedes sedentary WCUs from participating in physical activity and sports.

Some studies support a protective role for physical activity in the shoulder joint,

precluding degeneration of the involved structures. Given the positive outcomes

associated with habitual physical activity for people with SCIs, including

improvements in health, functional ability, quality of life and vocational

opportunities (115), as well as the higher rates and earlier onset of

cardiovascular diseases in this population, preventive strategies for shoulder

pain and shoulder injuries must be developed. Some of the solutions that require

further investigation are the development of educational programs teaching

alternative techniques for transfers and other daily activities, training endurance

capacity, optimizing posture, stretching and strengthening the upper limbs and

individualised fitting of the wheelchair to its user. Another solution that is of

particular interest to the current thesis is the adoption of injury prevention

strategies for the early identification of shoulder pain and injury risk factors in

WCUs. Infrared thermography may be a useful tool for this early-identification

process. This technique’s advantage, and the primary reason for its selection in

the present work, is that non-invasive. Although its application is promising in

this regard, it is important to bear in mind that IRT is not a diagnostic tool. Yet,

encouragingly, IRT allows for the detection of changes in skin temperature that

may be an indication of inflammatory responses contributing to injury

processes. Before its use in WCUs, it is necessary to measure the reliability of the

thermal imaging camera in this population, especially given the

thermoregulatory particularities of people with SCIs. Therefore, the first study of

the present thesis is an investigation of the reliability of the IRT in WCUs. The

aim of the second study is to ascertain the resting thermal profiles of wheelchair

athletes and nonathletes in regions that are involved in their ambulation and

Introduction

51

that are related to shoulder pain. The final study examines the thermal pattern of

wheelchair athletes after a 30 second maximal intensity wheelchair propulsion

test. Given that there is little agreement in the literature about the benefits or

harm to the shoulder joint during wheelchair exercise, the aim of the current

thesis is conduct the foundation studies to begin to understand whether

wheelchair exercise increase the load to the shoulder joint, and hence cause

shoulder pain, or will it build a strong and stable joint to propel the wheelchair

without pain.


52

Objectives

53

2 OBJECTIVES

2.1 STUDY 1

- To examine the reliability of infrared thermography in wheelchair users.

2.2 STUDY 2

- To compare the temperature profile of athletic and nonathletic

wheelchair users.

- To differentiate the shoulder pain of athletic and nonathletic wheelchair

user.

- To relate shoulder pain with upper body skin temperature in wheelchair

athletes and nonathletes.

2.3 STUDY 3

- To analyse the skin temperature measured by infrared thermography

before and after a maximal wheelchair propulsion test in athletes.

- To evaluate the relationship between shoulder pain and skin temperature

after a wheelchair propulsion test.

- To analyze the relationship of the shoulder pain with the kinematic

variables of the wheelchair propulsion test.


54

3 MATERIAL AND METHODS

3.1 STUDY DESIGN

We designed a reliability study to analyse the IRT in WCUs, and an observational

and descriptive study (cross-sectional or transversal) to analyse the relation of

Tsk and shoulder pain in different groups of WCUs: athletes and nonathletes. It

was a test retest reliability design.

During one month, the same researcher visited the rehabilitation center where

the nonathletic WCUs received treatment (the Rehabilitation Center of ASPAYM

Castilla y León) or the sport facilities where the athletic WCUs trained (in

Valladolid and Palencia) to perform thermographic analysis in basal state on two

consecutive days to each subject, with the objective to analyse the IRT technique.

In those days two physical activity questionnaires specific for people with

disabilities were distributed, including The Physical Activity and Disability

Survey (PADS) (331) and The Physical Activity Scale for Individuals with

Physical Disabilities (PASIPD) (440). Posteriorly, all subjects attended one

session at the laboratory of the Research Centre for Physical Disabilities (CIDIF)

to be evaluated on the following battery of tests: a shoulder pain questionnaire

(the Wheelchair Users Shoulder Pain Index or WUSPI); a wheelchair propulsion

test (T-CIDIF) (261); and two additional thermograms taken before, one minute

after and ten minutes after the T-CIDIF. The section 3.5 details each of those

measures. Experiments were performed on their own daily wheelchair.

3.2 SAMPLE

A total of 54 manual WCUs participated voluntarily in the initial data collection

of this thesis (Table 2). From the 32 nonathletic WCUs, 15 were male (age:

45.1±12.2 years; height: 177±0.09 cm; weight: 76.7±10.2 kg; IMC: 24.4±3.1 kg·m-

2) and 17 female (age: 42.4±10.5 years; height: 161±0.05 cm; weight: 56.4±10.3

Material & Methods

55

kg; IMC: 21.7±4.1 kg·m-2). The 22 male wheelchair athletes belonged to the

wheelchair basketball teams: Fundación Grupo Norte from Valladolid and

Minusválidos Unidos por la Integración (MUPLI) from Palencia. The season of the

data collection (2009-2010), the Fundación Grupo Norte team was the winner of

the “European Cup Willi Brinkmann”; second position in the European League;

third position in the “Copa de S.M. El Rey”; and fourth position in the Spanish

League honour division as well as champion of fourth different Spanish

tournaments; being champion of the Spanish League in the following season.

MUPLI team competed in first division and trained 2 hours 3 days per week, vs.

the 2 hours and 6 days per week of the Fundación Grupo Norte team.

Table 2. Number of subjects per group

Sport Sex

Lesion

Total Paraplegic Tetraplegic Others

Nonathlete Men 6 5 4 15

Women 10 1 6 17

Total 16 6 10 32

Athlete A1 Men 1 10 11

Total 1 10 11

Athlete B2 Men 10 1 11

Total 10 1 11

All 54

1 Athletes that use the wheelchair only for sport 2 Athletes that use the wheelchair for sport and daily live

3.2.1 Ethics norms followed in this study

Prior to the investigation, subjects were fully familiarized with testing

procedures and informed about the risks and benefits of the study, and signed an

institutionally approved informed consent document. The protocol was

approved by the Ethics Committee of the Technical University of Madrid

following the principles outlined by the World Medical Declaration of Helsinki

(445). Moreover, all procedures used in this study conformed to the Spanish law

for Protection of Personal Data 15/1999.


56

3.2.2 Inclusion and exclusion criteria

All participants have propelled their own manual wheelchair for at least one

year, and use a wheelchair for at least 50% of home and community mobility. In

addition, they must be over 18 years old. Subjects were classified as athletes if

they were involved in organized, competitive wheelchair sports of recreational

to elite levels of competition, had participated in at least three competitions per

year and if they trained at least 3 h·wk-1 (120). The vast majority of athletes

involved in the study, being at an elite level of competition, far exceeded these

requirements.

3.2.3 Demographic data of the studies 1 and 2

In the first and second studies, experimental data were collected from 24

experienced manual WCUs, 22 men and 2 women. 19 were manual wheelchair

dependent and 5 were wheelchair independent (use of wheelchair only to

practice sport), 14 were subjects with paraplegia, 3 with tetraplegia and 7

presented other disabilities (amputation, multiple sclerosis, and poliomyelitis).

From all, 13 were nonathletes (11 males and two females) and 11 were male

athletes. Table 2 summarizes the number of subjects that belongs to each group

and Table 3 the main characteristics of the sample.

Table 3. Group subject characteristics from studies 1 and 2 expressed by mean±Standard Deviation

Sport Gender n Age (yr) Height (cm) BMI (kg·m-2)

Nonathletes Male 11 45.1±11.6 177.6±9.1 23.2±2.5 Female 2 44.5±3.5 158.0±1.4 25.9±5.3

Athletes Male 11 32.3±6.4 173.4±8.7 24.7±3.8

All 24 39.2±10.9 174.0±9.9 24.1±3.3

n, number of subjects; BMI, body mass index.

Material & Methods

57

3.2.4 Demographic data of the study 3

Twelve male wheelchair athletes (age: 32.58±6.16 years; height: 173.58±8.34

cm; body mass: 74.24±12.73 kg; body mass index: 24.61±3.66 kg/m2) recruited

from the elite and the recreational wheelchair basketball teams, volunteered to

participate in this study.

3.3 EQUIPMENT

3.3.1 Material for the thermographic evaluation

The three studies used the same common instruments for the IRT analysis.

Infrared thermal imaging of the upper extremities and the trunk were recorded

using a thermal camera (FLIR T335, FLIR® Systems, Danderyd, Sweden), with a

thermal sensitivity of 50 mK, an object temperature range from -20°C to +120°C,

a length spectrum range of 7.5-13 μm, an infrared spectral band of 320 x 240

pixels FPA (Focal Plane Array), a IR resolution of 320 x 240 pixels and an

accuracy of ±2% or 2% of the measurement (Figure 13). The temperature data

was extracted and the IRT images were analyzed with specific software

(ThermaCAM Reporter, version 8, FLIR® Systems, Danderyd, Sweden).

Figure 13. IRT camera T335 (FLIR® Systems, Sweden)


58

The camera was calibrated before each trial using an external temperature

reference source (thermistor PT-100, Telemeter Electronic®, Donauworth,

Germany) and was turn on 20’ before to avoid calibration problems. The wall

behind body figures was covered with a white “Roll-up” 125x206 cm (in the

study 1 and 2) and a black background (in the study 3) to create a homogeneous

background behind body figures and to avoid any kind of reflection or radiation

emitted by other objects. A fixed area of the black background was taken as the

reference temperature. Images were obtained assuming skin emissivity of 0.98

(383). A tripod Hama Omega Premium II (Hama®, Monheim, Germany) was

used to hold the camera during the data collection. The environmental

conditions in the testing room were monitored by a portable weather station

(BAR-908-HG® model, Oregon Scientific®, USA). The table 4 shows the

characteristics of this weather station.

Table 4. General characteristics of the weather station, model BAR-908-HG® (Oregon Scientific, Portland, Oregon)

Characteristics of the portable weather station

Weight 370 grams.

Dimensions 188 x 120 x 86 mm. (height x width x depth

Temperature Interior (-5 / + 50%)

Humidity Interior and exterior (25 – 95%)

Atmospheric pressure Numeric value; 500 – 1050 mb/hPa.

Resolution 1 mb/hPa

Indicators Trends and comfort zones

Others - Evolution charts of the atmospheric pressure in the last 24h

- Weather forecast with symbols

3.3.2 Material for the shoulder pain evaluation

The WUSPI is a questionnaire with a maximum total score of 150 which

integrates a series of visual analogue scales (consisting of 10-cm lines anchored

by ‘no pain’ and ‘worst pain ever experienced’) to provide an accumulated index

of the intensity of shoulder pain suffered during the previous week while

performing 15 different daily activities. Due to individual characteristics, not all

the activities listed on the WUSPI were performed by the subjects in their daily

Material & Methods

59

routines. Consequently, the Performance-Corrected score (PC-WUSPI) was

calculated by dividing the total raw score by the number of activities executed

and multiplied by 15 (80, 83). The WUSPI and the PC-WUSPI has been shown to

be both reliable and valid for people with SCI (82). We used the Spanish version

of this questionnaire validated by Arroyo et al. (23) (see Appendix 4 for the

English version and Appendix 5 for the Spanish version of the WUSPI).

3.3.3 Material for the register of the kinematic variables

The Research Centre for Physical Disability developed a test to analyze the

wheelchair propulsion; it was called the T-CIDIF and has been recently validated

(261) (Figure 14). It correlated well with pain and strength in the shoulder joint

of WCUs.


60

Figure 14. Elite wheelchair athlete ready to perform the wheelchair propulsion test (T-CIDIF)

Each subject placed his wheelchair over two rollers located one meter from a

wall, in which there was a fitness pulley (En-TREEPulley, Enraf-Nonius,

Rotterdam, Holland) and two linear position transducers (Sportmetrics,

Valencia, Spain). Each transducer was attached to the subject’s arm through a

glove. A cable connected each glove with the correspondent pulley to provide

resistance to the movement (Figure 15).

Material & Methods

61

Figure 15. T-CIDIF. Left: detail of the linear position transducers integrated with the fitness pulley. Right: detail of the gloves fixed to the forearm.

The load of the pulley was selected according to the body mass of each subject

(see Table 5). Kinematic data were collected bilaterally at a registration

frequency of 200Hz. It was obtained the number of propulsions, mean and

maximum peak power, and mean and maximum velocity of each arm.

Table 5. Rolling resistance to overcome depending on the subject's mass

Subject mass (kg) Selected pulley mass

(kg)

Real mass transmitted to the forearm

anchorage* (kg)

< 65 6 1.43

66-75 10 2.57

76-85 14 3.63

86-95 18 4.77

> 96 22 6.2

*Mass calculated trough placing a load cell (KERN HCB 200K100, Kern & Sohn GmbH,

Balingen, Germany) in the cable that is connected to the glove. The pulley system gears

down the initially selected load.

3.4 RESEARCH PERSONNEL

All the tests were carried out by the thermographic specialist, supported by the

technicians from the laboratory of the CIDIF formed of Sport Science experts.


62

3.5 PROCEDURES

3.5.1 Study 1: Infrared Thermal Imaging

Two thermographic photographs corresponding to the anterior and posterior

upper body were performed over two days with an interval of one day. Skin

temperature of 16 and 20 body areas or ROIs of the front and rear upper body

respectively, were measured using IRT. All images were taken and analyzed by

the same observer. Images were taken with the subject’s own daily wheelchair in

anatomical position. The camera was positioned perpendicular to the ground,

and the distance between the subject and the infrared camera was from 2 m to 3

m, depending on the height of subjects, as the aim was to match the center of the

image with the geometric center of the area to be evaluated. A transparent

template helped the technician on the placement of the camera (Figure 16).

Figure 16. Thermographic analysis of an athlete (left) and a nonathlete (right)

Each image was manually divided into different body areas (Figure 17) based on

previous proposals (13, 147, 406, 407), and on the areas corresponding to the

Material & Methods

63

main muscles involved in the wheelchair propulsion task (341). Uematsu et al.

selected the ROIs coinciding with the dermatomes, which are skin areas

innervated by the major peripheral nerves (407). In this way, it is possible to

associate the ROIs’ data with the corresponding nerves. In our case, we

substitute the squares used by other authors for areas more similar to the real

muscles; it increased the drawing difficulty but gained in accuracy (Figures 17

and Figure 18).

Figure 17. A total of 16 areas on the front body were studied in the study 1.

Example from a wheelchair athlete

1

3

2

4

6 51

7

9 8

100

11

12

13

14

15

16

1. Left anterior forearm 2. Flexor of the left elbow 3. Left anterior arm 4. Left anterior shoulder 5. Left anterior trapezius 6. Anterior neck 7. Left pectoral 8. Left side of the abdomen 9. Abdomen 10. Right side of the abdomen 11. Right pectoral 12. Right anterior trapezius 13. Right anterior shoulder 14. Right anterior arm 15. Flexor of the right elbow 16. Right anterior forearm


64

Figure 18. A total of 20 areas on the rear body were studied in the study 1. Example from a wheelchair athlete

Several body areas were eliminated from the analysis: the lumbar area was

hidden by the wheelchair; the abdomen and both flanks were not considered a

relevant muscular area as many subjects with SCIs do not have muscle tone in

that area; elbows and cubital fosses areas are not important for the propulsion of

the wheelchair; the pectoral data of women were discarded due to the influence

of the bra.

17

18

19

20

21

22 23

24

25

26

27

28

29

30 31

32 33

34

35

36

17. Left posterior forearm 18. Left elbow 19. Left posterior arm 20. Left posterior shoulder 21. Left posterior trapezius 22. Left supraspinatus 23. Left central posterior trapezius 24. Left infraspinatus 25. Left dorsal 26. Lumbar 27. Right dorsal 28. Right infraspinatus 29. Right central posterior trapezius 30. Posterior neck 31. Right posterior trapezius 32. Right infraspinatus 33. Right posterior shoulder 34. Right posterior arm 35. Right elbow 36. Right posterior forearm

Material & Methods

65

The circadian rhythm effect over Tsk (270) was avoided by always testing each

subject at the same hour of the day. During the first session, the subject

responded verbally to a demographic and medical questionnaire. Before every

thermographic examination subjects were instructed to refrain from the

following in the 24 hours before the test: applying creams or perfume, smoking,

drinking alcohol or coffee, sunbathing, showering, receiving treatment, therapy,

massage or undertaking exercise. All subjects postponed their weekly therapies

after the thermographic tests, and they were asked not to push their wheelchairs

before the test more than was strictly necessary. Prior to the assessment,

subjects were asked to remain at rest, without clothes and jewelry on the upper

body for at least 10 minutes before being photographed. This acclimatization

period allowed the subjects’ Tsk to stabilize (332). Every test was performed

under equal conditions and in the same room, in which the temperature was

fixed at 23°C and drafts were eliminated.

