Rheumatology Advance Access originally published online on January 20, 2007
Rheumatology 2007 46(5):821-829; doi:10.1093/rheumatology/kel412
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The challenges of integrating ultrasonography into routine rheumatology practice: addressing the needs of clinical rheumatologists
Academic Unit of Musculoskeletal Disease, University of Leeds, Chapel Allerton Hospital, Leeds, LS7 4SA, 1Medical Education Unit, School of Medicine, University of Leeds, Leeds, LS2 9NL and 2Department of Radiology, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK.
Correspondence to: Dr Andrew K. Brown, MBChB, MRCP, Academic Unit of Musculoskeletal Disease, University of Leeds, Chapel Allerton Hospital, Leeds, LS7 4SA, UK. E-mail: andrewkbrown{at}ukonline.co.uk
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Abstract |
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Objectives. The practice of musculoskeletal ultrasonography (MSKUS) by UK rheumatologists remains limited, despite their reported enthusiasm. This study aimed to investigate factors that may encourage or limit future dissemination of rheumatologist-performed MSKUS and provide insights into perceived clinical importance and learning motivation relating to published recommendations by MSKUS experts.
Methods. A written questionnaire study was conducted, involving 48 rheumatologists. Questions included the potential role of self-performed MSKUS, skills that they would be willing to learn and factors that may encourage or limit learning and practice. Competency recommendations proposed by imaging experts (142 skills in 7 anatomical areas) were reviewed, and quantitative and qualitative data collected regarding ‘value to their practice’ and ‘learning motivation’.
Results. Eighty-nine percent wished to learn MSKUS. Factors influencing learning and practice included time to achieve competency; relative-added clinical value of MSKUS examination; limited training infrastructure; access to existing imaging service; equipment funding. Skills offering greatest clinical utility were inflammatory arthritis assessment and guided procedures; least useful were evaluation of ligament/muscle lesions and soft tissue masses. There was a close correlation between clinical utility, learning motivation and competency standard.
Conclusions. A trade-off between added clinical value and time to achieve competency is the major factor influencing practice and training in MSKUS. Most rheumatologists report limited time to devote to training and therefore need to prioritize areas of importance for dedicated learning. Educational programmes need to be highly focused and relevant to clinical and job–plan requirements in order to encourage future dissemination of MSKUS practice by rheumatologists.
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There is growing interest amongst the rheumatology community in the practice of musculoskeletal ultrasonography (MSKUS) [1–4]. However, despite increasing evidence demonstrating the potential benefits to clinical practice [5–9], at present only a relatively small number of rheumatologists, particularly in the United Kingdom, are able to perform this imaging technique [10]. Possible explanations may include an absence of suitable training programmes, prohibitive equipment costs and limited time to learn the necessary skills in a busy clinical environment [11, 12], but there may be others.
So, will MSKUS be a skill that is eventually performed by all rheumatologists, as proposed by a number of authors, or will it remain a tool practiced by the minority? What steps need to be taken to promote the integration of MSKUS into routine clinical rheumatology?
Despite an evolving literature proposing the implementation of an appropriate educational infrastructure [11–13], the present reality is an absence of a unified and structured approach to the education of rheumatologists in ultrasonography. Such educational challenges are beginning to be addressed [14–17] and imaging experts have proposed a consensus of best practice standards for rheumatologists in MSKUS. This comprises appropriate knowledge, skills, indications and anatomical areas [18] together with competency-based educational outcomes to guide teaching and learning [19]. This represents a potential blueprint for the development of a specific rheumatology MSKUS curriculum and a framework for rheumatologist-performed MSKUS practice.
However, rheumatologists are important stakeholders in such a curriculum and as experts in their specialty, it would be advantageous to obtain their opinion as to the clinical relevance of these proposals and incorporate these views in the development of such a syllabus. What aspects of MSKUS do they believe to be most relevant to their clinical practice? What is their level of motivation to acquire such skills? Furthermore, what are their reasons for holding such opinions? Acknowledging these requirements may encourage wider dissemination of this imaging technique by providing more clearly defined, clinically focused learning outcomes in line with both imaging expert and consumer rheumatologist opinion.
