application for recognition part i - preliminary a · title: application for recognition part i -...

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August 29, 2017 Dr. Jason Frank Director, Specialty Education, Strategy and Standards Office of Specialty Education The Royal College of Physicians and Surgeons of Canada 774 Echo Drive Ottawa, ON K1S 5N8 RE: Spring COS Outcome Neuromusculoskeletal Ultrasound AFC Application Letter of response April 26, 2017 Dear Dr. Jason Frank, Thank you and all the members of the Committee on Specialties who participated in the review of our submission. We are now requesting that our Part 1 application for an AFC Diploma in NMSKUS, receive further consideration in light of the clarifications we are providing. We will address each concern from the COS with additional information and explanations in this response. Sponsorship of an Inclusive broad group of Specialties: We would like to clarify that this application is made to be inclusive of a very broad group of Specialities. We have amended the application to reflect that all specialties that have common or shared interest in neuromuscular and musculoskeletal disorders are encouraged to be included in this AFC. NMSKUS is viewed as a unique pairing of related disciplines with closely overlapping areas of competencies. These Specialties would share core competencies and each would also develop separate, specific competency training requirements unique to their specialty. At this time the Specialties of Adult Rheumatology, Pediatric Rheumatology, Physical Medicine and Rehabilitation and Neurology are SPONSORS of this application for an AFC in NMSKUS. We have contacted the Royal College representatives of Orthopedic surgery and Sports and Exercise Medicine as related disciplines. Both sections support our application and anticipate that their members will join this AFC when they are ready to encourage supplementary ultrasound skills among their trainees or Fellows. At the present time they are not in a position to advance to this stage.

AFC in NMSKUS is not “point of care ultrasound” (POCUS) nor Ambulatory Care Ultrasound:

The catch phrase “POCUS” stands for point of care ultrasound. It is easy to say but confusing to the sonography world. We would like to clarify that this term was specifically designed to differentiate ultrasound in the emergency department from that in the imaging department. The term originated from papers that were published in journals related to emergency medicine. We

would also like to clarify that the only group of physicians that utilize this term are those associated with emergency medicine and internal medicine. A search through PubMed will only generate articles published in journals of internal medicine, emergency medicine and critical care. No other group of sonographers, or physicians recognize this term. The primary example of this is seen when reviewing the most comprehensive ultrasound institute framework–the American Institute of Ultrasound in medicine (AIUM), and the current American Authority for certification in ultrasound–the Alliance for Physician Certification and Advancement (APCA). These institutions recognized that point of care ultrasound (POCUS) reflects that which is completed in the emergency room and in primary care. Point of care ultrasound generally reflects pathology that is intra-abdominal or intrathoracic.

Therefore, we view many other medical specialties (such as General Internal Medicine, General Surgery, Critical Care, Respirology, Geriatrics) more closely aligned to the Point of Care Ultrasound - Acute Care AFC. They deal with disorders of the heart, lungs, abdomen, and circulatory system. Separate streams in the currently approved Acute Care Point of Care Ultrasound AFC would be most appropriate. For example, the POCUS- GIM stream could be developed at a later date for specialists in internal medicine, geriatrics, and ICU medicine.

We also do not subscribe to the notion that NMSKUS is specifically ambulatory care in nature. Many inpatients and outpatients alike will benefit from the skills that NMSKUS diplomates will bring to their patients. Location is irrelevant to the deployment of diagnostic ultrasound to complement the clinical evaluation of patients. The reach of diagnostic ultrasound is extensive when deployed by highly trained clinicians. This change in paradigm is largely related to the fact that high-resolution complex processing and portable ultrasound is a distinct new technology and is now widely available and more affordable than 20 years ago. Finally, many of the applications of NMSKUS require expensive, non-portable cart based ultrasound units due to the processing power required for deep muscles, tendons, joints and nerves and detection of inflammatory blood flow in the soft tissue structures. The equipment used is similar to that found in most radiology departments.

Are there Core Training Requirements in Ultrasound in Fellowship Training? This application reflects a specific skill set not currently recognized within the spectrum for Fellowship training. None of the Specialties identified in the application have requirements for skills in interpretation and performance of diagnostic ultrasound in their objectives of training or competency training requirements. Furthermore, the training Directors have explicitly concluded that:

a) There is insufficient time to introduce these advanced skills during primary Fellowship training.

b) Most candidates that enroll in these Specialty training programs request exposure to Ultrasound instruction. The recruitment of NMSKUS Diplomats as teachers, could attract more trainees to Canadian centres.

c) Some training programs have developed introductory ultrasound courses;

However, enhanced skills that would allow for independent unsupervised practice cannot be achieved within primary specialty training.

d) All training directors are in need of Clinical instructors with advanced Ultrasound training. These Diplomats could serve as Faculty for curriculum development, teaching and research.

Current state of ultrasound training within the core competencies of disciplines in related fields:

At the present time, if you review the core competencies within the objectives of training for orthopedic surgery, neurology, physiatry, rheumatology, and sport and exercise medicine you will see that there is no dedicated time to learn how to use an ultrasound machine. Although there may be some exposure during the diagnostic imaging rotations, or within the academic half days of these programs, it is currently not mandatory and currently not tested during either written, OCSE, or oral components of the Royal College examinations. Some programs have the capacity to generate ultrasound curricula but this is an exception to the rule. Graduates from current programs would not be considered to be able to practice this skill without supervision.

Given the state of affairs, there is a significant lack of future capability through the current framework of residency training programs to meet the need in gaps of care. It is estimated that it will take several decades and an entire generation of physicians to facilitate the widespread training of diagnostic ultrasound outside of diagnostic radiology residency training programs. Even within diagnostic radiology the skill set is only partial when compared to that of the NMSKUS diplomats.

Learning ultrasound requires dedicated hands-on exposure and extensive repetition in daily practice. Training within the current framework for residency programs of the entry specialties is not practical. There is not enough elective or selective time within the programs to ensure competence. As can be seen from the attached letters of support from multiple specialties, a change to competency based training will not allow for the skills required for the NMSKUS diploma program.

The NMSKUS AFC application aims to fill a deficiency, by developing a group of clinicians

with enhanced skills that are needed within academic medicine and within the community itself.

How this AFC will enhance the scope of practice of some physicians: Not all trainees and subspecialty physicians may choose to acquire these skill sets. We view this discipline as available to those who may acquire an interest. In Rheumatology, it would be similar to acquiring advanced training in Lupus, Vasculitis, Osteoporosis or Laboratory Research. In Neurology, it would be similar to choosing advanced training in Epilepsy, Movement Disorders, or Neuro-oncology.

How this AFC will protect the scope of practice of physicians One of the primary positions of the Royal College of Physicians and Surgeons of Canada is to formulate the scope of practice of physicians and that scope of practice should always be consistent with the specialized training and education offered to healthcare providers. This AFC will create an education and certification process for non-radiologists and will set the standard for education and certification for all healthcare providers performing diagnostic NMSKUS in Canada. Setting the bar high will force other stakeholders to acknowledge the level of skill expected of physicians within the NMSK community. It will be looked upon by other parahealth stakeholder organizations as an example of excellence. For example, at the present time many physical therapists are embarking upon diagnostic MSK ultrasound without any clear standard of reference. Having a reference standard for physicians would force the hand of international and national non-physician stakeholders to look upon the Royal College as a reference standard of excellence. How this AFC will affect Scope of Practice:

The skill sets acquired in this AFC would be the same for academic or community based practitioners. Academic physicians would be expected to advance this discipline with teaching, research, and a service delivery to both inpatients and outpatients. The community based physicians would be engaged in delivery of care with this added skill set, and provide the additional needed resources within their community and local hospitals. The NMSKUS diplomats (MSK and Rh Streams) would be able to provide diagnostic and interventional services currently provided by radiologists in larger centers such as blocks of the lateral femoral cutaneous nerve of the thigh, glenohumeral joint injections, and ultrasound evaluation of the shoulder, hip and knee; settings where MRI is not required. They would also be able to expand the services to inpatients in local hospitals where the wait times for interventional radiology are long thereby reducing length of stay and adding cost savings. Additionally, they could serve as a secondary resource to colleagues who do not have these ultrasound skills.

Some examples in Rheumatology include identification of synovitis or tenosynovitis in patients that are symptomatic but clinically well, but with abnormal serology, or determination of drug induced remissions. Other instances are the provision of interventional procedures like iliopsoas bursal injections or subtalar joint injections, all, in an office based setting. A plastic surgeon or neurologist may have a patient with a suspected ulnar neuropathy at the wrist and the NMSKUS diplomats could evaluate that patient and aid in the diagnostic and therapeutic management. The diplomats would aid in reducing wait list for hospital based procedures by providing similar procedures in the outpatient setting i.e. drainage of ganglia, Baker’s cysts, or carpal tunnel perineural injections.

In 2017, graduating specialists in orthopedic surgery, physiatry, rheumatology, and sport and exercise medicine will have obtained the skills to know when to order an ultrasound to aide in the management of pathology of the shoulder but would not be able to place the transducer upon the shoulder and obtain these images themselves. Nor would they be able to adequately interpret the images. Although the spectrum of skills of graduates are very broad, and some individuals

do obtain formal and informal education by themselves, even still, these individuals may only be able to identify a large effusion, or a massive rotator cuff tear. Rheumatology specialists would not be able to differentiate a hip effusion from iliopsoas bursitis, or active wrist synovitis, from a chronic damaged wrist joint. Imaging about the shoulder also provides an excellent example of the layers of competence between a general radiologist and an MSK fellowship trained radiologist. The general radiologist would not be able to confidently diagnose tendinopathy off of the coracoid process. This, however, is within the scope of the MSK fellowship trained radiologist.

The following are examples of the spectrum of current expected skills amongst specialties:

Able to verbally describe the indications, contraindications, risks and benefits of ultrasound guided glenohumeral joint injection

Able to correctly position the patient, perform selection of injectate, identified the target and infiltrate the glenohumeral joint under ultrasound guidance

Able to perform a preprocedural diagnostic examination of the posterior shoulder, and consistently and independently perform the injection

Able to differentiate shoulder effusion from spinoglenoid notch cysts or synovitis.

Orthopedic Surgery

Physiatry

Rheumatology

Some Internal Medicine

Radiology

NMSKUS Diplomate

MSK Radiologist

Ultrasound Guided Glenohumeral Joint Injection

Skill Progression

Able to correctly identify and obtain images of the tendons of the shoulder

Able to identify full thickness tears of tendons of the shoulder

Able to consistently identify partial thickness tears of the shoulder

Orthopedic Surgery

Physiatry

Rheumatology

Some Internal Medicine

Radiology

NMSKUS Diplomate

MSK Radiologist

Ultrasound of the Shoulder

Able to consistently identify the suprascapular, and axillary nerve of the shoulder or tendinopathy’s of the coracoid process

Able to describe the indications for diagnostic ultrasound of the shoulder and list structures requiring imaging

Skill Progression

Able to correctly identify and obtain images of the carpal tunnel

Able to identify pathology of the median nerve in the carpal tunnel

Able to consistently identify a neuroma of the palmar cutaneous branch of the median nerve, or concomitant synovitis of wrist & tendons

Orthopedic Surgery

Physiatry

Rheumatology

Sport and Exercise Medicine

Radiology

NMSKUS Diplomate

MSK Radiologist

Ultrasound of the Median Nerve at the Wrist

Neurology

Able to describe the indications for diagnostic ultrasound of the carpal tunnel and list its structures requiring imaging

Skill Progression

Obtains images of the hip joint and identifies hip effusion

Obtains images of anterior hip, and identifies labral tear and paralabral cyst

Obtains dynamic imaging of anterior hip joint, diagnoses partial tear of iliopsoas tendon with snapping of iliopsoas tendon.

Orthopedic Surgery

Physiatry

Rheumatology


Radiology

NMSKUS Diplomate

MSK Radiologist

Ultrasound of the Anterior Hip

Neurology

Skill Progression

Obtains images of anterior tibiotalar joint and identifies effusion

Identifies tibialis posterior tenosynovitis and ATFL tear

Identifies deep peroneal neuroma, or Schwanoma of plantar nerve or subtalar effusion.

Orthopedic Surgery

Physiatry

Rheumatology


Radiology

NMSKUS Diplomate

MSK Radiologist

Ultrasound of the Ankle

Skill Progression

The key differentiating factor between the NMSKUS AFC diplomate and the MSK fellowship trained radiologist is the additional skills that the radiologist has in diagnosis and interpretation using multiple imaging modalities such as MRI, CT, and nuclear medicine.

The advantage the NMSKUS Diplomate is afforded, is being able to correlate the symptoms, physical findings of the pre scanning examination and then tailor the ultrasound examination to the most likely region of interest and pathology. It is often the case that an ultrasound request sent to an imaging department fails to identify the correct source of the symptoms despite imaging the correct body structure.

i.e. Suspected carpal tunnel syndrome may result in focal swelling of the median nerve at the carpal tunnel inlet, but associated symptoms and physical findings, would direct the sonographer to search for inflammatory changes in the wrist joint and tendons.

i.e. A requested ultrasound of an ankle, might fail to identify characteristic and diagnostic features of Gout in the forefoot, that the clinician sonographer would search for in light of a history of recurrent attacks of monoarthritis.

For additional case examples please refer to Appendix 2

Common pathologies may require expert skills

It is recognized within the family medicine and the MSK medicine community that not all shoulder injections provide the relief that is required for daily function. Shoulder pain is very common and some shoulder injections are felt to be easy to perform. However, a common scenario is where a family physician or orthopedic surgeon performs a subdeltoid bursa injection by palpation and anatomic guidance and has the patient referred to physical therapy for treatment of a potential rotator cuff tendinopathy. If the patient does not respond positively the question remains whether or not the rotator cuff is causing the symptoms. Depending on the algorithm that is followed, often an ultrasound or MRI are ordered. The wait time for this can be lengthy depending on the province. The imaging that is performed describes the structures but does not describe the etiology of the pain that the patient is experiencing. For this, a diagnostic injection of either the glenohumeral joint, acromioclavicular joint, biceps tendon sheath or subdeltoid bursa is required. The availability of these diagnostic injections are not universal, and the procedural wait time varies widely. Having an MSK or rheumatology ultrasound imaging specialist available in the community can decrease the need for additional imaging, and interventional referrals. In fact, referral directly from a family doctor can reduce the diagnostic and treatment times for patients by many months. We see this daily in our clinical practice.

World Leaders in Physician Ultrasound Education and Training:

We thank you and all the members of the Committee on Specialties (COS) who participated in the review of our submission. We look forward to meeting you in November and will answer any additional questions or comments regarding this application at that time. If individual members of the COS have specific questions or comments before the November meeting we would be happy to correspond directly by telephone, videoconference or email.

The framework of this AFC, if accepted, will be a great advancement for the application of neuromusculoskeletal ultrasound in the clinical setting.

The Royal College of Physicians and Surgeons of Canada will be recognized as innovators in the education and certification of physician sonographers.

Appendix 1:

Letters of Support and Sponsorship.

Specialty committee letters of support:

Diagnostic radiology

Neurology

Orthopedic surgery

Physical medicine and rehabilitation

Rheumatology

Pediatric rheumatology

Sport and exercise medicine

Intention to initiate training program(s):

McMaster Department of Rheumatology

University of Toronto Department of Rheumatology

Letters of support from primary national associations:

Canadian Neurological Society (CNS)

Canadian Association of Physical Medicine and Rehabilitation (CAPMR)- pending

Canadian Rheumatology Association (CRA)

Physician Representatives of this NMSKUS application:

Neuromuscular Neurology - Dr. Ari Breiner

Physical Medicine and Rehabilitation (MSK and Neuromuscular medicine)– Dr. Peter Inkpen

Adult Rheumatology – Dr. Abraham Chaiton

Pediatric Rheumatology – Dr. Johannes Roth

Appendix 2:

Additional Case examples:

An MSK ultrasound specialist receives a phone call from a community radiologist to ask if s/he would complete an injection of the iliopsoas bursa. The patient in questioned was referred from an orthopedic surgeon to the diagnostic imaging department of the local hospital. The Diplomate was able to evaluate the patient, ultrasound the anterior hip to show that there was no evidence of bursitis, and then perform a confirmatory diagnostic block of the bursal space. This illustrates the collaboration between community radiology, and an MSK ultrasound specialist.

A neuromuscular ultrasound specialist receives a referral from a plastic surgeon to follow a patient who had recently had a radial nerve to axillary nerve transfer. The patient was having prolonged recovery without improvement in shoulder abduction and there were two questions being asked. The first was “is the nerve transfer intact” requiring ultrasound visualization and nerve tracking, and the second was “is there any reinnervation to the deltoid”. In some instances, ultrasound visualization of the muscle during needle EMG helps to decrease the false negative EMG examinations in complex patients.

A Rheumatology Ultrasound Diplomat receives a referral from a community rheumatologist for diagnostic clarification of the examination of a hand. The patient in question also has fibromyalgia, pseudogout, primary generalized osteoarthritis, and a recent exacerbation of symmetric polyarthralgias with increased CRP and negative rheumatoid factor. The ultrasound specialist is able to clearly answer the question by detecting synovial proliferation in B-mode and synovitis with power Doppler. This abates the need for an MRI of the hand, and decreases the time between diagnosis and treatment for the patient which is exceptionally important for managing inflammatory arthropathies.

Canadian Neurological Society 143N – 8500 Macleod Trail SE, Calgary, Alberta T2H 2N1 Canada

Dr. Jason Frank, Committee on Specialties Royal College of Physicians & Surgeons of Canada 774 Echo Drive Ottawa, Ontario K1S 3W9 August 14, 2017 Re: Proposed Area of Focused Competence Diploma in Neuromusculoskeletal Ultrasound Dear Dr. Frank: The Canadian Neurology Society (CNS) was recently contacted by Dr. Abraham Chaiton, and asked to support the proposed Area of Focused Competence Diploma in Neuromusculoskeletal Ultrasound. The CNS has had the opportunity to confer as a Board, and seek feedback from several neuromuscular colleagues across the country. The overall consensus from the CNS is that ultrasound is a useful diagnostic tool, which has the potential to enhance the evaluation traditionally offered by neurophysiology laboratories. The CNS is prepared to offer endorsement for this proposal. We have identified several recommendations from our advisors, which we believe will strengthen this proposal, particularly with respect to its relevance for neurologists. We hope that you will take these recommendations under strong consideration, as this process moves forward. Recommendations:

• The “neuromuscular stream” referenced in this document should be restricted to specialists who have passed their Canadian Society of Clinical Neurophysiology (CSCN) examinations in electromyography, and do neuromuscular work. Furthermore, the CSCN should be involved in the revision of the proposed Area of Focused Competence and should specifically contribute towards the competency requirements for the “neuromuscular stream”.

• The planning group does not appear to include any neuromuscular neurologists, and consideration should be given to including colleagues from this sub-specialty.

Sincerely yours,

Fiona Costello President, Canadian Neurological Society Associate Professor, Departments of Clinical Neurosciences and Surgery University of Calgary

Jodie Burton Vice President, Canadian Neurological Society Assistant Professor, Departments of Clinical Neurosciences and Community Health Sciences University of Calgary

&. H~alt_h Sciences Centre W wmmpeg

July 11 , 2017

Committee on Specialties Royal College of Physicians and Surgeons of Canada 774 Echo Drive Ottawa, ON KIS 3W9

Dear Committee:

Arthritis Centre

David Robinson, MD, MSc, FRCPC * RR 149-800 Sherbrook Street

Winnipeg, MB R3A I M4

Appointments: (204) 787-2392 Office: (204) 787-2208

Fax: (204) 787-4594

• Denotes Medical Corporation

I am writing this letter in my capacity as Chair of the Specialty Committee for Rheumatology with regard to the AFC application for point of care musculoskeletal ultrasound. I am aware that in this application process there have been questions raised as to the differentiation of the advanced training in the AFC application versus the competencies currently required in our training programs.

At this point, musculoskeletal ultrasound is not part of the objectives of training for adult or pediatric rheumatology. This is largely due to a lack of skilled faculty, time, physical resources and adequate billing structures. Musculoskeletal point of care ultrasound is a staple of training in Europe and is becoming so in the United States. In the near future (five to seven years) we anticipate that POCUS will become a core competency but in a somewhat limited fashion. In contrast, a few individuals are anticipated to pursue this to the expert level hopefully through the AFC. These individuals would become trainers, set standards and curriculum and promote research.

The Specialty Committee has had extensive discussions around this AFC as it pertains to Rheumatology. We feel it is analogous to echocardiography in the field of cardiology and are supportive ofthis application.

Sincerely,

David Robinson, MD MSc FRCPC Associate Professor of Medicine Head, Section of Rheumatology Director, Arthritis Centre University of Manitoba DR/ls

Adult Office (204) 787-1851 Appointments (204) 787-2392 Fax (204) 787-4594 I Pediatric Office (204) 787-2020 Fax (204) 787-2475

RR149, 800 Sherbrook Street, Winnipeg, Manitoba Canada R3A 1 M4

An operating WI• Winnipeg R<gional division of the Health Authonty

Offi~ regional dela sante de Winnipeg

www.hsc.mb.ca

Affiliated " UNIVERSITY With t he w Q!' MANIT O BA

J. K. Yao, MD, FRCPC G.F Strong Rehab Centre Head, UBC Division of 4255 Laurel Street Physical Medicine & Rehabilitation Vancouver, BC, V5Z 2G9

Faculty of Medicine The University of British Columbia

July 4, 2017 Dr. Jason Frank Director, Specialty Education, Strategy and Standards Office of Specialty Education The Royal College of Physicians and Surgeons of Canada 774 Echo Drive Ottawa, ON K1S 5N8 Dear Dr. Frank, RE: Pending application: Area of Focused Competence - Diploma of Neuromusculoskeletal Ultrasound

(NMSKUS) I have reviewed the above-mentioned AFC application that is pending before the office of education with the Specialty Committee in Physical Medicine and Rehabilitation. Currently, our committee has not yet incorporated ultrasound as an objective of training (OTR), but we plan on introducing basic ultrasound competencies into our new documents under Competency by Design this November. Our specialty anticipates the incorporation of ultrasound from a therapeutic role in terms of procedural guidance. With greater training and proficiency, as required by this AFC, diagnostic use of ultrasound will become another tool for interested physiatrists. At present, program directors are increasingly looking to providing ultrasound exposure to trainees as part of the PMR training experience. The Specialty Committee in PMR consistently supports the development of standards of training in NMSK ultrasound use so that we can work towards an agreed upon expectation in basic ultrasound competency. We believe that an AFC certification in Neuromusculoskeletal Ultrasound will be an excellent complement to standard postgraduate training even after ultrasound has been incorporated into the objectives of training of our specialty. This certification will assist in standardizing the expectations for competency for those who wish to pursue NMSK ultrasound more fully and promote the incorporation of ultrasound into clinical practice. We fully endorse the above-mentioned application and anticipate that members of our respected specialty will participate in the diploma program as committee members and as diplomats in the streams of neuromuscular (NMUS) and musculoskeletal ultrasound (MSKUS). Sincerely,

Jennifer K. Yao, MD, FRCPC Clinical Associate Professor and Head UBC Division of Physical Medicine and Rehabilitation Chair, Specialty Committee in Physical Medicine and Rehabilitation

From: [email protected]: Kraemer, William Joseph; Royal College Committee on Specialties; Frank, Jason; Roth, Johannes; Inkpen, Peter

ClintonSubject: NMSKUS AFC proposalDate: July-18-17 1:48:59 PM

Dear Dr William KraemerThank you for your recent response to my request that Orthopedic Surgery considerco-sponsoring an application before the Committee on Specialties, for an Area ofFocused Competency Diploma (AFC)in NeuroMusculoskeletal Ultrasound (NMSKUS).At the present time , your Specialty has elected not to pursue this avenue ofsupplementary training.While this AFC is currently sponsored by Rheumatology and Physical Medicine &Rehabilitation,we will ensure that this AFC allow multi specialty entry points, from a number ofrelated disciplines,where a member is interested in acquiring advanced skills in the application ofNMSKUS at the bedside.We propose that Orthopedic Surgery would serve as an entry route for this AFCshould there be an interest from a trainee or graduate, in acquiring advancedcompetencies in NMSKUS,after basic Orthopedic residency training.We will inform you of our progress before the COS this Fall.

Sincerely,Abraham Chaiton MD,MSc,FRCPCAssistant Professor , University of Toronto







From: [email protected]: Zetaruk, Merrilee Nicolette; Royal College Committee on Specialties; Frank, Jason; Roth, Johannes; Inkpen, Peter

ClintonSubject: Royal College AFC in NMSKUSDate: July-18-17 2:47:12 PM

Dear Dr. Merrilee ZetarukThank you for your recent response to my request that Sports & Exercise Medicineconsider co-sponsoring an application before the Committee on Specialties, for anArea of Focused Competency Diploma (AFC),in NeuroMusculoskeletal Ultrasound (NMSKUS).At the present time , your Specialty is still in discussion regarding this avenue ofsupplementary training, while fully supporting Sport & Exercise Medicine as an entryto this AFC in NMSKUS.Although this AFC is currently sponsored by Rheumatology and Physical Medicine &Rehabilitation,we will ensure that this AFC allow multi specialty entry points, from a number ofrelated disciplines,where a member is interested in acquiring advanced skills in the application ofNMSKUS at the bedside.We propose that Sports & Exercise Medicine would serve as an entry route for thisAFC should there be an interest from a trainee or graduate, in acquiring advancedcompetencies in NMSKUS, after basic SEM residency training.We will inform you of our progress before the COS this Fall.

Sincerely,Abraham Chaiton MD,MSc,FRCPCAssistant Professor , University of Toronto







From: [email protected]: Royal College Committee on SpecialtiesSubject: Fwd: Royal College area of focused competency (AFC) in NMSKUS (neuromusculoskeletal ultrasound) at point of

care.Date: June-26-17 10:44:11 PM

Please add this response to our file for an AFC Diploma.

Abraham Chaiton

---- Original Message ----From: william kraemer <[email protected]>To: 'A' <[email protected]>Sent: Fri, Jun 23, 2017 9:13 pmSubject: FW: Royal College area of focused competency (AFC) in NMSKUS (neuromusculoskeletalultrasound) at point of care.

Dear Dr. Chaiton:

The Specialty Committee in Orthopaedic Surgery discussed the AFC diploma inMSK U/S at our meeting on Friday June 16.

A number of Orthopaedic Surgeons across the country are currently using U/Sas a diagnostic and therapeutic tool.

After some discussion, and review fo our OTRs, the committee members feltthat this is already within the scope of practice of Orthopaedic Surgery andalready covered in our OTRs, and therefore it would be redundant to obtainan AFC diploma.

Regards,

William Kraemer, MDChair, Orthopaedic Specialty Committee

-----Original Message-----From: A [mailto:[email protected]]Sent: May 30, 2017 9:09 PMTo: [email protected]; Johannes Roth <[email protected]>; Peter Inkpen<[email protected]>Subject: Royal College area of focused competency (AFC) in NMSKUS(neuromusculoskeletal ultrasound) at point of care.

Dear Dr KraemerI have been asked by the Committee on Specialties to contact you asSpecialty Chair of Orthopedics. I am head of a committee that has drafted and submitted a request forrecognition of a new AFC Diploma in NMSKUS. Currently our applicationlists 3 streams each with its own CTR or competency training requirements -adult Rheumatology, Pediatrics Rheumatology , and Physiatry or PhysicalMedicine & Rehabilitation. Neurology may consider joining at a later date. If Orthopaedics is considering US as an added expertise among some of your


mailto:[email protected]?




practitioners , the Committee on Specialties would like your opinion as toyour interest now or in the future of joining this AFC group within anexisting CTR or designing your own. I can forward to you our current CTRproposal. Please call me to discuss as we must draft a response to the COS by the endof the summer. Cell # 416-705-0696. Abraham Chaiton MD,FRCPCAssistant Professor RheumatologyUniversity of Toronto

Abe

July 10, 2017 Abraham Chaiton MD,FRCPC Assistant Professor University of Toronto. Sunnybrook & Humber River Hospitals Dear Dr. Chaiton, I am writing to you as Chair of the AFC Committee in Sport ands Exercise Medicine (SEM) regarding your proposal for an AFC in Neuromusculoskeletal Ultrasound. As we discussed, I am personally very supportive of including SEM as an entry point to this potential new AFC. Unfortunately, our committee has not met since we first corresponded about this, although I have had feedback from several committee members who are supportive. Until I have heard from the remaining members, I am only able to say tentatively that we would support SEM as an entry to the AFC in Neuromusculoskeletal Ultrasound. We will be discussing this further at our committee level and I will confirm our involvement shortly thereafter. Sincerely, Merrilee Zetaruk, MD, FRCPC Chair, AFC Committee in Sport and Exercise Medicine

August 2017 VERSION 1.3

DEFINITION

Neuromusculoskeletal Ultrasound is that area of enhanced competence within medicine concerned with the study of diagnostic ultrasound within the scope of practice of clients in neuromuscular, musculoskeletal and rheumatologic medicine.

