Clinical Rheumatology

, Volume 32, Issue 9, pp 1249–1254 | Cite as

Assessing rheumatoid arthritis disease activity with ultrasound

  • Rafael Mendonça da Silva ChakrEmail author
  • José Alexandre Mendonça
  • Claiton Viegas Brenol
  • Ricardo Machado Xavier
  • João Carlos Tavares Brenol
Review Article


In practice, composite indices are used for rheumatoid arthritis (RA) disease activity evaluation. Despite valid and widely used, not rarely composite indices miss accuracy. Ultrasound (US) is more precise than clinical examination in synovitis appraisal. US-based disease activity estimation depends on the detection of synovitis. The most common synovitis abnormalities are proliferation, effusion, and neoangiogenesis. Gray scale ultrasound identifies synovial hypertrophy and effusion with its good soft tissue contrast. Additionally, power Doppler ultrasound depicts neoangiogenesis within synovia, remarking local inflammation. Several studies have combined local US findings to develop a patient level disease activity index. Most of them summed selected joint scores in an overall score of disease activity and evaluated its correlation with clinical composite indexes. To be incorporated into clinical practice, an overall US score must have some fundamental characteristics such as reproducibility, viability, and sensitivity to change over time. In global US score development, finding the joints that truly estimate individual disease activity is highly challenging. This article presents an up-to-date literature review on assessing RA disease activity with US and depicts the challenges in finding the perfect global US score.


Disease activity Rheumatoid arthritis Scoring systems Synovitis Ultrasonography Ultrasound 



We thank Professor Jorge Chakr for the proofreading.




