Foundations of Diagnostic Imaging for Physical Therapist

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Foundations of Diagnostic Imaging for Physical Therapist

  1. 1. Diagnostic Imaging forRehabilitation Professionals Dana Tew PT DPT
  2. 2. ObjectivesBecome familiar with various medical imagingmodalitiesDemonstrate understanding of the advantagesand disadvantages of different imagingmodalitiesBe able to recommend the correct modalitygiven a case studyIntegrate diagnostic imaging information intophysical therapy practice
  3. 3. Why do physical therapist needto understand medical imaging?• Clinical Reasons? How will it effect treatment? How will it effect prognosis? What about direct access?• Research Implications?
  4. 4. Medical Imaging•Radiography • Plain Film/ X-Ray/ Roentgen Rays • Computed Tomogaphy (CT Scan) • DEXA • Bone Scan•Magnetic Resonance Image (MRI)
  5. 5. Radiography
  6. 6. Basic Concepts What is an X-Ray?  Electromagnetic Radiation - short wavelength
  7. 7. 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
  8. 8. What Roentgensaw Todays Image
  9. 9. Radiodensity When an object absorbs  X-rays not absorbed, the X-rays - fewer screen produces protons produced, film photons when struck, stays light and exposes the film, turning it dark Radiopaque Radiolucent
  10. 10. belong?
  11. 11. The objects on the screen may not be what they appear Take a piece of paper and draw a geometric shape on it. (Square, triangle, circle etc.) Now take that shape and make it 3-D (square=cube)
  12. 12. What are you looking at? Must be familiar with I feel exposed! the form of a tissue/structures, if not, you can not anticipate it‟s radiological appearance, and can not decipher normal from abnormal
  13. 13. 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
  14. 14. Alignment
  15. 15. Alignment
  16. 16. Bone
  17. 17. Bone
  18. 18. What do I need to look for? Distal tibia and fibula F- fifth metatarsal base L- lateral process of the talus O- os trigonum A- anterior process of the calcaneus T- talar dome
  19. 19. Cartilage
  20. 20. Dee other stuff
  21. 21. Dee other stuff
  22. 22. The role ofimaging is toconfirm theinfection andshow extent.Radiography willshow theinfection,however usuallylate. Radiographyhas a highspecificity but low Dangsensitivity.Ledermann HP, Morrison WB,Schweitzer ME. Pedal abscesses inpatients suspected of having pedalosteomyelitis: analysis with MRimaging. Radiology 2002;224(3):649-655
  23. 23. Viewing Images X-ray study named for the direction the beam travels  AP  PA  Lateral Orient film as if you were facing the patient, his/her Left will be on your Right
  24. 24. Views Lateral Oblique
  25. 25. Lumbar Spine, Oblique View Superior articulating facet Transverse process Pedicle Lamina Inferior articulating facet
  26. 26. Lumbar Spine, Oblique View “SCOTTY DOG”
  27. 27. Lumbar Spondylolysis The defect „lysis‟ involves the pars inarticularis and can allow the vertebra above to sublux forward
  28. 28. Views Dens AP Open Mouth
  29. 29. Still Alive?
