Journal of Bodywork & Movement Therapies 28 (2021) 478e482

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Diagnostic Methods

Thermography evaluation of low back pain in pregnant women: Cross-

sectional study

bora Renata Sales de Santana d,
Camilla Medeiros Araujo a, b, Diego de Sousa Dantas c, De
Marcos Leal Brioschi e, Caroline Wanderley Souto Ferreira c, Juliana Netto Maia f, *
a
Program of Multiprofessional Health Residency, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil
b
Graduate Student of the Post-graduate Program in Physiotherapy, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil
c
Post-graduate Program in Physiotherapy, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil
d
Academic, Undergraduate Student of the Physiotherapy Course, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil
e
Program of Medical Thermography, Universidade de Sa ~o Paulo (USP), Sa
~o Paulo, SP, Brazil
f
Program of Multiprofessional Health Residency, Universidade Federal de Pernambuco (UFPE). Recife-PE, Brazil. Department of Physiotherapy, Universidade
Federal de Pernambuco (UFPE), Recife, Pernambuco, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Background: Low back pain during pregnancy is very common and thermography seems to be a
Received 20 June 2020 promising method of evaluation for pregnant women, because it is painless and safe. The aim of the
Received in revised form present study was to evaluate low back pain, during pregnancy, using thermography together with
18 May 2021
artificial intelligence.
Accepted 17 July 2021
Methods: A cross-sectional study was carried out with pregnant women recruited from a university
hospital. The following data were collected: (a) clinical data; (b) physical assessment with mobility and
Keywords:
low back pain provocation tests; and (c) thermograms acquisitions, in a controlled environment. Artificial
Thermography
Low back pain
intelligence and the statistical tests were used to compare the groups’ mean: with low back pain (LBP)
Pregnancy and without low back pain (WLBP).
Results: Thirty pregnant women took part, with fifteen in each group. The mean ± Standard Deviation
temperature of the lumbar region in both groups were 32.7 ± 1.05
C and 32.6 ± 1.01
C for LBP and
WLBP, respectively. There was not any difference in temperature between the groups; however, the
artificial intelligence software found thermogram differences between groups; furthermore, the corre-
lation between pain intensity and functionality was found.
Conclusion: Thermography associated with artificial intelligence analyses demonstrated to be a prom-
ising method as an adjunct to clinical evaluation.
© 2021 Elsevier Ltd. All rights reserved.

1. Introduction The assessment of patients with LBP during pregnancy includes

Low back pain (LBP) during pregnancy is very common, with a
prevalence of 30 %e78 % (Carvalho et al., 2017). The pain may affect
only the low back region or it can radiate to one or both legs; it can
impact, in a negative way, sleeping, daily activities, and social
participation of these women (Wang et al. 2004; Elden et al., 2013).
It is commonly a musculoskeletal problem that may be associated
with mechanical, hormonal, social and psychological factors
(Sabino and Grauer 2008).
* Corresponding author. Universidade Federal de Pernambuco, Av. Jorn. Aníbal
Fernandes, 173 - Cidade Universit
aria, Recife, PE, 50740-560, Brazil.
E-mail address: Juliana.netto@ufpe.br
(J.–M.P.Q.Juliana.nettoufpe.br-.P.P.response.K.further.–>a.N. Maia).
the location of the pain, the clinical history and specific physical
tests (Casagrande et al., 2015). Despite having good sensitivity and
specificity, the physical tests to evaluate LBP only give data about
presence or absence of pain, do not offer quantitative data on the
integrity of the structures, which is a limitation for clinical practice
(Mens et al., 2001; Albert et al., 2000). In cases of severe LBP,
complementary imaging tests, such as magnetic resonance imaging
and ultrasound, may be requested (ACOG 2017); however, these
imaging tests increase the costs for the health system (Carregaro
et al., 2019).
The skin is one of the largest organs in the human body, forming
a complex thermoregulation system together with vessels and
nerves, which controls local blood flow. The system works in an

