|Year : 2018 | Volume
| Issue : 5 | Page : 65-71
Use and scope of ultrasonography in rheumatology in India
Parasar Ghosh1, Prasan Deep Rath2
1 Department of Rheumatology, Institute of Postgraduate Medical Education and Research and SSKM Hospital, Kolkata, West Bengal, India
2 Department of Rheumatology, Max Super Speciality Hospitals, New Delhi, India
|Date of Web Publication||1-Aug-2018|
Prof. Parasar Ghosh
Department of Rheumatology, Institute of Postgraduate Medical Education and Research and SSKM Hospital, 220, AJC Bose Road, Kolkata - 700 020, West Bengal
Source of Support: None, Conflict of Interest: None
Musculoskeletal ultrasound (MSUS), once a sole territory of radiologists, has over the past decade been increasingly exploited by rheumatologists in clinical practice and as a research tool. Technical expansion in the field of ultrasonography has made MSUS a powerful tool in the early identification of inflammatory and noninflammatory rheumatic disease, monitoring disease, predicting therapeutic responses and guidance for procedures such as diagnostic fluid aspiration and peri- or intra-lesional therapeutic injections. US can be performed readily in the clinic, with an assessment of multiple joints at the same appointment, providing a “one-stop” answer to many MS problems. MSUS is widely accepted as an adjunct to clinical examination among rheumatologists in Europe and is rapidly gaining acceptance in the United States. In India, US is under the purview of the preconception and prenatal diagnostics techniques Act, which does not acknowledge the multiple role of point-of-care ultrasonography. There are some other critical issues of equipment costs, training and certification and the relationship of rheumatologists and radiologists in advancing the field of MSUS in India.
Keywords: Arthritis, color Doppler ultrasound, musculoskeletal radiology, soft tissue rheumatism
|How to cite this article:|
Ghosh P, Rath PD. Use and scope of ultrasonography in rheumatology in India. Indian J Rheumatol 2018;13, Suppl S1:65-71
| Evolution of Musculoskeletal Ultrasonography|| |
Ultrasonographic evaluation of the musculoskeletal (MS) system is increasingly becoming a natural extension of the clinical examination performed by rheumatologists and is emerging as the initial imaging modality in a range of rheumatic diseases, from inflammatory arthritis to vasculitis and soft-tissue rheumatism. Adopted since long  in other fields of medicine, the first report of ultrasound (US) about MS tissue was published by McDonald and Leopold. They used a contact B-mode, real-time US scanner to differentiate between Baker's cyst and thrombophlebitis; 6 years later, in 1978, gray scale US was used to demonstrate synovitis in patients with rheumatoid arthritis (RA). Since then, there has been a progressive advance in applications, imaging definition, the size, portability, and cost of sonographic equipment.
The uptake of ultrasonography by rheumatologists shows considerable variability. MSUS is a routine part of rheumatology curriculum in Italy, Germany, and Switzerland. A survey in the United Kingdom (UK) in 2005 revealed that up to 93% of the UK rheumatologists used US in the management of rheumatology patients, with 33% performing it themselves. In response to increasing interest and experience in this area, the American College of Rheumatology (ACR) has also developed recommendations for reasonable use of MSUS in rheumatology clinical practice.
| Technical Aspects of Musculoskeletal Ultrasonography|| |
MS ultrasonography (MSUS) offers the benefits of being less expensive, is easily repeatable, noninvasive, does not expose patients to ionizing radiation, does not require contrast for imaging, can be delivered at the point of care, is sensitive and allows real-time imaging of several joints in a relatively short space of time. This imaging technique is more sensitive than clinical examination in detecting enthesitis and synovitis,, 6.5-fold more sensitive than X-ray in detecting small erosions, and comparable to magnetic resonance imaging (MRI) while detecting subclinical inflammation.
