Paz Collado

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.

Recommendations for the content and conduct of European League Against Rheumatism (EULAR) musculoskeletal ultrasound courses

Objective: To develop education guidelines for the conduct of future European League Against Rheumatism (EULAR) musculoskeletal ultrasound (MSUS) courses. Methods: We undertook a consensus-based, iterative process using two consecutive questionnaires sent to 29 senior ultrasonographer rheumatologists who comprised the faculty of the 14th EULAR ultrasound course (June 2007). The first questionnaire encompassed the following issues: type of MSUS educational model; course timing; course curriculum; course duration; number of participants per teacher in practical sessions; time spent on hands-on sessions; and the requirements and/or restrictions for attendance at the courses. The second questionnaire consisted of questions related to areas where consensus had not been achieved in the first questionnaire, and to the topics and pathologies to be assigned to different educational levels. Results: The response rate was 82.7% from the first questionnaire and 87.5% from the second questionnaire. The respondents were from 11 European countries. The group consensus on guidelines and curriculum was for a three-level education model (basic, intermediate and advanced) with timing and location related to the annual EULAR Congresses. The topics and pathologies to be included in each course were agreed. The course duration will be 20 h. There will be a maximum of six participants per teacher and 50–60% of total time will be spent on practical sessions. There was also agreement on prerequisite experience before attending the intermediate and advanced courses. Conclusion: We have developed European agreed guidelines for the content and conduct of EULAR ultrasound courses, which may also be recommended to national and local MSUS training programmes.

Is ultrasound a validated imaging tool for the diagnosis and management of synovitis in juvenile idiopathic arthritis? A systematic literature review

Ultrasound (US) has been shown to be a sensitive tool for evaluating synovitis in rheumatoid arthritis. However, the validity of US has not yet been established in juvenile idiopathic arthritis (JIA). The purpose of this study was to assess the validity of US for detecting synovitis for both diagnosis and followup in JIA.

A Health System Program To Reduce Work Disability Related to Musculoskeletal Disorders

