Skip to main content
PMC home page
Annals of the Rheumatic Diseases logoLink to Annals of the Rheumatic Diseases
. 2001 Sep;60(9):817–827.

Radiographic scoring methods as outcome measures in rheumatoid arthritis: properties and advantages

S Boini 1, F Guillemin 1
PMCID: PMC1753828  PMID: 11502606

Abstract

BACKGROUND—Use of scored radiographs as an outcome measure can help estimate the progression of rheumatoid arthritis (RA). Radiographs not only provide permanent records with which to evaluate RA serially, but can also be randomised and blinded, a major advantage in clinical trials.
OBJECTIVES AND METHOD—Medline was searched for information about the principal methods of assessing joints affected by RA. Each technique was evaluated for its measurement properties, advantages, and limitations.
MAIN FINDINGS—The most commonly used methods are those devised by Sharp, Larsen, and van der Heijde/Sharp, and their variants. Methods based on the Sharp technique provide separate scores for erosion and for joint space narrowing. Larsen and variants, together with the Simple Erosion Narrowing Score (SENS) method, provide an overall score. Each method's measurement properties (feasibility, time consumption, etc) depend on the degree of detail it considers. Authors consistently recommend taking a posteroanterior view of hand and foot radiographs, and the use of trained raters. Intra- and interrater reliability values are generally higher than 0.70 (less often assessed by the intraclass correlation coefficient than the correlation coefficient). Sensitivity to change is calculated by several techniques (standardised response mean (SRM), adjusted SRM, minimal detectable change, smallest detectable difference). Most methods assessed with SRM reach a value of 0.80 or more.
CONCLUSION—Standardised procedures are available for performing and reading radiographs in RA. The choice of scoring method depends on the time and staff available, and the required degree of reliability and sensitivity to change.