Therefore, the aim of the present study was to evaluate the attitudes of rheumatologists towards performing MSKUS examinations, and investigate any factors that may encourage or limit the ability of rheumatologists to acquire the necessary skills. This was directed towards four particular aspects:
- What are the potential barriers which may limit training and practice of MSKUS?
- What is the perceived value to a rheumatologist's clinical practice of possessing specific MSKUS skills?
- What is the level of motivation amongst rheumatologists to learn the technique of MSKUS?
- What is the correlation between stakeholder rheumatologists’ opinion on areas of clinical importance in MSKUS and those articulated by imaging experts?
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Questionnaire design
A questionnaire was designed and administered to all Yorkshire rheumatologists (consultants and specialist registrars or equivalents, n = 48) by postal mail. Rheumatologist ultrasonographers (n = 3) were excluded. The questionnaire comprised an eight-page document beginning with an introduction and outline of the aims of the study. It was divided into three further sections. The first of these requested demographic and background information and included a series of open questions designed to provide qualitative data concerning current access to MSKUS, previous MSKUS experience, perceived areas of clinical benefit, learning motivation and potential barriers to learning and practice. The second section contained a list of MSKUS skills divided into their respective anatomical areas that had been obtained from a previous consensus defining exercise [18]. Information was also provided as to the corresponding competency category for each skill, assigned by imaging experts [19]. These categories have been previously defined as follows: must know (core knowledge and skills required by every rheumatologist ultrasonographer and represents the minimum standard that is necessary to be judged competent); should know (rheumatologist ultrasonographers should know this but it is a little more than the minimum knowledge or skills that they require and is probably only needed at an intermediate level); could know (only really required by a small number of rheumatologist ultrasonographers at an advanced or subspecialty level); don't need to know (not required or appropriate for ultrasound assessment by rheumatologists) [19]. Each respondent was asked to rate each MSKUS skill in terms of ‘value to their practice’ and ‘learning motivation’ using reference Likert scales (Table 1). A total of 142 MSKUS skills were assessed in seven anatomical areas. The final section reverted to a free text format with open questions requesting respondents to summarize why they would be willing to learn some MSKUS skills but not others and provide any additional comments.
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Analysis
Data evaluation and statistical analysis were carried out using SPSS version 10 under the direction of our departmental statistician specializing in rheumatology medical research. Demographic, response rate and current practice data are presented using standard summary statistics. Qualitative data have been analysed for recurring themes with the most common being presented in order of popularity. Specific statistical tests and pre-defined criteria were used in the analysis of the following sections:
1. Is value to practice and learning motivation related?
The value to practice and learning motivation scores were compared for each respondent and levels of agreement were calculated using percentage exact agreement and kappa statistics. If a close relationship were determined, these two categories would be combined into a single value to practice grouping for subsequent analyses.
2. Calculating overall value to practice and learning motivation
The overall value to practice was calculated by adding together the percentage responses in the ‘essential’ and ‘useful’ categories. Data were also summarized using the group median scores and the percentage frequency of responses within each value to practice category. Demographic data were used to evaluate any statistical differences between groups, e.g. grade (consultant vs specialist registrar), setting (teaching vs district general hospital), number of years in practice and previous MSKUS experience. In this analysis, non-parametric statistical tests were used to assess levels of significance (independent samples were compared using the Mann–Whitney test; related samples were compared using the Wilcoxian Rank test).
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Demographics
A questionnaire was sent to 48 Yorkshire rheumatologists, all of whom were invited to take part in the study. Of the 48 rheumatologists, 29 were consultants (60%), 16 specialist registrars (33%) and 3 staff grade (6%) rheumatologists. The overall response rate was 37/48 (77%). This comprised 24/29 (83%) consultants, 11/16 (69%) specialist registrars and 2/3 (67%) staff grade rheumatologists.
