Reliability of ultrasonography in detecting shoulder disease in patients with rheumatoid arthritis

Intraobserver Reliability on Classifying Bursitis on Shoulder Ultrasound

Purpose: Bursitis is a common musculoskeletal cause of shoulder pain and treatment varies, thus correctly diagnosing and grading bursitis is paramount in deciding management. Our aim was to assess reliability in grading shoulder bursitis on ultrasonography among fellowship trained musculoskeletal radiologists at our institution. Methods: Retrospective study of patients diagnosed with bursitis on ultrasonography. Single-sonographic images of the subacromial-subdeltoid bursa were collected for each patient and randomized to form a test-bank of varying degrees of bursitis. Three months after the test was administered, the cases were randomized and readministered. The radiologists graded each case as: within normal limits, mild, moderate or severe. Intraobserver variability was measured using Cohen's kappa coefficient. Linear regression model was performed to assess correlation between years of experience and kappa. Results: 10 radiologists reviewed 70 cases of bursitis. Kappa values ranged from .53 to .91, indicating 'moderate' to 'almost perfect' variability amongst radiologists. A moderate positive correlation of improving variability (r = .69) with increasing years of experience exists. Conclusion: Fellowship trained musculoskeletal radiologists were able to grade shoulder bursitis with moderate to almost perfect variability, with a positive correlation of improved variability with increasing experience. This may help clinicians choose the correct treatment more confidently in their patients with shoulder pain.

Ultrasound is more reliable than clinical tests to both confirm and rule out pathologies of the long head of the biceps: a systematic review and meta-analysis

PURPOSE

To synthesize the literature and critically appraise current evidence to determine the most accurate physical examination (clinical test or ultrasound) to detect pathologies of the long head of the biceps tendon (LHBT).

METHODS

A search was performed on PubMed, Embase®, and Cochrane. Studies that compared the diagnostic accuracy of clinical tests or ultrasound versus arthroscopy for the assessment of LHBT pathologies were included.

RESULTS

Seven studies were included reporting on a total of 448 patients. One study on instability using ultrasound reported sensitivity and specificity of 1.00 and 0.96, respectively. Two studies on full-thickness tears using ultrasound reported sensitivity and specificity of 0.88-0.95 and 0.71-0.98, respectively. Four studies on partial-thickness LHBT tears reported sensitivity and specificity of 0.17-0.68 and 0.38-0.92, respectively, for clinical tests, versus 0.27-0.71 and 0.71-1.00, respectively, for ultrasound. Three studies on other LHBT pathologies reported sensitivity and specificity of 0.18-0.79 and 0.53-0.85, respectively, for clinical tests, versus 0.50 and 1.00, respectively, for ultrasound.

CONCLUSION

To detect LHBT pathologies, sensitivity is high-to-excellent using ultrasound, and moderate using Neer's sign and Speed's test, while specificity is high-to-excellent also using ultrasound, as well as the belly press, lift-off and Kibler's tests. The clinical relevance of these findings is that clinical tests are only reliable either to confirm or rule out LHBT pathologies, whereas ultrasound is reliable both to confirm and rule out LHBT pathologies. While diagnostic imaging cannot substitute for patient history and physical examination, the reliability and accessibility of ultrasound render it practical for routine use, particularly if clinical tests render unclear or contradictory findings.

LEVEL OF EVIDENCE

Level III.

3D imaging has good specificity but poor sensitivity for the diagnosis of pathologies of the long head of the biceps: a systematic review and meta-analysis

PURPOSE

To systematically review and meta-analyse the literature to determine which three-dimensional (3D) imaging modality provides the best diagnostic accuracy to detect pathologies of the long head of the biceps tendon (LHBT).

MATERIALS AND METHODS

A search was performed on PubMed, Embase^®, and Cochrane. Studies that compared the diagnostic accuracy of 3D imaging modalities versus arthroscopy for the assessment of LHBT pathologies were included. Studies assessing superior labral anterior posterior (SLAP) lesions were excluded.

