the use of musculoskeletal ultrasound by rheumatologists...

Bulletin of the NYU Hospital for Joint Diseases 2010;68(4):292-8292

Samuels J, Abramson SB, Kaeley GS. The use of musculoskeletal ultrasound by rheumatologists in the United States. Bull NYU Hosp Jt Dis. 2010;68(4):292-8.

Abstract

Fewer United States rheumatologists perform or utilize musculoskeletal ultrasound (MSUS) than those in Europe, though this disparity is narrowing. To document perceptions and use of MSUS in the U.S. rheumatology community, we sent an anonymous electronic survey to American College of Rheumatology (ACR) physicians and tailored versions to fellows and program directors. A separately-conducted sur-vey was sent to a smaller group of rheumatologists already utilizing MSUS. Acknowledging survey bias, we found that 20% of rheumatologists and fellows who responded are uti-lizing MSUS, and those using it primarily do so for diagnosis and injection guidance. Many rheumatologists across the country think that ultrasound should become a standard tool in rheumatology training, practice, and research. Despite an inherent survey bias likely overstating interest in MSUS, this study is valuable as the first to document this trend among U.S. rheumatologists.

Rheumatologists have increasingly incorporated musculoskeletal ultrasound (MSUS) technology into their practices and research during the last

decade.1-7 MSUS improves the accuracy of aspirations and injections8,9 and also aids in the diagnoses and evaluations of a host of musculoskeletal disorders, from

regional pain disorders and soft tissue and degenerative syndromes to vasculitides and inflammatory and crystal arthritides.10-12

MSUS provides a number of advantages over plain radiography and magnetic resonance imaging (MRI),10,13 as it is faster and can be conveniently performed at the bedside or in clinic while examining multiple joints at one visit. In addition, the cost and space requirements are only a fraction of that for MRI. Furthermore, MSUS does not carry the radiation risks of radiography or com-puted tomography (CT), the claustrophobia and anxiety provocation of MRI and CT, the metal implant limitations of MRI, or the intravenous (IV) contrast difficulties of MRI or CT. There are a number of other distinct advan-tages over MRI, including the ability to view dynamic images by moving tendons and joints, rapid comparison of a potential abnormality with the contralateral side, and demonstration of active synovitis via power Doppler without the use of contrast.10,13-15

Interest in MSUS by international rheumatologists has grown over the last few decades. This trend argu-ably began in the 1980s when German rheumatologists started utilizing MSUS7; other nations’ rheumatology communities soon followed. Italian fellowship curricula added an ultrasound component, in 1996,4 and the Ul-trasound School of the Spanish Society of Rheumatol-ogy established training as well.5 By 1999, a survey of rheumatologists from 19 European nations suggested that more than 40% of departments were already starting to use MSUS.1 This interest has blossomed in other nations, as evidenced by recent surveys of rheumatologists in the United Kingdom2,3,16 and Latin America.16

In the United States, however, MSUS use by rheu-matologists and training programs is far less common. This discrepancy across international lines likely results from MRI access, as well as the lack of incorporation of

The Use of Musculoskeletal Ultrasound by Rheumatologists in the United States

Jonathan Samuels, M.D., Steven B. Abramson, M.D., and Gurjit S. Kaeley, M.B.B.S., M.R.C.P.

Jonathan Samuels, M.D., is Assistant Professor of Medicine, Divi-sion of Rheumatology, and Steven B. Abramson, M.D., is Professor of Medicine, Division of Rheumatology, NYU Hospital for Joint Diseases, and Vice Dean for Education, Faculty, and Academic Affairs, NYU Langone Medical Center, New York, New York. Gurjit S Kaeley, M.B.B.S., M.R.C.P., is Assistant Professor of Medicine, Division of Rheumatology, University of Florida, Col-lege of Medicine, Jacksonville, Florida.Correspondence: Jonathan Samuels, M.D., 14th Floor, Division of Rheumatology, Hospital for Joint Diseases, 301 E. 17th Street, New York, New York 10003; [email protected].