Current practice
The mean number of years in rheumatology practice of the group was 10 (standard deviation 8.2, range 0.8–28). There was a relatively equal split between respondents practicing in a teaching hospital [18 (49%)] and a district general hospital [19 (51%)]. All had access to a MSKUS service although this was performed by both rheumatologists and radiologists either locally or at another site: 14 (38%) referred patients for MSKUS assessment to a teaching hospital rheumatologist; 12 (32%) district general hospital radiologist; 7 (18%) teaching hospital rheumatologist and teaching hospital radiologist; 2 (5%) teaching hospital radiologist; 1 (3%) district general hospital radiologist and teaching hospital rheumatologist; 1 (3%) district general hospital radiologist, teaching hospital rheumatologist and teaching hospital radiologist. Only 7 (19%) rheumatologists had personally performed a MSKUS examination of their patients. In response to direct questioning, 34 (93%) believed that being able to personally perform a MSKUS examination would be of benefit to their practice and 33 (89%) stated that they would be willing to learn the technique.
Qualitative value to practice and learning motivation data
Prior to reviewing the remainder of the questionnaire, including the MSKUS skills defined as appropriate for rheumatologist ultrasonographers by imaging expert consensus, respondents were asked a number of open questions regarding the perceived role of self-performed MSKUS in their rheumatological practice, the skills that they would be willing to learn and the reasons that may encourage or limit their study of this technique.
The common themes that were identified are summarized in Table 2.
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Is value to practice and learning motivation related? (Table 3)
There was good agreement between value of practice and learning motivation data. All kappa statistical scores range from 0.55 to 1.0 (mean 0.82) and percentage exact agreement scores range from 72.2 to 100% (mean 89.2%).
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In general, the agreement scores were greater in anatomical regions of the lower limb than the upper limb. Higher agreement scores were more common in the competency categories of ‘must know’ or ‘don't need to know’, rather than the ‘should know’ or ‘could know’ categories. In areas of disagreement, the learning motivation score was more likely to be higher than the value to practice score for each individual competency item.
In view of this close relationship between the value to practice and learning motivation scores, only the value to practice scores have been used for all subsequent analyses.
Calculating overall value to practice and learning motivation (Table 4)
The overall value to practice was calculated by adding together the percentage responses in the ‘essential’ and ‘useful’ categories. The relative value to practice of each competency item is represented chronologically for each anatomical area in Table 4.
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Detection of synovial fluid or effusion was regarded as the most important MSKUS skill in rheumatology practice as this category received the highest value to practice score in each anatomical area, ranging from 86% in the ankle and heel to 75% in the elbow (mean 80%). US-guided aspiration and injection were also high scoring items ranging from 84% in the ankle and heel to 65% in the knee. US-guided injection was slightly more popular than aspiration with mean scores of 75% and 73%, respectively. Likewise, detection of synovial thickening was deemed to be a particularly useful skill by most respondents, varying from 78% at the ankle and heel compared with 64% at the elbow (mean 70%). Identification of bone erosion was also important especially in the hand and wrist (76%) and forefoot (64%) (mean 56%, range 36–76%). Other inflammation-related pathologies received slightly lower results and included enthesitis (mean 53%, range 41–64%) and bursitis (mean 60%, range 46–68%). Tendon pathology featured fairly prominently, particularly tenosynovitis with an 81% value to practice rating in the hand and wrist, ankle and heel. Also, certain rotator cuff-related tendon pathologies received comparatively high scores such as bicipital tendonitis (72%), subacromial impingement (71%), calcific tendonitis (69%) and complete rotator cuff tear (68%). However, other tendon lesions, particularly identification of tendon nodules, were given relatively low totals with a mean score of 43% in the relevant anatomical sites. In addition, certain tendon abnormalities in the knee, particularly related to the quadriceps tendon as well as rupture of the patellar tendon, were thought to be less valuable to rheumatology practice with scores between 37 and 43%. Disease monitoring was somewhat less popular with monitoring disease activity scoring slightly higher than monitoring disease progression (mean 45 vs 43%; range 38–57%). Almost universally, competency items related to ligament, muscle and nerve pathology, soft tissue mass lesions and calcified cartilage received low scores in all anatomical areas with mean scores of 30, 23, 19, 19 and 29%, respectively. Some exceptions to this included popliteal cyst (65%), knee collateral ligament tear (58%), Morton's neuroma (54%), carpal tunnel syndrome (49%), ganglion (mean 46%, range 39–49) and ankle ligament enthesopathy (39%).
