POINT: All rheumatologists should offer it to their patients.
Like other point-of-care tests used all the time in medicine – spirometry, blood pressure measurement, the finger-stick glucose test – point-of-care ultrasound is invaluable in the diagnosis and management of rheumatologic conditions.
Ultrasound has a number of merits: It is portable and inexpensive; can be used on multiple joints; allows imaging of both bones and soft tissue, and assessment of vascularity; permits contralateral-side comparison; facilitates accurate injections; and serves as an informational and educational tool for patients. Contemporary machines have resolution down to 0.1 mm, much greater than the 1-2 mm for magnetic resonance imaging.
Photo: Susan London/IMNG Medical Media
From left to right: Dr. David Collins, Dr. Christopher Penney, Dr. Maggie Larchè, and Dr. Johannes Roth.
A recent poll of Canadian rheumatologists about musculoskeletal ultrasound yielded some eye-opening findings. For example, 83% reported having to wait more than 2 weeks to obtain this exam if they referred patients to a radiology service, and just 56% reported that their radiology service offered assessment for inflammatory arthritis (Clin. Rheumatol. 2011;30:1277-83).
We know that information provided by ultrasound changes behavior in rheumatology: It leads to a change in diagnosis in 53% of patients and a change in management in 56% (Arthritis Rheum. 2001;44:2932-3). Ultrasound also improves diagnostic confidence in clinical findings (Skeletal Radiol. 2009;38:1049-54). Diagnostic certainty is key, as musculoskeletal symptoms are some of the most imprecise, and although we now have powerful medications for rheumatologic diseases, they don’t come cheap. Yet we are basing treatment decisions on clinical assessment alone. In an era of budget constraints, we owe it to patients and payers to make an accurate diagnosis and assessment: This is really all about providing an adequate standard of diagnosis and care.
In addition to aiding diagnosis, ultrasound helps in other ways, such as determining the risk of erosions (Arthritis Res. Ther. 2003;5:210-3) and predicting response to treatment (Arthritis Care Res. 2011;63:1477-81). It is more sensitive than clinical measures for assessing disease remission (Arthritis Rheum. 2008;58:2958-67). As patients have to live decades with their joints, and their quality of life is on the line, it is our responsibility to confirm clinically apparent remission with ultrasound.
An ultrasound exam can be done in the office in as few as 5 minutes; often, evaluation of just a single joint will suffice. The time spent more than makes up for the time that would be needed to coordinate a referral to radiology and to follow up on that referral. And there are plenty of examples on how to successfully integrate ultrasound into your office workflow.
In summary, ultrasound should be used as an extension of our clinical examination. It allows for immediate imaging correlation, and it assists with decision making in an environment where radiology services have limitations. It is also phenomenally powerful when it comes to patient contact and education. True point-of-care ultrasound is fast, high quality, and cost efficient. If you show this information to patients, their families, taxpayers, and politicians, they will agree: There is no question that point-of-care ultrasound is the way to go.
Dr. Maggie Larché is a rheumatologist at St. Joseph’s Hospital and McMaster University Hospital, both in Hamilton, Ont. She is also vice president and treasurer of the Canadian Rheumatology Ultrasound Society. Dr. JohannesRoth is head of pediatric rheumatology at Children’s Hospital of Eastern Ontario, Ottawa, and is president of the Canadian Rheumatology Ultrasound Society. Dr. Larché disclosed no relevant conflicts of interest. Dr. Roth disclosed no relevant conflicts of interest.
COUNTERPOINT: Its use at present is best left to experts.
Ultrasound is an amazing tool, and we are not disputing its merits. Thus, the question is not so much whether it should be used in the rheumatologist’s office, but whether you should use it in your office.
Europe is often cited as a hotbed of ultrasound use in rheumatology to be emulated. But in fact, in only 10% of European countries do the majority of rheumatologists use ultrasound, and in no country do the majority of rheumatologists perform ultrasound-guided arthrocentesis (Rheumatol. 2012;51:184-90).
We don’t know if it is feasible to use ultrasound findings as outcome measures in routine clinical care. A recent systematic review noted the difficulty of determining the minimum number of joints to be included in a global ultrasound score and recommended further validation (J. Rheumatol. 2011;38:2055-62). The time needed to perform the exam ranged from 15 to 60 minutes.
Indeed, time and resource constraints are rightly cited as major barriers to wider use of ultrasound in the rheumatology office. Exam time is not the only consideration: The time to acquire ultrasound skills and then to maintain and improve them is also considerable. There is unquestionably a learning curve; it takes about 4-6 months to become good at this. Then you have to continually upgrade your skills.