As with many chronic diseases, studies indicate that early, accurate diagnosis and treatment of crippling musculoskeletal conditions such as rheumatoid arthritis may prevent and even reverse irreparable joint damage. Though slow to catch on in the United States, the use of ultrasound has greatly enhanced physicians’ accessibility, accuracy, and timeliness in detecting and managing rheumatologic conditions.
Seema Agrawal, MD
Using the same technology that monitors the development of unborn babies and diagnoses heart irregularities, rheumatologists can directly visualize the pathophysiology of patients’ bone and joint damage and precisely administer therapeutic injections in highly sensitive areas surrounded by major blood vessels. The advantages of musculoskeletal ultrasound (US) are numerous: for the patient, it is a noninvasive, radiation-free procedure that can be administered at the time of the office visit. The physician can conduct comparative scans on multiple joints in the same session; administer "dynamic exams" to assess the relationship of structures during movement, including tendon coordination; and make a diagnosis, identify possible solutions, and recommend a treatment plan undeterred by waiting time for referrals and test results.
Dr. Seema Agrawal, an assistant professor of rheumatology who is RhMSUS certified and performs musculoskeletal ultrasounds on patients at Einstein/Montefiore, recalled the benefits of the test on a recent patient with rheumatoid arthritis. "She had been feeling well and her physical exam didn't show much active synovitis, so based on that my recommendation would have been little to no change in treatment," said Dr. Agrawal. "Her ultrasound, however, showed many dopplerable effusions [fluid buildup] on her hands and wrists, indicating ongoing disease activity. It was helpful for both of us—she realized that her disease was more active than she’d thought, and I was able to start her on a more aggressive treatment protocol."
A lengthwise ultrasound scan of the metacarpophalangeal (largest hand) joint. shows inflammation, new blood vessel development, ingrowth of the blood vessels, and early erosion. (provided by P. O'Connor for diagnosticimaging.com)
In addition to being a more portable, flexible diagnostic method than the traditionally used magnetic resonance imaging (MRI), ultrasound may lower healthcare costs. In situations where ultrasound and MRI would yield similar information, ultrasound has been estimated to result in Medicare savings of nearly $7 billion by the year 2020, according to a study conducted by researchers at Thomas Jefferson University Hospital in Philadelphia.
Despite its numerous advantages, adoption of US amongst rheumatologists in the United States has lagged far behind their peers overseas. Though US has been practiced throughout Europe for over thirty years, the first official training program (through the Ultrasound School of North American Rheumatologists, or USSONAR) was founded in 2006, and the first official rheumatology-specific U.S. certification (Musculoskeletal Ultrasound Certification in Rheumatology, or RhMSUS, through the American College of Rheumatology) was established in 2013. Despite these advances, a recent Report of the American College of Rheumatology Musculoskeletal Ultrasound Task Force described intermediate and advanced U.S. learning opportunities as "sparse", and standards for competence lacking.
“We are working towards a standardization of the way musculoskeletal ultrasounds are performed, recorded, billed, and taught, and as the potential for ultrasound in rheumatology gains more recognition, we are inching closer to making that happen,” said Dr. Agrawal. “Having an official certification exam by the ACR established this year was a huge step.”
Dr. Agrawal completed USSONAR training during her fellowship at George Washington University, and incorporated the use of ultrasound into her practice when she joined the Einstein/Montefiore faculty in 2011. She currently performs musculoskeletal ultrasounds at the Montefiore Medical Arts Pavilion office.
Dr. Agrawal works regularly with both fellows and residents and participates in medical school teaching opportunities, and is currently establishing a US curriculum for fellows—basic joint scanning during the first year, full incorporation into weekly clinics the second year—with the goal of having each fellow be completely comfortable and competent in ultrasound by the end of their fellowship.
"Our fellows pick up the scanning techniques quickly and enjoy the ability to visualize the pathology. They learn the anatomy better, understand the usefulness of the technology, and know that this training puts them at a distinct advantage when they look for jobs," Dr. Agrawal said.