Abstract
Objective
The purpose of this study was to correlate potential the stabilometric parameters of baropodometry with the superficial temperature of the legs of cancer patients during and after treatment.
Methods
This study included 30 volunteers of both sexes, divided into the following groups: chemotherapy-radiotherapy group (n = 15; age = 57.13 ± 16.74 years) and cancer group without current treatment (n = 15; age = 63.29 ± 7.34 years). They were assessed for superficial temperature of the legs using infrared thermography with anterior and posterior views. Assessment of postural balance was conducted using a baropodometer, in 2 conditions—participants’ open and closed eyes—to obtain the center of pressure (COP) of anteroposterior displacement, center of pressure of mediolateral displacement (COP-ML), and center of pressure of displacement area.
Results
When their eyes were open, the chemotherapy-radiotherapy group presented a high correlation between the displacement of the ML and the surface anterior temperature of both legs (right: r = 0.578; P = .030; left: r = 0.619; P = .018) and posterior region of the right leg (r = 0.571; P = .033), and they presented a high correlation between COP with anterior surface temperature of both legs (right: r = 0.585; P = .028; left: r = 0.540; P = .046). When patients’ eyes were closed, no correlation was found between the thermography and the stabilometric parameters evaluated.
Conclusion
During the chemotherapy-radiotherapy, cancer patients present ML and COP displacement that correlates with infrared thermography evaluation when their eyes are open.
Introduction
Posture and balance changes can affect people with cancer during treatment and up to 1 year afterward.1,2 Chemotherapy is capable of inducing changes in the postural control system, and some agents, such as taxanes, promote neurofunctional alterations such as reduction of proprioceptive acuity2,3 and inflammation of the dorsal root ganglion and peripheral nerves.4 Such changes are amenable to rehabilitation, but they require early intervention for better maintenance of quality of life.2,3,5
The muscular system plays an important role in the regulation of postural control, mainly in the maintenance of the center of mass within the support base.6,7 Another factor that can affect the balance occurs through the movement of the center of pressure (COP) of the body. Thus, control of upright posture can be accomplished through the displacement of the COP, which generates a moment of ground reaction force applied to the body to counterbalance the displacement of the center of mass, guaranteeing the stability of the system.8 Studies have shown that people with cancer who are undergoing treatment or who have already completed chemotherapeutic treatment may present with disturbances of balance.4,9 These individuals may present neuropathic lesions induced by chemotherapy,2,9 which contribute to loss of balance and increased COP oscillation associated with increased rates of muscle contraction, as evaluated by surface electromyography.2 In addition, other factors may compromise postural balance, such as muscle weakness, changes in vision,9 loss of body mass,10 and muscle fatigue.11
Studies related to muscle temperature indicate that regional changes in this parameter are related to the presence of fatigue and reduced muscle strength,12,13 in addition to joint thermal changes associated with the presence of inflammatory processes.13
Central and peripheral fatigue are common symptoms in people with cancer. In addition, signs of muscle weakness, gait impairment, impaired balance, and reduced visual acuity may be present in this population, which can increase their risk of falls, similar to healthy elderly individuals.10 With these issues in mind, the present study evaluated the possible relationship between the stabilometric parameters obtained by baropodometry with thermal profiles of the legs obtained in the anterior and posterior views of the volunteers. Thus, the aim of this study was to investigate the potential correlation between the displacement of the stabilometric variables of the baropodometer and the thermal profiles of cancer patients.
Methods
Design Study and Ethics Aspects
This correlational study was carried out in the March Laboratory of the Federal University of Alfenas from March 2014 to April 2015. This study was approved by the Ethics and Research Committee of the Federal University of Alfenas, Minas Gerais, Brazil, under number 923.589 and registered under Brazil platform number 38628314.3.0000.5142. All study participants were informed about the procedures and signed an informed consent form.
Participants
Participants of both sexes were selected for convenience and recruited from Santa Casa de Alfenas, Minas Gerais, Brazil. They were divided into 2 groups: cancer patients undergoing chemotherapy or radiotherapy (CRG) (n = 15), and cancer patients who had already completed chemotherapy or radiotherapy treatment at least 6 months prior and continued medical follow-up (CAG) (n = 15). The following inclusion criteria were adopted: age 18 to 80 years; of both sexes; in stages 0, I, II, and III of the disease; residents of the municipality of Alfenas.
