ACR Supports Best Practices For Ultrasonography Use In Rheumatology

Main Category: Arthritis / Rheumatology
Also Included In: Lupus;  Gout
Article Date: 31 Oct 2012 – 0:00 PDT

ACR Supports Best Practices For Ultrasonography Use In Rheumatology
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More rheumatologists are embracing musculoskeletal ultrasound (MSUS) to diagnose and manage rheumatic diseases. In response, the American College of Rheumatology (ACR) assembled a task force to investigate and determine best practices for use of MSUS in rheumatology practice. The resulting scenario-based recommendations, which aim to help clinicians understand when it is reasonable to integrate MSUS into their rheumatology practices, now appear online in Arthritis Care & Research.
In Europe, more than 100 million individuals are affected by rheumatic diseases, according to the European League Against Rheumatism (EULAR). The ACR estimates that nearly 50 million Americans are burdened by arthritis and more than 7 million individuals suffer from inflammatory rheumatic diseases such as systemic lupus erythematosus, rheumatoid arthritis and gout.
“With so many people affected by rheumatic diseases, including arthritis, a diagnostic tool such as MSUS that is minimally invasive and with little risk to patients is an important tool for rheumatologists,” explains lead researcher Dr. Tim McAlindon from Tufts Medical Center in Boston, Mass. “Our task force goal was to establish when use of MSUS was ‘reasonable’ in a number of medical situations.”
The task force reviewed medical literature to come up with scenario-based recommendations for how MSUS could be used in rheumatology practice. These recommendations include a rating by type of evidence, with Level A supported by at least two randomized clinical trials or one or more meta-analyses of randomized trials; Level B backed by one randomized trial, non-randomized studies or meta-analyses of non-randomized studies; and Level C confirmed by consensus expert opinion, case studies, or standard clinical care.
The complete list of 14 recommendations of the reasonable use of MSUS in rheumatology, along with level of evidence, is published in the article. Partial list of recommendations includes:

  • For a patient with articular pain, swelling or mechanical symptoms, without definitive diagnosis on clinical exam, it is reasonable to use MSUS to further elucidate the diagnosis at the following joints: glenohumeral, acromioclavicular, sternoclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle, midfoot and metatarsophalangeal. Level of evidence: B.
  • For a patient with diagnosed inflammatory arthritis and new or ongoing symptoms without definitive diagnosis on clinical exam, it is reasonable to use MSUS to evaluate for inflammatory disease activity, structural damage or emergence of an alternate cause at the following sites: glenohumeral, acromioclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle, midfoot and metatarsophalangeal, and entheseal. Level B.
  • For a patient with shoulder pain or mechanical symptoms, without definitive diagnosis on clinical exam, it is reasonable to use MSUS to evaluate underlying structural disorders; but not for adhesive capsulitis or as preparation for surgical intervention. Level B.
  • It is reasonable to use MSUS to evaluate the parotid and submandibular glands in a patient being evaluated for Sjögren’s disease to determine whether they have typical changes as further evidence of the disorder. Level B.
  • For a patient with symptoms in the region of a joint whose evaluation is obfuscated by adipose or other local derangements of soft tissue, it is reasonable to use MSUS to facilitate clinical assessment at the glenohumeral, acromioclavicular, elbow, wrist, hand, metacarpophalangeal, interphalangeal, hip, knee, ankle/foot, and metatarsophalangeal joints. Level C.
  • For a patient with regional neuropathic pain without definitive diagnosis on clinical exam, it is reasonable to use MSUS to diagnose entrapment of the median nerve at the carpal tunnel; ulnar nerve at the cubital tunnel; and posterior tibial nerve at the tarsal tunnel. Level B.
  • It is reasonable to use MSUS to guide articular and peri-articular aspiration or injection at sites that include the synovial, tenosynovial, bursal, peritendinous and perientheseal areas. Level A.

The benefits of MSUS use include a faster, more accurate diagnosis, better measurement of treatment success, reduced procedural pain, and improved patient satisfaction. However, the authors highlight that economic impact was not part of this study. Dr. McAlindon concludes, “Further study of the cost-effectiveness and long-term outcomes of MSUS is necessary to determine its value compared to other interventions.”

Article adapted by Medical News Today from original press release. Click ‘references’ tab above for source.
Visit our arthritis / rheumatology section for the latest news on this subject.
Full citation: American College of Rheumatology Report on Reasonable Use of Musculoskeletal Ultrasonography in Rheumatology Clinical Practice.” Timothy McAlindon, Eugene Kissin, Levon Nazarian, Veena Ranganath, Shraddha Prakash, Mihaela Taylor, Raveendhara R Bannuru, Sachin Srinivasan, Maneesh Gogia, Maureen A McMahon, Jennifer Grossman, Suzanne Kafaja, John FitzGerald. Arthritis Care and Research; Published Online: October 29, 2012 (DOI: 10.1002/acr.21836).Wiley
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Back Pain? Steroid Shots May Raise Fracture Risk

illustration of human spine

Oct. 25, 2012 — Steroid injections to the spine were widely considered to be safe before being linked to an outbreak of fungal meningitis that by mid-week had killed 24 people in 17 states.

But a study out today raises new concerns about the injections that are used to treat millions of back pain sufferers every year — and it has nothing to do with the tainted steroids blamed for the meningitis outbreak.

Spine Injections May Raise Fracture Risk

Epidural steroid shots are injected into the space around the spinal cord. The steroid works to curb inflammation in the area, leading to pain relief.

The study suggests that epidural shots increase the risk of spinal bone fractures, and researchers say patients with bone loss should be warned about this risk. 

The research was presented today in Dallas at the annual meeting of the North American Spine Society.

Bone fractures of the spine are the most common fractures in patients with osteoporosis.

According to the American College of Rheumatology, one in two women over 50 and one in six men will suffer a fracture related to osteoporosis.

“For a patient population already at risk for bone fractures, steroid injections carry a greater risk than previously thought,” says researcher Shalom Mandel, MD, of Henry Ford Hospital in Detroit.

While other steroid treatments, such as those taken orally or by IV, have long been linked to bone loss, epidural steroid shots are thought to have little impact on bones because they are delivered directly to the problem area and believed to have less effect on the rest of the body.

But Mandel says this may not be the case.

“If epidural steroids are causing fractures, it is probably because the treatment is not localized,” he says. “The drug may be entering the circulatory system.”

More Study Needed, Doctor Says

The Henry Ford Hospital researchers examined data on 6,000 patients treated for back pain between 2007 and 2010.

Half the patients were treated with at least one epidural steroid shot and the other half had never had the treatment.

According to the analysis, spinal fracture risk increased by 29% with each steroid shot. This was an association though, and does not prove cause and effect.

Mandel still uses epidural steroid shots to treat patients with back pain, and he says he has even had the injections himself.

“They were very helpful,” he says. “There is definitely a place for this treatment.”

But he adds that patients at risk for fractures should be warned about the risk and followed closely if they have the treatment.

Orthopaedic surgeon Neil S. Ross, MD, of Lenox Hill Hospital in New York City, who reviewed the research, says the study does not convince him that epidural spinal shots increase fracture risk.

While he does not give the shots, Ross says he has referred many patients to doctors who do.

“I would not change my recommendations about this treatment based on this study,” he says, adding that more study is needed to confirm the findings.

These findings were presented at a medical conference. They should be considered preliminary as they have not yet undergone the “peer review” process, in which outside experts scrutinize the data prior to publication in a medical journal.

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