Functional Thermography in Diverse Medical Practice

William Cockburn, DC, FIACT, FABFE Academic Dean – Academy of Medical Infrared Training

ABSTRACT

In the past twenty years, applications for medical thermography have begun to enjoy greater acceptance. While thermal imaging is a known tool for the differential diagnosis in musculo-skeletal injuries and breast cancer screening, these two applications are only the tip of the iceberg. This paper will explore many of the recent, intriguing developments in medical IR. Infrared imaging is being integrated into endocrinology, cardiac surgery, burn evaluation, and even clinical psychiatry.

INTRODUCTION

The utilization of IR for adjunctive screening and diagnostic purposes has been widely scrutinized and reported in the literature. However, this imaging modality has not yet reached its full potential as a valuable tool in many medical specialties and sub-specialties.

This is in part due to problematic usage of the technology in the personal injury and workers compensation field, wherein thermal imaging became a plaintiff’s tool for litigation purposes, or more clearly stated, as a fact based tool for permanent injury and disability. As a result, many fraudulent thermographic examinations were subject to scrutiny and the industry lost favor within the trial court system.

In addition, the use of thermography for breast cancer screening purposes has been extensively studied and consistently demonstrated to have high negative predictive value for non cancerous breasts [97%] with equal to or better than true predictive value for cancer as compared to mammography.

These two areas of medical application, while reliable in qualified hands, are none the less historically controversial and in need of fact based proofs and not anecdotal information. (Beyond the scope of this paper). We will now look briefly at a variety of applications for thermal imaging (thermography) in a variety of medical applications.

PAIN DIAGNOSIS AND MANAGEMENT

Many individuals suffer from acute or chronic pain, which is often difficult to treat as the source of such pain can be elusive. Often, soft tissue injuries that do not heal place both the treating physician and the patient in a difficult and suspicious realm due to the Tort System of litigation where money damages are requested as a result of injury. In reality, many people who suffer from daily pain and discomfort and loss of function can be easily evaluated with the use of infrared cameras and software to reveal a) the fact that dysfunction exists and b) the location of primary and secondary or adaptive heat signatures to assist in the guidance of treatment and rehabilitation.

In the posterior torso image (Figure 1) focal heat patterns can be seen quite easily at the lower left cervical spine and upper left trapezius region (Sprain Strain) as well as to the right of the thoracic spine (Active Trigger point irritation or myofascitis) and to a lesser degree in the right scapula (muscle strain). A milder blush hyperthermia is seen in the lower thoracic spine midline which suggests compensating biomechanics.

In addition, the upper arms are seen as hypothermic, which is a classic indicator of sympathetic nervous system induced vasoconstriction of the dermal capillaries (skin) an example of pain fiber irritation and the body’s reactive defense mechanism (fight or flight response). If untreated, this can develop into permanent spinal disability and CRPS / RSD (Chronic Regional Pain Syndrome, Formerly called Reflex Sympathetic Dystrophy).

Figure 1. Posterior Torso - Human Figure 2. Anterior Cranial Facial - Human

PAIN DIAGNOSIS AND MANAGEMENT

The patient in Figure 1 is presented again in Figure 2, a view of the anterior face and skull. Note the cooling of the right forehead. This is often seen in cervico-genic headaches, and in this case correlates well with the finding at the insertion of the sterno-cleido-mastoideus upon the right clavicle, a muscle often torn during hyperextension cervical spine injuries. This patient is obviously not pretending to be in pain (malingering). In this case, a clinical psychiatrist was able to use the thermographic evidence to obtain further treatment for the patient and stop the psychiatric medication prescribed for a hysterical patient.

Figure 3. Oblique Right Facial - Human Figure 4. Oblique Left Cervical - Human

Figure 3 above represents an oblique facial presentation confirming the findings of the craniofacial view above and Figure 4 is a posterior oblique cervical spine view, also confirming the previous myofascial irritation finding. An additional posterior deltoid trigger point is evident, indicating involvement of the shoulder.

