Recommendations for the content and conduct of European League Against Rheumatism (EULAR) musculoskeletal ultrasound courses

Teaching enthesis ultrasound: experience of an ultrasound training workshop

To evaluate a standardised enthesis ultrasound training method, a workshop was conducted to train rheumatologists on enthesis ultrasound. After a theoretical session about ultrasound elementary enthesis lesions (changes in tendon architecture/thickness, bone proliferation/erosion, bursitis or Doppler signal), a reading exercise of 28 entheses' ultrasonographic images (plantar fasciae, Achilles, origin and insertion of patellar tendon) was completed. Participants scored through an electronic multiple-choice device with six possible lesions in each enthesis. To assess the adequacy and efficacy of the workshop, we explored the following: (1) subjective outcomes: a 12-item structured satisfaction questionnaire (graded 1-5 using Likert scale) and (2) objective outcomes of reliability: sensitivity (Se), specificity (Sp) and percentage of correctly classified cases (CC). Forty-nine participants attended the workshop. The satisfaction questionnaire demonstrated a 4.7 mean global value. The inter-reader Kappa reliability coefficient was moderate for the plantar fascia (0.47), Achilles tendon (0.47), and distal patellar tendons (0.50) and good for the proximal patellar tendon (0.63). The whole group means comparing to teachers' consensus were as follows: (a) plantar fascia: Se, 73.2%; Sp, 87.7%; CC, 83.3%; (b) Achilles: Se, 66.9%; Sp, 85.0%; CC, 79.5%; (c) distal patellar tendon: Se, 74.6%; Sp, 85.3%; CC, 82.1%; and (d) proximal patellar tendon: Se, 82.2%; Sp, 90.6%; CC, 88%. The proposed learning method seemed to be simple, easily performed, effective and well accepted by the target audience.

Challenges to expanding the clinical application of musculoskeletal ultrasonography (MSUS) among rheumatologists: from a second survey in Japan

Our previous survey in 2008 revealed that only 22% of Japanese rheumatologists used musculoskeletal ultrasonography (MSUS) for patient management, because of insufficient educational opportunities. To clarify the current state of MSUS usage and to identify further challenges, we conducted a second survey between October 2010 through January 2011 by sending questionnaires to 200 randomly selected Japanese rheumatologists, consisting of 100 participants in a meeting in 2009 on imaging in rheumatic diseases and 100 board-certified rheumatologists. Among the respondents, a majority (85 and 67%, respectively) used magnetic resonance imaging (MRI). MSUS users had increased from 32 to 60% of meeting participants and from 11 to 27% of other rheumatologists. The majority of MSUS users had begun using MSUS within the previous 3 years. Whereas most respondents in the previous survey had been self-taught, in the current survey many had attended training courses or had received informal training from skilled users. Despite an increase in skills and equipment ownership, obstacles to implementing MSUS remained, most prominently a lack of time. In conclusion, training courses and informal training have contributed to the popularization of MSUS in Japan. To further increase MSUS usage, additional training opportunities and education about the advantages of MSUS will be needed.

Ultrasonographic measurements of joint cartilage thickness in healthy children: age- and sex-related standard reference values

OBJECTIVE

Loss of joint cartilage may be an early feature of chronic inflammatory joint diseases like juvenile idiopathic arthritis (JIA). Conventional radiography usually detects only late changes such as joint space narrowing and bone erosion rather than early inflammatory changes. Joint cartilage is easily visualized with high-frequency ultrasonography (US), but age- and gender-related normal standard reference values should be established before US measurement of cartilage thickness becomes standard procedure in the clinic.

METHODS

A cross-sectional study of bilateral grey-scale US cartilage thickness of the knee, ankle, wrist, and second metacarpophalangeal (MCP) and second proximal interphalangeal (PIP) joints was performed in 394 (215 boys/179 girls) healthy Danish Caucasian children aged between 7 and 16 years.

RESULTS

Cartilage thickness differed significantly between sexes (p < 0.001 for all joints), boys having thicker cartilage than girls. Cartilage thickness clearly decreased with increasing age in both sexes. A formula for calculating sex-specific cartilage thickness at different ages in childhood is suggested. No difference between the right and left side of the investigated joints was observed.

CONCLUSION

Using US, we established age- and sex-related normal reference intervals for cartilage thickness of the knee, ankle, wrist, and MCP and PIP joints in 7- to 16-year-old children, and designed a formula for calculating hyaline cartilage thickness in all age groups throughout childhood.

Pan-American League of Associations for Rheumatology (PANLAR) recommendations and guidelines for musculoskeletal ultrasound training in the Americas for rheumatologists

OBJECTIVE

To develop guidelines for Musculoskeletal Ultrasound (MSKUS) training for rheumatologists in the Americas.

