Monday, April 7, 2025

RehabTech Solution: Parallel Bars- Addressing a Critical Need

More than 5 million ICU patients are admitted annually, with older adults and those with cardiac, respiratory, or neurological conditions most frequently affected. For patients connected to ventilators and other monitoring equipment, standing is incredibly challenging and getting to the rehab gym is nearly impossible. Isolation, fatigue, delirium, and staffing shortages exacerbate the issue, leading to hospital-induced deconditioning, longer stays, higher costs, and severe health complications, including pressure sores, respiratory issues, and cognitive decline.


During the pandemic, these challenges reached a crisis point, exposing an urgent need for early mobility solutions. The stakes were especially high for ventilated patients, who make up 20-40% of ICU admissions, critical standing and balancing exercises were often unattainable.

Patient falls alone cost the US healthcare system $50 billion annually, underscoring the need for interventions that improve mobility, enhance recovery, and reduce costs. Safe Patient Handling (SPH) protocols aim to address these challenges and improve patient quality of life, but more adaptable, innovative solutions are essential to closing the gaps in care.


Interventions for Safe Patient Handling (SPH) in Intensive Care Units (ICU) and Beyond

Effective rehabilitation necessitates tailored interventions designed to address the specific needs of individual patients. Evidence-based programs, such as the ABCDEF Bundling framework and the Veterans Administration Mobility and Screening Tool, have demonstrated efficacy in systematically implementing protocols that consider a patient’s clinical status. These methodologies have proven to minimize complications, such as hospital-acquired deconditioning while enhancing recovery outcomes. Interdisciplinary teams undergo structured training through hands-on workshops to develop proficiency in deploying evidence-based practices and utilizing assistive technologies. These workshops are critical for ensuring confidence and competence in executing mobility protocols. Despite the demonstrated benefits, logistical barriers, such as resource limitations and the integration of Safe Patient Handling (SPH) equipment into existing workflows, often hinder the consistent application of these interventions, underscoring the need for innovative, adaptable solutions to support early mobility initiatives.



A New Solution: Portable Parallel Bars

In response to this critical need, Portable Parallel Bars were designed with input from physical and occupational therapy experts at the Veterans Health Administration Innovators Network (VHA iNet). This mobile tool was codeveloped with Wareologie™, a product development consulting firm, to enable bedside therapy, overcoming many of the barriers associated with immobility.

The bars fold, have wheels, and are stable, empowering clinicians to assist patients in standing, balancing, and strength-building without requiring time-consuming transfers to therapy gyms. Preliminary outcomes highlight the device’s significant impact: clinicians report enhanced safety and ease of use, while patients regain confidence and access therapy more effectively and sooner in the recovery process.

“We can deliver therapy on wheels and be more mobile and give benefits to patients earlier on..For PT's the device will reduce physical strain that we have while mobilizing patients." 

Peter DiSalvo, DPT, VHA Innovation Network, Central VHA, Richmond, VA


Particularly valuable for complex patient populations—including trauma, neurological, bariatric, and pediatric cases—the bars reduce fatigue associated with gym transfers and restore dignity by enabling activities like using a bedside commode instead of a bedpan, lowering risks of complications such as urinary tract infections (UTIs). 

For clinicians, the Portable Parallel Bars address pressing workforce challenges. Patient transfers and manual therapy account for over 55% of workers’ compensation claims, costing hospitals $4 billion annually, with lower back injuries being especially common. This mobile, durable solution reduces these risks and supports safer, more efficient workflows.


The ability to be portable with the bars helps me safely treat Veterans while using a ceiling lift.” Dr. Brittany Applebee PT, DPT, GCS, Louis Stokes VA Medical Center, Cleveland, OH

Adoption is growing across ICUs, acute care, skilled nursing, and outpatient facilities. Clinicians value the familiarity and versatility of the bars, which integrate seamlessly into SPH protocols and enable more independent care. Early Mobility Advocates and SPH managers endorse the device for its transformative impact on patient outcomes and clinician safety.


Preliminary Feasibility Survey Results: Transforming Care with Mobile Treatment

Preliminary feasibility surveys paint a compelling picture of success. Clinicians rated the Portable Parallel Bars an average of 5.5 out of 6 on a Likert scale, reflecting widespread satisfaction with its safety, usability, and positive impact on recovery outcomes.

Key findings include:

Safety and Confidence: Clinicians feel secure using the device, while patients demonstrate improved mobility and confidence.

Enhanced Accessibility: Bedside therapy becomes more immediate and effective.

Ease of Use: The intuitive design integrates seamlessly into care routines.

Recovery Impact: Early adopters report improved outcomes, even in complex cases.

Positive Experiences: Clinicians overwhelmingly recommend the device.


Real-world applications span diverse patient populations and care settings. The device supports trauma patients, stroke survivors, bariatric and pediatric cases, ventilated patients, cancer survivors, and individuals managing chronic conditions like multiple sclerosis. By allowing patients to stand, balance, and build strength at their bedside, the bars reduce both physical and emotional strain associated with traditional therapy routines.

Beyond clinical settings, the potential for home use offers hope to aging adults and individuals with spinal cord injuries seeking safe, effective ways to maintain mobility and independence.


“Our Rehab Therapists in Novi are one of the first to use this ground-breaking, innovative piece of equipment that will positively impact customer service/patient outcomes.  We envision that in addition to impacting a patient's outcome, there may be a positive financial/cost-savings to our hospital, as this may afford earlier mobility at the bedside of our most vulnerable patients, leading to shorter length of stay in the ICUs, shorter hospital LOS, decreased episodes of delirium and/or all of the other detrimental effects from prolonged bed rest.”  

Annette M. Bielski, PT, CLT, Manager Rehab Services, & SCCE, Ascension Providence Hospital, Novi Campus, MI


Call to Action

The Portable Parallel Bars are more than a tool—they are a lifeline that restores dignity, independence, and hope to patients while enhancing clinician safety and efficiency. Healthcare leaders, policymakers, and care providers must prioritize investments in early mobility training practices and investments in innovations like this. By integrating these solutions into SPH protocols and expanding their use to home health settings, we can transform recovery outcomes for millions of patients.

Let’s take confident steps toward a future where mobility challenges no longer hinder recovery, dignity, or quality of life.


AUTHOR

GINA ADAMS is a life-long advocate for the advancement of non-invasive health innovations and modalities. She employs her MBA to foster a profound communication bridge between industry, clinical sciences, and the many victims of chronic illness and traumatic injury. As an entrepreneur, Gina led entire product development projects and formed partnerships within the healthcare industries while successfully navigating through the challenges of acquiring FDA compliance for patient rehabilitation technologies.  Her latest undertaking is spearheading a national outreach to unite with global advocates, clinical specialists, and public educators to expand resources. As a ranking member of the Women's Professional Health Collaborative, she is dedicated to expanding resources, education, and actionable solutions to improve lives.


Reference

1. Cameron et al., 2015; Desai, Law, & Needham, 2011; Lipshutz & Gropper, 2013; Needham et al., 2012, https://cjccn.ca/wp-content/uploads/2020/09/CJCCN-29-3-2018Rev.pdf#page=26

2. Intensive Care Statistics by Society of Critical Care Medicine https://www.sccm.org/communications/critical-care-statistics#:~:text=More%20than%205%20million%20patients,exacerbations%20of%20complex%20chronic%20conditions.