https://doi.org/10.1016/j.jbmt.2021.07.040
1360-8592/© 2021 Elsevier Ltd. All rights reserved.
C.M. Araujo, D. de Sousa Dantas, D.R. Sales de Santana et al.
integrated way, controlled by the sympathetic nervous system
(SNS), and there is not an anatomical or physiological difference
between the left and right side. Because of these reasons, infrared
thermography has been applied to investigate changes in body
surface temperature, which are linked to vascular changes and pain
(Fern
andez-Cuevas et al., 2015; Papaleo et al., 2016).
With the medical thermographic system, it is possible to
perform a visual mapping of body temperature from the capture of
infrared radiation emitted by the body at real-time (Hildebrandt
et al., 2010; Pascoe et al., 2008). As it is a non-invasive and highly
sensitive method, it allows the evaluation of thermoregulation
mechanisms, tissue metabolism, and inflammatory response, in a
qualitative and quantitative way (Calkosinski et al., 2015).
According to some authors, Infrared Thermography is a prom-
ising method and has been applied in the clinical evaluation of
musculoskeletal disorders (Co ^ rte and Hernandez 2016), vascular
(Ilo et al., 2019) and also to evaluate the therapeutic effect of many
treatments (Ring and Ammer 2012; Polidori et al., 2018; Fidut-
wronska et al., 2019). However, there are only limited numbers of
studies, generally with low methodological quality, that have used
thermography as an assessment tool (Alfieri et al., 2017).
Besides being a safe method, painless, non-invasive, low cost
and non-radiant (Jiang et al., 2005; Lima et al., 2015), the ther-
mography can be of great use in the clinical evaluation of pregnant
women with LBP (Alfieri et al., 2019); as well as guiding the
application of therapeutic techniques. Thus, the aim of this study
was to assess the thermographic parameters of pregnant women
with and without LBP and compare them between groups.
2. Methods
2.1. Design and participants
A cross-sectional study was conducted from July to December
2019, at a university hospital in the city of Recife, Pernambuco,
Brazil. Pregnant women who were waiting for the routine prenatal
consultation, at the obstetrics clinic, were invited to take part in this
study. They were informed about the objective, the risks and ben-
efits; as well as all procedures of the study. In each case of accep-
tance, the eligibility criteria were checked, and then the informed
consent form was signed to start the data collection. This study was
approved by the EBSERH Ethics Committee for Research with Hu-
man Subjects (CAAE: 05569119.1.0000.8807) and conducted ac-
cording to the declaration of Helsinki.
Inclusion criteria were: pregnant women aged between 18 and
45 years, at the 2nd and 3rd gestational trimester, with or without
complaints of LBP. Exclusion criteria were: skin lesions in the lower
back, cancer, previous surgical interventions in the lower back,
neurological disorders, psychiatric disorders, rheumatic diseases,
severe postural changes, cognitive, visual or hearing impairment,
being on pharmacological or physical therapy treatment for LBP,
having used painkillers and cosmetic preparations, medications
with vascular effect, or transdermal in the last 24 h, having prac-
ticed physical activity in the 12 h before the measurement.
The sample calculation used the temperature of 32 ± 1.5
C for
patients with low back pain and 29.7 ± 1.8
C for the control group
(Alfiere et al., 2019), and it was performed using the G * Power
software (Universitat Kiel, Germany), with a standard error of 0.05,
power of 0.95. The sample size required was at least 15 subjects per
group.
2.2. Procedures
The evaluation started by taking the clinical history of the
pregnant women, where they had to answer the following
479
Journal of Bodywork & Movement Therapies 28 (2021) 478e482
question: “Do you experience low back pain in this pregnancy?“,
then depending on the answer, they were divided into two groups:
Low Back Pain (LBP) and Without Low Back Pain (WLBP) group,
based on complaints of low back pain. The volunteers from both
groups answered a sociodemographic questionnaire (age, address,
marital status, parity, education, occupation, and anthropometric
data) to characterize the sample. The volunteers in the LBP group
also answered questions to characterize the pain (type, what trig-
gers the pain, location and the intensity that was measured by the
Visual Analogue Scale -VAS), followed by the Oswestry Disability
Index (ODI) to verify the impact of pain on their functionality
(Vigatto et al., 2007).
The physical examination was initiated by the mobility and low
back pain provocation tests. During the pain provocation test the
volunteers were standing and they were asked to perform the
flexion, extension, side to side and rotation movements of the
trunk. In addition, they were asked to tell if they felt any pain or
discomfort during these movements (Gomes et al. 2013). The
straight leg elevation test (Mens et al., 2001), posterior pelvic pain
€
provocation (Ostgaard et al., 1994), FABER (Albert et al., 2000), and
GAESLEN (Laslett et al., 2005) were made to differentiate the low
back pain from the pelvic pain.
The infrared thermography was performed, according to the
guidelines of the American Academy of Thermology (2015), in a
windowless, air-conditioned room, with a temperature maintained
at 23
C. The volunteers stayed in the room for 15 min, with the
lower back exposed, for acclimatisation. Two thermograms were
captured, with the sensor in a horizontal position, 60 cm away from
the volunteer and about 1.1 m high (the height was dependent on
the patient's height, taking the lumbar region as a reference). The
volunteers, in standing position, stayed with the dorsal region
facing the machine. All acquisitions were made with the multi-
spectral thermographic camera (FLIR C2 Education k, TermoCam)
with spatial thermal definition of 80  60, and visual 640  480,
thermal resolution of 0.1
C.
The thermograms were analysed using the FLIR
TOOLS þ program, and the Rainbow colorimetric scale, with a
temperature range of 23
Ce35
C and an emissivity standard of
0.98. The best image contrast was chosen, and a rectangular area
was selected to be analysed by the software, that made the calcu-
lation of the maximum, average and minimum temperatures, in
Celsius degrees (
C). This rectangular area was selected using the
Fig. 1. Thermographic analysis at lumbar region of a pregnant woman with low back
pain complaining using the FLIR TOOLS þ program.
C.M. Araujo, D. de Sousa Dantas, D.R. Sales de Santana et al. Journal of Bodywork & Movement Therapies 28 (2021) 478e482