METHODS

A total of 25 Rheumatologists from 19 countries of the American Continent participated in a consensus-based interactive process (Delphi method) using 2 consecutive electronic questionnaires. The first questionnaire included the following: the relevance of organizing courses to teach MSKUS to Rheumatologists, the determination of the most effective educational course models, the trainee levels, the educational objectives, the requirements for passing the course(s), the course venues, the number of course participants per instructor, and the percentage of time spent in hands-on sessions. The second questionnaire consisted of questions that did not achieve consensus (>65%) in the first questionnaire, topics, and pathologies to be covered at each course MSKUS level.

RESULTS

General consensus was obtained for MSKUS courses to be divided into 3 educational levels: basic, intermediate, and advanced. These courses should be taught using a theoretical-didactic and hands-on model. In addition, the group established the minimum requirements for attending and passing each MSKUS course level, the ideal number of course participants per instructor (4 participants/instructor), and the specific topics and musculoskeletal pathologies to be covered. In the same manner, the group concluded that 60% to 70% of course time should be focused on hands-on sessions.

CONCLUSION

A multinational group of MSKUS sonographers using a consensus-based questionnaire (Delphi method) established the first recommendations and guidelines for MSKUS course training in the Americas. Pan-American League of Associations for Rheumatology urges that these guidelines and recommendations be adopted in the future by both national and regional institutions in the American continent involved in the training of Rheumatologists for the performance of MSKUS.

Reliability of ultrasonography to detect synovitis in rheumatoid arthritis: a systematic literature review of 35 studies (1,415 patients)

OBJECTIVE

To perform a systematic review on the reliability of ultrasonographic (US) synovitis detection in rheumatoid arthritis (RA) by B-mode and power Doppler (PD) in image acquisition and still-image interpretation. US is a sensitive method for synovitis detection. However, reliability is still a key concern.

METHODS

Articles reporting any US reliability results for synovitis in RA in PubMed, EMBase, the Cochrane Library, and meeting abstracts were selected. Data were extracted from the collection of data on US synovitis detection (either qualitatively [binary] or semiquantitatively [0-3 scale], for intraobserver and interobserver reliability in B-mode and PD, and for image acquisition and still-image interpretation). The type of joints tested, the experience of the ultrasonographer, and the quality of the studies were assessed. Data analysis involved descriptive and graphic interpretation of reliability and its potential determinants.

RESULTS

Thirty-five studies (12 for B-mode, 11 for PD, or 12 for both) with a total of 1,415 patients were analyzed. Intraobserver and interobserver reliability for still images in B-mode and PD was high (kappa = 0.5-1.0 [14,991 joints] for intraobserver reliability for B-mode, kappa = 0.59-1.0 [14,934 joints] for PD, kappa = 0.49-1.0 [3,138 joints] for interobserver for B-mode, and kappa = 0.66-1.0 [3,325 joints] for PD). Interobserver reliability for image acquisition in both US modes was lower than still-image interpretation (kappa = 0.22-0.95). Few studies reported intraobserver image acquisition reliability.

CONCLUSION

Intraobserver and interobserver reliability of still-image interpretation was high, especially for PD, in published studies involving highly trained observers. However, reliability of acquisition of US should be further assessed.

Use of musculoskeletal ultrasound in Japan: a survey of practicing rheumatologists

We aimed to describe how often Japanese rheumatologists currently use musculoskeletal ultrasound (MSUS), and how they are currently being trained in the use of this imaging technique. Questionnaires were sent to 200 Japanese rheumatologists: 100 to participants attending the first Scientific Meeting of the Japanese Society of Imaging in Rheumatic Diseases in 2006, and 100 to other randomly selected rheumatologists certified by the Japan College of Rheumatology. A total of 139 questionnaires (74 from meeting participants, 65 from randomly selected rheumatologists) were completed and analyzed. Twenty-four of the 74 respondents (32.4%) in the meeting participants group used MSUS imaging for patient management, while only 7 of the 65 respondents (10.8%) in the certified rheumatologists group used MSUS imaging for patient management. Sixty-five of the 74 respondents (87.8%) in the meeting participants group and 54 of the 65 respondents (83.1%) in the certified rheumatologists group considered MSUS to be a useful tool. Only a minority of respondents used MSUS in the management of their patients. Lack of training in MSUS was the principal reason for not performing MSUS. Japanese rheumatologists would prefer future training in the form of intensive courses and training sessions.

