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The EUSTAR model for teaching and implementing the modified Rodnan skin score in systemic sclerosis
  1. László Czirják1,
  2. Zoltán Nagy1,
  3. Martin Aringer2,
  4. Gabriela Riemekasten3,
  5. Marco Matucci-Cerinic4,
  6. Daniel E Furst5,
  7. on behalf of EUSTAR
  1. 1Department of Immunology and Rheumatology, University of Pécs, Pécs, Hungary
  2. 2Department of Rheumatology, Internal Medicine III, Medical University of Vienna, Vienna, Austria
  3. 3Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
  4. 4Department of Medicine, Division of Rheumatology, University of Florence, Florence, Italy
  5. 5Rheumatology Division, Geffen School of Medicine, University of California–Los Angeles, Los Angeles, California, USA
  1. Correspondence to:
    Professor L Czirják
    Department of Immunology and Rheumatology, University of Pécs, H-7621 Pécs, Irgalmasok u. 1, Hungary; laszlo.czirjak{at}


Objective: To evaluate the ability to teach scleroderma experts and young rheumatologists to perform the modified Rodnan skin score test.

Methods: Three international “teaching courses for teachers” were conducted with 6–9 experts who performed 3–9 skin score tests each. In addition, an international course for 90 young rheumatologists, in which 18 patients with systemic sclerosis (SSc) participated, was also organised. Finally, a local repeated training course for 5–9 rheumatologists was performed, in which 6–7 patients with SSc participated.

Results: When 6–9 scleroderma specialists investigated the patients, the intraclass correlation coefficient (ICC) showed “good” to “excellent” values (0.865 and 0.710, respectively). When 90 young rheumatologists were involved in one teaching course, the coefficient of variation (CV) was relatively satisfactory (35%) owing to the high number of investigators, and with a considerable within-patient SD value of 5.4.

Repeated teaching of 5–9 young rheumatologists in local courses clearly improved the consistency. The ICC increased from 0.496 to a “good” level of 0.722. The within-patient SD values for intraobserver variability ranged between 2.5 and 2.9. The intraobserver CV was about 20%.

Conclusions: This study strongly supports the need for standardisation among different centres when using skin scoring for clinical trials. The intraobserver variability and within-patient SD values can be significantly reduced by repeated teaching. For inexperienced rheumatologists, at least one repeated teaching course is needed.

  • ICC, intraclass correlation coefficient
  • MRSS, modified Rodnan skin score
  • SSc, systemic sclerosis

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  • Funding: This work was supported by a EULAR educational grant provided for EUSTAR.

  • Competing interests: None declared.

  • EUSTAR is the EULAR Scleroderma Trials and Research group. Besides the authors, further participants in the skin score measurements are listed in the Acknowledgements.

  • Published Online First 18 January 2007