Context Nonoccupational musculoskeletal disorders account for a large proportion of work disability and represent a major financial burden on society. Contribution A voluntary, randomized, controlled intervention study consisted of avoidance of bed rest, early mobilization, avoidance of splints, stretching exercises, ergonomic training, provision of educational booklets, and suggestions for optimal levels of physical activity. Although return to work was never forced, temporary work disability, long-term disability, and costs were significantly decreased in the intervention group. Implications The personal and financial impact of work disability due to musculoskeletal disorders (not related to work injury) may be mitigated by a voluntary program of education and rehabilitation. The Editors Musculoskeletal disorders (MSDs) are prevalent and potentially disabling conditions (1) that consume a large proportion of health care resources (2-4) and together are the leading cause of functional loss in adults (3-8). The social costs of MSDs are enormous, often overshadowing those of other chronic conditions (9, 10). In industrialized societies, MSDs are one of the most common causes of temporary work disability and the chief cause of permanent work disability (11), accounting for productivity losses equivalent to 1.3% of the U.S. gross national product (12). Work disability related to MSDs is a challenge to employability, business productivity, and the capacity of health and social security systems. Various strategies for addressing MSD-related work disability have been promoted in the field of occupational health, including strategies involving legislation, risk management, ergonomics, prevention, education, and social work (13). However, the role of health systems remains ill-defined in this field. The purpose of this study was to evaluate whether an intervention program, integrated into the health system and offered to the working population, could reduce the impact of recent-onset MSD-related temporary work disability. Methods Setting Of the 5.5 million persons in Madrid, Spain, 98% receive health coverage from the Instituto Madrileo de Salud. Care is organized into 11 health districts. Patients have direct access to primary care physicians, who refer patients to specialized care if needed. Disability compensation payments are made by the Instituto Nacional de la Seguridad Social (INSS), a division of the Ministry of Work. Any worker who requires sick leave is given a temporary work disability initiation form that states the diagnosis made by the primary care physician and entitles the worker to receive INSS compensation payments. The form is renewed weekly by the primary care physician until the worker 1) recovers and receives an ending form, 2) reaches a maximum of 18 months of temporary work disability, or 3) receives a proposal for evaluation for permanent work disability. Proposals for permanent work disability are evaluated by the INSS, which determines the need for and type of long-term compensation. Inspection services in each health district oversee all administrative aspects of these processes. Design We did a randomized, controlled study, unblinded for both patients and physicians, to test whether a clinical intervention could improve the outcome of patients with recent-onset MSD-related temporary work disability. The study began in March 1998 in health district 7 and in March 1999 in health districts 4 and 9. Selection and randomization of patients was done during the first year of the study in each district. Follow-up lasted for another year. Patients and Selection Criteria Health districts 4, 7, and 9 were chosen. Health district 4 had a total population of 508249 persons and an active working population of 192939 persons; health district 7 had a total population of 522742 persons and an active working population of 179155 persons; and health district 9 had a total population of 371294 persons and an active working population of 135475 persons (14). The inclusion criterion was the issue of a common diseases temporary work disability initiation form, with an MSD-related cause reported by the primary care physician, within the inclusion period. The MSD-related causes included all arthropathies, connective tissue disorders, back disorders, soft-tissue rheumatisms, bone and cartilage disorders, musculoskeletal pain not caused by cancer, and nerve entrapment syndromes. Patients were excluded if they had a common diseases temporary work disability form with an MSD-related cause resulting from trauma or surgery. They were also excluded if they had work accidents or professional diseases noted on the temporary work disability initiation form. Work accidents are primarily sudden, external, violent causes of disease occurring at work or during travel to work, and they represent less than 27% of cases of temporary work disability. Professional diseases include silicosis, asbestos-related mesothelioma, and noise-induced hearing loss, and they represent less than 1% of cases of temporary work disability. Randomization All temporary work disability initiation forms meeting the selection criteria were collected daily by a study rheumatologist and coded. The patients associated with the forms were randomly assigned to either the intervention group, which received a specific care program, or the control group, which received standard care (Figure 1). Computer-generated lists of pseudorandom numbers were produced for each district. Group assignments were randomly done in blocks of 50 patients with intervention:control ratios of 1:1 in district 7 and 2:3 in districts 4 and 9. This was done so that similar numbers of patients would be seen by the rheumatologists in all areas. The ratios were based on the number of episodes of MSD-related temporary work disability registered in previous years. Patients maintained their group assignments in successive episodes of MSD-related temporary work disability during follow-up. Figure 1. Flow diagram of the study. Care in the Intervention Group A secretary contacted all patients assigned to the intervention group by telephone or mail as soon as possible after the initiation form was issued, offering them an appointment in the program. Patients who voluntarily decided to enter the program were attended by 2 rheumatologists in each district who worked full-time for the study. Patients were seen as often as necessary until the episode of temporary work disability was resolved or recovery was deemed unrealistic. Patients who were assigned to the intervention group but were unable or unwilling to participate, were already working, or could not be located were considered to be assigned to the intervention group throughout the study for statistical purposes. Within the intervention program, care was delivered in regular visits and included education, clinical management, and administrative duties. Education At the first 45-minute visit, patients received a specific diagnosis, reassurance that no serious disease was present, instructions on self-management, instructions on taking medications on a fixed schedule, and information on indications for return to work before complete symptom remission. Return to work was negotiated with patients and was never forced on them. Instructions on self-management included instructions to avoid bed rest, instructions to promote early mobilization of the painful regions, restrictions on the use of splint and neck collars, training in stretching and strengthening exercises (15-18), teaching of ergonomic care (19), delivery of booklets in instances of back or neck pain (19), and information on optimal levels of physical activity (20). Patients with higher degrees of disability or abnormal pain behavior received immediate extra reassurance, information on pain-relieving positions, and a telephone call or second visit within 72 hours. Specific protocols were created for low-back (21), neck, shoulder, arm and hand, knee, and foot pain (19, 22-25) and included the 3-level clinical-management system described later. Moving a patient from the lower to the upper levels of the system implied the need for further diagnostic or therapeutic procedures and was indicated 1) after a patient spent a predefined period at the lower level without return to work or substantial clinical improvement or 2) by the clinical judgment of the rheumatologist. At the first level of the system, patients received the clinical management started at the first visit, including a diagnosis based on clinical criteria, pharmacologic treatment of pain and inflammation, pharmacologic treatment of anxiety and depression, peripheral intra- and periarticular injections (26), and education. Time spent at the first level averaged 2 to 6 weeks. At the second level, patients received maintenance of therapy plus referral for formal rehabilitation and laboratory tests, radiography, computerized tomography, magnetic resonance imaging, and electromyography. After 4 to 8 weeks with no improvement at the second level, patients were moved to the third level and received further diagnostic procedures or referral for surgical or other specialized care. Red flags were defined, including age older than 50 years for patients with axial pain, previous trauma, cancer, serious medical illness, inflammatory pain, night pain, drug abuse, corticosteroid use, fever, weight loss, progressively deteriorating function, and progressive neurologic deficit. The presence of a red flag precluded the use of the level system, and the patient in question was managed according to clinical criteria, with a focus on excluding serious illness. Treatment Failures Patients who did not respond to interventions at the second level of the system were examined for the presence of yellow flags, which included psychiatric illness, family problems, sociolabor conflicts, unemployment, and occupational causes of disability. The presence of a yell

EULAR-PReS points to consider for the use of imaging in the diagnosis and management of juvenile idiopathic arthritis in clinical practice