3. “Clinical and Psychological Effects of Early Mobilization in Patients Treated in a Neurologic ICU: A Comparative Study”, Klein, Kate ACNP-BC, CCRN1; Mulkey, Malissa MSN, RN, CCNS, CCRN, CNRN2; Bena, James F. MS3; Albert, Nancy M. PhD, CCNS, CCRN, FCCM4. *. Critical Care Medicine 43(4):p 865-873, April 2015. | DOI: 10.1097/CCM.0000000000000787


Sunday, April 6, 2025

AIUM PRESENTATION: Advances in Portable Imaging & POCUS in the Evaluation of Breast and Liver Disease

 

PRESENTER 1: DR. MENA RAMOS

Thank you so much for, for being here. My name is Dr. Mena Ramos. I'm a family physician by training and co-founder of the Global Ultrasound Institute. I am so honored to be sharing the stage with Dr. Bard. We will be leading a discussion, um, about advances in portable non-invasive imaging, specifically elastography microvascular imaging, thermography and point of care ultrasound in the evaluation of breast and liver disease. And we will be exploring these concepts within a global framework. Disclosures. Um, I'm the co-founder of Gussie, and we have received grant funding from various, um, foundations, including the Gates Foundation.

I wanted to just start off our talk by taking a step back and, and looking at the global landscape today. There continues to exist diagnostic deserts, meaning areas of the world where access to diagnostic imaging continues to be a, a, a serious limitation. In this Lancet paper, approximately half of the world, that's 4 billion people. And when we take a look at even more advanced modalities like elastography, like thermography, microvascular imaging, that percentage is even lower. And some places 10 to 30%, really depending on the country in which you live, whether you live in a city or a rural area, what kind of insurance access you have.

And so I wanted to take a step back and frame our conversation within this larger global framework, because I think it's important to contextualize all of these different applications that we're gonna discuss. Typically, these advanced applications are not, um, discussed with POCUS in the same sentence. They're usually very separate. And so how and why are we bringing point of care ultrasound into the conversation? And what is pocus? There have been many talks, case studies, um, at this conference, uh, related to POCUS point of care ultrasound. Um, and I think it's important to remember that in addition to being, or a, in addition to, uh, displaying how technology has advanced and become more portable, but it's also a workflow, a re-engineering of workflows that streamline a clinical workflow wherein a clinician, a provider, a clinician, is both gathering information, gathering data, performing a scan, and also interpreting that scan.

We've seen how this can and can both narrow a differential diagnosis when appropriate or expand a differential diagnosis, lead to potential cost savings and, um, um, speed up referrals or eliminate the need for unnecessary referrals. Um, uh, I think it's important to just, you know, think about how streamlined workflows can be, um, can be helpful when it comes to, to addressing this, um, this gap in access to imaging overall. Now thinking about this, these streamlined workflows, this is, has been accelerated by advances in technology. I was having a very interesting conversation yesterday with Dr. Reinhardt, who I asked, what has been a surprise over the last, you know, several decades in the, in, in, in your experience in the ultrasound world? And it's been how, how technology specifically image and image quality has improved every, every one to two years. There are, there are new developments, um, uh, across the industry that have led to improved, um, image quality portability.

Certainly. Um, we've seen more and more, uh, options in terms of, um, uh, portable devices. And in addition to that technological advancement, interconnectivity. So, uh, interconnectivity that allows expertise to be paired with, um, uh, with learners with less expertise. So it's facilitated training, it's facilitated quality assurance, um, gathering of data and analytics and study. And I won't even get completely dive into, um, the new advances in artificial intelligence, um, which we are seeing more and more of. And so when we take a step back and think about point of care ultrasound, uh, ultrasound is a paradigm, both in terms of streamlined clinical workflows and advances in technology. What makes point of care ultrasound, uh, powerful is that it's taken within a specific context. So what do I mean by context? Well, first, there's the clinical context, right? Um, it's the taking into account not only an image, but how does that relate to a patient's presentation, history, physical exam, other ancillary studies.

What is the pretest probability? What is the clinical question being answered here? What are the limitations to the scan? Um, and so there's the clinical context, but there's also the context within the system in which a patient and their healthcare provider are working. And so how does this, how does this data impact management? How does this data impact, um, uh, referrals or, um, what are the, the treatment options or what is the workup that that, um, uh, can be, uh, performed as a result of being able to answer this question? And so the clinical context, both at an individual level, but also at a systems level, um, are, um, are greatly impacted by and impact how point of care ultrasound as a workflow and as a technology, um, can be utilized. And so if we continue to take a step back and look at the big picture, the global landscape, um, looking at and seeing the, uh, top 10 leading causes of death across, um, the world and low income countries, we see that this is a, um, the technology itself can be applied to a wide array of illnesses that contribute a significant burden of, uh, of, uh, morbidity and mortality globally.

And so the, this solution, um, or this workflow and technology combined have the potential to impact many, many, many lives across the spectrum of care, um, across multiple, across multiple specialties. And just to round out our, our introduction into, um, advanced imaging at the point of care, I just wanted to take a moment to look at, um, uh, to look at health within a global policy lens. Because how do we transform health systems, including, uh, funding? And how do we connect these dots to improve good health and wellbeing if we don't have the language for it at a global scale? And so the sustainable development goals are, uh, useful, um, uh, to give us that language. And as you can see, number three is, is the most obvious application, good health and wellbeing, but also number 10, reduce inequalities. We've also seen number four and number five being impacted by, uh, point of care ultrasound, um, uh, projects.

I won't spend too much time on po within this framework. Um, uh, but I do want to use that as a jumping off point to begin to address, um, take one step further in, um, in advanced noninvasive imaging. Is it audacious to even propose that this could be a point of care tool? How can that play a role within a global health and global framework where as we know, half of the world, if not more, still has very limited access to imaging. Um, and so with this, you know, with this framework of point of care ultrasound, both as a workflow and as a technology, uh, contextualized, I wanted to take one step further and introduce advanced noninvasive imaging, more specifically elastography, thermography and microvascular imaging. And thank you all, um, for, for, for being here. I see some familiar faces across both academia and industry.

So it's great to have this, um, uh, this, this gathering of minds. Um, and, uh, without further ado, I, um, want to, um, uh, introduce Dr. Robert Bard, uh, who has been a pioneer in the field of radiology and ultrasound. Um, and also, uh, as a pioneer ear in how workflows can be re-engineered, keeping the patient in the center of the equation. How do we do what makes sense, um, and improve patient care and push the envelope. Um, and so Dr. Bard, um, will go through a series of cases, um, with respect to these advanced, um, par, uh, with advanced advanced your hand.

