Practice, training, and assessment among experts performing musculoskeletal ultrasonography: toward the development of an international consensus of educational standards for ultrasonography for rheumatologists

Solid validity evidence for two tools assessing competences in musculoskeletal ultrasound: a validity study

OBJECTIVES

Musculoskeletal ultrasound (MSUS) is increasingly used by rheumatologists in daily clinical practice. However, MSUS is only valuable in trained hands, and assessment of trainee competences is therefore essential before independent practice. Thus, this study aimed to establish validity evidence for the EULAR and the Objective Structured Assessment of Ultrasound Skills (OSAUS) tools used for assessing MSUS competences.

METHODS

Thirty physicians with different levels of MSUS experience (novices, intermediates, and experienced) performed four MSUS examinations of different joint areas on the same rheumatoid arthritis patient. All examinations were video recorded (n = 120), anonymized, and subsequently assessed in random order by two blinded raters using first the OSAUS assessment tool followed by the EULAR tool 1 month after.

RESULTS

The inter-rater reliability between the two raters was high for both the OSAUS and EULAR tools, with a Pearson correlation coefficient (PCC) of 0.807 and 0.848, respectively. Both tools demonstrated excellent inter-case reliability, with a Cronbach's alpha of 0.970 for OSAUS and 0.964 for EULAR. Furthermore, there was a strong linear correlation between the OSAUS and the EULAR performance scores and the participants' experience levels (R2 = 0.897 and R2 = 0.868, respectively) and a significant discrimination between different MSUS experience levels (P < 0.001 for both).

CONCLUSIONS

MSUS operator competences can be assessed reliably and valid using either the OSAUS or the EULAR assessment tool, thereby allowing a uniform competency-based MSUS education in the future. Although both tools demonstrated high inter-rater reliability, the EULAR tool was superior to OSAUS.

TRIAL REGISTRATION

ClinicalTrials.gov, http://clinicaltrials.gov, NCT05256355.

E-learning and practical performance in musculoskeletal ultrasound: a multicentre randomized study

OBJECTIVES

To examine the effect of pre-course e-learning on residents' practical performance in musculoskeletal ultrasound (MSUS).

METHODS

This was a multicentre, randomized controlled study following the Consolidated Standards of Reporting Trials (CONSORT) statement. Residents with no or little MSUS experience were randomized to either an e-learning group or a traditional group. One week before a 2-day face-to-face MSUS course, the e-learning group received access to an interactive platform consisting of online lectures, assignments, and practical instruction videos aligned with the content of the course. The traditional group only received standard pre-course information (program, venue, and time). All participants performed a pre- and post-course practical MSUS examination and were assessed by two individual raters, blinded to the group allocation, using the validated Objective Structured Assessment of Ultrasound Skills (OSAUS) tool.

RESULTS

Twenty-eight participants completed the study. There were no statistically significant differences in the pre- or post-course practical MSUS performance between the e-learning group and the traditional group; the mean pre-course OSAUS score (s.d.) in the -learning group was 5.4 (3.7) compared with 5.2 (2.4) in the traditional group (P = 0.8), whereas the post-course OSAUS score in the e-learning group was 11.1 (2.8) compared with 10.9 (2.4) in the traditional group (P = 0.8). There was a significant difference between the mean pre- and post-course scores (5.74 points, P < 0.001). The OSAUS assessment tool demonstrated good inter-rater reliability (intra-class correlation = 0.84).

CONCLUSION

We found no significant impact of pre-course e-learning on novices' acquisition of practical MSUS skills. Hands-on training is of the utmost importance and improves MSUS performance significantly. The OSAUS assessment tool is an applicable tool with high interrater reliability.

TRIAL REGISTRATION

https://clinicaltrials.gov/ NCT04959162.

