1. Drive carefully, life is precious
Diagnostic Imaging for Rehab
Doctors

2. Learning outcome and
objectives
1. Become familiar with various medical imaging
modalities
2. Understanding the advantages and disadvantages of
different imaging modalities
3. Be able to recommend the correct modality given a
case study
4. Integrate diagnostic imaging information into
physical therapy practice

3. Why do rehab doctors need to
understand medical imaging?
1. Clinical Reasons?
• How will it effect treatment?
• How will it effect prognosis?
• What about direct access?
2. Research Implications?

4. Clinical reasons:
1.not responding as expected,
2.possible undiagnosed fracture,
3.deg changes (joint space),
4.-assess status of hardware,
5.-make clinical decisions whether surgery vs. no
surgical treatment
Research reasons:
1.-biomechanical studies,
2.-correlate clinical tests with imaging findings,
3.-look at reliability and validity of imaging tools,

5. Imaging modalities
Ionizing modalities Non-ionizing modalities
Radiography/Plain x-ray MRI
CAT Scan or CT scan US & Doppler
Isotope bone scan
Flouroscopy

6. Radiography

7. Basic Concepts
What is an X-Ray?
Electromagnetic Radiation -
short wavelength

8. An X-ray machine is essentially a camera.
Instead of visible light it uses X-rays to expose the film.
X-rays are like light in that they are electromagnetic
waves, but they are more energetic so they can penetrate
many materials to varying degrees.
When the X-rays hit the film, they expose it just as light
would.
Since bone, fat, muscle, tumors and other masses all
absorb X-rays at different levels, the image on the film
lets you see different (distinct) structures inside the body
because of the different levels of exposure on the film.

9. Professor Roentgen
Discovered accidentally in
1895
Experimenting with a
machine that, unknown to
him, was producing x-rays
Saw the bones of his hand
in the shadow cast on a
piece of cardboard in his
lab

10. What Roentgen
saw Today's ImageToday's Image

11. Radiodensity
X-rays not absorbed,
screen produces photons
when struck, and exposes
the film, turning it dark
When an object
absorbs the X-rays -
fewer photons
produced, film stays
light
Radiopaque Radiolucent

12. Principle components of x-ray tube:
Source of electrons
 Target
 Evacuated envelope
 High-voltage source

13. The X-ray tube parts:
Cathode (-)
Filament made of
tungsten
Anode (+) target
Tungsten disc that turns
on a rotor
Stator
motor that turns the
rotor
Port
Exit for the x-rays

14. X-ray Production
X-rays are produced when high velocity electrons are
decelerated during interactions with a high atomic number
material, such as the tungsten target in an X-ray tube.
An electrically heated filament within the X-ray tube
generates electrons that are then accelerated from the
filament to hit the tungsten target by the application of a
high voltage to the tube.
The electron speed can exceed half the speed of light
before being rapidly decelerated in the target.

15. X-ray production
Push the “rotor” or “prep”
button
Charges the filament –
causes thermionic emission
(e- cloud)
Begins rotating the anode.
Push the “exposure” or
“x-ray” button
e-’s move toward anode
target to produce x-rays

16. X-rays characteristics
Highly penetrating, invisible rays
Electrically neutral
Travel in straight lines.
Travel with the speed of light in vaccum:
300, 000 km/sec or 186, 400 miles/sec.
Ionize matter by removing orbital electrons
Induce fluorescense in some substances. Fluorescent
screen glow after being stricken with photons.
Can't be focused by lenses nor by collimators.

19. CONCONVENTIONAL
CONcCCORADIOGRAPHY
PRODUCES STATIC IMAGES

20. Shielding

21. Therapeutic x-ray production, where mega
electron volts (MeV) are used, has a higher
conversion of electrons into photons.
In the diagnostic range (KeV), there is more
conversion of the electrons to heat.
Total number of electrons converted to heat is
99%.
Only 1% of the electrons are converted to photons

22. Attenuation
Attenuation – reduction in the number of
photons as they pass through matter
Attenuation occurs in several different
ways:
Some photons are absorbed by matter they
pass through
Other’s change course in matter, called “scatter

23. A-B-C-D
A- Alignment- is the bone in good general
alignment
B- Bone- general bone density
C- Cartilage- sufficient cartilage space
D- Dee other stuff??
Muscles, fat pads and lines, joint capsules,
miscellaneous soft-tissue findings, bullets

24. Alignment

25. Alignment

26. Bone

27. Bone

29. Cartilage

31. Dang
The role of
imaging is to
confirm the
infection and
show extent.
Radiography will
show the
infection,
however usually
late. Radiography
has a high
specificity but low
sensitivity.