Full Text

The Full Text of this article is available as a PDF (193.3 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Bland J. M., Altman D. G. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986 Feb 8;1(8476):307–310. [PubMed] [Google Scholar]
  2. Brower A. C. Use of the radiograph to measure the course of rheumatoid arthritis. The gold standard versus fool's gold. Arthritis Rheum. 1990 Mar;33(3):316–324. doi: 10.1002/art.1780330303. [DOI] [PubMed] [Google Scholar]
  3. Cuchacovich M., Couret M., Peray P., Gatica H., Sany J. Precision of the Larsen and the Sharp methods of assessing radiologic change in patients with rheumatoid arthritis. Arthritis Rheum. 1992 Jul;35(7):736–739. doi: 10.1002/art.1780350703. [DOI] [PubMed] [Google Scholar]
  4. Drossaers-Bakker K. W., Amesz E., Zwinderman A. H., Breedveld F. C., Hazes J. M. A comparison of three radiologic scoring systems for the long-term assessment of rheumatoid arthritis: findings of an ongoing prospective inception cohort study of 132 women followed up for a median of twelve years. Arthritis Rheum. 2000 Jul;43(7):1465–1472. doi: 10.1002/1529-0131(200007)43:7<1465::AID-ANR8>3.0.CO;2-L. [DOI] [PubMed] [Google Scholar]
  5. Edmonds J., Saudan A., Lassere M., Scott D. Introduction to reading radiographs by the Scott modification of the Larsen method. J Rheumatol. 1999 Mar;26(3):740–742. [PubMed] [Google Scholar]
  6. Ferrara R., Priolo F., Cammisa M., Bacarini L., Cerase A., Pasero G., Ferraccioli G. F., Alberighi O. D., Antonellini A., Marubini E. Clinical trials in rheumatoid arthritis: methodological suggestions for assessing radiographs arising from the GRISAR Study. Gruppo Reumatologi Italiani Studio Artrite Reumatoide. Ann Rheum Dis. 1997 Oct;56(10):608–612. doi: 10.1136/ard.56.10.608. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Fries J. F., Bloch D. A., Sharp J. T., McShane D. J., Spitz P., Bluhm G. B., Forrester D., Genant H., Gofton P., Richman S. Assessment of radiologic progression in rheumatoid arthritis. A randomized, controlled trial. Arthritis Rheum. 1986 Jan;29(1):1–9. doi: 10.1002/art.1780290101. [DOI] [PubMed] [Google Scholar]
  8. Genant H. K., Jiang Y., Peterfy C., Lu Y., Redei J., Countryman P. J. Assessment of rheumatoid arthritis using a modified scoring method on digitized and original radiographs. Arthritis Rheum. 1998 Sep;41(9):1583–1590. doi: 10.1002/1529-0131(199809)41:9<1583::AID-ART8>3.0.CO;2-H. [DOI] [PubMed] [Google Scholar]
  9. Genant H. K. Methods of assessing radiographic change in rheumatoid arthritis. Am J Med. 1983 Dec 30;75(6A):35–47. doi: 10.1016/0002-9343(83)90473-4. [DOI] [PubMed] [Google Scholar]
  10. Guth A., Coste J., Chagnon S., Lacombe P., Paolaggi J. B. Reliability of three methods of radiologic assessment in patients with rheumatoid arthritis. Invest Radiol. 1995 Mar;30(3):181–185. doi: 10.1097/00004424-199503000-00008. [DOI] [PubMed] [Google Scholar]
  11. Jiang Y., Genant H. K., Watt I., Cobby M., Bresnihan B., Aitchison R., McCabe D. A multicenter, double-blind, dose-ranging, randomized, placebo-controlled study of recombinant human interleukin-1 receptor antagonist in patients with rheumatoid arthritis: radiologic progression and correlation of Genant and Larsen scores. Arthritis Rheum. 2000 May;43(5):1001–1009. doi: 10.1002/1529-0131(200005)43:5<1001::AID-ANR7>3.0.CO;2-P. [DOI] [PubMed] [Google Scholar]
  12. KELLGREN J. H. Radiological signs of rheumatoid arthritis; a study of observer differences in the reading of hand films. Ann Rheum Dis. 1956 Mar;15(1):55–60. doi: 10.1136/ard.15.1.55. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Kaye J. J., Nance E. P., Jr, Callahan L. F., Carroll F. E., Winfield A. C., Earthman W. J., Phillips K. A., Fuchs H. A., Pincus T. Observer variation in quantitative assessment of rheumatoid arthritis Part II. A simplified scoring system. Invest Radiol. 1987 Jan;22(1):41–46. doi: 10.1097/00004424-198701000-00006. [DOI] [PubMed] [Google Scholar]
  14. Larsen A., Dale K., Eek M. Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol Diagn (Stockh) 1977 Jul;18(4):481–491. doi: 10.1177/028418517701800415. [DOI] [PubMed] [Google Scholar]