US uses reflected pulses of sound to assess soft tissue, cartilage, bone surfaces, and fluid-containing structures. The basic principle of US is that the denser the material the sound wave is passing through, the more reflective it is, and the whiter (or echoic) it appears on the screen. Therefore, the frequency of the probe is of utmost importance; higher frequency probes (10–20 MHz) have higher resolution, smaller field of view, and poor tissue penetration, and thus are ideal for small superficial structures. Lower-frequency probes (<7.5 MHz) with greater penetration are useful for larger joints like the shoulders and hips. Modern machines are generally equipped with multi-frequency transducers. Resolution is enhanced with larger equipment. However, small portable systems are sufficient for everyday clinical practice. For “difficult cases” or for research purposes, it would be ideal if ultrasonographers have access to a larger, high-resolution system.
Colour and power Doppler (PD) imaging can additionally detect pathologic synovial blood flow, which in turn reflects joint inflammatory activity and therefore are desirable. PD US offers greater sensitivity for detection of low-velocity blood flow and small vessels than conventional color Doppler. Addition of microbubble-based US contrast agents increases the Doppler signal intensity and improves detection of low volume and low-velocity blood flow. Most US equipment can also be personalized with a variety of software options, including elastography to assess the mechanical stiffness of tissues, 3D imaging to measure the size of erosions, and contrast-enhanced imaging to enhance poorly visualized structures.
US being highly dependent on the skill and experience of the operator, inter-observer variability is an important concern. However, a study by the Outcome Measures in Rheumatology (OMERACT) task force has revealed that MSUS shows moderate-to-good inter-observer reliability while assessing the main peri-articular and intra-articular ultrasonographic pathologies.
A practical limitation to imaging of MS tissues is its dependence on body habitus. The US beam is attenuated as it penetrates deeper into tissue. Therefore, images of deeper structures remain less clear even when low-frequency probes are used. Joints such as the hip and the wrist have a limited acoustic window due to anatomical restriction, and thus a lower sensitivity to detect erosions and involvement of synovial pathologies. The US beam cannot penetrate bone. Therefore, intraosseous changes cannot be visualized.
| Developments in Standardization, Education, and Training|| |
MS US is gaining popularity. However, there is still a lack of standardization for the use of US in rheumatology. Consequently, the first guidelines for MS US in rheumatology were published by the European League Against Rheumatism (EULAR) Working Group for Uses of MSUS in 2001. This was followed by the first consensus set of definitions for US pathologies by the OMERACT group which have provided an initial framework for subsequent studies [Table 1]. This task force has been working toward the development of a standardized US scoring system, especially for synovitis, to standardize the findings in RA, enthesopathies, and osteoarthritis (OA).
|Table 1: Definitions of musculoskeletal pathologies shown by ultrasound in inflammatory joint diseases (Outcome Measures in Rheumatology Clinical Trials)|
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Owing to its intrinsic real-time nature of image acquisition, US becomes an operator-dependent imaging modality. Appropriate training and competency assessment are therefore essential to ensure skilled and reliable use of MSUS by rheumatologists. The EULAR has supported MSUS training by providing beginner, intermediate, and advanced level courses since 1998. MSUS is a routine part of rheumatology curriculum in Italy, Germany, and Switzerland. Recommendations for the content and conduct of EULAR MSUS courses have also been published in 2007. In the United States, MSUS training for rheumatologists began around 2000, with courses being offered by international experts. US Society of North American Rheumatologists, a nonprofit organization, now offers an 8-month-long web-based fellow training course as well as a Train-the-Trainer program for clinician educator faculty development. To standardize rheumatology competency in MSUS, the ACR task force has commenced a certification examination specific for rheumatology providers in 2013.