Another application of thermal imaging is found in low back pain syndromes, one of the most common injuries in the workplace. They are also common in athletic injuries, often requiring surgery that results in failed back syndrome. Figure 5 below reveals a very significant increase in the normal lumbar stripe heat pattern. As the lumbar spine is under tremendous pressure from body weight and gravity, there is normally a small linear heat signature above the supraspinous ligament. This image is a gross exaggeration of that normal heat signature and indicates significant alteration of the normal lordotic (forward) curve of the lumbar spine. Note also that the buttocks are bilaterally hypothermic.

While the buttocks are often seen as cool in obese patients, this finding is common place with significant lumbar injury and confirms abnormal neurology and a possible herniated central disc as the finding is indeed bilateral. Also note the lower right of the lumbar spine splay pattern indicating potential nerve root irritation at L5. A small focal heat pattern in the right flank of the torso is related to an old surgical scar which has formed a keloid, typically seen as hyperthermic.

Figure 6 is a view of the plantar surface of the feet as the patient kneels on a chair with arm supports for stability. The heels are seen as bilaterally hypothermic which is an L5 dermatome distribution finding, again related to sympathetic nervous system responses (fight or flight). The toes of the right foot are hypothermic, consistent with the radicular finding at the right L5 pattern seen in the posterior torso view, again revealing a consistency between patient complaint and known neurologic pathways.

Figure 7 is a view of the same patient, revealing heat in the talo-crural (ankle) articulation. This finding is consistent with altered gait and locomotive mechanics related to alteration and injury of the lumbar spine, a finding that was denied by radiology. This is an interesting and critical factor in evaluating patients. As mentioned previously, this patient was on mood altering medication as the orthopedist and radiologist involved with her case based their opinion on x-rays taken both at the time of initial injury and at the end of physical therapy which never helped the patient. She was believed to be malingering until a combination of thermal imaging and forensic evaluation of the medical record were undertaken. The radiology findings were based on plain film x-ray taken in a non weightbearing position, in other words, lying down, which provides no stress loading of the lumbar spine. Subsequent weightbearing film revealed a moderate to severe slippage of the L5 vertebra with disc involvement, later confirmed on MRI magnetic resonance imaging).

PAIN DIAGNOSIS AND MANAGEMENT

The utilization of thermal imaging as an adjunctive tool in the war against breast cancer is well documented, and one of the most studied areas in medical infrared imaging. Thermography of the breast fell in to dispute in the early 90’s due to great variance of interpreting skills and variety of cameras utilized that produced many false positives. Some surgeons performed mastectomy (surgical removal of the breast) based on an abnormal thermogram before they realized that other conditions than cancer (pathologic) can cause heat in the breast.

Figures 8 and 9 demonstrate a normal thermographic evaluation of the female breast, as well as a highly abnormal thermogram demonstrating a heat pattern in the right breast related to an adeno-carcinoma. A dramatic abnormality ion in the left breast is related to advanced proliferative DCIS (Ductal Carcinoma In Situ).

As the science of breast thermography is currently being taught as a 4 day program by our academy, only a small sampling is provided in this general thermography paper. The goal is to acquaint the reader with the value of this procedure, particularly when properly utilized by competent thermographers with competent interpretation and correlation.

Figure 8. Normal Breast Thermogram - Human Figure 9. Abnormal Breast Thermogram - Human

Figure 10 below are the oblique low resolution (color) and high resolution (linear grayscale) images of the patient seen in Figure 9. Color imaging is utilized to look for inflammatory processes (blush and focal hyperthermia’s) and linear is utilized to view vascular signatures specific to carcinoma which can not be well resolved by the human retina in color in many cases.