A musculoskeletal ultrasound course for physical medicine and rehabilitation residents

Musculoskeletal ultrasound is an imaging modality that can be used to evaluate nerve, tendon, muscle, ligament, and joint disorders and to guide therapeutic procedures. A growing proportion of physiatrists are interested in musculoskeletal ultrasound as demonstrated by the increasing number of musculoskeletal ultrasound articles published in physical medicine and rehabilitation journals and quantity of musculoskeletal ultrasound courses and workshops at physical medicine and rehabilitation conferences. The Mayo Clinic (Rochester, MN) Physical Medicine and Rehabilitation residency program developed a musculoskeletal ultrasound course for their physical medicine and rehabilitation residents, which was implemented in 2008. A detailed description of the course is provided in this article. In addition, results from a premusculoskeletal ultrasound course and postmusculoskeletal ultrasound course practical and written test are presented, and the results of a postmusculoskeletal ultrasound course resident survey are discussed. This information can be used by other physical medicine and rehabilitation residency programs to assist in the creation of their own musculoskeletal ultrasound course.

Using ultrasonography to facilitate best practice in diagnosis and management of RA

The key to successful management of rheumatoid arthritis (RA) is early objective quantification of inflammation and ongoing precise, tailored therapy to ensure long term suppression of inflammatory disease activity. Musculoskeletal ultrasonography (MSKUS) has emerged as a tool with the potential to enhance disease assessment and management in this area. This includes applications in patients with undifferentiated arthropathy attending an early inflammatory arthritis clinic, in which the diagnosis of inflammatory disease may be confirmed or refuted at an early stage, and those with treated RA where accurate measurement of outcomes, such as response to therapy, structural damage and disease remission, are extremely important. This imaging modality is safe and portable, making it ideal for outpatient and inpatient settings, and can be used to assess many joints in multiple planes and to demonstrate changes in disease activity and structural damage over time. MSKUS is gaining popularity among rheumatologists, as increasing evidence supports the added value of a physician-performed ultrasonography assessment above traditional clinical, laboratory and radiographic measures, enabling greater confidence in diagnostic and management decisions. Although additional longitudinal data are required and further applications are likely to arise, MSKUS may well possess the necessary attributes to facilitate best practice in inflammatory arthritis management.

Becoming a musculoskeletal ultrasonographer

Over the last decade, increasing numbers of rheumatologists have incorporated musculoskeletal ultrasound (MSUS) as a valuable diagnostic tool into their clinical practice. Some countries have established training programmes for MSUS. The European League Against Rheumatism has developed education guidelines for the content and conducting of MSUS courses and it would be useful to standardize rheumatology MSUS training worldwide. A thorough knowledge of sectional anatomy, ultrasound physics and technology, joint US scanning methods, the sonographic pattern of normal and pathological musculoskeletal tissues, artefacts, diagnostic criteria and Doppler technique are necessary to perform efficient MSUS. MSUS training includes attending theoretical and practical courses, as well as studying textbooks, DVDs or websites. Having access to US equipment and performing supervised normal and pathological MSUS examinations for a training period is mandatory for consolidating MSUS learning. A proposal to accredit and certificate competence in MSUS is now being discussed.

The Belfast musculoskeletal ultrasound course

OBJECTIVES

To conduct a training course in musculoskeletal ultrasound (MSUS) for rheumatologists in Northern Ireland with the aim of equipping the participants with a basic knowledge of the theoretical and practical aspects of MSUS as they are applied to rheumatology.

METHODS

Between September 2007 and June 2008, 10 rheumatologists attended a course in basic MSUS that was delivered by 7 rheumatologists with experience in MSUS. The course consisted of five separate modules that included tutorials on MSUS, self-directed learning of scanning techniques and personal mentoring. Progress was monitored throughout the course by the use of personal logbooks. Competency was formally assessed using the Royal College of Physicians' Direct Operational Procedural Skills (DOPS) assessment and an exit examination.

RESULTS

Five trainees completed the entire course and passed both the practical and written elements of the exit examination. All were deemed to have attained a basic level of competency in MSUS. The main obstacle to completion of the course was a lack of scanning practice and an inability to complete the required number of scans and DOPS assessments. Participants were more likely to fulfil the requirements of the course if they were employed full time in the regional rheumatology unit where the course was based. All participants reported high levels of confidence in their basic scanning skills at the conclusion of the course. They also felt that the training enhanced their clinical examination skills and their understanding of musculoskeletal anatomy.

CONCLUSIONS

A basic MSUS training course can be successfully delivered using a modular design that takes account of the trainee's level of experience and their work schedule. Important elements of such a course should include personal mentoring and the recording of scanning activity using a logbook. Periodic assessment of the trainee's performance is a useful means to motivate learning. Basic training in MSUS should become an accepted part of the routine training of rheumatologists in the UK.