ELEGIBILITY REQUIREMENTS

The Area of Focused Competence (AFC) trainee must have a medical degree. To be eligible for the Royal College certification portfolio in Neuromusculoskeletal Ultrasound, all trainees must be certified in their primary Royal College specialty or equivalent, or hold an academic certification in the following: Internal Medicine (including Adult Rheumatology), orthopedic surgery, Neurology, Neurosurgery, Pediatrics (including Pediatric Rheumatology), Physical Medicine and Rehabilitation, or Sport and Exercise Medicine.

GOALS

Upon completion of training, an AFC diplomate is expected to function as a competent specialist in Neuromusculoskeletal Ultrasound, capable of an enhanced practice in this area of focused competence, within the scope of their stream of Neuromusculoskeletal Ultrasound. The AFC trainee must acquire a working knowledge of the theoretical basis of the discipline, including its foundations in the sciences and research.

The discipline of Neuromusculoskeletal ultrasound includes:

1. Knowledge of the basic physics, safety principles, hardware and software associated with ultrasound

2. Knowledge of imaging acquisition, optimization, archiving and export a. Annotation of images b. Dynamic (video/cine-loop) and split screen (side to side) comparison and

extended field of view image acquisition c. Proficient transducer movement, scanning ergonomics and patient positioning d. Basics of B-mode optimization and Doppler image optimization

i. Gain adjustment, B-mode and Doppler frequency, pulse repetition frequency, wall filter, colour priority, focus and depth

3. Knowledge of common B-mode and Doppler imaging artifacts: a. Anisotropy b. Posterior acoustic shadowing c. Posterior acoustic enhancement d. Increased through transmission e. Reverberation

COMPETENCY TRAINING REQUIREMENTS IN NEUROMUSCULOSKELETAL ULTRASOUND

Page 2 of 32 © 2016 The Royal College of Physicians and Surgeons of Canada. All rights reserved.

f. Ring-down artifact g. Comet-tail artifact h. Mirror image i. Beam width artifact j. Side-lobe artifact

4. Ability to identify normal neuromusculoskeletal tissue imaging

characteristics on ultrasound: a. Dermis, adipose and other subcutaneous tissue b. Tendon and ligaments c. Muscle, fascia and nerve d. Vessels e. Hyaline and fibrocartilage, synovium, bone and nails

5. Ability to identify common neuromusculoskeletal imaging pathologies on

ultrasound: a. Synovitis including joint effusion and synovial hypertrophy b. Bursitis c. Ganglion cyst d. Tenosynovitis e. Paratenonitis f. Enthesopathy including enthesitis g. Tendinopathy and tendon tears h. Bony pathology (osteophytes, enthesophytes, cortical interruptions including

erosions) i. Focal nerve enlargement j. Soft tissue mineralization k. Muscle (tears, inflammation, infection) l. Skin and subcutaneous tissues (cellulitis, edema)

6. Basic knowledge and ability to characterize soft tissue lesions or masses

that warrant further imaging or referral: a. Characterization and composition b. Simple or complex c. Origin (determine the anatomic epicenter) d. Vascularization

Guidance: The purpose of this training requirement is to ensure that the applicant has a working knowledge of the fundamental pitfalls of using ultrasound exclusively for diagnosis, management, or prognostication of soft tissue mass. It is expected that the applicant has a clear working knowledge of the necessity to refer solid masses for further evaluation.

7. Performance, utility and limitations of ultrasound guided needle placement: a. Manual technique of probe and needle manipulation b. Procedural imaging acquisition and labelling

8. Education of physicians, ultrasound technologists, medical students and/or

residents learning ultrasound

9. Completion of a personal learning project



10. Conducting or contributing to a neuromusculoskeletal ultrasound research

project or related scholarly activity

11. Conducting ongoing quality improvement processes including written documentation and re-evaluation

12. Implementation of an image archiving program for all ultrasound examinations at all sites of patient care

13. Participation in a quality assurance program with follow up that includes imaging review, clinical follow up and pathology review where applicable

The neuromusculoskeletal ultrasound diplomate MUST choose at least ONE of the following streams of additional competence:

o Neuromuscular Ultrasound (NMUS)

o Musculoskeletal Ultrasound (MSKUS)

o Adult Rheumatology Ultrasound (RhMSKUS)

o Pediatric Rheumatology Ultrasound (pRhMSKUS)

ADDITIONAL GOALS: Neuromuscular Ultrasound (NMUS)

The Neuromuscular Ultrasound stream includes knowledge of and ability to demonstrate:

1. Ultrasound as a compliment to electrodiagnostic evaluation of neuromuscular patients:

a. As a tool to facilitate the evaluation of proximal neuropathies such as: i. Meralgia paresthetica ii. Suprascapular neuropathy

b. To confirm electrode and stimulator placement in technically difficult studies c. To guide needle electromyography in:

i. Anticoagulated patients ii. Muscles not routinely evaluated

d. To identify pathologic muscles for needle electromyography e. To correlate exonal loss, conduction block or focal slowing with nerve size and

continuity f. To facilitate patient education

2. Identification of these common anatomic variants:

a. Accessory hypothenar muscle b. Anconeus epitrochlearis c. Bifid median nerve

3. Identification of normal muscles including:

a. Sternocleidomastoid, trapezius, levator scapulae, rhomboid major and minor



b. Pectoralis major and minor c. Upper limb muscles including the biceps brachii, brachialis, triceps brachii,

pronator teres, flexor carpi ulnaris, flexor digitorum profundus, flexor digitorum superficialis, extensor digitorum communis

d. Muscles of the hand including the first dorsal interosseous, abductor pollicis brevis and abductor digiti minimi

e. Diaphragm f. Pelvic girdle muscles including the gluteus maximus, medius and minimus and

piriformis g. Muscles of the thigh including tensor fascia lata, sartorius, rectus femoris,

vastus medialis, vastus lateralis, biceps femoris, semitendinosus and semimembranosus

h. Muscles of the leg including gastrocnemius, soleus, tibialis posterior, flexor halluces longus, tibialis anterior, extensor digitorum longus, peroneus longus and peroneus brevis

i. Muscles of the foot including abductor hallucis, extensor digitorum brevis and abductor digiti minimi

4. Describing the ultrasound imaging characteristics of abnormal atraumatic muscle pathology:

a. Size i. Atrophy ii. Swelling

b. Echogenicity c. Vascularity d. Calcifications e. Fat infiltration

5. Identification of fasciculations

6. Identifying the normal anatomy and fascicular echostructure of the

following nerves: a. Brachial plexus b. Musculocutaneous nerve c. Radial nerve d. Ulnar nerve e. Median nerve f. Saphenous sensory nerve g. Sural nerve h. Lateral femoral cutaneous nerve i. Sciatic nerve at the posterior knee j. Peroneal nerve at the fibular head k. Tibial nerve at the medial ankle

7. Demonstrating the normal and abnormal nerve cross sectional area (CSA) in

common focal peripheral neuropathies: a. Median at the wrist b. Ulnar at the elbow c. Peroneal nerve at the fibular head



d. Tibial nerve at the medial ankle e. Sciatic nerve in the thigh

8. Describing the ultrasound characteristics of partial and complete

(neurotmesis) nerve lesions

9. Identification and description of peripheral nerve sheath tumors: a. Contour, shape, echogenicity and vascularity

10. Describing ultrasound characteristics of acquired and hereditary

demyelinating polyneuropathies 11. Describe the ultrasound characteristics of axonal polyneuropathies

12. The performance of stress (dynamic) maneuvers:

a. Subluxation of the ulnar nerve at the elbow

ADDITIONAL GOALS: Musculoskeletal Ultrasound (MSKUS)

The Musculoskeletal Ultrasound stream includes the knowledge of and ability to demonstrate:

1. Common anatomic variants including: a. Accessory muscles and tendons of the wrist and fingers b. Bifid median nerve c. Anconeus epitrochlearis d. Subluxation of the ulnar nerve at the elbow e. Accessory head of the proximal long head biceps tendon f. Accessory ossicles of the peroneus longus g. Accessory navicular bone h. Accessory muscles and tendons of the ankle

2. Effusions in large synovial joints:

a. Glenohumeral b. Elbow c. Wrist d. Hip e. Knee f. Ankle

3. Bursal fluid:

a. Subdeltoid bursa b. Olecranon bursa c. Greater trochanteric bursa d. Pre/infrapatellar bursa e. Retrocalcaneal bursa

4. Common nerve lesions:

a. Median nerve enlargement at the wrist b. Morton’s neuroma



c. Peripheral nerve sheath tumor

5. Normal tendons and abnormal tendon pathologies: a. Elbow

i. Lateral (tennis elbow) 1. Extensor digitorum 2. Extenstor carpi radialis brevis 3. Extensor digiti minimi 4. Extensor carpi ulnaris

ii. Medial (golfer’s elbow) 1. Pronator teres 2. Palmaris longus 3. Flexor carpi ulnaris 4. Flexor carpi radialis

iii. Anterior 1. Distal biceps tendon insertion

iv. Posterior 1. Distal triceps insertion

b. Wrist and hand i. Dorsal

1. The six extensor compartments and their contents ii. Volar

1. Flexor digitorum superficialis 2. Flexor digitorum profundus 3. Flexor pollicis longus 4. Flexor carpi ulnaris 5. Flexor carpi radialis 6. Palmaris longus

c. Hip i. Lateral

1. Gluteus minimus 2. Gluteus medius 3. Gluteus maximus 4. Tensor fascia latae 5. Iliotibial band

ii. Medial 1. Adductor longus, brevis and magnus origin 2. Pubic symphysis

iii. Anterior 1. Sartorius and tensor fascia latae tendons originating from ASIS 2. Rectus femoris originating from AIIS

iv. Posterior 1. Conjoined semitendinosus, semimembranosus, and biceps

femoris tendon originating from the ischial tuberosity d. Knee

i. Lateral 1. Biceps femoris 2. Iliotibial band 3. Popliteus



ii. Medial 1. Semitendinosus 2. Gracilis 3. Sartorius

iii. Anterior 1. Quadriceps tendon 2. Patellar tendon

iv. Posterior 1. Medial gastrocnemius 2. Lateral gastrocnemius 3. Semimembranosus 4. Baker’s Cyst (see synovial and soft tissue masses)

e. Ankle and foot i. Lateral

1. Peroneus longus 2. Peroneus brevis

ii. Medial 1. Tibialis posterior 2. Flexor digitorum longus 3. Flexor hallucis longus

iii. Anterior 1. Tibialis anterior 2. Extensor digitorum longus 3. Extensor halluces longus

iv. Posterior 1. Achilles 2. Plantaris

6. Normal anatomy of ligaments and pulleys and their associated pathologies:

a. Elbow i. Medial collateral ligaments ii. Radial collateral ligaments iii. Annular ligament

b. Wrist and hand i. Finger pulleys ii. Dorsal

1. Scapholunate ligament iii. Medial iv. Triangular fibrocartilage complex

c. Knee i. Medial collateral ligament ii. Lateral collateral ligament iii. Distal iliotibial band insertion

d. Ankle and foot i. Anterolateral

1. Anterior talofibular 2. Calcaneofibular

ii. Anterior 1. Anterior tibiofibular



iii. Posteromedial 1. Deltoid

iv. Plantar 1. Plantar fascia

7. Muscle Disorders:

a. Intramuscular lesion i. Simple cyst ii. Complex fluid collection iii. Solid mass requiring further imaging iv. Complete and partial tears v. Calcification

b. Atrophy c. Fat infiltration

8. The standard scanning protocol and pathological lesion identification of

common shoulder pathologies: a. Specific tendon lesions of subscapularis, biceps, supraspinatus, infraspinatus,

and teres minor tendons i. Tendinosis ii. Calcifications iii. Partial thickness tears iv. Bursal fluid v. Neovascularization

b. Massive rotator cuff tear c. Joints

i. Acromioclavicular ii. Glenohumeral

d. Notch cysts i. Spinoglenoid ii. Supraspinous

e. Rotator cuff muscle pathology i. Atrophy ii. Fatty infiltration iii. Fasciculations

Guidance: The evaluation of the shoulder is common, but the spectrum of pathologies is complex. It is the expectation that the candidate be proficient in identification of lesions that may require urgent surgical evaluation or warrant further study with MRI +/- intra-articular contrast. It is the expectation that the candidate clearly identifies full thickness tears and characterizes the extent of the tear. Though very skilled physician sonographers can identify partial width and partial thickness tears, further expertise may be gained by the candidate through ongoing postgraduate education.

9. Other synovial and soft tissue mass lesions: a. Baker’s cyst b. Paralabral cyst c. Meniscal cyst



10. Performance of stress (dynamic) maneuvers: a. Subacromial impingement b. Peroneal tendon subluxation c. Anterior talofibular ligament (ATFL) d. Calcaneofibular ligament (CFL) e. Medial collateral ligament of the knee

11. Detecting deep vein thrombosis in the lower limb

12. Knowledge of ultrasound guided interventions including:

a. Indications, precautions, contraindications and side effects of common interventional therapies including:

i. Injectates: 1. Corticosteroids 2. Viscosupplementation 3. Platelet Rich Plasma

ii. Aspiration: 1. Joint effusion 2. Simple cyst 3. Tendon fenestration and calcific lavage

13. Knowledge and performance of ultrasound guided interventions including:

a. Obtaining patient consent b. A working knowledge of the indications and contraindications for ultrasound

guidance c. The ability to identify normal and abnormal tissues encountered during

ultrasound guided procedures d. The recognition of relevant anatomic variations and unexpected findings

i. Appropriate transducer selection and image optimization ii. Recognition of relevant anatomic variations and unexpected findings

1. Interpretation and correlation of ultrasound images with available complementary diagnostic imaging and clinical information

iii. Ergonomic considerations for procedural planning iv. Appropriate selection of equipment:

1. Needle or device selection 2. Injectate selection

e. The ability to perform ultrasound guided needle of device tracking using both in-plane and out-of-plane approaches

i. Describes the limitations of each technique and methods to optimize needle visualization

f. Recognition and management of common artifacts relevant to interventional procedures

g. A working knowledge of the recognition and management of procedural complications:

i. Vagal response ii. Local anesthetic toxicity iii. Injection site swelling or hematoma iv. Post procedural pain



v. Post procedural infection vi. Rupture of tendon, ligament and/or fascia

h. Methods of documentation and reporting of ultrasound-guided procedures i. Labelling and recording of images and/or videos

i. Diagnostic and therapeutic injections and/or aspiration of the following structures:

i. Glenohumeral joint ii. Acromioclavicular joint iii. Elbow iv. Wrist v. Carpometacarpal (CMC) vi. Hip vii. Knee viii. Tibiotalar ix. Subtalar x. First metatarsalphalangeal joint

j. Diagnostic and therapeutic peripheral nerve injections i. Median nerve at the wrist ii. Regional nerve blocks of the arm, forearm, popliteal fossa and ankle

k. Therapeutic tendon and/or tendon sheath injections i. De Quervain’s tenosynovitis (APL, EPB) ii. Trigger finger (A1 pulley) iii. Tennis elbow (EDC/ECRB) iv. Rotator cuff interval v. Gluteus medius and minimus vi. Achilles tendon

ADDITIONAL GOALS: Adult Rheumatology Ultrasound (RhMSKUS)

The Adult Rheumatology Ultrasound stream includes knowledge of and ability to demonstrate:

1. Common anatomic variants including: a. Sesamoids in the hand and feet b. Accessory muscles/tendons of the wrist and fingers c. Bifid median nerve d. Anconeus epitrochlearis e. Subluxation of the ulnar nerve at the elbow f. Accessory head of the proximal long head biceps tendon g. Accessory ossicles of the peroneus longus h. Accessory navicular bone i. Accessory muscles and tendons of the ankle

2. Optimal positioning of joints for the static and dynamic assessment of

effusions, tendons including the enthesis and ligaments

3. Effusions in synovial joints: a. Glenohumeral b. Acromioclavicular



c. Elbow recesses and joint space d. Wrist e. Metacarpophalangeal, proximal interphalangeal and distal interphalangeal f. Hip g. Knee h. Ankle and midfoot joints i. Metatarsalphalangeal, proximal interphalangeal, distal interphalangeal

4. Periarticular cystic lesions:

a. Ganglion b. Synovial (eg. Baker’s cyst) c. Other (eg. Meniscal cyst)

5. Bursal thickening and free fluid in the bursae about the:

a. Shoulder b. Elbow c. Hip d. Knee e. Ankle

6. Normal tendons and abnormal tendon pathologies in the:

a. Elbow i. Lateral (tennis elbow)

1. Extensor digitorum 2. Extenstor carpi radialis brevis 3. Extensor digiti minimi 4. Extensor carpi ulnaris







c. Hip i. Lateral

1. Gluteus minimus



2. Gluteus medius 3. Gluteus maximus 4. Tensor fascia latae 5. Iliotibial band














7. Standard scanning protocol and pathological lesions of common shoulder

pathologies:



a. Specific tendon lesions of subscapularis, biceps, supraspinatus, infraspinatus, and teres minor tendons

i. Tendinosis ii. Calcifications iii. Partial thickness tears iv. Bursal fluid v. Neovascularization



d. Notch cysts i. Sphinoglenoid ii. Supraspinous


Guidance: The evaluation of the shoulder is common but the spectrum of pathologies is complex. It is the expectation that the candidate be proficient in identification of lesions that may require urgent surgical evaluation or warrant further study with MRI +/- intra-articular contrast. It is the expectation that the candidate clearly identifies full thickness tears and characterize the extent of the tear. Though very skilled physician sonographers can identify partial width and partial thickness tears, further expertise may be gained by the candidate through ongoing postgraduate education.

8. Characteristic features of arthropathies: a. Inflammatory arthropathies (RA, SpA, PsA):

i. Synovial hypertrophy 1. Abnormal hypoechoic intra-articular tissue, poorly displaceable,

with or without hypervascularity ii. Tenosynovitis

1. Abnormal hypoechoic or anechoic changes around tendons, with or without hypervascularity

iii. Paratenonitis 1. Abnormal hypoechoic or anechoic halo around tendon that lacks

a tendon sheath with or without hypervascularity iv. Effusions

1. Abnormal intra-articular anechoic and displaceable material without Doppler signal

v. Bone profile irregularities vi. Extra-articular features (subcutaneous edema, fasciitis) vii. Erosions

1. A discontinuity of the smooth echogenic bony surface profile, seen in 2 planes, with an irregular floor



viii. Enthesopathy (Describing the pathologic insertion of a tendon, ligament or joint capsule into bone)

1. Pathology is defined by: a. Hypoechogenicity b. Increased thickness c. Calcifications d. Erosions e. Cortical irregularity f. Doppler signals

b. Crystalline arthropathies: i. Gout

1. Joints and bursae a. Heterogenous hyperechoic aggregates (HAG’s)

2. Cartilage a. Hyperechoic, regular or irregular, continuous or

intermittent, enhancements of the superficial chondrosynovial margin independent of angle of insonation (double contour sign)

3. Tendons a. Hyperechoic linear bands in tendons (HLB’s)

4. Soft tissue (extra-articular, intra-articular or intratendinous) a. A circumscribed inhomogenous, hyperechoic or

hypoechoic aggregation (tophus), with or without acoustic shadowing, and may include and anechoic halo

5. Erosions a. An intra and/or extra-articular discontinuity of the bone

surface visible in 2 planes

ii. Calcium pyrophosphate deposition disease (CPPD) 1. Hyaline cartilage

a. Hyperechoic deposits within the substance of hyaline cartilage without acoustic shadowing

2. Fibrocartilage a. Amorphous or rounded hyperechoic deposits in

fibrocartilage as seen in the TFCC or knee meniscus 3. Synovial fluid

a. ‘Floaters’ or aggregates of high echogenicity, even at low gain, that are rounded or irregular, producing a ‘snow storm’ like image due to crystals

iii. Septic arthritis 1. The diagnosis of septic arthritis is based on clinical assessment

and should prompt arthrocentesis. Ultrasound has limited discriminatory ability as imaging can mimic inflammatory and crystal induced joint inflammation even when polyarticular, or may complicate a known underlying joint disease

iv. Osteoarthritis (OA) 1. Conventional radiography is the current standard for OA

imaging. Knowledge and ability to demonstrate added value of ultrasound to identify osteoarthritic joints:



a. Focal degeneration of hyaline cartilage b. Synovial hypertrophy and vascularity c. Effusions d. Erosions e. Osteophytes f. Bursitis g. Periarticular cyst formation

v. Polymyalgia Rheumatica (PMR) 1. Ultrasound features may include:

a. Bilateral subacromial bursitis b. Long head of biceps tenosynovitis c. Glenohumeral synovitis d. Trochanteric bursitis e. Hip joint synovitis

vi. Giant Cell Arthritis (GCA) 1. Knowledge and ability to demonstrate the vascular settings

required to study the temporal vessels (common, frontal and parietal) and axillary artery

2. Able to demonstrate an ability to image the temporal and axillary vessels and identify and measure the intimal/media complex, and if present, to identify the segmental periluminal hypoechoic thickening, halo or segmental luminal occlusion

vii. Salivary Glands 1. Demonstrate an ability to scan normal parotid and

submandibular salivary glands and to recognize normal echogenicity from hypoechogenicity, heterogeneity, and cystic changes seen in Sjogren’s syndrome, that can occur in at least 2 or more salivary glands

viii. Colour and Power Doppler in low flow settings for diagnosis and monitoring of inflammatory disease

1. Knowledge in the use of colour and power Doppler and able to demonstrate use for diagnosis and monitoring of synovitis, tenosynovitis, tendinitis and enthesitis

2. Knowledge of a semi quantitative method of grading the Doppler signal

3. Knowledge of Doppler artifacts in low flow settings 4. Random noise, motion, aliasing, mirror, blooming,

reverberation, focus and probe pressure effects 5. Knowledge of common pitfalls in the evaluation of the Doppler

signal in MSK disorders 6. Positioning, pressure, ambient temperature, diurnal variation,

treatment effects and machine settings (frequency, colour box, scale, contour priority, filters and gain)

9. Normal anatomy of ligaments and pulleys and their common associated pathologies:

a. Elbow i. Medial collateral ligaments ii. Radial collateral ligaments



iii. Annular ligament b. Wrist and hand

i. Finger pulleys ii. Scapholunate ligament iii. Triangular fibrocartilage complex


d. Ankle i. Anterolateral





10. Normal anatomy and ultrasound findings of common focal peripheral

neuropathies: i. Median nerve at the wrist ii. Ulnar nerve at the elbow iii. Tibial nerve at medial malleolus iv. Peroneal nerve at the fibular head v. Lateral femoral cutaneous nerve of the thigh

11. Ultrasound guided interventions including:


i. Injectates 1. Corticosteroids 2. Viscosupplementation 3. Platelet Rich Plasma

ii. Aspiration 1. Joint effusion 2. Simple cyst 3. Tendon fenestration and calcific lavage











e. The ability to perform ultrasound guided needle or device tracking using both in-plane and out-of-plane approaches



g. A working knowledge of the recognition and management of procedural complications

i. Vagal response ii. Local anesthetic toxicity iii. Injection site swelling or hematoma iv. Post procedural pain v. Post procedural infection vi. Rupture of tendon, ligament and/or fascia



i. Small and large joints: 1. Glenohumeral 2. Acromioclavicular 3. Sternoclavicular 4. Elbow 5. Radiocarpal 6. Carpometacarpal 7. Proximal interphalangeal 8. Distal interphalangeal 9. Hip 10. Knee 11. Tibiotalar 12. Subtalar 13. Mid foot joints 14. Metatarsophalangeal 15. Intermetatarsal cyst

ii. Peritendinous and intrabursal injections: 1. Hand 2. Wrist 3. Elbow 4. Shoulder 5. Hip (trochanteric and iliopsoas) 6. Ankle 7. Forefoot (intermetatarsal)



iii. Perineural injections 1. Median at the wrist 2. Morton’s neuroma

13. Identification of normal muscle sonographic appearance and imaging

characteristics of: a. Denervated muscle b. Inflammatory myopathies

ADDITIONAL GOALS: Pediatric Rheumatology Ultrasound (pRhMSKUS)

The Pediatric Rheumatology Ultrasound stream includes knowledge of and ability to demonstrate:

1. Sonographic features of joints in healthy children including: a. Hyaline cartilage b. Ossified portion of articular bone including epiphyseal and apophyseal

secondary ossification centers c. Normal joint capsule d. Normal intra- and peri-articular sonographic vascular development e. Normal intraarticular fat pads and fibrocartilage

2. Normal cartilage, ligaments, capsule, ossification centers and joint fluid

seen in the following joints through the pediatric age range: a. Shoulder b. Elbow c. Wrist d. Finger joints (MCP, PIP, DIP) e. Hip f. Knee g. Ankle and midfoot joints h. Toe joints (MTP, PIP, IP)

3. Normal entheseal development in children including ossification and

vascularization

4. Normal tendons and entheses in the: a. Elbow

i. Lateral 1. Extensor digitorum 2. Extenstor carpi radialis brevis 3. Extensor digiti minimi 4. Extensor carpi ulnaris

ii. Medial 1. Pronator teres 2. Palmaris longus 3. Flexor carpi ulnaris 4. Flexor carpi radialis




iv. Posterior 1. Distal triceps tendon insertion




c. Hip i. Lateral







ii. Medial 1. Semimembranosus 2. Semitendinosus 3. Gracilis 4. Sartorius


iv. Posterior 1. Medial gastrocnemius 2. Lateral gastrocnemius 3. Baker’s Cyst (see synovial and soft tissue masses)






iii. Anterior iv. Posterior

1. Achilles 2. Plantaris




1. Scapholunate ligament 2. Lunatotriquetral ligament

iii. Medial 1. Triangular fibrocartilage complex

c. Knee i. Medial collateral ligaments ii. Lateral collateral ligament iii. Distal iliotibial band insertion




iii. Posteromedial 1. Deltoid ligament


6. Common anatomic variants including:

a. Sesamoid bones in the hand and feet b. Accessory muscles/tendons of the wrist and fingers c. Bifid median nerve d. Anconeus epitrochlearis e. Subluxation of the ulnar nerve at the elbow f. Accessory head of the proximal long head biceps tendon g. Accessory ossicles of the peroneus longus h. Accessory navicular bone i. Accessory muscles/tendons of the ankle and foot



7. Optimal positioning of joints for assessment of effusions, tendons, entheses and ligaments

8. Effusions in synovial joints: a. Glenohumeral b. Acromioclavicular c. Elbow recesses and joint space d. Wrist e. Metacarpophalangeal, proximal interphalangeal and distal interphalangeal f. Hip g. Knee h. Ankle and midfoot joints i. Metatarsalphalangeal, proximal interphalangeal, distal interphalangeal

9. Bursal thickening and free fluid in the bursae of the:


10. Synovial cysts, ganglion cysts and other cystic lesions

11. Findings in inflammatory arthropathies including:

a. Synovial hypertrophy i. Abnormal hypoechoic intra-articular tissue, poorly displaceable, with or

without hypervascularity b. Tenosynovitis

i. Abnormal hypoechoic or anechoic changes around tendons, with or without hypervascularity

c. Paratenonitis i. Abnormal hypoechoic or anechoic halo around tendon that lacks a

tendon sheath with or without hypervascularity d. Effusions

i. Abnormal intra-articular anechoic and displaceable material without Doppler signal

e. Bone profile irregularities f. Extra-articular features (subcutaneous edema, fasciitis) g. Erosions

i. A discontinuity of the smooth echogenic bony surface profile, seen in 2 planes, with an irregular floor

h. Enthesopathy (Describing the pathologic insertion of a tendon, ligament or joint capsule into bone)

i. Pathology is defined by: 1. Hypoechogenicity 2. Increased thickness 3. Calcifications 4. Erosions 5. Cortical irregularity



6. Doppler signals

12. Findings of synovitis, synovial hypertrophy, tenosynovitis, paratenonitis and enthesopathy (enthesitis) through the spectrum of pediatric illnesses and in the various joints (identified under 2) including quantification using semi-quantitative or qualitative grading systems

13. Transient synovitis a. In the appropriate clinical context, transient synovitis is characterized by

finding of fluid accumulation without significant synovial thickening. Additional diagnostic and/or imaging methods will need to be applied, as appropriate.

14. Septic arthritis a. The diagnosis of septic arthritis is based on a clinical assessment and should

prompt arthrocentesis. Ultrasound has limited discriminatory ability as imaging can mimic joint inflammation even when polyarticular, or may complicate a known underlying joint disease.