RESULTS

Fifteen studies were included; nine were eligible for meta-analysis. Six studies on instability indicated a sensitivity of 0.68 (CI 0.46-0.84) and specificity of 0.76 (CI 0.68-0.82). Four studies on full-thickness tears indicated a sensitivity of 0.56 (CI 0.28-0.81) and specificity of 0.97 (CI 0.93-0.99). Four studies on partial-thickness tears indicated a sensitivity of 0.52 (CI 0.20-0.82) and specificity of 0.64 (CI 0.25-0.91). Two studies on any tear indicated a sensitivity of 0.58 (CI 0.28-0.83) and specificity of 0.99 (CI 0.93-1.00). Only one study on other pathologies indicated a sensitivity of 0.61 and specificity of 0.84.

CONCLUSION

To diagnose LHBT pathologies, 3D imaging modalities overall have low-to-moderate sensitivity, but high-to-excellent specificity. The consistency in reported sensitivity is generally poor, while the consistency and reported specificity is good for the detection of instability, full-thickness tears and any tear, but poor for the detection of partial-thickness tears. 3D imaging may be adequate to rule out LHBT pathologies, but are not sufficiently reliable to confirm the presence of such pathologies.

LEVEL OF EVIDENCE

III.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

Ultrasonography of Shoulder in Rheumatoid Arthritis: A Reliability Exercise Using Consensual Definitions among Maghrebian Rheumatologists

The shoulder may be affected in a large portion of patients with rheumatoid arthritis (RA) worldwide. However, this joint does not receive the attention required during follow-up. Indeed, although numerous clinical tests for diagnosis of a painful shoulder are available, differentiating articular from peri-articular lesions may be difficult in daily practice. Fortunately, the precise diagnosis of shoulder pain in RA has benefited from a reliable imaging modality used to detect its exact origin-ultrasonography (US). This study was aimed at assessing the intra- and inter-observer reliability of ultrasonographic findings for patients with established RA with shoulder pain in a patient-based exercise as a clinical challenge among Maghrebian rheumatologist experts in US. A total of 7 operators examined 10 patients in two rounds independently and blindly of each other. Before beginning the session, all of the rheumatologists reached a consensus on sites and US settings by performing a brief exercise on a normal shoulder. Outcome Measures in Rheumatology Clinical Trials (OMERACT) definitions of US-detected pathologies were used. Each patient underwent US scanning of the painful shoulder in predefined sites based on US technical guidelines of the European Society of Musculoskeletal Radiology: long head of biceps (LHB), subscapularis recess, posterior recess and axillary recess. The presence of subdeltoid or subcoracoid bursitis or full rupture of the suprasupinatus was identified if present. Intra- and inter-observer reliability measures were calculated using the κ coefficient. Intra-observer reliability was good for gray-scale (GS) synovitis in subscapularis and posterior recesses (κ = 0.77 and 0.73, respectively). It was moderate in the presence of GS synovitis and effusion in LHB (κ =0.53 and 0.40, respectively), posterior and subscapularis recess effusion (κ = 0.56 and 0.60, respectively) and GS and power Doppler (PD) synovitis in axillary recesses (κ = 0.58 and 0.49, respectively). Inter-observer reliability was good for PD for LHB signals (κ = 0.78). It was moderate for GS for LHB synovitis (κ = 0.54). Inter-observer agreement was poor for effusion and GS synovitis for subscapularis, posterior and axillary recesses, and very poor for PD signals in these recesses. US was a reliable imaging tool for detecting tenosynovitis in the LHB. However, reliability was moderate to poor in detecting synovitis in subscapularis, posterior and axillary recesses. These findings could be optimized by standardization of sites to assess.

What is the added value of ultrasound joint examination for monitoring synovitis in rheumatoid arthritis and can it be used to guide treatment decisions? A systematic review and cost-effectiveness analysis

BACKGROUND

Synovitis (inflamed joint synovial lining) in rheumatoid arthritis (RA) can be assessed by clinical examination (CE) or ultrasound (US).

OBJECTIVE

To investigate the added value of US, compared with CE alone, in RA synovitis in terms of clinical effectiveness and cost-effectiveness.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE and the Cochrane databases were searched from inception to October 2015.

REVIEW METHODS

A systematic review sought RA studies that compared additional US with CE. Heterogeneity of the studies with regard to interventions, comparators and outcomes precluded meta-analyses. Systematic searches for studies of cost-effectiveness and US and treatment-tapering studies (not necessarily including US) were undertaken.