293Bulletin of the NYU Hospital for Joint Diseases 2010;68(4):292-8

ultrasound into fellowship curricula and a steep anatomy learning curve. These and other hurdles are slowly being addressed by advocates within their rheumatology com-munities. The main focus group, USSONAR (Ultrasound Society of North American Rheumatologists), gathers at intervals throughout the year and, as well, at the annual American College of Rheumatology (ACR) meeting, and has formulated a curriculum for rheumatology fel-lows. The ACR has expanded its MSUS offerings since it first scheduled an introductory course at its Annual Scientific meeting in 1999.The College held its two first stand-alone training conferences for two days in August 2010 and two days before the November 2010 Annual Scientific meeting. Through two independent electronic surveys (the smaller one soliciting only a small group of rheumatologists who were experienced sonographers), we sought to document perceptions and use of MSUS in the U.S. ultrasound community.

Methods and MaterialsThe main survey questioned all U.S. ACR fellows, pro-gram directors, and members, in order to ascertain the current attitudes and use of MSUS in both practice and research. In April 2008, we e-mailed letters with a link to our questionnaires through the New York University (NYU) main website survey program to 6234 ACR mem-ber rheumatologists. All of the U.S. physicians listed with an e-mail address in the 2007 membership directory were included. At the same time, we used the website to send questionnaires to all 512 ACR fellows and 135 program directors (including both adult and pediatric) with the assistance of the ACR office. The survey program enabled us to send modified versions to each of the three groups and exclude responses from foreign rheumatologists who were inadvertently included. The solicitation e-mail stated that the survey could be completed in roughly 3 minutes, and asked recipients to click on a link in the email to answer a set of multiple-choice questions (with a few free-text entries included). We asked a variety of questions covering demograph-ics, job descriptions, views on the utility of ultrasound in rheumatology, and individual exposure to and use of MSUS (See Table 1 for the full list of questions in the main survey; tailored versions were sent to the fellows and program directors). A second “reminder” e-mail was sent 2 weeks later. Responses were analyzed blindly unless physicians identified themselves in a specified comment section. In April 2007, a separate electronic survey was sent to 39 rheumatologists in the U.S. who were known to use MSUS to provide a more focused understanding of practice patterns. These physicians were identified from the membership of MSK-USS.org, the focus group of rheumatologist sonographers. The survey polled for experience level, type of equipment used, and incorpo-

ration into practice flow. It also polled for utilization in evaluation and monitoring of inflammatory arthropathies, injection guidance, and research capabilities. Responses were analyzed anonymously and in aggregate.

ResultsACR-Wide SurveysSurvey Responders The three broader surveys yielded responses from one-third of the program directors (46/138, 33%), one-quarter of the fellows (133/512, 26%), and a large group from the ACR membership (573/~6,234, 9%) of the U.S. Of those who responded, we found representation from 46 of the 50 states, Puerto Rico, and Washington, DC, as well as proportionately more responses from New York, California, and Massachusetts (58, 48, and 38, respec-tively), given their greater overall number of rheumatolo-gists. We also asked ACR members how many years ago they completed fellowship training and how they would describe their current job responsibilities. Of the 573 responses, 57% completed training more than 15 years ago, 25% had finished from 5 to 15 years ago, and only 18% were out of fellowship for less than 5 years (Fig. 1). More than 60% of the responders are in private practice, while roughly 20% answered positively to each of the following: faculty practice, hospital clinics, education, and clinical trials (most rheumatologists answered that their jobs fulfilled more than one category). Only 10% engage in clinical research, while 2.7% work in basic science, and 1.4% are employed by industry (Fig. 2).

Current Clinical Use We do acknowledge an inherent bias to the surveys that might overestimate the following data, and we address them in the discussion section below. Still, of the fellow trainees, 20% (27/130) reported regular clinical use of the ultrasound machines. Similarly, 21% of the ACR mem-

Figure 1 Number of years since ACR member respondents com-pleted fellowship training.


bers who responded (123/573) said they currently use MSUS with patients, while an additional 26% (147/573) said they routinely refer patients to radiologists for diag-nostic and therapeutic procedures (Table 1). When asked what role(s) MSUS serves for them, 188 ACR members responded with the following indications: diagnosis (82%), aspiration-injection (82%), gauging response to therapy (37 %), and research (14 %). Subgroup analyses by geography and levels of experience did not reveal any significant differences in purposes for using MSUS. The 27 fellows who said they use MSUS answered this ques-tion similarly to the ACR members: diagnosis (74%), aspiration-injection (78%), gauging response to therapy

(19%), and research (22%).

