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College of Radiology (ACR) response criteria. Morphologic assessment of painful
sites using MSUS would help to identify whether the cause of pain is either synovi-
tis, tenosynovitis, or enthesitis. This would help avoid overestimation of patients/
physicians global assessment, meanwhile it will help in setting a treatment program
tailored to the patient’s underlying pathology. Recently it was reported to show
signifi cant correlation with disease activity better than the physician global assess-
ment particularly in RA patients presenting with moderate-high disease activity
[ 71 ]. The relation between US and variable patient reported outcome measures was
depicted as secondary outcomes of earlier published studies. In a study carried out
on established RA patients to compare clinically active joints to sonographically
active joints in RA patients, results revealed signifi cant correlations between sono-
graphic fi ndings (Grayscale score ≥ 2, PD score ≥ 2) and other clinical measures,
such as laboratory results, VAS score for pain, patient’s global assessment of dis-
ease activity, physician global assessment of disease activity, as well as duration of
morning stiffness [ 60 ]. In concordance, similar fi ndings were reported in another
study, which included early infl ammatory arthritis patients who were treated to tar-
get and monitored for 52 weeks [ 50 ]. Results revealed that changes in the functional
disability scores and duration of morning stiffness were signifi cantly correlated to
changes in PD scores. These fi ndings show that, indeed, the differences between
sonographic and patient reported outcome measures are considerably low in par-
ticular when higher cutoff points for defi ning an active joint in sonography is used.
Ultrasound and Adherence to Therapy
Whilst several studies depicted the value of US in the management of infl ammatory
arthritis and its ability to detect subclinical synovitis, assess joint damage, and guide
joint aspiration as well as injection [ 71 – 75 ], there is little published data regarding
its use in patient education or as a tool to improve adherence/compliance to medica-
tion. Humans possess an innate cognitive preference for visually presented informa-
tion [ 76 , 77 ]. It is therefore not surprising to fi nd that the use of pictorial aids was
associated with improved medication instruction recall, comprehension, and
adherence, especially when combined with supportive written or verbal information
[ 78 ]. This was supported by the fi ndings of earlier studies that revealed that health
interventions containing visual elements and simple comprehensible information
were effective at improving patient understanding of the condition and treatment
[ 79 , 80 ].
Musculoskeletal US can be a valuable patient education tool [ 81 ] as it enables
the treating clinician to enhance patient understanding through “real-time” visual
demonstration of joint structures, synovial infl ammation, and articular damage. The
ability to navigate around the site of interest on the patient’s own anatomy may
improve patient understanding more than the traditional static images, especially
when combined with clinician–patient interaction at close quarters. Furthermore,
the recognition of structural damage with MSUS—such as erosions, tendon dam-
J. Uson and Y. El Miedany