Ultrasounds for Rheumatoid Arthritis, Part 3

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Ultrasounds as sensational tests for RA

Over the last couple of days, we have taken a look at musculoskeletal ultrasound tests for Rheumatoid Arthritis. We explored the value of ultrasounds (MSUS) compared to other tests for RA. We have seen that ultrasounds for Rheumatoid Arthritis are more precise and sensitive than x-ray tests for RA. The machines are less expensive and the procedure is less invasive than MRI’s which are of similar value to “see” the damage of Rheumatoid Arthritis.

Problems with obtaining a valid MSUS for Rheumatoid Arthritis

Then, we examined some problems with obtaining a valid ultrasound for Rheumatoid Arthritis. MSUS is highly dependent upon the expertise of the operator. There is a need for standardization of training, standardization of interpretations of data, and skillful interpretation of a patient’s specific data. Consistency is difficult to obtain. In order to get a valid ultrasound for RA, you have to find just the right person to do the test. And it would seem that the stars must also be aligned…

Maybe we won’t really like having ultrasound tests for RA

Last week, I was reading a collection of radiological abstracts while doing research for a different project. I came across a study which shocked me. It was one of those “eureka” moments when I called out to whoever was home to come, “Look at this!”

The study reported that doctors changed plans for the treatment of Rheumatoid Arthritis patients after performing ultrasounds on the RA patients. Rheumatologists in this study were much less likely to prescribe disease modifying drugs for RA (DMARD’s) after the MSUS test. “A total of 88.7% of patients had DMARD as a proposed management option before US vs. 48.4% after US (p<0.001). In addition, 4.84% of patients had NSAID/ review as outpatients as a proposed management option before US vs. 45.26% after US (p<0.001).”

The doctors had planned to prescribe DMARD’s based upon clinical examination, lab tests, and reports from the patients about their conditions. The results of the ultrasound tests changed the minds of almost half of the doctors so that they prescribed NSAID’s (glorified aspirin) instead, for treatment of the disease. Listen to the conclusion of the original report: “Conclusion: Sonography of the hands and/or feet significantly influences the rheumatologists’ diagnostic confidence in specific clinical findings and management plans.”

That influence is significant indeed. And it is not a positive influence in my opinion. I wish that patients’ descriptions of their own disease states had such influence.

Let’s not get lost in the woods

Aren’t “early and aggressive” the watchwords for treating Rheumatoid Arthritis? I’ve met some RA’ers whose doctors have seen evidence of their Rheumatoid Arthritis using ultrasound, enabling them to obtain treatment for RA which was creating invisible damage. Ultrasound tests have been especially valuable for RA’ers who are seronegative. Obviously, what we see in that last study describes an opposite scenario. Patients who would have been treated for Rheumatoid Arthritis will not receive treatments because of an ultrasound result.

When I read that, I suddenly had no desire for an ultrasound test for my RA. Would the doctor cut off my disease treating DMARD’s if he could not detect my RA with his MSUS? Would he assume it was his own user error? How many docs do you know who usually see things that way?

Part 1 of this series, Ultrasounds for Rheumatoid Arthritis.

Recommended reading:

Kelly Young

Kelly Young is an advocate providing ways for patients to be better informed and have a greater voice in their healthcare. She is the president of the Rheumatoid Patient Foundation. Kelly received national acknowledgement with the 2011 WebMD Health Hero award. Through her writing, speaking, and use of social media, she is building a more accurate awareness of Rheumatoid disease aka Rheumatoid Arthritis (RA) geared toward the public and medical community; creating ways to empower patients to advocate for improved diagnosis and treatment; and bringing recognition and visibility to the Rheumatoid patient journey. In 2009, Kelly created Rheumatoid Arthritis Warrior, a comprehensive website about RA of about 950 pages and writes periodically for other newsletters and websites. Kelly served on the Mayo Clinic Center for Social Media Advisory Board. There are over 42,000 connections of her highly interactive Facebook Fan page. She created the hashtag: #rheum. Kelly is the mother of five, a home-schooler, Bible teacher, NASA enthusiast, and NFL fan. You can also connect with Kelly by on Twitter or YouTube, or LinkedIn. She has lived over nine years with unrelenting Rheumatoid disease. See also http://www.rawarrior.com/kelly-young-press/

23 thoughts on “Ultrasounds for Rheumatoid Arthritis, Part 3

  • November 25, 2009 at 10:44 am
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    Wow, very interesting. I’m one of those RAers for whom ultrasound confirmed the diagnosis and warranted the use of DMARDs. Early and aggressive. Well, actually, early diagnosis would have been 4-5 years earlier when my PCP first looked at possible lupus to explain troubles with my hands.

    X-rays didn’t show bone erosion, but ultrasound did. I had RF all of a piddly 8 and SED rate of 31. Not exactly impressive numbers but six months of double doses of NSAIDs had done absolutely nothing for the pain. It took methotrexate to bring down the inflammation (and pain) to a mild level.