In the image below, Figure 11, the patient is seen following mastectomy (surgical removal) of the left breast. The heat patterning seen at the remaining chest is core heat escaping though the very thin layer of tissue which remains above the ribcage. Note that the adeno-carcinoma of the right breast mentioned previously is still present but not as inflammatory. This is likely due to the chemotherapy prescribed following mastectomy. The right breast tumor was not treated as it could not be diagnosed at the time of other medical testing, which is a common problem for clinical thermographers. It was thought to be a “false positive” as mammography and ultrasound were both within normal limits, and bilateral breast carcinoma is quite rare. In fact, the patient had subsequent mammography one year later for the right breast as well as a PET scan (Positron Emission Tomography) which both clearly revealed the carcinoma in the right breast allowing treatment. The patient survives to date, some 7 years following initial positive bilateral thermal indicators when other testing proved to be normal. There in lies the rub.

NEUROLOGY APPLICATION

Consistent with previous thermograms in the pain management section, the dysfunction of the sympathetic nervous system until the 90's has been difficult to determine. Often, warfare erupts when the neurologist has evaluated a patient to be normal when the thermographic clinician has found significant abnormality.

In the author’s personal practice experience of over 30 years, this is an all too common and unnecessary dilemma. This problem occurs when the neurologist tests with Needle EMG (electromyography) and/or SSEP (Somato-Sensory Evoked Potential) and has found normal signal amplitude and conduction. EMG is a test of Motor Nerves. SSEP is a test of Sensory Nerves.

Neither of these tests demonstrate Autonomic Nervous System Dysfunction, in this case the Sympathetic aspect. Figure 12 reveals a significant cervical spine injury combined with cooling of the hands as seen in Figure 13. An adjustment of thermal range downward is attempted in Figure 14 in an attempt to visualize fingers so comparison of nerve distribution heat changes (dermatomes) can be made accurately.

Figure 14 (bottom – Recalibrated for Digits

The radial surface of the forearms is shown in Figure 15. Clearly the left forearm (C6 dermatome distribution) is hypothermic as compared to the left, again consistent with CRPS / RSD (Chronic Regional Pain Syndrome, Formerly called Reflex Sympathetic Dystrophy).

In the Lumbar region (Figure 16), heat from a low back lifting injury with consequences in the L5 dermatome distribution (Fig. 17) on the right buttock and thigh is evident. This is also a sympathetic indexed pain syndrome indicator.

PODIATRIC APPLICATION

The evaluation of the human foot provides an opportunity for Doctors of Podiatric Medicine, Chiropractors, Orthopedists, Physical Therapists and Rehabilitation specialists to evaluate the foot for pathologies undetected by other methodologies.

Figure 18 is a view of the bottom (Plantar Surface) of a patient’s feet while kneeling in a chair supported with arm rests for stability. Multiple foot abnormalities are found in this thermogram. The patient’s initial complaint was pain at the front of the heel radiating to the ball of the foot (metatarsal pad). This heel heat is clearly visualized with infrared imaging and was correlated on x-ray examination as a large heel spur (calcaneal) growing towards the anterior foot. This is a common finding in patients with abnormal gait and pedal mechanics.

In addition, a Morton’s Neuroma which was atypically symptom-less was discovered after the thermogram revealed a focal hyperthermia in the metatarsal pad. The longitudinal arch of the foot is also quite hyperthermic and is related to myofascitis related to altered gait and pedal mechanics resulting from favoring the sore foot. (Abnormal foot strike) Figure 19 is the same patient and a hyperthermia of the opposite ankle (left), which is an adaptive strain hyperthermia again related to abnormal gait cycle. (Failed pedal mechanics). The lower aspect of the shins is also hyperthermic bilaterally, consistent with shin splints (tibialis anterior myofascitis).

SURGICAL APPLICATION

The utilization of thermal imaging in the surgical arena is a nearly untapped resource for surgeons and surgical teams. Pre-evaluation of patients for procedures such as leg amputation in diabetics allow for accurate assessment of pre -skin perfusion vs. tissue necrosis for the best possible surgical outcome.