The above findings are corroborated using other methods of analysis. If the data are summarized using the group median scores, one competency item (detection of synovial fluid/effusion in the hand and wrist) was deemed ‘essential’ to rheumatology practice (median score = 1); 69 (49%) competency items were thought to be ‘useful’ (median score = 2); 53 (37%) were regarded as ‘limited value’ (median score = 3) and 19 (13%) ‘not needed’ (median score = 4). If the data are analysed using the percentage of responses within each value to practice category, the competency items thought to be most valuable to rheumatology practice, reflected by the highest frequency of responses in the ‘essential to my practice’ category, were detection of synovial fluid/effusion in the hand and wrist (51%) and complete rotator cuff tear (50%). A further 20 items were thought to be ‘essential’ by about 40–49% of respondents, the most common being detection of synovial fluid/effusion and US-directed procedures, all in a variety of anatomical sites. Regarding items believed to be least valuable, indicated by the highest frequency of responses in the ‘not needed in my practice’ category, 15 scored over 50% and included nerve lesions, muscle and ligament pathology and soft tissue masses in each anatomical region.
Differences related to demographic or experience characteristics
No statistically significant differences were observed between the value to practice scores obtained between grades (consultant vs specialist registrar), setting (teaching vs district general hospital) and number of years in practice or previous MSKUS experience.
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Conclusions |
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The aim of this study was to assess the attitudes of rheumatologists towards acquiring the necessary skills to perform MSKUS. Opinion was sought from a large number of rheumatologists within the Yorkshire region. The response rate was good, perhaps reflecting the interest amongst the respondents in MSKUS and the nature of this work. Almost two-thirds were consultant grade, with an equal mix between secondary and tertiary care practice. This was helpful to ensure an appropriate balance of backgrounds amongst questionnaire recipients with the intention of accurately representing the views of the wider rheumatologist population, although repetition of this study in another geographical location would be of interest as a validation exercise. All had access to a MSKUS service and, interestingly, a greater proportion referred patients to a teaching hospital rheumatologist for such an assessment than anywhere else. This rheumatologist-run MSKUS service is relatively unique in the United Kingdom and was initiated in response to research and clinical interests of the authors, together with demand for a service not routinely offered by radiologists in the context of a previous culture of more orthopaedic-based MSKUS practice. This may provide the respondents with a greater insight into the capabilities of MSKUS and gives their responses added validity. In concordance with previous data, relatively few rheumatologists (19%) had personally performed a MSKUS assessment of their patients (although three local rheumatologist ultrasonographers were not included in the data collection), whereas approximately 90% believed that being able to personally perform an ultrasound examination would be of benefit to their practice and stated that they would be willing to learn the technique.