Also, for the CRG, those patients who were undergoing chemotherapy or radiotherapy treatment were considered. For CAG, only patients under medical care at least 6 months after the conclusion of chemotherapy or radiotherapy treatments were considered.
This study excluded patients with cancer diagnosed at stage 4, patients presenting cognitive disorders that limited understanding of assessment systems, and patients presenting balance disorders or lower-limb amputations.
Procedures
The evaluations of volunteers were conducted in 2 phases. In phase 1, a characterization instrument was applied in the form of an interview, which contained information about identification data, anthropometric data, and history of cancer treatments. In phase 2 of the study, thermographic records of the lower limbs were collected through infrared thermography (IRT) and stabilometric parameters using the FootWork Pro baropodometer (IST Informatique, France) to observe the displacement of the body pressure center in 2 conditions visions: eyes open and eyes closed. Both examinations were conducted in the same place by a single examiner who was previously trained to handle the evaluation instruments.
Temperature Analysis of Lower Limbs
For the measurement of lower limb temperature, the FLIR T-420 thermal imager (FLIR Systems AB, Sweden) was used with a measurement rate of −20°C to 650ºC, a measurement accuracy of ± 0.2ºC, a sensitivity of 0.045ºC, a spectral infrared band of 7.5 to 13 μm, a repetition rate of 60 Hz, and a resolution of 320 × 240 pixels focal plane array. The images were obtained assuming a skin emissivity of 0.98 and analyzed by FLIR Tools Software (FLIR Systems AB).
All volunteers were previously informed about the recommendations proposed by the European Association of Thermology.14 On the day of the evaluation, the volunteers wore shorts, and the thermographic recordings were performed in a room with temperature controlled at 23ºC, relative humidity of 55%, and air velocity of less than 0.2 m/s. Each volunteer remained in dorsal decubitus with the lower limbs free of any contact with the gurney for 15 minutes15 before obtaining the thermographic records. During this period, they were instructed not to perform sudden movements, not to cross their arms and legs, not to rub and scratch their hands or any other region of the body, and not to come in contact with materials that could alter the body temperature, especially in the region being evaluated.
Each volunteer was positioned in orthostatism, with the lower limbs equidistant from the thermal imager at 2.4 m in relation to the participant. Regions of interest were collected in the anterior and posterior views of both lower limbs. Surface anatomical areas were delimited to obtain the temperature values. In the anterior view, the use of a rectangle of the largest area of interest was standardized and positioned 5 cm below the inferior border of the patella and 10 cm above the medial malleoli of the ankle,16 as show in Figure 1A. The posterior view, shown in Figure 1B, was standardized with the use of a rectangle that encompassed the largest area of interest, and the same standardization was adopted in the anterior view.
Fig 1.
Analysis model of the legs in the (A) anterior and (B) posterior views. The rectangles represent the region of interest.
Postural Control
The static balance was evaluated by positioning the volunteers in orthostatism on a platform (dimensions: 57.5 cm long × 45cm wide × 2.5 cm high) with the feet positioned at 10 cm of intermalleolar distance. The volunteers had their eyes open and their gaze directed toward a wall at a distance of 5 m in front of them. Another evaluation was done with the volunteer’s vision and hearing prevented, ensured by glasses and earplugs positioned in both ears. The evaluation time for each condition was 20 seconds.17 Between the evaluations, there was a rest period of 1 minute to avoid possible fatigue.
Data were acquired from the baropodometer at a frequency of 100 Hz and analyzed using FootWork Pro version 3.2.2.0 (IST Informatique). For the measurement of the stabilometric parameters of the standing postural balance, COP of anteroposterior displacement, COP of mediolateral displacement, and COP of displacement area were analyzed.
Statistical Analysis
Initially, the sample size was estimated by means of a pilot study. The sampling power for the correlation test was calculated using G*Power 3.1.7 (Franz Faul, Universität Kiel, Germany). A sampling power was obtained for the variable COP area with participants’ open eyes using the following parameters: test family: t tests > statistical test: means: difference between 2 independent means (2 groups) > type of power analysis: a priori: compute required sample size given α, power, and effect size. Thus, the sample calculation showed the following results (CRG = 2.27 ± 0.83 cm2; CAG = 1.80 ± 0.39 cm2; effect size = 0.724; ρ = 0.812) requiring a minimum sample of 22 volunteers (CRG: n = 11; CAG: n = 11). Values above 0.80 were considered to have high power.18
The data obtained from the interventions were analyzed using descriptive statistics. At first, all study variables were tested for their normality using the Shapiro-Wilk test. The homogeneity of the characteristics between the groups, such as age, body mass, and level of physical activity, was analyzed through the independent t test. The sociodemographic and clinical characteristics of the participants, such as sex, type of cancer, stage, and chemotherapy, were analyzed using chi-square testing.