MATHEMATICAL MODEL

A model was constructed that estimated, for patients in whom drug tapering was considered, the reduction in costs of disease-modifying anti-rheumatic drugs (DMARDs) and serious infections at which the addition of US had a cost per quality-adjusted life-year (QALY) gained of £20,000 and £30,000. Furthermore, the reduction in the costs of DMARDs at which US becomes cost neutral was also estimated. For patients in whom dose escalation was being considered, the reduction in number of patients escalating treatment and in serious infections at which the addition of US had a cost per QALY gained of £20,000 and £30,000 was estimated. The reduction in number of patients escalating treatment for US to become cost neutral was also estimated.

RESULTS

Fifty-eight studies were included. Two randomised controlled trials compared adding US to a Disease Activity Score (DAS)-based treat-to-target strategy for early RA patients. The addition of power Doppler ultrasound (PDUS) to a Disease Activity Score 28 joints-based treat-to-target strategy in the Targeting Synovitis in Early Rheumatoid Arthritis (TaSER) trial resulted in no significant between-group difference for change in Disease Activity Score 44 joints (DAS44). This study found that significantly more patients in the PDUS group attained DAS44 remission (p = 0.03). The Aiming for Remission in Rheumatoid Arthritis (ARCTIC) trial found that the addition of PDUS and grey-scale ultrasound (GSUS) to a DAS-based strategy did not produce a significant between-group difference in the primary end point: composite DAS of < 1.6, no swollen joints and no progression in van der Heijde-modified total Sharp score (vdHSS). The ARCTIC trial did find that the erosion score of the vdHS had a significant advantage for the US group (p = 0.04). In the TaSER trial there was no significant group difference for erosion. Other studies suggested that PDUS was significantly associated with radiographic progression and that US had added value for wrist and hand joints rather than foot and ankle joints. Heterogeneity between trials made conclusions uncertain. No studies were identified that reported the cost-effectiveness of US in monitoring synovitis. The model estimated that an average reduction of 2.5% in the costs of biological DMARDs would be sufficient to offset the costs of 3-monthly US. The money could not be recouped if oral methotrexate was the only drug used.

LIMITATIONS

Heterogeneity of the trials precluded meta-analysis. Therefore, no summary estimates of effect were available. Additional costs and health-related quality of life decrements, relating to a flare following tapering or disease progression, have not been included. The feasibility of increased US monitoring has not been assessed.

CONCLUSION

Limited evidence suggests that US monitoring of synovitis could provide a cost-effective approach to selecting RA patients for treatment tapering or escalation avoidance. Considerable uncertainty exists for all conclusions. Future research priorities include evaluating US monitoring of RA synovitis in longitudinal clinical studies.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015017216.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Recommendations for the use of ultrasound and magnetic resonance in patients with rheumatoid arthritis

OBJECTIVE

To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA).

METHODS

Recommendations were generated following a nominal group technique. A panel of experts, consisting of 15 rheumatologists and 3 radiologists, was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of experts voted ≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist.

RESULTS

A total of 20 recommendations were proposed. They include the validity of US and MRI regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies.

CONCLUSIONS

These recommendations will help clinicians use US and MRI in RA patients.

Structural damage in rheumatoid arthritis: comparison between tendon damage evaluated by ultrasound and radiographic damage

OBJECTIVE

To compare structural damage assessed by conventional radiography and tendon damage assessed by musculoskeletal US (MSUS) at wrist and ankle in RA patients.

METHODS

We evaluated 72 consecutive patients [56 (77.8%) females] with RA. The MSUS evaluation consisted in a B-mode examination of bilateral extensor carpi ulnaris and tibialis posterior tendons. Tendon damage was defined and scored according to OMERACT. A total score for the tendon damage score (TDS) was calculated by summing the grades for each tendon. For the radiographic evaluations we used the van der Heijde score; a total radiographic score (RTS) was calculated by summing a bone erosion score (ERS) and a joint space narrowing score (JSNS).

RESULTS

We evaluated 288 tendons. The mean (s.d.) of TDS was 2.3 (1.8). Fifty-four (75%) patients presented tendon damage of at least one tendon. From all evaluated tendons, 134 (46.5%) had no tendon damage, 146 (50.7%) had grade 1 and 8 (2.8%) had grade 2 tendon damage. The mean (s.d.) for RTS was 91.4 (97), for ERS was 47.3 (61.9) and for JSNS was 44.1 (37.2). We found a significant correlation between disease duration and both TDS and RTS (r = 0.413 and r = 0.560, respectively; P < 0.0001). We found a good significant correlation between TDS and all variables of radiographic structural damage (RTS, r = 0.65; ERS, r = 0.637; JSNS, r = 0.618; P < 0.001).

