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Original research
Procedures for the content, conduct and format of EULAR/PReS paediatric musculoskeletal ultrasound courses
  1. Silvia Magni-Manzoni1,
  2. Valentina Muratore2,
  3. Jelena Vojinović3,4,
  4. Denise Pires Marafon1,
  5. Maria Antonietta D'Agostino5,6 and
  6. Esperanza Naredo7,8
  7. the Paediatric Rheumatology European Association (PReS) Imaging Working Party
    1. 1Rheumatology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
    2. 2Primary Care, ATS Pavia, Pavia, Italy
    3. 3Faculty of Medicine, University of Niš, Niš, Serbia
    4. 4Department of Pediatric Rheumatology and Immunology, Nis, Nis, Serbia, Clinical Centre Niš, Niš, Serbia
    5. 5Rheumatology Department, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
    6. 6INSERM, Paris, France
    7. 7Rheumatology, Bone and Joint Research Unit, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
    8. 8Universidad Autónoma de Madrid, Madrid, Spain
    1. Correspondence to Dr Silvia Magni-Manzoni; silvia.magnimanzoni{at}


    Background Despite the worldwide increasing request of education on paediatric musculoskeletal ultrasound (PedMSUS), content, conduct and format of PedMSUS courses have never been internationally agreed.

    Objectives To produce educational procedures for the conduct, content and format of EULAR/PReS PedMSUS courses.

    Methods After a systemic literature review and expert opinion collection, a panel of items for the development of procedures on PedMSUS courses was identified. Agreement on the items was assessed through Delphi surveys among a taskforce of 24 members, which included 18 experts in PedMSUS (8 rheumatologists, 1 radiologist, 9 paediatric rheumatologists), 1 methodologist and rheumatologist expert in MSUS, 2 patient research partners, 1 health professional in rheumatology and 2 EMEUNET/EMERGE members, from 8 different European countries. Each item was assessed through a 5-point Likert scale (0, full disagreement; 5, full agreement); agreement was reached for >75% of answers rating 4–5. All items with agreement were included in the preliminary core set of educational procedures, which underwent external assessment by a broader Consensus group (Faculty and Tutors of previous EULAR PedMSUS courses and PReS Imaging Working Party members), through Delphi survey.

    Results Two Delphi surveys produced the preliminary core set of procedures for basic, intermediate, advanced and teach-the-teachers (TTT) PedMSUS courses. A Delphi survey within the Consensus group produced agreement on the proposed procedures.

    Conclusions Shared EULAR/PReS procedures for the conduct, content and format of basic, intermediate, advanced and TTT PedMSUS courses were identified on international basis.

    • Ultrasonography
    • Arthritis, Juvenile
    • Health services research
    • Outcome Assessment, Health Care

    Data availability statement

    No data are available.

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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    • Despite the flourishing of paediatric musculoskeletal ultrasound (PedMSUS) courses on international ground in the recent years, the content, conduct and format of such courses have never been internationally agreed so far. The current project is the first one dealing with the need of international standardised, high-level education in PedMSUS.


    • The study produced shared procedures for the content, conduct and format of PedMSUS courses, through the involvement of physicians with different background, health professionals in rheumatology and patient research partners, from all over the world.


    • The results of the project provide a number of procedures that will efficiently support the fruitful organisation of future PedMSUS courses at high level of standardised education, for successful training on an increasingly requested imaging technique.


    The potentialities of musculoskeletal ultrasound (MSUS) in the evaluation of children with arthritis have been widely acknowledged in the recent years, as confirmed by the blooming of literature on the topic.1–6 The quality advances in the resolution of small and superficial structures, along with the decrease in costs of US equipment and concomitant wider accessibility, spread its use in the clinical setting, enhanced its potential role in research and led to an increasing need for specific education on paediatric MSUS (PedMSUS), among a variety of specialists, ranging from paediatric and adult rheumatologists to radiologists and physiotherapists.7–10

    Since 2007, lectures on MSUS in children have been included in the advanced level of the EULAR Sonography Courses and, since 2012, several EULAR endorsed PedMSUS courses have been held. More recently, two joined EULAR/PReS (Paediatric Rheumatology European aSsociation) PedMSUS courses took place in Madrid, in 2017 and 2019, respectively, with much appreciation by participants as well as by faculty members and tutors. These educational events demonstrated the effectiveness of joined efforts of EULAR ultrasound experts and teachers, who holds a long-lasting MSUS educational experience,11–15 and the younger PReS ultrasonographer community, who is particularly aware of the peculiar US features and changes in joints at different paediatric ages, entailing absolutely specific issues in PedMSUS training.16–26 Further, they highlighted that the variability in background (certified education) and experience in PedMSUS in different countries has a relevant impact on the quality of the courses. Nonetheless, content, conduct and format of PedMSUS courses have never been internationally agreed so far.