  1. 1.
    Katchamart W, Bombardier C (2010) Systematic monitoring of disease activity using an outcome measure improves outcomes in rheumatoid arthritis. J Rheumatol 37(7):1411–1415PubMedCrossRefGoogle Scholar
  2. 2.
    Smolen JS, Landewe R, Breedveld FC, Dougados M, Emery P, Gaujoux-Viala C et al (2010) EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis 69(6):964–975PubMedCrossRefGoogle Scholar
  3. 3.
    Smolen JS, Aletaha D (2011) Monitoring rheumatoid arthritis. Curr Opin Rheumatol 23(3):252–258PubMedCrossRefGoogle Scholar
  4. 4.
    Anderson J, Caplan L, Yazdany J, Robbins ML, Neogi T, Michaud K et al (2012) Rheumatoid arthritis disease activity measures: American College of Rheumatology recommendations for use in clinical practice. Arthritis Care Res 64(5):640–647CrossRefGoogle Scholar
  5. 5.
    Smolen JS, Aletaha D, Bijlsma JW, Breedveld FC, Boumpas D, Burmester G et al (2010) Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis 69(4):631–637PubMedCrossRefGoogle Scholar
  6. 6.
    van Tuyl LH, Felson DT, Wells G, Smolen J, Zhang B, Boers M (2010) Evidence for predictive validity of remission on long-term outcome in rheumatoid arthritis: a systematic review. Arthritis Care Res 62(1):108–117CrossRefGoogle Scholar
  7. 7.
    Gaujoux-Viala C, Mouterde G, Baillet A, Claudepierre P, Fautrel B, Le Loet X et al (2012) Evaluating disease activity in rheumatoid arthritis: which composite index is best? a systematic literature analysis of studies comparing the psychometric properties of the DAS, DAS28, SDAI and CDAI. Joint Bone Spine 79(2):149–155PubMedCrossRefGoogle Scholar
  8. 8.
    Felson DT, Smolen JS, Wells G, Zhang B, van Tuyl LH, Funovits J et al (2011) American College of Rheumatology/European League against rheumatism provisional definition of remission in rheumatoid arthritis for clinical trials. Ann Rheum Dis 70(3):404–413PubMedCrossRefGoogle Scholar
  9. 9.
    Rathbun AM, Reed GW, Harrold LR (2012) The temporal relationship between depression and rheumatoid arthritis disease activity, treatment persistence, and response: a systematic review. Rheumatology, OxfordGoogle Scholar
  10. 10.
    Ranzolin A, Brenol JC, Bredemeier M, Guarienti J, Rizzatti M, Feldman D et al (2009) Association of concomitant fibromyalgia with worse disease activity score in 28 joints, health assessment questionnaire, and short form 36 scores in patients with rheumatoid arthritis. Arthritis Rheum 61(6):794–800PubMedCrossRefGoogle Scholar
  11. 11.
    Jousse-Joulin S, d’Agostino MA, Marhadour T, Albert JD, Bentin J, Chary Valckenaere I et al (2010) Reproducibility of joint swelling assessment by sonography in patients with long-lasting rheumatoid arthritis (SEA-Repro study part II). J Rheumatol 37(5):938–945PubMedCrossRefGoogle Scholar
  12. 12.
    Le Boedec M, Jousse-Joulin S, Ferlet JF, Marhadour T, Chales G, Grange L (2013) Factors influencing concordance between clinical and ultrasound findings in rheumatoid arthritis. J Rheumatol 40(3):244–252PubMedCrossRefGoogle Scholar
  13. 13.
    Lillegraven S, Prince FH, Shadick NA, Bykerk VP, Lu B, Frits ML et al (2012) Remission and radiographic outcome in rheumatoid arthritis: application of the 2011 ACR/EULAR remission criteria in an observational cohort. Ann Rheum Dis 71(5):681–686PubMedCrossRefGoogle Scholar
  14. 14.
    Damjanov N, Radunovic G, Prodanovic S, Vukovic V, Milic V, Simic Pasalic K et al (2012) Construct validity and reliability of ultrasound disease activity score in assessing joint inflammation in RA: comparison with DAS-28. Rheumatology (Oxford) 51(1):120–128CrossRefGoogle Scholar
  15. 15.
    Dougados M, Jousse-Joulin S, Mistretta F, Agostino MA, Backhaus M, Bentin J (2010) Evaluation of several ultrasonography scoring systems for synovitis and comparison to clinical examination: results from a prospective multicentre study of rheumatoid arthritis. Ann Rheum Dis 5:828–833CrossRefGoogle Scholar
  16. 16.
    Naredo E, Bonilla G, Gamero F, Uson J, Carmona L, Laffon A (2005) Assessment of inflammatory activity in rheumatoid arthritis: a comparative study of clinical evaluation with gray scale and power Doppler ultrasonography. Ann Rheum Dis 64(3):375–381PubMedCrossRefGoogle Scholar
  17. 17.