CONCLUSION

The MSUS assessment of only four tendons can be an additional feasible method to assess structural damage in RA patients.

The Role of Power Doppler Ultrasonography as Disease Activity Marker in Rheumatoid Arthritis

Structural damage in rheumatoid arthritis (RA) occurs early if inflammation is not treated promptly. Treatment targeted to reduce inflammation, in particular, that of synovial inflammation in the joints (synovitis), has been recommended as standard treat-to-target recommendations by rheumatologists. The goal is to achieve disease remission (i.e., no disease activity). Several accepted remission criteria have not always equated to the complete absence of true inflammation. Over the last decade, musculoskeletal ultrasonography has been demonstrated to detect subclinical synovitis not appreciated by routine clinical or laboratory assessments, with the Power Doppler modality allowing clinicians to more readily appreciate true inflammation. Thus, targeting therapy to Power Doppler activity may provide superior outcomes compared with treating to clinical targets alone, making it an attractive marker of disease activity in RA. However, more validation on its true benefits such as its benefits to patients in regard to patient related outcomes and issues with standardized training in acquisition and interpretation of power Doppler findings are required.

The OMERACT Ultrasound Working Group 10 Years On: Update at OMERACT 12

Musculoskeletal ultrasound (US) now thrives as an established imaging modality for the investigation and management of chronic inflammatory arthritis. We summarize here results of the Outcome Measures in Rheumatology (OMERACT) US working group (WG) projects of the last 2 years. These results were reported at the OMERACT 12 meeting at the plenary session and discussed during breakout sessions. Topics included standardization of US use in rheumatic disease over the last decade and its contribution to understanding musculoskeletal diseases. This is the first update report of WG activities in validating US as an outcome measure in musculoskeletal inflammatory and degenerative diseases, including pediatric arthritis, since the OMERACT 11 meeting.

Is there subclinical synovitis in early psoriatic arthritis? A clinical comparison with gray-scale and power Doppler ultrasound

OBJECTIVE

Arthritis activity assessments in psoriatic arthritis (PsA) have traditionally relied on tender and swollen joint counts, but in rheumatoid arthritis, multiple studies have demonstrated subclinical inflammation using modern imaging. The aim of this study was to compare clinical examination and ultrasound (US) findings in an early PsA cohort.

METHODS

Forty-nine disease-modifying antirheumatic drug-naive patients with recent-onset PsA (median disease duration 10 months) underwent gray-scale (GS) and power Doppler (PD) US of 40 joints plus tender and swollen joint counts of 68/66 joints. GS and PD were scored on a 0-3 semiquantitative scale for each joint. Clinically active joints were defined as tender and/or swollen and US active joints were defined as a GS score ≥2 and/or a PD score ≥1.

RESULTS

The most common sites for subclinical synovitis were the wrist (30.6%), knee (21.4%), metatarsophalangeal (MTP) joints (26.5-33.7%), and metacarpophalangeal joints (10.2-19.4%). Excluding MTP joints and ankles, 37 (75.5%) of 49 patients had subclinical synovitis with a median of 3 (interquartile range [IQR] 1-4) joints involved. In contrast, clinical overestimation of synovitis occurred most commonly at the shoulder (38%) and ankle (28.6%). Twelve of 49 patients were classified clinically as having oligoarthritis; of these, subclinical synovitis identified 8 (75%) as having polyarthritis with an increase in their median joint count from 3 (IQR 1-4) to 6 (IQR 5-7).

CONCLUSION

This study has demonstrated that subclinical synovitis, as identified by US, is very common in early PsA and led to the majority of oligoarthritis patients being reclassified as having polyarthritis. Further research is required into the relationship of such subclinical synovitis to structural progression.