15. Common acute and chronic avulsion (apophysitis) injuries at the following: a. Medial epicondyle of the elbow b. Lateral epicondyle of the elbow c. Distal triceps tendon insertion d. Distal biceps tendon insertion e. Anterior superior iliac spine (ASIS) f. Anterior inferior iliac spine (AIIS) g. Ischial tuberosity h. Greater trochanter i. Inferior pole of the patella j. Tibial tubercle k. Calcaneus l. Navicular of the ankle m. Tuberosity of the fifth metatarsal



i. Injectates 1. Corticosteroids

ii. Aspiration 1. Joint effusion 2. Simple cyst



















ii. Peritendinous and intrabursal injections: 1. Hand 2. Wrist 3. Elbow 4. Shoulder 5. Hip (trochanteric and iliopsoas)



6. Ankle 7. Forefoot (intermetatarsal)




The following Competencies pertain to each of the above streams. Details of Competencies pertaining to each of the 4 NMSKUS streams (NMUS, MSKUS, RhMSKUS, pRhMSKUS) are described above. At the completion of the training, the diplomate will have acquired the following competencies and will function effectively as a: MEDICAL EXPERT Definition: As Medical Experts, Neuromusculoskeletal Ultrasound diplomates integrate all the CanMEDS Roles by applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centred care. The Medical Expert is the central physician role in the CanMEDS framework. Key and Enabling Competencies: Neuromusculoskeletal Ultrasound diplomates are able to…

1. Establish and maintain clinical knowledge, skills and attitudes appropriate to the practice of NMSKUS:

a. Apply knowledge of the clinical and basic medical sciences relevant to NMSKUS

b. Describe the principles and instrumentation of ultrasound including Doppler imaging and B mode sonography

c. Integrate the knowledge of anatomy, physiology, and relevant disease processes into the NMSKUS consultation

2. Recognize the limitations of an ultrasound assessment and the role of

other imaging modalities and investigations relevant to patient care. 3. Function effectively as consultants, integrating all of the CanMEDS Roles to

provide optimal, ethical and patient-centered medical care a. Identify and respond to relevant ethical issues arising in patient care b. Demonstrate the ability to prioritize professional duties when faced with

multiple patients and problems c. Demonstrate compassionate patient-centered care d. Recognize and respond to the ethical dimensions in medical decision-

making

4. Perform an ultrasound consultation, including the presentation of well-documented assessments and recommendations in written, oral, or video format, in response to a request from another physician.

5. Establish and maintain clinical knowledge, skills and attitudes appropriate to Neuromusculoskeletal Ultrasound:

a. Apply knowledge of the clinical, socio-behavioral, and fundamental biomedical sciences relevant to Neuromusculoskeletal Ultrasound



b. Participate in maintenance of certification (MOC) in continuing professional development

c. Integrate the best available evidence and best practices to enhance the quality of care and patient safety in Neuromusculoskeletal Ultrasound

6. Perform a complete and clinically appropriate NMSKUS assessment of a

patient: a. Describe common B mode and Doppler ultrasound artifacts b. Identify normal tissue, normal variants, and abnormal pathology of the

body region and tissue of interest c. Identify the abnormal sonographic appearance of neuromuscular and

musculoskeletal tissues during disease states d. Correlate ultrasound findings with the history, physical examination, and

other investigations relevant to the patient and disease process e. Demonstrate effective clinical problem solving and judgment to address

patient problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

7. Demonstrate proficient and appropriate use of procedural skills, both

diagnostic and therapeutic: a. Demonstrate appropriate and timely application of therapeutic

interventions relevant to NMSKUS to enhance patient care b. Demonstrate effective, appropriate, and timely performance of diagnostic

procedures relevant to Neuromusculoskeletal Ultrasound c. Ensure appropriate informed consent is obtained for procedures d. Ensure adequate follow up is arranged for procedures performed

8. Seek appropriate consultation from other health professionals, recognizing

the limits of their own expertise: a. Demonstrate insight into their own limits of expertise b. Demonstrate effective, appropriate, and timely consultation of another

health professional as needed for optimal patient care c. Arrange appropriate follow-up care services and additional investigations or

consultations for patients COMMUNICATOR Definition: As Communicators, Neuromusculoskeletal Ultrasound diplomates effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter. Guidance: In the following sections and within this document as a whole, the term "patient" refers to the patient itself or the guardian/parent as appropriate. Key and Enabling Competencies: Neuromusculoskeletal Ultrasound diplomates are able to…



1. Develop rapport, trust, and ethical therapeutic relationships with patients and families:

a. Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty, and empathy

b. Develop a good patient relationship during the Neuromusculoskeletal Ultrasound exam with appropriate attention to patient comfort, patient confidentiality, privacy and autonomy

c. Facilitate a structured clinical encounter effectively integrating Neuromusculoskeletal Ultrasound

2. Accurately elicit and synthesize relevant information:

a. Seek out and synthesize relevant information from other sources, including but not limited to patient records and additional complementary diagnostic investigations

b. Interpret the relevant questions to be answered by the Neuromusculoskeletal Ultrasound examination using information from the referring provider and initial medical evaluation

3. Convey relevant information and explanations accurately to patients and

families, colleagues, and other professionals: a. Deliver the results of the clinical encounter and ultrasound examination to

the patient and referring physician in a professional and understandable manner

4. Utilize NMSKUS to facilitate the education of patients and their families

regarding normal anatomy and disease processes.

5. Convey effective oral and written information about a medical encounter: a. Maintain clear, concise, and accurate records of clinical encounters, plans

and ultrasound images b. Convey medical information in a timely fashion to ensure safe transfer of

care c. Develop a written report, using appropriate terminology, summarizing the

pertinent positive and negative neuromusculoskeletal ultrasound findings

6. Demonstrate the ability to obtain informed verbal and/or written consent for any interventional procedures performed:

a. Ensures that the patient has been fully informed, has the capacity to provide consent and that the patient demonstrates a willingness to participate in the procedure

b. Ensures that the patient understands the information relevant to the decision at hand, retains the information for the decision process, and is able to communicate their decision and all of the material risks of the intervention

COLLABORATOR Definition:



As Collaborators, Neuromusculoskeletal Ultrasound diplomates work effectively within a health care team to achieve optimal patient care. Key and Enabling Competencies: Neuromusculoskeletal Ultrasound diplomates are able to…

1. Participate effectively and appropriately in an inter-professional health

care team: a. Demonstrate leadership within the diplomates parent specialty to

disseminate knowledge and skills regarding Neuromusculoskeletal Ultrasound

b. Describe the NMSKUS specialist’s roles and responsibilities to other professionals

c. Recognize and respect the diverse roles, responsibilities and competencies of other professionals in relation to their own

d. Demonstrate the ability to work closely with the clinical staff in an ultrasound laboratory, clinical office, or interventional suite, to assist in the exam preparation and performance

MANAGER Definition: As Managers, Neuromusculoskeletal Ultrasound diplomates are integral participants in health care organizations, organizing sustainable practices, making decisions concerning the allocation of resources, and contributing to the effectiveness of the health care system. Key and Enabling Competencies: Neuromusculoskeletal Ultrasound diplomates are able to…

1. Improve quality and participate in activities that contribute to the effectiveness of their health care organizations and systems:

a. Employ efficient use of ultrasound equipment, clinical staff, facilities and resources in an efficient manner

b. Participate in Medical Peer Review c. Participate in routine quality assurance of ultrasound

2. Manage their practice and career effectively:

a. Set reasonable priorities and manage time to balance patient care, practice requirements, and personal life

b. Implement achievable goals and processes to ensure personal practice improvement

c. Employ information technology appropriately for patient care 3. Allocate finite health care resources appropriately:

a. Describe the appropriate indications, contraindications, risks, and clinical utility of Neuromusculoskeletal ultrasound



b. Recognize the importance of just allocation of health care resources, balancing effectiveness, efficiency, and access with optimal patient care

c. Apply evidence and management processes for cost-appropriate care HEALTH ADVOCATE Definition: As Health Advocates, Neuromusculoskeletal Ultrasound diplomates use their expertise and influence responsibly to advance the health and well-being of individual patients, communities, and populations. Key and Enabling Competencies: Neuromusculoskeletal Ultrasound diplomates are able to…

1. Deliver patient-centered care a. Diplomates must demonstrate the requisite knowledge, skills, and attitudes

for effective patient-centered care and service to a diverse population. In all aspects of specialist practice, the diplomate must be able to address ethical issues and issues of gender, sexual orientation, age, culture and ethnicity in a professional manner.

2. Respond to individual patient health needs and issues as part of patient care:

a. Describe the role of ultrasound in educating patients b. Describe the role of Neuromusculoskeletal ultrasound in diagnosis and

managing neuromuscular, musculoskeletal and rheumatologic disease states , sexual orientation, age, culture and ethnicity in a professional manner.

SCHOLAR Definition: As Scholars, Neuromusculoskeletal Ultrasound diplomates demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application, and translation of medical knowledge. Key and Enabling Competencies: Neuromusculoskeletal Ultrasound diplomates are able to…

1. Maintain and enhance professional activities through ongoing learning:

a. Describe the principles of maintenance of competence (MOC) in Neuromusculoskeletal Ultrasound

b. Describe the principles and strategies for implementing a personal knowledge management system regarding Neuromusculoskeletal Ultrasound given the evolving knowledge base

c. Recognize and reflect on learning issues in practice i. Conduct personal practice audits ii. Pose an appropriate learning question

d. Access and interpret the relevant evidence



i. Integrate new learning into practice ii. Evaluate the impact of any change in practice iii. Document the learning process according to the diplomates’ parent

certifying body

2. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others:

a. Describe principles of Neuromusculoskeletal Ultrasound and scanning techniques effectively to patients, families, students, residents, and other health professionals

b. Identify collaboratively the learning needs of ultrasound trainees c. Select effective teaching strategies and content to facilitate the training of

other physicians d. Deliver effective live demonstrations, lectures, or presentations relevant

to Neuromusculoskeletal ultrasound e. Assess and reflect on teaching encounters f. Provide effective feedback of trainee ultrasound performance

3. Contribute to the development, dissemination, and translation of new

knowledge and practices: a. Describe the principles of research and scholarly inquiry b. Incorporate new and established techniques into a NMSKUS practice. c. Pose a scholarly question and incorporate new techniques and knowledge

into the practice of Neuromusculoskeletal ultrasound PROFESSIONAL Definition: As Professionals, Neuromusculoskeletal Ultrasound diplomates are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour. Key and Enabling Competencies: Neuromusculoskeletal Ultrasound diplomates are able to…

1. Demonstrate a commitment to their patients, profession, and society through ethical practice:

a. Exhibit appropriate professional behaviours in practice, including honesty, integrity, commitment, compassion, respect, and altruism.

b. Work with physicians, other health care professionals, and staff in a collegial and professional manner

c. Mange conflicts of interest d. Maintain appropriate patient boundaries

2. Demonstrate a commitment to their patients, profession and society

through participation in profession-led regulation: a. Demonstrate knowledge and an understanding of professional, legal, and

ethical codes of practice b. Fulfil the regulatory and legal obligations required of current practice c. Demonstrate accountability to professional regulatory bodies



d. Recognize and respond appropriately to others’ unprofessional behaviours in practice

3. Demonstrate a commitment to physician health and sustainable practice: a. Balance personal and professional priorities to ensure personal health and a

sustainable practice b. Strive to heighten personal and professional awareness and insight c. Recognize other professionals in need and respond appropriately

RECOMMENDED TRAINING EXPERIENCES

• While it is recognized that AFC trainees achieve proficiency at varying rates, it is anticipated that a minimum of 12 months of experience in clinical practice with an experienced Neuromusculoskeletal physician sonographer will be required to obtain the required scanning skills, learn the requisite anatomy, and see an adequate volume and spectrum of pathology. • The maximum duration of training to complete the competency portfolio is 36 months. • It is recognized that the numbers of cases to obtain competency is variable between trainees. The decision of competence is ultimately in the hands of the supervising physician(s) and is reflected in the competency portfolio. • A monthly reflection of progress, imaging and quality review strongly is encouraged.

This document is to be reviewed by the AFC (Sub)Committee in [INSERT NAME OF DISCIPLINE] by [INSERT DATE] [Reviewed/Revised/etc.] – [AFC Committee/Specialty Standards Review Committee, etc.] – [month year] Template document:

Editorial revisions – Office of Education – December 2012

Reviewed and revised – Clinician Educator – January 2013

Approved – Office of Education – February 2013

Revised – Office of Education – August 2013

Revised – Office of Specialty Education – December 2013



Consensus Principles Addendum to NMSKUS AFC Diploma Submitted to the Royal College Committee on Specialties General Principles for Accreditation/Application Standards – NMSKUS AFC Diploma In discussions with base imaging specialties several core principles inherent to imaging emerged from our discussions. The NMSKUS AFC Diploma application group have reached consensus with the Diagnostic Imaging Specialty Committee regarding the following concepts: 1. The NMSKUS AFC committee will ensure invited representation from the base imaging specialties including diagnostic radiology. 2. Sites that offer the NMSKUS AFC Diploma must have a robust and mandatory image archiving program for NMSKUS examinations. 3. Sites that offer the NMSKUS AFC Diploma will already have in place a robust quality assurance program with follow up that includes comprehensive imaging review, clinical follow up and pathology review. 4. The AFC Diploma would require the submission of a comprehensive case log and imaging-based portfolio, not dissimilar to the AFC Echocardiography image submission process.

Application for Recognition of an AFC (Diploma) Discipline Application Part 1

1

Area of Focused Competence (AFC) Diploma in

Neuromusculoskeletal Ultrasound


2

Table of Contents

IDENTIFICATION OF APPLICANT BODY AND/OR SPONSORING ORGANIZATION 3

IDENTIFICATION OF APPLICANT BODY AND/OR SPONSORING ORGANIZATION 4

EXECUTIVE SUMMARY 5

GENERAL INFORMATION 6

SPECIFIC INFORMATION 8

SPECIFIC INFORMATION: NATIONAL REPRESENTATION 12

SPECIFIC INFORMATION: INTERNATIONAL PRESENCE 15

SPECIFIC INFORMATION: EFFECTS OF THE DIPLOMA 19

DISCIPLINE SPECIFIC INFORMATION 26

APPENDIX A: 28

FORM LETTER SENT TO SUBSPECIALTY HEADS 28

APPENDIX B: 31

APPENDIX C: 32

AMERICAN COLLEGE AND SOCIETY POSITION STATEMENTS 32

APPENDIX D 35

APPENDIX E 36

APPENDIX F 37

HISTORY OF CRUS: PUBLISHED IN CANADIAN RHEUMATOLOGY ASSOCIATION JOURNAL 2013 37

APPENDIX G 41

APPENDIX I 49

GENERAL REFERENCES 49


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Identification of Applicant Body and/or Sponsoring

Organization

Name of the proposed diploma discipline (in both official languages):

Neuromusculoskeletal Ultrasound (NMSKUS) – Adult Rheumatology Stream Neuromusculoskeletal Ultrasound (NMSKUS) – Pediatric Rheumatology Stream Neuromusculoskeletal Ultrasound (NMSKUS) – Musculoskeletal Stream Neuromusculoskeletal Ultrasound (NMSKUS) – Neuromuscular Stream *** needs a French translation*** emailed Hung

Name and address of applicant

Dr. A. Chaiton Assistant Professor of Rheumatology University of Toronto 2115 Finch Avenue West Suite #405 Toronto, Ontario M3N 2V6 Telephone #416-741-2456 Cell # 416-705-0696 Fax #416-741-2454 E-mail: [email protected] Submission date: September 1 2015

Signature:

Single address for receipt of all correspondence relating to this application is the address

of Dr. A Chaiton as indicated above.



4

Identification of Applicant Body and/or Sponsoring

Organization

Co-Applicants

Karen Adams Adult Rheumatologist CHUL du CHUQ 2705 Blvd Laurier, H-1365 Quebec, QC G1V 4G2 Pooneh Akhavan Assistant Professor Staff Rheumatologist Mount Sinai Hospital Suite 2-029,60 Murray Street Toronto, ON M5T 3L9 Alessandra Bruns Assistant Professor, Dept. of Rheumatology Dept. of Medicine Universite de Sherbrooke 2500 boul. De L’Universite Sherbrooke, QC J1K 2R1 Vivian Bykerk Assistant Professor of Medicine University of Toronto Mount Sinai Hospital 60 Murray Street Toronto, ON M5T 3L9 Navjot Dhindsa Assistant Professor, Dept. of Internal Medicine University of Manitoba Health Sciences Centre RR149-800 Sherbrook Street Winnipeg, MB R3A 1M4 Peter Inkpen Clinical Lecturer, Dept. of Medicine University of British Columbia 3203 34 Street Vernon, BC V1T 5X7 Edward Keystone Professor of Medicine, University of Toronto Mount Sinai Hospital 60 Murray Street Room #2-006, Box 4 Toronto, ON M5T 3L9

Margaret Larche Associate Professor, Division of Rheumatology, Departments of Medicine and Paediatrics St. Joseph’s Healthcare Hamilton/McMaster Hospital 25 Charlton Avenue East Suite #702 Hamilton, ON L8N 1Y2 Christopher Penney Clinical Associate Professor, Division of Rheumatology, Faculty of Medicine, University of Calgary Richmond Road Diagnostic and Treatment Centre 1820 Richmond Road SW Calgary, AB T2T 5C7 Johannes Roth Associate Professor, Department of Pediatrics, Faculty of Medicine, University of Ottawa Children’s Hospital of Eastern Ontario Department of Paediatrics 401 Smyth Road Ottawa, ON K1H 8L1 Michael Stein Assistant Professor of Medicine McGill University Division of Rheumatology 5300 Cote des Neiges, Suite 400 Montreal,QC H3T 1Y Diane Wilson Clinical Rheumatology and Ultrasound Box 1617 Lunenburg, NS B0J2C0


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Executive Summary

Neuromusculoskeletal Ultrasound (NMSKUS) is characterized by the application of ultrasound technology at the patient’s bedside for diagnostic, therapeutic and prognostic purposes. Competency

in this technology requires training beyond that available in the parent Royal College training programs. Much like electrodiagnostic training in both Neurology and Physiatry residency programs in North America, NMSKUS includes in-depth knowledge of principles of ultrasound, enhanced knowledge of anatomy, technical skills in image acquisition and expertise in interpretation of imaging. Visualization of pathology at the bedside, in the clinic, and in the EMG laboratory provides an opportunity to enhance physician patient communication and may help engage the patient in their own medical management. Given the ability of NMSKUS to enhance patient assessment and to affect treatment decisions at the bedside, it should improve the efficiency of individual patient care and improve outcomes. Use of NMSKUS enhances accuracy of interventions such as joint injections and aspirations. The Physician Applicant:

The target audience for this diploma include Neurologists, Physiatrists, Adult and Pediatric Rheumatologists, and Sport and Exercise Medicine Physicians practicing in the community and academic setting. NMSKUS differs from Ultrasound within a diagnostic imaging facility offered by radiologists in that images may be obtained in real-time at the patient’s bedside by the treating physician in areas of pathology that are largely outside of the scope of practice of the technician sonographer and community radiologist. The additional information added to data from a comprehensive history and physical examination is applied immediately to diagnostic and management decisions. This sequence of events readily decreases the number of ordered investigations, minimizes further imaging requests and physician referrals. In addition to expertise in the technical practice of NMSKUS, diplomates will learn to be academic and clinical leaders. They will promote NMSKUS training and education, provide the quality assurance and administration necessary to sustain a high-quality program, and will conduct and promote research within the field. Training: Avenues for training exist within various specialties within North America and Europe. For the neuromuscular neurologist educational activities exist through the AANEM; physiatrist and sport medicine physician have options via multiple organizations in Canada and the USA; rheumatologists have well organized programs in Canada, USA, and Europe. Fellowship training is available within Canada for Neuromuscular and Musculoskeletal streams. Benchmark evaluations are available through American organizations – American registry of diagnostic medical sonographers (ARDMS) for MSK and American college of Rheumatology (ACR) for RhMSKUS. Assessment:


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AFC (Diploma) programs are based upon a period of medical training and supervision, and like other formal disciplines recognized by the Royal College, require demonstration of proficiency in those skills and competencies outlined in the national standards. Unlike Royal College specialties and subspecialties, however, the AFC (Diploma) programs will not be assessed by comprehensive (written and oral) examinations. AFC (Diploma) program requirements will be assessed using a structured summative portfolio.

The portfolios will be based upon a template developed by the Office of Education that will include a list of available assessment tools that can comprise the portfolio. Each specialty committee will then be responsible for developing their portfolio requirements that document achievement of all competencies and experiences outlined in the AFC (Diploma) Competencies Training Requirements (CTR), and selecting the most appropriate assessment tools based on the requirements being assessed. The portfolio for each AFC (Diploma) discipline will be reviewed and endorsed by the Evaluation Committee before being implemented.

Why not include Ultrasound Skills into the Objectives of Training Requirements for the

respective residency programs?

There is a current urgent need for training that cannot be met with existing resources. Certification is an important step in professional development , especially as it applies to incorporating an new scope . Technology, and specifically ultrasound in the hands of every clinician, is having a major impact on future practice, workforce needs, and the overlapping scope of physician specialty practice. The Royal College is recognized by provincial and federal health care organizations and credentialing bodies as an important marker of quality. The Royal College AFC Diploma program is the ideal format to introduce an accredited training program in NMSK ultrasound in Canada. The Royal College is well suited to take this lead role as recognition by the College will further support the acceptance of this new technology as an important addition to the skill set of many Rheumatologists , Physiatrists, and other neuromuscular specialists. The Royal College AFC Diploma in NMSKUS will facilitate standardization and accreditation to all proposed training programs. It will provide the foundation for skill validation in the NMSKUS credentialing process. This recognition and standardization will provide an accredited pathway for competency, an important element that will encourage others to seek such training and discourage practice in untrained hands. Formal recognition will also allow Universities to develop predictable funding models for trainees. The NMSKUS program will include maintenance for continuing education to maintain competency.

General Information

1. What is the name of the proposed diploma discipline (in both official languages)?

Neuromusculoskeletal Ultrasound (NMSKUS) – Adult Rheumatology Stream Neuromusculoskeletal Ultrasound (NMSKUS) – Pediatric Rheumatology Stream Neuromusculoskeletal Ultrasound (NMSKUS) – Musculoskeletal Stream


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Neuromusculoskeletal Ultrasound (NMSKUS) – Neuromuscular Stream L’Échographie neuromusculosquelettique (NMSKUS) – flux de la Rhumatologie adulte L’Échographie neuromusculosquelettique (NMSKUS) - flux de la Rhumatologie Pédiatrique L’Échographie neuromusculosquelettique (NMSKUS) - flux Musculosquelettiques L’Échographie neuromusculosquelettique (NMSKUS) - flux Neuromusculaire 2. What are the entry criteria for this discipline?

Type A: Royal College specialty (please specify): Type B: Royal College subspecialty in Rheumatology, etc( include others).

X Type C: Any MD

Type D: Conjoint program with the CFPC (still under development)_

3. For Type A and Type B above, describe the relationship of this proposed diploma

discipline to the parent specialty(ies) or subspecialty(ies).

N/A

X Sponsor – See letters from Heads of Rheumatology, rheumatology to specialty committee, the Canadian rheumatologic ultrasound Society, and the Physical Medicine and Rehabilitation Specialty Committee. Given the breadth and depth of the proposed diploma, usually candidates will be in training or in practice in one of the base specialty streams. The parent specialties are fully engaged in the development of ultrasound as a diagnostic modality.

4. Is there a National Specialty Society for the parent specialty(ies) or subspecialty(ies)?

X Yes

No

N/A

If yes, please specify. X Canadian Rheumatology Association- see attached letter from Canadian Rheumatology

Association- President 5. Is there a National Specialty Society for the proposed diploma discipline?

X Yes

No

If yes, please identify.

X Canadian Rheumatology Ultrasound Society (www.crus-surc.ca) 6. Describe the relationship between these societies (if applicable).

The CRA endorses the efforts of CRUS to promote education and research in the application of Point of Care U.S. by its membership. The Canadian Rheumatology Ultrasound Society is comprised of community and academic leaders in point of care ultrasound from across the country. Both are nonprofit organizations and financially independent.

http://www.crus-surc.ca/

Application for Recognition of an AFC (Diploma) Discipline Application- Part I

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Specific Information

1. Please describe the unique nature of the proposed diploma discipline

(What supplemental competencies or highly specific scope of practice is included that requires

distinct recognition? What is the defined and recognized societal health need not currently being

satisfied by any other recognized discipline? What positive contribution towards improving medical

care and health outcomes does this discipline make?)

Expanding the Scope of Clinical Evaluation

Neuromusculoskeletal Ultrasound (NMSKUS) is characterized by the application of ultrasound technology at the patient’s bedside for diagnostic, therapeutic and prognostic purposes covering the broad scope of practice of neuromuscular, musculoskeletal and rheumatologic medicine. Competency in this technology requires training beyond that available in the parent Royal College training programs. This includes in-depth knowledge of principles of ultrasound, enhanced knowledge of anatomy, technical skills in image acquisition and expertise in interpretation of imaging. Providing Access to Otherwise Unavailable Imaging

NMSKUS differs from the Ultrasound Diagnostic Imaging offered by Radiologists in that images may be obtained in real-time at the patient’s bedside by the treating physician. This additional

information may be added to data from comprehensive histories and physical examinations to be applied immediately to treatment decisions. In some disciplines such as rheumatology, reliance on traditional ultrasonography for detailed evaluation of joints is frustrated by lack of widespread expertise in inflammatory arthritis amongst radiology-trained ultrasonographers and excessive wait times for ambulatory appointments. Use of traditional ultrasound departments for evaluation of inflammatory arthritis is thus extremely rare in Canadian practice. This is despite accumulating evidence that US is more accurate than clinical examination at detecting disease activity as well as joint damage. Early detection of both of these features affects treatment decisions and thus long-term outcomes (Larche, Chaiton, Keystone- CRUS position paper 2012). The same concept applies to physicians practicing in the neuromuscular laboratory where the evaluation of the peripheral nervous system is enhanced through muscle and nerve evaluation. EMG evaluation is commonly used to enhance diagnosis of peripheral nervous system pathology (Padua. L, 2007). However, it does not provide spatial information about the nerve anatomy towards surroundings. In this sense, ultrasound complements nerve conduction studies and electromyography increasing the sensitivity and specificity of diagnosis in the neuromuscular laboratory. With current technology, the fascicular pattern of nerves is easily visualized and the resolution is much superior with superficial nerves when compared to MRI. Even three Tesla MRI struggles to match the imaging characteristics of high-frequency ultrasound in superficial nerves and lacks the dynamic ability to evaluate continuity and motion (Martinoli 200, 2004, 2005). Only a few ultrasonographers in academic teaching hospitals, under the guidance of an MSK fellowship trained radiologist, have experience evaluating the peripheral nerves and muscles. Essentially no ultrasonographers in community practice and nonacademic hospitals have skills to evaluate peripheral nerves and muscles. Therefore, despite the potential skills of the local radiologist, there is an unmet need for the evaluation of these pathologies. In the musculoskeletal outpatient clinic and the sports medicine clinic, wait times for standard shoulder ultrasound are frustratingly long-term and the use of MRI is inappropriate in many situations. Diagnostic musculoskeletal ultrasound is helpful in superficial structures and helps to tailor rehabilitation and training programs as well as make bedside clinical decisions decreasing the burden of care on both physician and patient. In addition to this, musculoskeletal ultrasound is not a part of the curriculum for ultrasonographers within standard training programs in North America. Therefore, the burden for training these sonographers is resting upon community radiologists. The scope of practice of


9

ultrasonographers in the community rarely strays from the shoulder. Musculoskeletal related complaints are a very common cause for a visit to a primary care physician (St. Sauver, 2013). The incidence of musculoskeletal and neuromuscular pathologies are an overburden on the current resources within academic and community radiology departments. Therapeutic options for patients in rheumatology have expanded significantly over the past years and the appropriate administration of these therapies in a time-efficient manner will directly impact the long-term outcome for the patient. At each time point where therapeutic decisions will be taken, a comprehensive assessment including history, clinical exam and ultrasound exam is mandatory for appropriate and evidence based decision making. This will also ensure responsible use of resources of costly therapies. Timely access to the imaging component of the comprehensive assessment and availability of the information can only be guaranteed in a point of care setting. Visualization of pathology at the bedside also provides an opportunity to enhance patient physician communication and may help engage the patient in their medical management. Given the ability of NMSKUS to enhance patient assessment and to affect treatment decisions at the bedside, it should improve the efficiency of individual patient care and improve outcomes. Use of NMSKUS enhances accuracy of interventions such as joint injections and aspirations. In addition to expertise in the technical practice of NMSKUS, diplomat candidates will learn to be academic and clinical leaders. They will promote NMSKUS training and education, provide the quality assurance and administration necessary to sustain a high-quality program and will conduct and promote research within the field. Published guidelines on using US at in Rheumatology:

American College of Rheumatology (ACR) Recognition

The ACR recognizes MSKUS as a “meaningful tool for rheumatologists in the diagnosis, management

and treatment of rheumatic conditions” (American College of Rheumatology Musculoskeletal Ultrasound Task Force, 2010; McAlindon et al., 2013). Furthermore, the ACR identifies the need to train rheumatologists in the appropriate use of this modality in their daily practice and recognizes and encourages rheumatologists to pursue MSK US training and certification through the Musculoskeletal Ultrasound Certification in Rheumatology (RhMSUS, 2014; Kissin, 2014). Guidelines from Europe

MSKUS is routinely used to assess rheumatological disorders in many European countries including Italy, Spain, Germany, France, Switzerland and the United Kingdom. Whilst no written guidelines are published, the utility of NMSKUS is well validated. Guidelines for MSK US reporting have been published (Iagnocco et al., 2013).