For the correlational analysis, the variables used were standing postural balance by means of displacement for COP of mediolateral displacement, COP of anteroposterior displacement, and COP area with the superficial thermal records of the legs in the anterior and posterior views. Furthermore, the Pearson correlation test was used. The following interpretation parameters were adopted: >0.50 showed a strong correlation; between 0.30 and 0.50, moderate correlation; and between 0.00 and 0.29, low correlation.19 All analyses used the software Statistical Package for Social Sciences version 20.0 for Windows (IBM Corp, Chicago, Illinois), with a significance level of P < .05.18
Results
Table 1 shows the sociodemographic and clinical data of the study participants. For the anthropometric and clinical variables between the evaluated groups, no significant differences were found except for the number of chemotherapy sessions, which was higher in the CRG.
Table 1.
Sociodemographic and Clinical Characteristics of Study Participants
| Characteristics (Mean ± SD) | CRG (n = 15) | CAG (n = 15) | P value |
|---|---|---|---|
| Age (y)a | 57.13 ± 16.74 | 63.29 ± 7.34 | .165 |
| BMI (kg/m2)a | 24.81 ± 4.63 | 24.72 ± 4.57 | .300 |
| Extra physical activities (per wk)a | 1.00 ± 1.85 | 1.21 ± 1.76 | .752 |
| Sex, n (%)b | |||
| M | 1 (6.67) | 5 (25.00) | .167 |
| F | 14 (93.3) | 10 (75.00) | |
| Cancer diagnosis (mo) | 23.92 ± 36.91 | 50.50 ± 53.92 | |
| Cancer diagnosis (%)b | |||
| Gastrointestinal tract | 7.14 | 6.66 | 1.00 |
| Breast | 42.86 | 20.00 | .232 |
| Abdominopelvic | 35.71 | 20.00 | .409 |
| Oropharyngeal | 0.00 | 26.67 | .032 |
| Others | 14.29 | 26.67 | .666 |
| Stage (%)b | |||
| 0 | 14.29 | 8.33 | .543 |
| I | 21.43 | 33.33 | .409 |
| II | 35.71 | 50.00 | .269 |
| III | 28.57 | 8.33 | .142 |
| IV | 0.00 | 0.00 | |
| Chemotherapy (%)b | |||
| Platinum | 33.33 | 26.67 | .690 |
| Alkaloids | 13.33 | 33.33 | .361 |
| Taxanes | 26.66 | 20.00 | .666 |
| Others | 26.68 | 20.00 | .666 |
| Types of treatment (numbers)a | |||
| Chemotherapy sessions | 14.27 ± 10.07 | 4.77 ± 4.38 | <.05 |
| Radiotherapy sessions | 22.63 ± 13.66 | 20.77 ± 18.57 | .817 |
Others (cancer diagnosis): leukemia, lymphoma, bone cancer, brain, chronic myeloid lymphoma; others (chemotherapy): ABVD, CMF.
ABVD, adriamycin, bleomycin, vinblastine, and dacarbazine; BMI, body mass index; CMF, carboplatin-methotrexate; fluorouracil; F, female; M, male.
Represents analysis of variance test.
χ2: represents chi-square test.
Table 2 shows the stabilometric values of anteroposterior, mediolateral, and COP area displacements, with participants’ open eyes and closed eyes of both groups.
Table 2.
Mean and Standard Deviation of the AP and ML Displacement (cm) of the COP in the Groups Evaluated in the Condition of EO and EC
| Group | AP-OE | AP-CE | ML-OE | ML-CE | COP-OE | COP-CE |
|---|---|---|---|---|---|---|
| CRG | 1.98 ± 0.62 | 2.13 ± 0.76 | 1.34 ± 0.48 | 1.34 ± 0.42 | 2.12 ± 1.15 | 2.29 ± 1.31 |
| CAG | 1.98 ± 0.65 | 2.35 ± 1.38 | 1.45 ± 0.451 | 1.48 ± 0.85 | 2.31 ± 1.12 | 2.26 ± 1.48 |
AP, anteroposterior; CAG, cancer group without current treatment; COP, center of pressure; CRG, chemotherapy-radiotherapy group; EC, eyes closed; EO, eyes open; ML, mediolateral.