    The purpose of the project was to produce practical and educational procedures for the conduct, content and format of different levels of EULAR/PReS PedMSUS courses (ie, basic, intermediate, advanced and teach-the-teachers (TTT) level), to ensure high-quality and homogeneous training by an international consensus.


    Study design

    The convenors (EN, SM-M), EULAR Methodologist (MAD’A) and project Fellow (VM) (Core Team) led a multidisciplinary Taskforce, in accordance with the EULAR standardised operating procedures.27 The Taskforce was composed of 24 members from 8 different countries and included PedMSUS experts (8 rheumatologists, 1 radiologist, 9 paediatric rheumatologists), 1 methodologist and rheumatologist, 2 patient research partners previously involved in PedMSUS projects/educational events,28 1 health professional in rheumatology (HPR) and 2 EMEUNET (EMerging EULAR NETwork)/PReS EMERGE (EMErging RheumatoloGists and rEsearchers) members.

    A Consensus group was recruited among faculty members and tutors of previous PedMSUS courses, PReS Imaging Working Party members, colleagues and fellows with interest in PedMSUS education on Taskforce members’ knowledge. It included 114 people from 29 countries all over Europe, North America, South America, Central America, Asia and Africa.

    The project was developed in three main phases, as summarised in figure 1.

    Figure 1

    Summary of the three study phases. TTT, teach-the-teachers

    Questionnaire design

    In the initial step, a systematic literature and events review, including extensive search on educational projects/events regarding PedMSUS on websites and networks, was performed in December 2018. The search engines consulted were: PubMed, Cochrane, Embase, ERIC, Medline, CINAHL complete, Google, Yahoo, Ask, Baidu, Bing, Lycos, Duckduckgo. The keywords entered were: “musculoskeletal”, “ultrasound”, “sonography”, “course”, “education”, “training”, “children”, “paediatrics”, “pediatrics”. Only courses/events, articles and books in English were considered. No articles neither books on educational recommendations for the content, conduct and format of PedMSUS courses were found. A total of 17 PedMSUS courses were identified: five were not in English language; additional two online courses and three residential were not consistent with the purpose of our task, and were excluded. The literature review was extended (ELR) with inclusion of courses of Taskforce’s knowledge with available complete information (n=1). Eight courses were finally included for the analysis (figure 2).

    Figure 2

    Flow chart of the extended systematic literature and events review. PedMSUS, paediatric musculoskeletal ultrasound.

    The documentation retrieved was registered according to three main areas: content, conduct and format (table 1). Descriptive analysis was performed and results discussed online within the Taskforce for the selection of items on each area to be investigated (qualitative Delphi).29 Final drafts of the questionnaires for the different level of competency PedMSUS courses were approved online by the Taskforce.

    Table 1

    Summary of the main features of the eight PedMSUS courses analysed for developing of the survey questionnaires (I phase of the project)

    The questionnaire dealing with basic, intermediate and advanced PedMSUS courses was composed of 121 questions divided into three sections, according to the areas of content, conduct and format.

    The conduct section comprised: educational model, distribution between theoretical and practical part, number of participants per teacher in practical sessions, type of models to be included in the practical part, course duration and hours distribution per day. The educational model ranged among these possibilities: two-level education (basic, advanced), three-level education (basic, intermediate and advanced), two-level education and/or additional courses on selected subjects. that is, focused courses. Three options were identified regarding the distribution between theoretical and practical part: 50%–50%, 40%–60%, 30%–70%. The questions about the number of participants per teacher in practical sessions included three options: four, five or six course participants. Healthy children or patients were the two possibilities offered for models in the practical sessions. The hours distribution per day provided three options: 20 hours over 2 days, 20 hours over 3 days or 24 hours over 3 days.

