Ultrasound for Rheumatoid Arthritis, Part 1
What is the best test for Rheumatoid Arthritis?
We’ve looked at tests for RA before on the blog. Last week, we took a humorous look at an MRI for Rheumatoid Arthritis. What about an ultrasound for detecting signs of Rheumatoid Arthritis?
Earlier this year, I asked that question. Do I need an ultrasound for RA? In the next couple of blogs, I will surprise you with what I found.
Ultrasounds detect erosions of Rheumatoid Arthritis
I had never even had an x-ray to check my joints, so I wondered: could an ultrasound allow the doctor to see how much damage Rheumatoid Arthritis had done to my joints? I learned that ultrasounds are much more sensitive than x-rays at detecting the effects of Rheumatoid Arthritis. Realizing that an ultrasound might help me to be better treated for this practically invisible illness, I did some research on ultrasounds and RA.
There are many studies which prove that ultrasounds are superior to x-rays for RA. In one study, 80 joints were examined. Bone erosions due to Rheumatoid Arthritis were detected by both x-ray and ultrasound methods. The x-rays detected a total of 6 joints with bone erosions. The ultrasound test detected 17 joints with bone erosions. Yes, they were the same joints. The authors of the study concluded that the use of ultrasound in “RA can detect erosions not seen with radiography and may be complementary to radiography in establishing the presence of erosive disease in early RA.”
Ultrasounds to detect synovitis of Rheumatoid Arthritis
Ultrasound or musculoskeletal ultrasound (MSUS) is useful for detecting synovitis that is “subclinical” or less likely to be detected in a clinical setting. In other words, this is synovitis that the rheumatologist cannot readily see with his or her eyes. Rheumatoid Arthritis swelling can be subtle, especially in fingers and hands. MRI can also detect early or subclinical synovitis, but it is much more invasive and expensive than MSUS.
Since ultrasound is also useful to detect inflammatory activity, US may aid in diagnosis of Rheumatoid Arthritis in patients who are seronegative for Rheumatoid factor. PDUS, which is power Doppler ultrasonography, could be valuable for monitoring inflammatory activity. And QUS, quantitative ultrasound helps detect bone loss. Various modes of ultrasound use different types of beams to obtain specific types of images.
Advantages to ultrasound for Rheumatoid Arthritis
We have seen that MSUS is more sensitive than x-rays for bone erosions. It is can be as sensitive as MRI for detecting bone loss or inflammatory activity. Ultrasound is less expensive than MRI. It is also less burdensome to the patient and the doctor because the machines are portable and more comfortable to use. The results are available immediately.
Note that MSUS would not only permit earlier and more precise diagnosis of Rheumatoid Arthritis in patients whose synovitis is subclinical or whose Rf is negative. It could also provide the much needed guidance with the tricky issue of remission. As we have discussed previously on the blog, clinical remission currently has a somewhat subjective definition.
Musculoskeletal ultrasound sounds perfect for RA
MSUS sounds wonderful, doesn’t it? That’s what I thought, too. I even knew a couple of women whose rheumatologists had used it to finally “see” their RA so it could be treated.
When I decided to try to get an ultrasound for my own joints, I called every rheumatology office in my region. I asked, “Does the doctor do ultrasound for Rheumatoid Arthritis?” The answers would make a funny blog post. I heard things like, “Whatever for?” and “Of course not!”and “Are you kidding?”
Stay tuned for part 2 of Ultrasounds for Rheumatoid Arthritis.
We’ll ask, “Why don’t we all get an ultrasound right now?” and, “Is there anything bad about ultrasounds for RA?”
Recommended reading:
Rheumatoid Arthritis and Medication: Are Natural Medicines Better?
Celebrities and Rheumatoid Arthritis
Great information! Very timely.
Thank you. 😎
I use ultrasound more frequently than before. Not for erosion but to detect early arthritis in patients without swollen joints, where pain is the main concern. Colour coded doppler can detect small vessels in the synovium and is therefore very helpful.
Ultrasound is time consuming and I don’t use it if the decision could be made by clinical examination and X-ray.
All good points.
Did you ever get the ultra sound doc you were looking for? Did any of the offices ever explain why your question puzzled them?
