Priority 17 from the Psoriatic Arthritis PSP

UNCERTAINTY: What role does imaging such as x-ray, MRI and ultrasound play in the diagnosis and management of psoriatic arthritis?  (JLA PSP Priority 17)
Overall ranking 17
JLA question ID 0108/17
Explanatory note The current evidence does not fully explain the best type of imaging to use to diagnose and monitor people living with psoriatic arthritis. It is also unclear how frequently imaging should be used and whether it is most beneficial to use independently or in combination. For example, using ultrasound and MRI to identify and quantify synovitis. It is hoped this question will generate evidence to fill the gaps. These are examples of uncertainties that reflect the evidence gaps. What is the most relevant imaging to use in early disease in peripheral psoriatic arthritis? Does ultrasound show changes in clinical and subclinical conditions, in psoriatic arthritis patients? 

This question has been partially addressed in the evidence base from the following systematic reviews and guideline:
Medonca, 2019. Despite the potential relevance of ultrasonography for the diagnosis of nail disease, additional studies are needed to determine which features are more reliable and clinically pertinent to ensure accuracy in the evaluation of nail involvement in PsO and PsA
Elalouf, 2019. Sonographic enthesitis scoring instruments have been developed for SpA, only a few have been validated in PsA. None of them passed the OMERACT filter in patients with PsA. Additional research is required before endorsing a specific instrument for the assessment of enthesitis in patients with PsA
Sapundzhieva, 2020. Data suggested that ultrasound examination of the joints, tendons and enthesis of the hands has a major role in the differentiation between RA and PsA. Future research needed
Sakellariou, 2020. Not a specific systematic review for PsA, a mixed group of inflammatory arthropies .Very limited evidence on ultrasounds additional value over clinical diagnosis was tested. Further research needed
Yue, 2018. Evidence to suggest various imaging modalities such as ultrasound, magnetic resonance imaging (MRI) and high-resolution peripheral quantitative computed tomography (HR-pQCT), are able to detect early joint damage, early diagnosis of inflammatory arthritis, monitor the progression or even ascertain whether the inflammatory process is effectively suppressed to allow repair of joint damage by novel therapeutic agents
Macia-Villa, 2020. A systematic review of the literature to evaluate the use of the enthesis ultrasound Madrid Sonographic Entesis Index (MASEI) concluded MASEI is a feasible, reliable and valid ultrasound score for the study of enthesis in spondyloarthritis, psoriatic arthritis and other diseases
Mathew, 2019. Identifed a lack of a comprehensive, validated score warrants additional research to develop an MRI enthesitis scoring system to increase the utility of MRI as an outcome measure in SpA and PsA clinical trials
NICE, 2018. Adults with suspected axial spondyloarthritis and an X‑ray that does not show sacroiliitis have an MRI using an inflammatory back pain protocol

Health Research Classification System category Inflammatory and immune system
Extra information provided by this PSP
Original uncertainty examples How should we diagnose patients with psoriatic arthritis who have non-radiological  findings? 
Submitted by 16 uncertainties submitted 
PSP information
PSP unique ID 0108
PSP name Psoriatic Arthritis
Total number of uncertainties identified by this PSP. 46  (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop 12 July 2021