The medical community needs safe non-invasive means to eliminate pain and suffering. In order assess which treatment can help; we need to measure what we interpret as pain. Measurement is the scientific way we can identify any treatment that can benefit pain and therefore increase the payers’ willingness to provide insurance coverage.

Medicine is lacking tools to measure objective pain or Myofascial Trigger Points (MFTPs). For accurate assessment, researchers and practitioners need objective clinical tools. Since pain is a subjective phenomenon and has no external singular criteria, one can never be certain of the validity of any given pain measure, it presents difficult and intriguing challenges to scientists.

Pain questionnaire and scales, although useful, when used alone, rely heavily on interpretation and or patients’ description of pain and severity.

Subjectively interpreted, pain can leave patients inadequately assessed and treated. Practitioners can only know if the person is in pain by his or her statements or actions.

Content validity was used to support Thermography, Galvanometers, Algometry, and Electronic Stethoscopes.

  • In 1995 an article in Spine magazine identified that scans were interpreted as showing abnormalities (herniated disc, bulging disc, for animal stenosis) in as many as 19% of the asymptomatic subjects; the frequency of abnormalities was 28% in subjects aged 40 or older. It can be expected that its use, in patients with Whiplash Associated Disorders will be impeded by this high proportion of false positive findings. (Spine Magazine, April 1995)
  • The lack of general agreement as to appropriate diagnostic criteria for examining TrPs according to Mense, Simons, Russel “has been an increasingly serious impediment to more widespread recognition of myofascial and to comparable studies of the effectiveness of treatment.” (Muscle Pain: Understanding Its Nature, Diagnosis and Treatment Mense, Simons, & Russell 2001 )

Researchers need to find pain measurement tools to evaluate objective outcomes towards best treatment practices.

In certain cases, individuals may be unable to express the feeling of pain effectively. This includes the disabled, elderly, children and animals.

Health Care Providers are inadequately equipped to identify how much pain a patient feels, where the pain is coming from or whether the treatment applied was effective.

Subjective Measurement Tools

“Because pain is highly subjective, it is challenging to evaluate. On a zero to-10 pain scale, one person’s 10 might be another is two.” (Strassels 2009)

When pain exists in the absence of observable injury, self-report is the only assessment tool. If an inability to communicate corresponds with an unobservable injury, the lack of report hampers effective pain management.

Subjectively measuring pain is usually left up to the patient to describe on a zero to ten scale.

According to Wikipedia, a pain scale measures a patient’s pain intensity or other features. Pain scales are based on self-report, observational (behavioural), or physiological data. Self-report is considered primary and should be obtained if possible. Pain scales are available for neonates, infants, children, adolescents, adults, seniors, and persons whose communication is impaired. Pain scores are sometimes regarded as “the Fifth Vital Sign.” Partial list of pain measurement scales

Objective Measurement Tools

Physiological phenomena such as heart rate, blood pressure, skin conductance have been used to measure pain however, they were found to have only a relationship to pain and no phenomena specific to pain was found. These methods were not found to be adequate objective measures of pain. (Lange, Michael, & Ilya, 2003)

The medical field recognizes a need for a validated science-based pain assessment tool that assesses pain independent of the self-report.

Pain or inflammation can be objectively measured with algometers, galvanometers, thermography, and electronic stethoscopes or ultra sound.

Injury causes inflammation of the soft tissue, which produces heat in the same manner that a child runs a fever. Sweat is also created to evaporate heat. Sweat glands, which are part of the flight fright nervous system, are stimulated to stop the bleeding. Sweat glands contain a conductive fluid that is called Galvanic Skin Response (GSR). GSR is used to measure the sweat.

Inflamed tissues have a withdrawal reflex and painful with varying amounts of pressure measured by Algometers. Crepitus, which is a medical term to describe the grating, crackling or popping sounds and sensations experienced under the skin and joints, increases with age. Other attributes of inflammation include tenderness, heat, sweat, and crepitus at a specific site or point of pain.

By combining the various inflammation measurement devices into one multimodal probe practitioners would require less time to collect and compare multilevel inflammatory measurements of healthy tissue for differential diagnosis. It would be conceivably cheaper to purchase a multimodal probe than buying several independent devices. In addition, it would potentially provide all four corroborative inflammatory findings simultaneously. This would definitely be a better tool to objectify subjective pain and MFTPs than individual devices used independently.

These objective measures will also correlate palpation findings and gold pain measurement scales to the objective measurements. Each device examined is an FDA approved device and practitioners currently use in neurological, dental, and vascular diagnostic diagnostics. A discussion and synopsis on a multi-modal biosensor device and software system follows.

Heat

“Inflammation creates heat and can be measured using infrared or digital thermal imaging equipment. “Skin temperature as in thermography, can change subjective pain to a color image.” (Kim & Cho, 1995)

Typically these areas are hotter Thomas, Smith, Isaacs, (2011) explained a simple method for measuring joint inflammation with a differential thermistor probe thermometer was applied to acute synovitis of the knee. Temperature assessments were made immediately before and serially after intra-articular steroid therapy. The method was capable of showing a significant difference in temperature between inflamed and normal knees. Knee temperature assessments correlated well with clinical parameters and were essentially independent of room temperature. (Thomas, Smith, & Isaacs, 2011)

Thermography is used to measure heat from inflammation infrared or digital thermal imaging equipment all can be used measure excess or lack of heat. Young-Soo Kim, Yong-Eun Cho (1995) correlated skin temperature as in thermography can change subjective pain to a color image. (Kim & Cho, 1995)

Heat is a measure of inflammation used by Hippocrates and is the oldest for inflammation.

Thermograms are used to study heat distribution in structures or regions, for example in detecting tumours. (From Wikipedia, the free encyclopedia)

Thermography is a non-invasive diagnostic technique that converts infrared radiation emitted from the skin surface into electrical impulses that are visualized in colour. The spectrum of colours indicates an increase or decrease in the amount of infrared radiation being emitted from the body surface. Medical Thermography can graphically display and record the subject feeling of pain by objectively displaying the changes in skin surface temperature that are produced by pain states. Medical Thermography’s major clinical value is in its high sensitivity to pathology in the vascular, muscular, neural, and skeletal systems. This aids and contributes to diagnosis by a clinician. Thermography is the only method available for accurately visualizing pain and pathology. Thermography can assess pain at any level, anywhere in the body. It is a very useful adjunctive tool for other diagnostic methods, as well as for case management.

Kimio Otsuka and Tatsuo Togawa found Hippocrates (the father of modern medicine) appears to have been the first to obtain thermograms. Hippocrates’ method involves covering the patient’s thorax with an earth-soaked cloth. As the warmer areas dry faster, the pattern of enlargement of the dry area shows the temperature distribution. (Otsuka & Togawa 1997)

Fischer named two basic diagnostic features of Myofascial Trigger Points (MFTPs), namely, local tenderness and alteration of tissue consistency (such as in taut bands, muscle spasm), can be documented quantitatively by simple hand-held instruments. A pressure threshold meter (algometer) assists in location of TPs and their relative sensitivity. Thermography (heat imaging) demonstrates discoid shaped hot spots over TPs. Muscle activity, spasm, or contraction is visualized as increased heat emission in the shape of the active muscle. (Documentation of myofascial trigger points Fischer 1988)

Canavan, Gratt examined electronic thermography units as having the promise of being a nonionizing, noninvasive, low-cost diagnostic alternative for the evaluation of temporomandibular joint disorders. This study design measured the use of electronic thermography as a tool to select between asymptomatic (control) subjects and a patient group with mild to moderate temporomandibular joint disorders. Electronic thermography shows promise as a method of diagnosing mild to moderate joint disorders. (Electronic thermography for the assessment of mild and moderate temporomandibular joint dysfunction. Canavan D1, Gratt BM.)

