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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.
I have never heard of that approach, but it sounds smart. That doc sounds like a keeper; I’d probably send her muffins! 😎
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! 🙂
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.
YES! We have big job ahead of us to educate about RA; unfortunately that includes some doctors. :curse:
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!
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.
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…
Great series Kelly, really great.
Thank you, Heather. So much work to make it sound simple but also present some evidence…
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!
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 :).
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.
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.
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.
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.
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!
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.
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.
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.
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.
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.
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.