Quantitative diagnostic method for biceps long head tendinitis by using ultrasound

Objective. To investigate the feasibility of grayscale quantitative diagnostic method for biceps tendinitis and determine the cut-off points of a quantitative biceps ultrasound (US) method to diagnose biceps tendinitis. Design. Prospective cross-sectional case controlled study. Setting. Outpatient rehabilitation service. Methods. A total of 336 shoulder pain patients with suspected biceps tendinitis were recruited in this prospective observational study. The grayscale pixel data of the range of interest (ROI) were obtained for both the transverse and longitudinal views of the biceps US. Results. A total of 136 patients were classified with biceps tendinitis, and 200 patients were classified as not having biceps tendinitis based on the diagnostic criteria. Based on the Youden index, the cut-off points were determined as 26.85 for the transverse view and 21.25 for the longitudinal view of the standard deviation (StdDev) of the ROI values, respectively. When the ROI evaluation of the US surpassed the cut-off point, the sensitivity was 68% and the specificity was 90% in the StdDev of the transverse view, and the sensitivity was 81% and the specificity was 73% in the StdDev of the longitudinal view to diagnose biceps tendinitis. Conclusion. For equivocal cases or inexperienced sonographers, our study provides a more objective method for diagnosing biceps tendinitis in shoulder pain patients.

Responsiveness in Rheumatoid Arthritis. A Report from the OMERACT 11 Ultrasound Workshop

Objective.

To summarize the work performed by the Outcome Measures in Rheumatology (OMERACT) Ultrasound (US) Task Force on the validity of different US measures in rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA) presented during the OMERACT 11 Workshop.

Methods.

The Task Force is an international group aiming to iteratively improve the role of US in arthritis clinical trials. Recently a major focus of the group has been the assessment of responsiveness of a person-level US synovitis score in RA: the US Global Synovitis Score (US-GLOSS) combines synovial hypertrophy and power Doppler signal in a composite score detected at joint level. Work has also commenced examining assessment of tenosynovitis in RA and the role of US in JIA.

Results.

The US-GLOSS was tested in a large RA cohort treated with biologic therapy. It showed early signs of improvement in synovitis starting at Day 7 and increasing to Month 6, and demonstrated sensitivity to change of the proposed grading. Subsequent voting questions concerning the application of the US-GLOSS were endorsed by > 80% of OMERACT delegates. A standardized US scoring system for detecting and grading severity of RA tenosynovitis and tendon damage has been developed, and acceptable reliability data were presented from a series of exercises. A preliminary consensus definition of US synovitis in pediatric arthritis has been developed and requires further testing.

Conclusion.

At OMERACT 11, consensus was achieved on the application of the US-GLOSS for evaluating synovitis in RA; and work continues on development of RA tenosynovitis scales as well as in JIA synovitis.

Value of ultrasound in rheumatologic diseases

The use of musculoskeletal ultrasound in rheumatology clinical practice has rapidly increased over the past decade. Ultrasound has enabled rheumatologists to diagnose, prognosticate and monitor disease outcome. Although international standardization remains a concern still, the use of ultrasound in rheumatology is expected to grow further as costs fall and the opportunity to train in the technique improves. We present a review of value of ultrasound, focusing on major applications of ultrasound in rheumatologic diseases.

The evolution of ultrasound in rheumatology

Musculoskeletal ultrasound is a powerful tool not only for evaluating joint and related structures but also for assessing disease activity. Ultrasound in rheumatology has rapidly evolved and been incorporated into routine clinical practice over the past decade. Moreover, technological development of equipment has made it more accessible for rheumatologists. We present a review of advances in ultrasound in rheumatology, focusing on major chronological developments.

The role of ultrasonography in early detection and monitoring of shoulder erosions, and disease activity in rheumatoid arthritis patients; comparison with MRI examination

OBJECTIVES

To determine the accuracy of ultrasound in early detection of bone erosions and monitoring disease activity in rheumatoid arthritis (RA) patients using magnetic resonance imaging (MRI) as a gold standard technique.

MATERIAL AND METHODS

This prospective study was carried out on 50 patients with known RA and 15 healthy controls. Conventional radiography was standardized and performed in two planes. Ultrasound (US) and MRI was performed to evaluate the presence of synovitis, tenosynovitis, and bursitis as well as erosions on ultrasound and MRI. The results in the study group were compared with those obtained in a control group.

RESULT

In the study group, the most frequent US finding of shoulder joint was Tenosynovitis of the long head of the biceps tendon. Tenosynovitis was observed in the long head of biceps tendon in 20 joints (40%). Erosions of the humeroscapular joint were detected by conventional radiography in 15 (30%), by US in 41 (82%), and by MRI in 46 (92%) of the shoulders examined, no statistically significant difference is noted between US and MRI in overall detection of erosion (P = .333).