McDonald AG, Land DV, Sturrock RD  concluded “microwave thermography can measure inflammatory activity in the knee joints of patients with inflammatory arthritis and can respond to clinical change brought about by major treatment intervention. (Microwave thermography as a noninvasive assessment of disease activity in inflammatory arthritis. McDonald AG, Land DV, Sturrock RD, 1994)

Walko, Janouschek  stated: To provide information on how cervicothoracic pain responds to osteopathic manipulative treatment, five subjects with acute or chronic pain received appropriate medication and three osteopathic manipulative treatments by the principal investigator using thrust and nonthrust techniques. The use of thermograhic analysis in clinical osteopathic research seems warranted. (Effects of osteopathic manipulative treatment in patients with cervicothoracic pain: pilot study using thermography. Walko EJ1, Janouschek C.)

Barnes RB. stated that under standard and normalized environmental conditions, the thermal contrasts or patterns that exist on the exposed human skin are determined largely by the heat conducted to the skin locally from underlying organs, or variations in blood flow. These localized temperatures give rise to corresponding variations in the rates at which ir (infrared) energy is radiated. Instruments are available that are capable of translating these differences in rates to photographic images or thermograms. In the absence of disease or pathology, there exists a normal thermal signature for each human. The presence of pathology grossly alters the thermogram and gives rise to a valuable diagnostic procedure-to a unique method of nondestructive testing or remote sensing. (Diagnostic thermography. Barnes RB.)

Mustafin AM. stated that there is a correlation between temperature difference of symmetric acupuncture points of helix and psychophysiological asymmetry of motor and optical brain centers. The regulation of blood circulation has been suggested to be involved in this phenomenon. (Relationship between acupuncture points and psychological functions A. M. Mustafin 1993)

Li H, Shen X, Ying J, Zhao L, Jin M, Thu S, Sun C, Voorhorst F, Soiland H, Lende T, Bank JP (2009) identified Digital infrared thermal imaging (DITI) results for breast cancer detection was shown to be valuable. Infrared temperature imaging of specific skin points is a rapid, non-invasive method to identify patients requiring mammography to confirm hyperplasia of mammary glands (HMG). (Li et al 2009)

Eight digital infrared thermal imaging (DITI) has resurfaced in this era of modernized computer technology. Its role in the detection of breast cancer is evaluated. DITI identified 58 of 60 malignancies, with 97% sensitivity, 44% specificity, and 82% negative predictive value depending on the mode used. Compared to an overall risk score of 0, a score of 3 or greater was significantly more likely to be associated with malignancy (30% vs. 90%, P < .03). DITI is a valuable adjunct to mammography and ultrasound, especially in women with dense breast parenchyma. (Arora, Martins, Ruggiero, Tousimis, Swistel, Osborne, Simmons 2008)

Mense, Simons, Russel affirmed that the thermographic hot spot of a TrP is described as a discoid region 5 to 10 cm in diameter, displaced slightly from directly over the TrP. Five studies reported a region of hyperthermia over the TrP (a total of 170 TrPs) none reported a finding of hypothermia. (Muscle Pain: Understanding Its Nature, Diagnosis, and Treatment By Siegfried Mense, David G. Simons, I. Jon Russell)

Sweat

Sweat is produced by sympathetic skin response (SSR). The body uses sweat to dissipate heat and can be measured using electro-diagnostic devices including galvanometers and electro-dermal response(ED). “A sensory probe used to acquire skin physiological parameters, such as galvanic skin resistance (GSR) as it has been proved that pain is associated with GSR.” (Zapata-Ferrer, 1992)

When tissue are hot the body uses sweat to dissipate heat creating a sticky end feel due to sweat.

Estañol, Corona, Elías, Téllez-Zenteno , Infante, noted skin blood vessels and sweat glands are both innervated by sympathetic C fibers. The simultaneous recording of skin blood flow and the SSRs provides a more complete assessment of the sympathetic outflow to the skin than either one alone. (Estañol, Corona, Elías, Téllez-Zenteno, & Infante, 2004)

Skin sympathetic nerve activity (SSNA) is microneurographically recorded from the skin nerve fascicle in the peripheral nerves. It is elicited by mental stress and arousal stimuli, e.g., sound, pain, electric stimulation. It comprises vasoconstrictor (VC) and sudomotor(SM) activity, as well as vasodilator (VD) activity. VC and SM discharge independently, whereas VD is the same activity with different neurotransmission. The VC and SM are differentiated by effector response, e.g., laser Doppler flowmetry and skin potential changes. SSNA function in thermoregulation in the human body; however it is also elicited by mental stress. SSNA is the lowest at thermoneutral ambient temperature (approximately 27 degrees C). The clinical application of SSNA comprises the following: 1) clarification of sweating phenomenon, clarification of thermoregulatory function and diagnosis of thermoregulatory disorder, clarification of pathophysiology and diagnosis of vascular diseases, e.g., Raynaud and Buerger diseases. (Iwase 2009)

Galvanometer electro-dermal (ED) and or Sympathetic Skin Responses (SSR) test for increases or decreases in conductivity from sweat. Created by the sympathetic nervous system, the body dissipates heat by sweating. Galvanometers Zapata-Ferrer, A.R. (1992) found that a biosensor probe could be used to acquire skin physiological parameters, such as Galvanic Skin Resistance (GSR)” and stated, “it has been proven that pain is associated with GSR. (Zapata-Ferrer, 1992)

Skin conductance, also known as galvanic skin response (GSR), electrodermal response (EDR), psychogalvanic reflex (PGR), skin conductance response (SCR) or skin conductance level (SCL), is a method of measuring the electrical conductance of the skin, which varies with its moisture level. This is of interest because the sweat glands are controlled by the sympathetic nervous system, so skin conductance is used as an indication of psychological or physiological arousal. There has been a long history of electrodermal activity research, most of it dealing with spontaneous fluctuations or reactions to stimuli. (From Wikipedia, the free encyclopedia)

Cho SH, Chun SI noted the inhibitory component of the skin against given electrical current, also called as the electrical skin resistance, is subject to change in response to many factors, especially pain; basal skin resistance (BSR), represent active points which have a more consistent BSR characters than other points and most of them share same locations with “acupuncture points” which is easy to localize accurately and repeatedly in normal subject. (Cho SH, Chun SI 1994)

Shultz SP, Driban JB, Swanik CB. noted skin resistance changes between MTP and the surrounding tissue supporting the inclusion of this technique to help identify MTPs. The similarity between MTP states warrants investigation into the physiologic differences at specific anatomic locations. (Shultz SP, Driban JB, Swanik CB 2007)

Hyvarinen J, and Karlsson M studied electrical resistance of skin with the aid of a specially designed meter that compared the resistance per surface area of small skin points with that of the surrounding skin. In a systematic study of the hands, face and ears in five subjects’ low-resistance skin points were repeatedly found in characteristic acupuncture loci, comparable in different individuals and symmetric about the body midline. The low-resistance skin points had diameters of 1.5 +/- 0.5 mm and their borders were abrupt. On the dry skin, resistance values were around 10 kilo-ohms at the center of the points but around 3 mega-ohms in the surrounding skin. Voltages could also be recorded at these points, but they proved to be result of electrode polarization reflected at these points because of their low electrical resistance. The distribution of the low points in the hands, face, and ears resembled that of classical acupuncture points. (Hyvarinen J, Karlsson M 1977)