    Backhaus M, Burmester GR, Gerber T, Grassi W, Machold KP, Swen WA et al (2001) Guidelines for musculoskeletal ultrasound in rheumatology. Ann Rheum Dis 60(7):641–649PubMedCrossRefGoogle Scholar
  18. 18.
    Thiele RG (2012) Ultrasonography applications in diagnosis and management of early rheumatoid arthritis. Rheum Dis Clin North Am 38(2):259–275PubMedCrossRefGoogle Scholar
  19. 19.
    Wakefield RJ, Balint PV, Szkudlarek M, Filippucci E, Backhaus M, D’Agostino MA et al (2005) Musculoskeletal ultrasound including definitions for ultrasonographic pathology. J Rheumatol 32(12):2485–2487PubMedGoogle Scholar
  20. 20.
    Terslev L, Torp-Pedersen S, Qvistgaard E, Danneskiold-Samsoe B, Bliddal H (2003) Estimation of inflammation by Doppler ultrasound: quantitative changes after intraarticular treatment in rheumatoid arthritis. Ann Rheum Dis 62(11):1049–1053PubMedCrossRefGoogle Scholar
  21. 21.
    Weidekamm C, Koller M, Weber M, Kainberger F (2003) Diagnostic value of high-resolution B-mode and Doppler sonography for imaging of hand and finger joints in rheumatoid arthritis. Arthritis Rheum 48(2):325–333PubMedCrossRefGoogle Scholar
  22. 22.
    Naredo E, Gamero F, Bonilla G, Uson J, Carmona L, Laffon A (2005) Ultrasonographic assessment of inflammatory activity in rheumatoid arthritis: comparison of extended versus reduced joint evaluation. Clin Exp Rheumatol 6:881–884Google Scholar
  23. 23.
    Schirmer M, Duftner C, Schmidt WA, Dejaco C (2011) Ultrasonography in inflammatory rheumatic disease: an overview. Nat Rev Rheumatol 7(8):479–488PubMedCrossRefGoogle Scholar
  24. 24.
    Terslev L, Ellegaard K, Christensen R, Szkudlarek M, Schmidt WA, Jensen PS et al (2012) Head-to-head comparison of quantitative and semiquantitative ultrasound scoring systems for rheumatoid arthritis: reliability, agreement, and construct validity. Rheumatology (Oxford) 51(11):2034–2038CrossRefGoogle Scholar
  25. 25.
    Schueller-Weidekamm C (2009) Quantification of synovial and erosive changes in rheumatoid arthritis with ultrasound—revisited. Eur J Radiol 71(2):225–231PubMedCrossRefGoogle Scholar
  26. 26.
    Scheel AK, Hermann KG, Kahler E, Pasewaldt D, Fritz J, Hamm B et al (2005) A novel ultrasonographic synovitis scoring system suitable for analyzing finger joint inflammation in rheumatoid arthritis. Arthritis Rheum 52(3):733–743PubMedCrossRefGoogle Scholar
  27. 27.
    Terslev L, Torp-Pedersen S, Qvistgaard E, von der Recke P, Bliddal H (2004) Doppler ultrasound findings in healthy wrists and finger joints. Ann Rheum Dis 63(6):644–648PubMedCrossRefGoogle Scholar
  28. 28.
    Szkudlarek M, Court-Payen M, Jacobsen S, Klarlund M, Thomsen HS, Ostergaard M (2003) Interobserver agreement in ultrasonography of the finger and toe joints in rheumatoid arthritis. Arthritis Rheum 48(4):955–962PubMedCrossRefGoogle Scholar
  29. 29.
    Ribbens C, Andre B, Marcelis S, Kaye O, Mathy L, Bonnet V et al (2003) Rheumatoid hand joint synovitis: gray scale and power Doppler US quantifications following antitumor necrosis factor-alpha treatment: pilot study. Radiology 229(2):562–569PubMedCrossRefGoogle Scholar
  30. 30.
    Filippucci E, Iagnocco A, Salaffi F, Cerioni A, Valesini G, Grassi W (2006) Power Doppler sonography monitoring of synovial perfusion at the wrist joints in patients with rheumatoid arthritis treated with adalimumab. Ann Rheum Dis 65(11):1433–1437PubMedCrossRefGoogle Scholar
  31. 31.
    Shio K, Homma F, Kanno Y, Yamadera Y, Ohguchi Y, Nishimaki T et al (2006) Doppler sonographic comparative study on usefulness of synovial vascularity between knee and metacarpophalangeal joints for evaluation of articular inflammation in patients with rheumatoid arthritis treated by infliximab. Mod Rheumatol 16(4):220–225PubMedCrossRefGoogle Scholar
  32. 32.
    Naredo E, Collado P, Cruz A, Palop MJ, Cabero F, Richi P et al (2007) Longitudinal power Doppler ultrasonographic assessment of joint inflammatory activity in early rheumatoid arthritis: predictive value in disease activity and radiologic progression. Arthritis Rheum 57(1):116–124PubMedCrossRefGoogle Scholar
  33. 33.
    Naredo E, Rodriguez M, Campos C, Rodriguez-Heredia JM, Medina JA, Giner E et al (2008) Validity, reproducibility, and responsiveness of a 12-joint simplified power Doppler ultrasonographic assessment of joint inflammation in rheumatoid arthritis. Arthritis Rheum 59(4):515–522PubMedCrossRefGoogle Scholar