3.5.2 Study 2: Infrared Thermal Imaging and The Wheelchair User Shoulder Pain Index

For the second study, subjects attended one session at the laboratory and two

thermograms corresponding to the anterior and posterior subject’s upper body

were taken. Therefore the basal Tsk was studied in the same day, instead of over

two days such as the study 1. Another difference with the previous protocol was

the number of ROIs studied, which was reduced from 36 to 22 ROIs. In the study

2, Tsk of 8 anterior and 14 posterior ROIs of the upper body were measured,

which were left and right: anterior and posterior Arm, Shoulder, Pectoral,

anterior and posterior Trapezius, Dorsal, Infraspinatus, Supraspinatus, Central

Trapezius. The rest of the procedure remained equal to the precedent data

collection regarding position of the camera, room conditions, instructions to the

subjects, and same researcher performing the tests.

After thermographic examination, each subject completed the Wheelchair User

Shoulder Pain Index (WUSPI).


66

3.5.3 Study 3: Infrared Thermal Imaging, The Wheelchair User Shoulder Pain Index and the wheelchair propulsion test T-CIDIF

The Tsk of the body ROIs was obtained from thermographic images following the

same criteria described by Rossignoli et al. (342). The Tsk analysis included the

following 26 ROIs (left and right): anterior and posterior Arm, anterior and

posterior Shoulder, anterior and posterior Forearm, Pectoral, anterior and

posterior Trapezius, Dorsal, Infraspinatus, Supraspinatus and Central Trapezius.

The ROIs were manually drawn on the basis of previous studies (13, 342, 406,

407). Three sets of 4 thermographs for each subject in anatomical position were

taken and analyzed by the same previously trained observer. Subjects were

instructed to remove clothes and jewelry from their upper body and remain 10

min at rest in a conditioned room (23°C±1.9°C). After the acclimatization period

and before the wheelchair propulsion test, four thermograms were recorded

including two images each (trunk/upper limbs) of the anterior and posterior

sides of the body (pre-test); right after performing the T-CIDIF, the subject

placed his wheelchair in the same location of the previous IRT analysis and

another four thermograms were recorded (post-test); 10 min after the post-test

two new thermograms were taken (post-10) (Figure 19).

The camera was placed perpendicular to the ground, at 2-3 m away from the

subject’s skin to match the center of the image with the geometric center of the

area to be evaluated. A transparent template was affixed to the camera screen to

ensure the correct placement of the camera during the session.

Before the assessment, subjects were instructed to avoid consuming alcohol or

caffeine, using any type of cream or perfume, smoking, sunbathing, showering,

receiving treatment, therapy, massage or performing vigorous exercise in the 24

h preceding the measurements (same instruction than in the studies 1 and 2).

After the basal thermographic data collection, the subjects performed a

maximum wheelchair propulsion test (T-CIDIF) (261). The subject completed a

10 min warm-up period, consisting on 6 min propelling their wheelchair at a

high speed, followed by 4 min of progressions of 20s propelling and 20s resting.

Material & Methods

67

Two minutes after the warm-up period, the subject was asked to propel his

wheelchair as fast as possible during 30s.

Figure 19. Measurements of the study 3. Pre-test, thermographic evaluation before the wheelchair exercise test; Post-test, thermographic evaluation one

minute after completing the wheelchair exercise test; Post-10, thermographic evaluation ten minutes after completing the wheelchair exercise test


68

3.6 VARIABLES

Table 6 show the dependent, independent and control variables considered in

the studies of this thesis:

Table 6. Variables and their values

Name/Abbreviation Type Values

De

pe

nd

en

t

Skin temperature (Tsk) Continuous (interval) Celsius degrees (°C)

Asymmetries or side-to-side

skin temperature (ΔTsk)

Continuous (interval) Celsius degrees (°C)

Shoulder pain questionnaire

(WUSPI and PC-WUSPI)

Continuous (interval) Pain score (0 to 150

points)

Number of propulsions Continuous (ratio)

Mean peak torque Continuous (ratio) Watt (W)

Mean power Continuous (ratio) Watt (W)

Maximum velocity Continuous (ratio) (m·s-1)

Average maximum velocity Continuous (ratio) (m·s-1)

Total work Continuous (ratio) Watt (W)

Age Continuous (ratio) Years

Height Continuous (ratio) Cm

Body Mass Index Continuous (ratio) Kg/m2

Weight Continuous (ratio) Kg

Ind

ep

en

de

nt

Group Dichotomous Athletes / nonathletes

Time Ordinal Before exercise (pre-

test), one minute after

exercise (post-test),

after 10 minutes (post-

10); day 1 and day 2

Regions of interest (ROI) Nominal ROI (left and right)

Body areas Nominal ROI (right minus left)

Co

ntr

ol Room temperature Continuous (interval) Celsius degrees (°C)

Humidity Continuous (ratio) %

Atmospheric pressure Continuous (interval) Mb/hPa

Material & Methods

69

3.7 STATISTICAL ANALYSIS

The statistical treatment of data was performed using SPSS 19.0 software for

Windows (SPSS Inc., Chicago, IL, USA). The level of significance was always set at

α ≤ .05 for all statistical analyses. The specific calculations for each section are

described in the following points.

3.7.1 Study 1

After applying the Kolmogorov-Smirnov tests with the Lilliefors correction,

asymmetry and kurtosis, ±1 and ±2 respectively (58, 247), the normality of the

dependent variables was verified and parametric statistics were therefore

applied.

Intraclass Correlation Coefficient (ICC) was used to analyze the reliability and

Coefficient of Variation (CV) (SD*100/mean) to analyze the dispersion data. ICC

was characterized as follows (69): Poor reproducibility: 0–0.39, Fair

reproducibility: 0.40–0.59, Good reproducibility: 0.60–0.74, Excellent

reproducibility: 0.75–1.0. Descriptive statistics were used (mean ± SD) to

describe, organize and summarize the data for the number of assessments (day 1

and day 2). Side-to-side skin temperature differences (ΔTsk) were calculated for

each area by subtracting the mean temperature of the maximum values of the

right side from that of the left side. The minimum difference was calculated for

all the body areas to study the relevancy of day-to-day Tsk. Student-T Test for

related samples was used to ascertain whether there were any differences across

the two measures.

3.7.2 Study 2

The bilateral skin temperature difference (ΔTsk) was calculated by subtracting

the temperature of the right side from that of the left side. The normality of the

thermographic values was analysed with the Shapiro-Wilk test. If normality was

assumed, the independent student t test was used to compare thermographic


70

values between nonathletic and athletic subjects. If normality was not assumed,

the U Mann-Whitney test was used for this comparison. The comparison

between athletes and nonathletes in relation with WUSPI and PC-WUSPI was

done with the U Mann-Whitney test. The relation between thermographic values

and WUSPI or PC-WUSPI was analysed with the Spearman rho. Thermographic

values are expressed as mean ± Standard Deviation and WUSPI and PC-WUSPI

values are expressed as median ± Interquartile Range.

3.7.3 Study 3

The interside temperature difference (ΔTsk) was calculated for each ROI by

subtracting the temperature of the right side from that of the left side. Bilateral

ΔTsk more than 0.5°C was considered abnormal (54).

The normality of the thermographic values and the variables obtained in the T-

CIDIF was tested with the Shapiro-Wilk tests. If normality was assumed, the

repeated measures ANOVA test was used to compare the absolute levels of ΔTsk

before (pre), after one minute (post1) and after 10 minutes (post-10) the T-

CIDIF. The post hoc applied was the least significant difference, due to the

reduced number of participants. If normality was not assumed, the Friedman’s

test with the Bonferroni procedure was applied for this comparison.

The relations between the T-CIDIF variables and WUSPI or PC-WUSPI, likewise

between thermographic values and WUSPI or PC-WUSPI, were analysed with the

Spearman rho, since WUSPI or PC-WUSPI are ordinal variables. The correlation

between thermographic values and T-CIDIF variables was analysed with the

Spearman rho coefficient.

Results

71

4 RESULTS

4.1 STUDY 1: RELIABILITY OF INFRARED THERMOGRAPHY IN SKIN TEMPERATURE EVALUATION OF WHEELCHAIR USERS

4.1.1 Reliability of measurements

A total of 1728 images for the trunk and upper extremities were recorded from

24 subjects. By comparing the assessment of day 1 and day 2 for the temperature

profile, no significant differences were observed in any of the 36 zones, or in the

mean or maximum values. The only differences were observed in the average Tsk

of the right posterior arm (P=0.041), with a difference of 2.05°C between day 1

and day 2.

The best maximum Tsk values of ICC were found in the left anterior forearm,

right posterior forearm, left posterior arm and left anterior trapezius, with 0.76,

0.77, 0.77, 0.79, respectively (see Table 7).

For the average values the highest ICC was the following: left posterior forearm,

0.80; right posterior arm, 0.88; right dorsal, 0.79; right pectoral, 0.95; left

supraspinatus, 0.76 (see Table 8). Some zones presented a poor reproducibility:

right anterior forearm, 0.22; left anterior forearm, 0.24; left anterior arm, 0.18;

left posterior arm, 0.23; left anterior shoulder, 0.15; left pectoral, 0.39; left

posterior trapezius, 0.38. Hence, IRT in WCUs showed a poor to excellent

reliability for the left posterior arm and right posterior arm (ICC= 0.15 and 0.95,

respectively). For a graphical view of the day-to-day analysis of reliability see

Figure 20.


72

Table 7. Descriptive maximum values of the skin temperature profile on day 1, day 2 and between both the assessments of the analyzed area

ROIs Day 1 Day 2 Day 1 and 2

Mean ± SD Mean ± SD CV ICC Scale

R A Forearm 33.31 ± 1.36 33.38 ± 1.16 1.56 0.6 Good

L A Forearm 33.10 ± 1.17 33.00 ± 1.13 1.23 0.76 Excellent

R A Arm 33.96 ± 0.75 33.97 ± 0.99 1.36 0.52 Fair

L A Arm 33.50 ± 0.72 33.53 ± 0.92 1.14 0.58 Fair

A Neck 33.67 ± 0.84 33.79 ± 0.77 1.13 0.56 Fair

R A Shoulder 34.15 ± 0.65 34.21 ± 0.83 1.17 0.52 Fair

L A Shoulder 33.90 ± 0.72 33.85 ± 1.19 1.51 0.49 Fair

R Pectoral 34.29 ± 0.62 34.39 ± 0.83 1.05 0.59 Fair

L Pectoral 34.19 ± 0.61 34.24 ± 1.00 1.5 0.39 Poor

R A Trapezius 34.12 ± 0.71 33.93 ± 1.36 1.5 0.53 Fair

L A Trapezius 33.91 ± 1.01 33.98 ± 1.17 1.12 0.79 Excellent

R P Forearm 32.94 ± 1.53 33.15 ± 1.65 1.54 0.77 Excellent

L P Forearm 33.06 ± 1.68 33.20 ± 1.47 1.8 0.69 Good

R P Arm 32.63 ± 0.83 32.90 ± 1.04 1.62 0.46 Fair

R P Arm 32.55 ± 1.28 32.69 ± 1.20 1.44 0.77 Excellent

P Neck 33.54 ± 0.76 33.61 ± 0.91 1.31 0.53 Fair

R Dorsal 33.01 ± 0.99 33.07 ± 1.22 1.57 0.59 Fair

L Dorsal 33.01 ± 0.69 33.10 ± 1.20 1.51 0.54 Fair

R P Shoulder 32.81 ± 1.09 32.70 ± 1.73 2.04 0.6 Good

L P Shoulder 33.17 ± 0.72 33.24 ± 1.03 1.41 0.54 Fair

R P Infraspinatus 33.14 ± 0.88 33.35 ± 1.22 1.44 0.67 Good

L P Infraspinatus 33.27 ± 0.86 33.42 ± 1.15 1.47 0.6 Good

R P Supraspinatus 33.27 ± 0.75 33.47 ± 0.99 1.27 0.65 Good

L P Supraspinatus 33.45 ± 0.82 33.53 ± 1.05 1.37 0.59 Fair

R P Central Trapezius 33.85 ± 0.77 33.91 ± 0.95 1.47 0.49 Fair

L P Central Trapezius 33.72 ± 0.89 33.75 ± 1.01 1.49 0.52 Fair

R P Trapezius 33.58 ± 0.79 33.62 ± 1.01 1.26 0.64 Good

L P Trapezius 33.61 ± 0.92 33.61 ± 1.03 1.48 0.58 Fair

Total X

1.42 0.59 Fair

Abbreviations: CV, coefficient of variation; ICC, coefficient of intraclass correlation;

Scale, scale of reproducibility of Cicchetti (1981); X, average. ROI, Regions of interest. L,

left side. R, right side. A, anterior. P, posterior.

The CV between day 1 and day 2 ranged between 1.05% (right pectoral

maximum values) and 6.18% (left posterior trapezius average values). Table 7

shows the variability and the reliability of each variable (maximum values) and

Table 8 presents the same descriptive values for variables that describe average

Results

73

Tsk values. The mean of the average values of all the areas studied was:

31.83±2.04; CV, 2.80%; ICC, 0.56, with a ΔTsk between day 1 and 2 of 0.08°C. The

analysis of the main body areas (see Table 9) allows appreciating a lower Tsk in

the limbs (31.63±1.97) than in the trunk (31.98±1.79), and a lower Tsk in the

distal extremities (forearms colder than arms, arms colder than shoulders).

Figure 20. Day-to-day analysis of the reliability in all body areas measured


74

Table 8. Descriptive average values of the temperature profile on day 1, day 2 and between both the assessments for each analyzed area

ROIs Day 1 Day 2 Day 1 and 2

Mean ± SD Mean ± SD CV ICC Scale

R A Forearm 31.26 ± 2.54 31.40 ± 2.35 3.56 0.24 Poor

L A Forearm 31.28 ± 2.63 31.19 ± 2.45 3.65 0.24 Poor

R A Arm 32.42 ± 0.96 32.19 ± 1.25 1.58 0.57 Fair

L A Arm 30.93 ± 4.20 32.19 ± 1.15 3.14 0.18 Poor

A Neck 32.44 ± 1.21 32.84 ± 1.21 1.63 0.67 Good

R A Shoulder 33.09 ± 0.87 33.24 ± 0.96 1.45 0.56 Fair

L A Shoulder 33.01 ± 0.80 32.10 ± 3.94 4.14 0.15 Poor

R Pectoral 31.14 ± 2.91 31.47 ± 2.89 1.61 0.95 Excellent

L Pectoral 31.99 ± 1.57 31.91 ± 2.06 2.39 0.62 Good

R A Trapezius 32.54 ± 3.00 31.29 ± 5.13 4.66 0.6 Good

L A Trapezius 30.65 ± 5.51 31.08 ± 5.49 4.84 0.69 Good

R P Forearm 31.04 ± 3.62 31.55 ± 2.72 2.74 0.66 Good

L P Forearm 30.95 ± 3.91 30.95 ± 3.68 2.48 0.8 Excellent

R P Arm 29.21 ± 4.35 31.25 ± 1.35 1.38 0.88 Excellent

R P Arm 29.89 ± 3.12 30.44 ± 2.49 5.17 0.23 Poor

P Neck 32.53 ± 0.91 32.73 ± 1.05 1.59 0.46 Fair

R Dorsal 30.98 ± 3.62 30.28 ± 4.13 3.59 0.79 Excellent

L Dorsal 31.27 ± 1.82 31.22 ± 2.43 3.16 0.5 Fair

R P Shoulder 31.13 ± 2.92 29.97 ± 4.91 5.14 0.58 Fair

L P Shoulder 32.12 ± 0.83 32.11 ± 1.16 1.66 0.51 Fair

R P Infraspinatus 32.28 ± 1.10 32.48 ± 1.29 2.01 0.51 Fair

L P Infraspinatus 32.48 ± 0.91 32.60 ± 1.21 1.65 0.55 Fair

R P Supraspinatus 32.64 ± 0.92 32.89 ± 1.13 1.34 0.68 Good

L P Supraspinatus 32.15 ± 1.91 31.95 ± 2.48 2.23 0.76 Excellent

R P Central Trapezius 31.90 ± 1.95 32.12 ± 2.14 2.06 0.73 Good

L P Central Trapezius 32.79 ± 0.86 32.92 ± 1.16 1.79 0.47 Fair

R P Trapezius 32.92 ± 0.83 32.90 ± 1.10 1.47 0.63 Good

L P Trapezius 31.57 ± 3.96 31.43 ± 4.06 6.18 0.38 Poor

Total X

2.80 0.56 Fair

Abbreviations: CV, coefficient of variation; ICC, coefficient of intraclass correlation;

Scale, scale of reproducibility of Cicchetti (1981); X, average. ROI, Regions of interest.