CONCLUSION

US is a helpful imaging method and in comparison with MRI in assessing the shoulder joint and, preferably with MRI, are recommended as additional techniques in the initial diagnostic evaluation when radiography yields negative results.

The role of Doppler ultrasound in rheumatic diseases

The use of Doppler techniques, including power, colour and spectral Doppler, has greatly increased in rheumatology in recent years. This is due to the ability of Doppler US (DUS) to detect pathological vascularization within joints and periarticular soft tissues, thereby demonstrating the presence of active inflammation, which has been reported to be correlated with the local neo-angiogenesis. In synovitis, DUS showed a high correlation with histological and MRI findings, thus it is considered a valid tool to detect pathological synovial vascularization. Moreover, it is more sensitive than clinical examination in detecting active joint inflammation and in the evaluation of response to treatment. In addition, DUS may be considered as a reference imaging modality in the assessment of enthesitis, MRI being not sensitive and histology not feasible. Moreover, it has been demonstrated to be able to detect changes in asymptomatic enthesis. In conclusion, DUS is a useful and sensitive tool in the evaluation and monitoring of active inflammation. Its widespread use in clinical rheumatological practice is recommended. The aim of this article is to review the current literature about the role of DUS in rheumatic diseases, analysing its validity, reliability and feasibility.

A comparison of physical examinations with musculoskeletal ultrasound in the diagnosis of biceps long head tendinitis

Provocative tests are useful in diagnosing biceps tendon tendinitis. This is the first study to establish the reliability of these tests by comparing the resuts with musculoskeletal ultrasound (US) findings. This study examined 125 patients (69 women and 56 men) and 143 shoulders with shoulder pain. Yergason's test, Speed's test and a bicipital groove tenderness test were performed and musculoskeletal US findings were used as standard reference. Biceps tendon tendinitis was diagnosed with US in 39.1% of the patients and, of those, 55.3% had coexisting rotator cuff injury. The sensitivity and specificity of Yergason's test were 32% and 78%, respectively. The sensitivity and specificity of Speed's test were 63% and 58%, respectively. In conclusion, all three tests are limited by poor sensitivity. US can be an image modality choice in diagnosing biceps pathology.

The OMERACT Ultrasound Task Force — Status and Perspectives

This article reports the most recent work of the Outcome Measures in Rheumatology (OMERACT) Ultrasound Task Force, and highlights the future research priorities discussed at the OMERACT 10 meeting. Results of the following studies were presented: (1) intra- and interobserver reliability of ultrasound detecting and scoring synovitis in different joints of patients with rheumatoid arthritis (RA); (2) systematic review of previous ultrasound scoring systems of synovitis in RA; (3) enthesitis systematic review and Delphi definition exercise in spondyloarthritis enthesitis; (4) enthesitis intra- and interobserver reliability exercise; and (5) Delphi definition exercise in hand osteoarthritis, and reliability exercises. Study conclusions were discussed, and a future research agenda was approved, notably further validation of an OMERACT ultrasound global synovitis score (GLOSS) in RA, emphasizing the importance of testing feasibility, predictive value, and added value over standard clinical variables. Future research areas will include validating scoring systems for enthesitis and osteoarthritis, and testing the metric qualities of ultrasound for evaluating tenosynovitis and structural damage in RA.

A prospective study of shoulder pain in primary care: prevalence of imaged pathology and response to guided diagnostic blocks

BACKGROUND

The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ).

METHODS

Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks.

RESULTS

In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p ≤ 0.05).

CONCLUSIONS

Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.

Validity of ultrasonography and measures of adult shoulder function and reliability of ultrasonography in detecting shoulder synovitis in patients with rheumatoid arthritis using magnetic resonance imaging as a gold standard

OBJECTIVE

To assess the intra- and interobserver reproducibility of musculoskeletal ultrasonography (US) in detecting inflammatory shoulder changes in patients with rheumatoid arthritis, and to determine the agreement between US and the Shoulder Pain and Disability Index (SPADI) and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, using magnetic resonance imaging (MRI) as a gold standard.

METHODS

Eleven rheumatologists investigated 10 patients in 2 rounds independently and blindly of each other by US. US results were compared with shoulder function tests and MRI.