Test-Retest Reliability of Ultrasonographic Measurements from the Rectus Femoris Muscle 1-5 Years after Anterior Cruciate Ligament Reconstruction in the Ipsilateral and Contralateral Legs: An Observational, Case-Control Study

About 40% of traumatic injuries in sports are related to the knee. Of these, 33% require arthroscopic surgery. The rehabilitative ultrasound imaging technique is a simple method to obtain objective real-time results on the state and measurement of the musculoskeletal tissue and its use can represent an important change in the process of functional diagnosis and recovery of these injuries. The aim was to quantify the differences in the thickness, muscle contraction time, and muscle relaxation time of the rectus femoris muscle between individuals with knee arthroscopy and healthy individuals and to verify the reliability of the inter-examiner measurements in these ultrasound variables. An observational case-control study with individuals (18−60 years aged) who underwent surgery for anterior cruciate ligament through knee arthroscopy a year or more before. A total of 38 subjects were divided into 2 groups, case and control. Ultrasound measurements were taken of the following outcomes: thickness at rest and contraction, muscle contraction time, and muscle relaxation time of the rectus femoris muscle. Excellent inter-examiner reliability was obtained for all ultrasound measurements (ICC3.3 > 0.90). No significant changes were found in the rate of contraction or rest of the rectus femoris muscle. On the other hand, if significant changes in the thickness of the rectus femoris muscle were found between control and case group. Arthroscopic surgery for anterior cruciate ligament reconstruction does not appear to modify function but does modify the thickness of the rectus femoris muscle on ultrasound examination. Ultrasound appears to be a reliable tool for the study of these measurements in the rectus femoris muscle.

Training and assessment of musculoskeletal ultrasound and injection skills-a systematic review

OBJECTIVES

To examine how residents are trained and assessed in musculoskeletal ultrasound (MSUS), MSUS-guided and landmark-guided joint aspiration and injection. Additionally, to present the available assessment tools and examine their supporting validity evidence.

METHODS

A systematic search of PubMed, Cochrane Library, and Embase was conducted in accordance with the PRISMA guidelines and studies published from January 1, 2000 to May 31, 2021 were included. Two independent reviewers performed the search and data extraction. The studies were evaluated using the Medical Education Research Quality Instrument (MERSQI).

RESULTS

9,884 articles were screened, and 43 were included; 3 were randomized studies, 21 pre- and post-test studies, 16 descriptive studies, and 3 studies developing assessment tools. The studies used various theoretical training modalities e.g. lectures, anatomical quizzes and e-learning. The practical training models varied from mannequins and cadavers to healthy volunteers and patients. The majority of studies used subjective "comfort level" as assessment, others used practical examination and/or theoretical examination. All training programs increased trainees' self-confidence, theoretical knowledge, and/or practical performance, however few used validated assessment tools to measure the effect. Only one study met the MERSQI high methodical quality cut-off score of 14.

CONCLUSION

The included studies were heterogeneous, and most were of poor methodological quality and not based on contemporary educational theories. This review highlights the need for educational studies using validated theoretical and practical assessment tools to ensure optimal MSUS training and assessment in rheumatology.

Musculoskeletal Ultrasound Instruction in Adult Rheumatology Fellowship Programs

OBJECTIVE

Musculoskeletal ultrasound (MSUS) in rheumatology in the US has advanced by way of promotion of certifications and standards of use and inclusion of core fellowship curriculum. In order to inform endeavors for curricular integration, the objectives of the present study were to assess current program needs for curricular incorporation and the teaching methods that are being employed.

METHODS

A needs-assessment survey (S1) was sent to 113 rheumatology fellowship program directors. For programs that taught MSUS, a curriculum survey (S2) was sent to lead faculty. Programs were stratified according to program size and use of a formal written curriculum.

RESULTS

S1 (108 of 113 respondents; response rate 96%) revealed that 94% of programs taught MSUS, with 41% having a curriculum. Curricular implementation was unaffected by program size. Formal curricular adoption of MSUS was favored by 103 directors (95.3%), with 65.7% preferring such adoption to be optional. S2 (74 of 101 respondents; response rate 73%) showed that 41% of programs utilized a formal curriculum. Multiple teaching strategies were used, with content that was generally similar. Use of external courses, including the Ultrasound School of North American Rheumatologists course, was prevalent. Fewer barriers were noted compared to past surveys, but inadequate time, funding, and number of trained faculty still remained. Lack of divisional interest (P = 0.046) and interest of fellows (P = 0.012) were noted among programs without a formal curriculum.

CONCLUSION

MSUS is taught by a significantly larger number of rheumatology fellowship programs today. Multiple teaching strategies are used with common content, and barriers still remain for some programs. Most program directors favor inclusion of a standardized MSUS curriculum, with many favoring inclusion to be optional.