 

PRESENTER 2: DR. ROBERT BARD

I'm inviting audience participation in this 'cause I've been around a long time. But the more important things is we have technologies that have changed in ultrasound. So ultrasound is replacing many technologies. Uh, point in specific example, I wrote two textbooks on MRI of prostate ultrasound textbooks. An MRII used to send out five MRIs a day. I send out maybe one a year now, and only for pelvic lymph nodes because the equipment is so good. We have 3D imaging, we have elastography. Um, one of my colleagues and I gave a talk last year on elastography of, uh, prostate cancer. So the future is here. We simply have to apply it. That's the <laugh>, that's the thing. Alright, let's take a clinical case. So somebody walks into the office and everybody can see the enlarging breast mass. Well, first of all, what can't you see in this picture? Let's start with what you can't see. You can't see under the breast, you can't see the xi. Of course, you look at the, uh, infraclavicular lesions and you see there's something going on, but you don't know what. Now the, the scan itself, we always scan the both sides first, just a simple complex hiss with hive through transmission, not a problem.

 

Then we look at the, the enlarged breast rest, and we see we have a mass lesion and notice it's extending into the dermis. And with our imaging, we see epidermal involvement. And that's another interesting point. If somebody's got a mass, is it affecting the skin, which will affect treatment and prognosis? This is what you couldn't see under the breast. There were two very small lesions. This is magnified. And with the microvascular imaging, you can see the 3D showing that it's vascular. And of course, the composite of 3D imaging. Now 3D imaging probes, they're big, they cover the whole area. And we do this in 10 to 15 seconds. A thyroid, 10 or 15 seconds. The, uh, prostate maybe takes, uh, 30 seconds to get 200 imaging. So again, the future is here. It simply has to be applied. Okay, now let, let's look at the axilla. So once you've got the probe and a patient, tell me about staging. What do you do next? Anybody in the audience? Nobody wants to stage this patient.

 

Well, routinely, this is what we do. You see the axilla, it's full. Here's the redness again, 3D image, which shows irregular borders extending up to the dermal lower dermal border. And again, the beautiful 3D composite. Now, what can you do with 3D volumetric imaging? Once you have volumetric imaging, you can do quantitative imaging. This is what I've been doing for

 

Looking at how aggressive it is. And more importantly, for monitoring patient treatment. We did this with, uh, say, prostate cancer. We did radio frequency ablation of it with, um, we have a lot of vessels. And you treat it, the vessels go away. We did later laser ablation of it in the prostate. You stick a laser needle in, zap it, and when the blood flow goes away, finished. But this is a quantitative way of measuring all this. So back to the, uh, left upper outer quadrant mass, the vessel density is 2%, which is not particularly high, but it's a measure of treatment options. The next one is, so what do you do next? Anybody? Do liver work? Would you scan the liver? Yes. Affirmative. Okay, so we look at the liver. First of all, we see a simple liver cyst, normal inflammation. And then we see the hepatic and portal venous system. So we look for lesions inside, which in this case, were clear. Now what about, here's another big problem. Almost everybody with inflammatory skin disease is put on biologics. Now, who knows what the side effects of biologics are? What's the possible side effect?

 

Cancer? Yeah, cancer lymphoma. This is, it's stated in the brochure. You can, if you get a lump, check it for lymphoma. This patient came in, tell me, we got a lipoma in the breast, and this is from one of the major medical centers in New York. Tell me it's a lipoma. And I said, well, guess what? This lipomas gonna bleed if you biopsy. So of course it was lymphoma recurrence. Now, when a patient comes in, this is for beginners from head to toe. How do you scan a person? We look at differential diagnosis. What can the bump be? It can be anything from an abnormal lymph node. Um, depending what country you're in, what climate you're in, it can be different things. We see a lot of strange things now 'cause people come in with subsurface bumps and nobody can see under the skin, as far as I know. So we use this and we've been using it for, um, almost half a century in New York City. Differential diagnosis. So what is it? Is it a fibrous lesion, a vascular lesion? Um, neuromas are rare, but they happen. You have to think of these things. Lymphoma is a big problem because it is completely missed by most imaging methods. It's particularly cutaneous. Lymphoma is red. They have no idea what's going on. And it's just a red area that sometimes itches. We can see it, we can measure it by not using standard, uh, B flow ultrasound. You need the vascular imaging and you need all the other technologies. We're we're showing you.

 

soft tissue palpable lesion. We do a huge amount of dermal imaging. With dermal imaging. We see the depth, we see the margins, we see the vascularity. So if a basal cell or god forbid, or melanoma is hypervascular, this is a killing lesion. If it's a squamous cell, it's still treatable. 'cause we are now treating these things without biopsy. We're doing the imaging, uh, border imaging with, uh, laser confocal microscopy, and then we laser it. You kill it. And when there's no more blood flow in it,

 

We are, we ask the patient to come back in a come back in a year. Let's see if it regrows. So this is what we do. We do the post laser treatment scanning for any kind of skin cancer, and we follow it. So soft tissue mass, you look at it like any clinician would. So be a clinician. First. Look at it, think about the differential diagnosis. Um, see what the pathology showed and see what you can do to see if it's involving any regional structures like nerves, subcutaneous tissues. Uh, in the skin, you get a lot of subsurface, uh, metastases called intrans metastases, especially with melanoma. Uh, so you ask the patient, when did you feel it? Is it painful? And actually have them point to it. Let them let you touch it so you feel what it is. 'cause a lot of soft tissue lesions, if you pressing it, they move and you get a negative scan because the lesion is out of the field.

So look at the skin. Is it red? Is it inflamed? Are any lumps around anywhere else? Pulsitile, pulsitile, aneurysms. When they clog, when when they get clouded anteriorly, you can't feel them. They're non pulsitile, like non pulsitile aortic aneurysms or anything that's clouded. It won't pulsate and no doppler 'cause it's, it's thrombosis on top. It's a big miss. Um, okay, the transducer, you put it on the, for the patient's comfort and your edification, you put it on the lesion first and the patient will say, no, it's not there because it moved. It happens. Uh, at least once a week, the patient will take the probe and say, no, this is where it is. 'cause they can feel it. And with the transducer, you can actually feel the lesion and the hardness.

 

So you are the, the doctor and the clinician as well. Uh, see where it's involved. See, get the, um, orthogonal measurements, at least in millimeters. Um, shape is important. Uh, spatial orientation, like, you know, most cancers are more vertical than, than horizontal, but it, it, it's useful, but not, not diagnostic. The shape is helpful, but it, it's, you can't use it. So with the transducers, you see where it is, uh, like the ganglion cyst, which is how we started 50 years ago at, um, uh, New York Hospital, which is now Cornell Medical Center. And the, we got a reaction, not from the patients who were happy to find the gling, the ganglion cyst, but from the orthopedic surgeons who's saying, look, we're gonna operate on this, don't touch it. So, okay, bursitis, schwans, uh, we we're seeing a lot of these, um, neural tumors now, which are unexpected. Lipoma is so common. Uh, hematomas resolving hematomas. Um, exostosis another big problem in the skull, or actually any bony projection. So you tell the patients this mass in your, um, in your neck, it's just an exostosis

 

Keratin cyst. Schwannomas sebaceous cyst, particularly, a lot of people will not want their sebaceous cyst. They say it's a cyst. But you show the patient this is the funnel and somebody squeezes it, it's going to break out. And you'll have a massive red arm or red, uh, red ankle, uh, for a long time. So then they get it cut out. So this is sort of a surgical emergency. So, um, cap metastasis, we're seeing a lot of them now. Now it's rare. Uh, breast cancer mets huge problem. Uh, we see it everywhere. So we look for it and we scan for it. Now looking at the transduce, so what can you do? Look for calcifications hair. Um, tail sign. Tail sign in melanoma metastasis, because you see the tail of the tumor because it's lymphatic involvement extending into the lymph nodes. And it's a mask with the tail on it, which is the dilated lymphatic vessels. Uh, this was written up in the European literature and presented here, uh, five years ago. Scars, another big deal, scars and fibrosis, because now with the elastography, we see scars, uh, calcification. It's important but useful, but no longer diagnostic. 'cause we have the other technologies that are more informative. This is a pigmented lesion. It's a melanoma in the heel rare location. But melanomas of the hand and of the soul are highly aggressive, especially in, uh, Asian, uh, communities. These are killing cancers.