  30. 30. Whew…Thatwas close
  31. 31.  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
  32. 32. 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
  33. 33. How „bout some evidence Physical therapists in the military have been credentialed to order various radiographic procedures, including plain film radiographs, bone scans, and magnetic resonance images (MRI), for over 30 years PT‟s shown to be more cost effective than ortho surgeons in management of MSK disorders (with no difference in outcomes) o Daker-White G et al., J Epidemiol Comm. Health, 1999 When given the opportunity, PT‟s order imaging up to 50% less, with no difference in outcomes o Greathose DG et al., JOSPT, 1994 o James JJ et al., Phys Ther, 1981 o James JJ et al., Phys Ther, 1975 Diagnositic accuracy – No difference found between PT‟s and Ortho‟s o Moore JH et al., JOSPT, 2005
  34. 34. Outcome of the modified Ottawa Ankle Rules foridentifying the need for radiographs when used by APhysical Therapist N = 157 Fracture No Fracture (+) OAR 6 (a) 90 (b) (-) OAR 0 (c) 61 (d) Sensitivity= a/(a+)=0.99 Specificity= d/(b+d)=.40 PPV=a/(a+b)=.62 NPV=d/(c+d)= 1.0 Likelihood Ratio= +LR= Sens/(1-Spec)= 1.6 Likelihood Ratio= -LR= (1-Sens)/Spec= .025
  35. 35. Ankle radiographs account forapproximately 10% of all radiographsordered in the emergency room.Dunlop MG, Beattie TF, White GK, Raab GM, Doull RI. Guidelines for selective radiologicalassessment of inversion ankle injuries. Br Med J (Clin Res Ed) 1986; 293(6547):603-605.Less than 25% of ankle fractures haveadequate physical examinations, andmore than 99% had radiographs.Vargish T, Clarke WR, Young RA, Jensen A. The ankle injury--indications for the selectiveuse of X-rays. Injury 1983; 14(6):507-512
  36. 36. Case Study Smith & Cleland PTJ 2004 9 year old female patient carried by her father to PT clinic direct access. Heard pop in anterior knee while attempting a backward flip the previous night. Unable to fully weight bear since injury. Physical Exam: isolated tenderness of the patella and unable to fully weight bear on the effected side. Unable to flex knee. What is your recommendation? What clinical exam/ imaging modality do you want to order? What do you think is problem? Why?
  37. 37. Ottawa Knee Rules Are 55 years of age or older; No Have palpable tenderness over the head of the fibula; No Have isolated patellar tenderness; Yes Cannot flex the knee to 90°; Yes Cannot bear weight immediately following the injury; Yes Cannot walk in ED Yes Pooled Sensitivity = 100%
  38. 38. Case Study Smith & Cleland PTJ 2004 Cont.Radiographrevealedhorizontalfracture of thelower patalla
  39. 39. To sum it up It is however, relatively much more important for a physical therapist to recognized 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 o Deyle GD JOSPT, 2005
  40. 40. Computed Tomography (CT)•X-Ray beam moves 360 around the patient•Consecutive x-ray “slices” around the patient•Computer can recreate 3D image of the body•Best for evaluating bone and soft tissuetumors, fractures, intra-articular abnormalities,and bone mineral analysis
  41. 41. Computed Tomography (CT)
  42. 42. RVLUNG RA LV LA AORTA SPINAL VERTEBRAL CANAL BODY RIB TRANSVERSE PROCESS
  43. 43. Magnetic Resonance Imaging(MRI)What is a MRI? The use of a High Power Magnet (.3 - 2.0 Teslas) To align hydrogen atoms in the body to which a radio wave frequency is applied to produce an image Higher Tesla level= increased resolution No standardization among imaging centers
  44. 44. 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
  45. 45. T1 Vs T2 T1  T2 Tissue with high  Tissue with high water content will water content will apear dark (grey) appear white/  Fat, edema, brighter infection  Tissue with low Tissue with low water content will water content will appear darker (grey) appear white/  World War II brighter  Water is white on  Bone, lungs T2
  46. 46. T1 vs. T2 T1 image of knee  T2 image of knee Quad Tendon Semimembranosus Popliteal vein Gastrocnemius Semitendonosus Semimembranosus ACL
  47. 47. Knee - MRI Sagittal ANTERIOR POSTERIOR CRUCIATE CRUCIATE LIGAMENT LIGAMENT