    The content section offered 46 questions about the topics that should have been treated respectively in the basic, intermediate and advanced level.

    The format section included: course timing, requirements and/or restrictions for the participants, prerequisites for faculty and tutors, and certification of competency. Questions on residential/live courses vs or combined with complementary online courses, and on courses to be placed prior to or apart the annual PReS or EULAR congress composed the course timing part. The requirements and restrictions for the participants comprised: allowed specialty of course attendants (paediatric rheumatologists, adult rheumatologists, radiologists), attendance to previous MSUS courses (certification on current MSUS education), minimum and maximum time from previous MSUS course for acceding to higher level of competency course (evaluation of adequate time for practising and potential need of refreshing), number of MSUS scans performed per week (current practical status). Thirteen questions regarded faculty members /tutors prerequisites and included the possibility of being rheumatologists or paediatric rheumatologists highly expert in PedMSUS, the status of EULAR or PReS members, the years of experience in PedMSUS, the number of PedMSUS scans per week, the attendance to TTT and/or EULAR MSUS advanced courses, and the achievement of national/international certification for teaching MSUS. With regard to the certification of competency, the following options were given: if required or not (yes/no answer), and, if required, whether it should be obtained in attending the full course, in successful assessment of theoretical and practical skills and/or in passing a final examination.

    The Delphi questionnaire regarding the TTT course included: content and evaluation of premeeting preparation; proportion between theoretical and practical part; duration of the course (options: 1,5 and 2 days); faculty’s features; timing (options: just prior the EULAR Congress and just prior the PReS Congress); evaluation of teaching skills and TTT competency assessment.

    Internal consensus

    In the second phase, the taskforce members tested internal agreement on each item of the questionnaires (5-point Likert scale: 0, full disagreement; 5, full agreement) through a Delphi technique, by online survey (SurveyMonkey). Free text space for comments and suggestions was available. Email reminders were sent after 1 month and then every 2 weeks for 2 months. Agreement was reached for >75% of answers rating 4–5. An additional questionnaire was planned for items with moderate consensus in the first Delphi, defined as 50%–75% of answers rating 4–5.

    External consensus

    All items with agreement within the Taskforce merged into the preliminary core set of procedures, which were tested for external agreement among the Consensus group. An explanatory and motivating letter introduced the online SurveyMonkey for recruiting answers as much as possible. Email reminders were sent every week for 6 weeks. Agreement and moderate consensus were defined as previously described.

    Patient and public involvement

    As above mentioned, two patient research partners were recruited in the Taskforce among young adults with juvenile idiopathic arthritis involved in previous international PedMSUS projects or educational events, who were motivated in improving educational PedMSUS courses, could understand and interact with the other Taskforce members. They provided their critical input and experience in the development, drafting and approval of the questionnaires for the different level of competency of the PedMSUS courses.

    Due to the peculiarity of the topic, no additional public involvement was considered appropriate.


    Descriptive analysis was performed on the results of the ELR. Results from the Delphi survey were described as percentages.


    Preliminary set of procedures

    For the basic, intermediate and advanced courses questionnaires, the Taskforce response rate was of 92% (22 out of 24) in the first Delphi survey and 82% (18 out of 22) in the second one. In the first survey, a total of 70 items/procedures reached agreement: 17 for the basic level, 27 for the intermediate level and 26 for the advanced level. Sixty-eight procedures obtained moderate consensus (15 for the basic, 22 for the intermediate and 31 for the advanced level). In the second survey, the items/procedures with previous moderate consensus reached agreement in 44, respectively distributed in 13 for the basic, 10 the intermediate and 11 the advanced level.

    Of note, for the basic level agreement was found in including colour/power Doppler physics and technology, and their application, indications and limitations in PedMSUS; however, optimisation of colour/power Doppler settings and artefacts, detection of synovial and entheseal inflammation, assessment and quantification of structural joint damage and US-guided intra-articular injections were excluded. Update on PedMSUS in paediatric rheumatology and the role of US in paediatric rheumatic diseases (PRDs) other than juvenile idiopathic arthritis were worthy to be content of the intermediate and the advanced level, respectively.