Evaluation of hernia of the male inguinal canal: sonographic method

Sonography of the male inguinal canal for hernia is a common request. There is debate about the accuracy and even need for sonographic assessment of inguinal hernia. A clear, concise method is presented, with correlated diagrams and sonographic images, which aims to improve the ability of sonographers to easily identify inguinal herniae.

Integrating Musculoskeletal Sonography Into Rehabilitation: Therapists' Experiences With Training and Implementation

Musculoskeletal sonography is rapidly extending beyond radiology; however, best practices for successful integration into new practice contexts are unknown. This study explored non-physician experiences with the processes of training and integration of musculoskeletal sonography into rehabilitation. Qualitative data were captured through multiple sources, and iterative thematic analysis was used to describe two occupational therapists' experiences. The dominant emerging theme was competency, in three domains: technical, procedural, and analytical. In addition, three practice considerations were illuminated: (a) understanding imaging within the dynamics of rehabilitation, (b) navigating nuances of interprofessional care, and (c) implications for post-professional training. Findings indicate that sonography training for rehabilitation providers requires multi-level competency development and consideration of practice complexities. These data lay a foundation on which to explore and develop best practices for incorporating sonographic imaging into the clinic as a means for engaging clients as active participants in the rehabilitation process to improve health and rehabilitation outcomes.

Economics of Musculoskeletal Ultrasound

Purpose of review

Healthcare costs have exploded in the past 30 years and they are a major concern for governments worldwide. Care management of musculoskeletal disorders and advanced imaging account for a large part of this socioeconomic burden.

Recent findings

Musculoskeletal ultrasound is now performed primarily by nonradiologists. Both musculoskeletal ultrasound and MRI total utilization rates continue to increase. Despite the existence of evidence-based diagnostic recommendations and the potential cost-savings of using musculoskeletal ultrasound instead of MRI in certain clinical situations, ensuring appropriate use of imaging among health professionals remains difficult for various reasons.

Summary

In the context of healthcare budgets restraints, use of imaging must be shown scientifically, to improve patient outcomes and be cost-effective. Current evidence recommends musculoskeletal ultrasound as the primary imaging modality in the investigation of rotator cuff disease. Policies aiming at ensuring the application of imaging guidelines among physicians are needed.

Educational recommendations for the conduct, content and format of EULAR musculoskeletal ultrasound Teaching the Teachers Courses

OBJECTIVE

To produce educational guidelines for the conduct, content and format of theoretical and practical teaching at EULAR musculoskeletal ultrasound (MSUS) Teaching the Teachers (TTT) Courses.

METHODS

A Delphi-based procedure with 24 recommendations covering five main areas (Duration and place of the course; Faculty members; Content of the course; Evaluation of the teaching skills; TTT competency assessment) was distributed among a group of experts involved in MSUS teaching, in addition to an advisory educational expert being present. Consensus for each recommendation was considered achieved when the percentage of agreement was >75%.

RESULTS

21 of 24 invited participants responded to the first Delphi questionnaire (88% response rate). All 21 participants also responded to the second round. Agreement on 19 statements was obtained after two rounds.

CONCLUSIONS

This project has led to the development of guidelines for the conduct, content and format of teaching at the EULAR MSUS TTT Courses that are organised annually, with the aim of training future teachers of EULAR MSUS Courses, EULAR Endorsed MSUS Courses, as well as national and local MSUS Courses. The presented work gives indications on how to homogenise the teaching at the MSUS TTT Courses, thus resolving current discrepancies in the field.

Role of sonographic imaging in occupational therapy practice

Occupational therapy practice is grounded in the delivery of occupation-centered, patient-driven treatments that engage clients in the process of doing to improve health. As emerging technologies, such as medical imaging, find their way into rehabilitation practice, it is imperative that occupational therapy practitioners assess whether and how these tools can be incorporated into treatment regimens that are dually responsive to the medical model of health care and to the profession's foundation in occupation. Most medical imaging modalities have a discrete place in occupation-based intervention as outcome measures or for patient education; however, sonographic imaging has the potential to blend multiple occupational therapy practice forms to document treatment outcomes, inform clinical reasoning, and facilitate improved functional performance when used as an accessory tool in direct intervention. Use of medical imaging is discussed as it relates to occupational foundations and the professional role within the context of providing efficient, effective patient-centered rehabilitative care.