Figures 20, 21 and 22 represent just such an application. Figure 20 is the pre-surgical thermogram of the lower legs and feet. It is clear that the distal aspect of the right foot is very hypothermic and this was in fact gangrene. Figure 21 is the surgical team shortly after removal of the right leg just above the knee. The level of amputation was partially determined by thermographic evidence of skin perfusion. Figure 22 is approximately 5 minutes following closure of the stump with suturing. The distal aspect of the remaining thigh can be seen to not quite perfused resulting in hypothermia. This was reevaluated real time, and within just a few minutes adequate perfusion was present and the surgery ended.

Thermal Imaging is also being utilized in brain and heart surgery. The primary purpose of this imaging technology, often called thermal angiography, is to determine if small bleeding is present that cannot be detected by the human eye prior to closing the patient’s head or chest cavity. Of course this thermography application can be utilized in virtually all forms of surgery, including burn grafting, to ensure that tissue is perfused so that necrotic process do not take place.

Figure 23 was provided by the courtesy of Dr Marcos Brioschi of Brazil. The image on the left is of the heart with clamps in place to prevent bleeding. The image on the right is after the clamps have been removed demonstrating the heat from blood now flowing through the unobstructed bypass with no bleeding from the vessel or its suture site.

GENERAL AND INTERNAL MEDICINE APPLICATION

Many clinical thermographers make claims that they can determine the function and or pathology of internal organs utilizing thermal imaging technology. Currently this is not true, although some very exciting research is promising in combining the use of Laser or Microwave energies. For the purpose of this paper, I discuss only the standard application of topographical surface measurement utilizing common low band and high band infrared camera systems.

Thermography in this regard measures only the temperature of human beings emitting from the skin at a depth of 6mm or less. However, keep in mind that the surgical uses of thermography as described above are looking at the “surface” of organs and tissues exposed to the camera via surgery, and not in a closed torso or cranium. Also, the appearance of blush hyperthermia's on the surface of the body remote to the organ are often seen during routine full body topographical study, an example being gall bladder pain referred to the right shoulder. These are commonly termed Viscero-Somatic Reflexes.

In Figure 24 and 25, we see very atypical vascular signatures in the high resolution linear grayscale images. These images are classic of a patient with end stage cirrhosis of the liver and portal hypertension. Mass screening of patients with suspected liver disease with non invasive and safe infrared cameras can play a major role in saving lives and in medical intervention.

Mass screening for testicular carcinoma is another exciting application for thermal imaging. Like mammography and palpation, cancers of the testes are often not found on other examination. However, the physiology of cancer produces a thermal signature as can be seen in Figures 26 and 27. Indeed prostate cancer is often revealed by a viscero-somatic heat signature in the lower abdomen as visualized in Fig 28.

CONCLUSION

Modern infrared thermography is now being utilized in multi-specialist roles in nearly all fields of medicine and the alternative healing arts. It Is incumbent upon all health care professionals to seek out proper training and IR equipment prior to utilization in the field of clinical practice or research.

ABOUT THE AUTHOR

Dr William Cockburn has been licensed in the State of California since 1975 and received his post graduate Board Certification in Thermal Imaging in 1985. In 1987, Dr Cockburn received his Diplomate in Thermal Imaging later achieving the status of Fellow in Thermal Imaging in 1989.

Dr Cockburn maintains a full service Thermal Imaging lab in Los Angeles, California and is the Founder and Academic Dean of the Academy of Medical Infrared Training, an educational program for technicians and physicians interested in perfecting Medical Thermography.

Dr Cockburn can be reached at;

11695 National Blvd. Los Angeles, California 90064	Mailing Address: PO Box 2382 Whittier, California 90610-2382
(562) 699-7921
www.breastthermography.org www.thermodoc.com
Email: ThermoDoc@verizon.net