Vickland V, Rogers C, Craig A, Tran Y change in amplitude of skin potential is one of the physiological indicators of electrodermal activity (EDA) and has been associated with the onset of a variety of sensory, cognitive and emotional stimuli. This study investigated the EDA physiological response to manual acupuncture. Results showed that the insertion, stimulation, and withdrawal of the acupuncture needles were associated with significant changes in EDA. The insertion of the needle was associated with the highest change in skin potential while the three consecutive manipulations of the needles showed a decline in EDA amplitude, thought to be consistent with physiological habituation. Anxiety level and previous familiarity with acupuncture did not influence outcomes. EDA response may be associated with the precise location of the acupuncture point. If further studies confirm such findings, then EDA may become a valuable physiological marker for the acupuncture phenomenon. (Vickland, Rogers, Craig, & Tran, 2008)

Gerosa, Zimlichman, Ventura, Fanelli, Riboldi, Meroni, Lupus (2006) noted the Electrical impedance of specific dermal zones might reflect the occurrence of pathological states in the corresponding internal organs, a systemic diagnostic screening tool. Such techniques are based on the rationale that measurement of a neuroreflexology-based diagnostic test in diagnosing immune-mediated diseases in a blinded single centre study. Future studies will define this tool place in routine evaluation and potential screening ability. (Gerosa et al 2006)

Colbert AP, Larsen A, Chamberlin S, Decker C, Schiffke HC, Gregory WL, Thong T. J  used electro dermal screening (EDS) based on three commonly held assumptions: acupuncture points (APs) have lower electrical resistance than non-APs; resistance at APs varies with health and disease; and effective acupuncture treatments are associated with normalization of resistance at APs explains. Although evidence confirming these assumptions is limited, EDS is frequently practiced worldwide. Researchers are also beginning to assess EDS’ utility as an outcome measure in acupuncture trials. Fundamental in developing EDS as a research tool is the need for an accurate and reliable measurement. We developed an automated multichannel prototype system, the Octopus, and recorded electrical resistance and capacitance at eight skin sites in 33 healthy participants over two hours. Resistance at APs was significantly lower than the nearby non-APs in one out of three comparisons. (Colbert AP, Larsen A, Chamberlin S, Decker C, Schiffke HC, Gregory WL, Thong T. J Acupunct Meridian Stud. 2009)

Ben H, Li L, Gao XY, He W, Rong PJ. observed the effects of acupuncture at acupoints and non-acupoints on the subcutaneous nitric oxide (NO) content and skin electric conduction quantity. Acupuncture stimulation can upregulate dermal NO content and the skin electric current of acupoint region was significantly higher than that of non-acupoint in healthy subjects, suggesting an increase of potential activity after acupuncture. (Ben H, Li L, Gao XY, He W, Rong PJ. 2009)

GSR is still considered the golden standard in peripheral neurophysiological and psychophysiological studies. The experimental results show that monitoring of the facial channels yields similar detecting power to GSRs. However, detailed quantification of the responses, although feasible in GSR through appropriate modeling, is quite difficult in the facial channels for the moment. Further improvements in facial tissue tracking and segmentation are bound to overcome this limitation. (Shastri, Merla, Tsiamyrtzis, & Pavlidis, 2009)

Szopinski J, Pantanowitz D, Jaros GG.  studied organ electrodermal diagnostics (OED) and clinical diagnoses, as a criterion standard a double-blind comparative study of the diagnostic results obtained by means of So-called organ projection areas do exist on the skin surface. The electrical impedance of the projection areas corresponding to diseased organs is increased, relative to that of healthy organ-related skin zones. The difference in impedance is proportional to the intensity of the pathological process. OED, which utilises these electrical phenomena of the skin, may detect diseased organs and estimate the extent of pathological process activity within these organs. To estimate the diagnostic accuracy as well as the scope of utilisation of a new bio-electronic method of organ diagnostics. (Szopinski, Pantanowitz, & Jaros, 1998)

Malich, Fritsch, Mauch, Boehm, Freesmeyer, Fleck, Anderson, Kaiser, showed the differentiation between inflammatory and malignant lymph nodes by ultrasound is difficult. Electrical impedance scanning (EIS) is a new diagnostic tool, EIS results were compared with histopathological and follow-up findings. 30/34 malignant lymph nodes were correctly detected using EIS. Electrical impedance scanning shows promising potential for further evaluation of equivocal suspicious mammographic and/or ultrasound findings, especially as an adjunctive diagnostic method. (Malich, Fritsch, Mauch, Boehm, Freesmeyer, Fleck, Anderson, Kaiser 2001)

Gomes, Nora, Becker, Ehlers, Schwartz, Giugliani, Ashton-Prolla, Jardim, did nerve conduction studies (NCS) and electromyography (EMG) and to verify whether the sympathetic skin response (SSR) is impaired in these patients. All patients had normal sensory and motor NCS and EMG. SSR, on the other hand, was significantly altered in all patients and this test could, therefore, be useful in the diagnostic evaluation of FD patients. We prospectively performed neurophysiologic studies in nine Fabry’s Disease (FD) patients (8 male and 1 female) in order to describe the results of nerve conduction studies. (Gomes, Nora, Becker, Ehlers, Schwartz, Giugliani, Ashton-Prolla, Jardim, 2003)

Sympathetic skin response (SSR) represents a potential generated in skin sweat glands stated they explained that our “it originates by activation of the reflex arch with different kinds of stimuli. The potential of rapid habituation after repeated stimuli is formed by biphasic or triphasic slow wave activity with relatively stable latency and variable amplitude. In healthy subjects younger than 60 years of age, the response is always present in all extremities. SSR is most frequently used in diagnosing the functional impairment of non-myelinated postganglionic sudomotor sympathetic fibres in peripheral neuropathies. In this study a more complex and informative view on the anatomical and physiological substrates of SSR, its character, normal values, and technique are presented, focusing on problems in evaluation of the response and factors that have influence on it. Based on personal experience normative latency and amplitude values of SSR in a group of 20 healthy individuals (x +/- SD), upper extremities: 1.48 +/- 0.80 sec., 444 +/- 167 microV, respectively; lower extremities: 2.06 +/- 0.93 sec., 203 +/- 87.4 microV, respectively) and recommendations for qualitative evaluation preference–the presence or absence of the response–over quantitative evaluation of latency and amplitude of the response in practical clinical use of the method are presented. (Kucera, Goldenberg, & Kurca, 2004)

Vetrugno, Liguori, Cortelli, Montagna, reviewed Sympathetic skin response (SSR) is defined as the momentary change of the electrical citing that potentials of the skin spontaneous or reflexively evoked by a variety of internal or by externally applied arousal stimuli. SSR has been proposed as a non-invasive approach to investigate the function of the sympathetic system. SSR is easy to apply but current procedures are not sufficiently reliable for diagnostic purposes, and show imperfect correlations both with clinical features and other measurements of autonomic, in particular, sudomotor dysfunction. (Vetrugno, Liguori, Cortelli, & Montagna, 2003)

Mimori, Tanaka, noted that Sympathetic skin response (SSR) is well correlated with other autonomic function tests and its abnormality is documented in a variety of neurologic disorders such as diabetic neuropathy cerebrovascular disease and Parkinson’s disease. In good methodological conditions, SSR is a simple, reliable indicator of sympathetic sudomotor outflow in central and peripheral nervous system disorders. (Mimori & Tanaka, 1992)