Ultrasound learning curve in gout: a disease-oriented training program

OBJECTIVE

To describe the learning curve of rheumatologists with limited experience using ultrasound (US) attending an intensive disease-oriented training program focusing on the skills required to obtain and interpret US signs of monosodium urate (MSU) crystal deposits in joint and periarticular tissues.

METHODS

Three investigators participated in a 7-day training program involving 12 men with gout. The agreement between the expert and beginners was calculated in 4 sessions involving 8 patients with gout. The US assessment was performed at the second and third metacarpophalangeal joints, knee, tibiotalar and first metatarsophalangeal joints, second and third finger flexors, quadriceps and patellar posterior tibialis, peroneus longus and brevis, and Achilles tendons. The presence or absence of synovial fluid/synovial hypertrophy, double contour sign, intra- or periarticular and intratendinous tophi, bursitis, bone erosions, and tendon tears was recorded.

RESULTS

A total of 416 anatomic sites were studied. Kappa values and overall agreement percentages of qualitative assessments of US gout findings at the end of the exercise both showed moderate to excellent agreement, while in the first session they showed poor/fair agreement. At the end of the training session, sensitivity, specificity, and capability of the beginners were also improved.

CONCLUSION

After 1 week of the disease-oriented training program, rheumatologists with limited experience in US were satisfactorily able to detect and interpret the main US signs indicative of MSU crystal deposits at different tissues in patients with gout.

The Impact of Education

Sonography has made substantial technological improvements over the years, removing many of the barriers to its application in evaluation of the musculoskeletal (MSK) system. Sonography offers the advantages of a dynamic, real-time evaluation that routinely incorporates patient movement, evaluation of MSK structures in symptomatic positions with real-time feedback from patients, and a patient-friendly, noninvasive imaging modality. However, educational standards and efficacy of musculoskeletal ultrasonography (MSUS) have demonstrated as much variance as published reports of MSUS accuracy and interobserver agreement. This review focuses on the available literature on MSUS utilization and training and the need for development of international standards and protocols that will serve to improve clinical application and interpretation as well as the quality of research, improving reliability and reproducibility of data.

The opinion and experiences of Dutch orthopedic surgeons and radiologists about diagnostic musculoskeletal ultrasound imaging in primary care: a survey

INTRODUCTION AND AIM

The use of diagnostic musculoskeletal ultrasound (DMUS) in primary health care has increased in the recent years. Nevertheless, there are hardly any data concerning the reliability, accuracy and treatment consequences of DMUS used by physical therapists or general practitioners. Moreover, there are no papers published about how orthopedic surgeons or radiologists deal with the results of DMUS performed in primary care. Therefore, our aim is to evaluate the opinion, possible advantages or disadvantages and experiences of Dutch orthopedic surgeons and radiologists about DMUS in primary care.

METHODS

A cross-sectional survey in which respondents completed a self-developed questionnaire to determine their opinion, experiences, advantages, disadvantages of performing DMUS in primary care.

RESULTS

Questionnaires were sent to 838 Dutch orthopedic surgeons and radiologists of which 213 were returned (response rate 25.4%). Our respondents saw no additional value for health care for diagnostic DMUS in primary care. DMUSs were generally repeated in secondary care. They perceived more disadvantages than advantages of performing DMUS in primary care. Mentioned disadvantages were: 'false positive results' (71.4%), 'lack of experience' (70%), 'insufficient education' (69.5%), not able to relate the outcomes of DMUS with other forms of diagnostic imaging' (65.7%), and 'false negative results' (65.3%).

CONCLUSION

Radiologists and orthopedic surgeons sampled in the Netherlands show low trust in DMUS knowledge of physical therapists and general practitioners. The results should be interpreted with caution because of the small response rate and the lack of representativeness to other countries.

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 conductance of MSUS courses and it would be useful to standardise rheumatology MSUS training worldwide. A thorough knowledge of anatomy, US physics and technology, US scanning methods, US pattern of normal and pathological musculoskeletal tissues, definitions for US pathology, artefacts and pitfalls in both greyscale and Doppler modalities is necessary to perform efficient MSUS. MSUS training includes attending theoretical-practical and online courses, as well as studying textbooks and using digital video discs (DVDs). Having access to US equipment and performing supervised normal and pathological MSUS examinations for a training period are mandatory for consolidating MSUS learning. A proposal to accredit and certificate competence in MSUS is now being discussed.