RESULTS

The positive and negative predictive values (NPVs) for axillary recess synovitis (ARS) were 0.88 and 0.43, respectively, for posterior recess synovitis (PRS) were 0.36 and 0.97, respectively, for subacromial/subdeltoid bursitis (SASB) were 0.85 and 0.28, respectively, and the NPV for biceps tenosynovitis (BT) was 1.00. The intraobserver kappa was 0.62 for ARS, 0.59 for PRS, 0.51 for BT, and 0.70 for SASB. The intraobserver kappa for power Doppler US (PDUS) signal was 0.91 for PRS, 0.77 for ARS, 0.94 for SASB, and 0.53 for BT. The interobserver maximum kappa was 0.46 for BT, 0.95 for ARS, 0.52 for PRS, and 0.61 for SASB. The interobserver reliability of PDUS was 1.0 for PRS, 0.1 for ARS, 0.5 for BT, and 1.0 for SASB. P values for the SPADI and DASH versus cuff tear on US were 0.02 and 0.01, respectively; all other relationships were not significant.

CONCLUSION

Overall agreements between gray-scale US and MRI regarding synovitis of the shoulder varied considerably, but excellent results were seen for PDUS. Measures of shoulder function have a poor relationship with US and MRI. Improved standardization of US scanning technique could further reliability of shoulder US.

Clinical value of single versus composite provocative clinical tests in the assessment of painful shoulder

OBJECTIVES

The aims of the present study were to investigate the clinical value of the provocative clinical tests and propose a composite index for the assessment of painful shoulder, using ultrasonography (US) as reference method.

METHODS

Two hundred three patients with painful shoulder underwent both clinical and US evaluations. The physical examination was carried out performing the Hawkins, Jobe, Patte, Gerber, and Speed tests. Each test was included in a composite index namely, SNAPSHOT (Simple Numeric Assessment of Pain by SHOulder Tests). The US examination was performed by a rheumatologist experienced in US and blinded to clinical findings. Sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratio of each clinical test were calculated. The receiver operating characteristic (ROC) curve analysis was used to assess the performance of the composite SNAPSHOT index.

RESULTS

Sensitivity was low for the clinical diagnosis of all shoulder abnormalities. The highest sensitivity and smallest negative likelihood ratio were found for the Hawkins (63.88% and 0.50%) and Patte (62.21% and 0.52%) tests. Specificity was good for Speed (76.33%), Gerber (75.42%), and Patte (74.20%) tests. Patte and Speed tests were the most accurate (71.12% and 66.41%, respectively). The calculated area under the ROC curve related to the SNAPSHOT composite index was 0.881 +/- 0.026. With an optimal cut-off point of 3, the sensitivity and specificity were 75.8% and 87.5%, respectively.

CONCLUSION

The results of the present study showed that SNAPSHOT is a feasible, informative and quantitative composite index for the assessment of painful shoulder in the clinical setting.

The thickness of the A1 pulleys reflects the disability of hand mobility in scleroderma. A pilot study using high-frequency ultrasound

BACKGROUND

Hand involvement in scleroderma is a serious concern. Clinical tests to asses hand dysfunction are based on the experience of the clinician.

OBJECTIVE

To asses if utrasonographic (US) measurement of A1 pulley thickness may be used as an indicator of hand mobility in scleroderma.

MATERIALS AND METHODS

Institutional review board approval and patient informed consent was obtained. Twenty-eight patients affected suffering from scleroderma and 40 healthy controls were prospectively evaluated by two blinded radiologists with US, with a transducer operating at 17MHz. A1 pulley thickness was measured and correlated with the Hand Mobility in Scleroderma Test (HAMIS) and disease duration.

RESULTS

The thickness of the A1 pulley was greater in sclerodermic patients than in controls (p < 0.05). Intra and inter-observer agreement were better for ultrasound (0.94;0.88) than for HAMIS tests (0.71;0.70). A good correlation between pulley thickness, hand mobility and disease duration was found (r = 0.78, p < 0.018; r = 0.54, p < 0.05).

CONCLUSION

A1 pulley thickness measured on ultrasound correlates with hand mobility and disease duration. Ultrasound is an useful tool to evaluate hand disability in scleroderma.