Comunetti A, Laage S, Schiessl N, Kistler A noted that some physicians use the electrical conductance of the skin, particularly at the acupuncture points, for diagnostic purposes. This paper deals with the quantification of the skin conductance at some acupuncture points under well-defined conditions using the electrode materials gold, graphite, silver, and brass. The observed current response appeared to be best described by two exponentials. (Comunetti A, Laage S, Schiessl N, Kistler A 1995)

Peter T. Dorsher published data suggest substantial anatomic, clinical, and physiologic (referred pain to meridian) overlap of Myofascial Trigger Points (MFTPs) and acupuncture points. The acupuncture tradition provides pain practitioners with millennia of accumulated clinical experience treating pain (and visceral) disorders and offers the potential for novel pain treatment approaches and understanding of pain neurophysiology. (Peter T. Dorsher 2009)

Since many acupuncture practitioners use a skin-resistance point finder to locate the appropriate place to insert the needle for inactivating a TrP (or for treating a pain-type acupuncture point), it would be of considerable interest to explore the region of a hot spot for a point of low resistance to see how consistently this is found in a blinded study and to what extent a point of low resistance is located within the hot spot and how consistently the low-resistance point has a TrP (active or latent) nearby, beneath it.  (Muscle Pain: Understanding Its Nature, Diagnosis, and Treatment By Siegfried Mense, David G. Simons, I. Jon Russell)

Sound

Crepitus is a medical term to describe the grating, crackling or popping sounds and sensations experienced under the skin and joints. (From Wikipedia, the free encyclopedia)

The term “crepitus” is taken directly from the Latin “crepitus” meaning “a crackling sound or rattle. As old the saying goes, we get old and decrepit or he is a old a decrepit man old, meaning in a bad condition or poor health, weakened, worn out, impaired, or broken down by old age, illness, or hard use. [Middle English, from Old French, from Latin dcrepitus, worn out, feeble : d-, de- + crepitus, past participle of crepre, to burst, crack.] (http://www.learnersdictionary.com/search/decrepit)

“Crepitus and inflammatory components are audible and palpable. Soft tissue sounds are created during movement and during palpation and when mobilized, “analysis of the emitted sound can provide feedback towards the success of a treatment.” (Conway, et al 1993)

Patients with Temporomandibular joint disorder (TMJD, TMJ, or TMD) say they can hear the crepitus sounds. Crepitus can be released through mechanical force and felt during palpation. When the fascia is stretched or mobilized, it can release the gas blockages forcing by or compressing waste out mechanically. Patients who visit chiropractors can hear these sounds during mobilization techniques. Therapist can feel crepitus using trained palpation skills.

Prinz JF, Ng KW (1996) recorded sounds from the temporomandibular joint on audiotape from 238 individuals by placing microphones in both ears. The recordings were later digitized at a sample rate of 1.7 kHz with 10-bit resolution and stored on computer disk. At least two open-close cycles were assessed from each individual; 2707 different individual sounds were analysed in the time and frequency domains. The sounds were classified as: (a) single, short duration (clicks), (b) multiple, short-duration (creaks) and (c) long duration (crepitus). The sounds were further subclassified into either high or low amplitude by (i) the attack, which produced hard and soft categories and (ii) comparing the amplitude between sides-bilateral sounds were those with amplitudes differing by < 40 mV; the rest were unilateral. To establish the robustness of the classification 42 acoustic events were selected to be classified visually by three observers on two separate occasions. Intraobserver agreement was 82% (kappa = 0.75) while interobserver agreement was 60% (kappa = 0.71). Statistically significant differences were noted between all classifications of sound. These were most marked in the time domain. A simple, automated classification scheme was devised that was capable of categorizing the sounds with 82% agreement (kappa = 0.71) compared to a human observer. (Prinz & Ng 1996)

Prinz JF. (1998) the aim of this paper to provide a framework with which to separate sounds resulting from the different underlying causes. Several different mechanisms are potentially capable of generating sounds in the temporomandibular joint (TMJ). These include impact, sliding and stick-slip friction, fluid dynamic effects and the release of elastic strain energy. It is Each mechanism is described and its relevance to TMJ sounds and clinical significance discussed. Since it is not possible to observe these mechanisms in vivo the arguments are based mainly on analogies which are used to make predictions of the characteristic acoustic signatures of the sounds produced by these different mechanisms. In particular, the changes in the characteristics of the sounds as parameters such as mandibular speed and loading are stressed. It is suggested that single short duration sounds (clicks) are due to impact, multiple short duration sounds (creaks) to stick-slip friction and defects of form and long duration sounds (crepitus) to simple sliding friction. Several other mechanisms which have no obvious clinical significance but which are capable of producing similar sounds are also described and methods of distinguishing them from the sounds that do have clinical implications are discussed. (Prinz & Ng 1996)

Chung SC, Kim JH, Kim HS, (1993) In an attempt to update the idea of recording knee sounds, 400 Osteoarthritis (OA) knees,100 knees from a young age group (18-31 years) and 100 knees from an age-matching group(46-60 years) were recorded by a computerized device using a special program that enabled the conversion of sounds–recorded in a fixed lapse of time–to waves which were then analyzed. From the work it can be deduced that computerized phonoarthrography can diagnose early cases of OA and is excellent for assessing and following up cases. (Chung, Kim, & Kim, 1993)

Walko EJ1, and Janouschek C. provides information on how cervicothoracic pain responds to osteopathic manipulative treatment, five subjects with acute or chronic pain received appropriate medication and three osteopathic manipulative treatments by the principal investigator using thrust and nonthrust techniques. The mean number of findings by both investigators on structural examination decreased considerably immediately after each of the three treatments. The number of findings increased in week 2 and decreased in week 3. The principal investigator observed a further decrease by the final session, but the coinvestigator reported an increase. The pain scale score improved an average of nearly 30%. Thermography showed cooling of the cervicothoracic region in all subjects and conversion to a normal pattern in four. Osteopathic manipulative treatment should be considered for patients with acute or chronic cervicothoracic pain. The use of thermographic analysis in clinical osteopathic research seems warranted. (Effects of osteopathic manipulative treatment in patients with cervicothoracic pain: pilot study using thermography. Walko EJ1, Janouschek C.,1994)

The results of a temporomandibular joint survey sent to 167 members of the Greater New York Academy of Prosthodontics indicated a great variation in the diagnosis and treatment of patients with temporomandibular joint dysfunction. Although most indicated that their background in temporomandibular joint disorders was from clinical experience and/or textbooks and the dental literature, only 59% treated patients for these disorders. The most common diagnostic procedures were occlusal evaluation; joint evaluation for tenderness, crepitus, and click; evaluation of range of motion of the mandible; and a muscular evaluation. (Arbree NS, Campbell SD, Renner RP, Goldstein GR, 1995)

Scapulothoracic crepitus and scapulothoracic bursitis are related painful disorders of the scapulothoracic articulation. Scapulothoracic crepitus is the production of a grinding or snapping noise with scapulothoracic motion, which may be accompanied by pain. Scapulothoracic bursitis manifests as pain and swelling of the bursae of the scapulothoracic articulation. (Kuhn JE, Plancher KD, Hawkins RJ 1998)