Table 3 shows the superficial thermographic results of the anterior and posterior legs of the CRG and CAG groups.
Table 3.
Mean and Standard Deviation of the Temperatures (Cº) of the Anterior and Posterior Regions of the Lower Limbs of the CRG and CAG
| Groups | AL | AR | PL | PR |
|---|---|---|---|---|
| CRG | 31.12 ± 1.30 | 31.19 ± 1.30 | 30.69 ± 1.55 | 30.79 ± 1.52 |
| CAG | 30.89 ± 1.40 | 31.11 ± 1.25 | 30.44 ± 1.67 | 30.36 ± 1.58 |
AL, anterior left; AR, anterior right; CAG, cancer group without current treatment; CRG, chemotherapy-radiotherapy group; PL, posterior left; PR, posterior right.
Table 4 shows the correlational data between the stabilometric parameters and the temperature of the legs in the anterior and posterior views in both evaluations—with participants’ eyes open and closed. Low correlation was evidenced between surface temperature and the COP displacement area in the conditions adopted for evaluation. Only in the CRG was high correlation between the displacement of the ML and the COP with superficial thermography of the former regions of both legs indicated. There was also a correlation between the ML and the superficial thermography of the posterior region of the left leg.
Table 4.
Correlation Between the Stabilometric Parameters and Infrared Thermography of the Legs of the Evaluated Groups With Open Eyes and Closed Eyes
| Groups | Stabilometry | Correlation | ºC AR | ºC AL | ºC PR | ºC PL | |
|---|---|---|---|---|---|---|---|
| Open eyes | CRG | ML | Pearson | .578 | .619 | .571 | .497 |
| P value | < .05 | < .05 | < .05 | .070 | |||
| AP | Pearson | .307 | .182 | .172 | .147 | ||
| P value | .286 | .534 | .560 | .616 | |||
| COP-Area | Pearson | .585 | .540 | .498 | .427 | ||
| P value | < .05 | < .05 | .070 | .128 | |||
| CAG | ML | Pearson | .362 | .345 | .211 | .110 | |
| P value | .204 | .228 | .470 | .708 | |||
| AP | Pearson | .205 | .215 | .254 | .275 | ||
| P value | .481 | .582 | .382 | .931 | |||
| COP-Area | Pearson | .333 | .351 | .288 | .249 | ||
| P value | .244 | .219 | .317 | .390 | |||
| Closed eyes | CRG | ML | Pearson | -.032 | -.108 | -.160 | -.164 |
| P value | .913 | .714 | .584 | .575 | |||
| AP | Pearson | -.229 | -.320 | -.255 | -.249 | ||
| P value | .431 | .265 | .379 | .392 | |||
| COP-Area | Pearson | .231 | .225 | .475 | .489 | ||
| P value | .448 | .459 | .101 | .090 | |||
| CAG | ML | Pearson | -.282 | -.155 | .427 | .374 | |
| P value | .555 | .596 | .128 | .188 | |||
| AP | Pearson | -.175 | -.155 | .227 | .195 | ||
| P value | .555 | .596 | .435 | .505 | |||
| COP-Area | Pearson | -.065 | -.069 | .334 | .457 | ||
| P value | .826 | .814 | .243 | .100 |
AD, left anterior view; AP, center of pressure anteroposterior displacement; AR, right anterior view; CAG, cancer group without current treatment; COP-Area, center of pressure of displacement area; CRG, chemotherapy-radiotherapy group; ML, center of pressure of mediolateral displacement; PE, posterior left view; PR, posterior right view.
Discussion
Chemotherapy causes toxicity of the neural fibers, resulting in structural and functional damage, such as reduction of excitability and conduction velocity6 capable of altering the processing of sensory information.5,20 In a systematic review, the chemotherapeutic agents derived from platinum-based chemotherapy showed reductions in the amplitude of potential sensory action.21 In turn, alkaloid agents, such as vincristine, vinblastine, and semisynthetic compounds, may lead to weakness of the dorsiflexor muscles and long extensor hallux,22 reducing proprioception and altering the static balance.2 This study evaluated the correlation between the stabilometric parameters obtained by baropodometry and the thermal profiles of the legs of cancer patients during and after treatment.
