Background/Purpose: Ultrasonography is an important modality to evaluate and diagnose a host of musculoskeletal and rheumatologic conditions. However, the interpretation of sonographic images is a challenging skill to acquire. Furthermore, there is a limited set of resources available to rheumatology fellows for self-study. To fill that gap, the investigators created a musculoskeletal ultrasound coloring book as an adjunct to didactic sessions, and assessed the utility of this book through a pragmatic randomized control trial.

Methods: The investigators prepared a coloring book using images obtained by scanning their own joints. Complete ultrasound scans of 10 joints were taken according to OMERACT protocols. Two sets of chapters were created: a ‘control’ chapter with faithful reproductions of the ultrasound images, and a ‘coloring’ chapter, with color inversions of black-and-white ultrasound images to enable participants to color in the spaces. Both have identical captions and interpretations underneath the images.

Participants were recruited from the University of Iowa Rheumatology Fellowship Program. All participants attended didactic hour-long weekly sessions and were administered four sets of distinct examinations: the pre-test, the immediate post-test, the 4-week post-test, and the 6-month post-test. Each participant was provided a copy of the modified coloring book which was composed of 5 randomly assigned ‘control’ chapters and 5 randomly assigned ‘coloring’ chapters. Participants were strongly encouraged to study the material prior to didactic sessions, follow along during sessions, and use the book chapters as resources thereafter. Test results were blinded to investigators until the end of the trial.

Results: 6 fellow physicians participated in 10 sessions each and appeared for each of the four 10-question exams. Therefore, the group had an overall total of 60 sessions, of which 30 were subject to intervention with the ‘coloring’ chapter and 30 were controls with the ‘standard’ chapter. The mean pre-test scores were 2.3 (SD = 1.9) for controls and 3.1 (SD = 1.4) for interventions. The mean post-test scores were 9.3 (SD=0.4) and 9.8 (SD=0.3) for controls and interventions, respectively. Mean 4-week post-test scores were 5.8 (SD=0.9) and 7.6 (SD=1.1), respectively, and 6-month post-test scores were 4.1 (SD=0.8) and 6.8 (SD=1.1), respectively. The differences between the pre-test, immediate post-test, and 4-week post-test scores were not statistically significant (p=0.736, p=0.322, and p=0.210, respectively). However, the difference between the mean 6-month post-test scores was statistically significant (p=0.05).

Conclusion: The musculoskeletal ultrasound coloring book is a useful adjunct to didactic sessions to promote six-month retention of sonoanatomy knowledge by fellow physicians. Further investigation is necessary to determine if this translates into greater fluency in interpretation of pathology, technique in obtaining images, and satisfaction. The investigators recommend implementation in multiple institutions to more definitively determine the utility of a musculoskeletal ultrasound coloring book as an adjunct to didactic sessions.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-utility-of-a-coloring-book-as-an-adjunct-tool-to-teach-musculoskeletal-sonoanatomy-a-pragmatic-randomized-control-trial/