Canadian Guidelines

MSKUS is an invaluable tool for the diagnosis and monitoring of inflammatory arthritidies based on current evidence (Larche and Lyddell, 2013). Although MSKUS is not yet included in the Canadian Clinical Practice Guidelines for assessment of disease activity in RA, ongoing local and international research is generating evidence of its value in clinical decision-making. MSKUS should now be considered an essential addition to future guidelines. The Canadian Association of Radiologists have provided a position statement on the use of NMSKUS (CAR, 2013). They state that as US is one of the most operator-dependent imaging modalities, adequate training is essential for any practitioner of NMSKUS. The aim of a Royal College Diploma of an Ambulatory Care NMSKUS-MSK Stream is to encourage a comprehensive standardized training program for Canadian doctors and Rheumatologists.


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Current Fellows Teaching Curriculum – Basic Introduction

During rheumatology fellowship training, several programs including McMaster, Toronto, Ottawa, Kingston and Sherbrooke are incorporating a basic introduction to NMSKUS. The curriculum includes basic physics and knobology; utility of Doppler; specific tutorials on joint regions: hand, wrist, elbow, shoulder, foot, ankle, knee and hip. There are a series of six sessions during the year (see curriculum proposal for Sunnybrook Hospital, Toronto). Currently, fellows with an interest in NMSKUS are encouraged to acquire more intensive training. Clinical Studies Suggesting NMSKUS for Rheumatological Disorders

Based on evidence from clinical trials, the use of ultrasound has been recommended for: the diagnosis and monitoring of RA by a EULAR expert group (Colebatch, 2013); aiding diagnosis in giant cell arteritis (GCA) by the British Society of Rheumatology (Dasgupta et al., 2010); the accurate placement of needles during arthrocentesis and joint injection (D’Agostino and Schmidt, 2013); diagnosis and treatment of carpal tunnel syndrome and other neuropathies (Fowler et al., 2014). The Use of Ultrasound in Spondyloarthritis

Seronegative spondyloarthritis (SpA) is a group of diseases affecting 0.5-1% of the general population. Psoriatic arthritis (PsA) and ankylosing spondylitis (AS) are the two main diseases included within the SpA group. This group of diseases is characterized by a predominant inflammation in the spine in addition to peripheral joint arthritis and extra-articular musculoskeletal inflammation. Enthesitis, inflammation at the attachment site of ligaments and tendons to the bone is considered a primary pathologic lesion in SpA. The presence of enthesitis is included in the classification criteria for SpA and PsA (Rudwaleit, 2011). Ultrasonographic detection of enthesitis may assist in early diagnosis of SpA as the clinical assessment of enthesitis is unreliable. High ultrasound enthesitis score have high specificity and positive predictive value to identify patients with SpA among a group of patients with non-specific back pain (De Miguel, 2011). Psoriatic arthritis, which predominantly affects the peripheral joints, can lead to severe damage and disability. Early diagnosis and treatment is important to prevent joint damage. Since most patients with PsA first develop psoriasis and only later develop arthritis, patients with psoriasis attending dermatology clinics serve as a target population for early diagnosis of PsA. Several studies have shown that musculoskeletal ultrasound assessment of patients with psoriasis identifies a significant proportion of patients with arthritis and enthesitis that were unaware of their disease (Eder 2014; Acquacalda, 2015; Naredo, 2011). Thus, musculoskeletal ultrasound assessment of this high-risk population can significantly improve early detection of PsA allowing prompt treatment and improved outcomes. With the advent of novel biologic medications that effectively suppress inflammation the achievement of remission in PsA became a realistic treatment goal. A structured patient management aiming for low disease activity leads to better outcomes compared to traditional means of follow-up (Coates, 2015). The achievement of tight disease control requires quantification of disease activity using reliable measurement tools. However, physical examination of the joints and the entheses is less sensitive in detecting inflammation compared to ultrasound. A large proportion of patients with PsA, considered being in clinical remission, continue to have active arthritis and enthesitis in ultrasound (Husic, 2014). In addition, the presence of active musculoskeletal inflammation in ultrasound predicted relapse of arthritis in patients who were in clinical remission whose immunosuppressive agents were withdrawn (Araujo, 2015). Therefore musculoskeletal ultrasound assessment in patients who are in a low disease activity state can guide treatment decisions. Overall, the use of musculoskeletal ultrasound in SpA has a significant potential to assist in early diagnosis and classification of the disease and guide treatment decisions.


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Effect on Health Care Budgets

The use and associated costs of MRI and MSKUS in the United States Medicare system from 1995 to 2005 were analyzed and observed trends extrapolated through the year 2020. From 1995 to 2005, there was a 26% increase in MSKUS use and a 354% increase in MRI use. During the study period, a large minority of all diagnoses could have been made through ultrasound. Imaging costs in 2020 were estimated at $3.6 billion, of which $2 billion were attributed to MRI. The authors determined that between 2006 and 2020, using MSKUS in place of MRI where appropriate would result in a savings of over $6.9 billion (Parker et al., 2008). Point-of-care MSKUS also has the capacity to improve quality and efficiency of care (Moore et al., 2011). Published Guidelines on using NMSKUS in Musculoskeletal Medicine American Institution of Ultrasound in Medicine (AIUM): Musculoskeletal ultrasound examination: Guidelines developed in conjunction with the American College of Radiology, the Society for Pediatric Radiology, and the Society of Radiologists in Ultrasound. AIUM practice guidelines for the performance of selected ultrasound-guided procedures: The AIUM recognizes the American College of Rheumatology certification in musculoskeletal ultrasound (given the designation of RhMSUS). Training Guidelines for physicians and chiropractors who evaluate and interpret diagnostic musculoskeletal ultrasound examinations: http://www.aium.org/officialStatements/51. See Appendix A: Form Letter Sent to Subspecialty Heads with Addendum.

http://www.aium.org/officialStatements/51


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Specific Information: National Representation

2. Please provide a list of journals and publications that support this special area. (Demonstrate the value that these add to the medical literature. Indicate if they are peer-reviewed, indexed, the scope of distribution [national/international], the subscription volume, and Canadian contribution to these publications. Where meetings or societies are cited indicate the scope of these and the contributions of Canadian physicians to these meetings or societies.)

Canadian Rheumatology Association Annual Scientific Meetings

2007: Ultrasonography in rheumatological practice. Workshop. Maggie Larche 2009: The utility of US in Rheumatology Practice. Plenary. Maggie Larche 2010: What can Ultrasonography do for my practice? Workshop. Maggie Larche and

Alessandra Bruns 2011: 1st Intermediate Refresher Course- Victoria, BC, Feb 2011, Alessandra Bruns. 2012: Ultrasonography: should it be used in practice. Great Debate. Maggie Larche and

Johannes Roth- at the Canadian Rheumatology Association Annual Meeting- Victoria 2012.

2012: 2nd Intermediate Refresher Course- Whistler, Alessandra Bruns Feb 3-4. Focus on

shoulder, and elbow. Presentations by Dr David Bong, Dr Ingrid Moller, Dr Johannes

Roth, Dr Alessandra Bruns 2013: Ultrasonography in pediatric rheumatology. Johannes Roth, Alessandra Bruns and

Maggie Larche 2014: Why All Rheumatologists Should be Sonographers. Dunlop-Dottridge Lectureship by Dr.

Walter Grassi. 2014: 3rd Intermediate Refresher Course- Whistler, BC, Alessandra Bruns. Feb 4-5. Focus on

hand/wrist and foot/ankle. Presentations by Dr Alessandra Bruns, Dr David Bong, Dr

Lene Terslev, Dr Walter Grassi, and Dr Johannes Roth

These have all raised awareness of the utility of US as a point-of-care test for

rheumatologists

Canadian Rheumatology Ultrasound Society

2009: Inaugural meeting 2010-present: Annual Basic Ultrasonography Course at McMaster University Canadian teaching faculty include: Johannes Roth, Alessandra Bruns, Maggie Larche, Abraham Chaiton, Michael Stein, Visithan Ky, Diane Wilson

This has been important to train rheumatologists (120 to date) from across Canada in the

skill of MSK US (see list of Trainees in Specific Information)

See Appendix F: History of CRUS

Canadian Webex Seminars and Problem Based Consultations

Supervised and coordinated by Dr. Johannes Roth, Associate Professor of Pediatrics at the University of Ottawa and Head of Pediatric Rheumatology at the Children’s Hospital of Eastern Ontario.


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Presentations:

The above program indicates the commettent of CRUS to continuing education.

Canadian Rheumatology Association – Annual National Meeting, February 2012-Present MSK Ultrasonography Refresher Course Dr. Alessandra Bruns – see details above. See Appendix B – Ultrasonography Refresher/Intermediate Course - Hand and Wrist; Foot

and Ankle. University of Sherbrooke Ultrasound Courses

Course Director: Alessandra Bruns Canadian Members of Teaching Faculty: Maggie Larche; Johannes Roth

McMaster University MSK Ultrasound CRUS Course – (http://crus-surc.ca)

Dr. Maggie Larche – Associate Professor of Medicine & Pediatrics, McMaster University, Course Director

Canadian Association of Physical Medicine and Rehabilitation:

Introductory NMSKUS Ultrasound courses held May 25, 2014 and June 5, 2015. Introductory NMSKUS Ultrasound course for residents March 18-20, 2012.

Publications that include NMSK Ultrasonography papers are in:

Arthritis Care & Research Nature Reviews Rheumatology British Medical Journal Nature Clinical Practice Rheumatology Journal of Rheumatology Seminars in Arthritis and Rheumatism Arthritis & Rheumatism Arthritis Research & Therapy Rheumatology International Journal of Clinical Rheumatology Muscle & Nerve Current Opinion in Rheumatology International Journal of Rheumatic Diseases Rheumatic Disease Clinics of North America Clinical Rheumatology Scandinavian Journal of Rheumatology Journal of Ultrasound in Medicine Pediatric Rheumatology Annals of the Rheumatic Diseases Modern Rheumatology

Journal of Clinical & Experimental Rheumatology Best Practice & Research in Clinical Rheumatology

First Session: TUI Objectives and Principals: Dr Paul Emery October 9th 2013: Setting up your ultrasound practice, review of machine purchase, new

ultrasound technologists, building requirements, machine maintenance and cleaning, reporting: Dr Abraham Chaiton

November 13th 2013: Ultrasound for Vasculitis: Dr Wolfgang Schmidt January 28th 2014: Pittfalls: Difficult Anatomy, Interesting Applications: Dr Alessandra

Bruns


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Specific Information: International Presence

• Members of the Targeted Ultrasound Initiative (TUI). National Ambassadors: Johannes Roth and

Maggie Larché • Active participants in the Outcome Measures in RA clinical trials organization (OMERACT): Maggie

Larche; Johannes Roth; Alessandra Bruns • Member of the ACR, USSONAR,PANLAR, Mexican Society of Rheumatology and EULAR teaching

faculty: Johannes Roth • Member of the ACR, Mexican College of Rheumatology teaching faculty: Alessandra Bruns • Member of the ACR certification review committee: Johannes Roth and Abraham Chaiton • Member of the ultrasound committee of American Association of Neuromuscular and

Electrodiagnostic Medicine (AANEM): Abraham Chaiton Presenting at AANEM Annual Meetings San Antonio Oct 2013, and Savannah Georgia, October 2014. Peter Inkpen

• Member of the ultrasound committee of the AANEM 2013-present: Peter Inkpen • Member of the Amercian Institute of Ultrasound in Medicine – Drs. Inkpen, Juong, Michaud. • Steering Committee Member of PMUSIC-International Pediatric MSK ultrasound standardization group: Johannes Roth 's •Member of the American Institute of Ultrasound in Medicine (AIUM): Drs. Chaiton and Inkpen

Canadian rheumatologists and physiatrists have a strong international presence in the

field of ultrasonography and are highly regarded across the world.

Peer Reviewed Articles in International Journals This is a short bibliography outlining the multitude of literature supporting the use of US

by physiatrists, sports medicine physicians and rheumatologists. Albrecht K, Grob K, Lange U, Muller-Ladner U, Strunk J. Reliability of different ultrasound quantification methods and devices in the assessment of therapeutic response in arthritis. Rheumatology 2008;47:1521-1526. Aletaha D et al Rheumatoid Arthritis Classification Criteria an ACR/EULAR collaborative initiative.Arthritis & Rheumatism 2010;62:2569-81. Backhaus M et al.Guidelines for Musculoskeletal Ultrasound in Rheumatology 2001 Annal of Rheum Dis;60:641-649. Borg F., Agrawal S., Dasgupta B. (2008) The use of musculoskeletal ultrasound in patient education. Ann Rheum Dis 67: 419 Brown AK, Conaghan PG, Karim Z, Quinn MA, Ikeda K, Peterfy CG, Hensor E, Wakefield RJ, O'Connor PJ, Emery P. An explanation for the apparent dissociation between clinical remission and continued structural deterioration in rheumatoid arthritis. Arthritis Rheum. 2008 Oct; 58(10):2958-67 Bruyn GA, Naredo E, Iagnocco A, Balint PV, Backhaus M, Gandjbakhch F, Gutierrez M, Filer A, Finzel S, Kaeley G, Magni-Manzoni S, Ohrndorf S , Pineda C, Richards B, Roth J, Schmidt WA, , Terslev L and D’Agostino MA, on behalf of the OMERACT Ultrasound Task ForceTen years OMERACT ultrasound working group : report of the OMERACT 12 conference. J Rheumatol. 2015 Mar 15


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Colebatch AN, Edwards CJ, Østergaard M, van der Heijde D, Balint PV, D'Agostino MA, Forslind K, Grassi W, Haavardsholm EA, Haugeberg G, Jurik AG, Landewé RB, Naredo E, O'Connor PJ, Ostendorf B, Potocki K, Schmidt WA, Smolen JS, Sokolovic S, Watt I, Conaghan PG. EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis. Ann Rheum Dis. 2013 Jun;72(6):804-14. del Cura JL. Ultrasound-guided therapeutic procedures in the musculoskeletal system. Curr Probl Diagn Radiol. 2008 Sep-Oct; 37(5):203-18 Damjanov N, Radunovic G, Prodanovic S, Vukovic V, Milic V, Simic Pasalic K, Jablanovic D, Seric S, Milutinovic S, Gavrilov N. Construct validity and reliability of ultrasound disease activity score in assessing joint inflammation in RA: comparison with DAS-28. Rheumatology (Oxford). 2012 Jan; 51(1):120-8 Dasgupta B, Schmidt WA et al. Classification Criteria for Polymyalgia Rheumatica a EULAR/ACR collaborative initiative . Arthritis & Rheumatism 2012;64:943-54. Ellegaard K, Christensen R, Torp-Pedersen S, Terslev L, Holm CC, Kønig MJ, Jensen PS, Danneskiold-Samsøe B, Bliddal H. Ultrasound Doppler measurements predict success of treatment with anti-TNF-α drug in patients with rheumatoid arthritis: a prospective cohort study. Rheumatology (Oxford). 2011 Mar;50(3):506-12. Filippucci, Emilio et al. E-learning in ultrasonography: a web-based approach. Ann of Rhem Dis. 2007;66: 962-965. Grassi W. Review Clinical evaluation versus ultrasonography: who is the winner? J Rheumatol. 2003 May; 30(5):908-9 Filippucci E.,Grassi W et al Ultrasound Imaging for the Rheumatologist 2006 Clin Exp Rheum ;24:1-5. Flexor carpi radialis tendon ultrasound pictorial essay. Luong DH, Smith J, Bianchi S.Skeletal Radiol. 2014 Jun;43(6):745-60. Review. Great saphenous vein leiomyosarcoma: a rare malignant tumor of the extremity--two case reports. Le Minh T, Cazaban D, Michaud J, Ginestet-Auge MC, Laporte MH, Patelli A, Marre A. Ann Vasc Surg. 2004 Mar;18(2):234-6. Gutierrez M, Filippucci E, De Angelis R, Salaffi F, Filosa G, Ruta S, Bertolazzi C, Grassi W. Subclinical entheseal involvement in patients with psoriasis: an ultrasound study. Semin Arthritis Rheum. 2011 Apr; 40(5):407-12 Iagnocco A, Epis O, Delle Sedie A ,et al. Ultrasound Imaging for the Rheumatologist XVII Role of colour Doppler and Power Doppler; Clin Exp Rheumatol 2008; 26(5):759-62. Iagnocco A, Naredo E, Wakefield R, Bruyn GA, Collado P, Jousse-Joulin S, Finzel S, Ohrndorf S, Delle Sedie A, Backhaus M, Berner-Hammer H, Gandjbakhch F, Kaeley G, Loeuille D, Moller I, Terslev L, Aegerter P, Aydin S, Balint PV, Filippucci E, Mandl P, Pineda C, Roth J, Magni-Manzoni S, Tzaribachev N, Schmidt WA, Conaghan PG, D'Agostino MA. Responsiveness in Rheumatoid Arthritis. A Report from the OMERACT 11 Ultrasound Workshop. J Rheumatol. 2013 Nov 15. [Epub ahead of print}

Imaging of neuropathies about the ankle and foot. Martinoli C, Court-Payen M, Michaud J, Padua L, Altafini L, Marchetti A, Perez MM, Valle M, Hovgaard C, Haugegaard M, Tagliafico A. Semin Musculoskelet Radiol. 2010 Sep;14(3):344-56. doi: 10.1055/s-0030-1254523. Epub 2010 Jun 10. Review.

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Joshua F, Edmonds J, Lassere M. Power Doppler Ultrasound in Musculoskeletal Disease: a systematic review. Seminars Arthritis Rheum 2006;36:99-108. Kane D, Balint PV, Sturrock RD. Ultrasonography is superior to clinical examination in the detection and localization of knee joint effusion in rheumatoid arthritis. J Rheumatol. 2003 May; 30(5):966-71 Kang T Lanni S, Nam J, Emery P, Wakefield RJ. The Evolution of Ultrasound in Rheumatology. Therapeutic Advan Musculoskeletal Disease 2012;4:399-411. Katchamart W, Bombardier C Systematic monitoring of disease activity using an outcome measure improves outcomes in rheumatoid arthritis. J Rheumatol. 2010 Jul;37(7):1411-5 Larché MJ, McDonald-Blumer H, Bruns A, Roth J, Khy V, de Brum-Fernandes AJ, Wakefield RJ, Brown AK, Bykerk V. Utility and feasibility of musculoskeletal ultrasonography (MSK US) in rheumatology practice in Canada: needs assessment. Clin Rheumatol. 2011 Oct;30(10):1277-83 Minimally invasive ultrasound-guided carpal tunnel release: a cadaver study. de la Fuente J, Miguel-Perez MI, Balius R, Guerrero V, Michaud J, Bong D. J Clin Ultrasound. 2013 Feb;41(2):101-7. doi: 10.1002/jcu.21982. Epub 2012 Sep 11. PMID: 22965620 Similar articles Select item 21876094. Naredo E, Collado P, Cruz A, Palop MJ,Cabero F, Richi P, Carmona L, Crespo M. Longitudinal Power Doppler Ultrasonographic Assessent of Joint Inflammatory Activity in Early Rheumatoid Arthritis: Predictive Value in Disease Activity and Radiologic Progression Arthritis& Rheumatism 2007;57:116-124. Naredo,E.,D’Agostino Maria A., et al. Current State of MSK Ultrasound training and Implementation in Europe. Rheumatology.2010;49:2438-2443. Newman J., Adler R., Bude R., Rubin J. (1994) Detection of soft-tissue hyperemia: value of power Doppler sonography. AJR Am J Roentgenol 163: 385–389. Pan-American League of Associations for Rheumatology (PANLAR) recommendations and guidelines for musculoskeletal ultrasound training in the Americas for rheumatologists. Pineda C, Reginato AM, Flores V, Aliste M, Alva M, Aragón-Laínez RA, González AB, Bouffard JA, Caballero-Uribe CV, Chávez-López M, Chávez-Pérez NN, Collado P, Díaz-Coto JF, Duarte M, Filippucci E, Galarza-Maldonado C, García-Kutzbach A, Godoy FJ, González-Sevillano E, Da Silveira IG, Gutiérrez M, Hernández-Díaz C, Hernández J, Lamuño-Encorrada M, Marcos JC, Marín-Arriaga N, Mendonça JA, Michaud J, Moya C, Muñoz-Louis R, Neubarth F, Quintero M, Reyes B, Ruta S, Rodríguez-Henríquez PJ, Solano C, Ventura-Ríos L, Möller I, Naredo E; Pan-American League of Associations for Rheumatology (PANLAR) Ultrasound Study Group. Patil P and Dasgupta B. Role of diagnostic ultrasound in the assessment of musculoskeletal diseases Ther Adv Musculoskelet Dis. 2012 October; 4(5): 341–355 Peluso G, Michelutti A, Bosello S, Gremese E, Tolusso B, Ferraccioli G.Clinical and ultrasonographic remission determines different chances of relapse in early and long standing rheumatoid arthritis. Ann Rheum Dis. 2011 Jan;70(1):172-5. Pincus TLimitations of a quantitative swollen and tender joint count to assess and monitor patients with rheumatoid arthritis 2008; Bulletin of the NYU Hospital for Joint Diseases 2008 ;66(3):216-223. Rebollo-Polo M, Bruns A, Roth J et al Ultrasound Findings on Patients with juvenile idiopathic arthritis in clinical remission. 2011 ;Arthritis Care & Research 63:1013-1018.






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Rosenberg C, Etchepare F, Fautrel B, Bourgeois P. Diagnosis of Synovitis by Ultrasonography in RA. Journal of Bone Spine 2009;76:265-7. Roth J, Collado P, Vojnovic D, Iagnocco M, dAgostino MA, Bruyn G, Naredo E. Omeract Definitions and Scoring for Synovitis on Ultrasonography in Children. Manuscript in preparation - 2015.

Roth J, Jousse-Joulin S, Magni-Manzoni S, Narrodi A, Tzaribachev N, Iagnocco A, Naredo E,

D’Agostino M.A, Collado P. Omeract Definitions for the Sonographic Features of the Normal Pediatric

Joint. Arthritis Care Res (Hoboken). 2014 Jul 21. doi: 10.1002/acr.22410

Rudwaleit M , van der Heijde D et al. The Assessment of Spondyloarthritis International Society Classification Criteria Ann Rheum Dis 2011;70:25-31. Saleem B et al. Can Flare be predicted in DMARD treated RA patients in remission ? A cohort Study. Ann Rheum Dis 2012;71:1316-21 Scheunemann I, Dannecker GE, Roth J. Phalangeal bone ultrasound is of limited value in patients with juvenile idiopathic arthritis. Rheumatology 2006; 45(9):1125-1128 Schmidt WA, What the practicing rheumatologist needs to know about technical fundamentals of ultrasonography.2008 Clinical Rheumatology;22:981-999. Sibbit W.L.et al. Does Sonographic Needle Guidance Affect the Clinical Outcome of Intraarticular Injections. J. of Rheum. 2009;36:1892-902. Sonographic appearance of the posterior interosseous nerve at the wrist. Smith J, Rizzo M, Finnoff JT, Sayeed YA, Michaud J, Martinoli C. J Ultrasound Med. 2011 Sep;30(9):1233-9. Stress fractures of the ankle malleoli diagnosed by ultrasound: a report of 6 cases. Bianchi S, Luong DH.Skeletal Radiol. 2014 Jun;43(6):813-8. Ultrasound demonstration of distal biceps tendon bifurcation: normal and abnormal findings. Tagliafico A, Michaud J, Capaccio E, Derchi LE, Martinoli C. Eur Radiol. 2010 Jan;20(1):202-8. Ultrasound demonstration of distal triceps tendon tears. Tagliafico A, Gandolfo N, Michaud J, Perez MM, Palmieri F, Martinoli C. Eur J Radiol. 2012 Jun;81(6):1207-10. doi: 10.1016/j.ejrad.2011.03.012. Epub 2011 Mar 21. Ultrasound-guided interventional procedures around the shoulder. Tagliafico A, Russo G, Boccalini S, Michaud J, Klauser A, Serafini G, Martinoli C. Radiol Med. 2014 May;119(5):318-26. doi: 10.1007/s11547-013-0351-2. Epub 2013 Dec 3. Review. US imaging of the musculocutaneous nerve. Tagliafico AS, Michaud J, Marchetti A, Garello I, Padua L, Martinoli C. Skeletal Radiol. 2011 May;40(5):609-16. doi: 10.1007/s00256-010-1046-6. Epub 2010 Oct. 8. Ultrasound of distal brachialis tendon attachment: normal and abnormal findings. Tagliafico A, Michaud J, Perez MM, Martinoli C. Br J Radiol. 2013 May;86(1025):20130004. doi: 10.1259/bjr.20130004. Epub 2013 Feb.

Visualization of the Long Thoracic Nerve using High-Resolution Sonography. Lieba-Samal D, Morgenbesser J, Moritz T, Gruber GM, Bernathova M, Michaud J, Bodner G. Ultraschall Med. 2015 Jun;36(3):264-9. doi: 10.1055/s-0034-1366084. Epub 2014 Mar.

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Wakefield RJ, Balint PV, Szkudlarek M, Filippucci E, Backhaus M, D'Agostino MA, Sanchez EN, Iagnocco A, Schmidt WA, Bruyn GA, Kane D, O'Connor PJ, Manger B, Joshua F, Koski J, Grassi W, Lassere MN, Swen N, Kainberger F, Klauser A, Ostergaard M, Brown AK, Machold KP, Conaghan PG, OMERACT 7 Special Interest Group. Musculoskeletal ultrasound including definitions for ultrasonographic pathology. J Rheumatol. 2005 Dec; 32(12):2485-7 Wakefield RJ, D’Agostino MA, Naredo E et al After Treat to target, can targeted ultrasound initiative

improve RA outcomes? Ann. Of Rheum Dis. 2011;10;1136.

Specific Information: Training Programs

3. Are there training programs and/or established clinical fellowships for this discipline

in Canada? Yes No (Please describe including where the training takes place, how many trainees/year, what is the duration of the training, what are the sources of funding for these programs.)

NMSKUS Fellowship - Université de Montréal

The University of Montreal is offering a fellowship program in neuromusculoskeletal ultrasound in 2016. The directors of this fellowship have been trained by pioneers in the field of neuromuscular and musculoskeletal ultrasound. It is expected to be the richest experience in neuromusculoskeletal ultrasound training outside of Europe. This experience will lead diplomats to challenge multiple streams of NMSKUS and be academic leaders in the field. CRUS Training Program McMaster University

Currently, those interested in ultrasound training for Rheumatology (RhMSK) obtain training from a number of varied programs including short courses in the United States and Europe. The best established and recognized training in Canada is offered through CRUS at McMaster University. A French language experience is offered at University de Sherbrooke. The current formal training available is less robust than anticipated for the AFC competency. The diversity of current training opportunities and lack of standardization of competencies is a key driver in the push for an AFC.

Specific Information: Effects of the Diploma

4. How will the recognition of this proposed diploma discipline affect the parent

(sub)specialty(ies) and other related specialties? (Will there be overlap of patient

populations, procedures, investigative techniques, areas of research? Please include both

positive and negative implications.)

The recognition of this diploma will compliment patient care by applying NMSKUS ultrasound in a timely manner and more precise evaluation of patients with MSK, Neuromuscular and rheumatological pathology. We do not see any conflict with other specialties. Anecdotal experience to date with the above applicants and co-applicant and local radiologists has been particularly positive. Notably, MSK radiologists often enjoy the discussion of difficult, interesting or rare cases. We view NMSKUS equivalent to using a stethoscope; it is a specialized tool to be employed by trained practitioners on the front lines of care. In musculoskeletal and neuromuscular medicine, the overlap with other specialists is minimal. Current imaging specialists often prefer MRI over

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ultrasound as it is less time consuming from both a data acquisition and reporting perspective and current resources do not support widespread use of ultrasound. As mentioned previously, training for technician sonographers is limited to the chest, abdomen and peripheral vascular systems. They have no exposure to the musculoskeletal system in technical school and have to be educated within hospital systems afterwards. Therefore, their exposure is only to the most common pathologies, such as the evaluation of the rotator cuff, Achilles tendon and Morton's neuroma. However, the use of ultrasound at the bedside for the spectrum of NMSK pathology has profound implications on the reduction of time to treatment, medical cost and return to work.

The use of ultrasound in the evaluation of the peripheral nervous system is restricted to a small group of subspecialty radiologists in only a few academic centres in Canada. There are no negative implications to using ultrasound to diagnose lesions of the peripheral nervous system as the unmet needs are significant and the benefits to patients and practitioners are great. The most obvious benefit will be the reduction of the use and dependence upon MRI as an imaging modality and reduce the number of unnecessary MRI evaluations. In fact, the resolution of ultrasound is better than MRI in the major of cases of injury to the peripheral nervous system. NMSKUS in the hands of skilled clinicians will also increase the complexity of the pathology referred to radiologists for MRI evaluation and enhance the academic radiology fellowship exposure.

