Assessing the construct validity of musculoskeletal ultrasound and the rheumatoid arthritis foot disease activity index (RADAI-F5) for managing rheumatoid foot disease

Objective The RA foot disease activity index (RADAI-F5) is a valid, reliable and clinically feasible patient-reported outcome measure (PROM) for the measurement of RA foot disease activity. Further validation of the RADAI-F5 against musculoskeletal ultrasonography (MSUS) for foot disease activity is necessary before clinical implementation. The aim of this study was to examine the construct validity of the RADAI-F5 in relationship to MSUS and clinical examination. Methods Participants with RA completed the RADAI-F5. MSUS was used to evaluate disease activity (synovial hypertrophy/synovitis/tenosynovitis/bursitis) and joint damage (erosion) using greyscale (GS) and power Doppler (PD) at 16 regions in each foot, including joints and soft tissues. These same regions were examined clinically for swelling and tenderness. The construct validity of the RADAI-F5 was assessed using correlation coefficients and a priori-specified hypotheses for the strength of associations. Results Of 60 participants, 48 were female, with a mean (s.d.) age of 62.6 (9.96) years and median disease duration of 15.49 (interquartile range 6-20.5) years. Theoretically consistent associations confirming construct validity [95% CI] were observed between the RADAI-F5 and MSUS GS (0.76 [0.57, 0.82]; strong), MSUS PD (0.55 [0.35, 0.71]; moderate), MSUS-detected erosions (0.41 [0.18, 0.61]; moderate), clinical tenderness (0.52 [0.31, 0.68]; moderate) and clinical swelling (0.36 [0.13, 0.55]; weak). Conclusion Moderate to strong correlations between RADAI-F5 and MSUS demonstrate the good measurement properties of this instrument. With greater confidence in the utility of the RADAI-F5, clinical use of this new instrument as an adjunct to the disease activity score for 28 joints (DAS-28) could help to identify RA patients at risk for poor functional and radiological outcomes. Lay Summary What does this mean for patients? Rheumatoid arthritis (RA) is a condition that commonly affects the feet. It is important to have a reliable way to measure the activity of RA in the feet. One such measure is called the RA foot disease activity index (RADAI-F5), which is a five-item questionnaire completed by patients. However, the RADAI-F5 still needs to be validated against other methods of assessing foot disease activity, such as musculoskeletal ultrasonography (MSUS) and clinical examination. In this study, 60 participants with RA were enrolled. Participants completed the RADAI-F5 questionnaire. Thereafter, MSUS was used to evaluate disease activity and joint damage in the participants' feet. Clinical examinations to assess swelling and tenderness were also conducted at this appointment. The results showed that there were strong to moderate consistent associations between the RADAI-F5 scores and MSUS greyscale images, MSUS power Doppler and the presence of joint damage. The RADAI-F5 scores were also correlated moderately with clinical tenderness and weakly with clinical swelling. These findings suggest that the RADAI-F5 is a reliable tool for measuring foot disease activity in RA patients. Implementation of the tool in clinical practice might aid in the identification of RA patients who are at risk for poor outcomes and might require more targeted treatment.