The questionnaire began with a series of open questions, designed to extract qualitative data, prior to revealing to the group the competency-based opinions of imaging experts. The purpose of this was to allow the rheumatologists to articulate any preconceived opinions regarding MSKUS, without the potential bias of expert opinion, and in particular to evaluate their views as to the perceived role of MSKUS in their clinical practice and areas in which they would be willing to learn the technique. This qualitative data were assessed for any common themes and was also used to aid in interpretation of the subsequent quantitative value to practice scores. The answers to these questions followed similar themes and indicated that rheumatologists would generally be willing to acquire the necessary MSKUS skills in areas where they believed the technique would provide helpful diagnostic and management information. Small joint and shoulder evaluation were the most popular regions for MSKUS examination and US-guided procedures, particularly local injections, assessment of inflammatory arthritis, differential diagnosis and tendon pathology, especially affecting the rotator cuff, were the most common indications. These qualitative themes largely concur with areas that have previously been identified as core competencies by imaging experts.
As with any new clinical skill, demonstration of its ability to enhance practice is essential to its uptake and dissemination. We asked rheumatologists to consider this value to practice concept in relation to predetermined expert-derived competency standards developed specifically for rheumatologists. It is likely that the concept of value to practice represents a composite of a number of different factors and it was felt that learning motivation might be a significant influence. Indeed, as it has been proposed that rheumatologists should perform such imaging for themselves, it was felt important to precisely establish levels of motivation to acquire the necessary skills. Therefore, separate categories of value to practice and learning motivation were used which would allow any relationship between these two areas to be analysed. In fact, it transpired that these two aspects were closely linked although analysis of the qualitative data also revealed other factors which may influence the value to practice scores, which will be discussed later. The association of these two characteristics also provides an endorsement of the process of developing a coordinated educational approach to rheumatology MSKUS as it suggests that there is an audience willing to train in MSKUS, as by and large, rheumatologists appear to be willing to learn what they perceive to be valuable to their practice. This was even apparent in the shoulder, which is widely regarded as one of the more difficult areas in which to achieve proficiency, but can yield valuable clinical information. In addition, in areas of relative disagreement between scores, learning motivation was more likely to score higher than value to practice, again suggesting an enthusiastic learner group. There was greatest agreement between value to practice and learning motivation in the imaging expert competency categories of ‘must know’ and ‘don't need to know’. By definition, these categories represent absolute or black and white opinion at the extremes of this scale, whereas it could be argued that the categories of ‘should know’ and ‘could know’ are less definite and may be more open to interpretation. As such, one may expect a greater difference of opinion in these more central categories.
The MSKUS skills that received the highest value to practice scores were detection of joint effusion and US-guided procedures. The distribution of joint regions corresponding to these particular skills is perhaps related to the relative difficulty of performing an accurate clinical examination or ‘blind’ procedure at these sites, e.g. ankle, shoulder and hip. Other indications that received relatively high scores were related to inflammatory arthritis, where there is a particular emphasis on early diagnosis and optimal suppression of inflammation, and rotator cuff pathology, where clinical evaluation can have a low sensitivity and specificity. In both these situations, published evidence suggests that MSKUS may be particularly helpful. Scores for monitoring disease activity and disease progression were perhaps lower than expected although at present these areas probably represent research applications with less evidence to support their routine use. Other subjects regarded as less valuable to rheumatology practice included certain tendon abnormalities including identification of tendon nodules, which may be clinically evident so obviating the need for MSKUS, and abnormalities of the quadriceps tendon and patellar tendon rupture, which may not be frequently encountered in the rheumatology clinic. Competency items related to ligament, muscle and nerve pathology, soft tissue mass lesions and calcified cartilage generally received low scores in all anatomical areas, all of which, except the latter, were also defined by imaging expert consensus as inappropriate for MSKUS by rheumatologists. The exceptions were more rheumatology-specific pathologies explicitly mentioned in the questionnaire such as popliteal cyst, Morton's neuroma, carpal tunnel syndrome and ganglia.
