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Rheumatology 2006;45:102–105 doi:10.1093/rheumatology/kei162
Advance Access publication 1 November 2005
Concise Report
Musculoskeletal ultrasound training in
rheumatology: the Belfast experience
A. Taggart, E. Filippucci
2
, G. Wright, A. Bell, A. Cairns, G. Meenagh,
A. Pendleton, M. Rooney, S. Wright, A. Grey
1
and W. Grassi
2
Objectives. Despite the increasing use of musculoskeletal ultrasound (MSUS) as a clinical tool in rheumatology, there is no
consensus yet regarding the standards requi red to achieve a basic level of competence in the use of this imaging technique.
A number of sonographers worldwide are developing curricula and standardizing teaching methods in order to improve training
in MSUS for rheumatologists. In the meantime, clinicians are devising informal means of training in order to acquire these new
skills. Here we describe the informal team approach to MSUS training adopted by a group of rheumatologists from the
Regional Rheumatology Centre in Belfast, UK.
Methods. Over a 5-yr period, eight rheumatologists from Musgrave Park Hospital in Belfast used a variety of means to learn
the basic skills of MSUS.
Results. Seven of the team underwent a formal assessment of their competency in a practical examination devised by an
experienced sonographer. All were judged to have attained a basic competency in MSU.
Conclusions. This Belfast experience shows what can be achieved despite the absence of formal MSUS training. Nevertheless,
the development of recognized training programmes and international standards of competency are important go als on the way
to achieving more widespread acceptance of MSUS as a useful tool in everyday clinical practice.
KEY WORDS: Musculoskeletal ultrasound, Training.
Over the last decade, there has been an explosion of interest in
the potential of musculoskeletal ultrasound (MSUS) as a clinical
tool in rheumatology [1–5]. Despite its undeniable value in a wide
range of rheumatic conditions, several issues concerning both
training and competency still wait to be addressed [6–12]. The
lack of a standardized training curriculum and the scarcity of
recognized training programmes are significant obstacles to the
more widespread use of MSUS in the field of rheumatology.
It is not uncommon for a rheumatologist in training to be
given the opportunity to acquire ultrasonographic (US) skills
and experience while the more senior members of the medical
team remain untrained. This can lead to a situation where the
rheumatologist–sonographer becomes an isolated figure within
the team. In this context, our experience in a busy rheumatology
department could represent one way of solving the problem of
sonographic training.
This paper describes how a group of rheumatologists from
Belfast adopted a team approach to enable them to acquire the
basic skills of MSUS.
The Belfast Rheumatology Unit
The Regional Rheumatology Centre for Northern Ireland is based
in Musgrave Park Hospital in Belfast and provides a specialist
service for a population of approximately one million people. Five
years ago, the medical team consisted of nine medical specialists
(five consultants and four specialist registrars in training). At that
time, our particular interests included the use of biological
therapies for severe inflammatory arthritis and the management
of systemic lupus erythematosus and paediatric rheumatology, but
none of us had any practical experience of MSUS.
In early 2000, two senior members of the team (A.T. and G.W.)
decided to explore the possibility of using clinic-based MSUS in
the unit. By a number of different means, we sought to acquire
the practical skills to enable the whole team to achieve basic
competency in MSUS. The Belfast training experience can be
summarized in five main steps:
Attending courses in basic ultrasonography;
Purchasing our own US equipment;
Sabbatical leave in a centre of excellence;
Direct experience assisted by a tutor;
Competency assessment.
Acquiring US skills
First step: attending courses in basic ultrasonography
Our introduction to MSUS began in April 2000 when five members
of the team attended the second EULAR (European League
Against Rheumatism) Course in Basic Sonography in Zurzach,
Switzerland. This was our first practical experience of the use
of US in rheumatic patients. It reinforced our determination
Correspondence to: A. Taggart, Department of Rheumatology, Musgrave Park Hospital, Stockman’s Lane, Belfast BT9 7JB, UK.
E-mail: allister.taggart@ntlworld.com
Department of Rheumatology, Musgrave Park Hospital,
1
Department of Radiology, Belvoir Park Hospital, Belfast, UK and
2
Department of Rheumatology,
Universita
`
Politecnica delle Marche, Ancona, Italy.
Received 2 June 2005; revised version accepted 14 September 2005.