32. Viewing Images
X-ray study named for the direction the beam travels
1. AP 2. PA
3. Lateral
Orient film as if you were facing the patient, his/her Left
will be on your Right

33. Views
Lateral

34. Oblique

35. Views
AP Open Mouth
Dens

36. Superior articulating facetSuperior articulating facet
Transverse processTransverse process
PediclePedicle
LaminaLamina
Inferior articulating facetInferior articulating facet
Lumbar Spine, Oblique View

37. Lumbar Spine, Oblique View
“SCOTTY DOG”

38. Lumbar Spondylolysis
The defect
‘lysis’ involves
the pars
inarticularis
and can allow
the vertebra
above to
sublux
forward

39. Still Alive?

40. …That was
close

41. Bullet can be in
any of these places
(anterior to
posterior at same
level)
1 - spinal cord
2 - trachea
3 – Superior
Vena Cava
4 - aorta

42. Viewing Images
A radiograph is a two dimensional
representation
Therefore, “One View is No View”
Two views are needed, ideally at 90
degress to one another for proper 3-D
like interpretation

43. Radiograph
revealed
horizontal
fracture of the
lower patalla

44. To sum it up
It is relatively much more
important for a physical
therapist to recognize the
indications for diagnostic
imaging,
to select the most appropriate
imaging study, and
to image the appropriate
area(s) than it is to interpret
the image

45. Computed Tomography (CT)
1. Also called CAT scanning or “CT”
2. X-Ray beam moves 360 around the patient
3. Consecutive x-ray “slices” around the patient
4. Computer can recreate 3D image of the body or
Image “slices” reconstructed by computation
5. Best for evaluating bone and soft tissue tumors,
fractures, intra-articular abnormalities, and
bone mineral analysis

46. Computed Tomography
6. The image formed is related to the subjects
density
7. Image display on computer or multiple films
8. New technology is multislice helical scanner

47. CT (by Picker)

48. Computed Tomography (CT)

49. LV
VERTEBRAL
BODY
SPINAL
CANAL
TRANSVERSE
PROCESS
RIB
LUNG
RA
LA
RV
AORTA

56. Magnetic Resonance Imaging
(MRI)
What is a MRI?
• The use of a High Power Magnet (.3
-2.0Teslas)To align hydrogen atoms in
the body to which a radio wave
frequency is applied to produce an
image
HigherTesla level= increased resolution

57. Magnetic Resonance Imaging
1. Also called “MRI”
2. Image formed by transmitting and receiving radio
waves inside a high magnetic field
3. Image “slices” reconstructed by computation
4. The image formed is related to:
1. Scanner settings
2. Patient hydrogen density
3. Patient hydrogen chemical/physical
environment
5. Image display on computer or multiple films

58. MRI by Picker

60. Indications for MRI
Diagnosing multiple sclerosis (MS)
Diagnosing tumors of the pituitary gland and brain
Diagnosing infections in the brain, spine or joints
Visualizing torn ligaments in the wrist, knee and
ankle
Visualizing shoulder injuries
Diagnosing tendonitis
Evaluating masses in the soft tissues of the body
Evaluating bone tumors, cysts and bulging or
herniated discs in the spine
Diagnosing strokes in their earliest stages

61. T1 Vs T2
T1
Tissue with high
water content will
apear dark (grey)
Fat, edema,
infection
Tissue with low
water content will
appear white/
brighter
T2
Tissue with high water
content will appear
white/ brighter
Tissue with low water
content will appear
darker (grey)
World War II
Water is white on
T2

62. T1 vs. T2
T1 image of knee T2 image of knee
Gastrocnemius
Semimembranosu
s
Popliteal vein
Quad Tendon
Semimembranosu
s
ACL
Semitendonosu
s

63. Knee - MRI Sagittal
ANTERIOR
CRUCIATE
LIGAMENT
POSTERIOR
CRUCIATE
LIGAMENT

64. PATHOLOGY
ACL Tear

65. Knee - MRI Sagittal
TORN POSTERIOR MEDIAL MENISCUS

66. Meniscus
Torn Meniscus

67. MRI shoulder
humerus
infraspinatus
S
c
a
p
u
l
a
Teres
m
inor
supraspinatus
D
e
lt
o
i
d
Clavicle
Glenoid labrum
Long Head
of Triceps

68. Shoulder - MRI – Axial Plane

69. SupS
D
D
IS
Shoulder - MRI – Axial Plane

70. Shoulder - MRI – Coronal Plane
Supraspinatus
Rotator Cuff
SS Tendon
Fluid in
Joint
Glenoid
Acr -- Clav

71. Shoulder
Supraspinatus
Tear
Subdeltoid Bursa

72. Lumbar Spine - MRI
Coronal T1 Sagittal T1 Sagittal T2

73. Axial T1
body
Axial T1
disc
Axial T2
body
Axial T2
disc
Lumbar Spine – MRI Axial

74. Bod
y
Psoa
s
Spinal
Canal

75. Herniated
disc
Lumbar Spine – MRI Sagittal T2

76. DEXA SCAN
Looks at bone mineral densities

77. Nuclear Scintigraphy
Uses gamma rays to produce an
image, emitted from the patient
Radioactive nuclide given IV, per os,
per rectum etc.
Abnormal function, metabolic activity,
abnormal amount of uptake
Poor for anatomical information
www.upei.ca/~vetrad

78. Nuclear camera

81. Skeletal Scintigraphy
(Bone Scan)
Indication
: Cancer,
stress or
hidden
fractures

82. Ultrasound
1. Also called “sono” or “echo” or “US”
2. Image formed by transmitting and receiving
high frequency sound waves
3. Image “slices” reconstructed by
computation
4. The image formed is related to interfaces
between tissue areas of differing sound
transmission characteristics
5. Image display on computer or multiple films

83. Convex 3.5 MHz
For abdominal and
OB/GYN studies
Micro-convex: 6.5MHz
For transvaginal and
transrectal studies
Ultrasound
machine
Ultrasound
examination

84. Text Books
David Sutton’s Radiology

85. THANK YOU