| Essential Applications of Msus in Rheumatology|| |
A good history and physical examination by a competent clinician can help achieve an accurate diagnosis in the majority of patients who present with MS pain. However, MS imaging is fast becoming an essential part of the diagnostic workup because, in addition to determining the anatomic source of the symptom, it can also determine the extent of anatomical pathology and discern the nature of pathology at the site with good precision. Ultrasonography is primarily considered as a qualitative diagnostic tool. Qualitative measures such as echogenicity, the appearance of neighboring structures and comparison with the contralateral side, combined with clinical findings, can guide the diagnosis of most rheumatological diseases [Table 2]. There is an increasing amount of data suggesting that the US can be useful in the detection of early disease and to rule out the differential diagnosis. Enthesial involvement in spondyloarthropathy (SpA) can be subclinical, and the US is shown to be better than clinical examination in revealing peripheral enthesitis, thus allowing early detection of SpA. OA pathology extends beyond bone and cartilage, and the US can detect the other manifestations such as effusion, synovitis, erosion, and osteophytes. MSUS is particularly relevant to knee assessments in OA, where it can identify Baker's cysts, multiple bursae, and tendon pathology. Visualization of crystal deposition in articular cartilage, soft tissues, and bone produces characteristic US images and can infer diagnosis of various crystal arthropathies. US can assess certain features of juvenile idiopathic arthritis (JIA), including effusion, synovitis, tendonitis, enthesitis, or pannus which are poorly attainable by traditional methods. A study by Haslam, et al. has even highlighted a discrepancy between clinical examination and the US when assessing the joints of children with JIA. The US can be particularly helpful in establishing the diagnosis of patients with typical polymyalgia rheumatica symptoms who have normal inflammatory markers.
There is evidence that MSUS may be used to diagnose not only for joint and muscle disease but also nerve compression syndromes, vasculitis, scleroderma, and Sjögren syndrome. Carpal tunnel syndrome is diagnosed based on secondary nerve changes demonstrated via the US. When compared to the invasive nerve conduction tests, US not only helps in diagnosis but also provides essential anatomic information which can modify the surgical approach. The role of MSUS in the diagnosis of vasculitis is being recognized, especially in giant cell arteritis where specific diagnostic biomarkers are lacking. Studies are underway to determine if the US can replace the current gold standard of temporal artery biopsy, an invasive technique with a complication rate of 0.5%. Doppler US shows great promise for the evaluation of tissue thickening, atrophy and architectural alterations seen in of localized scleroderma. High spatial resolution enables monitoring of changes in tissue thickness over the course of the disease. In diffuse scleroderma, high-frequency US can identify the oedematous phase that may precede palpable skin involvement, thus may be useful in early detection.
Imaging with the US is also being studied to replace the conventional minor salivary gland biopsy and sialography in the diagnosis of Sjögren syndrome.,,
| Msus in Rheumatoid Arthritis|| |
RA needs a special mention as this disease is most studied in rheumatology US. Clinical applications of MSUS in RA include detection of early disease, disease activity monitoring, and guidance of treatment decisions and in the confirmation of remission of RA.
It is well established that early identification and treatment of RA can affect disease outcomes. Recognizing early RA from non-RA at the onset of the disease is not straightforward. The typical radiographic features such as bone erosions may not be present in the early stages of the disease and serological markers have limitations of sensitivity and specificity, especially in early disease. MSUS can not only detect sub-clinical synovitis but can also assess the morphology and quantity of synovitis; synovial vascularity can also be measured by color or PD, and pannus can be visualized. A systematic review of six papers concluded that US had added value to clinical examination for diagnosing RA. Several studies have also confirmed that US is more sensitive than clinical examination in assessing inflammatory activity,,, and comparable to MRI, especially when finger joints are evaluated. Bone erosions represent a pathological hallmark of RA; the US can detect erosions at an earlier stage than traditional radiography. Tenosynovitis is common in RA but may be difficult to diagnose clinically, and the US has been proposed as the gold standard in assessing tendon involvement. Tenosynovitis of the extensor carpi ulnaris, commonly seen in early RA, can easily be detected in the US. MSUS has revealed the ability to rule out a differential diagnosis for scenarios involving polyarticular joint symptoms; an observational study showed that the original diagnosis was changed in several patients after MSUS. Another recent study also suggests an US method of differentiation between RA and psoriatic arthritis in seronegative patients without a clear diagnosis.