Current imaging specialists (radiologists) and subspecialists (MSK radiologists) are available as consultants when one requires expert advice on complex issues. In essence, the implications are generally positive and will help enhance research in all areas of NMSKUS. This can be seen in Europe where radiologists, rheumatologists, orthopedic surgeons and neurologists are combining efforts on research publications that overlap each of their fields of medicine.

5. a) How would recognition of this diploma discipline affect: (Impact should be

interpreted broadly and include community, the delivery of medical care, cost-savings.

Population health data should be included, if applicable.) i. Delivery of medical care

Synovitis assessments by clinicians, through the detection of swollen joints, has previously been assumed as the gold standard by many Rheumatologists. However it is poorly reproducible and insensitive (Pincus, 2008). There is a need for a better modality of assessment that can be applied in daily practice. Ultrasound can have the potential to fulfill this role and aid in clinical decision making, improvement in a timely diagnosis, procedural treatments and disease monitoring. Combining clinical findings with real time dynamic imaging and Doppler scanning makes the use of ultrasound a powerful addition to the diagnostic skills of a Rheumatologist. Improved efficiency will lead to fewer visits and reduced wait times. Improved diagnostic accuracy will lead to better treatment decisions and improved patient outcomes. Image guided procedures will be performed in a more timely manner, with improved accuracy, less pain and better outcomes. Trained clinician sonographers will be employing injection techniques for diagnosis and treatment in their office settings rather than referring to hospital facilities.

Neuromuscular practitioners often have to evaluate individuals over a series of appointments to complete the necessary nerve conduction studies and electromyography. Ultrasound has shown to be effective in decreasing the number of muscles evaluated, increasing the confidence in diagnosis of multiple focal peripheral nerve lesions and is helpful in technical procedures and guidance of the EMG needle. It also helps to overcome many of the technical pitfalls of nerve conduction studies and provides an anatomic correlate to demyelination where applicable.


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Anecdotally, patients are more satisfied with the clinical assessment and show greater engagement in their own assessment and care when ultrasound is used as a modality in the clinic. They appreciate the visual explanation of pathology and are amazed by the procedural applications and needle visualization. ii. Meeting community needs

Demand for care and evaluation has resulted in excessive wait times for MSK conditions that are a primary reason for seeking medical care. Prevalence of MSK conditions as a reason for medical care is very high, while the physician to population ratio is unacceptably low (St. Sauver JL, 2012). NMSKUS in the hands of skilled clinicians improves quality and efficiency of care (Moore, 2011) and has the capacity to significantly reduce health care costs (Micu 2013, Kay, 2014). iii. Health care budgets

A reduction in the use of more costly and limited access MRIs for NMSK conditions, especially in rural and smaller communities, but also in all urban centres. MRIs of shoulders will be replaced by shoulder ultrasounds in the majority of studies. Ultrasound will replace MRI’s for the detection of joint erosions.

Joint aspirations and injections will be conducted in ambulatory care settings. A reduction in the number of follow-up visits to review results from third party imaging departments can be anticipated. A reduction in referrals to orthopedic specialist for nonsurgical musculoskeletal pathologies and a reduction in second opinion consultations to fellow colleagues is anticipated because of the added diagnostic confidence from ultrasound. Health care savings are anticipated and budgets should not be adversely affected.

iv. By the numbers

Assume Catchment of 100,000 patients for simplicity Number of rotator cuff tendinopathies per year = 11,200 (Van der Windt, 1995). Assume half of the patients get better and half present with pathology 11200/2 =5600. To scan these patient a radiology dept would have to scan 15 shoulders a day, every day, all year (5600/365=15). This would overwhelm their resources without the addition of any other NMSK pathology. Assume 10% of these get an MRI = 560 MRIs ($448,000).

The average Shoulder MRI is ~$800-1500 with time to complete 30 mins. The average Shoulder US is ~$50-350 with time to complete 15 mins.

Note: A shoulder US is not a billable service by non-radiologists in most provinces.

Therefore, if one NMSKUS clinician reduces the number of MRIs required by 50% that clinician saves the health system $224,000.

Let us envision we only train 10 NMSKUS clinicians per province. With only 10 clinicians per province, the savings reach $30 million per year for ONE pathology.

b) What role will the consultant in the proposed diploma discipline play in meeting

community needs?

Diploma candidates will provide front line consultation for primary care physicians and specialists alike. They will assist in diagnosis and interventional therapy where ultrasound guidance is known to be of added benefit in both accuracy and efficacy.

http://www-ncbi-nlm-nih-gov.ezproxy.library.ubc.ca/pubmed/?term=St%20Sauver%20JL%5BAuthor%5D&cauthor=true&cauthor_uid=23274019


22

Establishing the proposed diploma will also facilitate the expanded education required for physician sonographers and thereby perpetuate the improvement in diagnostic ultrasound, enhanced patient care, reduction of wait times and health care costs.

c) Describe the academic role of the consultant in this discipline. (What would be the

requirements for teaching and research, if the specialist was part of an academic/tertiary

care centre?

NMSKUS specialists in Academic centres would be expected to act as resources for their colleagues as well as provide teaching ultrasound to local subspecialty trainees as well as AFC trainees as required. It is expected that as leaders in their field they will continue to participate in individual or group research projects that enhance the discipline.

d) Describe the patient population served by this discipline.

Any patient presenting to an adult or pediatric rheumatologist, physiatrist or sports and exercise medicine specialist may be a potential candidate for an ultrasound evaluation to compliment the history, clinical assessment, and prior investigations. Patients pathologies include degenerative arthritis and inflammatory disease such as RA, SLE, Sjogren’s syndrome, psoriatic arthritis, temporal arteritis, juvenile arthritis and all common regional conditions such as tendinopathy of hip and shoulder, and repetitive strain / overuse injuries. Crystal induced arthritis such and Gout and CPPD are also conditions that can be readily diagnosed on US, even before any laboratory confirmation is made. Ultrasound is the imaging modality of choice in the diagnosis for all tendinopathies, ligament lesions, enthesitis, joint effusions and for all injuries to peripheral nerves and pattern recognition in myopathies.

e) Please estimate how many physicians are currently practicing the proposed diploma

discipline in Canada and in which locations. (This should reflect the national physician

workforce for the proposed specialty/subspecialty.)

BC: 9 AB: 12 MB: 1 SK: 2 ON: 20 QC: 14 NS: 2 NL: 1 Approximately 60 physicians.

f) Describe the current practice profiles of the physicians engaged in this discipline.

Clinical adult and pediatric rheumatologists, many with academic appointments and others in urban and rural community practice.

Clinical electrophysiology specialists (both neurology and physiatry) with academic appointments in urban and rural community practice.

Clinical physiatrists in academic, urban and rural community practice.

Clinical Sport and Exercise Medicine physicians in academic, urban and rural community practice.


23

g) Outline future (5 years and 10 years periods) projected workforce needs (FTEs) for

practicing physicians in the proposed field.

Workforce needs are anticipated to increase with the aging Canadian population. Musculoskeletal, rheumatologic and neuromuscular pathologies within this demographic typically increased with age.

Therefore, all interested rheumatologists, physiatrists and other MSK physicians will see the need for training over the next 10 years. All current trainees in rheumatology and physiatry are encouraged to acquire these skills or be acquainted for when they should be employed. All current practicing physicians are offered the opportunity to train. h) What is the impact of technology both in terms of requirements to practice and

expected impact of future technological development on the need for the proposed

diploma?

All necessary equipment is currently available for purchase. Equipment required is developing yearly into more compact units with better resolution, faster processors and better storage systems. Hardware costs are expected to diminish. 6. Why is recognition by the Royal College essential for the success of the proposed

diploma discipline?

Certification is an important step in developing an area of physician practice and a large step in professional development. Technology, and specifically ultrasound in the hands of every clinician, is having a major impact on future practice, workforce needs and the overlapping scope of physician specialty practice. The Royal College is recognized by provincial and federal health care organizations and credentialing bodies as an important marker of quality. The Royal College AFC Diploma program is the ideal format to introduce an accredited training program in NMSK ultrasound in Canada. The Royal College is well suited to take this lead role as recognition by the College will further support the acceptance of this new technology as an important addition to the skill set of many rheumatologists and physiatrists. The Royal College AFC Diploma in NMSKUS will facilitate standardization and accreditation to all proposed training programs. It will provide the foundation for skill validation in the NMSKUS credentialing process. This recognition and standardization will provide an accredited pathway for competency, an important element that will encourage others to seek such training and discourage practice in untrained hands. Formal recognition will also allow universities to develop predictable funding models for trainees. The NMSKUS program will include maintenance for continuing education to maintain competency. 7. What would be the projected effects on the Canadian health care system from the

recognition of the proposed diploma discipline? Include both potential positive and

negative impacts.

Improved quality of care would meet or exceed standards that are now developing in the USA and Europe. There are no increased costs anticipated as any incurred will be offset by improved efficiencies and reduced utilization of physician services of other more costly modalities such as MRI. The potential negative impact might be the perceived necessity of obtaining this diploma credit to practice rheumatology and physical medicine and rehabilitation and other MSK programs at an advanced level. Physiatrists and rheumatologists have a long history of subsets of advanced training in all areas of clinical and laboratory medicine. All serve to enhance and advance the practice of their respected disciplines.


24

8. Please identify Canadian organizations and stakeholders who should be consulted

regarding this application. (Other than the groups identified in the Part II, Consultation

section.)

Specialty Committee of Diagnostic Radiology

Specialty Committee of Physical Medicine and Rehabilitation

Specialty Committee of Neurology

Specialty Committee of Sport and Exercise Medicine

Specialty Committee of Rheumatology

Canadian Association of Physical Medicine and Rehabilitation (CAPMR)

Canadian Rheumatology Association (CRA)

Canadian Association of Sport and Exercise Medicine (CASEM)

9. Please describe why the proposed diploma discipline has not been written into the

competency training requirements of the represented specialties.

A portion of the answer to this question is addressed above regarding recognition by the Royal College. At present, equipment, expertise and time are barriers to widespread implementation of ultrasound within each of the respective residency programs. A post graduate diploma certification in Neuromusculoskeletal Ultrasound will be required even after ultrasound has been incorporated into medical school curricula and competency training requirements for various residency programs in the future. At the present time residency training programs have minimal additional time for additional skills. The skills required for the NMSKUS diploma discipline could be started within a residency training program and we anticipate that all residency programs will create competency training requirement for ultrasound in the future. However, even this will take an additional 5-10 years prior to implementation. After residency there will be a need to standardize the expectations for competency and promote the incorporation of ultrasound into clinical practice and management. A precedent exists already within Canada. The knowledge base and skills in electrodiagnostic medicine (what many call “EMG”) are currently integrated into the objectives of training of both neurology and physiatry residency programs. However, the skills required to practice independently in the community or academic practice often require additional training either through electives or a fellowship. A standard evaluation is offered by the Canadian Society of Clinical Neurophysiologists and is considered the standard for credentialing EMG labs across the nation.

10. Why does Rheumatology (RhMSK) require a stream separate from MSKUS?

The focused competence of diagnostic ultrasound in the hands of a Rheumatologist is unique even within the realm of subspecialty radiologists including MSK fellowship trained radiologists. The foundational textbooks on musculoskeletal ultrasound (Bianchi et al., 2007; Jacobson, 2012) lend minimal emphasis on the inflammatory pathologies that are seen in daily practice by these specialists. The literature and research focus of RhMSK is almost exclusively performed by rheumatologists and MSK radiologists (in Europe, much less so in North America). The literature is found in academic journals of rheumatology almost exclusively.

11. Why does Pediatric Rheumatology (pRhMSK) require a stream separate from RhMSK?


25

Pediatric rheumatologists are first pediatricians. Therefore, there is no exposure to adult pathology other than clinical practice or during training. It would be unreasonable to expect a practicing clinician to learn and find pathology outside of their current scope of practice. Children are not simply “small adults” and the development process of the musculoskeletal system is paramount to

understanding the normal and pathologic imaging characteristics of patients who present to the pediatric rheumatologist. An adult rheumatologist, well versed in ultrasound, would have difficulty discerning normal from abnormal processes in a developing child as they have no exposure in clinical practice to normal developing joints. An adult rheumatologist would overcall pathology in this setting. Although the name of the pathology may be similar (eg inflammatory arthropathy) the imaging characteristic of presenting children and adults are vastly different. The expectations for the pRhMSK stream are to provide a standard to which all practicing pediatric rheumatologists can strive to achieve. Expecting a pediatric rheumatologist to be competent in adult medicine is akin to expecting an MSK radiologist to perform a shoulder exam like a physiatrist.

Application for Recognition of an AFC (Diploma) Discipline Application- Part I

26

Discipline Specific Information

A completed application form must include the following: 1. Competency Training Requirements (CTR) for the diploma discipline.

The Competency Training Requirements are attached in a separate document.

2. A proposed strategy for the assessment of competencies to ensure that graduates of

postgraduate training programs in this proposed diploma discipline are competent

specialists.

Assessment of competence will focus on three areas of knowledge and skill: knowledge base with standardized questions, image acquisition with image and video submission and procedural skills with video submission to an e-portfolio. The e-portfolio program would allow submission of acquired images and video, evaluation of this data by blinded assessors, return of images with commentary and the ability of students to read comments and resubmit revisions. Image categories for evaluation would be based on the stream of applicant. Please see examples in the attached CTR and “CRUS Images” documents. The use of an e-portfolio, much like Mainport, may be used to follow acquisition of competence and progress through the objectives of training.

Outline the implementation issues for the proposed diploma discipline. Include

information on:

a) Number of sites capable of mounting a training program in Canada, including the

number of training positions estimated at each site.

UBC 1 / UBCO 1 / Calgary 2/ Edmonton 1 / Toronto 1 / Hamilton-2/ Ottawa 2/ Sherbrook 2/ Montreal 2/ Winnipeg 1/ Saskatoon 1/ Nova Scotia 1. This assessment would be based on the presence of an approved supervising tutor.

b) Please estimate the number of faculty currently available nationally with expertise

in the proposed diploma discipline and identify where they are located across the

country.

Approximately 20 for all NMSK-NMSKUS Streams. Including: Drs. Chaiton, Inkpen, Larché, Rajasekaran, Michaud, Luong, Roth, Bruns, Bagovich, Chow, Eder, Fernandes, Wilson, Stein, Ahluwalia, Yuen, Hazeltine, Fallavollita and Ciubotariu.

BC Children’s Hospital/ Vernon / Edmonton / Calgary/ University of Toronto/ McMaster University/ Universite of Montreal / University of Ottawa/ University of McGill/ Sherbrooke/ Sunnybrook.

c) What will be the funding implications for training opportunities?

Fees as per the Royal College schedule for diploma programs. As trainees will be licensed specialists, it is anticipated that training may occur in modified working environments allowing them access to fee-for-service income.

Application for Recognition of a Specialty or Subspecialty Application- Stage II

27

d) Please describe any anticipated impacts on Postgraduate Medical Education or

practice systems in any region. There are no impacts anticipated. Some subspecialty trainees may elect to begin accrual of their diploma competencies during their available elective time.


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Appendix A:

Form Letter Sent to Subspecialty Heads

Dear Dr. _____________________,

The time has come in Canada for subspecialties to employ new emerging technology of bedside ultrasonography in the assistance of clinical problem solving by clinicians who are performing these assessments. In Rheumatology this skill is used to assist in diagnostic, therapeutic and prognostic purposes. We see this tool as a modern fixture in the hands of many physicians in multiple disciplines.

As representative of Canadian Rheumatologists and Chair of our committee on AFC Diploma Submission to the Royal College Committee on Specialties (COS), we have been encouraged to invite your Specialty group of ___________________ to consider joining our application as an independent stream in a new, yet to be approved, AMBULATORY CARE POINT OF CARE (AC_POCUS), AREA OF FOCUSED COMPETENCY (AFC), DIPLOMA program. Our interest is to encourage the skilled use of ultrasound in medical practice at point of care. The Royal College via the AFC Diploma structure would validate this extended scope of practice, ensure a standardized level of competency with training guidelines, provide a pathway to accreditation and encourage the establishment of funded training centres across the country.

I have attached for your interest the current definition of an AFC and a list of currently approved AFC’s. No ultrasound AFC has yet been established, however, Emergency Medicine has received

initial favorable approval for an EM-POCUS, Diploma program. This is currently in development. Their focus is solely emergency acute care scenarios.

There is a much broader need for the application of ultrasound in ambulatory care settings, not only in our Specialty of Rheumatology, but in _________________ as well. This emerging discipline is already considered standard of care in the USA and Europe. The Canadian Rheumatology Ultrasound Society has been engaged in teaching NMSKUS to over 100 practicing Rheumatologist and to fellowship trainees in many centres during the past 5 years.

We are hopeful that our Diploma application will be accepted favorably with the addition of your Specialty (__________________), and other subspecialties. Our intent is to make an application for an Ambulatory Care -POCUS- MSK stream. Letters of interest from yours and other specialties

are welcome, and would add to the strength of this proposal.

Ambulatory Care NMSKUS (AC-POCUS) is meant to be a generic category to which other Specialties could join . All programs would share a core competency and then each stream would define those skills that their practitioners need to acquire in order to satisfy the Diploma requirements.

What we need from you

Please discuss this request with your colleagues. At this stage we are interested in proceeding with a request for an Ambulatory Care POCUS Diploma and establishing Rheumatology as the initial stream. Our application would be strengthened by a letter of interest from your Specialty, and would pave the way for many added streams. Your letter could include a description of those skills or competencies required in your specialty stream.


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Time Frame

We intend to submit our application by September 1st, 2015. A letter of interest by then would be ideal, however if that time frame is too short , a letter indicating that this proposal is under discussion by Sept 1st followed with a final opinion, received by October 15th would be acceptable. The Committee on Specialties will table this application in early November.

For More Information

Contact the Royal College Committee on Specialties and speak to Sarah Taber, Lisa Gorman, Michael Powel, or Dr. Jason Frank. Phone: 1-800-668-3740 Or email [email protected]

Please call me to discuss this matter in greater detail if required. Cell # 416-705-0696 Or email @ [email protected]

**Attachment As of April 2015, the following AFC (diploma) disciplines have been formally approved by the Education Committee of the Royal College:

Addiction Medicine Advanced Heart Failure and Cardiac Transplantation Adolescent and Young Adult (AYA) Oncology Adult Cardiac Electrophysiology Adult Echocardiography Adult Hepatology Adult Interventional Cardiology Adult Thrombosis Medicine Aerospace Medicine Brachytherapy Child Maltreatment Pediatrics Clinician Educator Cytopathology Hyperbaric Medicine Solid Organ Transplantation Sport and Exercise Medicine Transfusion Medicine Trauma General Surgery

Addendum: This letter was sent in July, 2015 to Neurology, Family Medicine, General Internal Medicine, Plastic Surgery, Sports and Exercise Medicine, Orthopedics, Physical Medicine and Rehabilitation, and Rheumatology specialty committees. All but the latter two replied with interest. Since that time considerable revisions to the core application have been made and another letter sent describing the NMSKUS application. This letter was sent via email in November, 2015 and individual chairs of specialty committees were then contacted again in November via e-mail or phone. Again, a lack of response was generated. If there was an appetite to join the application or

tel:1-800-668-3740


tel:416-705-0696



30

reasonable opposition to the notion of this AFC Diploma than we would have heard some form of response. It is not for lack of effort on the part of the applicants that other specialty committees or societies have not responded as stakeholders in this AFC application. Template letter of support for the NMSKUS AFC Dr. Jason Frank

Director, Specialty Education, Strategy and Standards

Office of Specialty Education

The Royal College of Physicians and Surgeons of Canada

774 Echo Drive

Ottawa, ON K1S 5N8

RE: Pending application:

Area of Focused Competence - Diploma of Neuromusculoskeletal Ultrasound (NMSKUS)

Dear Dr. Frank, We have reviewed the above-mentioned AFC application that is pending before the office of education. Currently the Canadian Association of Physical Medicine and Rehabilitation (CAPMR) is interested in the role of NMSKUS in providing enhanced patient care. At present, equipment, expertise, and time are barriers to widespread implementation of ultrasound in clinical practice. However, with time we see a vastly expanded role of NMSKUS for our members. We believe that a post graduate diploma certification in Neuromusculoskeletal Ultrasound will be required even after ultrasound has been incorporated into the objectives of trainings multiple specialties in the future. There will be a need to standardize the expectations for competency and promote the incorporation of ultrasound into clinical practice. We fully endorse the above-mentioned application and anticipate that members of our respected specialty will participate in the diploma program as committee members, reviewers, and diplomats in the streams of neuromuscular (NMUS) and musculoskeletal ultrasound (MSKUS). Sincerely,


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Appendix B:

Ultrasonography Refresher/Intermediate Course – Hand and Wrist; Foot and Ankle

(Director: Alessandra Bruns, MD MSc)

Day 1

- Indications of Doppler Ultrasound in Rheumatology Maggie Larché, M.D. - Physics and Artefacts of Doppler Ultrasound Lene Terslev, M.D. - Optimizing Doppler Settings Lene Terslev, M.D. - « Hands-on » : Train to adjust Doppler settings correctly (patients) Hand and wrist – Review of Normal Sonoanatomy David Bong, MD« Hands-on » : Standardized scans of hand and wrist – normal subjects - What rheumatologists must know about ligaments of the hand and wrist? Alessandra Bruns, MD - « Hands-on » : hand and wrist pathology – patients Practical Evaluation – hand and wrist - normal subjects Day 2

- Bone damage in Inflammatory Arthritis Lene Terslev, M.D. - Foot and ankle – Review of Normal Sonoanatomy David Bong, MD - « Hands-on » : Standardized scans of foot and ankle – normal subjects - What rheumatologists must know about the subtalar joint and sinus tarsi? Alessandra Bruns, M.D. - Enthesitis Lene Terslev, M.D. - « Hands-on » : foot and ankle pathology - patients - Practical evaluation – ankle and foot - normal subjects Pediatric Group

- Hand and Wrist – Review of Normal Sonoanatomy (including ligaments and Doppler settings) Johannes Roth, MD - « Hands-on » : Hand and Wrist – normal children Johannes Roth, MD/Alessandra Bruns, M.D. - Foot and Ankle – Review of Normal Sonoanatomy (including ligaments and Doppler settings) Johannes Roth, MD - « Hands-on » : Foot and Ankle – normal children Johannes Roth, MD/ Alessandra Bruns, M.D


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Appendix C:

American College and Society Position Statements

Published 2013

AMERICAN COLLEGE OF RHEUMATOLOGY POSITION STATEMENT

SUBJECT: Musculoskeletal Ultrasound PRESENTED BY: Committee on Rheumatologic Care POSITIONS

Musculoskeletal ultrasound is a meaningful tool used by rheumatologists in the diagnosis, management, and treatment of rheumatic conditions.

The use of musculoskeletal ultrasound in rheumatology practice requires training and experience.

The ACR encourages rheumatologists to pursue a training/certification process of the members’ choice.

Rheumatologists who have pursued training /certification in musculoskeletal ultrasound should receive recognition for their musculoskeletal ultrasound services.

BACKGROUND Musculoskeletal ultrasound (MSUS) is patient friendly, noninvasive, radiation-free, and relatively inexpensive compared with other imaging modalities. This imaging modality is utilized widely for the diagnosis and treatment of many rheumatic conditions. For example, MSUS verifies joint inflammation and damage, detects erosions in all stages of disease, and clarifies the physical exam efficiently. This information enhances patient care by assessing responses to treatment, helping with decisions about changing therapy, and improving joint injection accuracy and outcome (1-3). MSUS guidance improves needle placement, reduces procedural pain during arthrocentesis, and improves clinical outcomes. For example, US guided aspiration, drainage, and injection of hips remains a reliable, lower cost procedure where imaging guidance is necessary (1). There is considerable evidence for the importance of ultrasound assessment in rotator cuff and other shoulder diseases (1). MSUS has been found to reliably detect disease where the clinical assessment remains uncertain and is particularly helpful in distinguishing inflammatory from noninflammatory conditions (4,6,9). Again, in many cases, an experienced user not only confirms the disease process, but also gathers necessary information that contributes to treatment decisions. The extent of disease and damage accrual may be determined at the point of care which avoids delays in appropriate therapy, precludes more expensive testing and procedures, and leads to more affordable, quality patient care (4-8). Reasonable use of MSUS by rheumatologists has recently been systematically reviewed and published (1). Rheumatologists continue to add value to the treatment of musculoskeletal conditions, and MSUS is just one example of how rheumatologists save money in healthcare. Appropriate substitution of MSUS over other modalities results in substantial cost savings (4-8). Moreover, earlier detection and treatment of rheumatic conditions may lead to a decrease in costly procedures, burdensome disease complications, and missed work or disability. Throughout the world, this technology is widely recognized as a forefront procedure that enhances patient care. Rheumatologists remain the authority in the management and treatment of arthritis conditions, and MSUS remains a meaningful diagnostic and interventional tool in rheumatology practices.

See Appendix A: American College of Rheumatology Position Statement Resources


33

The American College of Rheumatology has launched in May 2013 a Certification Program in MSK

Ultrasound. After meeting a set of eligibility requirements, they offer 6 pathways to certification to

become RhMSUS certified. In Canada , we feel that Education, Training and Certification of

Competence is best under the umbrella of the Royal College of Physicians and Surgeons

of Canada accreditation.

In a similar fashion and The American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM), has also published a Neuromuscular Ultrasound position statement regarding appropriate training for the ultrasound evaluation of peripheral nerve and muscle diseases in the EMG laboratory. (Walker, 2010). While neuromuscular Ultrasound is distinct from MSK Ultrasound there are overlapping areas of interest that include inflammatory muscle diseases and entrapment neuropathies. If approved, we feel that the neuromusculoskeletal point of care ultrasound (NMSK-NMSKUS) Diploma program, would be the best format to provide education and training to interested rheumatologists, physiatrists, and other neuromuscular and musculoskeletal practitioners in Canada.

American College of Rheumatology Position Statement Resources

American College of Rheumatology. Ultrasound in American Rheumatology

Practice: Report of the American College of Rheumatology Task Force. Arthritis Care and

Research, Vol. 62, No. 9, p 1206-1219, 2010. McAlindon, T. et. al. American College of Rheumatology Report on Reasonable Use of

Musculoskeletal Ultrasonography in Rheumatology Clinical Practice. Arthritis Care and

Research, Vol. 64, No. 11, 1625-1640 2012. Larche, J et al. Utility and Feasibility of Musculoskeletal ultrasonography (MSK US) in

rheumatology practice in Canada: needs assessment. Clinical Rheumatology, Vol 10, p 1277-83, 2011.

Moore, C. et al. Point-of-Care Ultrasonography. The New England Journal of Medicine, Vol. 364, p 749-757 2011.

Medicare Imaging Payments. Washington DC: Government Accountability Office.

(GAO-08-452) 2008.

Troum, O. et al. Newer Imaging Modalities; Their Use in Rheumatic Diseases. Update to

Rheumatic Disease Clinics in North America, Vol 4, No 3, 2011.

Parker, L. et al. Musculoskeletal imaging: medicare use, costs, and potential for costsubstitution. Journal of American College of Radiology, Vol. 5 No. 3, p 182-188, 2008.

Sibbitt W. et al. A randomized controlled tiral of the cost-effectiveness of ultrasound-guided intraarticular injection of inflammatory arthritis. J Rheumatol 2011; 38:252-639. Iagnococo, A. et al. Ultrasound imaging for the rheumatologist. XVII. Role of colour Doppler and power Doppler. Clin. Exp Rheumatol 2008;26:759-62.