Views on Current and Potential UtilityWhile one-fifth of respondents (both trainees and ACR mem-bers) said they now scan patients, fewer felt that MSUS has reached the status of a standard clinical tool. Fellows (11%) and program directors (13%) were even more skeptical than the ACR members (19%) (private practice-predominant) cohort in this regard. Interestingly, when the ACR members were separated into subgroups by experience level (less than 5 years, 5 to 15 years, or more than 15 years), all three groups responded similarly at less than 20%. There may be some geographical differences of opinion, however, as

Table 1 Electronic Survey to ACR Members*

1. How would you define your responsibilities in the workplace (check all that apply)? (private practice, faculty practice, hospital clinic practice, clinical trials, clinical/translational research, basic science research,

educator, industry, other)2. In which state do you work? (survey included checkboxes for each state, Puerto Rico, Washington, DC, and foreign)3. How many years ago did you complete your fellowship? (“0-5,” “5-15,” or “more than 15”)4. Do you think ultrasound is currently a standard clinical tool in the field of rheumatology? (yes/no)5. Do you think ultrasound should become a standard clinical tool in the field of rheumatology? (yes/no) If no, why not? (“would always rather use MRI,” “operator variability,” “other”)6. Should rheumatologists or radiologists be the ones performing the ultrasound examinations? (“rheumatologists,” “radiologists,” or “both”) If ONLY radiologists, why?7. Have you received any ultrasound training or attended any lectures or workshops? (“yes, at my institution,” “yes, at conferences,” “no, but I would like to do so,” or “no, and I am not interested”)8. Whether or not you are the one doing the scanning, does MSUS play any role in the management of your patients? (yes/no) If no, why not? (“no one qualified to do the studies in the institution,” “not useful or necessary,” “no machine,” “too time consuming”) If yes, do you perform the ultrasounds yourself? (yes/no) If yes, for what purpose(s)? (“diagnosis,” “tracking response to therapy,” “aspiration and injection anatomic guidance,” or “research”)9. Other comments?

*Tailored versions were sent to fellows and program directors.

Figure 2 Distribution of job responsibili-ties across ACR member respondents.


27% of Texans (9/33) thought it was a standard clinical tool, while only 12% of Californians (6/48) and 12% of New Yorkers (7/58) agreed. Yet a majority of respondents, with at least 63% endorsement by each large subgroup (by level of experience and by state lines), felt that ultrasound “should become” a standard clinical tool (Fig. 3).

Education and TrainingWhile survey bias may have inflated the results here as well, nearly one-half of the ACR members responded that they had attended conference sessions or workshops to learn MSUS, and more than one-third said they would like to do so. When broken down by experience, nearly two-thirds of rheumatologists who finished training within the last 5 years had been exposed to MSUS to some extent, and most of the rest were interested. Rheu-matologists out of training for 5 to 15 years were mostly split between having attended and interested in attending

(with only 9% saying they were not eager), but those who had worked for more than 15 years had fewer exposures (42%) or interest (35%) and were more opposed to such training (23%). The fellows who responded were evenly split between prior training and a desire to learn, with only 2% disinterested (Fig. 4). Given that courses are expensive and require travel and lodging, we asked the program directors in their surveys if they support such opportunities for their fellows. Of the 46 program di-rectors who answered our survey, 41% claim to include some aspect of MSUS in their training curricula, and 33% budget resources to send fellows to the courses.

ObstaclesThe surveys permitted everyone to express their concerns about the growth of MSUS in rheumatology. The most com-mon potential downsides included: 1. operator and reader variability versus other imaging modalities, 2. the initial cost

Figure 3 Perceptions of the role of MSUS as standard practice.

