Palpation

Our experimental recordings are based on a new 6TVC (resolution 1.3 Mpix, 120fps) G.O.A.L.S. (Global Opto-electronic Approach for Locomotion & Spine) (Bioengineering & Biomedicine Company S.r.l. Italy) stereo-photogrammetric opto-electronic system derived from Optitrack System (NaturalPoint Inc. USA), Fig 1. Data processing was carried out using a specially developed software package named ASAP 3D Skeleton Model (Bioengineering & Biomedicine Company S.r.l. Italy). In this elaboration software, a complete 3D parametric biomechanical human skeleton (3D spine included) has been modelled mathematically; the skeleton can be accurately scaled by fitting the 3D anthropometric bone size to the corresponding 3D opto-electronic measurements of a series of suitable body landmarks. After calibration the GOALS system provided 0.3–0.4mm 3D accuracy in 3D marker position reconstruction on a 3m x 3m x 2m working volume used for the present study. To analyse human posture and spinal related pathologies, a protocol of 27 body landmarks labelled by passive markers (Fig 2) was established and tested extensively in the clinical environment [21 (link)–25 ]. This protocol, named “ASAP POSTURE”, has been deposited under that name in protocols.io and has also been assigned its own identifier (DOI) [26 ]. This general methodology can be applied indifferently to any stereo-photogrammetric recording system, provided that the latter is able to accommodate all the required landmarks as three-dimensional coordinates. Hemispheric (10mm diameter) retro-reflective passive markers were selected for use on the spine and pelvis in order to minimise the bone-prominence/marker distance and reduce geometrical interferences [22 (link),27 (link)]. Moreover, for all subjects, marker positioning was determined by palpation by a single operator with more than 20 years experience, while the subject was standing.
In our data we do not include an explicit comparison of this method with X-ray measurement: this paper does not aim to validate the method under consideration. Validation and discussion of this method have been extensively treated in previous papers by D’Amico et al. [21 (link)–25 ]. Conversely, sagittal spino-pelvic and total body alignment parameters from the X-ray based literature will serve as the “gold standard” to establish the degree of disparity/congruity between the well-known and predominant X-ray approach on one hand, and the 3D stereo-photogrammetric based measurement approach described in this paper.

Pregnant women of all gravidities attending an ANC clinic for the first time and who had not received IPTp during their current pregnancy were invited to participate in the study after provision of informed consent. Inclusion criteria were: permanent residence in the study area, gestational age ≤28 weeks, negative HIV-testing at recruitment, absence of history of allergy to sulfa drugs or MQ, absence of history of severe renal, hepatic, psychiatric, or neurological disease, and of MQ or halofantrine treatment in the preceding 4 weeks. Gestational age was determined from fundal height measurement by bimanual palpation. Women not meeting inclusion criteria received standard ANC following national guidelines. Hemoglobin (Hb), HIV test and the syphilis rapid plasma reagin test (RPR) were assessed at the first antenatal visit as per local standard procedures. In Mozambique and Tanzania, HIV-infected women were invited to participate in a placebo-controlled trial evaluating MQ IPTp in women on daily cotrimoxazole prophylaxis [26] (link). The allocation of the participants to the study arms was done centrally by randomization stratified by country according to a 1∶1∶1 scheme. The sponsor's institution biostatistician produced the computer-generated randomization list for each recruiting site. Treatment allocation for each participant was concealed in opaque sealed envelopes that were opened only after recruitment. Study participants were assigned a unique study number linked to the allocated treatment group. All participants received a LLITN (PermaNet, Vestergaard Fransen) at enrolment as part of the study intervention.
Following physical examination, recruited women with gestational age ≥13 weeks received their first dose of IPTp (either SP or MQ) under supervision. Women allocated to the SP group received standard IPTp (three tablets of the fixed combination therapy containing 500 mg of sulfadoxine and 25 mg of pyrimethamine, Malastop, Sterop), whereas participants allocated to the MQ groups received 15 mg/kg of the drug (Lariam, Roche, tablets of 250 mg of MQ base). The number of tablets was calculated according to body weight, thus a woman weighing 70 kg would receive four and a quarter tablets. The maximum dosage would not exceed 1,500 mg of MQ base corresponding to six tablets. For women allocated to the MQ split dose group, the 15 mg/kg dose was divided into two halves and administered over two consecutive days with the second half dose administered either at the ANC clinic or at home (by study personnel). All study participants were observed for 60 minutes following IPT administration. Women who vomited within the first 30 minutes were provided a second full IPT dose and those vomiting 30–60 minutes after drug intake were given a half replacement dose. Home visits by field workers were done two days after IPTp administration to assess drug tolerability and correct LLITN use. The second IPTp-SP/MQ administration was given at least one month later than the first one.

The drugs used for latent MTrPs injection containing vitamin B₁₂ (JinYao Corp, Tianjin City, China; 2 ml:1 mg), 2% lidocaine injection (ZhaoHui Corp, Shanghai City, China; 5 ml:100 mg), and compound betamethasone injection (MSD Merck Sharp & Dohme AG, Switzerland; 1 ml: 5 mg betamethasone dipropionate and 2 mg betamethasone sodium phosphate) were diluted to 20 ml with 0.9% saline for a single injection. Injection of latent MTrPs was performed using needle 25 (0.5 mm × 36 mm) and a 20 ml syringe (We Go Corp, Weihai City, China).
The latent MTrPs were mainly found in the sternoclavicular joint, sternocleidomastoid, medial or lateral pterygoid muscles, and splenius capitis muscles by palpation (Figure 1). However, it was difficult to palpate when some trigger points were hidden in muscles, and the final therapeutic effects depend on the accuracy of palpated points (16 (link)). Accurate signs of latent MTrPs can be confirmed by the patient showing “jumping signs,” which may include head retraction, fascial (or forehead) wrinkles, verbal responses, or local twitch responses (LTRs) (11 (link), 12 (link)). Palpation and injection of latent MTrPs were performed according to Travell and Simons’ “Trigger Point Manual” (17 ).

When palpating the sternoclavicular joint, we had the patient sit upright and located the trigger point by palpation. Care was taken to avoid accidental injection of medication into the subclavian artery. Palpation and injection were performed by the same professor who has 30 years of experience.