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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.
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.
Our patients already wait for care. If we begin doing ultrasound in the office, they will wait even longer to see us. This is important, as, for example, just a few months of early rheumatoid arthritis is destructive to the joints. Additionally, even with rheumatologists working at their current pace, there is already a projected shortfall of nearly two-thirds in the number needed in Canada by 2026 (J. Rheumatol. 2010;37:1749-55).
Ultrasound-guided needle placement in joint spaces sounds wonderful, but we need more long-term proof that it improves outcomes. For instance, when it comes to sacroiliac joint injections, clinical outcome is the same whether the needle is placed in the joint space or in the adjacent tissue (Rheumatology 2010;49:1479-82).
Ultrasound is incredibly subjective and user dependent. You need a lot of training to become good at it: There is only fair to moderate agreement in assessing synovitis for beginners just getting up to speed (Int. J. Rheumatol. 2010;164518). So unless you are an elite expert, you are not going to be that proficient, and there is potential for doing more harm than good.
In summary, point-of-care ultrasound in rheumatology needs more investigation. At present, we recommend against widespread adoption in rheumatologists’ offices. Rheumatologists’ time is too precious to waste on ultrasound exams. Even cardiologists and obstetrician-gynecologists have techs who do the exams; if we try to do them ourselves, our patient wait lists will skyrocket. The cost to you and society makes the choice clear: We should not be doing ultrasound routinely in our office.
Dr. Christopher Penney is a rheumatologist at Foothills Hospital in Calgary, Alta. Dr. David Collins is a rheumatologist at Vancouver (B.C.) General Hospital. Dr. Penney disclosed no relevant conflicts of interest. Dr. Collins disclosed no relevant conflicts of interest. The comments were based on presentations given at the annual meeting of the Canadian Rheumatology Association in Victoria, B.C.
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.
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.
Our patients already wait for care. If we begin doing ultrasound in the office, they will wait even longer to see us. This is important, as, for example, just a few months of early rheumatoid arthritis is destructive to the joints. Additionally, even with rheumatologists working at their current pace, there is already a projected shortfall of nearly two-thirds in the number needed in Canada by 2026 (J. Rheumatol. 2010;37:1749-55).
Ultrasound-guided needle placement in joint spaces sounds wonderful, but we need more long-term proof that it improves outcomes. For instance, when it comes to sacroiliac joint injections, clinical outcome is the same whether the needle is placed in the joint space or in the adjacent tissue (Rheumatology 2010;49:1479-82).
Ultrasound is incredibly subjective and user dependent. You need a lot of training to become good at it: There is only fair to moderate agreement in assessing synovitis for beginners just getting up to speed (Int. J. Rheumatol. 2010;164518). So unless you are an elite expert, you are not going to be that proficient, and there is potential for doing more harm than good.
In summary, point-of-care ultrasound in rheumatology needs more investigation. At present, we recommend against widespread adoption in rheumatologists’ offices. Rheumatologists’ time is too precious to waste on ultrasound exams. Even cardiologists and obstetrician-gynecologists have techs who do the exams; if we try to do them ourselves, our patient wait lists will skyrocket. The cost to you and society makes the choice clear: We should not be doing ultrasound routinely in our office.
Dr. Christopher Penney is a rheumatologist at Foothills Hospital in Calgary, Alta. Dr. David Collins is a rheumatologist at Vancouver (B.C.) General Hospital. Dr. Penney disclosed no relevant conflicts of interest. Dr. Collins disclosed no relevant conflicts of interest. The comments were based on presentations given at the annual meeting of the Canadian Rheumatology Association in Victoria, B.C.
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.
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.
Our patients already wait for care. If we begin doing ultrasound in the office, they will wait even longer to see us. This is important, as, for example, just a few months of early rheumatoid arthritis is destructive to the joints. Additionally, even with rheumatologists working at their current pace, there is already a projected shortfall of nearly two-thirds in the number needed in Canada by 2026 (J. Rheumatol. 2010;37:1749-55).
Ultrasound-guided needle placement in joint spaces sounds wonderful, but we need more long-term proof that it improves outcomes. For instance, when it comes to sacroiliac joint injections, clinical outcome is the same whether the needle is placed in the joint space or in the adjacent tissue (Rheumatology 2010;49:1479-82).
Ultrasound is incredibly subjective and user dependent. You need a lot of training to become good at it: There is only fair to moderate agreement in assessing synovitis for beginners just getting up to speed (Int. J. Rheumatol. 2010;164518). So unless you are an elite expert, you are not going to be that proficient, and there is potential for doing more harm than good.
In summary, point-of-care ultrasound in rheumatology needs more investigation. At present, we recommend against widespread adoption in rheumatologists’ offices. Rheumatologists’ time is too precious to waste on ultrasound exams. Even cardiologists and obstetrician-gynecologists have techs who do the exams; if we try to do them ourselves, our patient wait lists will skyrocket. The cost to you and society makes the choice clear: We should not be doing ultrasound routinely in our office.
Dr. Christopher Penney is a rheumatologist at Foothills Hospital in Calgary, Alta. Dr. David Collins is a rheumatologist at Vancouver (B.C.) General Hospital. Dr. Penney disclosed no relevant conflicts of interest. Dr. Collins disclosed no relevant conflicts of interest. The comments were based on presentations given at the annual meeting of the Canadian Rheumatology Association in Victoria, B.C.