Figure 4 Exposure to ultrasound training or didactics.


of purchasing equipment, 3. fear of insufficient reimburse-ment for time and labor-intensive procedures, 4. lack of financial support for training, and 5. doubt of its utility and impact on patient care. Still, a clear majority of respondents raising these concerns said they would like to learn how to use the machines, and many of them were represented in the minority of ACR members and fellows currently using MSUS at the time of the study (20% and 21%, as mentioned above and listed in Table 2).

Sonographer-only SurveysSurvey RespondersTwenty-seven of the 39 known rheumatologist sonographers responded; however, only 24 were from the U.S., and two were excluded for not currently actively scanning. Of the 22 included in our evaluation, 14 (64%) were in private practice and 8 (36%) in university practices. Five (23%) had used MSUS for more than 5 years and 13 (59%) for 2 years or less; five (23%) used both console and portable machines, 11 (50%) portable machines only, and six (27%) console machines only.

Current Clinical UseThirty-six percent of responders scanned patients every workday, 35% also had dedicated sonography appointment slots, and 90% performed limited scans at patient visits. Most examined patients from their own practice or referred patients from fellow rheumatologists. Three responders (14%) used sonographic guidance for all joint injections, while 36% used MSUS in performing 30% to 60% of their arthrocentesis procedures, targeting joints, tendon sheaths, and the carpal tunnel. In this small cohort, mostly of private practitioners, few had set protocols for monitoring rheu-matoid arthritis (RA) or spondyloarthropathies—but rather scanned according to clinical need.

Data Storage and ArchivingThere was no preferred method of archiving images, as responses were varied between storing data on CD-ROMS, leaving it on machines, or exporting to external drives or network share. As well, there was no consensus for type of format of image storage: DICOM for 18% of respondents and JPEG-AVI for 23%, with a similar proportion using

native manufacturers’ formats.

DiscussionOur broad and novel survey of rheumatologists in the U.S. suggests there is an increasing interest in incorporating ultrasound into daily practice and research. In each of our three blinded questionnaires to different subgroups, more than 75% of responders suggested that MSUS should be-come a standard tool in rheumatology. That being said, they also acknowledged MSUS is far from reaching that status in the U.S. to date. This enthusiasm resonated in the entries consistently across state lines, with responses coming from most every state. Fellows and younger graduates responded more positively to learning how to use the technology than more senior rheumatologists, as might be expected, while program directors are now enabling fellows to obtain extra-mural training. This interest in the U.S. is due, in part, to the examples set by rheumatology communities in various parts of the world, such as Europe, where MSUS has been incor-porated into the fabric of practice and fellowship training.2-7,16

Perhaps most important, however, is that formal training in the U.S. is becoming more visible and obtainable. The ACR has offered brief workshops in MSUS for a number of years, often taught by some of the European pioneers, allowing prospective rheumatologists a glimpse into this technology and its clinical applications. Now, fellows and practicing physicians are attending longer weekend courses, offered by a few institutions to provide more comprehensive introductory training, and the institutions have now added intermediate level courses, demonstrat-ing an increased use and need. As of 2010, the ACR has expanded its own MSUS workshops at other conferences, and has already conducted its own two-day beginner ul-trasound courses in August and November 2010—with all spaces filled. On a nationwide level, the MSK-USS.org focus group (renamed USSONAR, as described earlier) enlisted 33 fellows from 20 programs in 2008 (and 56 in 2010) to follow a 12-month MSUS curriculum of standard image acquisition and pattern and pathology recognition in preparation for a practical examination (personal com-munication from Eugene Kissin, M.D.). Given all of this recent momentum—even since the time we administered the survey in 2008—our results in some respects underesti-

Table 2 Current Use of Ultrasound by Survey Responders

ACR Members (N = 573)

ACR Fellows (N = 130)

Percent using machines themselves 21 20Percent consulting radiologist sonographers 26 NA