  48. 48. PATHOLOGY ACL Tear
  49. 49. Meniscus Bow Tie Sign
  50. 50. Knee Meniscus
  51. 51. Knee - MRI Sagittal TORN POSTERIOR MEDIAL MENISCUS
  52. 52. Meniscus Torn Meniscus- Double PCL Sign
  53. 53. Your MRI is showing Clavicle supraspinatus Glenoid labrum D S e c l a humerus t p o u i l d a Long Head of Triceps
  54. 54. Shoulder - MRI – Axial Plane
  55. 55. Shoulder - MRI – Axial Plane D D SupS IS
  56. 56. Shoulder - MRI – Coronal Plane Rotator Cuff SS Tendon Supraspinatus Glenoid Fluid in Joint
  57. 57. ShoulderSupraspinatus Tear Subdeltoid Bursa
  58. 58. Lumbar Spine - MRI Coronal T1 Sagittal T1 Sagittal T2
  59. 59. Lumbar Spine – MRI AxialAxial T1 Axial T1 body discAxial T2 Axial T2 body disc
  60. 60. Body PsoasSpinal Canal
  61. 61. Lumbar Spine – MRI Sagittal T2 Herniated disc
  62. 62. Things that make you go Hmm 20-year-old male collegiate athlete who was referred to physical therapy for left knee pain Subjective: patient reports insidious onset of knee pain 1 yr. prior, but pain was exacerbated 3 weeks ago when he was tackled while playing football
  63. 63. Things that make you go Hmm Physical Exam:  ataxic gait with a widened, base of support  single-limb balance > 1 second bilateral  MMT non-specific weakness  Reflexes present  Clonus present on L (4 beats)  Extension reflex with Babinski
  64. 64. Recommendations? What is your recommendation? What clinical exam/ imaging modality do you want to order? What do you think is problem?
  65. 65. Walk JOSPT 2008 Insert case study by Matt Walk
  66. 66. Walk JOSPT 2008
  67. 67. DEXA SCANLooks at bone mineral densitiesThe “image” however, is secondary the importantinformation gathered is the bone mineral density
  68. 68. Skeletal Scintigraphy (Bone Scan) Indication: Cancer, stress or hidden fractures
  69. 69. Did you see that? Ankle Radiograph- 20 views Tibia Radiograph- 6 views Knee Radiograph- 2 views Chest Radiograph- 4 views Hand Radiogpraph- 2 views Finger Radiograph- 2 views CT chest Ultrasound Doppler Abdominal aortogram Angiogram Fluroscopy
  70. 70. Good Websites•http://www.freitasrad.net/index.html•http://www.gla.med.va.gov/mriatlas/index.html•http://www.mypacs.net•http://www.info-radiologie.ch/index-english.php•http://medinfo.ufl.edu/year1/rad6190/•http://www.physio-pedia.com/index.ph?title=Lectures_and_Presentations•http://www.mskcases.com/•TWU- anatomy tv
  71. 71. INTEGRATION A 54-year-old male safety consultant Mechanism of injury: The patient sustained a knee injury at the age of 17 and has periodically experienced varying levels of pain for 37 years. Subjective: He began to experience intermittent medial left knee pain about 4 months prior to seeking treatment. The pain worsened when he climbed up or down stairs and by twisting when weight bearing. Knee occasionally gives out.
  72. 72. Case #1
  73. 73. Case #1
  74. 74. INTEGRATION A 54 y.o. female school teacher Recently experienced sever headache and difficulty speaking Exam- presents with aphasia , dysarthria and coughs when eating. She has decreased strength and coordination in her left arm. 1st imaging option, 2nd option
  75. 75. Case #2
  76. 76. Case #2
  77. 77. INTEGRATION 3.  30 y.o. male who works as a construction worker with acute back pain when he lifted a jack hammer. Patient reports numbness and tingling present down the back of his left leg and into his left foot  Exam reveals weakness of dorsiflexion and great toe extension, (+) SLR and (+) slump, (+) cough/ sneeze  1st imaging option, 2nd option Explain what might be the problem and why you chose the modality
  78. 78. Case #3
  79. 79. Case #3
  80. 80. INTEGRATION Case 4. 17 y/o female student who plays club volleyball with complaints of weakness of plantar flexion and plantar foot pain with prolonged gait. Patient reports she feels a little weak when jumping and also walking  Exam reveals:  No lumbar pain  Weakness of S1 myotome testing  No lateral shift  Pain free in supine; even with exercise  No pain with cough or sneeze • Antalgic gait due to weakness  BMI below normal, overall excellent health
  81. 81. Case 4

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