TECHNICAL  PROTOCOLS  for
HIGH-RESOLUTION  INFRARED  IMAGING

A cool examination room is imperative.  16-20°C is the recommended temperature range, and it is important that the ambient room temperature not exceed 20°C.  The core temperature of the patient’s body must be stressed to provoke reactions in the sympathetic nervous system.

Room temperature should be controlled so that ambient temperature does not change more than 1°C during the course of the examination.

The examination room must have a thermometer to record the room temperature before, during, and after the examination.

Heat sources should be minimized in the examination room and must be kept well away from the patient.

In no case shall the temperature or humidity conditions in the examination room be allowed to provoke sweating on the part of the patient, as this would produce unacceptable artifact.

The floor surface on which a patient stands must be carpeted.

Typical doors and shaded windows should be sufficient to maintain the examination room free of obvious drafts.

Ventilation required to maintain the necessary cooling of the examination room should be as draft-free as possible, with no direct cold air blowing on the patient.

Standard fluorescent or diffused incandescent lights are adequate.

Shower or bathe the morning of the test to ensure that the skin is as clean as possible; however, avoid hot water exposure to the skin for at least two hours prior to the test.

Avoid placing any material of any kind on the skin, such as any skin lotions, deodorants, preparations, moisturizers, liniments, topical analgesics, etc.  Avoid make-up if the face is to be examined.

Wear loose clothing to the test; avoid anything binding against the skin; avoid support undergarments or pantyhose.  Do not wear jewelry, including rings if the hands are to be examined.

Eat lightly approximately two hours prior to the test, but avoid any spicy or stimulating foods for 2 hours prior to the test.

Avoid any source of nicotine for 4 hours prior to the test.

Avoid any source of caffeine (colas and coffee, including decaffeinated coffee) for 4 hours prior to the test.

Sunburn must be absolutely avoided for one week prior to the test.

Physical medicine procedures:

	Avoid skeletal manipulation, acupuncture, physical therapy, the use of TNS units, or electrodiagnostic testing for 24 hours prior to the test.
	Exercise:
	Normal light exercise is acceptable.

Bandages and braces:

Remove all bandages and braces for at least 12 hours prior to the test.

Medications:

	The use or withdrawal of medications should be coordinated with the prescribing physician; however, if possible, the test should be performed in the morning, and all medications should be withheld after midnight.  Certain medications have an effect on sympathetic function and could complicate interpretation of the test.
	Unless there is compelling reason to the contrary: sympathetic blockers should be avoided for 12 hours prior to the test. steroids should be avoided for 24 hours prior to the test. transdermal patches should be avoided for 24 hours prior to the test.
	Examples of medications that may produce alterations in surface temperature that could complicate the interpretation of an infrared image include but are not limited to: beta blockers, calcium channel blockers, alphaadrenergic blockers, vasodilators, opioids, analgesics, antiinflammatories, high-dose niacin, and topical or transdermal agents such as capsaicin cream or patch, clonidine patch, or nicotine patch.
	Sympathetic blocks: For original diagnostic studies, all sympathetic and neurolytic blocks must be avoided for at least 3 days prior to the test, preferably one week prior. Post-block studies may be performed to: assess the effectiveness of the sympathetic block. evaluate for and/or localize the area of nociception in cases of sympathetically-maintained pain and vasoconstriction seen in patients showing normal somato-autonomic or viscero-autonomic reflexes secondary to a pain generator(s). No equilibration is required for these post-block images, as an intentionally-induced sympathetic artifact is already present.  Region-of-interest spot views provide appropriate visualization, assuming that a full-protocol original diagnostic study has already been produced prior to the block.

Upon entrance to the thermal imaging lab, the patient shall remove all clothing (including undergarments) and jewelry in the area to be imaged and shall be issued a lightweight, loose examination gown.

The gowned patient shall remain in the temperature-controlled examination room for at least 20 minutes, provoking cooling of the body sufficient to stress the body’s core temperature.

The equilibration time may need to be extended, on a case-by-case basis, in obese patients or in those with certain endocrine disorders.

In most cases (other than above), greater than 30 minutes equilibration time is not generally advised.  Excessive equilibration times may cause patients to cool excessively and begin to tremble, thus inducing artifacts in the study.

If a time/temperature stress test (qv) is performed, no equilibration is required, as the purpose of the procedure is to show sympathetic function in response to equilibration over time.

Equilibration is not required for post-sympathetic-block follow-up evaluations (see above).

The body part to be imaged must be selectively uncovered for each view so that the infrared camera can detect surface infrared emanations.

A “study” is a collection of infrared views necessary to form a diagnostic impression.

The views imaged should encompass the symptomatic region of the body and all of its proximal and distal neurovascular components.  This is usually interpreted as follows:

	Upper body study For evaluation of neck, upper back, or upper extremity complaints
	Lower body study For evaluation of lower back, pelvic, and lower extremity complaints

Assuming that these protocols are followed, one study is adequate for diagnostic purposes; triplicate imaging is no longer required.

The field of view chosen for imaging should be appropriate to the image resolution inherent in the infrared camera equipment being utilized; higher resolution cameras allow larger fields of view.

It is recommended that all of the views imaged should also be permanently archived, for purposes of comparison of changes over time.

Autonomic stress testing may be required for some conditions, particularly for the Complex Regional Pain Syndromes.    This may be accomplished by immersing a body part not being imaged in cold water to further stimulate the autonomic nervous system; for example, if the hands and upper body are being imaged, the feet are chosen for cold water immersion.

Mechanical stress testing may be required to provoke mechanically-induced symptoms.

Sympathetic response to equilibration over time may be conducted, known as a time/temperature stress test.

Other stress tests may include water mist, warm water immersion, directed air draft produced by fan, or alcohol spray.

A description of the stress test must be entered in the chart and described in the report, and it is also recommended that the procedure be identified by legend affixed to the images.

The stress views shall be imaged and recorded as the last part of the study, after the standard views have been collected.

Spot studies of a region-of-interest may be produced to evaluate response to a sympathetic block.

The ordering or examining physician may decide on the appropriate stress test to be utilized for any given patient.

Only high-resolution electronic infrared scanners are appropriate.

Temperature repeatability and accuracy of 0.1°C temperature recording is necessary.

When multiple views are used for bilaterally equivalent areas, the equipment settings and technique should be identical.

Patient's name or identification code

Facility/doctor identification

Date the service was rendered