Ultrasound for Seeing Invisible Inflammation in Rheumatoid Patients

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Sonosite no error adI was a bit surprised at the tremendous response to my last post on trying to take the gloves off to talk about some typical things experienced with Rheumatoid disease. Several important conversations arose on the comments page. I always say the comments on this site are another whole blog. I’m blessed with such compassionate and intelligent readers with challenging ideas for improving treatment. One thing Helen said struck me:

There have to be better diagnostic tools.”

Is that something you think about too? I happened to have three different tabs open to articles about better diagnostic tools for Rheumatoid arthritis!

1. Detecting damaging “invisible” inflammation in Rheumatoid Arthritis?

Japanese investigators recently concluded that increased synovial vascularity (blood flow) is evident even with what appears to be “low disease activity.” And that increased activity correlates with joint damage even with apparent good response to treatment.

The researchers concluded: “Smouldering inflammation reflected by positive synovial vascularity under low disease activity was linked to joint damage. The damage progressed irrespective of the severity of positive synovial vascularity. Even with a favourable overall therapeutic response, monitoring of synovial vascularity has the potential to provide useful joint information to tailor treatment strategies.” Read more about observing synovial vascularity with ultrasound in the Oxford Journal of Rheumatology.

2. Clinical exams may miss most knee soft-tissue abnormalities

But such ideas are cutting edge… won’t it be years before such techniques are within reach?

A decade ago, Scottish investigators discovered a large discrepancy between joint problems detected by clinical exams (CE) and those revealed with ultrasound (US). As a patient with acute knee involvement that has never been examined or treated, this finding interests me (emphasis added):

They reported in the Journal of Rheumatology: “US detected soft tissue abnormality (suprapatellar bursitis, knee effusion, or Baker’s cyst) at 54/130 (42%) sites, while CE detected soft tissue abnormality at 36/130 (28%) sites. US detected 17 (39%) cases of suprapatellar bursitis in 44 knees, 7 (16%) of which were detected on CE. US detected 27 (61%) knee joint effusions in 44 knees, 16 (36.36%) of which were detected on CE. US detected 10 (23.81%) Baker’s cysts in 42 knees, 2 (4.76%) of which were detected on CE. Taking US of the knee as the gold standard, CE was specific but not sensitive in the detection of soft tissue abnormality of the knee in RA.”

I particularly like this one because it does not use hands. Patients will be better off when the myth of hand-concentrated disease ends.

3. Training is still a critical issue for using ultrasound to diagnose joints

If that was recognized a decade ago, what will it take to make ultrasound available so that Rheumatoid disease activity can be detected in patients who are suffering, untreated, or undertreated? Last month at the American College of Rheumatology (ACR) Scientific Meeting, instruction in musculoskeletal ultrasound (MSUS) was offered. In 2010, the ACR Musculoskeletal Ultrasound Task Force found “Learning opportunities beyond introductory courses remain sparse, with the only path to acquiring added skills being self-directed efforts with a steep curve leading to implementation in the clinic, since preliminary hands-on practice is time consuming. To date, standards are lacking for what constitutes competence in this operator-dependent technique. In addition, not all radiologists agree that US should be within the purview of rheumatologists.”

What we need to know

  1. MSUS is more sensitive than clinical examinations in detecting synovitis (inflammation) in established and early RA and discerning disease activity during so-called remission.
  2. US is more sensitive than radiography (x-ray) at detecting progression of erosions.
  3. Establishing proficiency with MSUS is still a huge problem because much experience is required to develop the expertise to make US reliable.

Bottom line

The thousands of patients who tell us their disease activity is more than what their clinicians think it is are likely right. When there is something abnormal and destructive going on inside your body, you tend to feel it. Asking patients which joints are involved and how is still the best starting point.

Do you have a blog – ANY KIND OF BLOG? You’re invited to post about a non-medicine item that brings you comfort or relief and might make a good present for someone living with a chronic disease like Rheumatoid disease. You can show just one item in a picture or create a whole list of items you love! Then email the link to your post to Kelly at rawarrior.com and I’ll put them all together and tell the world about your wonderful idea. We hope to get the Blog Carnival post up Wednesday so send your link asap!

Recommended reading

NOTE: Your comments are an important resource for future readers of this post in the months to come. Please find the comment link below each post.

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Kelly Young. All rights reserved.

This entry was posted on Monday, December 17th, 2012 at 4:55 am and is filed under RA Education. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.

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