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Ultrasound in Rheumatoid Arthritis

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Musculoskeletal Ultrasound in Rheumatology Review

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Abstract

Ultrasound is a valid and reliable imaging tool for evaluation of joint and tendon inflammation in patients with rheumatoid arthritis (RA). This chapter reviews how to use the probe and optimize the settings of the machine to obtain optimal images for the evaluation of synovitis. Synovitis in joints and tendons is usually scored semiquantitatively for both grayscale synovitis and power Doppler activity, and use of an atlas for ultrasound scoring has proven excellent reliability. Several validated scoring systems are reviewed.

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References

  1. Jaeger KA, Imfeld S. The damaging effect of ultrasound – to the examiner. Ultraschall Med. 2006;27(2):131–3.

    Article  CAS  PubMed  Google Scholar 

  2. Szkudlarek M, Court-Payen M, Jacobsen S, Klarlund M, Thomsen HS, Østergaard M. Interobserver agreement in ultrasonography of the finger and toe joints in rheumatoid arthritis. Arthritis Rheum. 2003;48:955–62.

    Article  PubMed  Google Scholar 

  3. Brown AK, Quinn MA, Karim Z, Conaghan PG, Peterfy CG, Hensor E, et al. Presence of significant synovitis in rheumatoid arthritis patients with disease-modifying antirheumatic drug-induced clinical remission: evidence from an imaging study may explain structural progression. Arthritis Rheum. 2006;54(12):3761–73.

    Article  CAS  PubMed  Google Scholar 

  4. Wakefield RJ, Green MJ, Marzo-Ortega H, Conaghan PG, Gibbon WW, McGonagle D, et al. Should oligoarthritis be reclassified? Ultrasound reveals a high prevalence of subclinical disease. Ann Rheum Dis. 2004;63(4):382–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Hammer HB, Michelsen B, Sexton J, Haugen IK, Provan SA, Haavardsholm EA, Uhlig T, Kvien TK. Swollen, but not tender joints, are independently associated with ultrasound synovitis: results from a longitudinal observational study of patients with established rheumatoid arthritis. Ann Rheum Dis. 2019;78(9):1179–85. https://doi.org/10.1136/annrheumdis-2019-215321.

    Article  PubMed  Google Scholar 

  6. Terslev L, Torp-Pedersen S, Qvistgaard E, Danneskiold-Samsoe B, Bliddal H. Estimation of inflammation by Doppler ultrasound: quantitative changes after intra-articular treatment in rheumatoid arthritis. Ann Rheum Dis. 2003;62(11):1049–53.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Taylor PC, Steuer A, Gruber J, Cosgrove DO, Blomley MJ, Marsters PA, et al. Comparison of ultrasonographic assessment of synovitis and joint vascularity with radiographic evaluation in a randomized, placebo-controlled study of infliximab therapy in early rheumatoid arthritis. Arthritis Rheum. 2004;50:1107–16.

    Article  CAS  PubMed  Google Scholar 

  8. Hammer HB, Sveinsson M, Kongtorp AK, Kvien TK. A 78-joints ultrasonographic assessment is associated with clinical assessments and is highly responsive to improvement in a longitudinal study of patients with rheumatoid arthritis starting adalimumab treatment. Ann Rheum Dis. 2010;69:1349–51.

    Article  CAS  PubMed  Google Scholar 

  9. Brown AK, Conaghan PG, Karim Z, Quinn MA, Ikeda K, Peterfy CG, et al. An explanation for the apparent dissociation between clinical remission and continued structural deterioration in rheumatoid arthritis. Arthritis Rheum. 2008;58(10):2958–67.

    Article  CAS  PubMed  Google Scholar 

  10. Naredo E, Möller I, Cruz A, Carmona L, Garrido J. Power Doppler ultrasonographic monitoring of response to anti-tumor necrosis factor therapy in patients with rheumatoid arthritis. Arthritis Rheum. 2008;58:2248–56.

    Article  PubMed  Google Scholar 

  11. Torp-Pedersen ST, Terslev L. Settings and artefacts relevant in colour/power Doppler ultrasound in rheumatology. Ann Rheum Dis. 2008;67:143–9.