ß The Author 2005. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
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to continue to invest in US training. Later that year, seven of
us attended the first BSR Course in Basic Ultrasound in
Cambridge, UK and the following April, five attended the third
EULAR Basic Sonography Course in Milan. In this way, the
majority of the rheumatologists from Belfast were introduced to
the practicalities of basic US and the conditions for learning
together as a group were created. From 2001 to 2004, different
members of the team attended a total of seven sonography courses
(four EULAR Sonography Courses and three British Society for
Rheumatology Courses), thus giving further impetus and
continuity to our training.
Second step: purchasing our own US equipment
After attending the EULAR Sonography Course in Switzerland,
we started to investigate the various options for acquiring our
own MSUS equipment, as none was freely available to us in our
hospital.
Initially, we purchased a Diasus (Dynamic Imaging,
Livingstone, UK), which is a dedicated MSUS machine with
high-frequency linear probes. Although this machine was not
equipped with power Doppler, it provided high quality B-mode US
imaging at a reasonable cost.
This proved ideal for training and detailed greyscale MSUS
examination. Subsequently, we acquired several portable SonoSite
180 machines (Sonosite, Bothwell, WA, USA), which could be
easily transported to outlying clinics for day-to-day clinical use,
such as joint injections. Even though these portable US systems do
not provide high-quality images, they permit a rapid assessment of
the basic US findings, which can be confirmed by more detailed
study at a later date, if necessary.
The acquisition of our own US equipment proved very
important for the development of our US skills. The equipment
was available to members of the team at all times and we were able
to practice our US techniques on each other as well as on our
patients.
During this phase, some members of our team attended
US clinics conducted by an experienced local radiologist with a
particular interest in sonography. He demonstrated US examina-
tion techniques at these clinics and at evening sessions specially
organized for the group as a whole. With his assistance, we
were able to build on the initial experience gained at the basic
US courses.
Finally, in April 2004, we acquired a top-quality US system
with power Doppler capability (Sonoline Antares; Siemens,
Munich, Germany). This machine has enhanced our assessment
of inflammatory rheumatic conditions and has enabled us to
embark on a number of US research projects.
Third step: sabbatical leave in a centre of excellence
Attending sonography courses was an important way to maintain
our enthusiasm for training in US but it was also a means of
meeting the experts who conducted these courses. One such
meeting led to an important training experience for several
members of our team. Following the EULAR Sonography
Course in Milan, Professor Walter Grassi invited one of our
registrars (G.M.) to spend a week in the Clinica Reumatologica of
the Universita
`
Politecnica delle Marche in Ancona, Italy. During
that visit, the trainee performed US examinations for a minimum
of 5 h each day under the direct supervision of an experienced
US rheumatologist (with 7 yr of experience) and a member
of the faculty of the EULAR Sonography Courses (E.F.).
The experience was such a success that, over the next 18 months,
a total of seven members of the Belfast team spent a sabbatical in
Ancona, performing US in this way. Each visit was organized as
an intensive 1-week US course for a maximum of two participants
at a time.
Fourth step: direct experience assisted by a tutor
Following these visits to Ancona, the medical team in Belfast
invited E.F. to come and study in the Regional Rheumatology
Centre in Northern Ireland. From April to June 2004, E.F. spent
3 months in Belfast. During that time, he assisted and supervised
members of the Belfast Rheumatology Unit in their MSUS
practice. Every Monday afternoon, he conducted a 2-h seminar
in practical MSUS techniques, focusing on specific topics as well
as interesting cases drawn from the rheumatology wards and
clinics. During this 3-month period, each trainee in the Belfast
Rheumatology Unit performed no less than 100 MSUS examina-
tions under expert supervision.
From July to November 2004, six members of the Belfast
team performed MSUS on a regular basis. The average time
devoted to MSUS by each member during this period was
approximately 5 h a week.
Fifth step: competency assessment
Following his visit to Belfast, E.F. was invited to design a formal
examination to test basic competency in clinical US which might
be applicable to rheumatology trainees. In November 2004, he
returned to Northern Ireland to conduct an evaluation of seven
of the Belfast rheumatologists in obtaining and interpreting
MSUS images.
The examination consisted of three parts: (i) a written paper of
multiple-choice questions; (ii) a MSUS examination of healthy
subjects; and (iii) a MSUS examination of patients with rheumatic
diseases.
The multiple-choice questions focused on four main topics:
MSUS technique, MSUS anatomy, MSUS pathology and MSUS
image interpretation. Each question had five possible answers,
only one of which was correct. There were 30 questions in total
and candidates were given 60 min to answer them. The pass mark
was 80%.
