Congratulations to the successful applicant for the CRUS Research Scholarship, Stephanie Tom!
The Canadian Rheumatology Ultrasound Society (CRUS) promotes the use of musculoskeletal ultrasound by rheumatologists. It is our aim to foster research in the area in order to provide an evidence based framework for the clinical use of this technology.
Given the lack of widespread ultrasound use among rheumatologists in Canada, our main priority at this point is to develop ultrasound skills in the rheumatology community which will serve as a basis for future research initiatives. We are currently offering training in musculoskeletal ultrasound for rheumatologists which contains novel teaching methods that are being scientifically evaluated at the same time. An online learning tool has been added to a traditional course model by asking participants to upload a defined set of images between course weekends that will be assessed online. The addition of this online-tool has two potential advantages:
1) A minimum amount of practice by participants between the course weekends is guaranteed
2) The feedback on images the participants create between course weekends might enhance the acquisition of ultrasound skills
We are evaluating this online-feedback model in the form of a controlled study among all participants.
Depending on available funding, future research competitions as well as possibilities to participate in research studies will be posted in this section.
Ultrasonography to detect synovitis and erosions in metatarsophalangeal joints of patients with rheumatoid arthritis
Dr Maggie Larché, McMaster University, Hamilton (PI) email@example.com
Dr Edward Keystone, Mount Sinai Hospital, Toronto
1. To compare clinical findings in feet of tender and swollen joints with ultrasonographic findings in metatarsophalangeal (MTP) joints in patients with early rheumatoid arthritis at baseline (ie is ultrasonography (US) better than clinical assessment in detecting active or damaged joints?).
2. To compare US findings with plain radiographs at baseline. (ie is US better than or as good as plain radiography in detecting damaged joints in the feet?)
3. To compare US findings with 1T peripheral MRI findings
3. To assess the ultrasonographic response after 6 weeks and 3 months of conventional disease modifying anti-rheumatic drugs (DMARD) treatment in patients who are naïve to these therapies at baseline.
4. To assess the ultrasonographic response following initiation of
biological treatment at baseline, 3 and 6 months.
Rationale and Background
Feet are often involved at an early stage in rheumatoid arthritis (RA): at baseline, erosions in the joints of the forefoot are seen in up to 37% of patients with early arthritis (within 1 year of diagnosis); and in the first 6 years of disease, radiographic progression of erosions is seen in the metatarsophalyngeal joints (MTPJ) more often than in the metacarpophalyngeal (MCPJ)1. In that study, nearly 10% of subjects had erosions of their 5th MTPJ at baseline, with 50% having erosions in that joint at 5 years. In comparison, the most frequently effected hand joint was the 1st MCP with 4% being eroded at baseline and 23.9% after 5 years. In a recent study, 56% of patients with a symptom duration of <3 years reported disability in walking at baseline, with 19% of patients having at least one erosion at baseline2.Furthermore, in a follow-up study, 40% of patients in DAS28 remission had at least one MTP joint which was either swollen or
tender suggesting that feet are often active even if disease is considered to be quiescent3. In 10 patients with very early disease (mean disease duration 9.4 weeks) magnetic resonance detected synovitis, erosions and bone marrow edema in MTP joints of 100% of patients whose MCPJs were normal according to the RAMRIS scoring4. Although the DAS44 includes examination of the feet, many trials and clinicians utilise the DAS28 (which does not include feet). Furthermore, synovitis of the MTPJs is difficult to detect clinically. Ultrasonography is a non-invasive, repeatable, reproducible and relatively cheap modality to image synovial thickening, synovial vascularity and erosions. Ultrasonographic assessment of feet has been used in several studies. Klocke and colleagues reported that in 30 patients with disease duration up to 6 years, ultrasonography detected erosions of 5th MTP in 50% joints compared to only
20% by conventional radiography5. More recently, Wakefield and colleagues have shown that US is more specific in detecting hindfoot pathology in patients with RA compared with clinical examination6. In a recent study using US in MTP joints of 149 patients with established RA, 40.3% of patients had a detectable bursa between the 3rd and 4th MTP heads compared with only 4% of control subjects7. The same group went on to describe a trend towards improvement in ultrasonographic findings of MTP joints in established RA following TNF inhibition8. To date, there are no reports of ultrasonographic assessment of erosions, synovitis or increased synovial vascularity in patients with early RA or in relation to response to treatment in patients with early RA. Nor have there been reports of the comparison between power Doppler/synovial thickening assessment of synovitis compared to clinical examination of the MTP joints of patients with early RA.
Few studies have compared MRI findings with radiographic erosions in patients with RA. In one recent study, whilst the positive predictive value of erosions or bone marrow edema on MRI for development of radiographic erosions was low, the negative predictive value was significant. 8 The RAMRIS scoring system has been shown to be a reliable method of assessing erosions in the forefoot and hindfoot in patients with RA9
Pressure analysis of gait may be helpful in determining foot pathology in patients with ERA, particularly in asymptomatic involvement of the feet11. To date, there
are no reports of comparisons between US findings and pedobarography in the assessment of ERA.
40 consecutive patients with early RA (within 12 months of diagnosis) attending the rheumatology clinics of McMaster University Division of Rheumatology and Rebecca McDonald Arthritis Centre at Mount Sinai Hospital, Toronto will be invited to participate. These patients will be DMARD and biologic naïve at baseline, and for the duration of the study will be treated with “standard care” which involves DMARDs for at least 3 months, followed by the initiation of a biologic at 3-6 months if inadequate response to DMARDs. Following clinical assessments, patients will undergo ultrasonographic, radiographic and MRI assessments as described below.
Primary outcome: mean synovitis score and power Doppler score (semi-quantitative scale 0-3 for each of synovial thickening and power Doppler) in 8 MTPJ (max score 48) compared to “active” joint count (number of TJC +/- SJC) (max score 16) at baseline.
It is predicted that
- US will detect more affected joints than either clinical assessment or plain radiography
- US may be more sensitive at determining erosions and synovitis especially in the 5th MTP than MRI
- US abnormalities will reflect abnormal pressure analysis at baseline
- US findings will change (improve) following DMARD treatment, but improvement in synovial vascularity may lag behind improvement in the
clinical assessments of TJC or SJC (this has already been shown in
MCPJ US 10)
- US findings will improve with biologic treatment and this will correlate with clinical improvement.
Value of results
Foot involvement in RA is often ignored by clinicians, and foot pathology results in significant morbidity with an impact on work activity and productivity. Ultrasonography may be able to detect MTP pathology more accurately than clinical examination, and therapy could be tailored according to US findings. This study will also determine change in US findings following DMARD and biologic treatment. This study is likely to show that US has potential to monitor disease activity and therefore improve disease outcome.