L, left side. R, right side. A, anterior. P, posterior.

The maximum Tsk values were taken as references to calculate the ΔTsk between

symmetrical sides of the body. Table 10 shows the absolute values of mean±SD;

the first and second columns are referred as ΔTsk between both sides of the body

on day 1 and day 2, respectively; the third column is related to ΔTsk between the

Results

75

days. The ΔTsk did not show any consistent pattern related to the handedness of

the subjects.

Table 9. Interrater-reliability measures in terms of ICC and CV organized by general areas

Body areas Average values Maximum values

Mean±SD CV ICC CV ICC

Arm 31.32±2.09 2.96 0.48 1.46 0.64

Shoulder 32.10±1.86 3.10 0.45 1.53 0.54

Trapezius 31.80±3.25 4.29 0.57 1.34 0.63

Pectoral 31.63±2.26 2.00 0.79 1.28 0.49

Back 32.07±1.67 2.23 0.62 1.45 0.58

Neck 32.63±0.97 1.61 0.56 1.22 0.54

Abbreviations: CV, coefficient of variation; ICC, coefficient of intraclass correlation.

Table 10. Mean maximal values of regional skin temperature °C (±) standard deviations and absolute values of the side-to-side differences (ΔTsk) for the different skin areas of the study subjects. Results of Student’s t-test for the two measures

Body areas ΔTsk Day 1 ΔTsk Day 2 ΔTsk between days

r P Mean±SD Mean±SD Mean±SD P

A forearm 0.12 ± 0.66 0.39 ± 0.65 0.27 ± 0.75 0.117 0.352 0.118

A arm 0.42 ± 0.41 0.35 ± 0.49 0.07 ± 0.43 0.479 0.540 0.008*

A shoulder 0.24 ± 0.30 0.16 ± 0.29 0.08 ± 0.20 0.081 0.778 0.001†

Pectoral 0.13 ± 0.29 0.07 ± 0.38 0.06 ± 0.27 0.287 0.703 0.001†

A trapezius 0.18 ± 0.72 0.01 ± 0.28 0.17 ± 0.74 0.283 0.146 0.517

P forearm 0.05 ± 0.61 0.05 ± 0.59 0.01 ± 0.53 0.969 0.609 0.003*

P arm 0.17 ± 0.78 0.22 ± 0.74 0.05 ± 0.72 0.752 0.553 0.006*

Dorsal 0.00 ± 0.48 0.03 ± 0.36 0.03 ± 0.42 0.737 0.536 0.007*

P shoulder 0.40 ± 1.06 0.31 ± 1.07 0.09 ± 0.35 0.237 0.946 0.001†

Infraspinatus 0.13 ± 0.47 0.07 ± 0.50 0.06 ± 0.29 0.335 0.821 0.001†

Supraspinatus 0.18 ± 0.48 0.06 ± 0.43 0.12 ± 0.38 0.137 0.648 0.001*

P central Trapezius 0.12 ± 0.33 0.12 ± 0.30 0.02 ± 0.25 0.745 0.679 0.001†

P trapezius 0.08 ± 0.29 0.07 ± 0.33 0.15 ± 0.38 0.078 0.269 0.226

Total X 0.17 ± 0.53 0.15 ± 0.49 0.09 ± 0.44

0.583

Abbreviations: A, anterior; P, posterior; r, Pearson correlation coefficient; X, average.

NOTE: Diagnostic accuracy of IRT using thermographic asymmetry.

*P<0.05.

†P<0.001.


76

4.2 STUDY 2: RELATIONSHIP BETWEEN PERCEIVED SHOULDER PAIN AND INFRARED THERMOGRAPHY IN WHEELCHAIR ATHLETES AND NONATHLETES

4.2.1 Comparison of thermography values in nonathletic and athletic subjects

The analysis of the maximum Tsk values in nonathletes and athletes ranged from

32.13±1.84 to 34.07±0.90°C and from 31.89±0.69 to 33.69±0.60°C, respectively.

No statistical difference was observed between both groups for any ROI (Table

11).

Table 11. Results of unpaired t-test in nonathletic and athletic subjects. Mean °C (±) Standard Deviation of the maximum basal values registered in ROIs. It is showed the values of each body side (right vs. left) for each ROI

ROIs Nonathletes Athletes P Dif.

R A Arm 33.45 ± 0.87 33.41 ± 0.63 0.888 -0.13%

L A Arm 33.15 ± 0.99 32.88 ± 0.75 0.476 -0.83%

R A Shoulder 34.02 ± 0.96 33.43 ± 0.74 0.107 -1.77%

L A Shoulder 33.54 ± 1.47 32.97 ± 0.81 0.268 -1.70%

R Pectoral 34.07 ± 0.90 33.49 ± 0.89 0.129 -1.71%

L Pectoral 33.95 ± 0.95 33.46 ± 0.90 0.209 -1.45%

R A Trapezius 33.55 ± 1.09 33.69 ± 0.60 0.701 0.41%

L A Trapezius 33.60 ± 1.36 33.56 ± 0.66 0.933 -0.11%

R P Arm 32.35 ± 1.02 31.89 ± 0.69 0.226 -1.43%

L P Arm 32.40 ± 1.18 32.12 ± 0.77 0.510 -0.87%

R Dorsal 32.58 ± 1.47 32.27 ± 1.12 0.594 -0.95%

L Dorsal 32.70 ± 1.30 32.36 ± 1.19 0.542 -1.03%

R P Shoulder 32.13 ± 1.84 32.06 ± 1.00 0.923 -0.19%

L P Shoulder 32.78 ± 1.47 32.41 ± 0.95 0.481 -1.15%

R P Infraspinatus 32.54 ± 1.36 32.05 ± 1.16 0.373 -1.52%

L P Infraspinatus 32.92 ± 1.49 32.38 ± 1.13 0.353 -1.64%

R P Supraspinatus 32.62 ± 1.33 32.30 ± 1.06 0.537 -0.98%

L P Supraspinatus 32.83 ± 1.56 32.53 ± 0.91 0.587 -0.91%

R P Central Trapezius 33.17 ± 1.42 33.10 ± 1.06 0.900 -0.20%

L P Central Trapezius 32.93 ± 1.43 33.17 ± 0.98 0.637 0.75%

R P Trapezius 32.98 ± 1.35 32.94 ± 0.96 0.925 -0.14%

L P Trapezius 32.92 ± 1.35 33.07 ± 0.84 0.746 0.47%

Total X ROI 33.05 ± 1.28 32.80 ± 0.90

Dif. = Difference between both groups calculated as: ([athletes-nonathletes / (athletes + nonathletes) / 2]·100%) R, right; L, left; A, anterior; P, posterior; X, average.

Results

77

The analysis of the average Tsk values in nonathletes and athletes ranged from

30.13±2.89 to 33.43±1.08°C and from 29.93±0.80 to 32.77±0.76°C, respectively.

No statistical difference was observed between both groups for any ROI (Table

12).

Table 12. Results of unpaired t-test in nonathletic and athletic subjects. Mean °C (±) Standard Deviation of the average basal values registered in the ROI. It is showed the values of each body side (right vs. left) for each ROI

ROIs Nonathletes Athletes P Dif.

R A Arm 31.63 ± 1.42 31.58 ± 1.12 0.927 -0.15%

L A Arm 31.61 ± 0.78 31.68 ± 0.96 0.854 0.22%

R A Shoulder 32.98 ± 1.14 32.56 ± 0.74 0.314 -1.26%

L A Shoulder 32.80 ± 1.42 32.25 ± 0.79 0.290 -1.69%

R Pectoral 30.84 ± 3.39 30.89 ± 1.97 0.964 0.17%

L Pectoral 31.30 ± 2.40 31.23 ± 1.10 0.931 -0.21%

R A Trapezius 33.29 ± 0.86 32.77 ± 0.76 0.192 -1.58%

L A Trapezius 33.43 ± 1.08 32.72 ± 0.77 0.107 -2.15%

R P Arm 30.59 ± 1.24 29.93 ± 0.80 0.158 -2.19%

L P Arm 30.20 ± 0.99 30.06 ± 0.81 0.732 -0.45%

R Dorsal 31.71 ± 1.67 30.97 ± 1.12 0.261 -2.36%

L Dorsal 30.13 ± 2.89 31.08 ± 1.08 0.347 3.11%

R P Shoulder 31.69 ± 1.53 31.08 ± 1.07 0.302 -1.94%

L P Shoulder 31.78 ± 1.50 31.31 ± 1.01 0.388 -1.50%

R P Infraspinatus 31.99 ± 1.44 30.89 ± 1.15 0.062 -3.50%

L P Infraspinatus 32.34 ± 1.46 31.48 ± 1.21 0.151 -2.68%

R P Supraspinatus 32.08 ± 1.45 31.65 ± 1.09 0.425 -1.37%

L P Supraspinatus 32.36 ± 1.70 31.87 ± 1.06 0.449 -1.52%

R P Central Trapezius 31.12 ± 2.49 31.23 ± 1.33 0.895 0.35%

L P Central Trapezius 32.27 ± 1.40 31.93 ± 0.92 0.502 -1.08%

R P Trapezius 32.37 ± 1.49 32.29 ± 0.99 0.888 -0.23%

L P Trapezius 32.44 ± 1.63 32.35 ± 0.96 0.891 -0.26%

Total X ROI 31.86 ± 1.61 31.54 ± 1.04

Dif. = Difference between both groups calculated as: ([athletes-nonathletes / (athletes + nonathletes) / 2]·100%) R, right; L, left; A, anterior; P, posterior; X, average.

The Figure 21 and Figure 22 represents the mean and standard deviation of the

average and maximum basal temperature values, Tsk and ΔTsk respectively, in all

ROIs. A ΔTsk of 0.5°C was considered the threshold for abnormal asymmetries.


78

Figure 21. Mean and standard deviation of the average and maximum basal skin temperature (Tsk) values

Figure 22. Mean and standard deviation of the average and maximum basal side-to-side skin temperature (ΔTsk) values

The side-to-side differences of maximum and average values in nonathletes and

athletes are presented in Tables 13 and 14. No statistical difference was

observed between both groups for any body area.

30

30.5

31

31.5

32

32.5

33

33.5

34

34.5

Tsk maximum Tsk average

Tem

pera

ture

(ºC

)Nonathetes

Athletes

0

0.5

1

1.5

ΔTsk maximum ΔTsk average

As

ym

me

trie

s (

ºC)

Nonathetes

Athletes

Results

79

Table 13. Results of unpaired t-test in nonathletic and athletic subjects. Mean °C (±) Standard Deviation of the side-to-side differences (ΔTsk) of maximum values between bilateral body areas in nonathletic and athletic subjects

Body areas Nonathletes Athletes P

A Arm 0.38 ± 0.28 0.52 ± 0.26 0.223

A Shoulder 0.61 ± 0.51 0.51 ± 0.82 0.722

Pectoral 0.38 ± 0.37 0.19 ± 0.23 0.164

A Trapezius 0.28 ± 0.33 0.22 ± 0.15 0.953

P Arm 0.53 ± 0.57 0.25 ± 0.24 0.134

Dorsal 0.38 ± 0.35 0.20 ± 0.20 0.161

P Shoulder 0.73 ± 0.86 0.35 ± 0.23 0.165

P Infraspinatus 0.53 ± 0.26 0.39 ± 0.36 0.318

P Supraspinatus 0.39 ± 0.30 0.25 ± 0.30 0.104

P Central Trapezius 0.36 ± 0.40 0.15 ± 0.14 0.268

P Trapezius 0.22 ± 0.23 0.19 ± 0.23 0.791

Total X ΔTsk 0.43 ± 0.41 0.29 ± 0.29

Dif. = Difference between both groups calculated as: ([athletes-nonathletes/(athletes+nonathletes)/2]·100%) A, anterior; P, posterior; X, average.

Table 14. Results of unpaired t-test in nonathletic and athletic subjects. Mean °C (±) Standard Deviation of the side-to-side differences (ΔTsk) of average values between bilateral body areas in nonathletic and athletic subjects

Body areas Nonathletes Athletes P

A Arm 0.84 ± 1.14 0.67 ± 1.08 0.735

A Shoulder 0.39 ± 0.25 0.26 ± 0.20 0.191

Pectoral 1.11 ± 1.46 0.78 ± 0.98 0.762

A Trapezius 0.23 ± 0.15 0.14 ± 0.10 0.160

P Arm 0.13 ± 0.12 0.25 ± 0.22 0.291

Dorsal 1.25 ± 2.07 0.25 ± 0.19 0.217

P Shoulder 0.42 ± 0.19 0.28 ± 0.20 0.119

P Infraspinatus 0.53 ± 0.41 0.68 ± 0.96 0.527

P Supraspinatus 0.38 ± 0.23 0.26 ± 0.19 0.291

P Central Trapezius 1.26 ± 1.61 0.75 ± 1.40 0.438

P Trapezius 0.25 ± 0.31 0.17 ± 0.14 0.475

Total X ΔTsk 0.62 ± 0.72 0.41 ± 0.51

Dif. = Difference between both groups calculated as: ([athletes-nonathletes/(athletes+nonathletes)/2]·100%) A, anterior; P, posterior; X, average.


80

4.2.2 Comparison of shoulder pain in athletic and nonathletic subjects

The WUSPI and PC-WUSPI scores were 8.7±20.3 (0.0, 38.49) and 9.1±20.4 (0.0,

52.81), respectively. The nonathletic group presented a higher WUSPI score

(11.9±28.4) in comparison to the athletic group (1.1±13.5, p=0.034). Likewise,

the nonathletic group presented a significantly higher PC-WUSPI score

(17.8±29.8) compared to the athletic group (1.3±13.5, p=0.022).

4.2.3 Relationship between thermography and shoulder pain

The Spearman Rho test revealed that there was no correlation between WUSPI

or PC-WUSPI and the basal temperatures of the different body regions in the

nonathletic group. Athletes presented a significant correlation between WUSPI

score and the Tsk maximum values in the following ROIs: Left Anterior Shoulder

(r=-0.622; p<0.05), Right Posterior Central Trapezius (r=-0.591; p<0.05), Left

Posterior Central Trapezius (r=-0.684; p<0.05); and between PC-WUSPI score

and the Tsk maximum values of these ROIs: Left Anterior Shoulder (r=-0.664;

p<0.05), Right Posterior Central Trapezius (r=-0.563; p<0.05), and Left Posterior

Central Trapezius (r=-0.647; p<0.05).

Considering the asymmetries, only the WUSPI and PC-WUSPI of the athletic

subjects were related with the ΔTsk of the average values of the Anterior Arm

(r=0.729 and r=0.729; p<0.05).

Results

81

4.3 STUDY 3: RELATIONSHIP BETWEEN SHOULDER PAIN AND SKIN TEMPERATURE MEASURED BY INFRARED THERMOGRAPHY IN A WHEELCHAIR PROPULSION TEST

The mean WUSPI and PC-WUSPI scores were 5.49±6.57 (0.0, 16.58) and

5.58±6.59 (0.0, 16.58), respectively. The maximum and average Tsk and ΔTsk was

compared before (pre-test), one minute after (post-test), and 10 min after (post-

10) the T-CIDIF. The thermal results and ROIs with significant differences are

showed in the Tables 15 and 16.