    Article  CAS  PubMed  Google Scholar 

  12. Torp-Pedersen S, Christensen R, Szkudlarek M, Ellegaard K, D’Agostino MA, Iagnocco A, et al. Power and color Doppler ultrasound settings for inflammatory flow: impact on scoring of disease activity in patients with rheumatoid arthritis. Arthritis Rheumatol. 2015;67(2):386–95.

    Article  PubMed  Google Scholar 

  13. Qvistgaard E, Røgind H, Torp-Pedersen S, Terslev L, Danneskiold-Samsøe B, Bliddal H. Quantitative ultrasonography in rheumatoid arthritis: evaluation of inflammation by Doppler technique. Ann Rheum Dis. 2001;60:690–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Gutierrez M, Filippucci E, Grassi W, Rosemffet M. Intratendinous power Doppler changes related to patient position in seronegative spondyloarthritis. J Rheumatol. 2010;37(5):1057–9.

    Article  PubMed  Google Scholar 

  15. Lee V, Zayat A, Wakefield RJ. The effect of joint position on Doppler flow in finger synovitis. Ann Rheum Dis. 2009;68(4):603–4.

    Article  CAS  PubMed  Google Scholar 

  16. Koenig MJ, Torp-Pedersen ST, Christensen R, Boesen MI, Terslev L, Hartkopp A, et al. Effect of knee position on ultrasound Doppler findings in patients with patellar tendon hyperaemia (jumper’s knee). Ultraschall Med. 2007;28(5):479–83.

    Article  CAS  PubMed  Google Scholar 

  17. D’Agostino MA, Terslev L, Aegerter P, Backhaus M, Balint P, Bruyn GA, Filippucci E, Grassi W, Iagnocco A, Jousse-Joulin S, Kane D, Naredo E, Schmidt W, Szkudlarek M, Conaghan PG, Wakefield RJ. Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce-part 1: definition and development of a standardised, consensus-based scoring system. RMD Open. 2017;3(1):e000428.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Witt M, Mueller F, Nigg A, Reindl C, Leipe J, Proft F, Stein N, Hammitzsch A, Mayer S, Dechant C, Schulze-Koops H, Grunke M. Relevance of grade 1 gray-scale ultrasound findings in wrists and small joints to the assessment of subclinical synovitis in rheumatoid arthritis. Arthritis Rheum. 2013;65(7):1694–701.

    Article  PubMed  Google Scholar 

  19. Terslev L, Østergaard M, Sexton J, Hammer HB. Synovial hypertrophy without Doppler activity sensitive to change? Post-hoc analysis from a rheumatoid arthritis ultrasound study. Arthritis Res Ther. 2018;20(1):224.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  20. Brown AK, Conaghan PG, Karim Z, Quinn MA, Ikeda K, Peterfy CG, Hensor E, Wakefield RJ, O’Connor PJ, Emery P. An explanation for the apparent dissociation between clinical remission and continued structural deterioration in rheumatoid arthritis. Arthritis Rheum. 2008;58(10):2958–67.

    Article  CAS  PubMed  Google Scholar 

  21. Naredo E, Möller I, Cruz A, Carmona L, Garrido J. Power Doppler ultrasonographic monitoring of response to anti-tumor necrosis factor therapy in patients with rheumatoid arthritis. Arthritis Rheum. 2008;58(8):2248–56.

    Article  PubMed  Google Scholar 

  22. Haavardsholm EA, Aga AB, Olsen IC, Lillegraven S, Hammer HB, Uhlig T, Fremstad H, Madland TM, Lexberg ÅS, Haukeland H, Rødevand E, Høili C, Stray H, Noraas A, Hansen IJ, Bakland G, Nordberg LB, van der Heijde D, Kvien TK. Ultrasound in management of rheumatoid arthritis: ARCTIC randomised controlled strategy trial. BMJ. 2016;354:i4205.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Dale J, Stirling A, Zhang R, Purves D, Foley J, Sambrook M, Conaghan PG, van der Heijde D, McConnachie A, McInnes IB, Porter D. Targeting ultrasound remission in early rheumatoid arthritis: the results of the TaSER study, a randomised clinical trial. Ann Rheum Dis. 2016;75(6):1043–50.