To develop evidence based points to consider the use of imaging in the diagnosis and management of juvenile idiopathic arthritis (JIA) in clinical practice. The task force comprised a group of paediatric rheumatologists, rheumatologists experienced in imaging, radiologists, methodologists and patients from nine countries. Eleven questions on imaging in JIA were generated using a process of discussion and consensus. Research evidence was searched systematically for each question using MEDLINE, EMBASE and Cochrane CENTRAL. Imaging modalities included were conventional radiography, ultrasound, MRI, CT, scintigraphy and positron emission tomography. The experts used the evidence obtained from the relevant studies to develop a set of points to consider. The level of agreement with each point to consider was assessed using a numerical rating scale. A total of 13 277 references were identified from the search process, from which 204 studies were included in the systematic review. Nine points to consider were produced, taking into account the heterogeneity of JIA, the lack of normative data and consequent difficulty identifying pathology. These encompassed the role of imaging in making a diagnosis of JIA, detecting and monitoring inflammation and damage, predicting outcome and response to treatment, use of guided therapies, progression and remission. Level of agreement for each proposition varied according to the research evidence and expert opinion. Nine points to consider and a related research agenda for the role of imaging in the management of JIA were developed using published evidence and expert opinion.

Ultrasound definition of tendon damage in patients with rheumatoid arthritis. Results of a OMERACT consensus-based ultrasound score focussing on the diagnostic reliability

Objective To develop the first ultrasound scoring system of tendon damage in rheumatoid arthritis (RA) and assess its intraobserver and interobserver reliability. Methods We conducted a Delphi study on ultrasound-defined tendon damage and ultrasound scoring system of tendon damage in RA among 35 international rheumatologists with experience in musculoskeletal ultrasound. Twelve patients with RA were included and assessed twice by 12 rheumatologists-sonographers. Ultrasound examination for tendon damage in B mode of five wrist extensor compartments (extensor carpi radialis brevis and longus; extensor pollicis longus; extensor digitorum communis; extensor digiti minimi; extensor carpi ulnaris) and one ankle tendon (tibialis posterior) was performed blindly, independently and bilaterally in each patient. Intraobserver and interobserver reliability were calculated by κ coefficients. Results A three-grade semiquantitative scoring system was agreed for scoring tendon damage in B mode. The mean intraobserver reliability for tendon damage scoring was excellent (κ value 0.91). The mean interobserver reliability assessment showed good κ values (κ value 0.75). The most reliable were the extensor digiti minimi, the extensor carpi ulnaris, and the tibialis posterior tendons. An ultrasound reference image atlas of tenosynovitis and tendon damage was also developed. Conclusions Ultrasound is a reproducible tool for evaluating tendon damage in RA. This study strongly supports a new reliable ultrasound scoring system for tendon damage.

Definitions for the sonographic features of joints in healthy children

Musculoskeletal ultrasonography (US) has potential in the assessment of disease activity and structural damage in childhood arthritides. In order to assess pathology, the US characteristics of joints in healthy children need to be defined first. The aim of this study was to develop definitions for the various components of the normal pediatric joint.

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.

Toward standardized musculoskeletal ultrasound in pediatric rheumatology: Normal age related ultrasound findings

The Outcome Measures in Rheumatology Ultrasound Task Force has recently started to work on the validation and standardization of musculoskeletal ultrasound (MSUS) examination in children in order to improve its applicability to joint examination.

Pan-American League of Associations for Rheumatology (PANLAR) recommendations and guidelines for musculoskeletal ultrasound training in the Americas for rheumatologists.

Objective:To develop guidelines for Musculoskeletal Ultrasound (MSKUS) training for rheumatologists in the Americas. Methods:A total of 25 Rheumatologists from 19 countries of the American Continent participated in a consensus-based interactive process (Delphi method) using 2 consecutive electronic questionnaires. The first questionnaire included the following: the relevance of organizing courses to teach MSKUS to Rheumatologists, the determination of the most effective educational course models, the trainee levels, the educational objectives, the requirements for passing the course(s), the course venues, the number of course participants per instructor, and the percentage of time spent in hands-on sessions. The second questionnaire consisted of questions that did not achieve consensus (>65%) in the first questionnaire, topics, and pathologies to be covered at each course MSKUS level. Results:General consensus was obtained for MSKUS courses to be divided into 3 educational levels: basic, intermediate, and advanced. These courses should be taught using a theoretical-didactic and hands-on model. In addition, the group established the minimum requirements for attending and passing each MSKUS course level, the ideal number of course participants per instructor (4 participants/instructor), and the specific topics and musculoskeletal pathologies to be covered. In the same manner, the group concluded that 60% to 70% of course time should be focused on hands-on sessions. Conclusion:A multinational group of MSKUS sonographers using a consensus-based questionnaire (Delphi method) established the first recommendations and guidelines for MSKUS course training in the Americas. Pan-American League of Associations for Rheumatology urges that these guidelines and recommendations be adopted in the future by both national and regional institutions in the American continent involved in the training of Rheumatologists for the performance of MSKUS.