    The preliminary set of procedures in basic, intermediate and advanced PedMSUS courses also included: a three-level education model (basic, intermediate and advanced), courses placed prior to the annual PReS and EULAR or joined EULAR/PReS congresses, proportion between theoretical and practical part of 50%–50% for basic courses and 40%–60% for intermediate courses, a maximum of 4 participants per tutor in practical sessions; healthy children as models at the basic course, whereas at the intermediate and the advanced courses models should be represented by patients with 2 years of age or more; courses may be attended by paediatric rheumatologists, adult rheumatologists as well as radiologists; faculty members and tutors should fulfil prerequisites and have successfully attended EULAR MSUS TTT courses or an equivalent one; basic, intermediate and advanced courses should include a certification of competency, obtained by attending the full course, successful assessment of theoretical and practical skills and passing the final exam.

    With regard to the TTT course, the Taskforce response rate was 86% and 73%, in the first and second survey, respectively. Agreement was found in 11 out of 25 the items/procedures at the first survey, with concomitant moderate consensus on 9. Six out of these nine reached agreement in the second round. Among the procedures for the TTT level were the following: courses should be held just prior to the EULAR congress and linked to the EULAR/PReS Sonography course; the theoretical part should include how to prepare and deliver educational material, how to organise a PedMSUS course and how to conduct a practical session; practical and theoretical part in TTT should respectively cover 50% of the course; two types of certificate should be provided, namely a certificate of attendance and a certificate of successful achievement of competency.

    All the levels of PedMSUS resulted with full agreement if residential, with complete no agreement on combination with introductory or focused virtual webinars. Finally, the proposed procedures included that they should be organised prior the EULAR or the PReS or the joined EULAR/PReS annual congresses and excluded to be separate events during the year; the few open comments highlighted the increased costs for participants in attending separate educational events in the same year. Moderate or even less consensus was found for the course duration, hours distribution per day and the time frame between courses for all the different levels of competency; hence, this items were not included in the preliminary set of procedures.

    Final set of guidelines

    The Consensus group response rate in the Delphi survey on the proposed guidelines was of 52 out of 114 (46%). Table 2 shows the agreement on the proposed guidelines for each level of competency. Due to the very high level of agreement, an additional Delphi survey was not required.

    Table 2

    Final set of procedures and items to be considered for the basic, intermediate, advanced and teach-the-teachers (TTT) paediatric musculoskeletal ultrasound (PedMSUS) courses


    The recent technological improvement and increased accessibility of PedMSUS led to a terrific demand for education on its appropriate performance and use, which entails peculiar issues, not only with regard to the sonoanatomy changes in children during growth, but also in the education delivering.29 30 As sonographer, the paediatric rheumatologist has the exclusive advantage of correlating the overall clinical assessment with imaging findings in an integrated way to enhance clinical assessment and thus optimise the management of children with rheumatological diseases.31 ,32 Similarly to all imaging evaluations, PedMSUS is highly dependent on the operator expertise, which in this case is mainly due to the implicit real-time nature of the image acquisition and immediate interpretation of findings.33–36 Therefore, accurate knowledge and high-level training are mandatory for a correct scanning and accurate and reliable image interpretation. The present project provides shared procedures for guiding the organisation of PedMSUS courses at different levels of competency, through the involvement of an international panel of partners in the project Taskforce and the extension to an even wider community in the Consensus group. To the best of our knowledge, this represents the first task that have encompassed experts in MSUS in adults with rheumatic diseases and sonographers with specific knowledge in PedMSUS for fostering high level education on PedMSUS, with the contribution of health professionals and young adult patients with experience in such educational events.

    Of note, almost all the preliminary procedures reached high (>75%) agreement in the Consensus group, with the sole exception of 5 out of 129 (0.04%), that reached moderate agreement (>50%, <75%). For none of the proposed guidelines was observed disagreement. Despite the relatively low response rate in the Consensus group, the results appear quite strong in their global homogeneity.

