Editor
Giorgio Tamborrini
Authors
Giorgio Tamborrini
Hans Ruedi Ziswiler
Pascal Zufferey
Scientific Board Members
Giorgio Tamborrini
Hans Ruedi Ziswiler
Pascal Zufferey
Laure Brulhart
Adrian Ciurea
Burkhard Moeller
Michael Nissen
Ultrasound Scoring
in Rheumatoid Arthritis and Spondyloarthritis
Sonar-Scoring / Handbook
5. edition
Imprint
Copyright Sonar - www.sonar-group.ch
Swiss Sonography Group in Arthritis and Rheumatism
© 2008-2019 Sonar-group
© 2019 irheuma®™ design - production www.irheuma.com
a qir supported product - www.qir.ch
Herstellung und Verlag: BOD Books on Demand GmbH, Norderstedt
SONAR („Swiss Sonography Group in Arthritis and Rheumatism“) is a musculoskeletal ultrasound expert group founded in 2008. The group has developed a semi-quantitative score for Rheumatoid Arthritis using modified OMERACT criteria for synovitis, tenosynovitis and erosions. The score includes B mode and Powerdoppler mode in finger joints, wrists, elbows and knees, an erosion and tenosynovitis score and additional cartilage measurement in selected joints.
2015 we developed and introduced a semi-quantitative score for hip involvement in Spondyloarthritis and started teaching the score to rheumatologists nationwide (Sonar-Hip or CoxSonar Score).
Since 2008 we promote musculoskeletal ultrasound (msus) in the management of RA patients to increase the role of msus in RA and to improve patient outcomes. The Sonar-group offers msus courses to improve practical skills.
The scientific commitee of the Sonar-group works with and supports the SCQM (www.scqm.ch)
In 2018, the SONAR group has decided to focus more on the use of ultrasound in psoriatic arthritis and spondylarthitis. We have started a project concerning the implementation of a newly defined ultrasound enthesitis score in the registry.
A preliminary score based on the OMERACT definition of ultrasound elementary lesions observed in inflammatory enthesitis has been developped. The implementation process into SCQM has been finalyzed in 2019 followed by a validation study and teaching courses.
Targets of the Sonar-group:
The focussed advanced courses can be attended by Swiss rheumatologists FMH with msus education according to the national SGUM (SGUM = Schweizerische Gesellschaft für Ul-traschall in der Medizin) guidelines or for rheumatology fellows achieving the FMH rheumatology title (FMH = Foederatio Medi- corum Helveticorum = Verbindung der Schweizer Ärztinnen und Ärzte).
The practical Sonar courses prioritise since 2008 diagnostic msus, interventional msus and treatment monitoring (treat to target) in particular in rheumatoid arthritis (RA) and since 2015 also in spondyloarthritides (SpA).
Sonar organized since 2008 several courses to improve rheumatologists’ msus skills, to learn the Sonar-score for RA-patients and the Sonar-Hip, respectively the CoxSonar-score for SpA-patients. More than 150 rheumatologists in hospitals and in practice attended to the courses from 2008-2019 and included more than 1000 patients in the SCQM database.
This 5. edition (2. english edition) of the Sonar handbook explains the semi-quantitative Sonar score for Rheumatoid Arthritis, the 2015 introduced Sonar-Hip Score in SpA and the 2019 introduced enthesitis Score.
History of Sonar courses
Sonar is endorsed by SGUM and the SGR (Schweizerischen Gesellschaft für Rheumatologie = Swiss Rheumatology Society) and we cooperate with the Targeted Ultrasound Initiative (TUI), an educational programme to promote the greater use of ultrasound in the management of rheumatoid arthritis (http://targetedultrasound.net/).
All Sonar activities are listed here: www.sonar-group.ch.
Scientific board (according to http://www.scqm.ch)
SONAR
Swiss Med Wkly. 2013;143:w13861 - authorized reprint
Ultrasound (US) has become a useful tool in the detection of early disease, differential diagnosis, guidance of treatment decisions and treatment monitoring of rheumatoid arthritis (RA). In 2008, the Swiss Sonography in Arthritis and Rheumatism (SONAR) group was established to promote the use of US in inflammatory arthritis in clinical practice. A scoring system was developed and taught to a large number of Swiss rheumatologists who already contributed to the Swiss Clinical Quality Management (SCQM) database, a national patient register. This paper intends to give a Swiss consensus about best clinical practice recommendations for the use of US in RA on the basis of the current literature knowledge and experience with the Swiss SONAR score.
Literature research was performed to collect data on current evidence. The results were discussed among specialists of the Swiss university centres and private practice, following a structured procedure.
Musculoskelatal US was found to be very helpful in establishing the diagnosis and monitoring the evolution of RA, and to be a reliable tool if used by experienced examiners. It influences treatment decisions such as continuing, intensifying or stepping down therapy. The definite modalities of integrating US into the diagnosis and monitoring of RA treatments will be defined within a few years. There are, however, strong arguments to use US findings as of today in daily clinical care. Some practical recommendations about the use of US in RA, focusing on the diagnosis and the use of the SONAR score, are proposed.
The diagnosis of rheumatoid arthritis (RA) is based essentially on clinical and biological parameters, although the new ACR/EULAR classification criteria include magnetic resonance imaging (MRI) and ultrasound (US) as additional tools to assess objectively joint involvement [1, 2].
The primary treatment goal in RA is to maximise long-term health-related quality of life by controlling the symptoms, preventing structural damage, normalising or preserving function, and enhancing social participation. Since the era of the new biologic treatments, these goals can be achieved in most patients and the benefit of tight disease control has been demonstrated. To optimise outcome, therapies should be adjusted according to disease activity. The ACR (American College of Rheumatism) response criteria were not established for clinical practice but rather for clinical trials. In contrast, the DAS (disease activity score), CDAI (clinical disease activity index) and SDAI (simplify disease activity index) are clinically useful for the continuous prospective monitoring of individual patients [3] . In many studies, however, these indexes, in particular the DAS, yielded a low reproducibility when applied in the setting of a large group of physicians [4]. Up to 30% of patients fulfilling remission criteria according to DAS, ACR and European League against rheumatism (EULAR) criteria still had progression in joint damage, suggesting that clinical criteria may not be reliable [5].
There are more and more data suggesting that US is useful in differential diagnosis, detection of early disease, disease activity monitoring, guidance of treatment decisions, and in the follow-up of remission of RA [6]. Over the last decade, US technology and machines have progressed such that good quality machines are now available for a reasonable price, allowing a wide distribution among rheumatologists in both clinical and private practice. In Switzerland, about 40% of rheumatologists have access to an US machine and have received basic training in musculoskeletal US. Moreover, US has been included in the formal training curriculum for all future Swiss rheumotologists.
In 2008, the Swiss Sonography in Arthritis and Rheumatism (SONAR) group was set up as an educational progamme focussing on the use of US in inflammatory arthritis in clinical practice. A semiquantitative grayscale (B) mode and doppler (PD) score was developed in accordance with several earlier published scores and based on the recommendations of the of the OMERACT [7]. The scoring system was taught to 108 rheumatologists.
This paper summarises a Swiss consensus on best clinical practice recommendations for the use of US in RA, based on the current literature and experience with the Swiss SONAR score since it was implemented in the Swiss RA registry database (SCQM).