  15. Larsen A., Edgren J., Harju E., Laasonen L., Reitamo T. Interobserver variation in the evaluation of radiologic changes of rheumatoid arthritis. Scand J Rheumatol. 1979;8(2):109–112. doi: 10.3109/03009747909105347. [DOI] [PubMed] [Google Scholar]
  16. Larsen A. How to apply Larsen score in evaluating radiographs of rheumatoid arthritis in long-term studies. J Rheumatol. 1995 Oct;22(10):1974–1975. [PubMed] [Google Scholar]
  17. Lassere M., Boers M., van der Heijde D., Boonen A., Edmonds J., Saudan A., Verhoeven A. C. Smallest detectable difference in radiological progression. J Rheumatol. 1999 Mar;26(3):731–739. [PubMed] [Google Scholar]
  18. Mewa A. A., Pui M., Cockshott W. P., Buchanan W. W. Observer differences in detecting erosions in radiographs of rheumatoid arthritis. A comparison of posteroanterior, Nørgaard and Brewerton views. J Rheumatol. 1983 Apr;10(2):216–221. [PubMed] [Google Scholar]
  19. Nance E. P., Jr, Kaye J. J., Callahan L. F., Carroll F. E., Winfield A. C., Earthman W. J., Phillips K. A., Fuchs H. A., Pincus T. Observer variation in quantitative assessment of rheumatoid arthritis. Part I. Scoring erosions and joint space narrowing. Invest Radiol. 1986 Dec;21(12):922–927. doi: 10.1097/00004424-198612000-00007. [DOI] [PubMed] [Google Scholar]
  20. Paimela L., Laasonen L., Helve T., Leirisalo-Repo M. Comparison of the original and the modified Larsen methods and the Sharp method in scoring radiographic progression in early rheumatoid arthritis. J Rheumatol. 1998 Jun;25(6):1063–1066. [PubMed] [Google Scholar]
  21. Pincus T., Larsen A., Brooks R. H., Kaye J., Nance E. P., Callahan L. F. Comparison of 3 quantitative measures of hand radiographs in patients with rheumatoid arthritis: Steinbrocker stage, Kaye modified Sharp score, and Larsen score. J Rheumatol. 1997 Nov;24(11):2106–2112. [PubMed] [Google Scholar]
  22. Plant M. J., Saklatvala J., Borg A. A., Jones P. W., Dawes P. T. Measurement and prediction of radiological progression in early rheumatoid arthritis. J Rheumatol. 1994 Oct;21(10):1808–1813. [PubMed] [Google Scholar]
  23. Rau R., Herborn G. A modified version of Larsen's scoring method to assess radiologic changes in rheumatoid arthritis. J Rheumatol. 1995 Oct;22(10):1976–1982. [PubMed] [Google Scholar]
  24. Rau R., Wassenberg S., Herborn G., Stucki G., Gebler A. A new method of scoring radiographic change in rheumatoid arthritis. J Rheumatol. 1998 Nov;25(11):2094–2107. [PubMed] [Google Scholar]
  25. Salaffi F., Carotti M. Interobserver variation in quantitative analysis of hand radiographs in rheumatoid arthritis: comparison of 3 different reading procedures. J Rheumatol. 1997 Oct;24(10):2055–2056. [PubMed] [Google Scholar]
  26. Scott D. L., Coulton B. L., Bacon P. A., Popert A. J. Methods of X-ray assessment in rheumatoid arthritis: a re-evaluation. Br J Rheumatol. 1985 Feb;24(1):31–39. doi: 10.1093/rheumatology/24.1.31. [DOI] [PubMed] [Google Scholar]
  27. Scott D. L., Houssien D. A., Laasonen L. Proposed modification to Larsen's scoring methods for hand and wrist radiographs. Br J Rheumatol. 1995 Jan;34(1):56–56. doi: 10.1093/rheumatology/34.1.56. [DOI] [PubMed] [Google Scholar]
  28. Sharp J. T. An overview of radiographic analysis of joint damage in rheumatoid arthritis and its use in metaanalysis. J Rheumatol. 2000 Jan;27(1):254–260. [PubMed] [Google Scholar]
  29. Sharp J. T., Bluhm G. B., Brook A., Brower A. C., Corbett M., Decker J. L., Genant H. K., Gofton J. P., Goodman N., Larsen A. Reproducibility of multiple-observer scoring of radiologic abnormalities in the hands and wrists of patients with rheumatoid arthritis. Arthritis Rheum. 1985 Jan;28(1):16–24. doi: 10.1002/art.1780280104. [DOI] [PubMed] [Google Scholar]
  30. Sharp J. T., Gardner J. C., Bennett E. M. Computer-based methods for measuring joint space and estimating erosion volume in the finger and wrist joints of patients with rheumatoid arthritis. Arthritis Rheum. 2000 Jun;43(6):1378–1386. doi: 10.1002/1529-0131(200006)43:6<1378::AID-ANR23>3.0.CO;2-H. [DOI] [PubMed] [Google Scholar]
  31. Sharp J. T., Lidsky M. D., Collins L. C., Moreland J. Methods of scoring the progression of radiologic changes in rheumatoid arthritis. Correlation of radiologic, clinical and laboratory abnormalities. Arthritis Rheum. 1971 Nov-Dec;14(6):706–720. doi: 10.1002/art.1780140605. [DOI] [PubMed] [Google Scholar]