  34. 34.
    Hameed B, Pilcher J, Heron C, Kiely PD (2008) The relation between composite ultrasound measures and the DAS28 score, its components and acute phase markers in adult RA. Rheumatology (Oxford) 47(4):476–480CrossRefGoogle Scholar
  35. 35.
    Backhaus M, Ohrndorf S, Kellner H, Strunk J, Backhaus TM, Hartung W et al (2009) Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: a pilot project. Arthritis Rheum 61(9):1194–1201PubMedCrossRefGoogle Scholar
  36. 36.
    Ellegaard K, Torp-Pedersen S, Terslev L, Danneskiold-Samsoe B, Henriksen M, Bliddal H (2009) Ultrasound color Doppler measurements in a single joint as measure of disease activity in patients with rheumatoid arthritis–assessment of concurrent validity. Rheumatology (Oxford) 48(3):254–257CrossRefGoogle Scholar
  37. 37.
    Haavardsholm EA, Ostergaard M, Hammer HB, Boyesen P, Boonen A, van der Heijde D et al (2009) Monitoring anti-TNFalpha treatment in rheumatoid arthritis: responsiveness of magnetic resonance imaging and ultrasonography of the dominant wrist joint compared with conventional measures of disease activity and structural damage. Ann Rheum Dis 68(10):1572–1579PubMedCrossRefGoogle Scholar
  38. 38.
    Ziswiler HR, Aeberli D, Villiger PM, Moller B (2009) High-resolution ultrasound confirms reduced synovial hyperplasia following rituximab treatment in rheumatoid arthritis. Rheumatology (Oxford) 48(8):939–943CrossRefGoogle Scholar
  39. 39.
    Cheung PP, Ruyssen-Witrand A, Gossec L, Paternotte S, Le Bourlout C, Mazieres M et al (2010) Reliability of patient self-evaluation of swollen and tender joints in rheumatoid arthritis: a comparison study with ultrasonography, physician, and nurse assessments. Arthritis Care Res 62(8):1112–1119CrossRefGoogle Scholar
  40. 40.
    Hammer HB, Sveinsson M, Kongtorp AK, Kvien TK (2010) 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 69(7):1349–1351PubMedCrossRefGoogle Scholar
  41. 41.
    Kamishima T, Sagawa A, Tanimura K, Shimizu M, Matsuhashi M, Shinohara M et al (2010) Semiquantitative analysis of rheumatoid finger joint synovitis using power Doppler ultrasonography: when to perform follow-up study after treatment consisting mainly of antitumor necrosis factor alpha agent. Skeletal Radiol 39(5):457–465PubMedCrossRefGoogle Scholar
  42. 42.
    Larche MJ, Seymour M, Lim A, Eckersley RJ, Petavy F, Chiesa F et al (2010) Quantitative power Doppler ultrasonography is a sensitive measure of metacarpophalangeal joint synovial vascularity in rheumatoid arthritis and declines significantly following a 2-week course of oral low dose corticosteroids. J Rheumatol 37(12):2493–2501PubMedCrossRefGoogle Scholar
  43. 43.
    Kawashiri SY, Kawakami A, Iwamoto N, Fujikawa K, Satoh K, Tamai M et al (2011) The power Doppler ultrasonography score from 24 synovial sites or 6 simplified synovial sites, including the metacarpophalangeal joints, reflects the clinical disease activity and level of serum biomarkers in patients with rheumatoid arthritis. Rheumatology (Oxford) 50(5):962–965CrossRefGoogle Scholar
  44. 44.
    Vlad V, Berghea F, Libianu S, Balanescu A, Bojinca V, Constantinescu C et al (2011) Ultrasound in rheumatoid arthritis: volar versus dorsal synovitis evaluation and scoring. BMC Musculoskelet Disord 12:124PubMedCrossRefGoogle Scholar
  45. 45.
    Hartung W, Kellner H, Strunk J, Sattler H, Schmidt WA, Ehrenstein B et al (2012) Development and evaluation of a novel ultrasound score for large joints in rheumatoid arthritis: one year of experience in daily clinical practice. Arthritis Care Res 64(5):675–682CrossRefGoogle Scholar
  46. 46.
    Watanabe T, Takemura M, Sato M, Sekine A, Fukuoka D, Seishima M et al (2012) Quantitative analysis of vascularization in the finger joints in patients with rheumatoid arthritis using three-dimensional volumetric ultrasonography with power Doppler. Clin Rheumatol 31(2):299–307PubMedCrossRefGoogle Scholar
  47. 47.
    Scire CA, Montecucco C, Codullo V, Epis O, Todoerti M, Caporali R (2009) Ultrasonographic evaluation of joint involvement in early rheumatoid arthritis in clinical remission: power Doppler signal predicts short-term relapse. Rheumatology (Oxford) 48(9):1092–1097CrossRefGoogle Scholar