The areas with highest value to practice scores correspond to the most popular themes identified from the qualitative data collection. This information was gathered before the respondents had the opportunity to review the expert consensus recommendations. This corroborates the authenticity of the rheumatology MSKUS skills identified in previous stages of this work and demonstrates that providing the rheumatologists with the expert-derived information has not introduced any appreciable bias to the results. Indeed, if the rheumatologist believed that any area of importance was excluded from the questionnaire, they were prompted to include it as free text, but no additional indications were volunteered. In addition, the respondent's grade, working environment and previous MSKUS experience did not have a significant effect on the value to practice scores.
As previously stated, the use of MSKUS by rheumatologists is still relatively limited although the number of practitioners appears to be increasing. So, will MSKUS be a tool that is eventually used by all rheumatologists as proposed by a number of authors (and a number of respondents to this questionnaire), or will it remain a skill practiced by the minority? As the final part of this analysis into the attitudes of rheumatologists toward performing MSKUS, we sought to investigate any factors that may encourage or limit the ability of rheumatologists to acquire the necessary skills to perform a MSKUS assessment. This would also provide important data for future educational planning. A number of common themes were established from this qualitative data collection. Despite almost 90% of rheumatologists stating that they would be willing to learn the technique of MSKUS, almost all respondents mentioned some potential limitations that may restrict its widespread use, although some were keen do everything without condition. The most frequent constraint was time, not only to learn the technique and achieve the required competency standard but also to perform each imaging examination and to maintain the necessary skill levels, particularly in the context of an already busy clinical environment in which most practitioners operated. Some respondents commented that they simply did not have enough hours in the day to devote the necessary time to be safe ultrasonographers and others suggested that to do so would have to be at the expense of another clinical activity. This meant that more rheumatologists were motivated to acquire the more straightforward skills, which may be easier to learn and could be readily applied to common clinical problems that they encountered frequently in their practice. The other major consideration was clinical impact, for example ‘What added value would MSKUS provide that could influence my approach to a certain problem for the benefit of the patient?’ Most wished to concentrate on areas of greatest clinical reward that were most likely to influence clinical decision making, or indications which may offer important safety improvements. Access to an appropriate educational programme was also identified as a relevant issue by rheumatologists, which reflects the current lack of an appropriate training infrastructure in MSKUS. This observation is clearly of particular relevance to this current work and once again provides supporting evidence for the need for further educational development in this field. Other aspects that may have a bearing on uptake of MSKUS included the nature of their existing imaging service, whether this was already provided by another qualified practitioner performing MSKUS or access to other imaging modalities such as MRI was available. Financial considerations were also deemed important both for the purchase of the necessary hardware and software and the cost of the other support systems required to provide an imaging service. Acknowledegment of MSKUS as a viable clinical activity for rheumatologists by employers was also put forward as a possible issue. The fact that the time taken to train and perform MSKUS may itself require additional funding as this may be at the expense of other duties and would require appropriate recognition.
The overwhelming attitude influencing the practice of MSKUS within the rheumatology community appears to be based on a trade-off between added clinical value versus time to achieve competency and perform an imaging assessment. Most rheumatologists report a limited time to devote to MSKUS and therefore a need to prioritize areas of importance for dedicated learning and practice. These opinions endorse the requirement for any rheumatology MSKUS curriculum to be highly focused and relevant to the specific needs of the rheumatologist. Consequently, any educational development process needs to consider these important factors, as they are likely to profoundly influence the future dissemination of MSKUS practice by rheumatologists.
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The Arthritis Research Campaign, by way of awarding Andrew K. Brown an Educational Research Fellowship, funded this research. We would also like to acknowledge the contribution of our Yorkshire rheumatology colleagues for their assistance with this project.
The authors have declared no conflicts of interest.
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References |
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- Balint P and Sturrock RD. (1997) Musculoskeletal ultrasound imaging: a new diagnostic tool for the rheumatologist? Br J Rheumatol 36:1141–42.