Clinical recovery of two hip adductor longus ruptures: a case-report of a soccer player

Background

Non-operative treatment of acute hip adductor longus ruptures in athletes has been described in the literature. However, very limited information concerning the recovery of this type of injury exists. This case represented a unique possibility to study the recovery of two acute adductor longus ruptures, using novel, reliable and validated assessment methods.

Case presentation

A 22-year old male soccer player (Caucasian) sustained two subsequent acute adductor longus ruptures, one in each leg. The injuries occurred 10 months apart, and were treated non-surgically in both situations. He was evaluated using hip-strength assessments, self-report and ultrasonography until complete muscle-strength recovery of the hip adductors had occurred. The player was able to participate in a full soccer training session without experiencing pain 15 weeks after the first rupture, and 12 weeks after the second rupture. Full hip adductor muscle-strength recovery was obtained 52 weeks after the first rupture and 10 weeks after the second rupture. The adductor longus injuries, as verified by initial ultrasonography (10 days post-injury), showed evidence of a complete tendon rupture in both cases, with an almost identical imaging appearance. It was only at 6 and 10 weeks ultrasonographic follow-up that the first rupture was found to include a larger anatomical area than the second rupture.

Conclusion

From this case we can conclude that two apparently similar hip adductor longus ruptures, verified by initial ultrasonography (10 days post-injury), can have very different hip adductor strength recovery times. Assessment of adductor strength recovery may therefore in the future be a useful and important additional measure for determining when soccer players with hip adductor longus ruptures can return safely to play.

Feasibility of a standardized ultrasound examination in patients with rheumatoid arthritis: a quality improvement among rheumatologists cohort

Background

Quality improvement is important to facilitate valid patient outcomes. Standardized examination procedures may improve the validity of US.

The aim of this study was to investigate the learning progress for rheumatologists during training of US examination of the hand in patients with rheumatoid arthritis (RA).

Methods

Rheumatologists with varying degrees of experience in US were instructed by skilled tutors. The program consisted of two days with hands-on training followed by personal US examinations performed in their individual clinics. Examinations were sent to the tutors for quality control. The US examinations were evaluated according to a scoring sheet containing 144 items. An acceptable examination was defined as > 80% correct scores.

Results

Thirteen rheumatologists participated in the study. They included a total of 104 patients with RA. Only few of the initial examinations were scored below 80%, and as experience increased, the scores improved (p = 0.0004). A few participants displayed decreasing scores.

The mean time spent performing the standardized examination procedure decreased from 34 min to less than 10 minutes (p = 0.0001).

Conclusion

With systematic hands-on training, a rheumatologist can achieve a high level of proficiency in the conduction of US examinations of the joints of the hand in patients with RA. With experience, examination time decreases, while the level of correctness is maintained. The results indicate that US may be applied as a valid measurement tool suitable for clinical practice and in both single- and multi-centre trials.

Use of ultrasound imaging by physiotherapists: a pilot study to survey use, skills and training

OBJECTIVE

This study aimed to design and pilot a questionnaire to survey the use of ultrasound imaging (USI) by physiotherapists in the United Kingdom (UK), the type and content of ultrasound training physiotherapists using USI had undertaken and their perceived future training needs.

BACKGROUND

The use of USI by physiotherapists is becoming increasingly common but is highly operator dependent and there are safety and professional issues regarding use in physiotherapy practice. Currently there are no specific training guidelines relating to physiotherapists using USI.

METHODS

A questionnaire was developed, based on research literature and guidelines. Twelve experts in USI commented on the content and design. The electronic on-line questionnaire was piloted on groups that were likely to be users of USI.

RESULTS

Forty-six respondents completed the questionnaire. Results indicated that USI is used predominantly for biofeedback and there are many unmet training needs. Respondents reported a mismatch between techniques for which they had received training and those that they used in practice and indicated a more structured training framework is required.

CONCLUSIONS

The development and piloting of the questionnaire provides a starting point for a more extensive evaluation of how USI is being used, the training needs of physiotherapists and benefits as a biofeedback tool. Refinement is needed and replication in a larger sample. Results could assist the development of a structured formal training framework encompassing key skills.