    Interestingly, the final guidelines included several items on colour and power Doppler modality in the basic course, with insights on physics and technology, application, indications and limitations in PedMSUS, which in previous international (ie, EULAR/ EULAR-PReS) courses have been treated more in general at the basic level of competency. Indeed, this result is in line with the current trend in improving more and more the sensitivity of depiction of increased or abnormal vascularity, particularly relevant in the overall much vascularised paediatric joint structures.37 Conversely, US-guided injection guidelines were not included in the basic level content, but only in the intermediate and advanced ones. As expected, for intermediate and advanced courses, training on specific anatomic structures and their abnormalities was much more detailed than in the basic one. Notably, in both intermediate and advanced levels very high agreement was observed for updating on PedMSUS in paediatric rheumatology (91% and 98%, respectively) and on the role of US in PRDs other than chronic arthritides (97% in the advanced course), enhancing the paramount interest in PedMSUS and its application in the broad spectrum of PRDs, and not only in juvenile idiopathic arthritis, as frequently outlined in the recent years.38–43

    All levels of PedMSUS should be residential; however, since the Delphi surveys were performed just at the initial stages of the COVID-19 pandemic, other education tools (introductory webinars, focused online courses), though proposed in the initial questionnaires, might not have been taken into the same consideration they may deserve now.44 The Consensus group also showed agreement in organising PedMSUS courses just prior the EULAR or the PReS or the joined EULAR/PReS Meetings, likely due to the dampening of expenses in joined events.

    Since the project was performed across the COVID-19 pandemic waves, we might have not captured responses from colleagues that have been meaningwhile committed to the emergency, thus lowering the response rate of our Consensus group. We are not able to solve the concern; nonetheless, the global very high agreement from the responders supplies solidity to our results.

    In conclusion, the present EULAR/PReS project provides internationally shared procedures for content, conduct and format of PedMSUS courses, which will surely offer an efficient support in the fruitful organisation of future educational events on this topic.

    Data availability statement

    No data are available.

    Ethics statements

    Patient consent for publication


    The Authors acknowledge all Taskforce and Consensus Group members that provided their valuable contribution to the project, particularly: Tadej Avcin, Stefan Blazina, Paz Collado, Nemanja Damjanov, Daniela Fodor, Annamaria Iagnocco, Sandrine Jousse-Joulin, Stefano Lanni, Clara Malattia, Viviana Ravagnani, Linda Rossi-Semerano, Lene Terslev, Nikolay Tzaribachev, Daniel Windschall and the PReS Imaging Working Party. Special thanks to: Elisabetta Cavallari and Marija Kosanovic (PARE members); Aurora Pucacco and Annette Ladefoged de Thurah (Health Professional in Rheumatology, HPR); Dragana Lazarevic (EMEUNET and PReS EMERGE member); Angela Aquilani, Hanan Jadoun, Giusyda Tarantino and Andrea Uva, for their paramount support.



    • Collaborators PReS Imaging Working Party:Angela Aquilani, Francesca Ardenti Morini, Ellen Dalen Arnstad, Stefan Blazina, Sorina Boiu, Rosa Bou, Pernille Boyesen, Lucia Campos, Hans de Graaf, Vasiliki Dermentzoglou, Giovanni Filocamo, Lampros Fotis, Severine Guillaume, Miroslav Harjacek, Troels Herlin, Gry Børmark Hoftun, Christian Høst, Estibaliz Iglesias, Emilio Inarejos, Hanan Jadoun, Damjana Ključevšek, Manuela Krumrey, Rolf-Michael Küster, Stefano Lanni, Dragana Lazarevic, Alice Leahy, Hartwig Lehmann, Mirea Lopez Corbeto, Anette Lundestad, Silvia Magni-Manzoni, Clara Malattia, Giorgia Martini, Marta Mazzoni, Consuelo Modesto, Valentina Muratore, Rebecca Nicolai, Ellen Nordal, Soley Omarsdottir, Karin Palmblad, Linda Rossi Semerano, Marite Rygg, Nina Sande, Betul Sozeri, Giusyda Tarantino, Samar Tharwat, Ralph Trauzeddel, Maria Tsinti, Niklay Tzaribachev, Andrea Uva, Philomine Van Pelt, Marion Van Rossum, Mandica Vidovic, Jelena Vojinovic, Annette von-Scheven-Gete, Daniel Windschall.

    • Contributors SM-M, JV, MAD'A and EN conceived, designed and planned the project. SM-M, VM performed the SLR, provided acquisition and interpretation of data. SMM, VM and DPM performed the analysis and wrote the manuscript. JV, MAD'A and EN supervised the project. All Authors contributed to the interpretation of the results and to the critical revision of the manuscript.

    • Funding The project was supported by EULAR (EULAR project IMG015).

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.