Ultrasounds for Rheumatoid Arthritis, Part 2
A surprisingly different assessment of ultrasounds as tests for RA
Several weeks ago, when I met the new rheumatologist, I asked for an opinion of ultrasounds for RA. The reaction was surprising. The doctor told me that it would be a worthless thing to do. Of course, I brought up some of the fantastic reports about musculoskeletal ultrasound (MUS) that I shared with you yesterday on the blog, in part one of this series.
That was the beginning of the next segment of my mission to learning the truth about ultrasound tests for Rheumatoid Arthritis. I had now been told that doctors do not know how to perform the ultrasounds or how to interpret the tests’ results. This was a new direction for my investigation of ultrasounds. Previously, I’d heard either: “That’s a ridiculous test that no one needs” or “Ultrasounds are God’s gift to help us see RA.”
Well, you know where I went then: back to Dr. Google. I was going to find out more about whether or not ultrasounds are being performed well enough to be of any use. We need to know whether or not there is a way to see Rheumatoid Arthritis inflammation so that we can provide better treatment of this disease.
Problems with performing ultrasounds for Rheumatoid Arthritis
There are several issues. I read reports from both rheumatology researchers and radiologists, who perform ultrasound in most other circumstances. First, it is important to understand that the idea of using ultrasound to look at RA has only been around a few years. In fact, musculoskeletal ultrasound is still fairly new.
There is a well respected MUS training program at the University of Leeds, England, which I read about last summer when I was first seeking an MUS for myself. They regularly train nurses and radiological technicians as well as rheumatologists.
Expert training to perform MUS for RA is vital
Results of MUS depend upon the expertise of the one performing the test. “Ultrasound has unparalleled spatial resolution when applied to small joints, though its value depends on the experience of the user. MRI results are far less dependent on operator expertise,” said German radiologist Dr. Christian Glaser. Training to perform MUS appears to be critically important.
Radiologists will not be the ones who become expert in the use of MUS for Rheumatoid Arthritis in the USA. It sounds like they are leaving it to the rheumatology profession for good reasons. According to Dr. Philip O’Conner, a musculoskeletal radiologist at Leeds Teaching Hospital, “The problem is that there is no real training program in radiology built around inflammatory arthritis scanning with ultrasound. It is my belief that this will become a rheumatological procedure.” Rheumatologists will develop their own “training schemes and courses. I don’t think radiologists have the time or staffing to offer this service.”
Other concerns with making ultrasound for RA a valid test
In addition to the training issue, which is an elephant-sized matter, there are a few more troubles. One is consistency of the test operator (the ability of the test operator to be fully consistent with the performance of the test). Another is standardization of the procedure: general standards must be created for interpretation of the data. And, finally, skillful interpretation of a patient’s specific data will be absolutely necessary. Anyone who’s had any other kind of ultrasound knows that it is not always obvious what you are looking at on a Doppler screen. User error in any of these three areas makes the MUS test inaccurate.
An illustration of how difficult it will be
Last month at the ACR (American College of Rheumatology) conference, an article was presented which discussed experimental training of rheumatologists to do ultrasound tests for Rheumatoid Arthritis in hand joints. After intensive training, only 47% of the doctors were able to achieve an acceptable score (over 90%) with the Doppler technique. However, 97% were able to score over 80% with a grey-scale version of ultrasound. The authors concluded that the training was successful, but that doctors had possibly become careless during the MUS procedures which followed the testing period.
Personal reflection
Many have written to ask about the outcome of the doctor visit during my trip last summer. I didn’t want to write about that because it was not a good experience. I did see a doctor who would do an ultrasound on my RA. The doctor was extremely clumsy with the equipment and insisted, “We only do this joint.” He didn’t see anything remarkable about that joint. Does that matter?
I hope you can tune in tomorrow for part 3. (Read Ultrasounds for Rheumatoid Arthritis, Part1.)
Recommended reading:
Do You Take Methotrexate for Rheumatoid Arthritis?
Rheumatoid Arthritis and Football Season
Working and Rheumatoid Arthritis
We had a sponsored training in ultrasound at our hospital by one of the experts in Germany. Ultrasound may depend on the experience of the user, but the advantage is: you can do the procedure over and over again. Someone with more experience could review critical findings.
Sometimes patients can’t bear lying in a vault-like MRT, though some peripheral joints could be done in open MRTs.
One advantage more: untrasound is less cost intensive.
Lothar/Rheumatologe
The doing it over and over thing sounds like a good idea. Since it does no harm, it is another advantage.
Unfortunately, TIME to spend doing that is a problem for doctors – at least here in the US. We don’t have enough rheumatologists and they have to cram patients in, so they usually have to rush.
“We only do this joint.”
What?! Completely not my experience with the one time my rheumatologist used the ultrasound to visualize as many joints as possible in my hands.