Utility and feasibility of musculoskeletal ultrasonography (MSK US) in rheumatology practice in Canada: needs assessment

The utility of musculoskeletal ultrasound (MSK US) is being extensively explored and evaluated amongst European rheumatologists. However, utilization of MSK US by rheumatologists in Canada is much less common. This study aimed to evaluate the current use of MSK US in Canadian rheumatology practice, to determine beliefs and attitudes towards MSK US, and to determine factors that may encourage or limit its use. A 13-question needs assessment questionnaire was developed. All Canadian rheumatologists were invited via e-mail to participate in the survey. The overall response rate was 156/470 (33%). Fifty-one percent of participants used MSK US in their clinical practice. Lack of training appeared to be the main obstacle to its current use. Eighty-three percent believed that MSK US should be performed by rheumatologists and expressed a willingness to learn the technique. Skills offering greatest clinical utility were the assessment of inflammatory arthritis in small joints (i.e., hands (metacarpophalyngeal and proximal interphalangeal joints), wrists, feet (metatarsophalyngeal), shoulders, and ankles. Limited available time, equipment costs, and difficulties with billing were the main obstacles to MSK US utilization in the clinical setting. There is a great level of interest in learning and applying MSK US in Canadian rheumatology practice. The balance between added clinical value and lack of remuneration, equipment associated costs, and time to complete training is the major limiting factor influencing rheumatologists' willingness to take on MSK US. Training programs must be relevant to rheumatologists' needs before MSK US will be adopted into routine clinical practice in Canada.

Is musculoskeletal ultrasonography an operator-dependent method or a fast and reliably teachable diagnostic tool? Interreader agreements of three ultrasonographers with different training levels

Objectives. To assess interreader agreements and a learning curve between three (senior, junior, and beginner) different experienced musculoskeletal ultrasonographers. Senior served as the imaging "gold standard". Methods. Clinically dominant joints (finger, shoulder, knee, tibiotalar, and talonavicular) of 15 rheumatoid arthritis (RA) patients were examined by three different experienced ultrasonographers (senior 10 years, junior 10 months, and beginner one month). Each patient's ultrasonographic findings were reported unaware of the other investigators' results. κ coefficients, percentage agreements, sensitivities, and specificities were calculated. Results. 120 joints of 15 RA patients were evaluated. Comparing junior's and beginner's results each to the senior's findings, the overall κ for all examined joints was 0.83 (93%) for junior and 0.43 (76%) for beginner. Regarding the different joints, junior's findings correlate very well with the senior's findings (finger joints: κ = 0.82; shoulder: κ = 0.9; knee: κ = 0.74; tibiotalar joint: κ = 0.84; talonavicular joint: κ = 0.84) while beginner's findings just showed fair to moderate agreements (finger joints: κ = 0.4; shoulder: κ = 0.42; knee: κ = 0.4; tibiotalar joint: κ = 0.59; talonavicular joint: κ = 0.35). In total, beginner's results clearly improved from κ = 0.34 (agreement of 67%) at baseline to κ = 0.78 (agreement of 89%) at the end of the evaluation period. Conclusions. Ultrasonographic evaluation of a ten-month-experienced investigator in comparison to a senior ultrasonographer was of substantial agreement. Agreements between a beginner and a highly experienced ultrasonographer were only fair at the beginning, but during the study including ultrasonographical sessions of 15 RA patients, the beginner clearly improved in musculoskeletal ultrasonography.

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.

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.

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

OBJECTIVE

To develop education guidelines for the conduct of future European League Against Rheumatism (EULAR) musculoskeletal ultrasound (MSUS) courses.

METHODS

We undertook a consensus-based, iterative process using two consecutive questionnaires sent to 29 senior ultrasonographer rheumatologists who comprised the faculty of the 14th EULAR ultrasound course (June 2007). The first questionnaire encompassed the following issues: type of MSUS educational model; course timing; course curriculum; course duration; number of participants per teacher in practical sessions; time spent on hands-on sessions; and the requirements and/or restrictions for attendance at the courses. The second questionnaire consisted of questions related to areas where consensus had not been achieved in the first questionnaire, and to the topics and pathologies to be assigned to different educational levels.

