Advanced Practice Providers Should Learn Musculoskeletal Ultrasound

Ms. Benham performs an ultrasound scan on a patient with juvenile idiopathic arthritis.

I have worked as an advanced practice provider (APP) in pediatric rheumatology for nearly 16 years. My collaborating physicians have allowed me to function to the full extent of my scope of practice while allowing me to develop professionally within the subspecialty. My latest endeavor has been learning how to perform musculoskeletal ultrasound (MSUS) and incorporating it into my daily practice.

My interest in learning this skill began when our institution hired several radiologists with training and expertise in MSUS. I accompanied patients to the radiology department to observe their scans and ultrasound-guided steroid injections, and I was fascinated by the ability to visualize the impact of inflammatory arthritis in real time and determine changes in medical management that could lead to improved outcomes.

MSUS allows a provider to image multiple joints at the bedside, simultaneously integrating the results with information from the history and findings of the physical exam. MSUS helps providers identify subclinical disease activity and monitor response to therapy. This can contribute to more effective medical decision making, allowing for better disease control, prevention of joint damage and achievement of remission.

Training Opportunity

I started my journey in MSUS education by taking the two-day, MSUS—Fundamentals course at the 2015 ACR/ARHP Annual Meeting. I have attended several two-hour workshops on MSUS topics and participated in the USSONAR course from October 2016–June 2017. This nine-month, intensive curriculum cemented my foundational knowledge and supported my new love for this imaging modality.

In Practice

I began scanning patients on an almost daily basis to keep up with the course requirements. These interactions with my patients and families were invaluable and eye opening. While patients were helping me learn and complete my coursework, they were learning more about their disease and what arthritis actually looks like at the joint level.

While I had been performing blind joint injections for many years, this educational process allowed me to appreciate the increased efficacy of ultrasound-guided steroid injections for certain joints and in certain situations. Performing these procedures also allowed more intimate time with my patients and their families, which led to their increased understanding of the disease process and strengthened our relationships.

At the 2018 ACR/ARHP Annual Meeting, I attended the one-day MSUS—Advanced course. More recently, I passed the ACR RhMSUS certification exam. This increased my confidence in the use of MSUS. I remain engaged with USSONAR, am an active member of the Childhood Arthritis and Rheumatology Research Alliance Ultrasound Workgroup and continue to grow the MSUS aspect of my practice.

Future Plans

I am also working closely with our pediatric rheumatologists to develop MSUS training components for our fellowship program and hope to contribute to the development of educational activities focused on the pediatric elements of MSUS. I have developed profound collegial relationships with other providers, both pediatric and adult, who promote MSUS education, its use in practice and ongoing MSUS research.

As we continue to examine the projected workforce shortage in rheumatology and look toward APPs as one effective way to address the problem, I think it is important for practices to envision unique ways APPs can contribute to the improvement of patient care and clinical outcomes.

We can assess patients, formulate diagnoses, order labs and diagnostic studies, initiate and modify medical management, facilitate appropriate referrals and provide patient education. APPs can also participate in research, quality improvement initiatives, advocacy and leadership roles in the field.

I see education in and utilization of MSUS as a unique opportunity for APPs. I encourage other APPs to consider pursuing these MSUS educational opportunities and practices to consider this a valuable way APPs can contribute to patient care.

Heather Benham, DNP, RN, CPNP, RhMSUS, is a pediatric nurse practitioner in the Rheumatology Department at Texas Scottish Rite Hospital for Children, Dallas.