ACR Supports Best Practices for Ultrasonography Use in Rheumatology
More rheumatologists are embracing musculoskeletal ultrasound (MSUS) to
diagnose and manage rheumatic diseases. In response, the American
College of Rheumatology (ACR) assembled a task force to investigate and
determine best practices for use of MSUS in rheumatology practice. The
resulting scenario-based recommendations, which aim to help clinicians
understand when it is reasonable to integrate MSUS into their
rheumatology practices, now appear online in Arthritis
Care & Research.
In Europe, more than 100 million individuals are affected by rheumatic
diseases, according to the European League Against Rheumatism (EULAR).
The ACR estimates that nearly 50 million Americans are burdened by
arthritis and more than 7 million individuals suffer from inflammatory
rheumatic diseases such as systemic lupus erythematosus, rheumatoid
arthritis and gout.
“With so many people affected by rheumatic diseases, including
arthritis, a diagnostic tool such as MSUS that is minimally invasive and
with little risk to patients is an important tool for rheumatologists,”
explains lead researcher Dr. Tim McAlindon from Tufts Medical Center in
Boston, Mass. “Our task force goal was to establish when use of MSUS was
‘reasonable’ in a number of medical situations.”
The task force reviewed medical literature to come up with
scenario-based recommendations for how MSUS could be used in
rheumatology practice. These recommendations include a rating by type of
evidence, with Level A supported by at least two randomized clinical
trials or one or more meta-analyses of randomized trials; Level B backed
by one randomized trial, non-randomized studies or meta-analyses of
non-randomized studies; and Level C confirmed by consensus expert
opinion, case studies, or standard clinical care.
The complete list of 14 recommendations of the reasonable use of MSUS in
rheumatology, along with level of evidence, is published in the article.
Partial list of recommendations includes:
-
For a patient with articular pain, swelling or mechanical symptoms,
without definitive diagnosis on clinical exam, it is reasonable to use
MSUS to further elucidate the diagnosis at the following joints:
glenohumeral, acromioclavicular, sternoclavicular, elbow, wrist,
metacarpophalangeal, interphalangeal, hip, knee, ankle, midfoot and
metatarsophalangeal. Level of evidence: B.
-
For a patient with diagnosed inflammatory arthritis and new or ongoing
symptoms without definitive diagnosis on clinical exam, it is
reasonable to use MSUS to evaluate for inflammatory disease activity,
structural damage or emergence of an alternate cause at the following
sites: glenohumeral, acromioclavicular, elbow, wrist,
metacarpophalangeal, interphalangeal, hip, knee, ankle, midfoot and
metatarsophalangeal, and entheseal. Level B.
-
For a patient with shoulder pain or mechanical symptoms, without
definitive diagnosis on clinical exam, it is reasonable to use MSUS to
evaluate underlying structural disorders; but not for adhesive
capsulitis or as preparation for surgical intervention. Level B.
-
It is reasonable to use MSUS to evaluate the parotid and submandibular
glands in a patient being evaluated for Sjögren’s disease to determine
whether they have typical changes as further evidence of the disorder.
Level B.
-
For a patient with symptoms in the region of a joint whose evaluation
is obfuscated by adipose or other local derangements of soft tissue,
it is reasonable to use MSUS to facilitate clinical assessment at the
glenohumeral, acromioclavicular, elbow, wrist, hand,
metacarpophalangeal, interphalangeal, hip, knee, ankle/foot, and
metatarsophalangeal joints. Level C.
-
For a patient with regional neuropathic pain without definitive
diagnosis on clinical exam, it is reasonable to use MSUS to diagnose
entrapment of the median nerve at the carpal tunnel; ulnar nerve at
the cubital tunnel; and posterior tibial nerve at the tarsal tunnel.
Level B.
-
It is reasonable to use MSUS to guide articular and peri-articular
aspiration or injection at sites that include the synovial,
tenosynovial, bursal, peritendinous and perientheseal areas. Level A.
The benefits of MSUS use include a faster, more accurate diagnosis,
better measurement of treatment success, reduced procedural pain, and
improved patient satisfaction. However, the authors highlight that
economic impact was not part of this study. Dr. McAlindon concludes,
“Further study of the cost-effectiveness and long-term outcomes of MSUS
is necessary to determine its value compared to other interventions.”