RESULTS

The response rate was 82.7% from the first questionnaire and 87.5% from the second questionnaire. The respondents were from 11 European countries. The group consensus on guidelines and curriculum was for a three-level education model (basic, intermediate and advanced) with timing and location related to the annual EULAR Congresses. The topics and pathologies to be included in each course were agreed. The course duration will be 20 h. There will be a maximum of six participants per teacher and 50-60% of total time will be spent on practical sessions. There was also agreement on prerequisite experience before attending the intermediate and advanced courses.

CONCLUSION

We have developed European agreed guidelines for the content and conduct of EULAR ultrasound courses, which may also be recommended to national and local MSUS training programmes.

E-learning in ultrasonography: a web-based approach

OBJECTIVE

To propose e-learning methods that address the fundamental problems related to sonographic training in rheumatology.

METHODS

The project was designed for rheumatologists with strong motivation to learn ultrasound. A modular approach was constructed, consisting of a basic 3-day residential course, followed by a 6-month period of web-based tutoring, and culminating in a final 2-day residential course with a formal assessment of competency.

RESULTS

The website (http://www.e-sonography.com) was accessed by all 60 participants. A mean of 20 (range 10-80) log-on sessions were registered for each participant, and a mean of 250 min (range 60-600 min) of web access was recorded. A total of 163 sonographic images were submitted by 18 (30%) participants. The majority of the images focused on the following anatomical areas: shoulder 49 (30%), hand 34 (21%) and knee 20 (12%). A total time investment of approximately 14 h was made by the US tutors over the 6-month period for interaction with the participants.

CONCLUSIONS

The e-learning methods described in this report represent the first attempt to adopt a novel technique to circumvent several of the inherent barriers to the many facets of teaching musculoskeletal ultrasound to a wide audience.

Ultrasonography and the rheumatologist

PURPOSE OF REVIEW

An update of the latest developments in ultrasonography in rheumatology. Indications, technical aspects and representative examples of the potential of ultrasonography are illustrated. Finally, education and training issues are briefly discussed.

RECENT FINDINGS

Ultrasonography can be used in rheumatology for a wide spectrum of indications including inflammatory arthritis, tendon pathology, bursitis, disease activity monitoring, disease progression monitoring, guided aspiration and guided injections. Latest-generation ultrasonography systems provide a very sensitive assessment of both grayscale and Doppler findings. The quality of results in ultrasonography is conditioned by a series of elements that include the characteristics of the equipment, knowledge of relevant anatomy and pathology, experience of the sonographer, techniques used and patient positioning.

SUMMARY

Ultrasonography is challenging the standards of rheumatological clinical practice. It is more sensitive than clinical examination in the detection of synovitis and more sensitive than conventional radiography in the detection of bone erosions. Ultrasonography-guided injections may improve therapy effectiveness if compared with the traditional blind approach. Three-dimensional ultrasonography with a volumetric probe and the power Doppler mode may represent a very useful tool for therapy monitoring in patients with chronic arthritis.

Ultrasonography for rheumatologists: the development of specific competency based educational outcomes

BACKGROUND

A competency based approach to the education of rheumatologists in musculoskeletal ultrasonography (MSK US) ensures standards are documented, transparent, accountable, and defensible, with clear benefit to all stakeholders. Specific competency outcomes will facilitate informed development of a common curriculum and structured programme of training and assessment.

OBJECTIVE

To determine explicit competency based learning outcomes for rheumatologists undertaking MSK US.

METHODS

International experts in MSK US, satisfying specific selection criteria, were asked to define the minimum standards required by a rheumatologist to be judged competent in MSK US. They reviewed 115 MSK US skills, comprising bone and soft tissue pathology, in seven joints regions of the upper and lower limbs, and rated their relative importance according to specific criteria. These data are presented as specific educational outcomes within designated competency categories.

RESULTS

57 expert MSK US practitioners were identified and 35 took part in this study. Ten generic core competency outcomes were recognised including physics, anatomy, technique, and interpretation. Regarding specific regional competencies, 53% (61/115) were considered "must know" core learning outcomes, largely comprising inflammatory joint/tendon/bone pathology and guided procedures; 45% (52/115) were required at an intermediate/advanced level (18/115 "should know", 34/115 "could know"), and 2% (2/115) were deemed inappropriate/unnecessary for rheumatologist ultrasonographers.

CONCLUSIONS

This is the first study to developing a competency model for the education of rheumatologists in MSK US based on the evidence of international experts. A specific set of learning outcomes has been defined, which will facilitate future informed education and practice development and provide a blueprint for a structured rheumatology MSK US curriculum and assessment process.

