FSEM (UK) Guidelines for Musculoskeletal Ultrasonography in Sport and Exercise Medicine

There is a requirement for the Faculty to produce practical guidelines in the use of Ultrasound scanning in the practice of Sport and Exercise Medicine.

Recommendations

The Council is recommended to endorse:

The adoption of a modular approach to training. The SEM sonographer may wish to become proficient in some, but not all of the proposed modules within the syllabus.

Standards for the use of ultrasound in ongoing practice to satisfy ongoing accreditation and revalidation.

Background

Advances in technology have significantly improved the ability of ultrasound (US) to depict both normal anatomy and pathology in musculoskeletal (MSK) tissues. Reduction in cost and the improved portability of machines has increased the access to ultrasound for non-radiologists and it has therefore been increasingly utilised as an extension of the clinical examination by those practicing Sport and Exercise Medicine (SEM) ^{(1, 2)} SEM physicians are not Radiologists, but with appropriate training in MSK US can enhance the care pathway provided to patients by increasing diagnostic accuracy, guiding interventions and reducing patient episodes.

The Royal College of Radiologists (RCR) recognise that training of non-radiologist professional groups, such as SEM specialists, will help facilitate clinical decisions and reduce the burden on radiology departments.  In 2005 the RCR published guidelines for training in US for Medical and Surgical specialties ⁽³⁾.  This was revised in 2012.  Although this goes a long way to creating standards for training, it is not specific to SEM physicians and there is little evidence that it is followed.  In addition, there is a suggestion that SEM clinicians have found it difficult to access MSK radiologists to undertake the essential role of trainer⁽⁴⁾.    Other recommendations for training exist including a Delphi consensus, English Institute of Sport, EULAR (European League against Rheumatism) and the American Medical Society for Sports Medicine guidelines^(4-6), but similarly little evidence exists that SEM practitioners use them. This has led to large variations in the quality and delivery of training, which raises significant issues of quality assurance.

A large proportion of SEM training and delivery occurs outside of the National Health Service. This reduces access to consultant MSK Radiologists for training and mentoring.  There is therefore a requirement to increase the number of SEM physicians that are able to undertake this critical role alongside Radiologists.

There are an increasing number of training courses and postgraduate qualifications available to SEM practitioners. These are often delivered by members of the RCR, the British Society of Skeletal Radiology (BSSR) or a number of educational institutions.  Many of these institutions courses are validated by the Consortium for Accreditation in Sonographic Education (CASE) and run courses in MSK US including PG Cert, Diploma, MSc and modular short courses.

The RCR guidelines suggest that MSK US is more suited to a modular approach to training. This approach enables SEM practitioners to achieve competency in one specific anatomical area without the gamut of knowledge and skills provided by an MSK Radiologist.

There has been a lack of clear guidance for the use of this critical tool for the clinical evaluation of patients with MSK injury. The Faculty will publish independent guidelines, in conjunction with the BSSR.

Basic Competency

It is anticipated that most clinicians practicing in SEM would operate at this level. There would be three elements of training and professional development to ensure competency:

a. Initial Training

Achieved through a number of available basic introductory courses, usually over a minimum of 2 days. These courses should include both theory and practical sessions. 

b. Mentored Clinical Experience.

This is an essential component of training for which a logbook of cases should be maintained.

Practical training should consist of a minimum of 200 scans of which 100 would be directly supervised.  Indirect supervision requires regular case discussion and exchange of images with the approved mentor.  The point at which the trainee can move from direct to indirect supervision will be at the discretion of the mentor.

It is anticipated that SEM trainees with a NTN wishing to train in MSK US would undertake such training during ST5 and ST6 in discussion with their Training Program Director.

Mentors should be one of the following:

1. Consultant MSK US Radiologist
2. FSEM (UK) approved SEM mentor with a regular commitment to MSK US (operating at a minimum Level 2 as per RCR guideline)
3. MSK US Mentorship scheme offered by a University Course

On completion of a period of mentored clinical experience the mentor will confirm, in writing to the US subcommittee, that the individual has completed the recommended number of cases and is competent to undertake accredited assessment.

c. Accredited assessment.

Mentorship Level

Those wishing to train and mentor other SEM sonographers should fulfil the following:

Consultant MSK US Radiologist (operating at minimum Level 2 as per RCR guideline)

OR

FSEM UK approved MSK US Mentor with:

 Three years’ clinical MSK US experience

  Regular commitment to MSK US (minimum 1 clinic per week where US routinely used

 Undertake minimum 400 scans per year (irrespective of whether full/part-time job plan)

Approval as FSEM UK MSK US mentor (whether as part of University course, other course or stand-alone) will be based on Academy of Royal Colleges’ “Requirements for Colleges and Faculties in relation to Examiners and Assessors” guidance (2014) as adopted by the GMC.

Continuing Medical Education/Professional Development

FSEM (UK) approved MSK sonographers have responsibility to adhere to the principles of the GMC Good Medical Practice and only undertake scans and procedures within their competency. It is also recommended that they:

• Demonstrate minimum 200 scans/year (could take form of logbook or US clinic list for example) or 100 scans/year for a single body
• part/region
• Demonstrate breadth of scans against FSEM MSK US Syllabus (and if only scanning one region/body part demonstrate this)
• MSK US should feature in ongoing CPD and PDP
• MSK US should be included in annual appraisal and revalidation.
• Audit MSK US practice
• Keep up to date with relevant literature
• Peer review minimum every 2-3 years:

                – As part of MSK US Training course

OR

– by Consultant MSK US Radiologist

OR

– by FSEM UK Approved MSK US Assessor*

Must demonstrate competence on anatomy/joints/areas that Clinician regularly scans (MSK US practice must be limited to that body part or region however)

References

1.Wakefield RJ, Goh E, Conaghan PG, Karim Z, Emery P. Musculoskeletal ultrasonography in Europe: results of a rheumatologist-based survey at a EULAR meeting. Rheumatology 2003;42:1251–3.

2. Speed CA, Bearcroft PW. Training in musculoskeletal sonography: report from the first BSR course. Rheumatology 2002;41:346.

3. Faculty of Clinical Radiology, Royal College of Radiologists Ultrasound training recommendations for medical and surgical specialties. London: Royal College of Radiologists, 2005.

4. Roger Hawkes reference survey.

5. Backhaus M, Burmester GR, Gerber T et al. Guidelines for musculoskeletal ultrasound in rheumatology. Ann Rheum Dis 2001;60:641–9.

6. Brown AK, O’Connor PJ, Roberts TE, Wakefield RJ, Karim Z, Emery P. Recommendations for musculoskeletal ultrasonography by rheumatologists: setting global standards for best practice by expert consensus. Arthritis Rheum 2005;53:83–92.

6. Finnoff J, Lavallee ME, Smith J. Musculoskeletal ultrasound education for sports medicine fellows: a suggested/potential curriculum by the American Medical Society of Sports Medicine. Br J Sports Med 2010;44:1144-1148.

2019

The Faculty in conjunction with the BSSR May 2019 independent ultrasound guidelines .