433resources and time [ 63 ], there is renewed interest in examining the role of patient-
reported tender and swollen joint counts [ 64 – 66 ], which may be helpful in monitor-
ing disease activity between clinic visits. A study carried out by Cheung et al. [ 67 ]
to evaluate the relationship between patient-reported tender and swollen joints with
active infl ammation assessed by power Doppler and whether this relationship is
affected by signifi cant joint damage. The study included RA patients with long-
standing disease (median disease duration of 15 years) and moderate Disease
Activity Score (median DAS-28: 3.5). Results revealed that the joints showing sig-
nifi cant active infl ammation (e.g., grade 3 on PD assessment), RA patients identi-
fi ed 75 % as tender and 63 % as swollen. Swollen joints showed strong association
at the joint level with active synovitis when there was no signifi cant radiographic
damage (LR 2.54, 95 % CI 1.93–3.34). Swollen joint counts were statistically cor-
related with PDUS-DAS28 and CRP, but not PDUS score.
Sensitivity analysis revealed better agreement of tender and swollen joints with
active synovitis when DAS28 was ≤3.2 and when patient global pain was <50 mm
on visual analogue scale. These results are in agreement with the fi ndings of another
work done by El Miedany et al. [ 68 ] which included 121 RA patients who have
achieved remission and were monitored on a 3-monthly basis. The aim of the study
was to assess US imaging as an outcome measure in monitoring the RA patients’
response to therapy and its impact on the patients’ management. Also to identify
which joints should be US scanned in the standard clinical practice. Results revealed
that in comparison to clinical examination, US showed signifi cantly more joints
with effusion (mean 14.2) and synovitis (mean 16.1) than clinical examination
(mean 10.2, p < 0.05). A signifi cant correlation was found between patient self-
reported joint tenderness and both US-PD and total US scores. The study concluded
that in standard clinical practice, patient self-reported joint tenderness is the best
marker to identify joints that need to be US scanned. However, such signifi cant cor-
relation between patient reported tender joints and joint ultrasonography was not
reported in patients suffering from signifi cant joint damage, deformities, or long-
standing chronic synovitis [ 67 ]. A study by Janta et al. [ 69 ] compared disease activ-
ity assessed by the patient, the physician, and musculoskeletal US in patients with
RA in clinical remission. Results revealed that patient-assessed and physician-
assessed overall RA activity showed acceptable agreement, and that at the patient
level, physician-assessed joint swelling showed an acceptable concordance with
Doppler US synovitis.
Ultrasound Versus Other Reported Clinical Outcomes
Today’s therapeutic target in RA patients is achievement of disease remission or low
disease activity, whereby the term remission comprises lack of clinical disease
activity, halt of joint damage progression, and normalization or maximal improve-
ment of patient global assessment as well as physical function [ 70 ]. Patient global
assessment is included in both the DAS28 score assessment and the American
18 PROMs and Musculoskeletal Ultrasonography