sacroiliac joints (L5-S1) and the waistline (T12-L1) as reference Table 1

points (Tailor and Preston-Hsu 2019); thus, being the most medial Sociodemographic data and clinical characteristics of the volunteers.

region of the lumbar spine (Fig. 1). Variables LBP (n ¼ 15) WLBP (n ¼ 15) p-Value
(X ± SD)/n (%) (X ± SD)/n (%)
2.3. Data analysis Age 26 ± 5 31 ± 7 0.045
Marital status
Single 3 (20) e 0.068
Data analysis was performed using the SPSS (version 20, SPSS
Married 12 (80) 15 (100)
Inc., Chicago, IL, USA). The normality distribution of data was Level of Education
assessed by the Kolmogorov-Smirnov test and the difference be- Elementary 2 (13) 2 (13) 0.122
tween groups by the Student's T-test. For the analysis of categorical High School 6 (40) 3 (20)
variables, the chi-square test was used. The descriptive analysis was Post-secondary non-degree 4 (27) 1 (7)
University 3 (20) 9 (60)
used to present data.
Occupation
The thermogram sets were also analysed using a platform for Housewife 5 (33) 3(20) 0.078
medical image analysis (Thermofy®, Brazil), which used artificial Administrative services/Students 3 (20) 9 (60)
intelligence to classify the LBP and WLBP group thermograms Seller/Caregiver 7 (47) 3 (20)
Gestational age (weeks) 27 ± 8 26 ± 7 0.649
automatically. The image belonged to a group when it was 70 %
Parity
compatible with the images of that standard. Then the Spearman Nullíparous 5 (33) 7 (47) 0.456
test was performed to verify the correlation between the images of Multíparous 10 (67) 8 (53)
the LBP group and the pain intensity, as well as the functionality. BMI 27.6 ± 5.7 25.4 ± 4.4 0.382
Normal 5 (33) 6 (40) 0.913
Overweight 4 (27) 4 (27)
3. Results Obesity 6 (40) 5 (33)