82

Table 15. Descriptive values of the skin temperature (°C) of 22 ROIs in wheelchair athletes; repeated measures ANOVA correlation

ROI

Pre-test Post-test Post-10 F P

Mean ± SD Mean ± SD Mean ± SD

Ma

xim

um

Tsk

va

lue

s

R A Arm 33.51 ± 0.62 33.59 ± 0.92 34.29 ± 0.75 a b 10.670 0.001

L A Arm 33.12 ± 0.78 32.94 ± 1.02

33.90 ± 0.91 a b 12.185 0.002

R A Shoulder 33.91 ± 0.67 33.90 ± 1.44

34.48 ± 1.27 # ∞ 2.385 0.143

L A Shoulder 33.44 ± 1.06 33.38 ± 1.36 a 34.36 ± 1.25 1.686 0.208

R Pectoral 34.06 ± 0.70 34.04 ± 1.04

34.69 ± 1.16 b 3.879 0.036

L Pectoral 33.93 ± 0.69 33.84 ± 0.87

34.58 ± 0.90 a b 5.215 0.014

R A Trapezius 33.90 ± 0.41 33.90 ± 1.14

34.64 ± 1.08 a b 5.415 0.012

L A Trapezius 33.96 ± 0.70 33.73 ± 1.29

34.49 ± 1.03 ∞ 3.221 0.093

R P Arm 32.08 ± 0.81 32.23 ± 1.18

33.15 ± 1.12 a b 8.883 0.001

L P Arm 32.12 ± 0.97 32.30 ± 1.18

33.09 ± 0.72 a b 12.606 0.000

R Dorsal 32.76 ± 1.13 32.20 ± 0.91

32.90 ± 0.99 ∞ 3.179 0.066

L Dorsal 32.82 ± 1.17 32.29 ± 0.97

32.95 ± 0.90 ∞ 2.709 0.094

R P Shoulder 32.13 ± 1.39 32.25 ± 1.38

32.97 ± 1.54 ∞ 3.267 0.090

L P Shoulder 32.73 ± 1.11 32.66 ± 1.37

33.32 ± 1.29 a b 5.284 0.013

R P Infraspinatus 32.46 ± 1.20 32.13 ± 1.13

32.87 ± 1.48 a b 8.067 0.003

L P Infraspinatus 32.92 ± 1.29 32.58 ± 1.51

33.12 ± 1.51 ∞ 2.833 0.083

R P Supraspinatus 32.63 ± 1.03 32.31 ± 1.34

32.99 ± 1.44 b 3.824 0.038

L P Supraspinatus 32.88 ± 1.19 32.80 ± 1.50

33.37 ± 1.49 ∞ 2.949 0.073

R P Central Trapezius 33.52 ± 0.94 33.13 ± 1.49

33.74 ± 1.24 ∞ 2.503 0.127

L P Central Trapezius 33.39 ± 0.90 32.87 ± 1.45

33.57 ± 1.28 b 3.272 0.057

R P Trapezius 33.26 ± 0.84 32.98 ± 1.28

33.63 ± 1.28 b 3.903 0.035

L P Trapezius 33.26 ± 0.82 32.96 ± 1.27 33.58 ± 1.28 b 3.756 0.040

Av

era

ge

Tsk

va

lue

s

R A Arm 31.54 ± 1.32 31.78 ± 1.03 32.82 ± 1.18 a b 5.606 0.031

L A Arm 31.76 ± 0.75 31.42 ± 1.13 32.29 ± 1.23 # b 5.380 0.016

R A Shoulder 32.93 ± 0.73 32.55 ± 1.43 33.37 ± 1.47 b 4.808 0.034

L A Shoulder 32.66 ± 0.99 32.35 ± 1.34 33.39 ± 1.38 a b 5.792 0.011

R Pectoral 31.24 ± 2.44 30.99 ± 2.34 31.66 ± 2.37 ∞ 2.443 0.141

L Pectoral 31.68 ± 1.57 31.55 ± 1.61 32.43 ± 1.47 # b 4.219 0.046

R A Trapezius 33.11 ± 0.45 32.96 ± 1.27 33.78 ± 1.17 ∞ 2.648 0.130

L A Trapezius 33.21 ± 0.69 32.88 ± 1.39 33.59 ± 1.31 ∞ 2.545 0.106

R P Arm 30.23 ± 1.05 30.50 ± 1.12 31.46 ± 1.23 a b 11.850 0.000

L P Arm 30.10 ± 0.74 30.40 ± 1.19 31.26 ± 1.12 a b 10.155 0.005

R Dorsal 31.33 ± 1.26 30.90 ± 1.18 31.48 ± 1.34 ∞ 2.472 0.116

L Dorsal 31.08 ± 1.60 31.18 ± 1.21 31.52 ± 1.24 0.524 0.601

R P Shoulder 31.45 ± 1.26 31.18 ± 1.44 31.87 ± 1.61 b 5.505 0.012

L P Shoulder 31.65 ± 1.27 31.44 ± 1.46 32.10 ± 1.54 # b 4.819 0.018

R P Infraspinatus 31.36 ± 1.42 31.08 ± 1.40 31.59 ± 1.64 1.369 0.276

L P Infraspinatus 32.09 ± 1.41 31.57 ± 1.66 32.23 ± 1.62 b 3.671 0.044

R P Supraspinatus 32.03 ± 1.07 31.65 ± 1.31 32.38 ± 1.50 b 4.591 0.022

L P Supraspinatus 31.73 ± 1.74 30.69 ± 2.61 31.63 ± 2.09 ∞ 1.841 0.201

R P Central Trapezius 31.33 ± 1.41 30.63 ± 1.71 31.23 ± 1.70 ∞ 1.026 0.338

L P Central Trapezius 32.33 ± 0.82 31.14 ± 1.80 a 31.91 ± 1.71 b 5.391 0.013

R P Trapezius 32.66 ± 0.93 32.18 ± 1.26 # 32.78 ± 1.35 b 4.632 0.021

L P Trapezius 32.64 ± 0.93 31.88 ± 1.40 # 32.78 ± 1.56 b 6.630 0.007

Total maximum Tsk 33.13 ± 0.93 32.95 ± 1.23

33.67 ± 1.18

Total average Tsk 31.57 ± 1.21 31.17 ± 1.48

31.87 ± 1.52

Note: ROI, region of interest; Tsk, skin temperature; A, anterior; P, posterior; R, right; L, left; (a), significantly

Results

83

different with respect to pre-test at p<0.05; (b), significantly different with respect to post-test at p<0.05; (#),

tendency to significance with respect to pre-test p<0.1; (∞), tendency to significance with respect to post-test

p<0.1.

Table 16. Descriptive values of the side-to side differences (°C) of the 26 measured ROIs in wheelchair athletes; repeated measures ANOVA correlation

ROI

Pre-test Post-test Post10 F P

Mean ± SD Mean ± SD Mean ± SD

Ma

xim

um

ΔT

sk v

alu

es

A Arm 0.47 ± 0.25 0.62 ± 0.38 # 0.37 ± 0.29 1.988 0.161

A Shoulder 0.40 ± 0.35 0.43 ± 0.25 0.33 ± 0.24 0.621 0.547

A Forearm 0.37 ± 0.53 0.27 ± 0.23 0.30 ± 0.19 0.257 0.668

Pectoral 0.27 ± 0.28 0.22 ± 0.08 0.12 ± 0.15 0.004 0.996

A Trapezius 0.20 ± 0.14 0.30 ± 0.36 0.13 ± 0.12 0.241 0.788

P Arm 0.25 ± 0.23 0.48 ± 0.40 0.37 ± 0.23 0.038 0.963

Dorsal 0.32 ± 0.20 0.10 ± 0.06 0.13 ± 0.08 0.260 0.774

P Shoulder 0.40 ± 0.22 0.53 ± 0.25 0.37 ± 0.45 0.750 0.428

P Forearm 0.61 ± 0.56 0.49 ± 0.55 0.28 ± 0.29 a ∞ 5.126 0.015

P Infraspinatus 0.35 ± 0.33 0.80 ± 0.50 a 0.62 ± 0.44 b 3.582 0.047

P Supraspinatus 0.13 ± 0.20 0.55 ± 0.49 a 0.65 ± 0.37 2.466 0.108

P Central Trapezius 0.10 ± 0.11 0.17 ± 0.14 0.22 ± 0.20 1.193 0.322

P Trapezius 0.22 ± 0.17 0.12 ± 0.13 0.17 ± 0.23 0.815 0.413

Av

era

ge

ΔT

sk v

alu

es

A Arm 0.35 ± 0.21 0.13 ± 0.10 a 0.35 ± 0.30 b 4.142 0.036

A Shoulder 0.33 ± 0.23 0.27 ± 0.18 0.38 ± 0.34 0.235 0.793

A Forearm 0.28 ± 0.18 0.25 ± 0.19 0.46 ± 0.56 1.498 0.250

Pectoral 0.63 ± 0.93 0.20 ± 0.15 0.23 ± 0.19 0.290 0.645

A Trapezius 0.15 ± 0.10 0.22 ± 0.16 # 0.15 ± 0.14 1.617 0.226

P Arm 0.23 ± 0.19 0.22 ± 0.18 0.27 ± 0.15 1.048 0.371

Dorsal 0.23 ± 0.24 0.25 ± 0.25 0.27 ± 0.31 0.018 0.983

P Shoulder 0.33 ± 0.26 0.32 ± 0.23 0.48 ± 0.48 0.119 0.888

P Forearm 0.31 ± 0.21 0.37 ± 0.15 0.28 ± 0.23 1.181 0.328

P Infraspinatus 0.48 ± 0.54 0.47 ± 0.36 0.58 ± 0.36 0.288 0.631

P Supraspinatus 0.18 ± 0.18 0.45 ± 0.29 a 0.45 ± 0.39 3.470 0.087

P Central Trapezius 0.10 ± 0.11 1.02 ± 1.24 1.02 ± 1.20 # 0.158 0.707

P Trapezius 0.22 ± 0.17 0.43 ± 0.37 # 0.30 ± 0.17 2.416 0.118

Total average ΔTsk

values 0.29 ± 0.27 0.35 ± 0.30 0.40 ± 0.37

Note: ROI, region of interest; ΔTsk, difference between right and left skin temperature; A, anterior; P, posterior;

(a), significantly different with respect to pre-test at p<0.05; (b), significantly different with respect to post-

test at p<0.05; (#), tendency to significance with respect to pre-test p<0.1; (∞), tendency to significance with

respect to post-test p<0.1.


84

Table 17. Spearman Rho correlations between bilateral ΔTsk and shoulder pain

ROI

WUSPI PC-WUSPI

r P r P P

re-t

est

Ma

xim

um

ΔT

sk v

alu

es

A Arm -0.22 0.49 -0.22 0.49

A Shoulder -0.52 0.09 -0.54 # 0.07

A Forearm -0.21 0.53 -0.21 0.53

Pectoral -0.12 0.72 -0.13 0.68

A Trapezius 0.28 0.37 0.32 0.30

P Arm 0.33 0.30 0.34 0.28

Dorsal -0.15 0.68 -0.18 0.62

P Shoulder -0.58 * 0.05 -0.56 # 0.06

P Forearm 0.22 0.49 0.18 0.58

P Infraspinatus -0.06 0.87 -0.04 0.90

P Supraspinatus -0.19 0.56 -0.14 0.65

P Central Trapezius -0.27 0.40 -0.23 0.48

P Trapezius -0.05 0.88 -0.03 0.94

Av

era

ge

ΔT

sk v

alu

es

A Arm 0.36 0.28 0.36 0.28

A Shoulder -0.61 * 0.05 -0.65 * 0.03

A Forearm 0.50 0.14 0.50 0.14

Pectoral -0.24 0.48 -0.32 0.34

A Trapezius -0.33 0.34 -0.33 0.34

P Arm -0.15 0.66 -0.15 0.66

Dorsal 0.30 0.43 0.26 0.50

P Shoulder -0.20 0.56 -0.22 0.52

P Forearm 0.05 0.89 -0.04 0.91

P Infraspinatus -0.04 0.90 -0.12 0.73

P Supraspinatus -0.05 0.89 0.04 0.91


P Trapezius -0.34 0.34 -0.36 0.31

Po

st-t

est

Ma

xim

um

ΔT

sk v

alu

es

A Arm -0.04 0.91 -0.06 0.85

A Shoulder 0.03 0.93 0.04 0.89

A Forearm 0.18 0.60 0.18 0.60

Pectoral 0.47 0.12 0.42 0.17

A Trapezius 0.01 0.98 -0.03 0.92

P Arm 0.10 0.77 0.08 0.79

Dorsal 0.53 0.12 0.48 0.16

P Shoulder 0.22 0.49 0.20 0.54

P Forearm -0.18 0.57 -0.23 0.48

P Infraspinatus -0.07 0.83 -0.13 0.68

P Supraspinatus -0.33 0.29 -0.29 0.36


P Trapezius 0.03 0.94 0.09 0.79

Av

era

ge

ΔT

sk v

alu

es A Arm 0.42 0.23 0.42 0.23

A Shoulder 0.06 0.85 0.06 0.85

A Forearm -0.52 0.10 -0.52 0.10

Pectoral -0.22 0.52 -0.26 0.45

A Trapezius 0.08 0.81 0.05 0.87

Results

85

ROI

WUSPI PC-WUSPI

r P r P

P Arm 0.14 0.67 0.14 0.67

Dorsal -0.16 0.68 -0.16 0.68

P Shoulder 0.11 0.74 0.11 0.74

P Forearm -0.08 0.82 -0.13 0.71

P Infraspinatus -0.06 0.86 -0.10 0.75

P Supraspinatus -0.48 0.11 -0.45 0.14

P Central Trapezius -0.61 * 0.04 -0.59 * 0.04

P Trapezius -0.48 0.16 -0.51 0.13

Po

st-1

0

Ma

xim

um

ΔT

sk v

alu

es

A Arm 0.20 0.53 0.17 0.59

A Shoulder 0.24 0.46 0.29 0.36

A Forearm 0.21 0.54 0.21 0.54

Pectoral 0.07 0.83 0.08 0.81

A Trapezius -0.10 0.75 -0.08 0.81

P Arm -0.06 0.85 -0.09 0.79

Dorsal -0.71 * 0.02 -0.71 * 0.02

P Shoulder -0.32 0.31 -0.37 0.24

P Forearm -0.35 0.27 -0.37 0.24

P Infraspinatus -0.30 0.34 -0.35 0.26

P Supraspinatus -0.35 0.27 -0.32 0.32


P Trapezius -0.24 0.45 -0.23 0.48

Av

era

ge

ΔT

sk v

alu

es

A Arm 0.52 0.15 0.52 0.15

A Shoulder 0.46 0.13 0.41 0.18

A Forearm -0.07 0.84 -0.07 0.84

Pectoral 0.21 0.54 0.17 0.62

A Trapezius 0.55 0.10 0.62 * 0.05

P Arm 0.11 0.75 0.11 0.75

Dorsal -0.54 0.13 -0.45 0.22

P Shoulder -0.48 0.11 -0.49 0.10

P Forearm 0.09 0.80 0.03 0.93

P Infraspinatus -0.49 0.11 -0.51 0.09

P Supraspinatus -0.22 0.52 -0.17 0.63

P Central Trapezius -0.64 * 0.02 -0.63 * 0.03

P Trapezius 0.24 0.47 0.20 0.56

Note: ROI, region of interest; ΔTsk, difference between right and left skin temperature;

WUSPI, Wheelchair Users Shoulder Pain Index; PC-WUSPI, Performance Corrected WUSPI; A,

anterior; P. posterior; (*), significant difference (p<0.05); (#), Tendency to significance

p<0.1.

Significant inverse relationships between changes in ΔTsk in the Shoulder ROI

and the results from the shoulder pain questionnaire were found before the


86

wheelchair propulsion test (Table 17); while Posterior Central Trapezius ROI

presented significant inverse correlation with the questionnaire in the post-test

and post-10. In addition, negative relationships were verified between the Dorsal

ROI and both WUSPI and PC-WUSPI, as well as the Anterior Trapezius ROI with

the PC-WUSPI (Table 17). Those inverse correlations imply that the higher the

shoulder pain the lower the thermal asymmetry and vice versa.