 

Peral flow, we look for its seroma abscess, uh, metastatic AVMs. Now this is another cause for tremendous concern because you have an A VM in the skull, in the spine, in the sacrum. If it's midline, is it connected with the spinal canal? You don't know. The patient doesn't know. You stick a needle in and it's connected with the epidural sac. You got a patient who's paralyzed and people have died from this because people didn't check the, uh, connection to the spinal cord.

Speaker 3 (23:33):

Okay, the, uh, this is the a BM. Uh, we look at the blood flow. Now, uh, we all know that, um, uh, low cancer or cancer blood flow is, has a low systolic and, uh, high diastolic as opposed to normal. This is particularly important in fracture healing. This was in the Italian literature 30 years ago, that you can tell non-union of fractures because the healing will have high spikes. In other words, a high systolic low diastolic and a fracture that will not heal will be just the opposite. And for this, the entire field of pulse, electromagnetic scanning was created and used for fracture healing. It was FDA approved 30 some odd years ago. So this is important. You can look at fractures healing, uh, elastography, again, a big breakthrough. This is, uh, we started off with sheer wave of fibro lipomas or lipomas, uh, schwannomas.

Speaker 3 (24:43):

Uh, but the melanoma is different also. Different countries use different color schemes. So in Asia and different parts of the world, blue is hard in the, uh, America's, it's, uh, hard is red colors. So you have to find out what scale is being used. This is why quantitative elastography was developed. ShearWave. Okay, so ShearWave, this is the cyst wall. Now what else can we use this on? How about the wall of the carotid artery? In other words, interal thickness, you can see it. But what's happening to somebody with high blood pressure? Are they going to develop, uh, arteritis, wall thickening plaque because their arterial pressure changes is causing real problem that they can't feel and the blood pressure doesn't reveal. This shows disease before it happens.

Speaker 3 (25:44):

Okay, strain of lithography. You, you really don't use it on cysts per se or on, uh, any bony areas. So that's an area to be aware of. Liver elastography. This is an interesting case because you can see this is not a normal liver by any means. Maybe you have a little bit of normal liver up here in the midline, but huge, this is the liver filled with metastatic lesion. And the first thing I did, I asked the patient, how do you feel? I feel fine. They're going to, you know, burn my liver. I feel fine. So we did the blood flow. There was no blood flow in it. We did the elastography, which showed it's not very hide and not very hard. In other words, this is probably a dying metastasis. And the patient's doing well.

I think offering quality of life to patients is the most important thing we can do as a clinician. So liver and breast masses, uh, thyroid masses, uh, the skin, we we're using it on the skin. The Japanese have done studies 20 years ago on skin cancer and melanoma. I actually did the work with Hitachi in my office. My god, uh, <laugh> a long time ago. Okay, so thermography, let me mention it. Just the incidental, uh, it vascular lesions are hot. More temperature is a lady with the cyst. So audience is a cyst filled with blood vessels or no blood vessels. Is it hot or cold? Would it be Okay, this is done with a, a pocket thermal camera. You can see it's dark, no blood flow, and it's indicative of benign disease. So it's a simple guide and microvascular imaging. Beautiful. It's, it's giving us, um, advanced look at blood flow.

And I know the, our good, uh, doctor in the front row is using this for treatment follow up. When the microvascular flow goes away, this is, uh, a sign of treatment effect. So it's a good way to follow inflammatory disease. 'cause the clinicians can't see it's lit. It's looks less red or it's itching less. This is quantitative imaging. Uh, ammo completely unused because this is radio frequency imaging at Memorial and Rockefeller University. They're using it experimentally. But this is an easy way to do tissue signature. And this can be worked on in the future. Okay, more microvascular imaging. This is the same lady with liver filled with metastases I saw a couple of months later and no change. And she's feeling fine. She's refused chemotherapy.

So no neo vessels. Uh, here's an interesting use. We're working with trauma victims. This is happens to be military person and fell. So you can see that there's abnormal flow in the forehead. That's where he fell. But notice there's abnormal flow down here under the eye and in the head and neck. So he has from having hypertensive heart disease, he's got abnormal flow going to the brain. He also had a, uh, also look at the shoulder. Anybody see a difference in the shoulder between the right and left shoulder? Okay, well, you can see the right shoulder has more blood flow then the left, just grossly looking at it. And here's his, uh, inflamed tendon. He, it's a simple tendonitis, supraspinatus, uh, uh, disease. We, we see it commonly. Okay, thyroid scanning pocus. I, I've been working with all the POCUS manufacturers for the last, oh, probably 15 years.

The comparing, uh, high resolution POCUS with the thyroid. This is the carotid. Uh, this is a big screen with a 18 megaherz probe showing the micro calcium, um, carotid plaque here. We're scanning the fibroids, the fibrosis. A patient came in. Look at my thyroid, Hashimoto's. We're seeing a lot of that, especially in the, in the OR Florida area that we're seeing a lot of older people with Hashimoto's in the female population. So you see that she has no cancer, but you have this, this is some kind of fibrosis, but notice it was the, you have plaque in the carotid artery. This is 11 to 12 millimeters thick. So these are ways to evaluate what's going on and what's limits thermography and microvascular flow. It's your imagination. So what's, what can we use POCUS for? Uh, Mena? Yeah. What do you think the indications are? Yeah,

Speaker 1: Dr. Mena Ramos

So we just wanted to, um, that was, uh, a very, uh, rapid fire introduction to, um, some of these advanced imaging modalities across breast, liver, skin, soft tissue. Um, and the, you can see how these different modalities can potentially narrow down the differential diagnosis. But I, um, wanted to take the opportunity to just ask of these modalities, we'll say elastography, thermography and microvascular imaging, how, how often or how widely used is this currently in your experience? And I would also love to hear from the audience in your different clinical settings. Um, what, what your practice experience has been.

Speaker 2: Dr. Robert Bard

Well, you can use it any, it's not invasive. So you can use everything you've got on every patient. Uh, we have patients who come in, people come in mostly for breast scanning, thyroid and skin scanning. So I ask them, do your joints hurt? So we can do musculoskeletal imaging, like on this, uh, veteran who's injured. And, uh, we always ask, how are your knees? 'cause we are treating with the, uh, mi micro energy, the, um, the PMF and the red light, uh, near infrared treatments. Were treating arthritis. This has been done by Harvard University and they're rebuilding knee cartilage. But you have to ask the patient what else hurts. 'cause they're worried about their, their breasts, but maybe it's a red spot on their skin or the knees, which are really killing me. But they're happy they don't have cancer. So ask the patient, work with the patient, say, what else is going on? And then you can use whatever non-invasive technology is, uh, is next. And, um, training, you know, that's, yeah.