Thirty pregnant women were included in this research (Fig. 2).
They were divided into two groups, LBP and WLBP, with 15 vol-
unteers each. The groups were homogeneous in terms of age,
gestational age, body mass index (BMI), parity, education, occupa-
tion and marital status (Table 1).
Among the LBP Group, 86 % were suffering from moderate pain
intensity. The pain was felt like burning and tightness in 54 % and
33 %, respectively. It was usually triggered by maintained postures
in 33 % and at the end of the day in 26 %. Moreover, the Oswestry
Disability Index showed that the LBP group presented minimal to
moderate disability, as shown in Table 2.
There wasn't any difference between groups when the tem-
perature was compared (Table 3); however, when the thermogram
were compared by artificial intelligence, it was possible to safely
separate images into two groups. It revealed that the set of pain-
free thermograms had 69 % of chance of belonging to the WLBP
LBP: Low Back Pain Group. WLBP: Without Low Back Pain Group. X ± SD:
Mean ± Standard Deviation. BMI: Body Mass Index.
group; and the set of pain thermograms had 73 % of chance of
belonging to the LBP group (Table 4).
It was found a significant correlation between the thermogram
artificial intelligence analysis and the pain intensity, measured by
the VAS (0.78; p < 0.05); and the functionality, measured by the ODI
(0.77; p < 0.05), as shown in Table 5.
4. Discussion
The temperature itself didn't show any difference between the
LBP and WLB group, with an average of approximately 32.7
C,
making the authors think that there wasn't any inflammatory

Fig. 2. Flowchart volunteers recruitment.

480
C.M. Araujo, D. de Sousa Dantas, D.R. Sales de Santana et al. Journal of Bodywork & Movement Therapies 28 (2021) 478e482

Table 2 Furthermore, they found a higher rate of perfusion at local tissue, in

Pain group features. patients with higher pain intensity. The present study was unable
Variables n (%) to establish the same association, maybe due to the following
Pain intensity (X ± SD) 5,9 ± 1,1
methodological differences: the pain was assessed by its intensity
Moderate 13 (86) and not by its pain threshold; and, the thermographic analysis was
Severe 2 (13) made by an area, and not by a point of interest. In addition, the
Pain feature sample group was different, perhaps low back pain related to
Burn 8 (54)
pregnancy has a different pathophysiological mechanism from
Twinge 2 (13)
Squeeze 5 (33) those with chronic low back pain.
Pain trigger When the thermogram of the LBP and WLBP group were
Mainteined posture 5 (33) compared by artificial intelligence, it was possible to safely separate
Walking 2 (13)
images into two groups, because they had distinct patterns. The
Supine position 2 (13)
Trunk flexion 2 (13)
usage of intelligent Computer-based system for analysing ther-
End of the day 4 (26) mograms has emerged as a useful tool for providing support to
Functionality healthcare professionals. The analysis process involves pre-
Minimum disability 10 (67) processing the thermogram, extraction of the region of interest or
Moderate disability 5 (33)
segmentation, extraction of features and classification (Singh et al.
X ± SD: Mean ± Standard Deviation. 2020).
Artificial intelligence has been applied in health, for imaging
diagnosis, specifically through the deep learning method. It is a
Table 3
methodology that allows the identification of patterns and classi-
Comparison of superficial temperature between groups.
fication within a category through computational algorithms
Temperature LBP (X±SD) WLBP (X±SD) CI 95 p-Value (Santos et al., 2019). This type of analysis showed promising results,
Maximum (
C) 33.9 ± 0.94 33.8 ± 0.75 0.58 - 0.6 0.866 with 80.95 % accuracy, 83 %e85 % specificity and 75 % sensitivity in
Average (
C) 32.7 ± 1.05 32.6 ± 1.01 0.57 e 0.96 0.601 a study to detect breast cancer (Gonçalves 2017).
Minimum (
C) 31.02 ± 1.50 31.13 ± 1.26 1.17 - 0.95 0.838 Thermography evaluation, together with an artificial intelli-
LBP: Low back pain group, WLBP: Without low back pain group, gence resource, seems to be a promising method to evaluate more
X ± SD:Mean ± Standard deviations, CI: Confidence Interval. objectively low back pain complaints in pregnant women. In
addition, the infrared thermography is a fast, painless method, that
does not emit any radiation, and with relatively low cost (Jiang
process; however, a different thermal distribution on the skin
et al., 2005; Lima et al., 2015).
surface was found, between groups, by the artificial intelligence
The possibility of finding more objective tools to measure sub-
analysis. Nevertheless, it wasn't possible to determine what was
jective symptoms, as pain disorders, deserves further investigation.
causing this difference, i.e.: inflammatory process, muscular spasm,
Future studies should evaluate the pain threshold of pregnant
or another thing. The authors believe, that there is a mix of phe-
women with low back pain, as well as the possible associations
nomena leading to thermal changes related to the pain.
between the surface temperature and the threshold of pain, in
Marins et al. (2014) are trying to establish the reference tem-
addition to the accuracy, specificity and sensitivity of the artificial
perature for thermographic analysis in Brazil. They found an
intelligence analysis method in this population.
average temperature of 31.3
C ± 1.4, for the lower back area, among
healthy non-pregnant women. The difference found between
Marins et al. (2014) results and ours, of about 1.5
C, can be
5. Conclusions
explained due to the increase in volume and total blood flow that
occurs in the pregnant woman, which can lead to an increase in the
This study seems to be the first one to examine the use of
temperature (Gilson et al. 1997).
thermography to assess the low back pain in pregnancy. There was
Alfieri et al. (2019) proved that thermography was useful to
no difference in the mean temperature between the groups;
assess perfusion disorders in patients, with chronic low back pain.
however, the artificial intelligence software found thermogram
They identified a moderate correlation between the superficial
differences between the groups. Furthermore, the correlation be-
temperature of the skin, and the pain intensity perception.
tween pain intensity and functionality was shown.