No significant correlations were observed between the kinematic variables and

the shoulder pain questionnaire (Table 18).

Table 18. Descriptive values of the kinematic variables; Spearman Rho correlations between kinematic variables and shoulder pain

WUSPI PC-WUSPI

Variables Mean ± SD r P r P

Number of propulsions 46.75 ± 19.42 -0.02 0.96 -0.01 0.98

Mean peak torque (W) 217.05 ± 102.28 0.41 0.19 0.44 0.15

Mean power (W) 81.48 ± 26.63 0.33 0.30 0.38 0.23

Maximum velocity (m·s-1) 7.00 ± 1.29 -0.18 0.58 -0.15 0.64

Average maximum velocity (m·s-1) 5.60 ± 1.38 0.04 0.90 0.09 0.79

Total work (W) 1182.08 ± 401.69 0.25 0.43 0.29 0.36

Note: significant difference (p<0.05); r = coefficient of correlation Spearman Rho between both arms.

There were found the following significant differences between the kinematic

variables and the thermographic data (ΔTsk). The number of propulsions

correlated with the maximum values of the Dorsal ROI (r=0.778, p=0.008) and

the anterior Forearm (r=-0.862, p<0.001) in the pre-test.

The mean peak torque correlated with the average values of the Pectoral (r=-

0.578, p=0.063), Infraspinatus (r=-0.565, p=0.056) and Central Posterior

Trapezius (r=-0.716, p=0.009) ROIs, as well as maximum values of the

Infraspinatus (r=-0.637, p=0.026) in the post-test; and with the average values of

the Arm (r=0.667, p=0.050) and Central Posterior Trapezius (r=-0.730, p=0.007)

ROIs, as well as the maximum values of the anterior Forearm (r=0.734, p=0.010)

and Infraspinatus (r=-0.637, p=0.026) in the post-10.

Results

87

Mean power was the variable with higher number of correlated ROI, being for

pre-test: anterior Forearm (r=0.695, p=0.026) average values; for post-test:

Infraspinatus average (r=-0.668, p=0.018) and maximum values, and average

values of Central Posterior Trapezius (r=-0.688, p=0.013) and posterior

Trapezius (r=-0.737, p=0.015); for post-10: average values of anterior Trapezius

(r=-0.820, p=0.004), posterior Shoulder (r=-0.660, p=0.020), and Central

Posterior Trapezius (r=-0.575, p=0.050), and maximum values of Infraspinatus

(r=-0.688, p=0.013) and Central Posterior Trapezius (r=-0.596, p=0.041).

The maximum velocity correlated with average values of posterior Arm

(r=0.718, p=0.013) in pre-test; maximum values of Infraspinatus (r=-0.633,

p=0.027) in post-test and anterior Forearm (r=0.706, p=0.0153) in post-10.

Average maximum velocity present correlations with posterior Arm (r=0.662,

p=0.026) and Infraspinatus (r=-0.667, p=0.025) average values in pre-test;

posterior Forearm (r=-0.5633, p=0.056) and Infraspinatus (r=-0.601, p=0.039)

maximum values, and pectoral (r=-0.799, p=0.003) average values in post-test;

and maximum values of anterior Forearm (r=0.678, p=0.022) in post-10.

Finally, total work showed correlations in pre-test with the ROIs: average values

of anterior Forearm (r=0.800, p=0.005), and maximum values of anterior

Trapezius (r=0.593, p=0.042) and Dorsal (r=-0.673, p=0.033); in post-test with

the ROIs: maximum values of Infraspinatus (r=-0.615, p=0.033), and average

values of Infraspinatus (r=-0.547, p=0.065), Central Posterior Trapezius (r=-

0.663, p=0.019) and posterior Trapezius (r=-0.712, p=0.021); in post-10 with the

ROIs: average values of anterior Trapezius (r=0.712, p=0.021), posterior

Shoulder (r=-0.695, p=0.012), and maximum values of Infraspinatus (r=-0.713,

p=0.009) and Central Posterior Trapezius (r=-0.635, p=0.027).


88

5 DISCUSSION

5.1 STUDY 1: RELIABILITY OF INFRARED THERMOGRAPHY IN SKIN TEMPERATURE EVALUATION OF WHEELCHAIR USERS

Before establishing the efficacy of IRT as a tool for assessing the evolution of

pain, it is necessary to evaluate its reliability in order for it to be implemented on

populations with diverse characteristics. The main contribution of this study is

that its reliability is highly dependent on the area to be analyzed; IRT in WCUs

had a variable ICC and CV; and IRT demonstrated a poor to excellent reliability

(ICC: left anterior shoulder=0.15; right pectoral=0.95). This range of reliabilities

must be taken into account when interpreting thermographic data.

To our knowledge, there is only one study investigating IRT and skin

temperature evaluation of WCUs (365). It found that the temperature in the

palm, forearm, pectoral major and shoulder tended to increase during

wheelchair propulsion compared to other parts of the trunk. In the posterior

trunk the warmest areas corresponded to the trapezius and forearms (365). Our

results are similar, since the trunk was warmer than the limbs, and the forearm

and shoulder were warmer than the anterior trunk, but it is not possible to

compare both investigations since our measurements were undertaken while

the subjects were at rest.

There are no previous studies about reliability of IRT as a means of assessing

body temperature in WCUs, although some researchers have studied the IRT

reliability of non-WCUs. Our study is focused on works that studied similar areas

than us (the upper body except the hands, wrists and lumbar areas). A study by

Littlejohn et al. reached thermal ICC values for the forearm ranged from 0.19-

0.85 (236). The intra-examiner reproducibility of a study by Zaproudina et al.

varied from poor in the fingertips to moderately high in the core areas, with a

mean ICC of 0.47 (459). Most of their areas with low ICC are coincident with our

study, whereupon it is necessary to pay attention to those relevant areas

Discussion

89

(trapezius, forearm and shoulder). Burnham et al. compared the reliability of

three thermometers, finding that the infrared skin device was the most

responsive (ICC of 0.97) for the hand, forearm, shoulder, thigh, shin and foot

(54). Several studies (93, 253, 297, 306) about paraspinal Tsk discovered a fair to

excellent intraexaminer reproducibility (ICC 0.51-0.98). However, the surface of

some analyzed areas differs slightly between studies, and consequently, some

areas with the same name in each study (54, 459) corresponded to different

areas. Some studies only measured specific skin spots, because they used an

infrared skin thermometer (54), a handheld thermographic scanner (297), or a

handheld infrared paraspinal instrument (93) instead of an infrared camera.

Furthermore, Plaugher et al.’s research was undertaken with contact

thermography, whereas IRT is non-contact thermography (306). Their research

(306) relied on the examiner’s interpretation instead of a computerized reading

of data while other studies, including ours, manually measured the body areas

and compared one graph to another.

Injury processes of some body areas are the main explanation for the

fluctuations in the reliability, since the temperature varies depending on the type

and moment of the injury (post-traumatic pain syndrome and sympathetic nerve

involvement result in vasoconstriction and a colder area; acute and

inflammatory injury increase metabolism, blood flow and dermal temperatures)

(350). The particular characteristics of people with disabilities may have also

influenced the reliability, such as the thermoregulation problems presented by

the subjects with SCI (319) and sweating characteristics of multiple sclerosis

subjects (410). People with SCI have a loss of autonomic nervous system control

for vasomotor and sudomotor responses below the level of SCI, and a reduced

thermoregulatory effector response for a given core temperature (314, 355). As

a consequence of their poikilothermic behavior, they have a reduced ability to

tolerate thermal extremes (355); they have increased heat storage within the

lower body (314); and they tend to sweat less (314). This imbalance in

temperature regulation (most pronounced in individuals with tetraplegia rather

than paraplegia) makes skin temperature very changeable from one day to

another, influencing the reliability of our data. Other factors that may locally


90

change the blood flow and the skin temperature are the variation of the

peripheral circulation in the distal parts of the body (459), obliterating artery

disease, malignancies, varicose veins or inflammatory processes (441).

The distribution of the upper body temperature of our study was similar to the

literature (54, 462). Central sites were warmer than peripheral sites, and this

may be explained by blood distribution (462). Unlike Zhu et al. (462), subjects in

our study had slightly higher ventral body temperature (31.92±2.22) than dorsal

body temperature (31.77±1.92). Commonly the ventral area has greater skin

thickness than the dorsal area, and subcutaneous fat in the area is known to

influence thermal readings (236).

The mean ICC for average values (Table 8) is 0.56 (fair). When areas with lower

ICC values are removed (the forearm, arm, shoulder and trapezius) the mean ICC

augments to 0.64 (good). For the maximum values (Table 7) the mean ICC is 0.59

(fair) and without the most troubled area, the pectoral, the mean ICC becomes

0.60 (good). These sensitive areas to error are involved in wheelchair

propulsion; we suggest the participant is carried to the room to avoid doing any

exercise before the testing. The average values have a greater number of areas

with poor ICC than the maximum values. When regions of interest are manually

drawn certain limits can go out of the boundary and encompass part of the

background picture, and hence the average temperature of this area would be

lower. The maximum values are not affected by extreme values, and thus they

are more congruent; therefore, they were chosen as references to calculate the

ΔTsk between symmetrical sides of the body.

Burnham et al. affirmed that side-to-side temperature comparisons could be

used as a measure of an instrument’s reliability (54). Most of the articles found

ΔTsk or thermal asymmetry of around 0.5°C (54, 286), 0.4°C (459) and 0.3°C

(167, 407). Our data showed a ΔTsk for maximum values of: 0.17±0.53°C and

0.15±0.49°C in days 1 and 2, respectively; with a ΔTsk between both days of

0.09±0.44°C. SD values over 2.5-3 indicate a Tsk abnormality of certain part of

their bodies (286). There were no significant differences between day 1 and day

Discussion

91

2. The correlation was good for anterior and posterior arm, posterior forearm,

dorsal, supraspinatus, and central trapezius; and excellent for anterior and

posterior shoulder, pectoral and infraspinatus. The average correlation was

moderate (r=0.583). Low correlation was found in the anterior forearm, anterior

and posterior trapezius. Previous literature proposes different reasons that

could cause these variations, such as Owens et al., who suggested that changes

could be explained due to physiological variations rather than equipment error

(297).

In summary, this is the first study examining the reliability of IRT, in particular

when incorporating the FLIR T335 thermal imaging camera, the ThermaCAM

Reporter (v.8) software and the selection protocol for the regions of interest, to

evaluate the skin temperature in WCUs. The range of reliabilities must be taken

into account when interpreting thermographic data and it is being attributable to

the accuracy characteristics of IRT equipment; the measurement environment

and technique; as well as the greater physiological variability of the blood flow in

subjects with SCI than healthy population. We can conclude that the IRT

technique has the potential to be an objective quantifiable indicator of

autonomic disturbances, which was fast, easy to use and was shown to be

adequately reliable to monitor skin temperature in wheelchair users.


92

5.2 STUDY 2: RELATIONSHIP BETWEEN PERCEIVED SHOULDER PAIN AND INFRARED THERMOGRAPHY IN WHEELCHAIR ATHLETES AND NONATHLETES

The main findings of the study show that: (i) nonathletic and athletic WCUs

present a similar profile of body temperature; (ii) the side-to-side differences of

body temperature are similar in nonathletic and athletic subjects; (iii) shoulder

pain is greater in nonathletic subjects in respect to athletic subjects; and (iv) in

athletes the temperature of some body regions are negatively related with

shoulder pain.

To the best of our knowledge, there is no previous study that facilitates a general

or local thermal profile of WCUs that could work as a reference thermal pattern

for this population, except in our preceding research (342) where data of mean

Tsk and bilateral ΔTsk of the main body ROIs was provided. Few studies have

applied IRT technique for the evaluation of the Tsk particularly in wheelchair

users (340, 365, 434, 464). Any of these studies can be compared with our data

because of: different infrared technology used (434) since the Tsk obtained with

IRT is lower than that obtained with contact thermometry (286); time since

injury (464) as subjects with SCI after 6 months from the onset of the injury

adjust their thermoregulatory set point in the presence of an external ambient

stressor (25); ROIs analysed (340, 464); the subjects’ position (464); or the lack

of data provided (365). Until now no studies have applied this technique for the

comparison of the Tsk in athletic and nonathletic WCUs. Only one IRT study has

been undertaken which compares the Tsk of trained and untrained subjects, and

this analysed only the lower body (124). Interestingly, they discovered a faster

thermoregulation response in sportspeople than in sedentary people. However,

their results cannot be compared with ours since they did not study the upper

body.

The higher Tsk of our work is found in the anterior trapezius, pectoral and

anterior shoulder and the lower in posterior arm, dorsal and posterior shoulder.

The temperature pattern of the body regions nearly coincides with the literature

in able-bodied individuals, being higher in the ventral side compared to the

Discussion

93

dorsal and higher in the central regions than in the extremities mainly in our

maximum values (286, 462). When comparing our results with thermographic

data from healthy population we found different ROIs selected by each study. We

have compared the following similar ROIs: anterior and posterior arm, anterior

and posterior shoulder, pectoral or upper trunk, and superior back. Although

there were not significant differences between the Tsk of nonathletes and

athletes the Tsk average values of the anterior and posterior arm and shoulder

ROIs approximate Marins et al. (245), Niu et al. (286) and Zaproudina et al. (458)

being slightly higher in nonathletes than athletes, and finding lower values in

upper trunk and back. The results were lower than the values presented by Zhu

et al. (462) and Kolosovas et al. (218) in all the compared ROIs. Differences in

race of the subjects (462), age (218) or type of camera used (283) may explain

the variation in the Tsk. It is interesting to find that core area presented lower

average values than any other study, since the central regions usually have

higher Tsk than the extremities. The poor thermoregulation system as well as

trunk activity of SCI subjects might influence in their low core Tsk values.

Thermography offers information about the status and disturbances of the

sympathetic vasomotor tone (458), evaluating the vasomotor activity of the

sympathetic nerve fibers and detecting sympathetic dysfunctions (400). So et al.

affirmed that Tsk values with a SD over 2.5 to 3 are indication of abnormal Tsk in

patients suspect to have autonomic dysfunction (376). Our maximum Tsk values

in wheelchair athletes and nonathletes and the average Tsk values in athletic

subjects do not present more than 2 SD, although high SD was found in the

average Tsk values of nonathletic subjects in the following ROIs: right pectoral

(3.39 SD); left pectoral (2.40 SD); left dorsal (2.89 SD) and right central trapezius

(2.49 SD). In general, the Tsk profile in WCUs presents much higher SD than the

profiles of able-bodied individuals found in the literature. The reason may be the

peculiarity of each impairment, e.g. two people with the same level of SCI, same

degree of involvement, and similar respiratory and cardiovascular parameters

may have different levels of functional sensitive-motor capacity and

thermoregulatory responses (97). In addition, the affected area may present a

warmer or colder pattern depending on whether there is a complete or partial


94

interruption of the nerve fibers (406), therefore a complementary examination

of the patient should accompany the thermographic evaluation. Most of our

subjects present SCI, a condition that may imply autonomic nervous system

disruption, peripheral blood flow disturbances, and poikilothermic behavior that

is characterized by a poor body temperature regulation (25, 314). The

autonomic nervous system is one of the main factors that influence the Tsk; it

controls dilation and contraction of capillaries. In subjects with a SCI above the

6th thoracic vertebrae thermoregulation is affected since the neural pathway to

the hypothalamus is interrupted (314), disturbing autonomic responses such as

blood pressure. As a consequence, these subjects have impaired ability to reduce

body temperature by vasodilatation and sweat production (314), presenting

hypohidrosis below the level of the lesion and hyperhidrosis above and below

the level of the lesion (205). Their disturbed sweat production is translated in

hyperthermia in the affected skin area that evolves to hypothermia after 4-6

months (323). The normal thermal pattern of nerve fiber irritation or root

compression syndromes in the spine was described by Pochaczevsky et al. (308),

it may present changes due to inflammation or infection of vertebral or

paravertebral areas as well as 94 usculoligamentous injuries resulting in

hyperthermic zones anywhere along the spine or torso (308). A recent review

(14) confirmed the no-consensus and contradictory data in the literature on the

pattern of the healthy back, as well as the Tsk profile of various spinal

pathologies. They concluded that different spinal disorders might generate a

similar thermal pattern. Further development of the knowledge in

thermographic studies of the spinal disorders is needed.