Percent using MSUS for the followingACR Members

(N = 188)ACR Fellows

(N = 27)Diagnosis 82 74Aspiration-Injection 82 78Gauging treatment response 37 19Research 14 22


mate the appeal of MSUS to the rheumatology community in 2010 and further increase the relevance of our findings. We do acknowledge the inherent survey bias in our ef-forts, as rheumatologists using or interested in ultrasound were more likely to read and respond to the e-mail, and this could provide an overestimate of interest. In addition, since we only included ACR members who have e-mail addresses listed in the directory, this subset of persons potentially could be more up to date with technology and further inflate the results. Yet our cohort did include the balance of responses from those who do not use MSUS, many of whom provided a helpful list of common reserva-tions that rheumatologists hold with regard to MSUS. Echoing concerns previously raised by their interna-tional counterparts,10 some responders referred to potential obstacles such as the cost of machines, the investment of time and effort to become proficient and qualified in ultra-sound, incorporation into practice flow, and the challenges of unpredictable intra- and inter-reader variability and va-lidity of images. Regarding this last concern, the adoption of standard methods for scan acquisition17 and the use of consensus definitions of erosions and synovitis developed by the OMERACT (Outcome Measures in Rheumatoid Arthritis Clinical Trials) group18 may help overcome these obstacles. Furthermore, a recent study by Kissin and col-leagues19 suggested that rheumatologists who are largely self-trained without close mentorship can still become good sonologists, with diagnostic accuracy comparable to that achieved by highly experienced international experts. Our smaller survey focusing on rheumatologists cur-rently using sonography revealed that most of them scan the patients themselves (instead of referring patients to radiologists or training technicians to acquire the scans). However, there is a significant concern regarding training and competency of these personnel in MSUS. The Ameri-can Institute in Ultrasound Medicine is currently finalizing training pathways for physicians and sonographers but at this time is not addressing training of other personnel. Logistically, many of those already using MSUS responded that there was not a universal data storage preference. This is, in part, due to lack of economical PACS (picture archiving and communication systems) options for small practices. In the 2 years since this smaller survey was given, some manufacturers have released software that can archive and read images in RAW format, in addition to exporting images to CD-ROM with a DICOM viewer incorporated. Data storage and retrieval is important for comparison of sequential studies, documentation, and for quality assurance purposes. While more rheumatologists become familiar with MSUS, it is important for the community to address the different indications for its use. Our survey indicates that most rheumatologists who employ ultrasound do so for diagnosis or needle guidance, or both, but less than one-quarter take advantage of its potential to gauge disease

activity after the use of disease-modifying agents. As we become more reliant on newer biologic agents to treat the many inflammatory arthritis syndromes, some groups (from Europe) are studying the utility of sonographic evaluation of treatment response. The majority of these studies have concentrated on reliability of ultrasound for following response to therapy. As with MRI, sonography has also demonstrated continued synovitis in patients who clinically appear to be in remission.20,21

ConclusionWe provide the first documented report detailing the use and perception of MSUS by rheumatologists in the U.S. By our survey, nearly one-quarter of both fellows and fully trained rheumatologists are learning and using the technol-ogy. At the same time, we acknowledge the inherent survey bias that might have overstated current use and interest in MSUS. While other articles have reported such viewpoints of other rheumatologists in other countries over the last 2 decades, this survey is valuable, in that it may preview significant changes in the practice of our U.S. rheumatol-ogy workforce for the near future. Ultimately, the publication of more evidence-based studies in a variety of diseases is also crucial for cultivating MSUS interest among clinicians at home and abroad. The last few years have seen an increased stream of published reports regarding the utility of ultrasound in the diagnosis and monitoring of many musculoskeletal syndromes,12 yet the focus of its use in daily practice remains on guided aspirations and injections. With increased proficiency of rheumatologist songraphers, the use of MSUS may attain the status of a routine tool in the evaluation of numerous rheumatic and musculoskeletal diseases. Whether ultra-sound monitoring can emerge as a key biomarker and treat-ment guide to supplant or supplement older tools remains to be seen, both in the U.S. and abroad.

AcknowledgmentsThe authors would like to thank the American College of Rheumatology office, as well as Michael Pillinger, M.D., and David Daikh, M.D., Ph.D., from the Committee on Rheumatology Training and Workforce Issues, for assistance with distributing the main electronic survey.

