Recommendations, SOR and level of evidence
| Recommendation* | SOR, mean VAS 0–10 (95% CI) | Level of evidence | |
|---|---|---|---|
| 1 | When there is diagnostic doubt, CR, ultrasound or MRI can be used to improve the certainty of a diagnosis of RA above clinical criteria alone† | 9.1 (8.6 to 9.6) | III |
| 2 | The presence of inflammation seen with ultrasound or MRI can be used to predict the progression to clinical RA from undifferentiated inflammatory arthritis | 7.9 (6.7 to 9.0) | III |
| 3 | Ultrasound and MRI are superior to clinical examination in the detection of joint inflammation; these techniques should be considered for more accurate assessment of inflammation | 8.7 (7.8 to 9.7) | III |
| 4 | CR of the hands and feet should be used as the initial imaging technique to detect damage. However, ultrasound and/or MRI should be considered if conventional radiographs do not show damage and may be used to detect damage at an earlier time point (especially in early RA) | 9.0 (8.4 to 9.6) | IV |
| 5 | MRI bone oedema is a strong independent predictor of subsequent radiographic progression in early RA and should be considered for use as a prognostic indicator. Joint inflammation (synovitis) detected by MRI or ultrasound as well as joint damage detected by conventional radiographs, MRI or ultrasound can also be considered for the prediction of further joint damage | 8.4 (7.7 to 9.2) | III |
| 6 | Inflammation seen on imaging may be more predictive of a therapeutic response than clinical features of disease activity; imaging may be used to predict response to treatment | 7.8 (6.7 to 8.8) | III-IV |
| 7 | Given the improved detection of inflammation by MRI and ultrasound than by clinical examination, they may be useful in monitoring disease activity | 8.3 (7.4 to 9.1) | III |
| 8 | The periodic evaluation of joint damage, usually by radiographs of the hands and feet, should be considered. MRI (and possibly ultrasound) is more responsive to change in joint damage and can be used to monitor disease progression | 7.8 (6.8 to 8.9) | III |
| 9 | Monitoring of functional instability of the cervical spine by lateral radiograph obtained in flexion and neutral should be performed in patients with clinical suspicion of cervical involvement. When the radiograph is positive or specific neurological symptoms and signs are present, MRI should be performed | 9.4 (8.9 to 9.8) | III |
| 10 | MRI and ultrasound can detect inflammation that predicts subsequent joint damage, even when clinical remission is present and can be used to assess persistent inflammation | 8.8 (8.0 to 9.6) | III |
*Recommendations are based on data from imaging studies that have mainly focused on the hands (particularly wrists, metacarpophalangeal and proximal interphalageal joints). There are few data with specific guidance on which joints to image.
†In patients with at least one joint with definite clinical synovitis, which is not better explained by another disease.
Categories of evidence: Ia, evidence for meta-analysis of randomised controlled trials; Ib, evidence from at least one randomised controlled trial; IIa, evidence from at least one controlled study without randomisation; IIb, evidence from at least one other type of quasi-experimental study; III, evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case–control studies; IV, evidence from expert committee reports or opinions or clinical experience of respected authorities, or both.
CR, conventional radiography; RA, rheumatoid arthritis; SOR, strength of recommendation; VAS, visual analogue scale (0–10; 0=not recommended at all, 10=fully recommended).