Speaker 1: Dr. Mena Ramos

Uh, just a, a few other, a few other questions because, you know, I think the, in terms of clinical applications, they are vast. Um, and specifically within the primary care setting, um, thinking about skin, soft tissue, thyroid, breast, liver, et cetera. Um, the, the, the scope of how these, um, these advanced imaging modalities in, in addition adjacent to point of care ultrasound, um, is potentially revolutionizing. Um, yet we still see very limited adoption. Um, and I'm curious, before we, we discuss scope of practice, um, what are the kind of primary limiting factors, um, that you see to, to more wide scale adoption?

Speaker 2: Dr. Robert Bard

Well, I ask the patient, what do you wanna do about this? You have a breast lump. If it's a low grade cancer or cancer, what do you wanna do? Do you wanna treat it? Do you wanna watch it? Do you wanna get chemo? Um, 'cause people are trying all sorts of alternative therapies now, a lot of which work. So you ask the patient, what do you want? And then what else bothers you? And you do whatever you have in your arsenal of treatments to show them, well, I can do this. And you do it. You show them, well, this shows this, but it's not conclusive. And then you do more, we have all these imaging technologies available, and there are more coming out, as you see at this last conference. There are things we haven't seen before in, uh, 3D microvascular imaging of the, the, the cardiac walls hypertrophy. This is amazing what's possible in, in ultrasound imaging. And the future is in front of us. We just have to take hold of it.

 

The other interesting thing is training. We see the ai, which is showing the chambers of the heart, the location of the transducer, and measuring, finding the organ systems and telling you, no, it's, it's not the liver. You having to be on a big spleen, for example. So it, it guides you. And this has been going on for a couple of years now, but now it's, it makes training easier and it makes the practice of ultrasound wider. And I foresee the day where ultrasound imaging is going to replace a lot of biopsies that are unnecessary. You don't wanna give a woman a scar on the breast or on the, on the cheek for a benign inflammatory red spot.

 

And here's the other thing with, do you know, itching is the most common symptom worldwide, inflammatory skin disease, cancer, everything. And it's, once you've got psoriasis of the nail, for example, it's not a nail disease. It involves the joint, the emphasis, the spine, everything increased incidence of cancer and stroke. So you tell the patient, look, you have an increased, you have an inflammatory whole body disease. And rheumatologists will say, oh, it's the joint. A dermatologist will say it's the skin. So basically let the patient decide, lay out the options and say, well, what do you wanna do about it? You know, if they have your, you're, if you have consent, then you can go more and use all the different tools, and you'll have happy patients and their primary care physician may not like it, but you have very happy patients and you're boost, you're boosting the future of, uh, ultrasound imaging and non-invasive testing.

Speaker 1: Dr. Mena Ramos

I think this is a good moment to kind of pose a question to the audience. Um, within your different practice settings, how feasible is, are some of these more advanced imaging modalities alongside point of care ultrasound?

Let's talk about cost versus lifestyle. If you go through an unnecessary biopsy and the, the complications that can follow, we are finding that a lot of people are willing to spend a few extra dollars to pay for a test to avoid the time, the waste of, of their lifestyle, uh, their body motion to disfigurement. And a lot of times the diagnosis is inconclusive anyway. So they gotta go for more tests. And look, somebody's PSA, for example, a guy has a elevated PSA young healthy elevated PSA, they say, PSA is high, let's do an ultrasound. No, let's do an MRI, the MRI with infl inflammation in the breast, the neck or the prostate will turn out positives. So then the fellow gets a biopsy, they find low grade prostate cancer, they cut out his prostate, and he's an invalid, if not else psychologically. And oftentimes the recovery time is, is months to sometimes a year.

Speaker 2: Dr. Robert Bard

And if they get sepsis, we've seen people out in a hospital for, for nine months following a simple prostate biopsy. The same is true of any biopsy in the breast. You're introducing toxins, complications. There are a huge amount of misdiagnoses in, uh, frankly, in biopsies. That's how I got started in this, in 1996. I think a whole group of radiologists in New York were listening to the Memorial Sloan Kettering talk on prostate biopsies. Guess what? It was 16% accurate. What's the inaccuracy rate? So this is memorial, who does it? At any rate, we decided maybe there's a better way. So we started looking at advanced imaging options. And frankly, worldwide, in, in Europe, if there's a thyroid mass with, uh, no blood flow and lower elastography or a breast mass or uh, liver mass or kidney masses, now you can watch the patient offer them the option, Hey, it could be a cancer, but it could be something we can watch. So

 

So again, you ask the patient, what do they want to do? They do. They wanna watch it. Do you know that low grade prostate cancers from nine 11 from the toxic waste sites are extremely common. And we've been following low grade cancer in the first responders in fire department for years. And you can feel it, you can see it, you show it to the, uh, firefighter or cop, and you say, well see, it is one centimeter and it hasn't changed over the last 10 years. So you're giving people options. That's what they want. And they will, frankly, they'll pay for, for, uh, whatever's necessary if it's reasonable and the, it, it's not a waste of their time.

Speaker 1: Dr. Mena Ramos

I do think you bring up a very important point about just access to equipment. You know, training is certainly one big barrier. Um, but if you don't have the proper equipment with the appropriate software, then how do you actually apply training? And so this might be a great opportunity to kind of open the floor, um, to other members of the audience, what your experiences have been, what you see kind of in the pipeline in terms of accessibility of some of these more advanced imaging modalities within the point of care ultrasound, uh, realm. Um,

 

In terms of training, uh, from the, you know, uh, sonography training perspective, um, there are gaps. Uh, there are gaps in training, I think kind of across the board in multiple specialties and how this may relate to technology and the development of technology is, it's not just a one way street, right. Training impacts the use of technology, but the new applications that are, are developed, I mean, I'm just walking through the exhibit hall and seeing kind of what is now possible that wasn't possible, you know, 10, 15 years ago. I think will also, um, uh, impact how we, we we do training. So it's a bidirectional, um, bidirectional relationship that, um, I think those, that the, the pathways of communication need to be open. Hence, you know, conferences such as these are so important to have that exchange.

 

If we're, if we go a step beyond the sonography schools or medical schools or residency programs, how do you, how do you, um, uh, change workflows for people who are already in practice, which are the vast majority of clinicians, right? They're not in, they're not in traditional training programs anymore. So it, that poses another set of challenges. Um, we don't have all the answers, um, but we do, I think seeing where success has, where we've seen success in the point of care ultrasound space, I think some of those similar, uh, concepts can apply. Certainly there are extra limitations when it comes to what is available at, uh, a more, uh, accessible or affordable, um, uh, price then say, uh, for some of these advanced applications. But once again, if we take a look at what's available today versus what was available 15, 20 years ago, it's, it's night and day. Um, uh, DR.