  32. Sharp J. T. Radiologic assessment as an outcome measure in rheumatoid arthritis. Arthritis Rheum. 1989 Feb;32(2):221–229. doi: 10.1002/anr.1780320218. [DOI] [PubMed] [Google Scholar]
  33. Sharp J. T., Wolfe F., Mitchell D. M., Bloch D. A. The progression of erosion and joint space narrowing scores in rheumatoid arthritis during the first twenty-five years of disease. Arthritis Rheum. 1991 Jun;34(6):660–668. doi: 10.1002/art.1780340606. [DOI] [PubMed] [Google Scholar]
  34. Sharp J. T., Young D. Y., Bluhm G. B., Brook A., Brower A. C., Corbett M., Decker J. L., Genant H. K., Gofton J. P., Goodman N. How many joints in the hands and wrists should be included in a score of radiologic abnormalities used to assess rheumatoid arthritis? Arthritis Rheum. 1985 Dec;28(12):1326–1335. doi: 10.1002/art.1780281203. [DOI] [PubMed] [Google Scholar]
  35. Solymossy C., Dixey J., Utley M., Gallivan S., Young A., Cox N., Davies P., Emery P., Gough A., James D. Larsen scoring of digitized X-ray images. Rheumatology (Oxford) 1999 Nov;38(11):1127–1129. doi: 10.1093/rheumatology/38.11.1127. [DOI] [PubMed] [Google Scholar]
  36. Trentham D. E., Masi A. T. Carpo:metacarpal ratio. A new quantitative measure of radiologic progression of wrist involvement in rheumatioid arthritis. Arthritis Rheum. 1976 Sep-Oct;19(5):939–944. doi: 10.1002/art.1780190518. [DOI] [PubMed] [Google Scholar]
  37. Wassenberg S., Rau R. Problems in evaluating radiographic findings in rheumatoid arthritis using different methods of radiographic scoring: examples of difficult cases and a study design to develop an improved scoring method. J Rheumatol. 1995 Oct;22(10):1990–1997. [PubMed] [Google Scholar]
  38. Wolfe F., van der Heijde D. M., Larsen A. Assessing radiographic status of rheumatoid arthritis: introduction of a short erosion scale. J Rheumatol. 2000 Sep;27(9):2090–2099. [PubMed] [Google Scholar]
  39. de Carvalho A. Discriminative power of Larsen's grading system for assessing the course of rheumatoid arthritis. Acta Radiol Diagn (Stockh) 1981;22(1):77–80. doi: 10.1177/028418518102200111. [DOI] [PubMed] [Google Scholar]
  40. van Der Heijde D., Boonen A., Boers M., Kostense P., van Der Linden S. Reading radiographs in chronological order, in pairs or as single films has important implications for the discriminative power of rheumatoid arthritis clinical trials. Rheumatology (Oxford) 1999 Dec;38(12):1213–1220. doi: 10.1093/rheumatology/38.12.1213. [DOI] [PubMed] [Google Scholar]
  41. van der Heijde D. M. Plain X-rays in rheumatoid arthritis: overview of scoring methods, their reliability and applicability. Baillieres Clin Rheumatol. 1996 Aug;10(3):435–453. doi: 10.1016/s0950-3579(96)80043-4. [DOI] [PubMed] [Google Scholar]
  42. van der Heijde D. M., van Leeuwen M. A., van Riel P. L., Koster A. M., van 't Hof M. A., van Rijswijk M. H., van de Putte L. B. Biannual radiographic assessments of hands and feet in a three-year prospective followup of patients with early rheumatoid arthritis. Arthritis Rheum. 1992 Jan;35(1):26–34. doi: 10.1002/art.1780350105. [DOI] [PubMed] [Google Scholar]
  43. van der Heijde D. M., van Riel P. L., Nuver-Zwart I. H., Gribnau F. W., vad de Putte L. B. Effects of hydroxychloroquine and sulphasalazine on progression of joint damage in rheumatoid arthritis. Lancet. 1989 May 13;1(8646):1036–1038. doi: 10.1016/s0140-6736(89)92442-2. [DOI] [PubMed] [Google Scholar]
  44. van der Heijde D., Boers M., Lassere M. Methodological issues in radiographic scoring methods in rheumatoid arthritis. J Rheumatol. 1999 Mar;26(3):726–730. [PubMed] [Google Scholar]
  45. van der Heijde D., Dankert T., Nieman F., Rau R., Boers M. Reliability and sensitivity to change of a simplification of the Sharp/van der Heijde radiological assessment in rheumatoid arthritis. Rheumatology (Oxford) 1999 Oct;38(10):941–947. doi: 10.1093/rheumatology/38.10.941. [DOI] [PubMed] [Google Scholar]
  46. van der Heijde D. How to read radiographs according to the Sharp/van der Heijde method. J Rheumatol. 1999 Mar;26(3):743–745. [PubMed] [Google Scholar]

Articles from Annals of the Rheumatic Diseases are provided here courtesy of BMJ Publishing Group

RESOURCES