There is a compelling argument to suggest the addition of an US assessment is likely to improve the prediction of clinical outcomes;,, however, there is still a dearth of evidence to determine if targeting therapy to imaging measures would provide superior outcomes compared to treating to clinical targets alone. It is against this background that the targeted US initiative group have initiated the targeted US in RA study across eight countries that aim to determine whether there is an added value of US to the state-of-the-art management of RA.
Remission has become the primary therapeutic goal in RA management. However, remission when defined by clinical remission criteria (disease activity score, simplified disease activity index, etc.) may not accurately reflect real joint synovitis in patients with RA. Several recent studies have shown the ability of US to detect B-mode synovitis and synovial Doppler activity in patients in clinical remission according to the DAS or SDAI criteria.
To scan all peripheral joints for evidence of synovitis would be extremely time-consuming. Several different groups have developed sonographic scoring systems in a limited number of key joints using sets of joints, from 6 to 44. Naredo et al. compared different reduced models of US assessment with a comprehensive 44-joint US assessment in RA patients in clinical remission and concluded that the combination of bilateral wrist, metacarpophalangeal (MCP), ankle, and metatarsophalangeal (MTP) joints as well as the 12-joint assessment showed the highest correlations with the comprehensive 44-joint US. This study also concluded that assessment of wrist, MCP, ankle, and MTP joints could be highly sensitive for detecting B-mode and Doppler joint inflammation in RA patients in clinical remission.
| Interventional Musculoskeletal Ultrasonography|| |
Aspiration and examination of synovial fluid are of key importance in the differential diagnosis of arthritis. Similarly, corticosteroid (CS) injection into the joints, bursae, tendon sheaths or other soft tissues remains an important tool in daily clinical practice. These procedures are usually performed using palpation of bony landmarks for guidance. However, studies have shown that MSUS can improve the overall success of joint fluid aspiration, and also possibly alter diagnosis and consequently the decision to administer CS injections. Among the 14 clinical scenarios for reasonable use of MSUS, the ACR report supports MSUS-guided aspirations and injections with the highest level of evidence.
The exact placement of injection is essential to avoid any injury to the closely related nerves or vascular structures and also to avoid local adverse effects of the medication. A study reported that 50% of conventional joint injections are inaccurately placed, and this might possibly have an adverse effect on the clinical outcomes., MSUS can be used to assist needle positioning within the selected target area; a study has shown significantly greater accuracy even within a small joint. Accurate needle placement of US-guided steroid injections in patients with painful shoulder showed greater improvements in clinical response.
Percutaneous US-guided biopsy performed on an outpatient basis can be used to obtain synovial tissue samples. Kelly et al., showed that US-guided synovial biopsy is a safe, well-tolerated and reliable technique for obtaining high-quality synovial tissue from both for large and small joints. US-guided percutaneous biopsies of the bursae, tendon sheaths, major salivary glands, and muscles have also been reported.
In addition to above interventional applications, sonographic guidance can also be effective for the closed needle tidal joint irrigation, a procedure which has been proposed in knee OA, in septic arthritis and in patients with crystal related arthritis.
| Msus in Clinical Practice in India|| |
Rheumatologists worldwide have increasingly incorporated MSUS technology into their practices and research during the last decade. However, the use of MSUS by rheumatologists in India remains unexplored. The use of US is restricted by the Preconception and Prenatal diagnostic techniques (PC and PNDT) Act and Rules with its latest amendment in 2012. This Act is essentially prohibitive in nature, bans prenatal sex determination, and regulates the use of PNDT. This act is definitely an important milestone with the government making a consistent effort to register the doctors and machines. On the flipside, point-of-care US by nonsonographers is also under the purview of this act, thereby hampering the wide-scale use of this convenient and economical diagnostic technique. This act does not provide separate recognition to US centers other than genetic counseling centers, US clinics or imaging centers. In addition, to perform theUS, the personnel should be a sonologist, imaging specialist, radiologist or registered medical practitioner, having postgraduate degree or diploma or 6 months training or 1 year experience in sonography., The members of Central Supervisory Board, responsible for uniform implementation of the act, include only medical geneticists, gynecologists, obsretricians, and pediatricians, therefore, are not representative of the service provider segment of doctors. All US equipment are under the scanner of this act. However, equipment dedicated to MSUS may not support gender detection of the fetus. Therefore, an amendment to the PC and PNDT act is required to differentiate between regular sonography of fetus and point-of-care US done by nonsonologists.