    Article  PubMed  Google Scholar 

  24. Møller-Bisgaard S, Hørslev-Petersen K, Ejbjerg B, Hetland ML, Ørnbjerg LM, Glinatsi D, Møller J, Boesen M, Christensen R, Stengaard-Pedersen K, Madsen OR, Jensen B, Villadsen JA, Hauge EM, Bennett P, Hendricks O, Asmussen K, Kowalski M, Lindegaard H, Nielsen SM, Bliddal H, Krogh NS, Ellingsen T, Nielsen AH, Balding L, Jurik AG, Thomsen HS, Østergaard M. Effect of magnetic resonance imaging vs conventional treat-to-target strategies on disease activity remission and radiographic progression in rheumatoid arthritis: the IMAGINE-RA randomized clinical trial. JAMA. 2019;321(5):461–72.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Schmidt WA, Schönau V, Reiche BE, Oberdorfer PD, Ohrndorf S, Backhaus M. Grading of ultrasound Doppler signals in synovitis: does it need an update? Rheumatology (Oxford). 2015;54(10):1897–903.

    Article  Google Scholar 

  26. Hammer HB, Bolton-King P, Bakkeheim V, Berg TH, Sundt E, Kongtorp AK, et al. Examination of intra and interrater reliability with a new ultrasonographic reference atlas for scoring of synovitis in patients with rheumatoid arthritis. Ann Rheum Dis. 2011;70:1995–8.

    Article  PubMed  Google Scholar 

  27. Rezaei H, Af Klint E, Hammer HB, Terslev L, D’Agostino MA, Kisten Y, Arnaud L. Analysis of correlation and causes for discrepancy between quantitative and semi-quantitative Doppler scores in synovitis in rheumatoid arthritis. Rheumatology (Oxford). 2017;56(2):255–62.

    Article  Google Scholar 

  28. D’Agostino MA, Boers M, Wakefield RJ, Berner Hammer H, Vittecoq O, Filippou G, Balint P, Möller I, Iagnocco A, Naredo E, Østergaard M, Gaillez C, Le Bars M. Exploring a new ultrasound score as a clinical predictive tool in patients with rheumatoid arthritis starting abatacept: results from the APPRAISE study. RMD Open. 2016;2(1):e000237.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Aga AB, Hammer HB, Olsen IC, Uhlig T, Kvien TK, van der Heijde D, Fremstad H, Madland TM, Lexberg ÅS, Haukeland H, Rødevand E. Development of a feasible and responsive ultrasound inflammation score for rheumatoid arthritis through a data-driven approach. RMD Open. 2016;2:e000325.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Terslev L, Naredo E, Aegerter P, Wakefield RJ, Backhaus M, Balint P, Bruyn GAW, Iagnocco A, Jousse-Joulin S, Schmidt WA, Szkudlarek M, Conaghan PG, Filippucci E, D’Agostino MA. Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce-part 2: reliability and application to multiple joints of a standardised consensus-based scoring system. RMD Open. 2017;3(1):e000427.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Terslev L, Ellegaard K, Christensen R, Szkudlarek M, Schmidt WA, Jensen PS, et al. Head-to-head comparison of quantitative and semi-quantitative ultrasound scoring systems for rheumatoid arthritis: reliability, agreement and construct validity. Rheumatology (Oxford). 2012;51(11):2034–8.

    Article  Google Scholar 

  32. Terslev L, Torp-Pedersen S, Qvistgaard E, Bliddal H. Spectral Doppler and resistive index. A promising tool in ultrasonographic evaluation of inflammation in rheumatoid arthritis. Acta Radiol. 2003;44:645–52.

    CAS  PubMed  Google Scholar 

  33. Carotti M, Salaffi F, Morbiducci J, Ciapetti A, Bartolucci L, Gasparini S, et al. Colour Doppler ultrasonography evaluation of vascularization in the wrist and finger joints in rheumatoid arthritis patients and healthy subjects. Eur J Radiol. 2012;81:1834–8.

    Article  CAS  PubMed  Google Scholar 

  34. Terslev L, Torp-Pedersen S, Savnik A, von der Recke P, Qvistgaard E, Danneskiold-Samsøe B, et al. Doppler ultrasound and magnetic resonance imaging of synovial inflammation of the hand in rheumatoid arthritis: a comparative study. Arthritis Rheum. 2003;48:2434–41.