Bilateral ΔTsk values over 0.3-1.8°C (35, 111, 218, 245, 407, 458, 462), are

considered abnormal and may be an indication of dysfunction in the assessed

ROI such as disturbances in the autonomic nervous system (165), peripheral

blood flow (167, 356) as well as pain syndromes (10, 458) or overuse injuries

(167). In our study we have considered 0.5°C as the threshold for abnormal

asymmetries. The results in the Table 13 show that absolute ΔTsk of maximum

values exceeded 0.5°C in the following areas of the athletic subjects: anterior arm

(0.52) and anterior shoulder (0.51); as well as the next areas of the nonathletic

Discussion

95

subjects: posterior shoulder (0.73), anterior shoulder (0.61), posterior arm

(0.53), and infraspinatus (0.53). These areas with bilateral thermal imbalance

coincide with our WUSPI’s results, where WUSPI scores of nonathletic subjects

are higher than in athletic subjects, especially in the shoulder ROI that presents

the highest ΔTsk values. Ammer et al. found that healthy people have a much

lower ΔTsk than patients with peripheral nerve injury, 0.24 vs 1.55°C

respectively (14).

When we compare our ΔTsk with the literature of healthy subjects our average

values of ΔTsk of the ventral arm, pectoral (or upper trunk) as well as upper back

were higher than the literature (218, 286, 407, 459, 462), being higher in

nonathletic than athletic subjects. Our dorsal arm ΔTsk average values were

similar than Marins et al. (245) and Zaproudina et al. (459) but lower than the

rest of studies, either in athletes or nonathletes. The ventral shoulder ΔTsk

average values were similar to Kolosovas et al. (218) and Zhu et al. (462) but

higher than Uematsu et al. (407). Finally, the dorsal shoulder ΔTsk average values

in nonathletic subjects approximate the values published, being lower in athletic

subjects. Part of the interside ΔTsk may be explained by the dominant side

hyperthermia due to the higher muscle mass (21, 38, 144, 374), however the

bilateral propulsion of the wheelchair may compensate this asymmetry in WCUs

(377); even the athletic group, who perform unilateral repetitive sport gestures

with the dominant arm, presented a more symmetrical side-to-side Tsk than the

nonathletic group. This result may have been caused by the better wheelchair

propulsion technique of the athletes and the bilateral workout exercises that

they perform. The higher ΔTsk values of the nonathletic group can be explained

by the shoulder rotator muscle imbalance (292, 344) as well as the weakness of

the shoulder adductors (53, 372), as it is reflected in the WUSPI score and it is

highly studied in the literature (53, 94, 100, 219, 292, 344, 372).

The literature is not conclusive about whether wheelchair exercisers have a

higher or lower prevalence of shoulder pain than non-exercising WCUs (8, 45,

79, 120, 128, 225, 229, 387, 450). In our study, nonathletic WCUs have the

highest ΔTsk values, coinciding with the highest WUSPI score. The Tsk and ΔTsk


96

results both showed asymmetric values that reflect the muscle imbalance around

the shoulder developed by WCU population. Sports could have a positive effect in

WCUs preventing shoulder pain, however multiple factors responsible of the

shoulder joint impairment, such as wheelchair propulsion technique (325, 326)

or over-the-head reaching from a wheelchair position (8, 103) should be

considered.

Thermography has been rarely used for the assessment of shoulder disorders

(38, 232, 270, 394, 400, 426). The literature differentiates two groups of

patients, with hypothermic and hyperthermic pattern in the involved side, where

the hypothermic group has more restriction in the movement of the shoulder

(299, 426). A study of the circadian rhythm of impaired shoulders showed that

shoulders tendinitis did not significantly change their Tsk on the day of study in

comparison with normal shoulders or cuff tear shoulders that reduce their Tsk at

night, due to the inflammation of the subacromial bursal tissues of the tendinitis

shoulders versus the lower inflammation process of the rotator cuff tears (270).

Hypothermia has been linked to degenerative process and chronic injuries (111,

307, 308), vessel occlusion such as thrombosis, nervous damage, reflex

sympathetic dystrophy, nerve root injury, Raynaud phenomenon, or avascular

tissues such from wounds or burns (334), abnormal activity of the sympathetic

nervous system (323, 400), as well as muscle atrophy (299), and decreased ROM

(299). Hypothermic patterns do not correlate with pain since in chronic phases

the movement is avoided and consequently the pain is reduced. However, Ring et

al. affirm that pain is present in both responses (334). A new study confirms that

long-term injuries exhibit the lower asymmetry between bilateral sides (370).

On the contrary, hyperthermia has been associated with inflammatory process

(299, 334) in the painful side (111), arthritis, skin reactions (334), disorders

related to increased blood flow in the skin (such as infections, tendinitis, bursitis,

bone fractures, tennis elbow, acute muscular injuries and other degenerative or

traumatic injuries in an acute phase) (307, 308, 334), also decreased

sympathetic tone to the skin due to the inflammatory response after a

sympathetic fibers’ injury (310), or other impaired sympathetic function (323).

Discussion

97

In a study with 94 individuals with paraplegia was found that one third of the

subjects had shoulder pain, 75% of them had impingement and subacromial

bursitis and 65% had rotator cuff tear (32). After this preliminary study, other

investigations unveiled that the most common cause of shoulder pain is overuse

injuries of the rotator cuff (7, 32, 53, 100, 134, 158, 229, 284, 303, 366).

However, the shoulder impingement syndrome cannot be detected by IRT due to

its hidden location of the supraspinatus tendon in the coracoacromial arch and

subacromial space (299). This may explain the lack of correlation between IRT

and WUSPI test in nonathletes, and also the non-consistent patterns in shoulder

Tsk in rotator cuff tendinitis found by Vecchio et al. (426), who justify their

findings because of the low grade of inflammatory process. Since we did not

perform a clinical evaluation of the subjects’ shoulders, we cannot specify which

type of impairment they may have (whether both shoulders are affected

resulting in false-negative results) or in which phase of the development it is (as

each phase is characterized by a different thermal response). Despite the

absence of correlation between Tsk and WUSPI score in nonathletic subjects, the

higher WUSPI score and the higher ΔTsk values than in the athletes make suspect

a larger number of shoulder disorders in the nonathletic group. In addition,

Pogrel et al. assured that it is possible to have thermal asymmetry and not have

corporal pain (310). ΔTsk is a major distinctive factor than the absolute Tsk

between normal and abnormal conditions, as many studies show thermograms

of control group with symmetrical patterns (310). We consider a limitation of

the WUSPI score the fact that it does not discriminate between shoulders;

therefore, our correlation could have been stronger if the IRT of the shoulder ROI

had been compared with the specific painful shoulder. Additionally, the WUSPI

test is applied to just one ROI, the shoulder, while the IRT in this study includes

all the ROI involved in wheelchair propulsion. Another possible explanation for

the moderate correlation is the low intensity of the shoulder pain as it is

reflected in smaller WUSPI score than the literature (50, 101, 277). The score

range encompasses from 0 to 150 cm and our higher value was 52.81 cm.

Pulst et al. describes the microcirculation evolution of entrapment neuropathies,

from initial vasoconstriction caused by irritation of the sympathetic fibers;


98

posterior vasodilatation fruit of sympathetic denervation consequence of the

compression; and, ending with vasoconstriction, results of the postdenervation

hypersensitivity of the blood vessels to circulation (323). Suprascapular nerve

entrapment is a common nerve compression syndrome in WCUs; its irritation

may produce a sympathetic vasoconstriction reflex resulting in decreased Tsk

(408, 458). Our results are in agreement with these authors since we found a

negative correlation between the temperature of some ROIs and shoulder pain in

athletic subjects. Probably the higher basal metabolic rate and muscle mass in

wheelchair athletes (the group with less shoulder pain) justify the greater heat

emission and consequently major Tsk (238, 353), since the muscle is an active

metabolic tissue responsible of the heat production to keep the body warm (76).

Their better vasculature and strength due to exercise allows an improved blood

flow (represented by higher Tsk) and lowers the risk of injury (38). It may be the

reason of lower pain with higher temperature experimented by the athletes.

Nonathletes possibly have more adipose tissue, which better isolates body

temperature irradiating less heat (113), adding to higher pain and muscle

imbalance. Moreover, recent studies have found that brown adipose tissue, a

metabolically active tissue specialized in generating heat through the

thermogenesis process, is also present in human adults. This highly capilarized

tissue, stimulated by the sympathetic nervous system, is mainly located in the

supraclavicular region, anterior neck, paravertebral area, and upper chest (281)

ROIs of our study. Brown fat is inversely correlated with BMI (84), and is

reduced in most overweight or obese subjects (421). It can partially explain why

this correlation is present only in wheelchair athletes. In summary, the heat

emitted by the musculature at rest (231), the articular protection that muscles

provide (38) linked to lower pain thanks to a better load distribution, greater

percentage of muscle mass and fat-free mass in athletes, offers a possible

explanation to our findings. Physical activity is used in osteoarthritis

rehabilitation programs to prevent and treat pain thanks to the muscle mass

augmentation. We encourage WCUs to practice sports to prevent shoulder

injuries, especially at low angles as it improves blood flow patterns and avoids

impingement syndromes (38). From a practical point of view, our findings help

to understand the thermal map in WCUs and call for future studies to further

Discussion

99

examine the thermoregulation response of WCUs in exercise. The great

methodological differences between the studies that research the thermal Tsk

pattern in upper body differ in such a way that disturbs the comparison between

them. In order to avoid it, we recommend using the same standard room

temperature for future studies (21-25°C, no lower than 22°C when working with

SCI subjects) and to select the same ROIs for WCUs, which should be the same

areas used for wheelchair propulsion. Furthermore, it is advocated to reduce the

acclimatization period to no more of 10 minutes for subjects with SCI

characterized by poikilothermic behaviour, to prevent from discomfort and

hypothermia.


100

5.3 STUDY 3: RELATIONSHIP BETWEEN SHOULDER PAIN AND SKIN TEMPERATURE MEASURED BY INFRARED THERMOGRAPHY IN A WHEELCHAIR PROPULSION TEST

Our study focuses on the response of the Tsk to a maximal wheelchair propulsion

test and its relation (pre-test, post-test, post-10) with shoulder pain in WCUs.

Most the studies in which the subjects were exposed to constant and prolonged

exercise resulted in an increased Tsk (72, 118, 124, 168, 171, 182, 237, 411, 433,

437, 438, 457). In contrast, graded, intermittent or maximal exercises normally

performed for brief period, resulted in decreased Tsk (9, 20, 66-68, 263-265, 278,

403). Based on this trend our short test should produce a reduction of the Tsk

once it finalized. Our Tsk values in Table 15 clearly show a tendency to initially

decrease immediately after the test (in 81.81% of the ROIs, average values) and

next a significant increase after 10 minutes of completing the T-CIDIF (in 86.36%

of the ROIs, average values). These results are more common of prolonged

exercises.

In WCUs, it seems primordial to transfer the metabolic heat from the core to the

skin as it is reflected by the prompt increase of Tsk. Another possible explanation

could be the SCI condition presented by most of our sample, this population may

present cardiovascular limitations, and patients with compromised cardiac

function are characterized by a higher extent of vasoconstriction in comparison

with healthy (168), which could explain the initial reduction of the Tsk. Another

characteristic of paraplegic athletes is to have a larger heat storage in the lower

body that ends in a diminished ability to reduce their core temperature during

the recovery phase (314), that may explain the rise of Tsk in the reduced body

surface area for active thermoregulation even in brief exercises. Price et al. found

that lower body Tsk augmented during prolonged upper body exercise due to the

increased heat storage in that region (314, 315). Gass et al. also found an initial

decrease of the Tsk (measured with thermistors) followed by an increase in the

arm ROI during a prolonged wheelchair exercise with trained paraplegic men

(132). Normell indicated that there is a large individual variation of the

cutaneous thermoregulatory vasomotor response, specially at the lower spinal

lesion levels, highlighting differences in the somatosensory and sympathetic

Discussion

101

pathways, in the sympathetic outflow response, and in the type and degree of

reinnervation (289). The extent of vasodilation and sweating depend on the

lowermost intact portion of the sympathetic chain, level and completeness of SCI

(132), in other words, fluid losses during exercise and heat retention during

passive recovery from exercise are related to lesion level (314). Probably the

findings would be different with a higher number of subjects having the same

level of injury. For example, five of our subjects have a lesion level above T10,

which implies a lack of sympathetic innervation to the splanchnic area and

therefore may not have the ability to redirect blood flow from an inactive area to

the active areas. In subjects with extended skin regions denervated, the loss of

sympathetic vasomotor afferent fibers results in microcirculation changes that

are reflected in locally increase of the blood flow and Tsk.

Because of each subject performed the T-CIDIF in their own daily wheelchair, the

differences in the wheelchair design and seating position could have influenced

the venous return dynamics, and thus impact the blood distribution.

The lack of significant differences between the pre-test and post-test Tsk in

contrast with the amount of differences respect to post-10 could be due to the

short duration of the T-CIDIF; 30 seconds normally is not enough time to activate

the thermoregulation system, as the hypothalamus starts to respond after 6-7

minutes of the exercise’s onset (314). Most of the IRT studies chose longer

exercise protocols with the exception of Adamczyk et al., who found similar

results than our study: a decrease of the lower limbs Tsk (1.44°C) right after

finishing the exercise and a posterior rise during the recovery period (3).

However, we have chosen the T-CIDIF for being a validated test for WCUs (261)

and because of its characteristics allow trained as well as untrained participants

to perform it.

The thermal pattern can also be influenced by the fitness level; trained subjects

present better cooling capacity during exercise and faster recovery (264) thanks

to an improved thermoregulation system and greater vascularization of the

musculature compared with non-trained (2, 61, 124). The muscles of our highly


102

skilled sample may present earlier and more responsive skin blood flow

responses, consequently the onset of vasodilation would occur at lower internal

temperatures (338) and the Tsk would start growing sooner than in a less fit

sample. This finding is in agreement with previous thermal study of a martial art

comparing skilled and novice physically active females, where the skilled group

presented higher post-exercise Tsk values than the novice group (237). The

opposite will happen with a sample with greater fat percentage, as adipose tissue

has lower thermal conductivity preventing the transfer of the heat from the

muscles to the skin (238). Future studies could compare the thermoregulation

response at exercise of athletes vs. nonathletes wheelchair users, in order to

know whether the athletes’ rise of Tsk is not only happening earlier (more

responsive) than in nonathletes but also during a shorter period (faster

recovery), as it happens in able-bodied population (2, 66, 321).

A previous research of skin temperature measurement during wheelchair

exercise (365) found that the ROIs with higher Tsk under exercise (Shoulder,

upper Pectoral major, anterior and posterior Forearm, Palm, anterior and

posterior Trapezius) showed marked increase in Tsk during the first 15 min

recovery phase, and coincided with the areas of raised activity in EMG under

wheelchair driving. Interestingly, the ROI with lower EMG was the upper arm.

Shin-ichi et al. concluded that the surface temperature could be an index of

muscle activity during exercise (365). They also found a great body surface

temperature difference depending on the body fat percentage of the subject, with

higher drop of the Tsk during the test and larger Tsk variations between the pret-

test, during wheelchair driving and recovery in the fat subject.

According to the Table 16, the ΔTsk is statistically modified by exercise increasing

in post-test respect to pre-test in 5 ROIs (anterior Arm, Infraspinatus,

Supraspinatus, anterior and posterior Trapezius); rising in anterior Arm ROI and

decreasing in two ROIs (posterior forearm and Infraspinatus) in post-10 respect

to post-test; growing in one ROI (posterior Central Trapezius) and diminishing in

another ROI (posterior forearm) in post-10 respect to pre-test.