American Academy of Neuromuscular and Electrodiagnostic Medicine Position Statement

Resources


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Cartwright MS et al. Evidence-based guideline: neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. Muscle Nerve. 2012 Aug;46(2):287-93

Walker FO et al. Qualification for Practitioners of Neuromuscular Ultrasound: Position Statement

AANEM Muscle & Nerve 2010; September: 442-443.

http://www-ncbi-nlm-nih-gov.ezproxy.library.ubc.ca/pubmed/?term=Cartwright%20MS%5BAuthor%5D&cauthor=true&cauthor_uid=22806381


35

Appendix D

Data Collection Document to be Completed Every 12 Weeks for each Enrolled Patient


36

Appendix E

Rheumatology Enrollment Sites for ECHO Study

Hector Arbillaga #302 888 4th Ave. SW Calgary Calgary

AB

Vandana Ahluwalia 314-40 Finchgate Blvd. Brampton Brampton

ON

Sangeeta Bajaj 314-40 Finchgate Blvd Brampton Brampton

ON

Susan Barr 3280 Hospital Drive NW Calgary Calgary

AB

Claudie Bergeron Centre Hospitalier régional de Rimouski, 150 Avenue Rouleau Rimouski Q

C Elena Ciubotariu Les rhumatologues associés de l'hôpital du Sacré

Coeur de Montréal, 12245 Grenet, suite 410 Montreal

QC

Sabrina Fallavollita Jewish General Hospital, 3755 ch Cote-Sainte-Catherine Montreal Montreal

QC

Maggie Larche Suite 702, 25 Charlton Ave E Hamilton Hamilton

ON

Juris Lazovskis 31 Riverside Drive Sydney River Nova Scotia Sydney River

NS

Christopher

Lyddell 10309-98 St Grand Prairie Alberta Grand Prairie

AB

Frederic Massicotte 1551 rue Ontario Est Montreal Montreal

QC

Abraham Chaiton 2115 Finch Ave West suite # 405 Toronto Toronto

ON

Christopher J

Penney 3330 Hospital Drive NW Calgary Calgary

AB

Pooneh Seyed Akhavan

60 Murray St. Suite 2-029 Toronto Toronto

ON

Diane Wilson 78 Masons Beach Rd, box 1617 Lunenburg Nova Scotia

Lunenburg

NS

Olga Ziouzina 330-401 9 Ave SW Calgary Calgary

AB

Artur Fernandes 3001 12e av Nord Fleurimont Quebec Fleurimont

QC

Hany Demian 1250 Castlemore Ave, Unit #1 Markham Ontario Markham

ON

Lihi Eder 1E-415, Toronto western Hospital, 399 Bathurst street Toronto Toronto

ON

Aurore Fifi-Mah South Health Campus, 4448 Front St SE Calgary Calgary

AB


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Appendix F History of CRUS: published in Canadian Rheumatology Association Journal 2013

Utilization of Musculoskeletal Ultrasound in Daily Rheumatology Practice

and Research Maggie Larché, BSc, MBChB, MRCP (UK), PhD; Christopher Lyddell, MBChB, FCP(SA); Alessandra

Bruns, MD, MSc; Vivian Byjerk, MD, FRCPC; Navjot Dhindsa, MD; Karen Adams, MD, FRCPC; Michael Stein, MD, FRCPC; Johannes Roth, MD; Abe Chaiton, MD, MSc, FRCPC

An opportunity for improved diagnosis, therapeutic decision-making and understanding of

pathophysiology of rheumatic disease: The Canadian Experience. Utilization of point-of-care musculoskeletal ultrasound (MSK US) in daily practices of rheumatologists offers important benefits to clinical assessment alone, by facilitating more accurate diagnosis, better therapeutic decision-making, and a greater understanding of the underlying pathophysiology of rheumatic diseases. MSK US can also provide objective measures of clinical outcomes.

History of MSK US

The first reported use of MSK US was by Dussik and colleagues who measured the acoustic attenuation of articular and periarticular tissues including skin, adipose tissue, muscle, tendon, articular capsule, articular cartilage, and bone. Subsequently, MSK US was applied to a MSK diagnosis to differentiate Baker’s cyst from a deep venous thrombosis, and since that time has been

successfully used to investigate a wide range of soft tissue and bony pathologies. The first demonstration of synovitis in rheumatoid arthritis (RA) was performed in 1978 by Cooperberg,who correlated grey-scale images of synovial thickening and joint effusion in the knee with clinical and arthrographic findings before and after treatment with yttrium-90 injection. Several other studies have demonstrated that MSK US is better than clinical assessment in identifying small effusions or synovial proliferation and at evaluating early osteoarthritic changes and/or crystal deposition. Many other advantages of MSK US have been recognized. The high-quality machines that are currently available provide sharply defined images with a high level of spatial resolution (down to 0.1 mm). In addition, power Doppler capabilities, which demonstrate blood flow in the small vasculature, can act as a marker to identify local inflammation, and as a predictor of disease progression. Procedures can be carried out efficiently and are easily repeatable, thus providing an opportunity to monitor patient changes and responses to treatment over time. Furthermore, MSK US guidance provides more accurate needle placement, relative to surface anatomic guidance, for joint and bursa injections at various sites.

Advantages of MSK US Over Other Imaging Modalities

Non-invasive Radiation-free Portable Inexpensive, relative to computed tomography (CT) and magnetic resonance imaging (MRI) Readily accepted by patients, including children Capable of assessing multiple joints in real time Important tool for teaching and communication regarding pathology Advantageous for the dynamic assessment of clinically challenging joints Provides sharply defined images with a high level of spatial resolution Acts as a marker to identify local inflammation, and a predictor of disease progression through power Doppler capabilities Easily repeatable Facilitates more accurate needle placement, for joint and bursa injections15


38

Usage and Practice

MSK US may contribute to more effective disease management with earlier and more accurate detection of synovitis and implementation of optimal therapies. In Canada, this imaging modality provides a more timely evaluation than MRI, with a sensitivity that is equivalent at most sites, when evaluating soft tissue pathologies and bone erosions. Some of the challenges preventing more rapid and widespread implementation of MSK US in daily practice include access to machines, adequate training programs with sufficient numbers of expert mentors, need for harmonization of standards of use at the local and international levels through the introduction of certification programs, and necessary development of regulatory bodies, as well as establishing processes for reimbursement by public and/or private payers. Interest in MSK US among rheumatologists has dramatically increased over the past decade7, in response to its perceived utility in diagnosis and management of rheumatic and MSK disorders, as well as its potential for achieving better clinical outcomes. Europe and South America have been at the forefront of integrating MSK US into daily practice; ongoing initiatives for more than 25 years include the development of an educational framework and various training programs in these countries. MSK US is part of subspecialty training in several countries including Germany and Italy. In a recent questionnaire, it was recently reported that 80% of German rheumatologists use MSK US in daily practice. A 2005 survey found that 93% of British rheumatologists use MSK US in managing patients, and 33% perform US assessments themselves. Although uptake among North American rheumatologists has been slower, the efforts of rheumatology societies have succeeded in raising practitioner awareness that bedside MSK US provides important benefits complementing clinical assessment. Use of MSK US quadrupled in the United States between 2000 and 2008. This increase is primarily by non-radiologists.19 The American College of Rheumatology (ACR) has run an MSK US course for the past three years, and will soon launch a certification of competence examination for rheumatologists in MSK. A train-the-trainers program has as its goal to train at least one teacher at each academic site across the nation. Results of a 2010 needs assessment completed by 156 Canadian rheumatologists reported that 50% of these physicians use MSK US in clinical practice, but only 7% of users performed the scans themselves, with 92% referring to radiology. In the latter group, more than 50% reported a delay of four weeks or longer for the imaging to be carried out. There is clearly an opportunity for improving efficiency by training rheumatologists in point-of care MSK US. CRUS: Development, Research, and Training

Led by Dr. Vivian Bykerk and Dr. Ed Keystone, a committed group of rheumatologists convened an initial meeting in Toronto in January 2009 with the aim of establishing a formal society to promote implementation of MSK US in daily practice and research, and to develop training and certification programs. Through an unrestricted educational grant from Abbott, the Canadian Rheumatology Ultrasound Society (CRUS) was inaugurated in June 2010 and held its first meeting in September 2010. Dr. Bykerk, Dr. Karen Adams, Dr. Alessandra Bruns, Dr. Abe Chaiton, Dr. Maggie Larché, Dr. Johannes Roth, Dr. Michael Stein, Dr. Artur Fernandes, and the late Dr. Visithan Khy were the founding members. The initial focus of CRUS has been on building competence in MSK US among rheumatologists. This is to be achieved through integrated hands on teaching with e-learning (regular uploading of practice images, followed by expert review); Dr. Roth and Dr. Larché have led this initiative. As of May 2013, 65 rheumatologists had participated in the e-learning study, with an additional 25 currently in training. The course consists of three sets of weekend sessions; each session has a didactic and a hands-on training component, including anatomy sessions at McMaster University. Participants engage in self-directed practice sessions during the weeks betweenrweekend sessions. The uploading of images during this time to the CRUS website and expert review provides another learning modality. Thus, since 2010, 12% of Canadian rheumatologists (n = 537) have received training in MSK US. There are also moves to incorporate MSK US in the training programs for rheumatology fellows. A pilot scheme is near completion in Toronto, with 10 fellows being trained over the course of a year; these hands-on sessions are led by Dr. Chaiton, Dr. Larché, and Dr. Pooneh Akhavan. Self-directed practicing of the technique, uploading to the CRUS website, and expert feedback are all a part of the training. Led by Dr. Bruns, the rheumatology fellows at


39

Université de Sherbrooke have been learning US as part of their training for the past five years. In 2013-2014, Ottawa fellows will have the opportunity to learn MSK US with Dr. Roth.

A refresher/intermediate level course led by Dr. Bruns will be offered February 24-25, 2014, in the two days prior to the next Canadian Rheumatology Association (CRA) meeting in Whistler, British Columbia. A certification day will be held the day following the CRA Meeting, consisting of a two-hour written examination and a one-hour supervised scan acquisition using randomly assigned joints and a predefined score sheet. An advanced level course will be planned subsequently at Université de Sherbrooke. Since 2009, Dr. Bruns has run basic and intermediate/advanced courses alternating each year; these are held predominantly in French. A train-the-trainer initiative has begun, with Dr. Bruns leading a group of recently trained rheumatologists in best teaching techniques in US. Furthermore, during the CRUS courses, there are opportunities for more junior teachers to shadow an experienced trainer. In his capacity as officer for training and certification, Dr. Roth has led the development of a WebEx curriculum in rheumatologic US. A series of web-based US tutorials, led by a national or international expert, cover aspects of ultrasonography including treating to target in RA, incorporating US into practice, and challenges of US in vasculitis.

Research is another focus of CRUS. Led by Dr. Michael Stein, the Prospective Observational Study to Evaluate the Use of Musculoskeletal Ultrasonography to Improve Rheumatoid Arthritis Management: Canadian Experience (ECHO study) is a Canada-wide RA outcomes study with two arms (US and control groups) – Appendix C and D. Another initiative is BIODAM, an international study of biomarkers in RA, with seven Canadian centres recruiting for the US arm. Smaller investigator-initiated studies include a foot imaging study in RA, development of a pediatric US atlas, and assessment of the utility of US in decision-making in patients with RA. The practical aspects of implementation of MSK US are also being addressed by CRUS. These include reimbursement, improving access to machines, and advocating for inclusion of ultrasonography in the CRA Rheumatology Guidelines. In partnership with leading researchers, including Dr. Keystone, Dr. Boulos Haraoui, Dr. Bykerk and Dr. Denis Choquette, CRUS aims to increase the awareness of ultrasonography for rheumatologists, to incorporate US in a treat-to-target initiative, and to increase the funding base for rheumatologists to be reimbursed for these procedures. CRUS aims to ensure that the society represents all Canadian rheumatologists interested in MSK US; this will be accomplished by establishing a National Board that will advise the Executive of CRUS. This National Board would enable the creation of a database of rheumatologists interested in MSK US in Canada. CRUS has likewise undertaken an initiative to develop an image bank, a modular series of images for training purposes. The hip modules have been recently completed by Dr. Bruns. A password- protected “members-only” website is also being developed which includes content for further study

by recently trained rheumatologist ultrasonographers.

CRUS: Activism and International Efforts

Canadian rheumatologists involved with MSK US maintain a high profile at the international level. They participate in MSK US training courses offered at ACR and European League Against Rheumatism (EULAR) meetings and the Barcelona sonoanatomy course (held in February each year). Similarly, several international tutors participate in the Canadian basic weekend course. A number of Canadian rheumatologists also are involved in the Outcome Measures in Rheumatology (OMERACT) groups related to ultrasonography. Furthermore, Dr. Chaiton and Dr. Roth have been participating in the ACR certification endeavor as invited members of the Musculoskeletal Ultrasound Certification in Rheumatology (RhMSUS) Examination Development and Review Group for the ACR. Dr. Larché and Dr. Roth are ambassadors for the Targeted Ultrasound Initiative (TUI), an international effort to use MSK US in a treat-to-target approach for RA. Dr. Chaiton is also a member of the Ultrasound Committee of the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). CRUS is part of a multidisciplinary group developing a point of care ultrasonography Diploma with the Royal College of Physicians of Canada. Through these and future endeavors spearheaded by CRUS, the number of Canadian rheumatologists with sufficient expertise to use US in daily practice and monitor patients with MSK diseases will continue to grow until this becomes a widespread practice. CRUS strongly encourages Canadian rheumatologists to take part in the upcoming training opportunities:


40

• Université de Sherbrooke MSK US: o Basic and intermediate/advanced courses available. o For further information, please contact Dr. Bruns ([email protected]) • CRUS Course: o Basic: September 21-22, 2013 and February 1-2, 2014 at McMaster University, and on May 25-26, 2014 at McMaster University. o Refresher/Intermediate: February 24-25, 2014, prior to the CRA Annual Meeting in Whistler, B.C. o For further information, please contact Ms. Alyssa Long ([email protected]).

Maggie Larché, BSc, MBChB, MRCP(UK), PhD

Associate Professor, Division of Rheumatology,

Departments of Medicine and Pediatrics

Staff Rheumatologist, St. Joseph's Healthcare,

Hamilton and McMaster Hospital

Hamilton, Ontario

on behalf of Christopher Lyddell, MBChB, FCP(SA);

Alessandra Bruns, MD, MSc; Vivian Bykerk, MD, FRCPC;

Navjot Dhindsa, MD; Karen Adams, MD, FRCPC;

Michael Stein, MD, FRCPC; Johannes Roth, MD; and

Abe Chaiton, MD, MSc, FRCPC


41

Appendix G

Resident and Fellows Teaching Program at Sunnybrook Hospital, Toronto

Rheumatology Ultrasound Curriculum during PGY-4 and PGY 5 year

Rationale

Scope of problem

Early diagnosis and treatment of inflammatory arthritis such as rheumatoid arthritis is vital to stop

disease progression and prevent complications. Rheumatologists are experts in diagnosing and

treating inflammatory arthritis, however the clinical exam is often inadequate or technically difficult.

Joint effusions can be masked by adipose tissue, or mistaken for edema. There is evidence that the

detection of inflammation may be underestimated by clinical evaluation(1, 2). Similarly, enthesitis, a

feature of spondyloarthritis (SpA), is often difficult to detect, time consuming and has poor inter-

rater reliability(3).

Cortisone injections of joints are commonly used in rheumatology practice, however not all are

effective which may be secondary to improper placement(4). Some studies show the inaccuracy of

injections by clinical examination ranges from 29-63%(4-6). Inaccurately placed injections have

worse outcomes for patients(4). They can develop complications such as post-injection pain, crystal

synovitis, hemarthrosis, joint sepsis, cartilage atrophy or fat necrosis, as well as systemic effects

such as fluid retention or exacerbation of hypertension and diabetes mellitus(7). Therefore, imaging

modalities have been used to aid in correct diagnosis, monitoring and improved safety and efficacy

of joint injections.

Availability of effective solutions

Point-of-care ultrasound (US) is an established imaging modality used by the care provider in real

time to assist in diagnosis, monitoring and clinical interventions(8). The advantages of US compared

to other imaging modalities are its noninvasiveness, portability, relative inexpensive, no ionizing

radiation, real-time dynamic imaging, and repeatability to monitor treatment. In 2001, the Agency

for Healthcare Research and Quality listed the “use of real-time ultrasound guidance during central

line insertion” as one of the top patient safety practices designed to decrease medical errors(9).

In rheumatology, US can be used to diagnose and differentiate between synovitis, tenosynovitis,

tendonitis, tears, bursitis, enthesopathy, erosions, fasciitis and neuropathies(10). Musculoskeletal US

is considerably more sensitive than clinical examination at detecting synovitis(11, 12) and also more


42

specific(12). It has also been shown to predict erosive progression in rheumatoid arthritis and risk of

relapse in those who are in disease remission(13), thus may have a potential role as an imaging

biomarkers. It has been useful in differentiating between rheumatic diseases and monitoring disease

activity in patients receiving treatment. It is patient-friendly and often been referred to as “an

extension of the diagnostic finger” (13). It can be informative to patients and improve compliance.

The US7 score examines 7 of the most commonly affected small joints in RA and has been shown to

be reliable in daily clinical practice as it takes 10-15 minutes(11). US is better at detecting

enthesitis than clinical exam in the lower limbs in SpA (3). There may be an expanding role of

ultrasound for other diseases such as imaging temporal arteries for giant cell arteritis.

Besides clinical diagnosis, US can also improve success and decrease complications of

procedures(8). Whether static or dynamic, it can be used for guidance of aspiration, biopsy, and

injection treatment. Ultrasound has been shown to be more accurate than clinical exam for needle

placement for fluid aspiration of joints and soft tissue(14) (3, 15), up to 97% successful compared

to 32% in conventional group(16), even compared to more experienced rheumatologists (5). The

more accurate the injection, the greater the improvement of function and pain(6, 15), and the less

side effects of steroid (5) (17). US guidance should be considered for joints that are frequently

injected inaccurately such as shoulder, elbows, feet and ankles(2).

There is also evidence that ultrasound guided injections may reduce cost per patient relative to

anatomic guidance(15). In one study there was a 26% increase in responder rate and 62% decrease

in non-responder rate(6). This translates into lower healthcare costs, including fewer future clinic

visits, repeat procedures, telephone calls to physician, delayed surgical and reconstructive

procedures, less use of oral steroids and pain medications, and severe complications. Longer

outcome studies with extensive cost-benefit analysis are necessary to determine long term benefit.

However, it remains clear that US guided IA procedures were superior to blind injections including

reduced procedure pain, absolute and relative reduction in pain outcome, increase responder and

decreased non-responder rates. (6)

In the United States, one in five rheumatologists regularly utilizes musculoskeletal ultrasound in

their practice, although three out of four agree it should be a standard clinical tool for diagnosis,

injection guidance and gauging treatment response(18). As technology spreads, assuring patient

comfort and safety by employing the most accurate injection techniques possible is necessary.

Ultrasound represents the most practical option because it is safe, quick and comparatively less

expensive with no radiation. It is effective at improving clinical evidence and preliminary evidence

suggest patients benefit and may result in long-term health care savings.


43

RhMSK US Education

US is a user-dependent technology so ensuring competence, defining the benefits of appropriate

use, and limiting unnecessary imaging and its consequences is required(8). There must be

appropriate training and quality assurance. It has been postulated at least 70 examinations are

necessary to develop US competence in assessing synovitis in small joints of patients with RA (19).

However, competency should not just be based on numbers but demonstration of knowledge and

skills. To that end, a Diploma of focused competence in Point of Care MSK US is being developed for

the Royal College of Physician and Surgeons of Canada.

Furthermore, it is recognized that musculoskeletal ultrasound is an essential part of a rheumatology

training program, however few Canadian rheumatology trainees have access to regular supervised

training. In a survey of Canadian rheumatology program directors and rheumatology trainees, MSUS

training was available in only 52% of rheumatology trainees in Canada (20), where as every

European country is taught MSK ultrasound (21). The University of Toronto Rheumatology Training

Program is the largest in the country with trainees from across Canada and internationally, thus

providing this opportunity to trainees is valuable.

There is no standardized training program for MSUS and no standard accredited assessment of

competency for rheumatologists to perform MSUS (22, 23). However, an international

interdisciplinary consensus on specific indications, anatomic areas and knowledge and skills required

by rheumatologists performing MSUS was established (24). This is the basis that we have created

our MSUS curriculum.

Sunnybrook Health Sciences Centre is a quaternary care hospital with a large referral base, offering

a diverse range of high acuity in-patient cases as well as general rheumatology ambulatory patients.

There are 5 rheumatologist of whom all have experience as clinical teachers to medical trainees. Two

have had formal musculoskeletal ultrasound education and others have expressed interest in

learning MSK ultrasound. We are also in close proximity to several MSK US expert rheumatologists

who have pioneered the use of MSK ultrasound in Canada and are dedicated teachers. University of

Toronto PGY 4 trainees spend 2 months rotating at Sunnybrook Health Sciences Centre where they

act as a junior attending rotating through out-patient clinics and the inpatient consultation service.

This is an ideal rotation to obtain dedicated MSK ultrasound teaching.

Mission:


41

Appendix G

Resident and Fellows Teaching Program at Sunnybrook Hospital, Toronto

Rheumatology Ultrasound Curriculum during PGY-4 and PGY 5 year

Rationale

Scope of problem

Early diagnosis and treatment of inflammatory arthritis such as rheumatoid arthritis is vital to stop

disease progression and prevent complications. Rheumatologists are experts in diagnosing and

treating inflammatory arthritis, however the clinical exam is often inadequate or technically difficult.

Joint effusions can be masked by adipose tissue, or mistaken for edema. There is evidence that the

detection of inflammation may be underestimated by clinical evaluation(1, 2). Similarly, enthesitis, a

feature of spondyloarthritis (SpA), is often difficult to detect, time consuming and has poor inter-

rater reliability(3).

Cortisone injections of joints are commonly used in rheumatology practice, however not all are

effective which may be secondary to improper placement(4). Some studies show the inaccuracy of

injections by clinical examination ranges from 29-63%(4-6). Inaccurately placed injections have

worse outcomes for patients(4). They can develop complications such as post-injection pain, crystal

synovitis, hemarthrosis, joint sepsis, cartilage atrophy or fat necrosis, as well as systemic effects

such as fluid retention or exacerbation of hypertension and diabetes mellitus(7). Therefore, imaging

modalities have been used to aid in correct diagnosis, monitoring and improved safety and efficacy

of joint injections.

Availability of effective solutions

Point-of-care ultrasound (US) is an established imaging modality used by the care provider in real

time to assist in diagnosis, monitoring and clinical interventions(8). The advantages of US compared

to other imaging modalities are its noninvasiveness, portability, relative inexpensive, no ionizing

radiation, real-time dynamic imaging, and repeatability to monitor treatment. In 2001, the Agency

for Healthcare Research and Quality listed the “use of real-time ultrasound guidance during central

line insertion” as one of the top patient safety practices designed to decrease medical errors(9).

In rheumatology, US can be used to diagnose and differentiate between synovitis, tenosynovitis,

tendonitis, tears, bursitis, enthesopathy, erosions, fasciitis and neuropathies(10). Musculoskeletal US

is considerably more sensitive than clinical examination at detecting synovitis(11, 12) and also more


42

specific(12). It has also been shown to predict erosive progression in rheumatoid arthritis and risk of

relapse in those who are in disease remission(13), thus may have a potential role as an imaging

biomarkers. It has been useful in differentiating between rheumatic diseases and monitoring disease

activity in patients receiving treatment. It is patient-friendly and often been referred to as “an

extension of the diagnostic finger” (13). It can be informative to patients and improve compliance.

The US7 score examines 7 of the most commonly affected small joints in RA and has been shown to

be reliable in daily clinical practice as it takes 10-15 minutes(11). US is better at detecting

enthesitis than clinical exam in the lower limbs in SpA (3). There may be an expanding role of

ultrasound for other diseases such as imaging temporal arteries for giant cell arteritis.

Besides clinical diagnosis, US can also improve success and decrease complications of

procedures(8). Whether static or dynamic, it can be used for guidance of aspiration, biopsy, and

injection treatment. Ultrasound has been shown to be more accurate than clinical exam for needle

placement for fluid aspiration of joints and soft tissue(14) (3, 15), up to 97% successful compared

to 32% in conventional group(16), even compared to more experienced rheumatologists (5). The

more accurate the injection, the greater the improvement of function and pain(6, 15), and the less

side effects of steroid (5) (17). US guidance should be considered for joints that are frequently

injected inaccurately such as shoulder, elbows, feet and ankles(2).

There is also evidence that ultrasound guided injections may reduce cost per patient relative to

anatomic guidance(15). In one study there was a 26% increase in responder rate and 62% decrease

in non-responder rate(6). This translates into lower healthcare costs, including fewer future clinic

visits, repeat procedures, telephone calls to physician, delayed surgical and reconstructive

procedures, less use of oral steroids and pain medications, and severe complications. Longer

outcome studies with extensive cost-benefit analysis are necessary to determine long term benefit.

However, it remains clear that US guided IA procedures were superior to blind injections including

reduced procedure pain, absolute and relative reduction in pain outcome, increase responder and

decreased non-responder rates. (6)

In the United States, one in five rheumatologists regularly utilizes musculoskeletal ultrasound in

their practice, although three out of four agree it should be a standard clinical tool for diagnosis,

injection guidance and gauging treatment response(18). As technology spreads, assuring patient

comfort and safety by employing the most accurate injection techniques possible is necessary.

Ultrasound represents the most practical option because it is safe, quick and comparatively less

expensive with no radiation. It is effective at improving clinical evidence and preliminary evidence

suggest patients benefit and may result in long-term health care savings.


43

RhMSK US Education

US is a user-dependent technology so ensuring competence, defining the benefits of appropriate

use, and limiting unnecessary imaging and its consequences is required(8). There must be

appropriate training and quality assurance. It has been postulated at least 70 examinations are

necessary to develop US competence in assessing synovitis in small joints of patients with RA (19).

However, competency should not just be based on numbers but demonstration of knowledge and

skills. To that end, a Diploma of focused competence in Point of Care MSK US is being developed for

the Royal College of Physician and Surgeons of Canada.

Furthermore, it is recognized that musculoskeletal ultrasound is an essential part of a rheumatology

training program, however few Canadian rheumatology trainees have access to regular supervised

training. In a survey of Canadian rheumatology program directors and rheumatology trainees, MSUS

training was available in only 52% of rheumatology trainees in Canada (20), where as every

European country is taught MSK ultrasound (21). The University of Toronto Rheumatology Training

Program is the largest in the country with trainees from across Canada and internationally, thus

providing this opportunity to trainees is valuable.

There is no standardized training program for MSUS and no standard accredited assessment of

competency for rheumatologists to perform MSUS (22, 23). However, an international

interdisciplinary consensus on specific indications, anatomic areas and knowledge and skills required

by rheumatologists performing MSUS was established (24). This is the basis that we have created

our MSUS curriculum.

Sunnybrook Health Sciences Centre is a quaternary care hospital with a large referral base, offering

a diverse range of high acuity in-patient cases as well as general rheumatology ambulatory patients.

There are 5 rheumatologist of whom all have experience as clinical teachers to medical trainees. Two

have had formal musculoskeletal ultrasound education and others have expressed interest in

learning MSK ultrasound. We are also in close proximity to several MSK US expert rheumatologists

who have pioneered the use of MSK ultrasound in Canada and are dedicated teachers. University of

Toronto PGY 4 trainees spend 2 months rotating at Sunnybrook Health Sciences Centre where they

act as a junior attending rotating through out-patient clinics and the inpatient consultation service.

This is an ideal rotation to obtain dedicated MSK ultrasound teaching.

Mission:


44

This program will prepare a cadre of rheumatologists to understand the role of point-of-care

ultrasound in the care of rheumatology patients

Goals:

The program will teach rheumatology trainees basic musculoskeletal ultrasound skills to use in their

rheumatology practice.

Graduate Competencies:

Medical Expert Role:

By the end of the fellowship program, learners should be able to

1. Appreciate the role of musculoskeletal ultrasound to optimize clinical decision-making and

therapeutic management.

2. Understand principles of US technology and knowledge of ultrasound equipment to optimize image

quality.

3. Know joint anatomy. Perform a standard grey scale and power Doppler ultrasound scan of the

hands, wrists, elbows, knees, ankles, and feet (shoulders, hips). Employ ultrasound guidance

aspiration and injection techniques.

4. Recognize typical ultrasound pathology of

Joint effusion

Synovial hypertrophy

Bone erosion

Tenosynovitis

Enthesopathy

Bursitis

Osteoarthritis

Muscle abnormalities- atrophy, myopathy

Focal Nerve entrapments-median, ulnar, radial, posterior tibial nerves.

5. Seek appropriate consultation from other health professionals, recognizing the limits of their

expertise.

Communicator Role:


45

The learner will have skills to establish rapport with the patients and manage an encounter

The learner will obtain and provide information and explanation in oral and written form to the

patient, families and colleagues.

Collaborator Role:

The learner will participate effectively and appropriately in the interprofessional health care team

and effectively work to prevent, negotiate and resolve interprofessional conflict

Leader Role:

The learner will manage their time to effectively integrate musculoskeletal point of care ultrasound in

their practice.

The learner will allocate finite health care resources appropriately and make decisions that contribute

to a sustainable practice and health care system.

Health Advocate Role:

Learners will develop expertise to advocate for patients to obtain MSK point-of-care ultrasound to

advance the health and wellbeing of patients

Scholar Role:

Learners will demonstrate lifelong commitment to maintain and enhance their musculoskeletal

ultrasound skills. This is done through ongoing practice, reflective learning, courses/ workshops,

critical evaluation of information and its sources.

The learner will facilitate learning of patients, families and other health professionals on MSK point-

of-care US. They may contribute to creation, dissemination, application and translation of future

MSK ultrasound teaching and practices.

Professional Role:

Learners will demonstrate a commitment to ethical practice of MSK ultrasound to their patients,

profession and society.


46

Instructional Methods of Teaching

During their 8 week clinical rotation at Sunnybrook hospital, they will attend 1 hour weekly rounds

with ultrasound specialist to introduce topic. This will include a short lecture and the teacher will

demonstrate the skills and then deconstruct the skill by describing each step. The learner will

demonstrate comprehension by describing each step and scanning a patient while describing their

steps. This will be followed by a dedicated half-day MSUS clinic with patients and tutors to

demonstrate proficiency in MSK ultrasound.