    Article  CAS  PubMed  Google Scholar 

  35. Terslev L, von der Recke P, Torp-Pedersen S, Koenig MJ, Bliddal H. Diagnostic sensitivity and specificity of Doppler ultrasound in rheumatoid arthritis. J Rheumatol. 2008;35(1):49–53.

    PubMed  Google Scholar 

  36. Backhaus M, Ohrndorf S, Kellner H, Strunk J, Backhaus TM, Hartung W, et al. Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: a pilot project. Arthritis Rheum. 2009;61:1194–201.

    Article  CAS  PubMed  Google Scholar 

  37. Naredo E, Rodríguez M, Campos C, Rodríguez-Heredia JM, Medina JA, Giner E, et al. Validity, reproducibility, and responsiveness of a twelve-joint simplified power Doppler ultrasonographic assessment of joint inflammation in rheumatoid arthritis. Arthritis Rheum. 2008;59:515–22.

    Article  PubMed  Google Scholar 

  38. Ellegaard K, Torp-Pedersen S, Terslev L, Danneskiold-Samsøe B, Henriksen M, Bliddal H. Ultrasound colour Doppler measurements in a single joint as measure of disease activity in patients with rheumatoid arthritis – assessment of concurrent validity. Rheumatology. 2009;48:254–7.

    Article  CAS  PubMed  Google Scholar 

  39. Perricone C, Ceccarelli F, Modesti M, Vavala C, Di Franco M, Valesini G, et al. The 6-joint ultrasonographic assessment: a valid, sensitive-to-change and feasible method for evaluating joint inflammation in RA. Rheumatology (Oxford). 2012;51(5):866–73.

    Article  Google Scholar 

  40. Hammer HB, Kvien TK. Comparisons of 7- to 78-joint ultrasonography scores: all different joint combinations show equal response to adalimumab treatment in patients with rheumatoid arthritis. Arthritis Res Ther. 2011;13:R78.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Aga AB, Hammer HB, Olsen IC, Uhlig T, Kvien TK, van der Heijde D, et al. First step in the development of an ultrasound joint inflammation score for rheumatoid arthritis using a data-driven approach. Ann Rheum Dis. 2015;75(8):1444–51.

    Article  PubMed  Google Scholar 

  42. Scirè CA, Montecucco C, Codullo V, Epis O, Todoerti M, Caporali R. Utrasonographic evaluation of joint involvement in early rheumatoid arthritis in clinical remission: power Doppler signal predicts short-term relapse. Rheumatology (Oxford). 2009;48(9):1092–7.

    Article  CAS  Google Scholar 

  43. Lehtinen A, Paimela L, Kreula J, Leirisalo-Repo M, Taavitsainen M. Painful ankle region in rheumatoid arthritis. Analysis of soft-tissue changes with ultrasonography and MR imaging. Acta Radiol. 1996;37(4):572–7.

    Article  CAS  PubMed  Google Scholar 

  44. Maillefert JF, Dardel P, Cherasse A, Mistrih R, Krause D, Tavernier C. Magnetic resonance imaging in the assessment of synovial inflammation of the hindfoot in patients with rheumatoid arthritis and other polyarthritis. Eur J Radiol. 2003;47(1):1–5.

    Article  PubMed  Google Scholar 

  45. McQueen F, Beckley V, Crabbe J, Robinson E, Yeoman S, Stewart N. Magnetic resonance imaging evidence of tendinopathy in early rheumatoid arthritis predicts tendon rupture at six years. Arthritis Rheum. 2005;52(3):744–51.

    Article  PubMed  Google Scholar 

  46. Micu MC, Serra S, Fodor D, Crespo M, Naredo E. Inter-observer reliability of ultrasound detection of tendon abnormalities at the wrist and ankle in patients with rheumatoid arthritis. Rheumatology (Oxford). 2011;50(6):1120–4.

    Article  Google Scholar 

  47. Bøyesen P, Haavardsholm EA, van der Heijde D, Østergaard M, Hammer HB, Sesseng S, et al. Prediction of MRI erosive progression: a comparison of modern imaging modalities in early rheumatoid arthritis patients. Ann Rheum Dis. 2011;70:176–9.

    Article  PubMed  Google Scholar 

  48. Hammer HB, Haavardsholm EA, Bøyesen P, Kvien TK. Bone erosions at the distal ulna detected by ultrasonography are associated with structural damage assessed by conventional radiography and MRI: a study of patients with recent onset rheumatoid arthritis. Rheumatology. 2009;48:1530–2.