Disclosure StatementNone of the authors have further financial or proprietary interest in the subject matter or materials discussed, includ-ing, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

References1. Wakefield RJ, Goh E, Conaghan PG, et al. Musculoskeletal

ultrasonography in Europe: results of a rheumatologist-based survey at a EULAR meeting. Rheumatology (Oxford). 2003;42:1251-3.

2. Taggart A, Filippucci E, Wright G, et al. Musculoskeletal


ultrasound training in rheumatology: the Belfast experience. Rheumatology (Oxford). 2006;45:102-5.

3. Cunnington J, Platt P, Raftery G, Kane D. Attitudes of United Kingdom rheumatologists to musculoskeletal ultrasound practice and training. Ann Rheum Dis. 2007;66:1381-3.

4. Grassi W, Cervini C. Ultrasonography in rheumatology: an evolving technique. Ann Rheum Dis. 1998;57:268-71.

5. Uson J, Naredo E. Snap-shot of the Ultrasound School of the Spanish Society of Rheumatology. Reumatismo. 2005;57:1-4.

6. Pineda C, Filippucci E, Chavez-Lopez M, et al. Ultrasound in rheumatology: the Mexican experience. Clin Exp Rheumatol. 2008;26:929-32.

7. Manger B, Kalden JR. Joint and connective tissue ultraso-nography: a rheumatologic bedside procedure ? A German experience. Arthritis Rheum. 1995;38:736-42.

8. Epis O, Iagnocco A, Meenagh G, et al. Ultrasound imaging for the rheumatologist. XVI. Ultrasound-guided procedures. Clin Exp Rheumatol. 2008;26:515-8.

9. Bruyn GA, Schmidt WA. How to perform ultrasound-guided injections. Best Pract Res Clin Rheumatol. 2009;23:269-79.

10. Brown AK, Roberts TE, Wakefield R, et al. The challenges of integrating ultrasonography into routine rheumatology practice: addressing the needs of clinical rheumatologists. Rheumatology (Oxford). 2007;46:821-9.

11. Thiele RG, Schlesinger N. Diagnosis of gout by ultrasound. Rheumatology (Oxford). 2007;46:1116-21.

12. Meenagh G, Filippucci E, Kane D, et al. Ultrasonography in rheumatology: developing its potential in clinical practice and research. Rheumatology (Oxford). 2007;46(1):3-5.

13. Raftery G, Hide G, Kane D. Comparison of musculoskeletal

ultrasound practices of a rheumatologist and a radiologist. Rheumatology (Oxford). 2007;46:519-22.

14. Delle Sedie A, Riente L, Bombardieri S. Limits and per-spectives of ultrasound in the diagnosis and management of rheumatic diseases. Mod Rheumatol. 2008;18:125-31.

15. Katz JD, Nayyar G, Noeth E. Overview of imaging in inflam-matory arthritis. Ann N Y Acad Sci. 2009;1154:10-7.

16. Brown AK, Roberts TE, O‘connor PJ, et al. The development of an evidence-based educational framework to facilitate the training of competent rheumatologist ultrasonographers. Rheumatology (Oxford). 2007;46:391-7.

17. Backhaus M, Burmester GR, Gerber T, et al; Working Group for Musculoskeletal Ultrasound in the EULAR Standing Com-mittee on International Clinical Studies including Therapeutic Trials. Guidelines for musculoskeletal ultrasound in rheuma-tology. Ann Rheum Dis. 2001;60:641-9.

18. Wakefield RJ, D’Agostino MA, Iagnocco A, et al. OMERACT Ultrasound Group. The OMERACT Ultrasound Group: status of current activities and research directions. J Rheumatol. 2007;34:848-51.

19. Kissin EY, Nishio J, Yang M, et al. Self-directed learning of basic musculoskeletal ultrasound among rheumatologists in the United States. Arthritis Care Res. 2010;62:155-60.

20. Freeston JE, Emery P. The future of imaging in monitoring biologic therapy. Nat Clin Pract Rheumatol. 2007;3:2-3.

21. Brown AK, Conaghan PG, Karim Z. An explanation for the apparent dissociation between clinical remission and contin-ued structural deterioration in rheumatoid arthritis. Arthritis Rheum. 2008;58:2958-67.

the use of musculoskeletal ultrasound by rheumatologists...

Documents