MSUS is an operator-dependent procedure, and for rheumatologists wishing to implement MSUS, a key concern is to acquire imaging skills through appropriate training. In the absence of established training curriculum, guidelines for the duration of training and certification, there is considerable variability in the degree and type of training undertaken by rheumatologists who perform MSUS. Institutes like the Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow and Krishna Institute of Medical Sciences, Hyderabad offer short-term courses, whereas, training in MSUS at Christian Medical College, Vellore, SGPGIMS, Lucknow and Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry is a part of a postdoctoral fellowship curriculum. A useful starting point for rheumatologists wishing to train in MSUS is to at least attend formal, 2–3 days training workshops to obtain a standardized overview of the technique and to gain initial “hands-on” experience. Valuable resources for MSUS training are also available on the Internet, with some websites providing free technical information, guidelines, and illustrative US pictures for training, in addition to a wide array of pathological cases. Short courses can be a stimulus to learning and web-based packages a useful adjunct, but neither of these is a substitute for continuous learning with an experienced mentor. It would, therefore, be helpful if “training the trainer” programmes are introduced, following which training in MSUS could be made an integral part of the curriculum for rheumatology.
With few fresh medical graduates considering rheumatology as a subject of specialization, there are <100 dedicated whole time rheumatologists serving a billion plus people in the country. With the current workload, a major hindrance to the US in rheumatology practice could be the fear of impingement of the clinician's time. Although the introduction of MSUS may initially take longer, it soon takes only a few minutes to perform a scan in the out-patient setting. It is also likely that more accurate diagnosis, aspiration, and joint injection will lead to an improved patient outcome and fewer return visits by the patient, resulting in a freeing up of the rheumatologists time. Prohibitive expense of high-quality, high-resolution equipment may be cited as another reason for not practicing imaging in clinics. Costs of US equipment are continuously decreasing and quality improving; also significant reductions in cost can be obtained by programming the system solely for MS imaging. In the restricted environment for the use of MSUS in India, a clinic-based study evaluating its role in rheumatology was performed by Agrawal et al. at NIMS, Hyderabad. This study was carried out on retrospective data and revealed that MSUS had the potential to reduce diagnostic uncertainty. In addition, trial results showed that MSUS has a significant impact on treatment decisions, follow-up visits, and better outcomes. Rheumatologists in India must produce high-quality research to further validate the role of MSUS in rheumatological practice.
| Conclusion|| |
MSUS, a sensitive imaging tool to assess disease activity, to detect joint damage, to monitor treatment response, and to predict disease outcome in rheumatic diseases, is fast becoming an important adjunct to clinical examination. It is vital that rheumatologists take a leading role in the development of MSUS and produce high-quality research to further validate the role of MSUS in rheumatological practice. The technical advances are likely to make MSUS more accessible to rheumatologists and allow faster and more accurate imaging of joints and related structures. Various surveys worldwide have shown willingness among rheumatologists to learn the technique; hence, agreements on training and certification are essential to legitimize the training of new MSUS practitioners. The regulatory environment needs to be made conducive for point-of-care ultrasonography by nonsonographers.
Editorial support for this manuscript preparation was funded by Bristol-Myers Squibb and provided by DiagnoSearch Life Sciences Pvt. Ltd.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]