MRI and musculoskeletal ultrasonography as diagnostic tools in early arthritis

Rheumatoid arthritis (RA) is a chronic and progressive inflammatory disorder primarily affecting the synovium and is characterized by destruction of bone and cartilage. Early diagnosis and treatment of RA can improve disease outcomes substantially. Magnetic resonance imaging and musculoskeletal ultrasonography may facilitate early diagnosis and aid the targeting of intensive therapy. Magnetic resonance imaging and musculoskeletal ultrasonography also are able to monitor temporal changes in disease activity (ie, synovitis) and damage (ie, erosions). These imaging modalities are likely to be increasingly used in the management of early rheumatoid arthritis to ensure the best patient outcomes, although more work is required to determine their optimal roles.

Musculoskeletal ultrasound training in rheumatology: the Belfast experience

OBJECTIVES

Despite the increasing use of musculoskeletal ultrasound (MSUS) as a clinical tool in rheumatology, there is no consensus yet regarding the standards required to achieve a basic level of competence in the use of this imaging technique. A number of sonographers worldwide are developing curricula and standardizing teaching methods in order to improve training in MSUS for rheumatologists. In the meantime, clinicians are devising informal means of training in order to acquire these new skills. Here we describe the informal team approach to MSUS training adopted by a group of rheumatologists from the Regional Rheumatology Centre in Belfast, UK.

METHODS

Over a 5-yr period, eight rheumatologists from Musgrave Park Hospital in Belfast used a variety of means to learn the basic skills of MSUS.

RESULTS

Seven of the team underwent a formal assessment of their competency in a practical examination devised by an experienced sonographer. All were judged to have attained a basic competency in MSU.

CONCLUSIONS

This Belfast experience shows what can be achieved despite the absence of formal MSUS training. Nevertheless, the development of recognized training programmes and international standards of competency are important goals on the way to achieving more widespread acceptance of MSUS as a useful tool in everyday clinical practice.

Imaging and skeletal muscle disease

Imaging techniques have assumed increasing importance in the diagnostic approach to patients with muscle disease. These techniques include computed tomography, ultrasound, and magnetic resonance imaging (MRI). For most disorders of muscle, ultrasound and MRI are more useful than computed tomography. Advantages of ultrasound include accessibility at the bedside and lower cost. However, MRI remains the gold standard for detecting changes in muscle tissue. In some cases, MRI examinations can take the place of muscle biopsy for diagnosis. New advances in MRI include diffusion-weighted imaging, which permits assessment of fluid motion in muscles, and blood-oxygen-level-dependent imaging to evaluate tissue oxygenation.

Recommendations for musculoskeletal ultrasonography by rheumatologists: Setting global standards for best practice by expert consensus

OBJECTIVE

To establish an expert consensus of best practice for rheumatologists performing musculoskeletal ultrasonography (MUS).

METHODS

A panel of worldwide experts in MUS was identified by literature review, membership of teaching faculty, and peer recommendation. They were invited to take part in a 4-stage Delphi process employing 2 iterative rounds to establish a consensus of specific indications, anatomic areas, and knowledge and skills required by rheumatologists performing MUS.

RESULTS

Experts in MUS were identified (n = 57; 37 radiologists, 20 rheumatologists). Successive rounds of this rigorous Delphi exercise enabled group consensus to be achieved in 30 of the proposed 37 categories comprising 8 of 13 indications (inflammatory arthritis, tendon pathology, effusion, bursitis, monitoring disease activity, monitoring disease progression, guided aspiration, and injection), 8 of 10 anatomic areas (hand, wrist, elbow, shoulder, hip, knee, ankle and heel, and forefoot), and 14 categories of knowledge and skills (physics, anatomy, pathology, equipment, clinical application and relevance, indications and limitations, artifact, machine function and operation, patient and probe position, planes and system of examination, image optimization, dynamic assessment, color Doppler, and power Doppler).

CONCLUSION

We have produced the first expert-derived, interdisciplinary consensus of recommendations for rheumatologists performing MUS. This represents a significant advance that will not only direct future rheumatology MUS practice, but will facilitate informed educational development. This is an important step towards the introduction of a specific training curriculum and assessment process to ensure competent rheumatologist ultrasonographers.