Brodeur R. (1995) the audible release associated with joint manipulation. Objective: The objective of this paper is to review the literature on the audible release associated with manipulation. During the “crack” associated with a joint manipulation, there is a sudden joint distraction that occurs in less time than that required to complete the stretch reflexes of periarticular muscles. This suggests that the cavitation process provides a simple means for initiating the reflex actions and that without the cavitation process, it would be difficult to generate the forces in the appropriate tissue without causing muscular damage. (Brodeur R. 1995)

Protapapas Marina, Cymet TC. (2002) noted that “articular release is a physiologic event that may or may not be audible. A hypothesis about the noise that frequently accompanies this release is offered and includes anatomic, physiologic, and functional models of articular release. (Protapapas Marina, Cymet TC. 2002)

Okazaki M, (1988) the aim of this report was to establish a method for objective examination of TMJ sounds which is required for preventive care of the TMJ dysfunction, and to confirm its clinical importance by means of analysis of mandibular border movement and EMG. The subjects for the acoustical analysis of TMJ sounds consisted of 13 temporomandibular joints as the clicking group, 4 as the crepitus group, and 11 as the control group. The subjects for the analysis of the mandibular movement and EMG consisted of 8 adults with clicking as the clicking group and 11 without TMJ sounds as the control. The results obtained were as follows: 1. Clear and stable TMJ sounds waves could be recorded from the external auditory meatuses. 2. Clicking sounds waves showed a sharper rising and shorter duration than crepitus sounds waves. Comparing the three groups on the basis of the data of power spectrum analysis of frequencies using FFT, the spectrum of frequencies of the crepitus group was the highest and broadest, and that of control group was the lowest. 3. The deviation of the trace of mandibular border movement in the clicking group tended to be larger than in the control group. 4. In the clicking group, the frequency of occurrence of the silent period of EMG bursts during tooth tapping was lower and the duration of the silent period was shorter than in the control group. Duration, interval and cycle of EMG bursts during gum chewing in the clicking group was longer than in the control group. 5. From the above, it was suggested that the ones with TMJ sounds had the TMJ dysfunction latently, therefore it was considered valuable to use an analysis of TMJ sounds in the examination for the preventive care of the TMJ dysfunction. (Okazaki M, 1988)

Stethoscopes are used to measure Crepitus (tissue sounds). Crepitus is an inflammatory component involved in tissue damage. As we age, we get old and decrepit, creaking and cracking sounds are heard during movement. Nodules and taut tendon bands located in the subcutaneous fascia are highly palpable when felt during palpated in chronic areas of damaged tissue. Conway PJW, Herzog W, Zhang Y, Hasler Em, Ladly K (1993) found they could analyze emitted sound to provide feedback towards the success of a treatment. (Conway, et al.,1993)

Pain Pressure Threshold (PPT)

An algometer is an instrument for measuring a person’s sensitivity to pain produced by pressure. Algometers are recognized measurements of patients their intolerance to applied forces. Allodynia is induced pain; it requires a subjective response on the part of the patient to indicate whether or not the pressure stimulus is painful or not. Algometers calibrate the amount force or pressure being applied in order to evoke pain; levels of pain are recorded. Cited in many scientific studies evoked pain is referred to as Pain Pressure Thresholds (PPTs) or Sensory-Evoked Potentials (SEP).

Pain Pressure Threshold (PPT) is an objective means for determining the degree of pain tolerance. Pressure algometry is used to determine signs of sensitization according to van Wilgen CP, Keizer (2001) found sensitization as an explanation for the pain in chronic sports injuries is credible in a considerable proportion of patients and warrants the establishment of such neuropathic pain mechanisms is of clinical significance.(van Wilgen, Keizer, 2001)

Ylinen, Airaksinen, Kolari, found a new digital electronic operated tissue compliance meter to quantify the soft tissue hardness and resistance more objectively than the conventional hand-held mechanical tissue compliance meters. (Ylinen, Airaksinen & Kolari)

Algometers have been used as a means of determining the amount of force that can be applied to the soft tissue before a patient reach their Pain Pressure Threshold or Tolerance PPT level. Bendtsen L, Jensen R, Olesen J. (1996) study results demonstrate for the first time that nociceptive processes are qualitatively altered in patients with chronic myofascial pain and suggest that myofascial pain may be mediated by low-threshold mechanosensitive afferents projecting to sensitized dorsal horn neurons. Further investigations of these mechanisms may lead to an increased understanding and better treatment of these common and often incapacitation pain disorders. (Bendtsen, Jensen, Olesen 1996)

Algometry requires a subjective response on the part of the patient and therefore cannot, on its own, be considered completely objective. Normal, healthy tissue compliance is considered to be 10 pounds or 4 kg of pressure. The criteria for diagnosing fibromyalgia were presented in 1990 by a group of rheumatology investigators and officially endorsed by the American College of Rheumatology. The patient must have widespread pain of at least 3 months duration, and 11 of 18 tender point sites must be painful on digital palpation with approximately 4 kg of pressure. (Muscle Pain: Understanding Its Nature, Diagnosis, and Treatment By Siegfried Mense, David G. Simons, I. Jon Russell)

Delaney, McKee (1972) in this study established the intra-rater and inter-rater reliability of measurements of trigger point sensitivity using a commercially available pressure threshold meter showing that the pressure threshold meter is highly reliable in measuring trigger point sensitivity, between and within experimenters, and may be useful in the diagnosis and monitoring of treatment of myofascial pain syndrome. (Delaney, McKee 1972)

Buchanan HM, Midgley JA. (1987) Pain threshold was measured using a simple pressure algometer in 190 subjects. The measurement had a highly acceptable intra-observer error. Anxiety and fear of pain significantly reduced the threshold. (Buchanan, Midgley. 1987)

Nussbaum EL, Downes L. (1998) noted that Algometers have been used to measure muscle and other soft tissue tenderness. The PPT is a reliable measure, and repeated algometry does not change pain threshold in healthy muscle over three consecutive days. The PPT can be used to evaluate the development and decline of experimentally induced muscle tenderness. Reliability is enhanced when all measurements are taken by one examiner. (Nussbaum, Downes 1998)

Chesterton LS, Sim J, Wright CC, Foster NE. (2007) in this study provides new evidence that trained observers can apply an Algometer at a consistent rate and provide highly reliable measures of PPT in healthy humans, when PPT is calculated as the mean of three trials. (Chesterton, Sim, Wright, Foster 2007)

Louise Potter, Christopher McCarthy, Jacqueline Oldham (2006) PPT assessment by algometry is a reliable, both within-session and between-sessions, measure of a subject’s pain. This study provides further validity to the use of this measure as a suitable, convenient method of monitoring treatment effects. (Potter, McCarthy, Oldham 2006)

Futarmal, M. Kothari, E. Ayesh, L. Baad-Hansen. P. Svensson (2011) compared test-retest variability and accuracy measures between (1) manual palpation and a novel palpometer and (2) different force levels. The new palpometer had low test-retest variability and provides a more accurate pressure stimulus than manual palpation. (Futarmal, Kothari, Ayesh, Baad-Hansen, Svensson 2011)

Fenton, Palmieri, Durner, Fanning (2009) Chronic pelvic pain (CPP) is a syndrome involving 1 or more pain generating organs in the pelvis, which includes pain from the lower anterior abdominal wall. This entity has been termed myofascial pain syndrome (MFPS), but its characteristics, definition, and quantification have not been well described. In this study, pain pressure threshold (PPT) testing of the lower anterior abdominal wall in CPP patients was performed to determine the range and distribution of values at each site, and the clinical utility of using PPT in a definition of MFPS. PPT testing can be used to evaluate MFPS in CPP patients. (Fenton, Palmieri, Durner, Fanning 2009)