Table 4
Comparison of thermograms with artificial intelligence analysis.

Probability pain group (X±SD) Probability without pain group (X ±SD) Mean difference CI 95 % p-Value

LBP 0.86 ± 0.04 0.17 ± 0.13 0.73 0.66e0.80 <0.01

WLBP 0.13 ± 0.12 0.87 ± 0.03 0.69 0.61e0.77 <0.01

LBP: Low back pain group, WLBP: Without low back pain group, MD ± SD: Mean ± Standard deviation, CI: Confidence Interval. The probability was calculated by the Thermofy
® software.

Table 5
Correlation between the variables of the softwares, pain intensity, and funcionality.

Maximum Temperature Average Temperature Minimal Temperature Artificial Intelligence

ODI 0.35 0.26 0.25 0.77*

PAIN (VAS) 0.34 0.28 0.29 0.78*

ODI: Oswestry Disability Index, VAS: Visual Analogue Scale, *p < 0.05.

481
C.M. Araujo, D. de Sousa Dantas, D.R. Sales de Santana et al.
Clinical relevance
 Thermography evaluation together with artificial intelligence
resource seems to be a promising method to evaluate low back
pain complaints in pregnancy.
 These assessments may contribute to the clinical follow-up of
pregnant women with low back pain.
CRediT authorship contribution statement
Camilla Medeiros Araujo: Conceptualization, Methodology,
Investigation, Writing e original draft. Diego de Sousa Dantas:

bora
Formal analysis, Writing e review & editing, Visualization. De
Renata Sales de Santana: Investigation, Writing e original draft.
Marcos Leal Brioschi: : Artificial Intelligence analysis. . Caroline
Wanderley Souto Ferreira: Writing e review & editing, Visuali-
zation, Supervision. Juliana Netto Maia: Conceptualization, Meth-
odology, Resources, Supervision, Project administration.
Declaration of competing interest
The authors have no funding or conflicts of interest to disclose.
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Acknowledgements
The Authors wish to thank Mr. Craig Bernard Donnelly for proof
reading the manuscript regarding the English, as a native English
Speaker.
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