Ultrasound saves money, improves rheumatologic care

A few years back, 76-year-old Joseph Buggie woke up to pain so throbbing, he couldn't muster the strength to roll over, let alone crawl out of bed.

His primary care physician told him that the twinges shooting up his torso, hips and thighs were part of polymyalgia rheumatica - an inflammatory disorder that can strike overnight, bringing a host of muscle aches and stiff joints the next morning. A prescription of prednisone eased his discomfort temporarily, but more episodes followed. Soon Buggie, once an avid woodcarver with a flair for ornate architectural designs and historical restoration projects, began noticing sharp pain spreading to his shoulders, arms and hands.

Because of an implantable defibrillator that manages his heart condition, Buggie was barred from conventional MRI (magnetic resonance imaging) scans that would have offered his rheumatologist, Darren Tabechian, M.D., a beneath-the-skin glimpse into his sore joints and surrounding tissues. Luckily for Buggie, though, there was another option - he could have an ultrasound.

Though traditionally associated with prenatal care, rheumatologists are finding new uses for this decades-old technology, leveraging it as an inexpensive, at-their-fingertips tool for viewing soft tissues instantly. When Tabechian, an assistant professor of Medicine at the University of Rochester Medical Center (URMC), wheeled the machine into the exam room and used the on-screen picture to pinpoint a syringe into Buggie's shoulder, Buggie watched, riveted, savoring his first taste of what would be lasting comfort.

"Right before me, Dr. Tabechian pointed to the areas on screen where I was having arthritic flare ups," Buggie said. "It was really impressive. Thanks to that ultrasound scan, we were able to settle on a medicine and regimen that works, and my pain's been managed since. For the first time in years, I'm thinking about taking back up my woodcarving hobby."

Like Buggie's arthritis, many rheumatologic conditions are difficult to diagnose and even more elusive to treat. Consider psoriatic arthritis, which onsets asymmetrically and has no definitive blood test, or gout, which is mimicked by a condition called pseudogout that is symptomatically similar but requires completely different medicinal management. In many cases, MRI has reigned as the tool of choice for imaging these troublesome tissues, bones and joints, but the scans' steep cost (Medicare sets the cost at close to $1,200 per exam), prohibit them from being used routinely to follow a patient's progress and better tune his or her treatment.

But ultrasound imaging is a whole different story. The technology relies on electrified (Piezo) crystals that generate high-frequency sound waves which, when reflected, produce a clear picture of soft tissues. Performed at the bedside, the ultrasound generates live images and can even be used to guide procedures, such as difficult injections. Moreover, since the diagnostic information is provided instantaneously, no time is necessary to develop or review, and there's no need to schedule an additional procedure. Images or video clips can also be saved for later comparison - all at about a tenth of the cost of an MRI (Medicare estimates approximately $120 per ultrasound).

"That spread in price makes ultrasound something we can use consistently, providing serial assessments to see if and how quickly a certain therapy is helping a patient," said Ralf Thiele, M.D., also an assistant professor of Medicine and rheumatologist at URMC. "Without it, we might have to resort to relying on anecdotal reports as we tried various treatments - we'd have an initial MRI, but after that, we would have to ask patients if they hurt more or less, if they felt the medicine was working."

Recent studies comparing ultrasound and MRI to routine clinical assessments (without imaging) have shown that, while up to 20 percent of rheumatoid arthritis patients felt to be in remission by their treating rheumatologists, they in fact continued to experience joint-damaging inflammation only detectable by imaging. Now, with ultrasound at their disposal, Thiele and Tabechian can, right in the office, watch in real-time as inflammation as blood gathers around an arthritic joint - much like a Doppler weather radar screen on the nightly newscasts shows a mounting storm system.

"We can afford to image the patient every few weeks while getting their disease under control," he said.

Thiele conducts training nationwide, teaching rheumatologists how ultrasound technology can add value to their clinics. The URMC clinic which he works in routinely uses three ultrasound machines. More than half of Thiele's patients have benefited from ultrasound technology at some point in their care.

"In Europe, many countries - Spain, Germany, the UK, even Italy - are already harnessing ultrasound's potential for diagnosing and informing treatment for many rheumatologic conditions," Thiele said. "Here in the United States, we're just dipping our toes in. But interest is gathering, because it's resourceful, efficient, and plain old good medicine."

Another boon from having ultrasound machines at their fingertips at such a practical price - it's becoming much more economical to monitor for early detection.

"We're beginning to see a shortage of rheumatologists as the baby-boomers age," Thiele said. "Being able to diagnose in the first signs of disease means that we could stall, maybe even thwart damage. And in turn, with less-complicated, better-managed cases, we stand a better chance of accommodating the rise in demand that we expect in coming years."

Thiele admits that ultrasound has its limits, though.

"It can't see through bone, and it can only picture one small area at a time," he said. "It's also not as useful for ACL or meniscus tears, or for deep-joint imaging."

Still, he says ultrasound's potential for inflammatory arthritis is especially exciting.

"When a patient presents with swollen hands, for instance, we can't know with just at a glance what might be wrong," he said. "But we could get a lot closer to the answer with an ultrasound, and at small expense. And that's just the clinical care aspect; that says nothing of the wealth of research information this could help us collect, much less expensively, and how that knowledge in turn could shed new light on the disease."