Discussion

103

There is not a consistent tendency of the growth or decrement of the ΔTsk after

the T-CIDIF, although both average (0.29±0.27 vs 0.35±0.30) and maximum

(0.31±0.27 vs. 0.39±0.29) total ΔTsk values increased in post-test respect to pre-

test. The clear trend in Tsk vs. the no-tendency in ΔTsk make suspect of different

influence of exercise in each ROIs, and/or different implication of each muscle in

the wheelchair propulsion test. On one side, there is a different percentage of

involvement of the several muscles used during the wheelchair propulsion task,

and different wheelchair propulsion techniques applied (e.g. depending on their

impairment type and the size of the wheelchair). Any of the SCI participants have

tetraplegia, hence their upper extremities are fully innervated, and also, all of

them trained the same number of hours per week and same load of training, so

they have similar upper body work capabilities. On the other side, the initial

cutaneous vasoconstriction response needs dynamic activity by a significant

musculature, not being effective for smaller muscle groups (199). It is also

known that dominant side has a higher capacity to loss temperature and better

thermoregulation (374), getting cold in response to the onset of the activity

because of the vasoconstriction effect. This is not reflected in our results and it

can be due to the bilateral propulsion of the wheelchair that may compensate

this asymmetry in WCUs (377). Finally, Shin-ichi et al. found a non-uniform

distribution of the temperature in the bust rising heterogeneously during both

wheelchair exercise and recovery (365), which is consistent with our lack of

pattern in ΔTsk after exercise. Although the thermographic results are not

conclusive enough to make definitive assumptions, they provide an insight in the

thermal pattern of WCUs at exercise.

In Table 17 is observed an inverse correlation between shoulder pain and the

ΔTsk of the anterior and posterior Shoulder ROIs prior to T-CIDIF. One minute

after the wheelchair propulsion test, it is detected a negative relationship

between shoulder pain and the ΔTsk of the Central Posterior Trapezius. Ten

minutes after the test the ΔTsk of the Dorsal ROI correlates negatively with

shoulder pain, while the ΔTsk of the Central Posterior Trapezius and the Anterior

Trapezius correlate positively with shoulder pain. These are only a few

correlations in comparison with the amount of ROIs measured. Most of them


104

were negative; hence higher WUSPI or PC-WUSPI scores are related with lower

ΔTsk. Previous studies of the author found several negative relationships

between the shoulder pain test and the Tsk of 6 ROIs, but only one correlation

with the bilateral differences (342). These findings could be explained because of

the low shoulder pain experienced by our sample, our WUSPI and PC-WUSPI

scores were no higher than 6 cm in comparison with the range of the scale from

0 to 150 cm.

Our study has not found any correlation between shoulder pain and the

kinematic variables of the T-CIDIF (Table 18). This results are opposite of

previous findings that reported significant inverse relationships between the

kinematic variables of the T-CIDIF and the PC-WUSPI test (261). The reason

could be also the low shoulder pain score of our subjects. Moreover, they were

very disposed to give their best during the test due to their athletic and

competitive attitude, thereby they may have propelled at their maximum in spite

of their shoulder pain.

The findings show multiple correlations (mostly negative) between all the

kinematic variables of the T-CIDIF and the ΔTsk of many ROIs. Although it was

not part of our aims, we provide information of the relation between the exercise

and the thermographic variables. Menéndez et al. discovered high positive

correlations between the variables of the T-CIDIF and the peak torque, total

work, mean power, and mean of the peak torques of the internal and external

shoulder rotators obtained in a maximum isokinetic strength test (261). Based

on this outcome, they affirmed that T-CIDIF could be used as an alternative of the

isokinetic strength test. Consequently, the inverse correlations found between

the kinematic variables and the thermal data in our study could be translated to

the isokinetic dynamometer, such as, higher torque and power may also

correlate with lower ΔTsk. This is good reason to promote the strengthening of

the shoulder joint between WCUs. Additionally, the isokinetic strength test

performed by them did not correlate with the shoulder pain questionnaire,

implying that the pain is limited to functional gestures more than maximum

strength.

Conclusions

105

6 CONCLUSIONS

6.1 CONCLUSIONS STUDY 1

The conclusions derived from the achievement of the first study’s objective are:

- The reliability of infrared thermography in wheelchair users depends

on the analyzed region of the body. The regions of interest with higher

intraclass correlation coefficient for average temperature when

measurements were compared on separate days, and hence, the more

reliable ROIs were the left posterior forearm (0.80), right posterior arm

(0.88), right dorsal (0.79), right pectoral (0.95), left supraspinatus

(0.76). The ROIs with a lower ICC for average temperatures, and were

therefore less reliable, were the right anterior forearm (0.22), left

anterior forearm (0.24), left anterior arm (0.18), left posterior arm

(0.23), left anterior shoulder (0.15), left posterior trapezius (0.38).

- The reliability of the maximum temperature values improved when

compared from one day to the next. Those which showed an excellent

reproducibility were the left anterior forearm (0.76), right posterior

forearm (0.77), left posterior arm (0.77) and left anterior trapezius

(0.79). The left pectoral was the only region to show poor

reproducibility (0.39) for maximum temperature.


The conclusions to the first objective of the study 2 are:

- Nonathletic wheelchair users were shown to have a similar skin

temperature and a greater bilateral skin temperature than wheelchair

athletes in most regions of interest. Furthermore, both athletic and

nonathletic wheelchair users presented with a higher bilateral skin

temperature than able-bodied results published in the literature.


106

- In particular, nonathletes have higher skin temperature and bilateral

skin temperature differences in the anterior and posterior shoulder

than athletes.

The conclusion to the second objective of the study 2 is:

- The nonathletic group presented with higher shoulder pain in

comparison to the athletic group.

The conclusions to the third objective of the study 2 are:

- In athletic wheelchair users the analysis of the skin temperature could

be important since some regions of interest are related to shoulder

pain. The regions of interest, in which a relationship between

maximum skin temperature and pain was shown, were the left

anterior shoulder, the right posterior central trapezius, and the left

posterior central trapezius; and for the average bilateral skin

temperature differences: the anterior arm.


The conclusions to the first objective of the study 3 are:

- The thermal pattern of the wheelchair athletes observed after exercise

showed a decrease in skin temperature immediately after completing

a 30 second all-out wheelchair propulsion test, followed by an

increase at ten minutes after the test. The thermal pattern presented

significant differences between the skin temperature before the test

and 10 minutes after the maximal test in 12 regions; and between the

skin temperature measured in the minute immediately following the

test and at 10 minutes afterwards in most of the regions of interest.

- In contrast to the absolute skin temperature pattern, there were very

few significant differences in left-right asymmetries at the two time-

points following the wheelchair test. The differences between the left-

right skin temperature asymmetries were smaller than the differences

Conclusions

107

between the absolute values of skin temperature before and after the

wheelchair test.

The conclusions to the second objective of the study 3 are:

- After a 30 seconds maximum wheelchair propulsion test the bilateral

skin temperature difference of the posterior central trapezius, the

dorsal and the anterior trapezius was inversely related with shoulder

pain.

- The bilateral skin temperature difference of the regions of interest is

inversely related to the performance in the wheelchair propulsion

test.

The conclusion to the third objective of the study 3 is:

- No correlation was found between shoulder pain and the kinematic

variables of the wheelchair test.


108

7 LIMITATIONS

There are several aspects of this research that were necessarily foregone and

that must be considered when interpreting the results and applying them in

practical situations.

A manual system was used to draw the limits of each region of interest

when analysing the thermograms (Figure 23). Consequently, the

demarcation lines of the examined area could vary slightly from one

image to the next influencing the skin temperature measurements.

Figure 23. Manual drawing of the regions of interest

The skin temperature data may have been affected by temporary injuries

in some participants, as a prior physical examination was not conducted.

In the first study, the time interval between the two infrared

thermographic measurements was reduced to one day to minimize the

thermal evolution of potential lesions, given that initial warm areas may

quickly return to normal temperatures (406).

Limitations

109

An attempt was made to control for the natural 24-hour circadian

variation in skin temperature by testing at the same time of the day.

However, a time interval of 24 hours gives the highest error of reliability

acceptable. Taking thermal images on the same day aims to isolate the

daily skin temperature (352) and skin blood flow (391) variations from

other factors. In the second study, thermographic data was collected

twice on the same day to avoid any day-to-day variation.

Individual characteristics that can affect skin temperature values, such as

the physiological variability of the blood flow, thermoregulation

problems, hormonal changes, medication intake, scars and body fat,

should be given particular considerations when making infrared

thermograpy measurements. Constraints of time and resources meant

that not all of these characteristics could be accounted for during the

studies of this thesis.

It would be preferable to use a standard wheelchair when assessing the

skin temperature in a group of wheelchair users to normalize the

backrest heights (Figure 24). However, in the third study, all subjects

used their own wheelchair to perform the exercise test, which meant that

they could propel their wheelchair without having to change their

propulsion style.


110

Figure 24. The impact of different backrest on the thermal image. Backrest size is dependent upon the impairment of the subject

The results of the third study suggested that 10 minutes may not be

enough time following a 30 second all-out push test for the skin

temperature to return to its pre-exercise level. A longer period spent

evaluating post-exercise skin temperature, perhaps up to 30 minutes,

may be beneficial in future studies to properly understand the thermal

response to this type of exercise.

The WUSPI test was chosen for this thesis due to its specificity for the

wheelchair using population. However, it is limited to the fact that it

focuses only on the shoulders and none of the other regions of interest

investigated in the present studies. These additional regions were

selected because of their associated musculature, which is also involved

in the wheelchair propulsion task. Moreover, the WUSPI refers only to

pain in the shoulder during the previous week; a longer clinical history

should be sought because of the potential implications for previous

injuries on the skin and the measurement of skin temperature.

Future Research Lines

111

8 FUTURE RESEARCH LINES

A number of possible research lines have emerged from the investigations of this

thesis. In the first instance, a more comprehensive evaluation of the reliability

and validity of thermographic imaging would require a range of time intervals

between the capture of images, other indoor settings, exercise modes and

athletes of various sports. Longitudinal prospective studies of infrared

thermography reliability on specific health conditions with larger and more

homogeneous samples could help to explore the clinical application of infrared

thermography on those pathologies. Future research should aim to study the

potential association between skin temperatures of the muscles involved in

wheelchair propulsion with the pain in those areas in an effort to prevent

situations of injury risk. Moreover, infrared thermography could help to detect

hypo- and hyperthermia that warn medical professionals and coaches about

potential injuries (350).

The investigations in this thesis act as a starting point to establishing more direct

relationships between skin temperature and pain and injury processes and,

eventually, perhaps employing infrared thermography within the array of injury

monitoring tools. While the correlations between skin temperature and shoulder

pain are not sufficient to support infrared thermography as a diagnostic tool for

shoulder pain (and much less, for shoulder injuries), it could be reasoned that an

increase in skin temperature may be indicative of the inflammatory process and

that without treatment, strengthening and stretching and modifications to the

daily and/or sporting tasks, the accumulative effect of the inflammatory

response could be a shoulder injury. The conclusions supports the use of

infrared thermography as one of the tools for medical professionals and sports

coaches to monitor wheelchair users in preventing overuse injuries.

Future studies would benefit from larger sample sizes and broader populations.

More participants with different levels of SCI would allow for a differentiation

between these levels of injury. Specifically, it would be possible to verify the


112

differences of skin blood flow between subjects with SCI above and below T10

vertebrae, a crucial level in the sympathetic innervation, as well as above and

below T6 vertebrae, which is also implicated with thermoregulation.

The exercise test performed in the third study of the present thesis was a 30

second maximal intensity wheelchair propulsion test. Interestingly, Rodgers et

al. affirmed that there is a power shift in wheelchair propulsion from the

shoulder to the elbow and wrist with increasing fatigue (339). Ambrosio et al.

theorizes that this shift will not be so predominant in endurance-trained

individuals (12). One direction for future research could be identifying a

correlation between skin temperatures of the muscles involved in wheelchair

propulsion and shoulder pain following prolonged exercise. It will not only allow

time for the activation of the hypothalamus, but may also enable a possible

correlation between skin temperature and pain in other regions (such as elbow

and wrist) to be observed, which may only develop during fatigue or in

untrained wheelchair users. In this and other research that might investigate

skin temperatures in the entire upper body, more generic pain scales will need to

be employed (other than the WUSPI scale for shoulder pain used in this thesis) to

point to the regions where pain is being experienced, in real time.

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460. Zhang HY, Kim YS, Cho YE. Thermatomal changes in cervical disc herniations. Yonsei Med J. 1999 Oct;40(5):401-12.

461. Zheng F, Xu GL, Jang GT. The research on processing method of infrared thermography for diabetes. Zhongguo Yi Liao Qi Xie Za Zhi. 2000 Nov;24(6):330-2.

462. Zhu WP, Xin XR. Study on the distribution pattern of skin temperature in normal Chinese and detection of the depth of early burn wound by infrared thermography. Ann N Y Acad Sci. 1999 Oct 30;888:300-13.

463. Zivcak J, Hudak R, Kneppo P, editors. Application of Infrared Imaging in Rehabilitation Medicine in Spinal Cord Injured Individuals. INES 2005 IEEE

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464. Zivcak J, Kneppo P, Hudak R, editors. Methodics of IR Imaging in SCI Individuals Rehabilitation. IEEE-EMBS 2005 27th Annual International Conference of the Engineering in Medice and Biology Society; 2005 Sept. 1-4, 2005; Shanghai, China. IEEE.

465. Zontak A, Sideman S, Verbitsky O, Beyar R. Dynamic thermography: analysis of hand temperature during exercise. Ann Biomed Eng. 1998 Nov-Dec;26(6):988-93.

466. Zurek G, Dudek K, Pirogowicz I, Dziuba A, Pokorski M. Influence of mechanical hippotherapy on skin temperature responses in lower limbs in children with cerebral palsy. J Physiol Pharmacol. 2008 Dec;59 Suppl 6:819-24.


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10 APPENDIXES

10.1 APPENDIX 1. EXAMPLE OF INFORMED CONSENT FORM

In the following page it is presented an example of the informed consent form

distributed to the study’s participants.

Centro de Investigación en Discapacidad Física, ASPAYM CASTILLA Y LEÓN C/ Severo Ochoa, 33. Urbanización Las Piedras. 47130, Simancas, Valladolid, España.

983 591 044 // Fax 983 591 101 // [email protected]

Confidencialidad y revisión de documentos Usted comprende y es consiente que, con el fin de garantizar la fiabilidad de los datos recogidos en este estudio, será preciso que representantes del Centro de Investigación en Discapacidad Física (CIDIF), la Universidad Politécnica de Madrid (UPM) y eventualmente las autoridades sanitarias y/ o miembros del Comité Ético de Investigación Clínica, tengan acceso a sus datos comprometiéndose a la más estricta confidencialidad. De acuerdo con la Ley Orgánica 15/1999, de 13 de diciembre, de Protección de Datos de Carácter Personal, los datos personales que se le requieren (imágenes incluidas) serán objeto de tratamiento automatizado y se incorporan a un fichero propiedad de ASPAYM Castilla y León, debidamente registrado en la Agencia Española de Protección de Datos. En ninguno de los informes del estudio aparecerá su nombre y su identidad no será revelada a persona alguna salvo para cumplir con fines investigadores o docentes, y en caso de urgencia médica o requerimiento legal. Cualquier información de carácter personal que pueda ser identificable será conservada y procesada bajo condiciones de seguridad, con el propósito de determinar los resultados del estudio. Éstos podrán ser comunicados a las autoridades sanitarias y eventualmente, a la comunidad científica a través de congresos y/ o publicaciones. El abajo firmante declara haber sido informado de los riesgos e implicaciones que conlleva la participación en el presente estudio, y autoriza la realización de la batería de pruebas físicas y cuestionarios sobre su persona. Tras haber sido resueltas las dudas que le hayan surgido referentes a su colaboración, manifiesta que realiza voluntariamente dichas pruebas. Firma del informado Firma del testigo Dtor. del Estudio

DNI:_________________ DNI: _________________ DNI: __________________

Valladolid, a ……… de ……… de 2010.


148

10.2 APPENDIX 2. EXAMPLE OF THERMOGRAPHIC REPORT

Appendixes

149


150

10.3 APPENDIX 4. DATA COLLECTION INFORMATION SHEET FOR THE SUBJECTS

Appendixes

151


152

10.4 APPENDIX 4. WUSPI TEST IN ENGLISH

The Wheelchair Users Shoulder Pain Index developed by Curtis et al. (81):

ANEXO 1. Wheelchair Users Shoulder Pain Index

Place an “X” on the scale to estimate your level of pain with the following activities. Check box at right if

the activity was not performed in the past week.