  48. 48.
    Funck-Brentano T, Gandjbakhch F, Etchepare F, Jousse-Joulin S, Miquel A, Cyteval C, et al. Sonographic erosions and power-Doppler signal predict radiographic damage in early arthritis: The ESPOIR ultrasonography longitudinal study. Arthritis Care Res (Hoboken). 2012 Dec 4.Google Scholar
  49. 49.
    Saleem B, Brown AK, Quinn M, Karim Z, Hensor EM, Conaghan P et al (2012) Can flare be predicted in DMARD-treated RA patients in remission, and is it important? A cohort study. Ann Rheum Dis 71(8):1316–1321PubMedCrossRefGoogle Scholar
  50. 50.
    Kume K, Amano K, Yamada S, Hatta K, Kuwaba N, Ohta H (2011) Very early improvements in the wrist and hand assessed by power Doppler sonography predicting later favorable responses in tocilizumab-treated patients with rheumatoid arthritis. Arthritis Care Res 63(10):1477–1481CrossRefGoogle Scholar
  51. 51.
    Naredo E, Wakefield RJ, Iagnocco A, Terslev L, Filippucci E, Gandjbakhch F et al (2011) The OMERACT ultrasound task force—status and perspectives. J Rheumatol 38(9):2063–2067PubMedCrossRefGoogle Scholar
  52. 52.
    Mandl P, Naredo E, Wakefield RJ, Conaghan PG, D’Agostino MA (2011) A systematic literature review analysis of ultrasound joint count and scoring systems to assess synovitis in rheumatoid arthritis according to the OMERACT filter. J Rheumatol 38(9):2055–2062PubMedCrossRefGoogle Scholar
  53. 53.
    Ohrndorf S (2012) Backhaus M. Advances in sonographic scoring of rheumatoid arthritis, Ann Rheum DisGoogle Scholar
  54. 54.
    Aletaha D, Alasti F, Smolen JS (2011) Rheumatoid arthritis near remission: clinical rather than laboratory inflammation is associated with radiographic progression. Ann Rheum Dis 70(11):1975–1980PubMedCrossRefGoogle Scholar
  55. 55.
    Brown AK, Quinn MA, Karim Z, Conaghan PG, Peterfy CG, Hensor E et al (2006) 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 54(12):3761–3773PubMedCrossRefGoogle Scholar
  56. 56.
    Saleem B, Brown AK, Keen H, Nizam S, Freeston J, Karim Z et al (2009) Disease remission state in patients treated with the combination of tumor necrosis factor blockade and methotrexate or with disease-modifying antirheumatic drugs: a clinical and imaging comparative study. Arthritis Rheum 60(7):1915–1922PubMedCrossRefGoogle Scholar
  57. 57.
    Saleem B, Brown AK, Keen H, Nizam S, Freeston J, Wakefield R et al (2011) Should imaging be a component of rheumatoid arthritis remission criteria? A comparison between traditional and modified composite remission scores and imaging assessments. Ann Rheum Dis 70(5):792–798PubMedCrossRefGoogle Scholar
  58. 58.
    Peluso G, Michelutti A, Bosello S, Gremese E, Tolusso B, Ferraccioli G (2011) Clinical and ultrasonographic remission determines different chances of relapse in early and long-standing rheumatoid arthritis. Ann Rheum Dis 70(1):172–175PubMedCrossRefGoogle Scholar
  59. 59.
    Ozgocmen S, Ozdemir H, Kiris A, Bozgeyik Z, Ardicoglu O (2008) Clinical evaluation and power Doppler sonography in rheumatoid arthritis: evidence for ongoing synovial inflammation in clinical remission. South Med J 101(3):240–245PubMedCrossRefGoogle Scholar
  60. 60.
    van Tuyl LH, Vlad SC, Felson DT, Wells G, Boers M (2009) Defining remission in rheumatoid arthritis: results of an initial American College of Rheumatology/European League against rheumatism consensus conference. Arthritis Rheum 61(5):704–710PubMedCrossRefGoogle Scholar
  61. 61.
    Wakefield RJ, D’Agostino MA, Naredo E, Buch MH, Iagnocco A, Terslev L et al (2012) After treat-to-target: can a targeted ultrasound initiative improve RA outcomes? Ann Rheum Dis 71(6):799–803PubMedCrossRefGoogle Scholar

Copyright information

© Clinical Rheumatology 2013

Authors and Affiliations

  • Rafael Mendonça da Silva Chakr
    • 1
    Email author
  • José Alexandre Mendonça
    • 2
  • Claiton Viegas Brenol
    • 1
  • Ricardo Machado Xavier
    • 1
  • João Carlos Tavares Brenol
    • 1
  1. 1.Rheumatology Division Faculty, Universidade Federal do Rio Grande do SulHospital de Clínicas de Porto AlegrePorto AlegreBrazil
  2. 2.Rheumatology DivisionPontifície Universidade Católica de CampinasCampinasBrazil

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