Yes, it was a couple of PIP’s only. Wanted to also do only one hand. Unfortunately (??) for me, hands were one of the last places that I got RA. And I had already been established on DMARDs several months by then. They do hurt when I am not on meds, but they are usually not classically “swollen.” My new doc can feel the “thickening” in them even without the ultrasound. A much better doctor. RA does not always present with “obvious swelling,” and can cause plenty of damage without externally visible synovitis… 😛
Ultrasound (USG) is one of the best diagnostic tool presently available for diagnosis of musculoskeletal conditions. It remains one of the best & most economical tool to pick up RA (inflammatory arthritis) early. It costs just a fraction of what a MRI would cost.
However, training in musculoskeletal ultrasound remains an area of concern even among the Radiologists. Awareness about the utility of USG in early diagnosis of RA/ musculoskeletal conditions, its subjective nature & lack of expertise among the Radiologists needs to be adressed.
I agree completely.
Wow! A technology that could be done in a large medical center, and not invasive and cheaper. What is wrong here? The ultrasound tech would do the proceedure, and the radiologist or rheumy would interpret the images.
I think that this is a seriously underused “lab.” Its hard to get the medical profession doing things that are “new” and out of the comfort zone. Somehow it has got to be a money maker or easy and cheap. To get them excited. Isn’t that a shame.
Beth,
I do think that US will be able to become more widely used and even a money maker for some offices when it’s more accurately done. From what I’ve been able to determine interviewing doctors on the topic, we are just not “there yet” with the use of the technology. There is too much error still so it’s not reliable. I’m not sure if you read parts 1 and 3 of this series, but that was my conclusion to the issue. US is being used more to guide injections and hopefully eventually to “see” RA also.
I hope so. It would help so many people!…To make an invisible and hard to quantify disease more “real.” As you say, we can have pain without swelling and without a high sed rate or be sereonegative. Wouldn’t it be nice to have a doctor say, “Look Beth, its here and here and lets have a good watch on those bad joints, and keep up on them. Maybe splint them especially.” Wouldn’t it be nice to come back to our spouses that are hard to reach mentally and say, look honey, its the Left PIP here and this knee, and this wrist. Or yes, your neck needs extra watching because it is degenerating (and we need to watch it). Of course, this should be the case anyway. But the more concrete the result, the better off we are as a group. Our disease can be studied better. We can see if our biologics are halting or reversing our disease. Its just a matter of time and eventually, some ultrasound company is working on a device just for us, portable and for the office. However, ultrasound techs are few and far between, it takes a lot of physics and A & P to get through those studies. Therefore an expensive person to have on call. Doctors do not usually do imaging, I’m sorry its not “House” where the doctors do everything (really, the show cracks me up!) Therefore, they must go to an imaging center.
I’m impressed with your steadfastness with updating us with facts and research. You have been an anchor in this new process for me. I hope you are doing well. And I appreciate your teaching me all that you know. Much hugs, Beth
I think doctors who pass ultra sound off as a “ridiculous test” have just bought in to the “hopeless, no cure, what’s the point” mentality. They are also not putting themselves in the shoes of their patient and considering what it is like to have an “invisible” illness. Any opportunity I have to make my invisible illness more visible would be helpful! I think it would help doctors be more accurate with the meds they are prescribing. I agree with you Beth you made a lot of great points.
Hi Kelly
I have not yet been positively diagnosed with RA however have RF of 167 and have many clinical symptoms. I was interested to read your comments on US and RA. I live in Leeds England and believe that the consultants here are some of the international leaders in this technology. I had my first Rheumy appointment on 5th November and had an ultrasound at that appointment which the consultant came into the room to look at and was told I have some erosions. I have 2 follow up appointments on 11th and 12th. The 11th is for another ultrasound and will then see the consultant on the 12th. I consider myself to be very lucky to live here and be seeing such well renowned rheumys. Sorry that others do not have the same luxury ( if anything in RA is a luxury)
Just diagnosed with RA after 15 years of seeing 4 different rheumys, an endocrinologist, and a pain specialist. 3rd rheumy never even did an US and just told me I had fibromyalgia and sent me to a pain dr. she said she had nothing else to offer me. My newest rheumy did an US in the office and saw mild fluid on some hand joints but dismissed as OA as I am 50. I had told him of warm, swollen, red, painful hands, and other joints, but since he never saw them, he discounted this. He was aware of my symptoms of chills, profound fatigue and flares of severe pain all over; I have been disabled from my nursing job and on narcotics after trying all fibro Meds without relief. I took pictures of my hands when symptoms were active and when I showed him, he finally sent me for a r hand MRI. It showed profound damage and erosions. Then he comes in and says “now we have a dx, seronegative RA.” I wanted to tell him I have been beating me head against the wall for years with thee symptoms and a chronically elevated sed rate and crp. Why do they not listen? My whole body is in a major flare and there is no telling how much damage there really is cause they won’t MRI your whole body. A dr will see the cont of symptoms and not pursue the possibility of seronegative disease until it is so bad they can’t ignore it anymore. This has got to STOP!