Based on your experiences in the past week, how much shoulder pain do you experience when:

1. Transferring from a bed to a wheelchair?

not performed

No pain [ ] _________________________________________________ Worst Pain Ever Experienced [ ]

2. Transferring from a wheelchair to a car


3. Transferring from a wheelchair to a tub or shower?


4. loading your wheelchair into a car?


5. pushing your chair for 10 minutes or more?


6. pushing up ramps or inclines outdoors?


7. lifting objects down from an overhead shelf?


8. putting on pants?


9. putting on a t-shirt or pullover?


10. putting on a button down shirt?


11. washing your back?


12. usual daily activities at work or school?


13. driving?


14. performing household chores?


15. sleeping?


Appendixes

153

10.5 APPENDIX 5. WUSPI TEST IN SPANISH

The Wheelchair Users Shoulder Pain Index validated to Spanish by Arroyo-Aljaro

et al. (23):

ANEXO 2. Wheelchair Users Shoulder Pain Index (Castellano)

Coloque una “X” en la escala para estimar su nivel de dolor con las siguientes actividades. Marcar la caja “[

]” de la derecha si no ha realizado la actividad en la pasada semana.

Basado en su experiencia de la semana pasada, con qué intensidad le ha dolido el hombro cuando estaba:

1. pasando desde una cama a una silla de ruedas?

No realizado

Sin dolor [ ] _________________________________________________ Peor dolor que nunca ha

experimentado [ ]

2. pasando desde una silla de ruedas a un coche?


experimentado [ ]

3. pasando desde una silla de ruedas a un baño o ducha?


experimentado [ ]

4. cargando una silla de ruedas en el coche?


experimentado [ ]

5. empujando una silla durante 10 minutos o más?


experimentado [ ]

6. empujando una silla hacia arriba en rampas o pendientes exteriores?


experimentado [ ]

7. bajando objetos desde un estante situado por encima de la cabeza?


experimentado [ ]

8. colocándose los pantalones?


experimentado [ ]

9. colocándose una camiseta o jersey?


experimentado [ ]

10. colocándose una camisa de botones?


experimentado [ ]

11. lavándose la espalda?


experimentado [ ]

12. en actividades habituales diarias en el trabajo, el colegio o la universidad?


experimentado [ ]

13. conduciendo?


experimentado [ ]

14. realizando las tareas del hogar?


experimentado [ ]

15. durmiendo?

Sin dolor [ ] __________________________________________________Peor dolor que nunca ha

experimentado [ ]


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Curriculum Vitae

155

11 SUMMARIZED CV / CURRICULUM VITAE ABREVIADO 1. ACTIVIDAD LABORAL

2015-2016 Profesor Asociado de la Universidad Isabel I de Castilla. Asignatura: Actividad Física y Discapacidad Física.

2015 Asesor y miembro de la Comisión de Clasificación del Comité Paralímpico Español (CPE), España.

2012-2015 IPC Classification Research Manager, International Paralympic Committee (IPC), Alemania.

2014-2015 Ponente en: la Universidad Complutense de Madrid (UCM), Facultad de Medicina, asignatura “Valoración del daño funcional”; en la Universidad Politécnica de Madrid (UPM), Facultad de Ciencias de la Actividad Física y el Deporte (INEF), asignatura de doctorado “Diseño de Experimentos”, conferencia “Investigación en el Movimiento Paralímpico”; en la Universidad Europea Miguel de Cervantes, conferencia: “Del INEF al Comité Paralímpico Internacional”.

2011-2012 Profesor Asociado de la Universidad Camilo José Cela (UCJC). Asignatura: Educación Física y su Didáctica (Troncal).

2010-2012 Investigador colaborador del Laboratorio de Fisiología del Esfuerzo Humano del Departamento Salud y Rendimiento, INEF, UPM.

2010-2012 Investigador colaborador del Centro de Investigación en Discapacidad Física (CIDIF), ASPAYM Castilla y León.

2010-2012 Investigador colaborador en la empresa spin off pemaGROUP (Prevención de Lesiones mediante termografía infrarroja), empresa ganadora del 4º premio en la VII de actúaUPM, concurso de creación de empresas de la UPM, Diciembre 2010; y 1º premio del VIII concurso de creación de empresas CIADE de la Universidad Autónoma de Madrid, Diciembre 2010; premio al Mejor Plan de Empresa Madri+d, 2011.

2010-2011 Profesor Ponente de la UPM. Asignatura: Actividades y Deportes de Montaña (Optativa).

2009-2010 Profesor Asociado de la Universidad Camilo José Cela (UCJC). Asignatura: Educación Física y su Didáctica (Troncal).

2009-2010 Profesor Ponente de la UPM. Asignatura: Deportes Adaptados a Personas con Discapacidad Física (Obligatoria).

2008 Terapeuta deportivo en el Hospital Beitostolen Helsesportsenter (Noruega).

2008-2012 Profesor de Deportes Adaptados de la Federación Española de Atletismo, curso de Entrenador Nacional de Atletismo, Escuela Nacional de Entrenadores de Atletismo.

2008 Ponente y organizador del curso de “Deporte Adaptado” ofrecido en colaboración con la Dirección General de Educación Física de Guatemala.

2004, 2007, 2010-2012

Personal técnico de apoyo en las pruebas de esfuerzo máximo del Laboratorio de Fisiología del Esfuerzo del INEF, UPM.

2. FORMACIÓN

2008-2009 Erasmus Mundus Master in Adapted Physical Activity por la Katholieke Universiteit

Leuven (Bélgica), European Comission Education & Training, Beitostølen Helsesportsenter (Noruega), University of Queensland (Australia).


156

156

2006-2008 Máster Oficial de Postgrado en Investigación en Ciencias de la Actividad Física y el Deporte. Diploma de Estudios Avanzados (DEA) INEF, UPM.

2005-2007 Diplomada en Magisterio de Educación Física en la UCM.

2005-2006 Certificado de Aptitud Pedagógica (C.A.P.) en el INEF, UPM.

2005-2006 Entrenador Nacional de Atletismo, por la Real Federación Española de Atletismo.

2004-2005 Entrenador Superior de Natación, por la Real Federación Española de Natación.

2000-2005 Licenciada en Ciencias de la Actividad Física y el Deporte en el INEF, UPM. Especialidades: judo, natación y hockey. Maestrías en Natación y Deportes Adaptados de Alto Rendimiento. Itinerarios: Educación e Investigación en Deporte Adaptado.

3. ACTIVIDAD INVESTIGADORA

Comunicaciones y póster en congresos

2015, 3-5 septiembre

“Infrared Thermography and Shoulder Pain in Wheelchair Users”. Autores: Isabel Rossignoli, Manuel Sillero-Quintana, Azael J Herrero. Congreso: XIII Congress of the European Association of Thermology, INEF Madrid 2015.

2014, 25 noviembre

"Reliability of Infrared Thermography in Skin Temperature Evaluation of Wheelchair Users". Autores: Isabel Rossignoli, Pedro J Benito, Azael J Herrero. Journal: Spinal Cord. 2014 Nov 25;53:243-8. doi:10.1038/sc.2014.212.

2013, 1-4 mayo

“Relationship between perceived shoulder pain and kinematic analysis of wheelchair propulsion in sedentary and active wheelchair users”. Autor: Isabel Rossignoli. Congreso: VISTA 2013 Scientific Conference – Equipment & Technology in Paralympic Sports, International Paralympic Committee, Bonn (Germany).

2012, 3-5 septiembre

“Risk factors of shoulder pain and shoulder functionality in athletes and sedentary wheelchair users”. Autores: Azael Herrero, Isabel Rossignoli, Héctor Menéndez, Juan Martín, Cristina Ferrero, Pedro J. Marín. Congreso: International Spinal Cord Society, 51ST Annual Scientific Meeting, ISCOS 2012 – Advances in Spinal Cord Injury Management. Londres (Inglaterra).

2011, 15 diciembre

“Factores de riesgo del dolor y de la funcionalidad en la articulación del hombro en usuarios en silla de ruedas sedentarios y deportista”. Autores: Azael J. Herrero, Isabel Rossignoli1, Héctor Menéndez, Juan Martín, Cristina Ferrero y Pedro J. Marín. Congreso: CIDA 2011, III Conferencia Internacional sobre Deporte Adaptado, Fundación Andalucía Olímpica. Málaga (España).

2011, 4-8 julio

“Infrared Thermography in people with disabilities: a comparison between athletes and sedentary wheelchair users”. Autores: Isabel Rossignoli, Azael Herrero, Pedro J Benito. Congreso: 18th International Symposium on Adapted Physical Activity, International Federation of Adapted Physical Activity. París (Francia)

2010, 6-8 mayo

“Pilot Evaluation of Methods for Measuring Sports-Specific Coordination”. Autores: Isabel Rossignoli, Sean Tweedy, Alice Neiuwboer. Congreso: European Congress of Adapted Physical Activity 2010 / Finish Congress of Adapted Physical Activity, University of Jyväskylä and Finnish Society of Sport Sciences. Jyväskylä (Finlandia).

2008, 9-11 octubre

“Direct and on-court measurement of maximal aerobic performance of elite wheelchair basketball players”. Autores: Isabel Rossignoli, Javier Pérez. Congreso: European Congress of Adapted Physical Activity 2008 / Congress of EUFAPA, Universita Degu Studi Di Torino. Torino (Italia)

2008, 2-5 abril

"Medición directa en campo de la potencia aeróbica máxima de jugadores de baloncesto en silla de ruedas de alto nivel". Autores: Isabel Rossignoli, Javier Pérez, Pedro J Benito. Congreso: IV Congreso Internacional y XXV Nacional de Educación Física, Facultad de Ciencias de la Educación, Universidad de Córdoba. Córdoba (España).

Curriculum Vitae

157

2006, 16-20 mayo

“Shoulder Pain in Spanish Wheelchair Basketball Players: a pilot study”. Autores: Javier Pérez, Isabel Rossignoli, Raquel Martínez. Congreso: 15 Congreso Europeo de Medicina Física y Rehabilitación/44 Congreso Nacional de la Sociedad Española de Rehabilitación y Medicina Física, Physical Medicine and Rehabilitation Department; University of Medicine (UCM); Hospital Clínico San Carlos (Madrid); Departamento de Medicina Física y Rehabilitación de la Facultad de Medicina (UCM); Hospital Clínico San Carlos (Madrid). Madrid (España).

2005, 19-22 octubre

“Análisis biomecánico y muscular de la impulsión en silla de ruedas”. Autor/es: Isabel Rossignoli, José Artacho, Javier Pérez. Congreso: I Congreso Internacional sobre Deporte Adaptado, Facultad del Deporte de Toledo – Fundación del Hospital Nacional de Parapléjicos de Toledo para la Investigación y la Integración. Toledo (España).

Participación en proyectos de investigación

2014 Colaboración en el proyecto del Comité Paralímpico Internacional (IPC) y Anglia Ruskin University: “IPC Shooting Classification Research Project”, organización toma de datos y supervisión del proyecto.

2013-2014 Colaboración en el proyecto del IPC y Vrije Universitet Amsterdam: “IPC Swimming Classification Research Project”, toma de datos durante los Campeonatos del Mundo de Natación adaptado en Eindhoven, Holanda; organización de meetings de expertos; supervisión del proyecto.

2013-2014 Colaboración en el proyecto del IPC, Salzburg University, University of Tübingen, y University of Jÿvaskyla: “IPC Nordic Skiing Classification Research Project”, toma de datos durante los Campeonatos del Mundo de Esquí Nórdico adaptado en Sollefteå, Suecia; organización de meetings de expertos; supervisión del proyecto.

2013 Colaboración en el proyecto del IPC y University of Queensland: “IPC Atletics Classification Research Project”, toma de datos en Nairobi, Kenia.

2013 Colaboración en el proyecto del IPC: “IPC Para-snowboard Classification Research Project”, toma de datos en Cooper Mountain y Lake Tahoe, USA; organización de meeting de expertos.

2010-2011 Investigador principal en el proyecto del CIDIF y UPM: “Factores de riesgo del dolor y de la funcionalidad en la articulación del hombro en usuarios de silla de ruedas sedentarios y deportistas”.

2010 Colaboración en el proyecto del Grupo “PemaSiP” del Departamento de Deportes en el INEF y CSD: “Aplicación de la termografía como medio para la prevención de lesiones en deportistas de alto rendimiento (THERMOPREVENT)”.

2010-2012 Colaboración en el proyecto del INEF, Ministerio de Ciencia e Innovación, Federación Española de Gimnasia, Asociación de Padres y Familiares de Minusválidos Psíquicos y Sensoriales, Servicio Deportivo Munical de Leganés, Getafe FC SAD, Federación de Autismo de Madrid, Álava Ingenieros S.A., Rayo Vallecano CF SAD: “La termografía como medio de detección, prevención y seguimiento de problemas y lesiones derivados de la actividad físico-deportiva en poblaciones especiales (THERMOSPEC)”.

2009-2011 Proyecto I+D: con el Departamento de Salud y Rendimiento Humano del INEF, UPM; el Instituto de Investigación Marqués de Valdecilla – Universidad de Cantabria; y el Servicio de Nutrición, IDIPAZ, Hospital Universitario de la Paz: “PRONAF PROgramas de Nutrición y Actividad Física para el tratamiento de la obesidad”. Ministerio de Ciencia e Innovación. DEP2008-06354-C04-01.

2008-2009 Proyecto del master en la Universidad de Queensland, Australia: “Towards Evidence Based Classification In Paralympic Athletics: Pilot Evaluation Of Methods For Measuring Sports-Specific Coordination”. En colaboración con el IPC.


158

158

2007-2008 Proyecto para la elaboración del Diploma de Estudios Avanzados (DEA) en el INEF, UPM: “Valoración funcional en deportistas con discapacidad física de alto nivel: evaluación de la salud, tests de laboratorio y de campo”.

2007 Proyecto del CSD y el Laboratorio de Fisiología del Esfuerzo del INEF, UPM: “Valoración de las variables fisiológicas en competición al equipo nacional de lucha”.

2004-2005 Proyecto de promoción del Deporte Adaptado “Hospisport en Madrid”, INEF, UPM.

Publicaciones científicas Rossignoli I, Benito PJ, Herrero AJ. Reliability of infrared thermography in skin

temperature evaluation of wheelchair users. Spinal Cord. 2014;53:243-8.

Rossignoli I, Herrero AJ, Menéndez H, Sillero M, Benito PJ. Relationship between perceived shoulder pain and infrared thermography in wheelchair athletes and nonathletes. Disability and Health Journal. (Submitted)

Rossignoli I, Fernández-Cuevas I, Benito PJ, Herrero AJ. Relationship between shoulder pain and skin temperature measured by infrared thermography in a wheelchair propulsion test. Infrared Physics and Technology. (Submitted)

Estancias predoctorales en el extranjero Centro: Faculty of Kinesiology and Rehabilitation Sciences, Katholieke Universiteit

Leuven. Localidad: Leuven, Bélgica. Duración: agosto-octubre 2008 y enero 2009, 4 meses.

Centro: The Norweigan School of Sport Science, The Norwegian University of Sport and Physical Education. Localidad: Beitostolen, Noruega. Duración: noviembre-diciembre 2009, 2 meses.

Centro: School of Human Movement Studies, University of Queensland. Localidad: Brisbane, Australia. Duración: febrero-abril y agosto 2009, 4 meses.

4. OTROS DATOS DE INTERÉS

Premio de investigación 2008 del Convenio INEF-Consejo Superior de Deportes (CSD) por el Diploma de Estudios Avanzados (DEA). Proyecto: "Valoración funcional en deportistas de alto rendimiento con discapacidad física: evaluación de la salud, test de laboratorio y de campo" realizado en el INEF, UPM.

Miembro del grupo de investigación internacional: European Research Group in Disability Sport (ERGiDS).

Amplio historial deportivo en competiciones de Judo desde 1992 al 2007.

Miembro del equipo alpino internacional: The Mountain Academy, patrocinado por Mountain Hardware y Black Diamond.

Compitiendo en escalada deportiva desde 2011, siendo en la actualidad Campeona de España Universitaria de Escalada 2015.

Facultad de Ciencias de la Actividad Física y el

Deporte – INEF: 11


2015

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