 

Speaker 2: Dr. Robert Bard

Another thing is more uses. Uh, we had a lady came in from actually San Diego last week, and she had a molar problem, an abscess tooth. So we, we did the ultrasound, then I saw no inflammation in the tooth. 'cause she had it a month, I'm sorry, a year and one month old. But we did the ultrasound, we sound periosteal calcification, in other words, because of the abscess, she developed perio titis, which you can see with very high resolution ultrasound. And then it healed over. So she had a big hole in her jaw, but it was contained. And of course now she's got inflammation floating around her body. And as the dentist, they will tell you, dental disease and body health is, they're, they're, they, they're combined. They match. It causes a lot of disease that's completely unrecognized by dentist. The other thing is, what else can you do at, at lunch, we're sitting with a MFM and maternal fetal medicine, uh, person.

 

And I said, well, what problems do you have? Uh, no, no problems. Well, I, I thought back into my obstetrical days. Well, what about abrupt deal placenta? Okay, think about it. Is the placenta full of blood vessels? Lots of blood vessels. So on the imaging and the thermography, which is non-invasive, the vascular imaging, you can see blood vessels and if the blood vessels there will be heat. So with simple non-invasive imaging, you can see if there's a hole in the symmetric blanket of the, uh, placenta or not. And this will comfort women. And because you show them everything's intact, the lack of stress will decrease the chances of an abruptly or some preeclampsia. So it, it works in every area that you can think of. 'cause the people who are in the area aren't thinking of the what else can be done. They're happy with what they're, they're doing. But this society can bring the future by advancing it.

Speaker 1: Dr. Mena Ramos

The the applications are, are vast. I think that's actually one of the, the challenges is that because there are so many applications really being able to focus, um, on certain key ones that may get the most, say, uh, number needed to scan for this specific use case, really contextualizing can get, um, can lower the barrier to, to initial entry for someone or a health system that might be interested in making the investment in both training equipment, um, uh, to, to adopt some of these, um, these technologies. Um, I'm, I'm curious to hear from anyone else in the audience your experiences with respect to elastography microvascular imaging, um, uh, in your clinical settings or educational settings, um, or other research ideas. A really number needed to scan that's, that's opportunity.

 

We, we chose to focus on, um, skin soft tissue, breast and, and liver. But that's certainly not limited. The applications are not limited to those organ systems. So thank you for, um, for, for addressing that. Um, I mean the, I think a lot of research can come out of this. Um, but I think some of the, just to reiterate some of these common themes that are, uh, that have come out of this conversation, um, with respect to training, the challenges to, to adoption training, which also goes along with awareness that hey, these things are, these applications are possible. Um, the equipment to, to be able to support the training and, um, and vice versa. Um, and also just multi-specialty collaboration. Um, because we're seeing gaps, um, not just within one silo or one specialty, but we, you know, from the sonography perspective, from the radiology perspective, from the, uh, primary care family medicine perspective, um, I'd love to hear if, if there's folks in terms of the engineering or um, uh, uh, technological development industry perspective, what are some of the challenges there?

 

I think it would be very difficult to find the through line and move this forward for, you know, these technologies, I, we, you know, we say are advanced, but they have been described for well over a decade. Um, and so I love the way you put it, Dr. Uh, Dr. Bard. You know, it's, it's not just about, you know, this is, it's not about what we know. It's what we can apply. Um, and so how can we apply these known technologies that we know can benefit patients' lives, um, by connecting these dots. Um, I hope this, I hope this has been, um, a conversation starter, um, and a kind of a, uh, a, uh, reintroduction of, um, how, uh, these imaging modalities could be applied at, on a, uh, in a brighter, uh, broader scope, um, across the continuum of care. Um, um, and I just wanted to open the floor the last few minutes we have for any thoughts, questions, comments, uh, in the audience.

Speaker 2: Dr. Robert Bard

Well, let me add one thing. In the women's health community, we are imaging and treating endometriosis, which is often misdiagnosed for years because women don't complain about it. If they do, they complain to their physical therapist and not their doctors. So it, it gets mistreated. The other thing is menopause. I learned this week that working with one of the Florida, uh, thyroid experts, that hypothyroid and hyperthyroid also cause myocardial disease and carotid artery disease. All this thing is the, what's the biggest organ in the body? Anybody? Hmm? Skin. The skin, the endothelium lining is 64 acres. The lining of the endothelium, this is the most sensitive part of the body, and it's, it's a hormonal receptor. So this is the whole key behind cardiovascular disease. We can see it now. So, hypertension, stroke, uh, um, which is particularly virulent after menopause. It's, there's a high rate rate of, uh, cardiovascular disease. Uh, heart disease is killing more, uh, women and men than, uh, breast cancer, for example. So this is an area of education. So if you have any thoughts or ideas, email us. Give us a call, visit our center centers and, uh, we'll see if we can move together forward.

 

Thank you.

 

Thursday, April 3, 2025

Post-Production Notes: Successful Video Education Starts with BEST AUDIO


The Importance of High-Quality Audio in Educational Medical Videos

In the realm of medical education, the clarity of communication is paramount. Whether delivering a lecture on complex physiological processes or demonstrating a surgical technique, the ability to clearly convey information can mean the difference between understanding and confusion. While high-resolution visuals and engaging presentation styles are important, the foundation of any effective educational video is crystal-clear audio.

Visual EQ of video (above) shows quality & clarity difference in audio


Why Audible Medical Presentations Matter

Medical presentations are inherently detail-oriented, often containing nuanced terminology, critical data, and precise instructions. If audio is distorted, muffled, or plagued by background noise, the message is lost, and comprehension suffers.

For healthcare professionals and students, every word matters. Mishearing a term or misunderstanding an instruction due to poor audio can lead to misinformation, reduced engagement, and potential errors in clinical practice. A well-articulated, professionally recorded voice ensures that learners receive the full depth of knowledge intended.


High-Quality Audio Equipment / Recording Direct from the Board

Investing in professional audio equipment is an essential step toward producing effective medical videos. High-fidelity microphones, noise-canceling technology, and proper sound engineering can drastically improve the auditory experience. Clear speech with balanced tone and volume enables learners to focus on content without the distraction of hisses, echoes, or external noise.

Clear audio recording of mic’ed presentations is crucial for preserving the integrity and impact of the speaker’s message. Recording directly from the board ensures the highest sound quality, eliminating background noise, audience chatter, and room echo that can degrade clarity. By capturing the speaker’s voice at the source, the recording remains crisp, balanced, and easily intelligible, making it suitable for various applications, from post-event reviews to content distribution on digital platforms.

When presentations are recorded with poor audio quality, essential details can be lost or misinterpreted. A direct feed from the mixing board provides a controlled, consistent sound level, preventing issues like volume fluctuations or microphone dropout. This approach ensures that every word is captured as intended, preserving the speaker’s nuances, emphasis, and tone. Whether for corporate conferences, academic lectures, or live-streamed events, professional-grade recordings enhance accessibility and audience engagement.

How Bad Audio Diminishes Learning: Understanding the General Audience with Weak Attention Spans

Poor audio quality is one of the fastest ways to lose an audience's attention. When sound is unclear, listeners must strain to decipher words, leading to cognitive fatigue and frustration. This problem is exacerbated in medical education, where precise language is critical. Learners who struggle to hear key points may disengage, miss essential details, or misunderstand information altogether.

Additionally, many educational videos are consumed through headphones or mobile devices in environments where ambient noise is already a challenge. If the audio is not professionally produced, background interference can overpower the speaker’s voice, making it even harder for students and professionals to grasp the content.