In the practical session with healthy subjects, each candidate
was asked to perform 15 standard MSUS scans and store the best
example of each scan. The scans were chosen randomly from the
list of the standard scans outlined in the EULAR Guidelines for
Musculoskeletal Ultrasound in Rheumatology [13]. Candidates
were allowed 30 min to perform the 15 scans. The stored images
were judged for quality according to a set of predefined criteria,
which included satisfactory equipment setup, proper handling of
the US probe and the presence of correct bony landmarks. Eighty
per cent of the images had to be of satisfactory quality in order to
pass this part of the examination. Figure 1a shows a representative
sample of the US images taken in healthy subjects.
The practical session with patients consisted of an US exam-
ination of two different anatomical sites. These were randomly
chosen from the eight sites indicated in the EULAR Guidelines for
Musculoskeletal Ultrasound in Rheumatology [13]: shoulder,
elbow, wrist, hand, hip, knee, ankle and foot. The total time
allowed to perform the two MSUS examinations was 30 min.
Each candidate was asked to fill out a written report on their
examination outlining the presence or absence of each pathological
finding detectable by US. The day before the examination, the same
examination was performed on all the patients by an experienced
rheumatologist–sonographer (E.F.) or a local radiologist with a
particular interest in sonography (A.G.). This provided a gold
standard by which to judge the performance of each candidate.
Candidates had to concur with not less than 80% of the examiners’
findings in order to pass this part of the examination. Figure 1b
provides some examples of pathological conditions detected by the
candidates during their US examination of the patients.
The results of the competency assessment are summarized in
Table 1.
Ultrasound training in rheumatology 103
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Current practice
In our Department, MSUS is now used regularly as a clinical tool
to assist with patient assessment and joint or soft tissue injection.
Time constraints make it difficult for us to perform MSUS in our
busy out-patient follow-up clinics but more time is available in
the new patient clinics and in the in-patient and day ward setting.
We have not reduced the patient numbers at any of our clinics but
would have to do so were we to use US in our routine follow-up
clinics. Of the eight rheumatologists who embarked on this
programme of informal training, six are still practising MSUS on
a regular basis. On average, each member of the team performs
ultrasound during three or four clinical sessions per week on a
total of 15–20 patients. Some of these US examinations will be
assessments prior to joint aspiration/injection and others will
consist of more detailed study of an anatomical area. Because of
the nature of our clinical practice, over half of our scans are
carried out on patients with inflammatory arthritis (rheumatoid
arthritis, psoriatic arthritis, juvenile arthritis etc.) but a substantial
number are in patients with painful shoulders or soft-tissue
rheumatism (carpal tunnel syndrome, painful heel, tennis elbow).
Some joint injections are carried out under direct ultrasound
guidance (e.g. heel, shoulder) but others are performed after
scanning the joint and marking the skin (e.g. hip). US enables us
to pinpoint the exact depth of the structure to be injected as well
as its position. Simple joint injections are still carried out blindly
but the majority benefit from US assessment prior to injection.
In many cases, the examination reveals unsuspected
abnormalities of the tendons and soft tissues where isolated joint
pathology was suspected. Workers from Leeds have demonstrated
the value of MSUS in everyday clinical practice [5] and our
experience bears this out. In a recent audit, we estimated that US
scanning influenced the clinical management of our patients in
70% of cases.
Five years ago, approximately 5% of our patients were referred
to the Department of Radiology for formal US examination. This
figure has not changed significantly since then but this service is
still invaluable to us in cases of diagnostic uncertainty. In many
cases, our practice of clinic-based US complements rather than
duplicates that of the radiologist–sonographer. We do not seek to
use US to provide a detailed anatomical diagnosis but use the
technique to refine and extend our clinical skills. MSUS requires
a detailed knowledge of musculoskeletal anatomy. Acquiring
that knowledge has improved our musculoskeletal examination
technique and has given us a better understanding of exactly how
different diseases affect the joints.
Our overall investment in US equipment and courses now
exceeds £250 000. These funds have come from a variety of
different sources, including the pharmaceutical industry, a local
arthritis charity and two health-care trusts. These figures do
not take account of the considerable time invested in training.
Constant practice under expert guidance is the single most
important key to success in MSUS training.
FIG. 1. (a) US images taken during the practical session with
healthy subjects. (A) Longitudinal volar scan of a metacarpo-
phalangeal joint. (B) Longitudinal scan of the thenar eminence.