Hi Nikki, I think I talk a little about what I learned in parts 2 & 3, but no details about my experience. I did find a doc who would do the U/S, but he was not well trained in it. My new doc says that very few are trained in it for the purpose of identifying damage/erosions and it is completely unreliable for that due to user error levels. The new doc has an U/S machine for injections – has only had it about a month though. The doc offices in all the cities near me who told me “What the heck is that?” were just uninformed staff because their docs never use them. We are in need of better diagnostic tools as I say. MRI are better than the ol’ x-ray. U/S would be better if we knew just how to do it – some say bone scans work best – but my doc doesn’t really like them. I’ll have to get to the bottom of why. I’m just so glad to find a doc who says, “Let’s just treat this thing.” Thanks for a great question. Have you ever had any of these image tests?
I am hoping that all rheumatologists get the appropriate training to use ultrasound technology. Early diagnosis is supposed to be so important to prevent complications, but it’s very difficult to get a clear-cut diagnosis, as many patients don’t present with the current “textbook” clinical picture.
Ultrasound sounds like it would assist greatly in reaching earlier diagnoses. How great would that be, for patients who are suffering physically and emotionally; and for doctors, who are trying to help their patients as much and as quickly, as possible.
I was diagnosed in July last year, got things under control quickly with mtx and plaquenil, as well as some dietary changes. I’ve been symptom free since September, and thrilled. I just had MRIs (done on my wrists as part of a study my rheumy was interested in. I know they aren’t ultrasounds, but with the same intent, looking for disease activity that isn’t apparent. Just got back from my appt with her, and to both of our surprise, my right wrist really active. Moderate to severe synovitis and several erosions. Go figure – other than feeling a bit stiff when I do yoga or something not so smart like bowling with the kids this weekend – it seems fine, and all my blood work is well within normal range (and had been out of whack when I was diagnosed).
So now she and I are considering adding a biologic. I need to do my research, I know so many are on them, but I skim over as it wasn’t applicable before. Seems like a difficult decision to add such a “big” drug when I feel great, and barely notice anything with this wrist. But the more she reads about and speaks with colleagues about ultrasound and MRI as more advanced tools to monitor disease activity and change treatment, she is thinking about adding another drug, given that I’m 37, and a little bit of damage each year can add up to a lot.
Have any of you been through this? Anyone using ultrasound or MRI to track synovitis? I’m in Canada and there aren’t a lot of places that do this, so was lucky to get it done, though now it’s presented me with more questions…
I’m nervous about the biologics because of their side effects. Is slowing down joint erosion in one wrist worth it? She’s open to me taking any of the biologics, other than Remicade, saying I don’t need that one. From my reading, looks like it’s the case, but certainly not the answer I was hoping for!!
Amelia, there are some posts here tagged Biologics that you can find using the Tags list on the top right of the page. Here’s the link. Reading others’ comments might also help you feel more comfortable.
I’m glad your symptoms are mild now & I hope it stays that way – RA can change in an instant so your doc is probably concerned that it could become more severe and affect many more joints. Maybe that impression is from blood tests – I’m not sure.
Thanks for the links, I’ve got some research to do. Tough choices among the options, though at least there are treatment options. I’m pretty sure I’ll go with one of them and then we’ll do a follow up MRI in a few months to see what’s going on inside. But just when I’d gotten comfortable with mtx, now I’ve got another set of scary side effects to think about. I know I’m preaching to the choir.
Interesting. I had never heard of ultrasound for detecting RA erosion either, until the last time I visited my rheumatologist. Even though my lab levels seem to be improved, there has been a worsening of pain and fatigue. So she sent me away with a fist full of prescriptions and orders for xrays and ultrasound of my hands, wrists and feet. In the entire Western New York area, there is only one radiology clinic that does ultrasound on the hands and feet – and I had to get supervisory approval to even schedule the appointment.
This post confirmed my confidence in my rheumatologist. I found a good one for sure.
Awesome, Julie. I’m glad you did!
US is still not widely used because a lot of training and practice is needed to do it well – and there is another article about MSUS coming up soon – the research shows there is still the issue of user error, so that’s the risk – that something could be missed and there would be a false sense of security. BUT, a good dr uses the whole picture anyway, not any one tool.
My first rheumy appt 3 years ago involved ultrasounds. They had all of my hands done that day in office. The tech asked me as he went if “this joint hurts alot?” from seeing the ultrasound. He could see the damage clearly. They also use ultrasound when giving joint injections. I think it is a very valuable tool that needs utilized!