Japan, T Ogawa, Tanaka, T Ogimoto, N Okushi, K Koyano, K Takeuchia (2004) Several studies have been conducted using Algometers to measure the amount of pressure that can be applied before pain is experienced. This provides a more objective device especially when used in conjunction with facial expression scale or 1 to 5 or 1-10 and other modalities. It is interesting to note that studies have included areas for Mapping, profiling and clustering of pressure pain threshold (PPT). (Japan, Ogawaa, Ogimoto, Okushi, Koyano, Takeuchia 2004)

Michael M. Zimkowski Emily M. Lindley Vikas V. Patel Mark E. Rentschler (2011) One major goal is the capability of correlating pain stimuli with algometer pressure, heart rate, and blood pressure. If a predictable correlation between vital signs and pain could be established, significant gains in the understanding of pain could result. Better understanding of pain will ultimately lead to improvements in treatment and diagnosis of pain conditions, helping patients and physicians alike. (Zimkowski, Lindley, Vikas, Patel, Rentschler. 2011)

In conclusion Arendt-Nielsen, Graven in this article called Fibromyalgia from Complaints to Evidence, found many clinical studies report increased sensitivity to painful stimuli of deep tissues within and outside muscle pain areas in patients compared to controls. Peripheral sensitisation of muscle nociceptors might explain deep tissue hyperalgesia as this phenomenon decreases the mechanical excitation threshold and increases responses to noxious stimuli. Mechanical stimuli have been used extensively to assess the sensitisation of myofascial tissues in humans such as e.g. tender points, fibromyalgia, work related myalgia, myofascial pain, strain injuries, myositis, chronic fatigue syndrome, arthritis/orthroses, and other muscle/ tendon/joint inflammatory conditions. (Arendt-Nielsen, Graven date)

Antonaci F, Bovim G, Fasano ML, Bonamico L, Shen JM, (1992) Pain perception threshold (PPT) in the head was assessed with a pressure Algometer in 40 control individuals (24 females and 16 males). The mean of mean values showed that there was little asymmetry as for the thresholds pertaining to the head in the total material. Age and sex apparently played little role as for the outcome of the test. The assessment of PPT in the head might be a useful tool in the study of lateralization of pain in unilateral headache syndromes. (Antonaci, Bovim, Fasano, Bonamico, Shen, 1992)

Antonaci F, Bovim G, Fasano ML, Bonamico L, (1992) concluded manual Algometry is a rather inexpensive mechanical device has a good to excellent inter-rater reliability. When studying patients, however, the possible bias introduced by different examiners should be taken into account, both regarding study design and data analysis. (Antonaci, Bovim, Fasano, Bonamico, Shen, 1992)

Antonaci F, Sand T, Lucas GA, (1998) found a new procedure of applying force to a muscle site using a computer-mediated myometric procedure to measure a discomfort-pain threshold. This procedure appears to be a valid, reliable, and nonintrusive means of assessing the muscle discomfort-pain threshold. (Antonaci, Bovim, Fasano, Bonamico, Shen, 1992)

Pressure Algometry, as used in this study in healthy subjects, proved a reliable technique for the estimation of depth and PPT values. It may possibly serve for screening the response to experimental pain in various groups of pain patients. (Edwards, Baker, Eston, 1996)

Pressure threshold meter: its use for quantification of tender spots. The pressure threshold meter (PTM) and its use for evaluation of tender spots and trigger points are described. Pressure threshold is the minimum pressure inducing pain or discomfort. The PTM consists of a force gauge (11 kg range) to which a rubber disc with lcm2 surface is attached. This surface has been proven adequate for quantification of deep tenderness in soft tissues. Reaction to various forms of treatment such as physiotherapy and drugs can be assessed quantitatively. When trigger point injections are properly administered to affected areas, pressure threshold measurements usually increase by 4 kg/cm2. Failure to increase the reading indicates that the injection was incomplete and the procedure should be repeated. The PTM can be used for monitoring tenderness, inflammation, arthritis activity, and fibrositis. 17 athletes (Pressure tolerance over muscles and bones in normal subjects. Fischer AA. 1986)

E Tunks, J Crook, G Norman, S Kalaher established the low tenderness threshold observed at the tender points of fibromyalgia patients may reflect a more generalized lowering of tenderness thresholds, seen at non-tender points as well. (Tender points in fibromyalgia.
Tunks E1, Crook J, Norman G, Kalaher S.)

CT, MRI

Other diagnostic tests such as X-Ray, C.T., Ultrasound, and M.R.I. are all tests of anatomy or structure. They measure the structures of your body such as bone and mass. DITI is unique in its capability to show physiological change and metabolic processes. (Duprey, Debra, 2009)

Matsumoto, Fujimura, Suzuki, Nishi, Nakamura, Yabe, Shiga studied 497 asymptomatic subjects by MRI and evaluated the disc showing degeneration was the most common observation, being present in 17% of discs of men and 12% of those of women in their twenties, and 86% and 89% of discs of both men and women over 60 years of age. Their results should be taken into account when interpreting the MRI findings in patients with symptomatic disorders. (MRI of cervical intervertebral discs in asymptomatic subjects. Matsumoto M1, Fujimura Y, Suzuki N, Nishi Y, Nakamura M, Yabe Y, Shiga H.1998)

MRI scans are expensive, frequently prescribed CT expose patients to substantially higher dosage of radiation are they and are a leading cost in diagnosing low back pain.

  • Catherine Guthrie, in the first study of its kind, physicians at hospitals in Florida and Washington, D.C., evaluated the medical-imaging records of 1,243 randomly selected patients to calculate just how much radiation each patient had sustained in the past five years. Although CT scans were the biggest source of radiation, other offenders included X-rays and mammograms. The results of the study were disturbing: the average patient had received 45 millisieverts (mSv) of radiation.  (Time Magazine article How Dangerous Are CT Scans? By Catherine Guthrie June 27, 2008 Guthrie, 2008)

Tissue Compliance Meter

Algometer applies pressure to elicit pain; Compliance Meters use tissue for denting visual findings from inflammable tissues or pitting effects from edematous tissue. Substance like histamine cause tissues to turn red, a digital camera, can be mapped.

Facial expression scales are especially useful in measuring pain in children can indicate amounts of pain non-communicating subjects feel. Tomlinson D, von Baeyer CL, Stinson JN, Sung L. (2010) found that of the 4 faces pain scales were found to be “adequately supported by psychometric data found that in a total of 276 articles retrieved of which 182 were screened for psychometric evaluation, and 127 were included. (Tomlinson, von Baeyer, Stinson, Sung 2010)

Smalls LK, Randall Wickett R, Visscher MO cited that significant regional variations in biomechanical properties and dominant side effects were observed. (Smalls, Randall Wickett, Visscher 2006)

Khing Hua Njoo and Emiel Van der Does (1994) “suggested that the clinical usefulness of the presence of either jump sign or patient’s recognition of his pain complaint are used as criteria for the presence of trigger points in the M. quadratus lumborum and the M. gluteus medius.” (The occurrence and inter-rater reliability of myofascial trigger points in the ~uadratus lumborum and gluteus medius: a prospective study in non-specific low back pain patients and controls in general practice Khing’Hua Njoo * and Emiel Van der Does 1994)