    Article  PubMed  Google Scholar 

  49. Navalho M, Resende C, Rodrigues AM, Pereira da Silva JA, Fonseca JE, Campos J, et al. Bilateral evaluation of the hand and wrist in untreated early inflammatory arthritis: a comparative study of ultrasonography and magnetic resonance imaging. J Rheumatol. 2013;40(8):1282–92.

    Article  PubMed  Google Scholar 

  50. Wakefield RJ, O’Connor PJ, Conaghan PG, McGonagle D, Hensor EM, Gibbon WW, et al. Finger tendon disease in untreated early rheumatoid arthritis: a comparison of ultrasound and magnetic resonance imaging. Arthritis Rheum. 2007;57(7):1158–64.

    Article  CAS  PubMed  Google Scholar 

  51. Wakefield RJ, Freeston JE, O’Connor P, Reay N, Budgen A, Hensor EM, et al. The optimal assessment of the rheumatoid arthritis hindfoot: a comparative study of clinical examination, ultrasound and high field MRI. Ann Rheum Dis. 2008;67(12):1678–82.

    Article  CAS  PubMed  Google Scholar 

  52. Hammer HB, Kvien TK. Ultrasonography shows significant improvement in wrist and ankle tenosynovitis in rheumatoid arthritis patients treated with adalimumab. Scand J Rheumatol. 2011;40(3):178–82.

    Article  CAS  PubMed  Google Scholar 

  53. Naredo E, D’Agostino MA, Wakefield RJ, Möller I, Balint PV, Filippucci E, OMERACT Ultrasound Task Force, et al. Reliability of a consensus-based ultrasound score for tenosynovitis in rheumatoid arthritis. Ann Rheum Dis. 2013;72(8):1328–34.

    Article  PubMed  Google Scholar 

  54. Ammitzbøll-Danielsen M, Østergaard M, Naredo E, Terslev L. Validity and sensitivity to change of the semi-quantitative OMERACT ultrasound scoring system for tenosynovitis in patients with rheumatoid arthritis. Rheumatology (Oxford). 2016;55(12):2156–66.

    Article  Google Scholar 

  55. Ammitzbøll-Danielsen M, Østergaard M, Fana V, Glinatsi D, Døhn UM, Ørnbjerg LM, Naredo E, Terslev L. Intramuscular versus ultrasound-guided intratenosynovial glucocorticoid injection for tenosynovitis in patients with rheumatoid arthritis: a randomised, double-blind, controlled study. Ann Rheum Dis. 2017;76(4):666–72.

    Article  PubMed  CAS  Google Scholar 

  56. Gutierrez M, Filippucci E, Salaffi F, Di Geso L, Grassi W. Differential diagnosis between rheumatoid arthritis and psoriatic arthritis: the value of ultrasound findings at metacarpophalangeal joints level. Ann Rheum Dis. 2011;70(6):1111–4.

    Article  PubMed  Google Scholar 

  57. Wakefield RJ, et al. The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: a comparison with conventional radiography. Arthritis Rheum. 2000;43(12):2762–70.

    Article  CAS  PubMed  Google Scholar 

  58. Døhn UM, Terslev L, Szkudlarek M, Hansen MS, Hetland ML, Hansen A, Madsen OR, Hasselquist M, Møller J, Ostergaard M. Detection, scoring and volume assessment of bone erosions by ultrasonography in rheumatoid arthritis: comparison with CT. Ann Rheum Dis. 2013;72(4):530–4.

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway

    Hilde Berner Hammer

  2. Center for Rheumatology and Spine Diseases, Rigshospitalet-Glostrup, Copenhagen, Denmark

    Lene Terslev

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  1. Hilde Berner Hammer
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  2. Lene Terslev
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Correspondence to Hilde Berner Hammer .

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Editors and Affiliations

  1. Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Minna J. Kohler

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Hammer, H.B., Terslev, L. (2021). Ultrasound in Rheumatoid Arthritis. In: Kohler, M.J. (eds) Musculoskeletal Ultrasound in Rheumatology Review. Springer, Cham. https://doi.org/10.1007/978-3-030-73555-5_11

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  • DOI: https://doi.org/10.1007/978-3-030-73555-5_11

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