Each week will have a different focus as seen below. The learner should read around relevant

anatomy of the structures before the session. Ultrasound resource textbooks will be made available

and online videos and presentations will be recommended (such as www.e-sonography.com,

http://www.efsumb-atlas.org/v2/index.asp, http://ultrasoundcases.info/category.aspx?cat=68,

http://www.aium.org/communities/musculoskeletal.aspx,

http://www.eular.org/edu_online_course_msus.cfm).

Throughout the week, learners can practice their skills and consolidate their learning in their regular

outpatient rheumatology clinics. Learners should begin practice on peers or persons with normal

anatomy. They can then progress to performing the skill with real patients, under close supervision.

Scanned images can be uploaded and reviewed with staff. Immediate feedback from preceptors will

promote ongoing learning.

Throughout this program, MSK US experts will be training the trainers in MSK US.

8 Week curriculum at SB

Week 1: Knobology. Common Artifacts. Hand: MCP, PIP, and DIP. (Normal anatomy, effusions,

thickening, osteophytes and erosions, tenosynovitis)

Week 2: Wrist. Wrist effusion vs. tenosynovitis, erosions, ganglion cyst or nodules, Carpal tunnel

syndromes

Week 3: elbow. Effusions and erosions, bursitis, Tendonitis, entrapment of nerves,

Week 4: Feet: MTP and IP. Normal anatomy, Effusions and erosions, osteophyte, ganglion

Week 5: Knee. Effusions and bursitis, osteophytes, muscle atrophy, aspiration and injection

techniques

Week 6: Ankles: Effusions and erosions, Tendonitis, enthesitis, entrapments

Week 7: Shoulder/ Hip: effusions and tendonitis, Bursitis, muscle atrophy

http://www.e-sonography.com/

http://www.efsumb-atlas.org/v2/index.asp

http://ultrasoundcases.info/category.aspx?cat=68

http://www.aium.org/communities/musculoskeletal.aspx


47

Week 8: review, consolidation.

Total time: 8 hours of structured teaching and 24 hours of tutored supervision of ultrasound with

patients.

Trainee Assessment

- Regular formative feedback will be provided through direct observation of the trainee by the clinical

instructors.

- Trainee ultrasound skills can also be assessed through the submission of scans and a log of all their

ultrasound evaluations.

- At the end of the rotation, a consolidation session will be completed where the trainee will

demonstrate their techniques learned.

- We will complete a pretest and post test to assess MSK US knowledge.

Program Assessment:

- Throughout the program, we will be evaluating it and making iterative changes to ensure we are

providing trainees with the best educational experience possible.

- We will also be auditing cases seen, interventions made, and the patient outcomes.

- Further evaluation of the program includes whether the trainee will continue to use MSK ultrasound

while on other rotations (Early Arthritis Clinic with Dr. Pooneh Akhavan, Psoriatic Clinic with Dr. Lihi

Eder), pursue further training in MSK US (CRUS course, USSONAR, ACR course), scholarly research

in MSK ultrasound, and the number of trainees who continue to use MSK US in their practice.

Resources required:

- US machine, insurance, image storage, gel, clinic costs, and administrative support.

- Portable examining bed. There is a need to expand clinic capacity to have a room dedicated

for MSK US. Current exam tables are high and ideally, the examiner should be seated when

ultrasounding. As well, a portable exam bed could be brought to other locations, such as

conference rooms when we do larger group teaching.

- MSK US experts to spend 1 hour each week demonstrating MSK US. Coverage for parking

costs has been requested. University appointment is also needed for these tutors.

- Rheumatology staff time – half day each week to supervise dedicated MSUS clinic. There is a

need to have adequate trained faculty in ultrasound to supervise scanning through direct

observation and conduct quality assessments. A faculty development program to upgrade the

skills of staff rheumatologists in ultrasound is needed


48


49

Appendix I

General References

Acquacalda E, Albert C, Montaudie H, Fontas E, Danre A, Roux CH et al. Ultrasound study of entheses in psoriasis patients with or without musculoskeletal symptoms: A prospective study. Joint Bone Spine. 2015 Apr 13. [Epub ahead of print]

Agency for Healthcare Research and Quality. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. March 2013. Report No.: Publication No. 13-E001-EF.

A Iagnocco, E Filippucci, G Meenagh, et al. Ultrasound imaging for the rheumatologist III. Ultrasonography of the hip (Jrnl Title: Clin Exp Rheum. Clinical and Experimental Rheumatology. 2006. Albrecht K, Grob K, Lange U, Muller-Ladner U, Strunk J. Reliability of different ultrasound

quantification methods and devices in the assessment of therapeutic response in arthritis. Rheumatology 2008;47:1521-1526.

American College of Rheumatology. Musculoskeletal Ultrasound Course for Rheumatologists. http://www.rheumatology.org/Education/Profmeetingcourses/Musculoskeletal_Ultrasound_Co

rse_for_Rheumatologists—Fundamentals/

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January 2017 VERSION 1.1

DEFINITION

Neuromusculoskeletal Ultrasound is that area of enhanced competence within medicine concerned with the study of diagnostic ultrasound within the scope of practice of clients in neuromuscular, musculoskeletal and rheumatologic medicine.

ELEGIBILITY REQUIREMENTS

The Area of Focused Competence (AFC) trainee must have a medical degree. To be eligible for the Royal College certification portfolio in Neuromusculoskeletal Ultrasound, all trainees must be certified in their primary Royal College specialty or equivalent, or hold an academic certification in the following: Internal Medicine (including Adult Rheumatology), Pediatrics (including Pediatric Rheumatology), Physical Medicine and Rehabilitation, or Neurology.

GOALS

Upon completion of training, an AFC diplomate is expected to function as a competent specialist in Neuromusculoskeletal Ultrasound, capable of an enhanced practice in this area of focused competence, within the scope of their stream of Neuromusculoskeletal Ultrasound. The AFC trainee must acquire a working knowledge of the theoretical basis of the discipline, including its foundations in the sciences and research.

The discipline of Neuromusculoskeletal ultrasound includes:

1. Knowledge of the basic physics, safety principles, hardware and software associated with ultrasound

2. Knowledge of imaging acquisition, optimization, archiving and export a. Annotation of images b. Dynamic (video/cine-loop) and split screen (side to side) comparison and

extended field of view image acquisition c. Proficient transducer movement, scanning ergonomics and patient positioning d. Basics of B-mode optimization and Doppler image optimization

i. Gain adjustment, B-mode and Doppler frequency, pulse repetition frequency, wall filter, colour priority, focus and depth

3. Knowledge of common B-mode and Doppler imaging artifacts: a. Anisotropy b. Posterior acoustic shadowing c. Posterior acoustic enhancement d. Increased through transmission e. Reverberation f. Ring-down artifact g. Comet-tail artifact



h. Mirror image i. Beam width artifact j. Side-lobe artifact

4. Ability to identify normal neuromusculoskeletal tissue imaging

characteristics on ultrasound: a. Dermis, adipose and other subcutaneous tissue b. Tendon and ligaments c. Muscle, fascia and nerve d. Vessels e. Hyaline and fibrocartilage, synovium, bone and nails

5. Ability to identify common neuromusculoskeletal imaging pathologies on

ultrasound: a. Synovitis including joint effusion and synovial hypertrophy b. Bursitis c. Ganglion cyst d. Tenosynovitis e. Paratenonitis f. Enthesopathy including enthesitis g. Tendinopathy and tendon tears h. Bony pathology (osteophytes, enthesophytes, cortical interruptions including

erosions) i. Focal nerve enlargement j. Soft tissue mineralization k. Muscle (tears, inflammation, infection) l. Skin and subcutaneous tissues (cellulitis, edema)

6. Basic knowledge and ability to characterize soft tissue lesions or masses

that warrant further imaging or referral: a. Characterization and composition b. Simple or complex c. Origin (determine the anatomic epicenter) d. Vascularization

Guidance: The purpose of this training requirement is to ensure that the applicant has a working knowledge of the fundamental pitfalls of using ultrasound exclusively for diagnosis, management, or prognostication of soft tissue mass. It is expected that the applicant has a clear working knowledge of the necessity to refer solid masses for further evaluation.

7. Performance, utility and limitations of ultrasound guided needle placement: a. Manual technique of probe and needle manipulation b. Procedural imaging acquisition and labelling

8. Education of physicians, ultrasound technologists, medical students and/or

residents learning ultrasound

9. Completion of a personal learning project



10. Conducting or contributing to a neuromusculoskeletal ultrasound research project or related scholarly activity

11. Conducting ongoing quality improvement processes including written documentation and re-evaluation

12. Implementation of an image archiving program for all ultrasound examinations at all sites of patient care

13. Participation in a quality assurance program with follow up that includes imaging review, clinical follow up and pathology review where applicable

The neuromusculoskeletal ultrasound diplomate MUST choose at least ONE of the following streams of additional competence:

o Neuromuscular Ultrasound (NMUS)

o Musculoskeletal Ultrasound (MSKUS)

o Adult Rheumatology Ultrasound (RhMSKUS)

o Pediatric Rheumatology Ultrasound (pRhMSKUS)

ADDITIONAL GOALS: Neuromuscular Ultrasound (NMUS)

The Neuromuscular Ultrasound stream includes knowledge of and ability to demonstrate:

1. Ultrasound as a compliment to electrodiagnostic evaluation of neuromuscular patients:

a. As a tool to facilitate the evaluation of proximal neuropathies such as: i. Meralgia paresthetica ii. Suprascapular neuropathy

b. To confirm electrode and stimulator placement in technically difficult studies c. To guide needle electromyography in:

i. Anticoagulated patients ii. Muscles not routinely evaluated

d. To identify pathologic muscles for needle electromyography e. To correlate exonal loss, conduction block or focal slowing with nerve size and

continuity f. To facilitate patient education

2. Identification of these common anatomic variants:

a. Accessory hypothenar muscle b. Anconeus epitrochlearis c. Bifid median nerve

3. Identification of normal muscles including:

a. Sternocleidomastoid, trapezius, levator scapulae, rhomboid major and minor b. Pectoralis major and minor



c. Upper limb muscles including the biceps brachii, brachialis, triceps brachii, pronator teres, flexor carpi ulnaris, flexor digitorum profundus, flexor digitorum superficialis, extensor digitorum communis

d. Muscles of the hand including the first dorsal interosseous, abductor pollicis brevis and abductor digiti minimi

e. Pelvic girdle muscles including the gluteus maximus, medius and minimus and piriformis

f. Muscles of the thigh including tensor fascia lata, sartorius, rectus femoris, vastus medialis, vastus lateralis, biceps femoris, semitendinosus and semimembranosus

g. Muscles of the leg including gastrocnemius, soleus, tibialis posterior, flexor halluces longus, tibialis anterior, extensor digitorum longus, peroneus longus and peroneus brevis

h. Muscles of the foot including abductor hallucis, extensor digitorum brevis and abductor digiti minimi

4. Describing the ultrasound imaging characteristics of abnormal atraumatic muscle pathology:

a. Size i. Atrophy ii. Swelling

b. Echogenicity c. Vascularity d. Calcifications e. Fat infiltration

5. Identification of fasciculations

6. Identifying the normal anatomy and fascicular echostructure of the

following nerves: a. Brachial plexus b. Musculocutaneous nerve c. Radial nerve d. Ulnar nerve e. Median nerve f. Saphenous sensory nerve g. Sural nerve h. Lateral femoral cutaneous nerve i. Sciatic nerve at the posterior knee j. Peroneal nerve at the fibular head k. Tibial nerve at the medial ankle

7. Demonstrating the normal and abnormal nerve cross sectional area (CSA) in

common focal peripheral neuropathies: a. Median at the wrist b. Ulnar at the elbow c. Peroneal nerve at the fibular head d. Tibial nerve at the medial ankle e. Sciatic nerve in the thigh



8. Describing the ultrasound characteristics of partial and complete

(neurotmesis) nerve lesions

9. Identification and description of peripheral nerve sheath tumors: a. Contour, shape, echogenicity and vascularity

10. Describing ultrasound characteristics of acquired and hereditary

demyelinating polyneuropathies

11. The performance of stress (dynamic) maneuvers: a. Subluxation of the ulnar nerve at the elbow

ADDITIONAL GOALS: Musculoskeletal Ultrasound (MSKUS)

The Musculoskeletal Ultrasound stream includes the knowledge of and ability to demonstrate:

1. Common anatomic variants including: a. Accessory muscles and tendons of the wrist and fingers b. Bifid median nerve c. Anconeus epitrochlearis d. Subluxation of the ulnar nerve at the elbow e. Accessory head of the proximal long head biceps tendon f. Accessory ossicles of the peroneus longus g. Accessory navicular bone h. Accessory muscles and tendons of the ankle

2. Effusions in large synovial joints:

a. Glenohumeral b. Elbow c. Wrist d. Hip e. Knee f. Ankle

3. Bursal fluid:

a. Subdeltoid bursa b. Olecranon bursa c. Greater trochanteric bursa d. Pre/infrapatellar bursa e. Retrocalcaneal bursa

4. Common nerve lesions:

a. Median nerve enlargement at the wrist b. Morton’s neuroma c. Peripheral nerve sheath tumor

5. Normal tendons and abnormal tendon pathologies:











c. Hip i. Lateral







ii. Medial 1. Semitendinosus 2. Gracilis



3. Sartorius iii. Anterior

1. Quadriceps tendon 2. Patellar tendon










1. Scapholunate ligament iii. Medial iv. Triangular fibrocartilage complex


d. Ankle and foot i. Anterolateral




iv. Plantar



1. Plantar fascia

7. Muscle Disorders: a. Intramuscular lesion

i. Simple cyst ii. Complex fluid collection iii. Solid mass requiring further imaging iv. Complete and partial tears v. Calcification

b. Atrophy c. Fat infiltration

8. The standard scanning protocol and pathological lesion identification of

common shoulder pathologies: a. Specific tendon lesions of subscapularis, biceps, supraspinatus, infraspinatus,

and teres minor tendons i. Tendinosis ii. Calcifications iii. Partial thickness tears iv. Bursal fluid v. Neovascularization



d. Notch cysts i. Spinoglenoid ii. Supraspinous


Guidance: The evaluation of the shoulder is common, but the spectrum of pathologies is complex. It is the expectation that the candidate be proficient in identification of lesions that may require urgent surgical evaluation or warrant further study with MRI +/- intra-articular contrast. It is the expectation that the candidate clearly identifies full thickness tears and characterizes the extent of the tear. Though very skilled physician sonographers can identify partial width and partial thickness tears, further expertise may be gained by the candidate through ongoing postgraduate education.

9. Other synovial and soft tissue mass lesions: a. Baker’s cyst b. Paralabral cyst c. Meniscal cyst

10. Performance of stress (dynamic) maneuvers:

a. Subacromial impingement b. Peroneal tendon subluxation



c. Anterior talofibular ligament (ATFL) d. Calcaneofibular ligament (CFL) e. Medial collateral ligament of the knee

11. Detecting deep vein thrombosis in the lower limb



i. Injectates: 1. Corticosteroids 2. Viscosupplementation 3. Platelet Rich Plasma

ii. Aspiration: 1. Joint effusion 2. Simple cyst 3. Tendon fenestration and calcific lavage












g. A working knowledge of the recognition and management of procedural complications:


h. Methods of documentation and reporting of ultrasound-guided procedures



i. Labelling and recording of images and/or videos i. Diagnostic and therapeutic injections and/or aspiration of the following

structures: i. Glenohumeral joint ii. Acromioclavicular joint iii. Elbow iv. Wrist v. Carpometacarpal (CMC) vi. Hip vii. Knee viii. Tibiotalar ix. Subtalar x. First metatarsalphalangeal joint

j. Diagnostic and therapeutic peripheral nerve injections i. Median nerve at the wrist ii. Regional nerve blocks of the arm, forearm, popliteal fossa and ankle

k. Therapeutic tendon and/or tendon sheath injections i. De Quervain’s tenosynovitis (APL, EPB) ii. Trigger finger (A1 pulley) iii. Tennis elbow (EDC/ECRB) iv. Rotator cuff interval v. Gluteus medius and minimus vi. Achilles tendon

ADDITIONAL GOALS: Adult Rheumatology Ultrasound (RhMSKUS)

The Adult Rheumatology Ultrasound stream includes knowledge of and ability to demonstrate:

1. Common anatomic variants including: a. Sesamoids in the hand and feet b. Accessory muscles/tendons of the wrist and fingers c. Bifid median nerve d. Anconeus epitrochlearis e. Subluxation of the ulnar nerve at the elbow f. Accessory head of the proximal long head biceps tendon g. Accessory ossicles of the peroneus longus h. Accessory navicular bone i. Accessory muscles and tendons of the ankle

2. Optimal positioning of joints for the static and dynamic assessment of

effusions, tendons including the enthesis and ligaments

3. Effusions in synovial joints: a. Glenohumeral b. Acromioclavicular c. Elbow recesses and joint space d. Wrist e. Metacarpophalangeal, proximal interphalangeal and distal interphalangeal



f. Hip g. Knee h. Ankle and midfoot joints i. Metatarsalphalangeal, proximal interphalangeal, distal interphalangeal

4. Periarticular cystic lesions:

a. Ganglion b. Synovial (eg. Baker’s cyst) c. Other (eg. Meniscal cyst)

5. Bursal thickening and free fluid in the bursae about the:


6. Normal tendons and abnormal tendon pathologies in the:









c. Hip i. Lateral

1. Gluteus minimus 2. Gluteus medius 3. Gluteus maximus 4. Tensor fascia latae



5. Iliotibial band ii. Medial

1. Adductor longus, brevis and magnus origin 2. Pubic symphysis













7. Standard scanning protocol and pathological lesions of common shoulder

pathologies: a. Specific tendon lesions of subscapularis, biceps, supraspinatus, infraspinatus,

and teres minor tendons i. Tendinosis ii. Calcifications



iii. Partial thickness tears iv. Bursal fluid v. Neovascularization



d. Notch cysts i. Sphinoglenoid ii. Supraspinous


Guidance: The evaluation of the shoulder is common but the spectrum of pathologies is complex. It is the expectation that the candidate be proficient in identification of lesions that may require urgent surgical evaluation or warrant further study with MRI +/- intra-articular contrast. It is the expectation that the candidate clearly identifies full thickness tears and characterize the extent of the tear. Though very skilled physician sonographers can identify partial width and partial thickness tears, further expertise may be gained by the candidate through ongoing postgraduate education.

8. Characteristic features of arthropathies: a. Inflammatory arthropathies (RA, SpA, PsA):

i. Synovial hypertrophy 1. Abnormal hypoechoic intra-articular tissue, poorly displaceable,

with or without hypervascularity ii. Tenosynovitis

1. Abnormal hypoechoic or anechoic changes around tendons, with or without hypervascularity

iii. Paratenonitis 1. Abnormal hypoechoic or anechoic halo around tendon that lacks

a tendon sheath with or without hypervascularity iv. Effusions

1. Abnormal intra-articular anechoic and displaceable material without Doppler signal

v. Bone profile irregularities vi. Extra-articular features (subcutaneous edema, fasciitis) vii. Erosions

1. A discontinuity of the smooth echogenic bony surface profile, seen in 2 planes, with an irregular floor

viii. Enthesopathy (Describing the pathologic insertion of a tendon, ligament or joint capsule into bone)

1. Pathology is defined by: a. Hypoechogenicity b. Increased thickness



c. Calcifications d. Erosions e. Cortical irregularity f. Doppler signals

b. Crystalline arthropathies: i. Gout

1. Joints and bursae a. Heterogenous hyperechoic aggregates (HAG’s)

2. Cartilage a. Hyperechoic, regular or irregular, continuous or

intermittent, enhancements of the superficial chondrosynovial margin independent of angle of insonation (double contour sign)

3. Tendons a. Hyperechoic linear bands in tendons (HLB’s)

4. Soft tissue (extra-articular, intra-articular or intratendinous) a. A circumscribed inhomogenous, hyperechoic or

hypoechoic aggregation (tophus), with or without acoustic shadowing, and may include and anechoic halo

5. Erosions a. An intra and/or extra-articular discontinuity of the bone

surface visible in 2 planes

ii. Calcium pyrophosphate deposition disease (CPPD) 1. Hyaline cartilage

a. Hyperechoic deposits within the substance of hyaline cartilage without acoustic shadowing

2. Fibrocartilage a. Amorphous or rounded hyperechoic deposits in

fibrocartilage as seeoon in the TFCC or knee meniscus 3. Synovial fluid

a. ‘Floaters’ or aggregates of high echogenicity, even at low gain, that are rounded or irregular, producing a ‘snow storm’ like image due to crystals

iii. Septic arthritis 1. The diagnosis of septic arthritis is based on clinical assessment

and should prompt arthrocentesis. Ultrasound has limited discriminatory ability as imaging can mimic inflammatory and crystal induced joint inflammation even when polyarticular, or may complicate a known underlying joint disease

iv. Osteoarthritis (OA) 1. Conventional radiography is the current standard for OA

imaging. Knowledge and ability to demonstrate added value of ultrasound to identify osteoarthritic joints:

a. Focal degeneration of hyaline cartilage b. Synovial hypertrophy and vascularity c. Effusions d. Erosions e. Osteophytes



f. Bursitis g. Periarticular cyst formation

v. Polymyalgia Rheumatica (PMR) 1. Ultrasound features may include:

a. Bilateral subacromial bursitis b. Long head of biceps tenosynovitis c. Glenohumeral synovitis d. Trochanteric bursitis e. Hip joint synovitis

vi. Giant Cell Arthritis (GCA) 1. Knowledge and ability to demonstrate the vascular settings

required to study the temporal vessels (common, frontal and parietal) and axillary artery

2. Able to demonstrate an ability to image the temporal and axillary vessels and identify and measure the intimal/media complex, and if present, to identify the segmental periluminal hypoechoic thickening, halo or segmental luminal occlusionglands

vii. Salivary Glands 1. Demonstrate an ability to scan normal parotid and

submandibular salivary glands and to recognize normal echogenicity from hypoechogenicity, heterogeneity, and cystic changes seen in Sjogren’s syndrome, that can occur in at least 2 or more salivary glands

viii. Colour and Power Doppler in low flow settings for diagnosis and monitoring of inflammatory disease

1. Knowledge in the use of colour and power Doppler and able to demonstrate use for diagnosis and monitoring of synovitis, tenosynovitis, tendinitis and enthesitis

2. Knowledge of a semi quantitative method of grading the Doppler signal

3. Knowledge of Doppler artifacts in low flow settings 4. Random noise, motion, aliasing, mirror, blooming,

reverberation, focus and probe pressure effects 5. Knowledge of common pitfalls in the evaluation of the Doppler

signal in MSK disorders 6. Positioning, pressure, ambient temperature, diurnal variation,

treatment effects and machine settings (frequency, colour box, scale, contour priority, filters and gain)

9. Normal anatomy of ligaments and pulleys and their common associated pathologies:


b. Wrist and hand i. Finger pulleys ii. Scapholunate ligament



iii. Triangular fibrocartilage complex c. Knee

i. Medial collateral ligament ii. Lateral collateral ligament iii. Distal iliotibial band insertion






10. Normal anatomy and ultrasound findings of common focal peripheral

neuropathies: i. Median nerve at the wrist ii. Ulnar nerve at the elbow iii. Tibial nerve at medial malleolus iv. Peroneal nerve at the fibular head v. Lateral femoral cutaneous nerve of the thigh

11. Ultrasound guided interventions including:


i. Injectates 1. Corticosteroids 2. Viscosupplementation 3. Platelet Rich Plasma

ii. Aspiration 1. Joint effusion 2. Simple cyst 3. Tendon fenestration and calcific lavage







iii. Ergonomic considerations for procedural planning



iv. Appropriate selection of equipment: 1. Needle or device selection 2. Injectate selection

e. The ability to perform ultrasound guided needle or device tracking using both in-plane and out-of-plane approaches












13. Identification of normal muscle sonographic appearance and imaging characteristics of:

a. Denervated muscle b. Inflammatory myopathies

ADDITIONAL GOALS: Pediatric Rheumatology Ultrasound (pRhMSKUS)

The Pediatric Rheumatology Ultrasound stream includes knowledge of and ability to demonstrate:

1. Sonographic features of joints in healthy children including: a. Hyaline cartilage b. Ossified portion of articular bone including epiphyseal and apophyseal

secondary ossification centers c. Normal joint capsule d. Normal intra- and peri-articular sonographic vascular development e. Normal intraarticular fat pads and fibrocartilage

2. Normal cartilage, ligaments, capsule, ossification centers and joint fluid

seen in the following joints through the pediatric age range: a. Shoulder b. Elbow c. Wrist d. Finger joints (MCP, PIP, DIP) e. Hip f. Knee g. Ankle and midfoot joints h. Toe joints (MTP, PIP, IP)

3. Normal entheseal development in children including ossification and

vascularization

4. Normal tendons and entheses in the: a. Elbow

i. Lateral 1. Extensor digitorum 2. Extenstor carpi radialis brevis 3. Extensor digiti minimi 4. Extensor carpi ulnaris

ii. Medial 1. Pronator teres 2. Palmaris longus 3. Flexor carpi ulnaris 4. Flexor carpi radialis


iv. Posterior 1. Distal triceps tendon insertion






c. Hip i. Lateral







ii. Medial 1. Semimembranosus 2. Semitendinosus 3. Gracilis 4. Sartorius


iv. Posterior 1. Medial gastrocnemius 2. Lateral gastrocnemius 3. Baker’s Cyst (see synovial and soft tissue masses)



ii. Medial 1. Tibialis posterior



2. Flexor digitorum longus 3. Flexor hallucis longus

iii. Anterior iv. Posterior

1. Achilles 2. Plantaris




1. Scapholunate ligament 1.2. Lunatotriquetral ligament

iii. Medial 1. Triangular fibrocartilage complex

c. Knee i. Medial collateral ligaments ii. Lateral collateral ligament iii. Distal iliotibial band insertion




iii. Posteromedial 1. Deltoid ligament


6. Common anatomic variants including:

a. Sesamoid bones in the hand and feet b. Accessory muscles/tendons of the wrist and fingers c. Bifid median nerve d. Anconeus epitrochlearis e. Subluxation of the ulnar nerve at the elbow f. Accessory head of the proximal long head biceps tendon g. Accessory ossicles of the peroneus longus h. Accessory navicular bone i. Accessory muscles/tendons of the ankle and foot

7. Optimal positioning of joints for assessment of effusions, tendons, entheses

and ligaments

8. Effusions in synovial joints:



a. Glenohumeral b. Acromioclavicular c. Elbow recesses and joint space d. Wrist e. Metacarpophalangeal, proximal interphalangeal and distal interphalangeal f. Hip g. Knee h. Ankle and midfoot joints i. Metatarsalphalangeal, proximal interphalangeal, distal interphalangeal

9. Bursal thickening and free fluid in the bursae of the:


10. Synovial cysts, ganglion cysts and other cystic lesions

11. Findings in inflammatory arthropathies including:

a. Synovial hypertrophy i. Abnormal hypoechoic intra-articular tissue, poorly displaceable, with or

without hypervascularity b. Tenosynovitis

i. Abnormal hypoechoic or anechoic changes around tendons, with or without hypervascularity

c. Paratenonitis i. Abnormal hypoechoic or anechoic halo around tendon that lacks a

tendon sheath with or without hypervascularity d. Effusions

i. Abnormal intra-articular anechoic and displaceable material without Doppler signal

e. Bone profile irregularities f. Extra-articular features (subcutaneous edema, fasciitis) g. Erosions

i. A discontinuity of the smooth echogenic bony surface profile, seen in 2 planes, with an irregular floor

h. Enthesopathy (Describing the pathologic insertion of a tendon, ligament or joint capsule into bone)

i. Pathology is defined by: 1. Hypoechogenicity 2. Increased thickness 3. Calcifications 4. Erosions 5. Cortical irregularity 6. Doppler signals

12. Findings of synovitis, synovial hypertrophy, tenosynovitis, paratenonitis

and enthesopathy (enthesitis) through the spectrum of pediatric illnesses



and in the various joints (identified under 2) including quantification using semi-quantitative or qualitative grading systems

13. Transient synovitis a. In the appropriate clinical context, transient synovitis is characterized by

finding of fluid accumulation without significant synovial thickening. Additional diagnostic and/or imaging methods will need to be applied, as appropriate.

14. Septic arthritis a. The diagnosis of septic arthritis is based on a clinical assessment and should

prompt arthrocentesis. Ultrasound has limited discriminatory ability as imaging can mimic joint inflammation even when polyarticular, or may complicate a known underlying joint disease.