    My rheumatologist is kinda funny. During the recent visit where we discussed Rituxan, she wrote me a new order for routine bloodwork. This time she actually left off any tests of inflammatory markers for concern that they would come back within the normal range and that insurance might contest the need for a more “big gun” medication. Smart lady.

    Reply
    • November 29, 2009 at 7:29 am
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      I have never heard of that approach, but it sounds smart. That doc sounds like a keeper; I’d probably send her muffins! 😎

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  • November 25, 2009 at 9:20 pm
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    That is interesting. I actually just joined an AS study as a remote participant to see if there is a genetic link suggesting severity of AS. I am excited to hear results! 🙂

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  • November 26, 2009 at 1:22 pm
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    How frustrating!! The results from that study make no sense. Such potential for good diagnostic use, but it shouldn’t be used to limit or deny needed treatment when other diagnostic methods indicate DMARDs.

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    • November 29, 2009 at 7:31 am
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      YES! We have big job ahead of us to educate about RA; unfortunately that includes some doctors. :curse:

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  • November 26, 2009 at 1:24 pm
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    Kelly, I agree with the fact that the personnel involved in the testing should be highly trained in conducting the test. However, maybe this is because I am fortunate to live in an area that has a top national ranked rheumatology department, but the ultrasound tests that were conducted on me allowed even me to see the state of my disease. The wand that is used in the size of ball point pen. As he scaned each joint, the machine was turned to a color mode that actually would turn red when coming across the inflammation. He pointed out to me the areas that I already had erosions. My Dr. did not use any 1 of the tests ordered (blood, xrays, US) to make the diagnosis or determine the treatment plan. Again I will say this is probably due to established protocol at a hospital greatly involved in the advancement of treatments for RA. I guess, in a way, even though I knew from the pain, fatigue and mobility difficulties I had that what ever it was, it was widely spread, but actually gave me a chance to see things happening in joints I wasnn’t even aware were involved yet. I know you know that attitude of pushing through the pain and fatigue to accomplish things – especially for your kids. This was a wake-up call to me as to how important the treatments and rest in combination are to living daily with RA. I still am very stubborn about doings things for myself but as you may well know, it doesn’t take long for my body to remind me of its limitations!

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    • November 26, 2009 at 1:34 pm
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      That’s very interesting. I’m so glad for you. You are showing us the future / how it can be better. The test CAN be amazing as I said in part 1. But also terrifying as I showed in part 3.

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  • November 26, 2009 at 1:26 pm
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    Amy, we are in the same boat! I also push myself beyond the limits and after all this time you would think that I would know better…however, I am trying. Where do you live? I love that there are such protocols to give a definitive diagnosis and establish a course of treatment—what a concept! I live in Memphis and we have a limited amount of rheumys to begin with and they are still practicing in the Middle Ages. We still need to band together and force the drs to move ahead…Grace and Peace…

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  • November 26, 2009 at 1:27 pm
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    Great series Kelly, really great.

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    • November 26, 2009 at 1:36 pm
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      Thank you, Heather. So much work to make it sound simple but also present some evidence…

      Reply
  • November 26, 2009 at 1:28 pm
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    Kelly, I’m a technical editor. I have no idea how much time and work you put into your daily blogs, but I DO know it is much more than anyone would imagine. I know it is an enormous investment of your time; I would call it a sacrifice. rawarrior.com is a tremendous blessing to everyone who visits your site. Thank you for your dedication and hard work!

    Reply
  • November 26, 2009 at 1:30 pm
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    As one of my “catch up” things to do this weekend I plan on going back and reading all the blogs of yours I may have missed from time to time…because you clearly work so hard to get us wonderful information I don’t want to miss anything! I’m thankful for RA Warrior this year for sure :).

    Reply
  • November 26, 2009 at 1:40 pm
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    Interesting. I’ve wondered about that in addition to use of MRI to detect MRI damage or activity that isn’t clinically obvious to the doctor. I did read something on an ER blog where the doc discussed how ultrasounds would and are useful in some ER situations but not used nearly as often as they should be.

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  • January 26, 2011 at 2:57 pm
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    Came across this article as I’m having my USG tomorrow. This will be the first one for my hands, but fifth in five years of disease overall. I’ve had a very nice experience of using ultrasound on my joints as I see it as a fun thing and the last time I had a usg the man turned the screen to my side and explained every single detail on the screen and I got some pretty pictures. 😀
    My docs have never taken me off medication just because the arthritis has not left a mark visible on an X-ray or USG, or MRI. Probably because I’ve had Full Body Scan that lit up like a Christmas tree.

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  • August 8, 2011 at 9:59 am
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    I had US on my fingers and wrists at last rheumatology appointment. My RA diagnosis was in question because I had not responded to Enbrel and I am seronegative. My joints continue to ache symmetrically, my fatigue disables me… but no observation of inflammation on ultrasound lead the MD to suggest a diagnosis of Fibromyalgia rather than RA and prescribe Cymbalta. To be fair, she did not dismiss the possibility of RA completely.