Reliability of ultrasonography to detect synovitis in rheumatoid arthritis: a systematic literature review of 35 studies (1,415 patients)

OBJECTIVE

To perform a systematic review on the reliability of ultrasonographic (US) synovitis detection in rheumatoid arthritis (RA) by B-mode and power Doppler (PD) in image acquisition and still-image interpretation. US is a sensitive method for synovitis detection. However, reliability is still a key concern.

METHODS

Articles reporting any US reliability results for synovitis in RA in PubMed, EMBase, the Cochrane Library, and meeting abstracts were selected. Data were extracted from the collection of data on US synovitis detection (either qualitatively [binary] or semiquantitatively [0-3 scale], for intraobserver and interobserver reliability in B-mode and PD, and for image acquisition and still-image interpretation). The type of joints tested, the experience of the ultrasonographer, and the quality of the studies were assessed. Data analysis involved descriptive and graphic interpretation of reliability and its potential determinants.

RESULTS

Thirty-five studies (12 for B-mode, 11 for PD, or 12 for both) with a total of 1,415 patients were analyzed. Intraobserver and interobserver reliability for still images in B-mode and PD was high (kappa = 0.5-1.0 [14,991 joints] for intraobserver reliability for B-mode, kappa = 0.59-1.0 [14,934 joints] for PD, kappa = 0.49-1.0 [3,138 joints] for interobserver for B-mode, and kappa = 0.66-1.0 [3,325 joints] for PD). Interobserver reliability for image acquisition in both US modes was lower than still-image interpretation (kappa = 0.22-0.95). Few studies reported intraobserver image acquisition reliability.

CONCLUSION

Intraobserver and interobserver reliability of still-image interpretation was high, especially for PD, in published studies involving highly trained observers. However, reliability of acquisition of US should be further assessed.

Reproducibility of Joint Swelling Assessment by Sonography in Patients with Long-lasting Rheumatoid Arthritis (SEA-Repro Study Part II)

Objective.

To evaluate the intraobserver and interobserver reproducibility of B-mode and power Doppler (PD) sonography in patients with active long-standing rheumatoid arthritis (RA) comparatively with clinical data.

Methods.

In each of 7 patients being considered for a change in their RA treatment regimen, 7 healthcare professionals examined the 28 joints used in the Disease Activity Score 28-joint count (DAS28). Then 7 sonographers examined each of the 7 patients twice, using previously published B-mode and PD grading systems. The clinical reference standard was presence of synovitis according to at least 4/7 examiners. The sonographic reference standard was at least grade 1 (ALG1) or 2 (ALG2) synovitis according to at least 4/7 sonographers. Interobserver reproducibility of sonography was assessed versus the sonographer having the best intraobserver reproducibility. Agreement was measured by Cohen’s kappa statistic.

Results.

Intraobserver and interobserver reproducibility of B-mode and PD used separately was fair to good. Agreement between clinicians and sonographers at all sites using B-mode, PD, and both was 0.46, 0.37, and 0.36, respectively, for grade 1 synovitis; and 0.58, 0.19, and 0.19 for grade 2 synovitis. The number of joints with synovitis was smaller by physical examination (36.7%) than by B-mode with ALG1 (58.6%; p < 0.001). The number of joints with synovitis was higher by physical examination than by PD with both ALG1 (17.8%; p < 0.0001) and ALG2 (6.6%; p < 0.0001).

Conclusion.

PD findings explain most of the difference between clinical and sonographic joint assessments for synovitis in patients with long-standing RA.

The OMERACT Ultrasound Task Force — Advances and Priorities

This article reports the most recent work of the OMERACT Ultrasound Task Force (post OMERACT 8) and highlights of future research priorities discussed at the OMERACT 9 meeting, Kananaskis, Canada, May 2008. Results of 3 studies were presented: (1) assessing intermachine reliability; (2) applying the scoring system developed in the hand to other joints most commonly affected in rheumatoid arthritis (RA); and (3) assessing interobserver reliability on a deep target joint (shoulder). Results demonstrated good intermachine reliability between multiple examiners, and good applicability of the scoring system for the hand on other joints (including shoulder). Study conclusions were discussed and a future research agenda was generated, notably the further development of a Global OMERACT Sonography Scoring (GLOSS) system in RA, emphasizing the importance of testing feasibility and added value over standard clinical variables. Future disease areas of importance to develop include a scoring system for enthesitis and osteoarthritis.