15. Common acute and chronic avulsion (apophysitis) injuries at the following: a. Medial epicondyle of the elbow b. Lateral epicondyle of the elbow c. Distal triceps tendon insertion d. Distal biceps tendon insertion e. Anterior superior iliac spine (ASIS) f. Anterior inferior iliac spine (AIIS) g. Ischial tuberosity h. Greater trochanter i. Inferior pole of the patella j. Tibial tubercle k. Calcaneus l. Navicular of the ankle m. Tuberosity of the fifth metatarsal



i. Injectates 1. Corticosteroids

ii. Aspiration 1. Joint effusion 2. Simple cyst








The following Competencies pertain to each of the above streams. Details of Competencies pertaining to each of the 4 NMSKUS streams (NMUS, MSKUS, RhMSKUS, pRhMSKUS) are described above. At the completion of the training, the diplomate will have acquired the following competencies and will function effectively as a: MEDICAL EXPERT Definition: As Medical Experts, Neuromusculoskeletal Ultrasound diplomates integrate all the CanMEDS Roles by applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centred care. The Medical Expert is the central physician role in the CanMEDS framework. Key and Enabling Competencies: Neuromusculoskeletal Ultrasound diplomates are able to…

1. Establish and maintain clinical knowledge, skills and attitudes appropriate to the practice of NMSKUS:

a. Apply knowledge of the clinical and basic medical sciences relevant to NMSKUS

b. Describe the principles and instrumentation of ultrasound including Doppler imaging and B mode sonography

c. Integrate the knowledge of anatomy, physiology, and relevant disease processes into the NMSKUS consultation

2. Recognize the limitations of an ultrasound assessment and the role of

other imaging modalities and investigations relevant to patient care. 3. Function effectively as consultants, integrating all of the CanMEDS Roles to

provide optimal, ethical and patient-centered medical care a. Identify and respond to relevant ethical issues arising in patient care b. Demonstrate the ability to prioritize professional duties when faced with

multiple patients and problems c. Demonstrate compassionate patient-centered care d. Recognize and respond to the ethical dimensions in medical decision-

making

4. Perform an ultrasound consultation, including the presentation of well-documented assessments and recommendations in written, oral, or video format, in response to a request from another physician.

5. Establish and maintain clinical knowledge, skills and attitudes appropriate to Neuromusculoskeletal Ultrasound:

a. Apply knowledge of the clinical, socio-behavioral, and fundamental biomedical sciences relevant to Neuromusculoskeletal Ultrasound



b. Participate in maintenance of certification (MOC) in continuing professional development

c. Integrate the best available evidence and best practices to enhance the quality of care and patient safety in Neuromusculoskeletal Ultrasound

6. Perform a complete and clinically appropriate NMSKUS assessment of a

patient: a. Describe common B mode and Doppler ultrasound artifacts b. Identify normal tissue, normal variants, and abnormal pathology of the

body region and tissue of interest c. Identify the abnormal sonographic appearance of neuromuscular and

musculoskeletal tissues during disease states d. Correlate ultrasound findings with the history, physical examination, and

other investigations relevant to the patient and disease process e. Demonstrate effective clinical problem solving and judgment to address

patient problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

7. Demonstrate proficient and appropriate use of procedural skills, both

diagnostic and therapeutic: a. Demonstrate appropriate and timely application of therapeutic

interventions relevant to NMSKUS to enhance patient care b. Demonstrate effective, appropriate, and timely performance of diagnostic

procedures relevant to Neuromusculoskeletal Ultrasound c. Ensure appropriate informed consent is obtained for procedures d. Ensure adequate follow up is arranged for procedures performed

8. Seek appropriate consultation from other health professionals, recognizing

the limits of their own expertise: a. Demonstrate insight into their own limits of expertise b. Demonstrate effective, appropriate, and timely consultation of another

health professional as needed for optimal patient care c. Arrange appropriate follow-up care services and additional investigations or

consultations for patients COMMUNICATOR Definition: As Communicators, Neuromusculoskeletal Ultrasound diplomates effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter. Guidance: In the following sections and within this document as a whole, the term "patient" refers to the patient itself or the guardian/parent as appropriate. Key and Enabling Competencies: Neuromusculoskeletal Ultrasound diplomates are able to…



1. Develop rapport, trust, and ethical therapeutic relationships with patients and families:

a. Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty, and empathy

b. Develop a good patient relationship during the Neuromusculoskeletal Ultrasound exam with appropriate attention to patient comfort, patient confidentiality, privacy and autonomy

c. Facilitate a structured clinical encounter effectively integrating Neuromusculoskeletal Ultrasound

2. Accurately elicit and synthesize relevant information:

a. Seek out and synthesize relevant information from other sources, including but not limited to patient records and additional complementary diagnostic investigations

b. Interpret the relevant questions to be answered by the Neuromusculoskeletal Ultrasound examination using information from the referring provider and initial medical evaluation

3. Convey relevant information and explanations accurately to patients and

families, colleagues, and other professionals: a. Deliver the results of the clinical encounter and ultrasound examination to

the patient and referring physician in a professional and understandable manner

4. Utilize NMSKUS to facilitate the education of patients and their families

regarding normal anatomy and disease processes.

5. Convey effective oral and written information about a medical encounter: a. Maintain clear, concise, and accurate records of clinical encounters, plans

and ultrasound images b. Convey medical information in a timely fashion to ensure safe transfer of

care c. Develop a written report, using appropriate terminology, summarizing the

pertinent positive and negative neuromusculoskeletal ultrasound findings

6. Demonstrate the ability to obtain informed verbal and/or written consent for any interventional procedures performed:

a. Ensures that the patient has been fully informed, has the capacity to provide consent and that the patient demonstrates a willingness to participate in the procedure

b. Ensures that the patient understands the information relevant to the decision at hand, retains the information for the decision process, and is able to communicate their decision and all of the material risks of the intervention

COLLABORATOR Definition:



As Collaborators, Neuromusculoskeletal Ultrasound diplomates work effectively within a health care team to achieve optimal patient care. Key and Enabling Competencies: Neuromusculoskeletal Ultrasound diplomates are able to…

1. Participate effectively and appropriately in an inter-professional health

care team: a. Demonstrate leadership within the diplomates parent specialty to

disseminate knowledge and skills regarding Neuromusculoskeletal Ultrasound

b. Describe the NMSKUS specialist’s roles and responsibilities to other professionals

c. Recognize and respect the diverse roles, responsibilities and competencies of other professionals in relation to their own

d. Demonstrate the ability to work closely with the clinical staff in an ultrasound laboratory, clinical office, or interventional suite, to assist in the exam preparation and performance

MANAGER Definition: As Managers, Neuromusculoskeletal Ultrasound diplomates are integral participants in health care organizations, organizing sustainable practices, making decisions concerning the allocation of resources, and contributing to the effectiveness of the health care system. Key and Enabling Competencies: Neuromusculoskeletal Ultrasound diplomates are able to…

1. Improve quality and participate in activities that contribute to the effectiveness of their health care organizations and systems:

a. Employ efficient use of ultrasound equipment, clinical staff, facilities and resources in an efficient manner

b. Participate in Medical Peer Review c. Participate in routine quality assurance of ultrasound

2. Manage their practice and career effectively:

a. Set reasonable priorities and manage time to balance patient care, practice requirements, and personal life

b. Implement achievable goals and processes to ensure personal practice improvement

c. Employ information technology appropriately for patient care 3. Allocate finite health care resources appropriately:

a. Describe the appropriate indications, contraindications, risks, and clinical utility of Neuromusculoskeletal ultrasound



b. Recognize the importance of just allocation of health care resources, balancing effectiveness, efficiency, and access with optimal patient care

c. Apply evidence and management processes for cost-appropriate care HEALTH ADVOCATE Definition: As Health Advocates, Neuromusculoskeletal Ultrasound diplomates use their expertise and influence responsibly to advance the health and well-being of individual patients, communities, and populations. Key and Enabling Competencies: Neuromusculoskeletal Ultrasound diplomates are able to…

1. Deliver patient-centered care a. Diplomates must demonstrate the requisite knowledge, skills, and attitudes

for effective patient-centered care and service to a diverse population. In all aspects of specialist practice, the diplomate must be able to address ethical issues and issues of gender, sexual orientation, age, culture and ethnicity in a professional manner.

2. Respond to individual patient health needs and issues as part of patient care:

a. Describe the role of ultrasound in educating patients b. Describe the role of Neuromusculoskeletal ultrasound in diagnosis and

managing neuromuscular, musculoskeletal and rheumatologic disease states , sexual orientation, age, culture and ethnicity in a professional manner.

SCHOLAR Definition: As Scholars, Neuromusculoskeletal Ultrasound diplomates demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application, and translation of medical knowledge. Key and Enabling Competencies: Neuromusculoskeletal Ultrasound diplomates are able to…

1. Maintain and enhance professional activities through ongoing learning:

a. Describe the principles of maintenance of competence (MOC) in Neuromusculoskeletal Ultrasound

b. Describe the principles and strategies for implementing a personal knowledge management system regarding Neuromusculoskeletal Ultrasound given the evolving knowledge base

c. Recognize and reflect on learning issues in practice i. Conduct personal practice audits ii. Pose an appropriate learning question



d. Access and interpret the relevant evidence i. Integrate new learning into practice ii. Evaluate the impact of any change in practice iii. Document the learning process according to the diplomates’ parent

certifying body

2. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others:

a. Describe principles of Neuromusculoskeletal Ultrasound and scanning techniques effectively to patients, families, students, residents, and other health professionals

b. Identify collaboratively the learning needs of ultrasound trainees c. Select effective teaching strategies and content to facilitate the training of

other physicians d. Deliver effective live demonstrations, lectures, or presentations relevant

to Neuromusculoskeletal ultrasound e. Assess and reflect on teaching encounters f. Provide effective feedback of trainee ultrasound performance

3. Contribute to the development, dissemination, and translation of new

knowledge and practices: a. Describe the principles of research and scholarly inquiry b. Incorporate new and established techniques into a NMSKUS practice. c. Pose a scholarly question and incorporate new techniques and knowledge

into the practice of Neuromusculoskeletal ultrasound PROFESSIONAL Definition: As Professionals, Neuromusculoskeletal Ultrasound diplomates are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour. Key and Enabling Competencies: Neuromusculoskeletal Ultrasound diplomates are able to…

1. Demonstrate a commitment to their patients, profession, and society through ethical practice:

a. Exhibit appropriate professional behaviours in practice, including honesty, integrity, commitment, compassion, respect, and altruism.

b. Work with physicians, other health care professionals, and staff in a collegial and professional manner

c. Mange conflicts of interest d. Maintain appropriate patient boundaries

2. Demonstrate a commitment to their patients, profession and society

through participation in profession-led regulation: a. Demonstrate knowledge and an understanding of professional, legal, and

ethical codes of practice b. Fulfil the regulatory and legal obligations required of current practice



c. Demonstrate accountability to professional regulatory bodies d. Recognize and respond appropriately to others’

unprofessional behaviours in practice

3. Demonstrate a commitment to physician health and sustainable practice:

a. Balance personal and professional priorities to ensure personal health and a sustainable practice

b. Strive to heighten personal and professional awareness and insight c. Recognize other professionals in need and respond appropriately

RECOMMENDED TRAINING EXPERIENCES

• While it is recognized that AFC trainees achieve proficiency at varying rates, it is anticipated that a minimum of 12 months of experience in clinical practice with an experienced Neuromusculoskeletal physician sonographer will be required to obtain the required scanning skills, learn the requisite anatomy, and see an adequate volume and spectrum of pathology. • The maximum duration of training to complete the competency portfolio is 36 months. • It is recognized that the numbers of cases to obtain competency is variable between trainees. The decision of competence is ultimately in the hands of the supervising physician(s) and is reflected in the competency portfolio. • A monthly reflection of progress, imaging and quality review strongly is encouraged.

•

This document is to be reviewed by the AFC (Sub)Committee in [INSERT NAME OF DISCIPLINE] by [INSERT DATE] [Reviewed/Revised/etc.] – [AFC Committee/Specialty Standards Review Committee, etc.] – [month year] Template document:

Editorial revisions – Office of Education – December 2012

Reviewed and revised – Clinician Educator – January 2013

Approved – Office of Education – February 2013

Revised – Office of Education – August 2013

Revised – Office of Specialty Education – December 2013

Formatted: No bullets or numbering



Consensus Principles Addendum to NMSKUS AFC Diploma Submitted to the Royal College Committee on Specialties General Principles for Accreditation/Application Standards – NMSKUS AFC Diploma In discussions with base imaging specialties several core principles inherent to imaging emerged from our discussions. The NMSKUS AFC Diploma application group have reached consensus with the Diagnostic Imaging Specialty Committee regarding the following concepts: 1. The NMSKUS AFC committee will ensure invited representation from the base imaging specialties including diagnostic radiology. 2. Sites that offer the NMSKUS AFC Diploma must have a robust and mandatory image archiving program for NMSKUS examinations. 3. Sites that offer the NMSKUS AFC Diploma will already have in place a robust quality assurance program with follow up that includes comprehensive imaging review, clinical follow up and pathology review. 4. The AFC Diploma would require the submission of a comprehensive case log and imaging-based portfolio, not dissimilar to the AFC Echocardiography image submission process. Formatted: Font: 10 pt

12th September 2014 Committee on Specialties of the Royal College of Physicians and Surgeons RE: AFC Diploma Application for Point of Care Ultrasound (POCUS) On behalf of the Canadian Rheumatology Ultrasound Society (CRUS), I confirm the unreserved support of this application for an AFC Diploma in Point of Care Ultrasonography (POCUS). The technique of point of care ultrasonography is an invaluable addition to the clinical assessment of a patient with rheumatological disease, as it: clarifies diagnoses; monitors response to therapies; guides therapeutic interventions such as joint injections; is informative to patients; and aids in teaching MSK clinical skills to students, residents and fellows. We feel that a Royal College Diploma in POCUS will ensure thorough training and competency in this technique resulting in better care for our patients. Please do not hesitate to contact me if you would like me to expand on any of these issues. Kind regards

Maggie Larché, MRCP(UK), PhD President, CRUS 905 528 0489 [email protected]

AFC POCUS 228

April 14, 2014

Ms. Julia Lever COS/Diplomas Administrator, Educational Strategy, Innovations and Development (ESID) Unit Office of Specialty Education Royal College of Physicians and Surgeons of Canada [email protected]

Dear Ms. Lever

Re: AFC Diploma Application

Point of Care Musculoskeletal Ultrasound (MSKUS) in Rheumatology

The Canadian Rheumatology Association was able to review and discuss the AFC diploma application for Point of Care Musculoskeletal Ultrasound (MSKUS) in Rheumatology at our Annual Conference and Board Meeting in Whistler, BC, on February 27th, 2014. I am delighted to report that as President of the Canadian Rheumatology Association, our Specialty Society is fully supportive of the application to develop an AFC Diploma for Canadian Rheumatologists in Point of Care MSK Ultrasound. We lend our support to all of our members who are actively engaged in the development of this important focused training program that will no doubt improve the care provided to Rheumatology patients in Canada. Please do not hesitate to contact me if you require any further assistance from the Canadian Rheumatology Association. Sincerely,

Cory Baillie, MD President/Président Canadian Rheumatology Association/La Société canadienne de rhumatologie

MISSION STATEMENT

The Mission of the Canadian Rheumatology Association is to represent Canadian Rheumatologists and

promote their pursuit of excellence in Arthritis Care, Education and Research.

La Société canadienne de rhumatologie (SCR) a pour mission de représenter les rhumatologues

canadiens et d’encourager la quête de l’excellence dans les soins de l’arthrite, l’éducation et

la recherche.

AFC POCUS 227

SPECIALTIES UNIT 774, PROMENADE ECHO DRIVE, OTTAWA, ON, CANADA K1S 5N8

E-MAIL [email protected] TEL 613-730-8177 TOLL FREE 1-800-668-3740 FAX 613-730-3707

February 1, 2017 By Email: [email protected]

[email protected] [email protected]

Abraham Chaiton, MD, FRCPC Suite 405, Finch Avenue Site Humber River Regional Hospital 2115 Finch Ave W Toronto, ON M3N 2V6 Peter Inkpen, MD, FRCPC 3203 34th St Vernon, BC V1T 5X7 Johannes Roth, MD, FRCPC Apt 6, 319 MacKay St Ottawa, ON K1M 2B7 Dear Drs. Chaiton, Inkpen and Roth, RE: Application for AFC-diploma in Neuromusculoskeletal Ultrasound (AFC in NMSKUS) The national Specialty Committee for Diagnostic Radiology reviewed and discussed the AFC-diploma application for Neuromusculoskeletal Ultrasound (AFC in NMSKUS) at its meeting yesterday. I would like to relay to you that the specialty committee was generally supportive of the application for this diploma program with two small revisions. The revisions we are suggesting need to be done to the application submitted to the Royal College Committee on Specialities. The revisions are: 1. That we include the consensus statement on POCUS with the application. (attached) 2. On Page 14 of 31 of the document, there is a small typographical error under

b:Crystalline arthropathies, subparagraph ii, 2a it should read

‘Amorphous or rounded hyperechoic deposits in fibrocartilage as seen in the TFCC or knee meniscus’

The committee recognized the utility of point of care ultrasound in the management and treatment of patients in this clinical setting. The specialty committee would like to emphasize the importance of appropriate training for physicians who undertake this extension of their clinical skills, as well as emphasizing the importance of appropriate record keeping and appropriate quality assurance programs.


-2-

We wish you all the best in your application for recognition of Neuromusculoskeletal Ultrasound as an AFC-diploma. Please do not hesitate to contact me if you require anything further from me or the committee. Kind regards,

Jose Aquino, MD, FRCPC Chair, Specialty Committee in Diagnostic Radiology Encl. CC: Committee on Specialties

Addendum to NMSKUS AFC Diploma Submitted to the Royal College Committee on Specialties General Principles for Accreditation/Application Standards – NMSKUS AFC Diploma 1. The NMSKUS AFC committee will ensure invited representation from the base imaging specialties including diagnostic radiology. 2. Sites that offer the NMSKUS AFC Diploma must have a robust and mandatory image archiving program for NMSKUS examinations. 3. Sites that offer the NMSKUS AFC Diploma will already have in place a robust quality assurance program with follow up that includes comprehensive imaging review, clinical follow up and pathology review. 4. The AFC Diploma would require the submission of a comprehensive case log and imaging-based portfolio, not dissimilar to the AFC Echocardiography image submission process.

February 10, 2017 Dr. Jason Frank Director, Specialty Education, Strategy, and Standards Office of Education The Royal College of Physicians and Surgeons of Canada 774 Echo Drive, Ottawa Ontario K1S 5N8

Re: Proposal AFC Diploma Neuromuscular Skeletal Ultrasound

Dear Dr. Frank,

Dr. Abraham Chaiton contacted me as the Chair of the Internal Medicine Specialty Committee, on behalf of a group of physicians submitting a proposal for a new Area of Focussed Competence Diploma program in Neuromusculoskeletal Ultrasound (NMSKUS), to see if the IM Specialty Committee would support the application.

From the information provided by Dr. Chaiton, it is clear that the group has already developed a comprehensive curriculum to support the AFC application. It is also clear that the proposed program will focus on highly specialized knowledge and skills, beyond the competencies normally expected within a standard Internal Medicine or General Internal Medicine practice. I surveyed the nucleus members of the IM Specialty Committee, who unanimously supported the proposal.

Please feel free to contact me if you have any questions or require any additional information.

Yours truly,

William Coke MDCM, FRCPC, FACP Chair, IM Specialty Committee

Brian James Murray, MD FRCP(C) D,ABSM Associate Professor, Neurology and Sleep Medicine University of Toronto Department of Medicine Chair – Royal College Specialty Committee in Neurology Chair – Research Ethics Board Sunnybrook Health Sciences Center Room M1-600; 2075 Bayview Avenue Toronto, Ontario, Canada, M4N 3M5 phone (416) 480-6100x2461, fax (416) 480-6092 [email protected]

January 27 2017 Dr. Jason Frank Director, Specialty Education, Strategy, and Standards Office of Education The Royal College of Physicians and Surgeons of Canada 774 Echo Drive, Ottawa, Ontario K1S 5N8 RE: Proposed AFC Diploma in Neuromusculoskeletal Ultrasound Dear Dr. Frank, I am writing to you as chair of the Royal College specialty committee in Neurology to indicate no objection to the proposed Area of Focused Competence in Neuromusculoskeletal Ultrasound diploma program. This program may provide adjunctive technological training to neuromuscular neurology specialists. Few neurologists in Canada are using this technique currently, though this may increase over time. Therefore we appreciate that Neurology is an entry path to the program should some decide to pursue further training in this area in the future. The planning committee of the program may benefit from involvement of a Neurology representative in the future if an interested individual can be identified. I can be reached at [email protected] if you have any further questions. Sincerely, Brian Murray, MD, FRCPC, D,ABSM

February 3, 2017 Dr. Jason Frank Director, Specialty Education, Strategy and Standards Office of Specialty Education The Royal College of Physicians and Surgeons of Canada 774 Echo Drive Ottawa, Ontario K1S 5N8 Re: Pending application: Area of Focused Competency- Diploma in Neuromusculoskeletal Ultrasound (NMSKUS) Dear Dr. Frank, As Chair of the Specialty Committee in Pediatrics, I was asked to review the above-mentioned AFC application which is currently pending before the Office of Education. I have not, however, had the opportunity to present this application to the other members of the Specialty Committee. It seems clear that Neuromusculoskeletal Ultrasound (NMSKUS) is gaining increased recognition as an imaging modality of choice for a number of conditions seen by specialists in Rheumatology, Physical Medicine and Rehabilitation and Neurology, in both adult and pediatric patients. There are advantages to its use as a point-of-care practice in terms of rapidity of access, patient safety when used during procedures such as intra-articular aspiration and injection, and cost, especially when compared to MRI. Given the projected growth in its use, NMSKUS should be incorporated in residency training in the above-mentioned specialties, which, of course, requires the recognition of experts in the field to provide teaching and supervision. Approval of this AFC will not only promote the incorporation of NMSKUS into clinical practice, but will standardize the expectations for training to an expert level. In my opinion, it is unlikely that a paediatrician without subspecialty or combined training in one of the above fields would consider enrolment in

this AFC program. Nevertheless, I am willing to lend my support to the application.

Yours sincerely,

3175 Chemin Côte-Sainte-Catherine Montréal (Québec) Canada H3T 1C5

SSeerrvviiccee ddeess SSooiinnss IInntteennssiiffss PPééddiiaattrriiqquueess

Laurence Ducharme-Crevier, M.D., M.Sc Geneviève Du Pont-Thibodeau, M.D., M.Sc Guillaume Émeriaud, M.D., Ph.D Catherine Farrell, M.D. Directrice de programme Médecine de soins intensifs chez l’enfant Université de Montréal Karen Harrington, M.D., M.Sc Philippe Jouvet, M.D., Ph.D Chef de service Jean-Sébastien Joyal, M.D., Ph.D Jacques Lacroix M.D. Directeur : Programme cliniciens-chercheurs Université de Montréal Géraldine Pettersen, M.D., M.Sc François Proulx M.D. Baruch Toledano, M.D., M.Sc Marisa Tucci, M.D. Adjointe au Chef de service

Patricia Elhadad, Agente administrative Bureau 3408 Téléphone : 514.345.4931 #5549 Télécopieur : 514.345.7731

Nicole Poitras Gestionnaire de projets, Centre de recherche Téléphone : 514.345.4931 #2157 & Assistantes de recherche Téléphones: 514.345.4931 #2760 / #6343 Télécopieur : 514.345.2160

Catherine Farrell, MD, FRCPC Chair, Specialty Committee in Pediatrics Royal College of Physicians and Surgeons of Canada

GF Strong Rehab Centre 4255 Laurel Street Vancouver, BC V5Z 2G9 Tel: 604-714-4113 Fax: 604-737-6251

August 30, 2015 Dr. Jason Frank Director, Specialty Education, Strategy and Standards Office of Specialty Education The Royal College of Physicians and Surgeons of Canada 774 Echo Drive Ottawa, ON K1S 5N8 Dear Dr. Frank: RE: Letter of support for AFC Diploma in Ambulatory Care Point of Care Ultrasound (POCUS) from Royal College Specialty in Physical Medicine and Rehabilitation As Chair of the Royal College Physical Medicine and Rehabilitation specialty committee, I am writing in support of the application to create an Area of Focused Competence (AFC) Diploma in Ambulatory Care Point of Care Ultrasound (POCUS). The field of Physical Medicine and Rehabilitation is dedicated to the treatment and management of people with disabilities. Many of our patients required treatments that involve intramuscular, soft tissue and intra-articular injections. In recent years, some physiatrists have already begun to upgrade their skills in the use of ultrasound as a modality to help guide injection procedures. Workshops in ultrasound use are becoming increasing popular in Physiatry conferences and residents are also starting to learn its use. There is literature to support the use of ultrasound in procedures where accuracy is paramount to appropriate treatment, such as guidance of chemodenervation injections, versus conventional anatomical land-marking. I anticipate that Physiatry will be formally incorporating the use of ultrasound into its educational mandate in the near future. Point of care ultrasound is also increasingly being used in other specialties, and subspecialties, such as rheumatology. Its application has already been incorporated into Internal Medicine and Emergency Medicine. The use of ultrasound helps to improve patient care and procedural accuracy. Therefore, we feel that a focused Diploma in Ambulatory Care Point of Care Ultrasound that provides current, evidence-based education in POCUS for physicians from a variety of backgrounds would be greatly beneficial for promoting interdisciplinary care and improving the health of Canadians. Please contact me directly if I may provide any additional information in support of the AFC Diploma in Ambulatory Care POCUS. Sincerely,

Jennifer K. Yao, MD, FRCPC Physical Medicine & Rehabilitation Specialty Committee, Chair Email: [email protected] Tel: 604-714-4113 Fax: 604-737-6251


Toronto Western Hospital 1E-452

399 Bathurst Street, Toronto, ON M5T 2S8

Tel (416)603-5404, Fax (416)603-4348

October 2, 2014

Dr. Jason Frank

Director, Specialty Education, Strategy and Standards

The Royal College of Physicians and Surgeons of Canada

c/o Administrator, Committee on Specialties

77 Echo Drive

Ottawa Ontario, K1S 5N8

Re: AFC Diploma- Point of Care Ultrasonography (POCUS) Application

Dear Dr. Frank,

As Program Director of the Division of Rheumatology at the University of Toronto and Chair of the

Program Committee, I can represent that we are in full support of the AFC-Diploma-Point of Care

Ultrasound (POCUS) application to the Royal College. We have already taken advantage of the

McMaster Canadian Rheumatology Ultrasound Society (CRUS) course and their instructors to give our

rheumatology trainees the fundamentals for using ultrasound at the bedside.

We will work to ensure that the Diploma program is implemented effectively by encouraging our trainees

to attain these skills from MSK mentorships and formal teaching sessions. Supervised access to

ultrasound equipment in our clinics will be made a priority to ensure successful and meaningful exposure

in point of care ultrasound for our trainees.

We feel that point of care ultrasound will continue to grow as an implement for future rheumatologists. A

Royal College Diploma would assure maintenance of quality for training and clinical practice.

Yours truly,

Arthur A. M. Bookman MD FRCPC

Program Director, Division of Rheumatology

University of Toronto

Department of Director, Specialty Education, Strategy and Standards, Office of Education, The Royal College of Physicians and Surgeons of Canada (RCPSC), c/o Administrator, Committee on Specialties (COS), 774 Echo Drive Ottawa, ON K1S 5N8

19th September 2014.

Re: Royal College Diploma of Point of Care Ultrasound (POCUS)

Dear Committee,

I am writing as Chair of the Department of Medicine to support the development of a

Royal College Diploma of Point of Care Ultrasound (POCUS). I understand that the

Canadian Rheumatology Ultrasound Society have been running a basic ultrasound

course for rheumatologists at McMaster University annually for the past 3 years, and

have trained over 100 rheumatologists.

The Canadian Rheumatology Ultrasound Society is now extending this success by

liaising with emergency physicians to develop a Royal College Diploma of Point of Care

Ultrasound. We at McMaster University are uniquely qualified to provide this Diploma

because of the expertise gained through the CRUS courses, including the important

interaction with the anatomy department.

PAUL M. O’BYRNE Faculty of 1280 Main Street West Phone 905.521.2100 MB, FRCPC, FRSC Health Sciences Health Sciences Centre – 3W10 Ext. 76395 / 76373 E.J. Moran Campbell Professor Michael G. DeGroote Hamilton, ON, Canada Fax 905.521.4972 Chair, Department of Medicine School Of Medicine L8S 4K1

Should the proposed AFC Diploma in POCUS be approved, we will support the

implementation by facilitating ongoing training in ultrasonography for rheumatologists

lead by Dr Maggie Larché and other trainers from the Canadian Rheumatology

Ultrasound Society. In addition, we will work to ensure that the diploma program is

implemented effectively by supporting Dr Maggie Larché in managing and directing the

diplomates to achieve the goal of successful completion of their POCUS training for

rheumatologists.

I strongly endorse the application and look forward to the successful implementation of

the Diploma in POCUS.

Yours Sincerely,

Paul M O’Byrne MB, FRCP(C), FRSC.

EJ Moran Campbell Professor and Chair,

Department of Medicine.

application for recognition part i - preliminary a · title: application for recognition part i -...

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