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    • August 8, 2011 at 11:29 am
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      Suz, this is an article that was just posted on US that I found very helpful. It’s a great tool, but extremely user dependent. Also, I like how the article explains that different joints or tissues show better on one test than another. http://www.musculoskeletalnetwork.com/display/article/1145622/1916613

      There is a pretty large portion of patients who don’t respond to Enbrel, so I hate to hear of doctors using lack of response to Enbrel as a diagnostic indicator.

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  • October 15, 2011 at 9:47 am
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    Thank you so much for this info Kelly. I just printed the article you have linked to above; I also have my next rheum appointment next week and I am going to ask about US for my hands. My Doc is usually very connected to and informed about new research, which is why I have stayed with her for my entire term of care (just under 20 years now). This past year has seen my first hand involvement(as far as MY symptoms go) but she has always checked my hands visually and is always surprised that they don’t hurt. I had to come off Enbrel for 6 weeks earlier this year in order to have surgery on my toe, and my response to it since going back on has not been as well as before.
    I live in Massachusetts, so I’m hoping that if she is not set up or comfortable doing US that she can have me go into Boston….will keep you updated!

    Reply
    • October 15, 2011 at 4:20 pm
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      If you really need the MSUS, she may need to send you to an expert – it’s hard to find someone who can do this reliably – but you are in a good part of the country – good luck.

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  • February 3, 2012 at 5:35 am
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    Rheumatologists are not trained to correlate the US with the clinical. An orthopedic radiologists told me once that he was 500% better at interpretation of spinal issues after a flexed MRI than a regular radiologist. This ortho guy pointed out he looked at 100’s of these spinal films a month and that the smallest disparity jumped out at him. Could a rheumatologist take on such a challenge? Would many of them do it? We all hear of rheumy complacency. What would happen if they had a huge commitment with each patient for in-depth review of MSUS? One more personal experience. My rheumy had been injecting a shoulder joint for a couple of years-usually twice, sometimes three or four times annually. In frustration, I went to my orthopedic doc. Before he even saw an x-ray, the ortho described three major conditions occurring. After the x-rays in his office, he explained how the synovitis had ruptured the bursa, caused tendon shredding and pointed out the extreme bone spurs present. He wished for a good shoulder replacement and said he would overhaul the shoulder and try to get several more years from it. On the next rheumy appointment, I took the pics from the surgery. My rheumy expertly explained how my RA had affected the shoulder. When I asked him why he didn’t recommend the surgery, his only reply was no one knows when you are ready for surgery except you. I have faith in both my rheumy and my ortho (four TJRs). I just wish they would have a dialog about me. They are not at polar opposites; they just think so. My opinion on education and medicine in this country are the same: they both need an overhaul in humanity and commitment and money won’t fix either.

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  • October 21, 2012 at 12:06 am
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    Interesting. Thanks.
    I have been having joint pains for the past 7 months.
    Seronegative, including inflammatory factors.
    Yesterday Dr. did u/s to see if he could see any signs of inflammation. He won’t diagnose RA (or anything else) unless he can actually see something. HE didn’t see anything (and he did lookk carefully as far as I could tell – both hands wrists and MCPs).

    I am reassured that he can’t see anything, but that doesn’t explain the pain!

    Anyway, he’s ordered a retest for antibodies, and inflammatory factors.

    He wants to monitor closely.

    Reply
  • January 2, 2013 at 9:47 pm
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    I live in Idaho Falls, Id. and I am being treated by a Rheumatoid Arthritis doctor in an adjacent town. I have had two ultrasounds completed in two years. The first year showed no indication of the RA. However, after the second ultra-sound he was able to show the RA in my hands and feet. I found that the person doing the ultra-sound was very good and took a lot of time working through each joint in my hands and feet. I have mild RA at this time and I tried Plaquenil with bad reacations. Yesterday, I took my first dose of Methotrexate, felt fine today. Keep trying on the ultra-sound I do beleive that the right doctor can show you where your RA is active.

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    • January 2, 2013 at 10:04 pm
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      Good luck w/ the mtx treatment Jill. Thanks for that good advice. I agree. I hope it helps. Make sure they give you folic acid to help prevent side effects.

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  • June 3, 2017 at 4:02 pm
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    I’m seronegative and have been treated for 2 years with mtx and various biologics. I just had an US on my hands and it showed nothing. Perfectly normal hands, yet they hurt all the time, along with all of my other joints. I haven’t had my follow up with my doctor yet, but it makes me nervous what he is going to do with this info. I have had some success with biologics, but they either quit working after a few months or they aren’t effective enough. I’m scared he is going to change my treatment plan because of this. I just started my 3rd biologic 2 months ago and it’s just starting to work.

    Reply

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