The average audience has an incredibly short attention span when faced with poor audio quality. Research suggests that listeners will disengage within seconds if they struggle to understand a speaker due to muffled sound, background noise, or inconsistent volume levels. When audio clarity is compromised, the brain has to work harder to process speech, leading to listener fatigue and frustration. This cognitive overload quickly pushes audiences to tune out, seek alternative content, or abandon the experience altogether. Even compelling content cannot overcome the barrier of bad audio—if people cannot hear or comprehend the message, they simply won’t stick around.

In today’s digital age, where high-quality audio is expected across podcasts, webinars, and videos, subpar sound instantly signals a lack of professionalism. A crackling microphone, echo-filled room, or distorted voice can make even the most insightful discussion unbearable to listen to. Studies in communication and media consumption show that audiences are far more forgiving of poor visuals than bad audio—people will tolerate a low-resolution video but will not endure inaudible speech. Whether in a business presentation, online content, or live event, ensuring crisp and clear audio is essential to maintaining engagement and credibility.

 

Ensuring a Clear Message Through Professional Sound

To maximize the effectiveness of medical educational videos, creators should prioritize:

  1. Using High-Quality Microphones – Lavalier or condenser microphones reduce background noise and capture clear speech.

  2. Employing Soundproofing Techniques – Recording in quiet, acoustically treated environments prevents unwanted reverberation and interference.

  3. Professional Audio Editing – Enhancing clarity through equalization, noise reduction, and mastering ensures a polished final product.

  4. Consistent Volume Levels – Avoiding volume fluctuations prevents listeners from constantly adjusting their device settings.

  5. Testing Audio on Multiple Devices – Ensuring compatibility across headphones, speakers, and mobile devices guarantees an optimal experience for all viewers.


Conclusion

In medical education, where precision and comprehension are critical, investing in high-quality audio is not a luxury—it is a necessity. Crystal-clear sound ensures that the speaker’s message is fully understood, facilitating better learning outcomes and professional development. By prioritizing professional audio equipment and sound engineering, educators can significantly enhance the impact of their presentations, ensuring that their audience remains engaged and informed.

Tuesday, March 18, 2025

HEAD AND NECK: QUANTITATIVE THERMAL MEASUREMENT & A MEDICAL COMPLETEMENT TO THE ULTRASOUND

By: Robert L. Bard, MD     |     Edited by: Graciella Davi

The patient is a 65-year-old military veteran who sustained a fall, leading to a concussion that required a three-day hospital observation period. Upon discharge, he reported persistent shoulder pain. Ultrasound imaging of the shoulder revealed an inflamed biceps tendon, which was appropriately treated with physical therapy or targeted injection—avoiding unnecessary rotator cuff surgery, which had initially been planned. Given the patient’s recent concussion, ultrasound assessment was extended to the optic nerve, which was imaged within minutes and confirmed as normal, ruling out increased intracranial pressure.

Optic nerve swelling is also another a critical indicator of elevated intracranial pressure and is widely used in emergency medicine for concussion assessment. While hospital concussion screenings may clear a patient, they do not eliminate the risk of delayed-onset intracranial bleeding. Subdural hematomas, for example, can develop over days, weeks, or even months post-injury, gradually increasing intracranial pressure. Early detection using noninvasive imaging techniques is therefore essential and timely.

Case Study: Post-Concussion Symptoms / Cerebrovascular Blood Flow and 3D Ultrasound Imaging



Findings:

Head: There are signs of reduced blood flow—by about 50%—in the right and left ophthalmic arteries (which supply blood to the eyes and surrounding areas). Further testing suggests that the main arteries supplying the brain (the carotid arteries) may be partially narrowed (by about 50-70%). To compensate for this, smaller blood vessels in the face have grown larger to help maintain circulation.

Neck: The thermal scan suggests that the thyroid gland (located in the front of the neck) may be functioning at a lower-than-normal level. There are also signs of increased activity in lymph nodes under the jaw on both sides of the neck, which may be a reaction to an infection, inflammation, or exposure to toxins. These findings are not definitive for a specific disease but could indicate an underlying issue that may need further evaluation.


This report examines the application of quantitative thermal measurement in assessing cerebrovascular blood flow, utilizing the science of thermometry corroborated by 3D ultrasound imaging. This approach is significant because conventional carotid ultrasound primarily focuses on the carotid arteries, while transcranial Doppler imaging targets intracranial circulation. Similarly, ocular ultrasound is highly effective for evaluating the optic nerve, retinal vascular patterns, and temporal artery blood flow. However, a comprehensive, functional assessment of cerebrovascular circulation (considering dynamic blood flow changes due to factors such as physiological state, trauma, or medication) requires an integrative imaging approach.

The ability to predict abnormal flow patterns is crucial for early prognosis in conditions such as stroke. The cerebrovascular system comprises multiple collateral circulatory pathways, both inside and outside the brain, that can compensate for major vascular obstructions. An individual’s survival following a massive stroke is heavily influenced by the presence and functionality of these collateral pathways.


In this case study, ultrasound scans of the ophthalmic artery, carotid artery, and internal cerebral vessels—performed using transcranial Doppler—validated the thermal imaging findings. Extracranial vascular thermography enables real-time mapping of facial perfusion via the ophthalmic arteries, which originate from the internal carotid artery. This technique provides valuable insight into vascular function and offers a noninvasive screening tool for identifying potential interventional strategies.

The ability to perform noninvasive cerebrovascular screening allows for early detection of arterial supply abnormalities, which may warrant further evaluation using arteriography, vascular MRI, or targeted ultrasound imaging. This predictive capability is particularly relevant for stroke prevention.


Part 2: EXPANDED REVIEW on APPLICATIONS IN PREDICTIVE CARDIOVASCULAR AND DERMATOLOGICAL HEALTH

Beyond cerebrovascular applications, noninvasive thermal imaging is also emerging as a valuable predictor of cardiovascular disease, particularly in women, who often exhibit fewer symptoms before experiencing a catastrophic vascular event. Moreover, inflammatory skin conditions such as rosacea and psoriasis are systemic disorders with vascular implications. Quantitative thermal imaging can assess localized arterial involvement and track treatment response more effectively than visual monitoring of redness reduction, which is the conventional clinical endpoint.

A potential application of this technology in menopausal health screening involves assessing extracranial carotid blood flow in the face and neck. Given the increased cardiovascular risk in postmenopausal women, thermal imaging could serve as an early indicator of cerebrovascular and cardiovascular abnormalities.