Hi Kelly, I’ve just come back from my rheumy apt (I’m in the UK), where to my surprise he mentioned using MUS as a tool to track my flares as I don’t swell overmuch and my labs are stable and look good. He has sent me a way with lab forms to get filled during the next full on flare and he mentioned co-coordinating said flares with MUS to see exactly what is going on as my recent hand & foot x-rays look ok apart from one area on one PIP joint. He has a colleague on his team that does the MUS and when he mentioned it, your blog and these articles were the first thing that sprang to mind and I was able to discuss this tool with him having read about it here previously. If I end up getting one done I’ll update you.
I was recently diagnosed Sero positive RA in March this year using blood results, ultrasound (UK) and examination, I have little swelling but horrendous pain, I have been treated early although I haven’t noticed any results yet. from suspicion by G.P to referral and diagnosis was 7 weeks.
I am scheduled to have an US soon. I’m having labs in normal range but fairly severe pain and fatigue. I don’t know that I have ever been fortunate enough to have remission. It is all just a severity of pain levels. Maybe the US will tell us something more. Ivy been on biologics for years. I cannot take NSAIDs or any anti-inflammatory drugs due to anaphylactic allergy.
I am all-in for the U/S for RA. I had my first done in February this year (about 3 months after noticeable symptoms.) It showed several hand/finger joints with synovitis, so they started me on Plaquenil even though all the blood tests came back negative, and no pain when she examined me. Just my claims of swelling/stiffness/pain in the am and other times. Finally started MTX in August. It is now Dec 4, 2013, and my Rheumy just called to tell me that she wants me to start with biologics – all due to the second U/S I had yesterday afternoon. The subcutaneous injection of 25 mg MTX (weekly) + 400 mg Plaquenil + 10 mg prednisone + 200-400 mg celocoxib (all daily) weren’t stopping the progression or the daily, nearly constant pain.
So, up to today, it’s been called anything from Erosive Oseoarthritis (scary in it’s own right) to inflammatory polyarthritis and other non-specific arthritic diagnoses. But now I’ve got a “real” diagnosis: serum-negative Rheumatoid Arthritis (Disease). And I’m glad that they finally got there. I was fairly sure of it. The many joints involved – both in the U/S and experienced daily, had me convinced. However, it is the U/S from yesterday confirming synovitis even with all those meds in me that is allowing me to try the next level of treatment. The insurance company wants this kind of confirmation, especially since all of my blood work is normal.
So, while I’m not thrilled about the scary side-effects of the biologics, I am so looking forward to the possibility that I can find relief and forget that I have joints again. Someday…..
If you live near Birmingham, AL, and you want to be able to benefit from this technology and trained doctors that specialize in this, check out the “SuperDuper” Clinic in Birmingham. I’m not sure if I’m supposed to name it here – I’m new to the site. If I can, I will add it later.
Best of luck!
Jill
Kelly, thank you so much for all of the info and experience you put out on this blog. It’s so helpful. I am not sure if this is the right place to ask this question, but…My rheumy took an x-ray of my SI joint which she said showed sacrioiliitis. She put me on Humira and mtx weekly say that I had RA and Sjögren’s. Since I had been struggling with this for ten years and spent over 50 grand to find an answer (diagnosed with Fibro eight years ago), I was relieved to finally have an answer. Two months later she ordered an MRI and she tells me I have no arthritis or Sjögren’s and takes me off the Humira and mtx. Should I just accept this diagnosis? Thank you!
Wow that’s crazy, Monica. Sorry you are going through this. There are a few other comments like yours on the blog so I’ll try to do a longer post as an answer.
Knowing you are not the only one should help you know it’s not you – sometimes we doubt ourselves when doctors are inconsistent like this. I’ve been where you are, so stay strong and don’t doubt yourself.
No, I would not just accept it – xrays show changes at a later stage than we’d like – because earlier treatment can *prevent* xray changes (like erosion of bone). It’s hard, but you need to find a better doctor. Some things to think about – Did the meds help? Do steroids help? Do you have a family history of RA? Have you taken photos if you do get swelling sometimes? Have you had your antibodies tested – anti-CCP, Rheumatoid factor, and 14-3-3-eta? Those questions might help you sort out where you stand or when you talk to a new doc. Good luck.