Through our evaluation of the conditions induced by chemotherapy in the systems involved in patients’ postural control, we believe that both groups developed the same compensatory strategies for the maintenance of static balance because no significant difference was identified. It is possible that both groups may have developed a more pronounced cocontraction of the muscles responsible for postural control, thus compensating for the loss of somatosensory information.23, 24, 25 In this study, we believe that the greatest displacement of ML and COP area occurred owing to standardization of the placement of feet required during the collection, which could have reduced the support base in these individuals.
Infrared thermography is an important tool for the diagnosis, evaluation, and follow-up of cancer treatment and for understanding individuals’ physiological functions.26 Commonly, for the legs, thermal asymmetry values lower than 0.5ºC indicate similar condition clinics.15 This fact was observed in this study, which did not find significant differences in the surface temperatures between the groups.
Cancer patients present variations in body temperature,26 which occurs owing to the direct metabolic demand of the disease, immune response,27 and muscle catabolism induced by cytokines IL-6, tumor necrosis factor alpha, IL-1β, IFN-α, and IFN-γ.11,28 However, no prior studies were found that assessed the correlation between possible variations of leg temperature and static balance.
The results of this study draw attention to the fact that cancer patients undergoing (or after completing) treatment showed no significant correlations between temperature and stabilometric variables when evaluated with their eyes closed, which was expected in this study because vision directly influences static balance.1,10,23
For CRG, the evaluation demonstrated a high correlation between the thermographic analysis and the mediolateral and COP displacements when their eyes were open. There is the possibility that the volunteers in this group may have had undiagnosed ocular damage at the time of evaluation. The ocular toxicity induced by chemotherapy is generally underestimated and sometimes ignored by health care professionals during treatment for cancer. The occurrence of vision impairment has been reported in situations involving the use of higher doses and higher frequencies of chemotherapy than those recommended by the manufacturer.29 This study suggests the need for health professionals to carefully analyze possible ocular toxicity in people with cancer undergoing chemotherapy and/or radiotherapy. The results of this study show that cancer-related fatigue is a condition that deserves clinical attention during treatment because it is related to greater mediolateral and COP area oscillation, with repercussions for the balance of these individuals.
Limitations
The study was developed in a city that does not have a high population density, and it is difficult to ensure better control of the variables, such as the cancer composition of the groups, the number of chemotherapy or radiotherapy sessions, and staging of the disease.
Conclusion
The study found that cancer patients undergoing treatment showed a moderate and high correlation between ML and COP displacement when their eyes were open during analysis by IRT. With closed eyes, no correlation was found between the stabilometric parameters and the IRT of the legs of the volunteers of either group.
Funding Sources and Conflicts of Interest
Santa Casa de Alfenas and the Foundation for Research of the State of Minas Gerais-FAPEMIG, under APQ: 03580-13, and the Oncology Network of the State of Minas Gerais-FAPEMIG, under RED-11-14, provided support for this study. No conflicts of interest were reported for this study.
Contributorship Information
Concept development (provided idea for the research): R.S.A., D.H.I., I.C.P., J.B.C.B., K.O.P.M., L.C.C.
Design (planned the methods to generate the results): R.S.A., D.H.I., I.C.P., J.B.C.B., K.O.P.M., L.C.C.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): R.S.A., D.H.I., L.C.C.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): R.S.A., I.C.P., K.O.P.M.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): R.S.A., D.H.I., L.C.C.
Literature search (performed the literature search): R.S.A., D.H.I., I.C.P., J.B.C.B., K.O.P.M., L.C.C.
Writing (responsible for writing a substantive part of the manuscript): R.S.A., D.H.I., J.B.C.B., L.C.C.
Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): R.S.A., D.H.I., I.C.P., J.B.C.B., K.O.P.M., L.C.C.
Practical Applications
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•
People with cancer undergoing chemotherapy had high correlations between the stabilometry parameters and the temperature of their legs.
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•
Regardless of whether or not they were undergoing treatment, patients had similar static balance evaluated by stabilometry.
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•
People with cancer undergoing treatment showed superficial leg temperatures similar to people with cancer post-treatment.
References
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