Transverse (C) and longitudinal (D) volar scans of the carpal
tunnel. m, metacarpal head; p, proximal phalanx; o, articular
cartilage; ft, finger flexor tendons; fp, flexor pollicis longus
tendon; th, muscles of the thenar eminence; l, lunate bone;
n, median nerve; arrow, flexor carpi radialis tendon; r, radius.
(b) US images taken during the practical session with
patients with rheumatoid arthritis. (A, B) Metacarpophalangeal
joint. Longitudinal (A) and transverse (B) dorsal scans
showing synovial hypertrophy (s) and a bone erosion (*) of
the metacarpal head (m). p ¼ proximal phalanx. (C, D)
Wrist. VI compartment of the extensor tendons. Longitudinal
(C) and transverse (D) lateral scans showing a partial rupture (o)
of the extensor carpi ulnaris tendon (et). u, ulna; tr, triquetrum.
TABLE 1. Results of the competency assessment
CANDIDATE
Multiple-choice questions: number
of correct answers/number
of questions (%)
Practical session with the healthy subject:
number of satisfactory US images/total
number of US images (%)
Practical session with the patients: number
of correct US findings/number
of US findings to detect (%)
01 29/30 (96.7%) 15/15 (100%) Knee 13/14 (92.9%) Ankle 20/21(95%)
02 24/30 (80%) 15/15 (100%) Knee 14/14 (100%) Ankle 20/21(95%)
03 26/30 (86.7%) 15/15 (100%) Hand 9/9 (100%) Knee 12/14(85.7%)
04 26/30 (86.7%) 15/15 (100%) Hand 8/9 (88.9%) Knee 13/14(92.9%)
05 24/30 (80%) 15/15 (100%) Shoulder 18/19 (94.7%) Foot 8/8 (100%)
06 29/30 (96.7%) 15/15 (100%) Wrist 11/11 (100%) Foot 7/8 (87.5%)
07 29/30 (96.7%) 15/15 (100%) Shoulder 16/19 (84%) Ankle 21/21(100%)
Total 187/210 (89%) 105/105 (100%) 190/202 (94.1%)
104 A. Taggart et al.
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Discussion
The development of MSUS in the Belfast Rheumatology Unit has
been unusual in that a majority of the medical team have been
involved in the enterprise from the outset. Our experience shows
what can be achieved in a relatively short period of time despite the
lack of a formal training programme or curriculum. Although our
training has been largely informal, in many ways it has been more
rigorous than that undertaken by most UK radiology trainees.
In our case, the main obstacle to progress has been the lack of an
expert trainer in MSUS within our own hospital. We have
overcome this difficulty with the help of colleagues from outside,
but undoubtedly our task would have been easier if we had been
able to train under constant expert supervision and had had a
curriculum to follow.
Physicians who perform US must always be aware of the limits
of their experience and competence. This is particularly true for
those of us who are in the earlier phases of learning this new
technique. From the outset, we have audited our practice of MSUS
and all our trainees are required to keep a personal logbook of their
scans to facilitate this process.
At the present time, there is a lack of experienced musculo-
skeletal sonographers in the UK who are available to act as
trainers. This situation should improve as clinic-based US becomes
more widely accepted, but more controlled trials are needed if we
are to convince rheumatologists that the technique can improve
patient care [3, 14].
MSUS is an integral part of rheumatology training in a number
of European countries [15–17] and EULAR has recognized the
importance of MSUS by setting up its own Working Party on
Imaging in Rheumatology. This international dimension will
prove decisive in the development of recognized standards of
training and competency [7, 8]. This is an essential step towards
achieving more widespread acceptance of MSUS as a clinical tool
in rheumatology. It will also prove important from a clinical
governance perspective.
Our training experience is a testimony to the value of
collaboration with colleagues when developing new clinical skills.
We still have a great deal to learn before we can call ourselves
rheumatologist–sonographers but we would never have got this
far had it not been for the encouragement and support of our
radiology colleague and of the experts from the Clinica
Reumatologica of the Universita
`
Politecnica delle Marche in
Ancona.
Acknowledgements
We thank Dr Michelle McHenry and Sister Joyce Patton for
their assistance in organizing the competency assessment.
The authors have declared no conflicts of interest.
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Rheumatology
Key messages
There is no consensus yet regarding
the requirements for musculoskeletal
ultrasound training in rheumatology.
The scarcity of recognized training
programmes is an obstacle to the more
widespread use of ultrasound in our
specialty.
A flexible approach to training can
produce positive results but success
requires a significant commitment of time
and effort by both trainer and trainee.
Ultrasound training in rheumatology 105
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