Tissue compliance in 60 subjects with fibromyalgia (FS). Granges G, Littlejohn GO. (1993) found that “skinfold tenderness was present in 95% of FS and 33% of the normal controls NC but was absent in all exercising fit. These 4 clinical signs could differentiate patients from controls with a mean accuracy of 86%. Our study indicates that there are clinical signs, apart from the tender points, which are abnormal in FS that appear to be useful as objective signs in the assessment of patients with FS, whether for diagnostic, therapeutic or research purposes.” (Granges, Littlejohn 1993)

The Sydney Animated Facial Expressions, SAFE (1997) found children when asked to push the left or right arrow keys until the face matches his/her pain intensity, that the child could match “their feelings of pain in a facial expressions. (Sydney Animated Facial Expressions, SAFE 1997)

Khing Hua Njoo and Emiel Van der Does (1992) suggested that the clinical usefulness of the presence of either jump sign or patient’s recognition of his pain complaint are used as criteria for the presence of trigger points in the M. quadratus lumborum and the M. gluteus medius.” (The occurrence and inter-rater reliability of myofascial trigger points in the ~uadratus lumborum and gluteus medius: a prospective study in non-specific low back pain patients and controls in general practice Khing’Hua Njoo * and Emiel Van der Does 1994)

Palpation

Before modern diagnostic technologies arrived on the scene, early disease detection relied on physician’s palpation skills. Medical practitioners are trained in palpation (the use of one’s hands to evaluate the soft tissues for indication of disease). Studies on palpation show that it does not have a high inter- therapist reliability. It can take years of practice to develop sufficient tactile sensitivity to make someone an expert.

Palpation is used by medical experts to define the texture of a patient’s tissue such as fibrous densities, tone, crepitus, swelling, muscle spasm, twitch response, referred pain patterns. Tactile sensory examination of fascia could be supplemented using a probe that has smart biomaterials embedded in it.

Tough EA, White AR, Richards S, Campbell J, concluded that there is as yet limited consensus on case definition in respect of MFTP pain syndrome. Further research is needed to test the reliability and validity of diagnostic criteria. Until reliable diagnostic criteria have been established, there is a need for greater transparency in research papers on how a case of MFTP pain syndrome is defined, and claims for effective interventions in treating the condition should be viewed with caution. (Variability of criteria used to diagnose myofascial trigger point pain syndrome–evidence from a review of the literature. Tough EA1, White AR, Richards S, Campbell J. 2007)

Sciotti, Mittak, DiMarco, Ford, Plezbert, Santipadri, Wigglesworth, Ball, Myofascial Trigger Points (MFTPs)have been clinically described as discrete areas of muscle tenderness presenting in taut bands of skeletal muscle. Using well-defined clinical criteria, prior investigations have demonstrated interrater reliability in the diagnosis of TrPs within a given muscle. No reports exist, however, with respect to the precision with which experienced clinicians can determine the anatomic locations of TrPs within a muscle. This paper details a study wherein four trained clinicians achieved statistically significant reliability in estimating the precise locations of latent TrPs in the trapezius muscle of volunteer subjects (n=20). Finally, it should be recognized that the ability to precisely document TrP location appears critical to the success of future studies that may be designed to investigate the etiology and pathogenesis of this commonly diagnosed clinical disorder. (Clinical precision of myofascial trigger point location in the trapezius muscle.
Sciotti VM1, Mittak VL, DiMarco L, Ford LM, Plezbert J, Santipadri E, Wigglesworth J, Ball K. 2001)

Mense, Simons, Russel noted that spot tenderness of both TrPs and nodules would be the result of sensitized nociceptors. The nociceptors are most likely sensitized by substances released as a result of the local energy crisis and tissue distress, which apparently are associated with these histopathologic changes and endplate dysfunction. Bradykinin is an effective sensitizing agent that is released in hypoxic or ischemic tissue. (Muscle Pain: Understanding Its Nature, Diagnosis, and Treatment By Siegfried Mense, David G. Simons, I. Jon Russell )

Tough EA, White AR, Richards S, Campbell J, concluded that there is as yet limited consensus on case definition in respect of MFTP pain syndrome. Further research is needed to test the reliability and validity of diagnostic criteria. Until reliable diagnostic criteria have been established, there is a need for greater transparency in research papers on how a case of MFTP pain syndrome is defined, and claims for effective interventions in treating the condition should be viewed with caution. (Variability of criteria used to diagnose myofascial trigger point pain syndrome–evidence from a review of the literature. Tough EA1, White AR, Richards S, Campbell J. 2007)

Myofascial trigger points (MFTPs) have been clinically described as discrete areas of muscle tenderness presenting in taut bands of skeletal muscle. Using well-defined clinical criteria, prior investigations have demonstrated interrater reliability in the diagnosis of TrPs within a given muscle. No reports exist, however, with respect to the precision with which experienced clinicians can determine the anatomic locations of MFTPs within a muscle. This paper details a study wherein four trained clinicians achieved statistically significant reliability in estimating the precise locations of latent MFTPs in the trapezius muscle of volunteer subjects (n=20). Finally, it should be recognized that the ability to precisely document MFTPs location appears critical to the success of future studies that may be designed to investigate the etiology and pathogenesis of this commonly diagnosed clinical disorder. (Clinical precision of myofascial trigger point location in the trapezius muscle.
Sciotti VM1, Mittak VL, DiMarco L, Ford LM, Plezbert J, Santipadri E, Wigglesworth J, Ball K. 2001)

In order to palpate between healthy and damaged tissue accurately, we have to first understand human anatomy, etiology, and pathogenesis of inflammation. We should also look at the anatomy of the skin and fascia layers have special pain receptors called nociceptors.

Dubin, Patapoutian reviewed the nociceptive aspect of pain perception, focusing on nociceptors innervating the skin and subserving exteroception of noxious stimuli. (Nociceptors: the sensors of the pain pathway. Dubin AE1, Patapoutian A. 2010)

Palpation (tactile sensory examination) is used by Medical experts to assess the soft tissues and underlying fascia. Palpation can provide indicative signs of inflammations including heat, sweat, and pain with varying amounts of applied pressure, crepitus and swelling. Soft tissue fibrous densities, texture, tone, muscle spasm, twitch response, skin fold tenderness and referred pain are some of the properties felt with skilled hands. Palpation can be used concurrently with smart biomaterial for more accurate for quantifiable bio-physiological parameters are because ones hands cannot be calibrated.

The visual analogue scale is considered the ‘gold standard’ for assessment of clinical and suprathreshold experimental pain, and changes in visual analogue scale score are regarded as significant evidence of individual response to treatment, placebo, or experimental manipulation. Although its overall group accuracy and precision have been examined for both clinical and experimental pain, and found adequate (A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scales Donald D. Price, a, Francis M. Bushb, Stephen Longa, Stephen W. Harkinsc 1994)

Pain questionnaires are subjective by nature, Hovi, Lauri (1999) the intensity of pain using the visual analogue scale and the Finnish version of the McGill Pain Questionnaire, results showed that the differences between patients and nurses’ assessments were statistically significant for most intensive pain and for acceptable pain. (Pain assessment as a social transaction: beyond the “gold standard”)

Palpation criteria check list.

Pain Intensity Scale

Pain Intensity Scale

Release count less than 30 seconds to a 60-second maximum count

Pressure is applied up to the patient’s pain pressure threshold of tolerance see facial scales

Stage of condition

  • 1 – mild
  • 2 – sub-acute
  • 3 – chronic
  • 4 – chronic –acute
  • 5 – acute
Scale intensity used here is 1-5. Either patient or therapist can enter data.

Scale intensity used here is 1-5. Either patient or therapist can enter data.