Part 2:

DEFINING MEDICAL-GRADE THERMAL IMAGING
Transcribed from an interview with Dr. Phil Hoekstra (from Feb 22, 2025)

MEDICAL-GRADE THERMAL IMAGING is a term I use with a level of precision that differs from many others in the field. Let me clarify what I mean by it. Thermographic instruments were already in use before the FDA gained oversight over medical devices. Initially, they were grandfathered in as medical devices when the FDA assumed regulatory authority, but the standards set at the time were quite limited. Over the years, thermographic technology has advanced at a pace similar to personal computers. Just as we wouldn’t want to rely on a 1980s-era computer today, we shouldn't be using outdated thermal imaging standards for medical applications. Unfortunately, the FDA still maintains the original 1980s standards for medical thermographs. If a camera meets these older benchmarks, it can be FDA-approved—but this does not necessarily mean it is suitable for modern medical diagnostics. The performance of such cameras is inadequate for properly distinguishing breast cancer from benign conditions that may present with similar thermal patterns. (See Full report)



SPOTLIGHT ON MEDICAL CONFIRMATION OF THERMAL IMAGING: MEET THERMA-SCAN

DIRECT FROM THE SOURCE-  HealthTech reporter is proud bring you a mini-autobiographical tour of the science of THERMOLOGY.  We introduce Dr. Phil Hoekstra, a medical physiologist specializing in medical-grade thermal imaging. He is the Laboratory Director at Therma-Scan Reference Laboratory in Mesa, Arizona. With decades of experience in thermal imaging, Dr. Hoekstra has contributed extensively to the field, enhancing the clinical application of infrared imaging in medical diagnostics. Therma-Scan Reference Laboratory stands as the premier facility for medical thermal imaging, setting the standard for accuracy and reliability. The laboratory provides advanced thermographic analysis for various clinical applications, ensuring the highest level of diagnostic precision.

Dr. Hoekstra’s expertise extends beyond laboratory operations; he actively contributes to the advancement of thermal imaging technology and its integration into medical practice. His work has helped establish best practices and protocols that elevate diagnostic thermal imaging as a reliable tool in healthcare.

 

DEFINING MEDICAL-GRADE THERMAL IMAGING
Transcribed from an interview with Dr. Phil Hoekstra (from Feb 22, 2025)

MEDICAL-GRADE THERMAL IMAGING is a term I use with a level of precision that differs from many others in the field. Let me clarify what I mean by it. Thermographic instruments were already in use before the FDA gained oversight over medical devices. Initially, they were grandfathered in as medical devices when the FDA assumed regulatory authority, but the standards set at the time were quite limited. Over the years, thermographic technology has advanced at a pace similar to personal computers. Just as we wouldn’t want to rely on a 1980s-era computer today, we shouldn't be using outdated thermal imaging standards for medical applications. Unfortunately, the FDA still maintains the original 1980s standards for medical thermographs. If a camera meets these older benchmarks, it can be FDA-approved—but this does not necessarily mean it is suitable for modern medical diagnostics. The performance of such cameras is inadequate for properly distinguishing breast cancer from benign conditions that may present with similar thermal patterns.

When I refer to a medical-grade thermograph, I mean a state-of-the-art camera with the necessary precision and reliability for accurate medical diagnostics. While thermal cameras vary widely—from basic models used for home insulation inspections to advanced systems on the James Webb Space Telescope—medical thermographs fall somewhere in between. They must be both practically affordable and sufficiently high-performing. Specifically, a true medical-grade thermograph must be capable of resolving at least 0.001 degrees Celsius over a one-square-millimeter area of skin at the working distance of the lens, with repeatable accuracy. 

Beyond the equipment, medical-grade imaging also refers to the methodology applied in thermal imaging, which must align with the principles of medical oncology. Additionally, the laboratory handling these images must adhere to HIPAA regulations and the same rigorous standards and practices found in top-tier medical centers.

Medical-grade imaging starts with the facility performing the scans. The imaging process must follow strict protocols, utilizing high-quality equipment that meets our specifications. At Therma-Scan Reference Laboratory, we prefer to work with FLIR cameras, which are FDA-listed as medical devices. These cameras are radiometric, meaning each pixel functions as a thermometer that provides quantitative temperature data rather than merely producing a colorized image.

Our analysis relies heavily on specialty software, which is also FDA-listed. This software enables precise temperature measurements at various points, allows us to track changes over time, and facilitates diagnostic evaluations through dynamic applications such as a functional challenge procedures. This process involves taking baseline images, subjecting the patient to a controlled cooling stimulus, and capturing post-exposure images to assess physiologic responses. This level of quantification ensures that our results are not just qualitative interpretations but rigorously analyzed data.


(L) Dense Breast mammography
(R) Breast Thermology
THE ROLE OF NEOANGIOGENESIS IN BREAST CANCER DETECTION

One of the core principles of medical thermography is detecting physiologic changes associated with cancer. Neoangiogenesis—the formation of new blood vessels—is critical for tumor growth. Without it, cancerous cells would be unable to obtain the nutrients they need to proliferate. The abnormal structure of these new blood vessels was not well understood until the late 1980s, when studies revealed their unique porous nature.

Unlike normal blood vessels, which have a structured, three-layered composition, neoangiogenic vessels are disorganized and resemble a natural sponge, with an erratic, unregulated flow. Lacking smooth muscle and autonomic nervous system regulation, these vessels exhibit excessive and uncontrolled blood flow. As a result, areas of neoangiogenesis appear as "hot spots" in thermal imaging. Because breast tissue is located in the outer shell of the body, where body heat is regulated to maintain a stable core body temperature, these hot patterns can indicate malignancy, setting medical thermology apart as a functional imaging modality distinct from structural imaging techniques like mammography, ultrasound and MRI.

 

ADVANCING THE FIELD OF MEDICAL THERMOGRAPHY
Therma-Scan Reference Laboratory is at the forefront of innovation in medical thermography. Our approach is defined by strict adherence to quantitative, repeatable standards that ensure reliability. Many of the advances in the field—including the objective analytic standards, the adaptation of the Marseille system (later incorporated into the American College of Radiology’s BI-RADS system) and the high-caliber equipment used—originated with our work.

Unlike traditional thermographic assessments that relied on static images and pattern recognition, the future lies in dynamic thermology. This emerging field involves capturing real-time, streamed thermal images and applying digital subtraction analysis to detect physiological responses to stimuli. At Therma-Scan, we pioneered the adaptive challenge, in which we capture baseline thermal images, expose the patient to a mild cooling stimulus, and then record post-exposure images to assess changes. The next step in our research is refining this process with advanced digital subtraction techniques, enhancing diagnostic precision.

 Unfortunately, medical thermology has not benefited from significant funding or institutional support comparable to what mammography has received through organizations like the American College of Radiology. As a result, progress has been largely self-funded, requiring careful resource allocation to keep services affordable while driving innovation forward. Although medical thermology is recognized with CPT codes, it is not currently covered by insurance, adding another layer of financial challenge.

 

A LEGACY IN MEDICAL SCIENCE
My journey in medical thermology has been shaped by mentorship from pioneering experts in the field. I was fortunate to train under multidisciplinary leaders, including Harold Isard, a student of Jacob Gershon-Cohen, a key figure in early thermographic research. Through four separate fellowships, I gained hands-on experience and contributed to the field's development. To achieve professional certification, I submitted 50 cases to the American Board of Thermology for rigorous review, defending each case before a physician board in a process akin to a dissertation defense. As far as I know, I am the only individual who has pursued this level of certification across four different specializations in medical thermology. This dedication reflects my commitment to ensuring the highest standards in medical thermography and advancing the field through research, innovation and clinical application.

By continuously refining our methodologies, investing in new technologies and upholding the strictest standards, Therma-Scan Reference Laboratory remains the leader in the evolving landscape of medical thermal imaging. The future of thermology lies in dynamic, quantitative analysis—and we are proud to be paving the way.

 

 

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