[Free Full Text] - Canoso JJ. (2000) Ultrasound imaging: a rheumatologist's dream. J Rheumatol 27:2063–64.[Web of Science][Medline]
- D'Agostino MA and Breban M. (2002) Ultrasonography in inflammatory joint disease: why should rheumatologists pay attention? Joint Bone Spine 69:252–55.[CrossRef][Web of Science][Medline]
- Grassi W and Cervini C. (1998) Ultrasonography in rheumatology: an evolving technique. Ann Rheum Dis 57:268–71.
[Free Full Text] - Wakefield RJ, Green MJ, Marzo-Ortega H, et al. (2004) Should oligoarthritis be reclassified? Ultrasound reveals a high prevalence of subclinical disease. Ann Rheum Dis 63:382–85.
[Abstract/Free Full Text] - Karim Z, Wakefield RJ, Conaghan PG, et al. (2001) The impact of ultrasonography on diagnosis and management of patients with musculoskeletal conditions. Arthritis Rheum 44:2932–33.[CrossRef][Web of Science][Medline]
- Schmidt WA. (2001) Value of sonography in diagnosis of rheumatoid arthritis. Lancet 357:1056–57.[CrossRef][Web of Science][Medline]
- Wakefield RJ, Gibbon WW, Conaghan PG, et al. (2000) The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis – a comparison with conventional radiography. Arthritis Rheum 43:2762–70.[CrossRef][Web of Science][Medline]
- Kane D, Grassi W, Sturrock R, Balint PV. (2004) Musculoskeletal ultrasound – a state of the art review in rheumatology. Part 2: clinical indications for musculoskeletal ultrasound in rheumatology. Rheumatology 43:829–38.
[Abstract/Free Full Text] - Wakefield RJ, Goh E, Conaghan PG, Karim Z, Emery P. (2003) Musculoskeletal ultrasonography in Europe: results of a rheumatologist-based survey at a EULAR meeting. Rheumatology 42:1251–53.
[Abstract/Free Full Text] - Wakefield RJ, Brown AK, O'Connor PJ, Karim Z, Grainger A, Emery P. (2004) Musculoskeletal ultrasonography: what is it and should training be compulsory for rheumatologists? Rheumatology 43:821–22.
[Free Full Text] - Speed CA and Bearcroft PWP. (2002) Musculoskeletal sonography by rheumatologists: the challenges. Rheumatology 41:241–42.
[Free Full Text] - Wakefield RJ, Brown A, O'Connor P, et al. (2003) Rheumatological ultrasound. Rheumatology 42:1001.
[Free Full Text] - Backhaus M, Burmester GR, Gerber T, et al. (2001) Guidelines for musculoskeletal ultrasound in rheumatology. Ann Rheum Dis 60:641–49.
[Free Full Text] - Filippucci E, Unlu Z, Farina A, Grassi W. (2003) Sonographic training in rheumatology: a self teaching approach. Ann Rheum Dis 62:565–67.
[Abstract/Free Full Text] - D'Agostino MA, Maillefert JF, Said-Nahal R, Breban M, Ravaud P, Dougados M. (2004) Detection of small joint synovitis by ultrasonography: the learning curve of rheumatologists. Ann Rheum Dis 63:1284–87.
[Abstract/Free Full Text] - Taggart A, Filippucci E, Wright G, et al. (2006) Musculoskeletal ultrasound training in rheumatology: the Belfast experience. Rheumatology 45:102–05.
[Abstract/Free Full Text] - Brown AK, O'Connor PJ, Roberts TE, Wakefield RJ, Karim Z, Emery P. (2005) Recommendations for musculoskeletal ultrasonography by rheumatologists: setting global standards for best practice by expert consensus. Arthritis Rheum 53:83–92.[CrossRef][Web of Science][Medline]
- Brown AK, O'Connor PJ, Roberts TE, Wakefield RJ, Karim Z, Emery P. (2006) Ultrasonography for rheumatologists: the development of specific competency based educational outcomes. Ann Rheum Dis 65:629–36.
[Abstract/Free Full Text]
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