Swelling

Tissues become palpably swollen during inflammatory responses. Colloid osmotic pressure causes fluids to leak into the capillaries. Plasma colloid osmotic pressure (COP) is an important determinant in the appearance of edema. As a clinical tool, COP measurement represents an unduplicated contribution to the differential diagnosis of pulmonary edema. In critically ill patients, COP measurement represents a reliable predictor of survival. (Colloid osmotic pressure: its measurement and clinical value. Morissette 1977)

Redness

Cells absorb these extracellular the cell wall distends they become more venerable to membrane rupture under varying loads and burst. Mechanical pressure as exerted in palpation would perceivably cause pain from release of nociceptive substances (inflammation). Histamines release causes tissues to turn red as blood rushes in. Just beneath the skin live inflammatory mediator to protect us from invading bacteria, remove us from harm and stop us from bleeding. Tharp reported that there are 7,000 to 10,000 mast cell per MM3 in human skin; they release their inflammatory responses soup as a response to injury. (Tharp, 2011)

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Mast cell/ the skin-Videos

Visual Denting

Visual Denting is an additional device that measures tissue compliance to find pain and MFTPs. Visual measurement from inflammation can be created from a probe used to leave a visual pitting effect or dent in edematous effect the tissue. Histamine release causes visual redness and pitting effects due to edema/swelling digitized images can be imported into referential patient file record.

As the inflammatory tissues maturate fibrin exudates causes varying degrees of thickening. Tissue undergoing inflammatory changes become more fibrous, dense and does not give when pressed down as compared to soft and subtle surrounding structures.

Coagulation is fundamental for the confinement of infection and/or the inflammatory response to a limited area. Coagulation is initiated by the activation of thrombin, which, in turn, triggers fibrin formation by the release of fibrinopeptides. Fibrin is cleaved by plasmin, resulting in clot lysis and an accompanied generation of fibrin fragments such as D and E fragments. Various coagulation factors, including fibrinogen and/or fibrin [fibrin(ogen)] and also fibrin degradation products, modulate the inflammatory response by affecting leukocyte migration and cytokine production. Fibrin fragments are mostly proinflammatory; however, Bβ15–42 in particular possesses potential anti-inflammatory effects. Inflammation is a complex response to infection or injury with the aim to confine inflammation and/or infection to a limited area, eliminate noxious stimuli and restore homeostasis. However, this process is associated with the activation of the coagulation cascade. A wide range of inflammatory conditions including sepsis (1), rheumatoid arthritis, Alzheimer disease, and multiple sclerosis are not only attributed to an uncontrolled inflammatory response, but also to the disturbance of coagulation. Thus, when coagulation is compromised, it can contribute to the pathogenesis of various inflammatory conditions via fibrin deposition and microvascular failure; as well as by enhancing the inflammatory response. The contribution of fibrinogen and/or fibrin [fibrin(ogen)] to inflammation has been recognized, while the role of fibrin degradation products is still under investigation. We hypothesize that fibrin fragments also contribute to the pathophysiology of inflammation. (Novel aspects of fibrin(ogen) fragments during inflammation. Jennewein et al 2011)

PPTs and MFTPs

As the muscles withdraw from injury (inflammatory chemicals) palpated musculature will display a twitch response. Myofascial Trigger Points (MFTPs) are hyper-irritable spots in skeletal muscle associated with palpable nodules in the taut bands of muscle fibres. When these palpable nodules are stimulated mechanically, local pain and referred pain can be induced together with visible local twitch response.

Algometers enable practitioners to calibrate the amount pressure being applied to evoke pressure pain tolerances (PPTs) or sensory-evoked potentials (SEP). Allodynia or induced pain requires a subjective response on the part of the patient to indicate whether or not the pressure stimulus is painful so it is still not an objective means of determining the severity of soft tissue injury. Facial expression scales, especially useful measuring children in pain, also give an indication towards the amount of pain to help in quantifying it.

TrPs by spot tenderness in a palpable taut band and then using acupuncture techniques. He first identified the TrP as a spot of localized tenderness in a taut band and then identifies the precise skin location through which to insert the acupuncture needle by using a dermometer (point finder or skin resistance detector). Muscle Pain: Understanding Its Nature, Diagnosis, and Treatment By Siegfried Mense, David G. Simons, I. Jon Russell)

Mense, Simons, Russel noted that spot tenderness of both MFTPs and nodules would be the result of sensitized nociceptors. The nociceptors are most likely sensitized by substances released as a result of the local energy crisis and tissue distress, which apparently are associated with these histopathologic changes and endplate dysfunction. Bradykinin is an effective sensitizing agent that is released in hypoxic or ischemic tissue. (Muscle Pain: Understanding Its Nature, Diagnosis, and Treatment By Siegfried Mense, David G. Simons, I. Jon Russell)

Loss of Function

Two basic diagnostic features of Myofascial Trigger Points (MFTPs), namely, local tenderness and alteration of tissue consistency (such as in taut bands, muscle spasm), can be documented quantitatively by simple hand-held instruments.. The effect of treatment can be quantified. Pressure tolerance, measured over normal muscles and shin bones, expresses pain sensitivity. Myopathy is suspected if muscle tolerance drops below bone tolerance. (Documentation of myofascial trigger points Fischer 1988)

The Quebec Taskforce on Whiplash-Associated Disorders has suggested the following system for classifying the severity of cervical sprains:

  • 0 – No neck pain complaints, no physical signs
  • 1 – Neck pain complaints, only stiffness or tenderness, no other physical signs
  • 2 – Neck complaints and musculoskeletal signs (decreased range of motion [ROM] and point tenderness)
  • 3 – Neck complaints and neurologic signs (weakness, sensory and reflex changes)
  • 4 – Neck complaints with fracture and/or dislocation (Spine Magazine, April 1995)

Muscles normally provide a pumping action when relaxing and contracting, the stronger the muscle and the less lankness in the skin massaging away inflammation into the non pain receptive drainage pathways. Protective muscle guarding, immobilizes the area of trauma. Adhesion formations restrict movement, if the wound is stretched to suddenly it can cause further inflammation and pain tension cycle ensues causing a pain tension cycle. The act of palpation acts like a mechanical force when applied properly massage stretches scar tissue increases the movement of inflammatory waste into the lymphatic and venous return system filtrates.

Nociception

Nociception (synonym: nocioception or nociperception) is defined as “the neural processes of encoding and processing noxious stimuli.” It is the afferent activity produced in the peripheral and central nervous system by stimuli that have the potential to damage tissue. This activity is initiated by nociceptors, (also called pain receptors), that can detect mechanical, thermal or chemical changes above a set threshold. Once stimulated, a nociceptor transmits a signal along the spinal cord, to the brain. Nociception triggers a variety of autonomic responses and may also result in the experience of pain in sentient beings. (From Wikipedia, the free encyclopedia)

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Pain perception: Various types of nerve endings are found in the skin including those for Nociception

Pain is a high threshold sensation and the nociceptors (pain receptors) are free nerve endings.

burn-classification

  • First degree burns — affect only the outer layer of the skin (epidermis), causing pain and redness.
  • Second degree burns — extend to the second layer of the skin (the dermis), causing pain, redness, and blisters that may ooze. Deep second degree burns may progress to third degree burns over the course of several days.
  • Third degree burns — involve both layers of the skin and may also damage the underlying bones, muscles, and tendons. The burn site appears pale, charred, or leathery. There is generally no pain in the area because the nerve endings are destroyed.

pain chart 2image2