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Musculoskeletal screening examination pGALS for school-age children based on the adult GALS screen.

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Arthritis & Rheumatism (Arthritis Care & Research)
Vol. 55, No. 5, October 15, 2006, pp 709 –716
DOI 10.1002/art.22230
© 2006, American College of Rheumatology
ORIGINAL ARTICLE
Musculoskeletal Screening Examination (pGALS)
for School-Age Children Based on the
Adult GALS Screen
H. E. FOSTER,1 L. J. KAY,2 M. FRISWELL,3 D. COADY,1
AND
A. MYERS4
Objective. To develop and validate a musculoskeletal screening examination applicable to school-age children based on
the adult Gait, Arms, Legs, Spine (GALS) screen.
Methods. Adult GALS was tested in consecutive school-age children attending pediatric rheumatology clinics and was
compared with an examination conducted, on the same day, by a pediatric rheumatologist who classified children as
having abnormal or normal joints. Adult GALS was tested for validity compared with the pediatric rheumatologist’s
assessment and deficiencies in adult GALS were identified. Experts proposed amendments to adult GALS, achieving
consensus by modified Delphi techniques. The resultant pediatric screening tool (pGALS) was tested (methodology
identical to the testing of adult GALS) in an additional group of children.
Results. Adult GALS was tested in 50 children (median age 11 years, range 4 –16), of whom 37 (74%) had juvenile
idiopathic arthritis. Adult GALS missed important abnormalities in 18% of children, mostly at the ankle, foot, and
temporomandibular joints. The pGALS was tested in 65 children (median age 13 years, range 5–17 years) and demonstrated excellent sensitivity (97–100%) and specificity (98 –100%) at all joints, with high acceptability scored by child and
parent/guardian. The median time to perform pGALS was 2 minutes (range 1.5–3 minutes).
Conclusion. The pGALS musculoskeletal screening tool has excellent validity, is quick to perform, and is acceptable to
school-age children and parents/guardians. We propose that pGALS be incorporated into undergraduate and postgraduate medical training to improve pediatric musculoskeletal clinical skills and facilitate diagnosis and referral to
specialists.
KEY WORDS. Musculoskeletal; Children; Pediatric; Screening examination; Clinical skills; GALS; Medical education;
pGALS; Juvenile arthritis; Barriers to care.
INTRODUCTION
Musculoskeletal symptoms in children and adolescents
are very common, occurring in 4 –30% of young persons
(1–3) and accounting for 3% of day case attendances (4).
Supported by an Educational Project grant from the Arthritis Research Campaign (grant 16067).
1
H. E. Foster, MD, D. Coady, MD: University of Newcastle
upon Tyne, Newcastle, UK; 2L. J. Kay, MA (oxon): University
of Newcastle upon Tyne, Newcastle Hospitals National
Health Service Trust, Newcastle, UK; 3M. Friswell, MBChB:
Newcastle Hospitals National Health Service Trust, Newcastle, UK; 4A. Myers, MD: University of Newcastle upon
Tyne, Newcastle, and Northumbria Healthcare National
Health Service Trust, Northumberland, UK.
Address correspondence to H. E. Foster, MD, Rheumatology, Level 4, Catherine Cookson Building, The Medical
School, University of Newcastle upon Tyne, UK NE2 4HH.
E-mail: h.e.foster@ncl.ac.uk.
Submitted for publication November 2, 2005; accepted in
revised form January 19, 2006.
The differential diagnosis is broad, and although in many
cases the cause is self-limiting, musculoskeletal presentations are not uncommon in severe, even life-threatening
illnesses such as osteomyelitis, leukemia, juvenile idiopathic arthritis (JIA), vasculitis, or nonaccidental injury.
Careful performance of a competent musculoskeletal examination is vital to the diagnostic process, particularly
because musculoskeletal symptoms are not always easily
volunteered by children, parental observations may be
nonspecific (e.g., “my child is limping”), and joint swelling and abnormal gait (such as limp) rather than reported
pain are the most common presenting features of JIA (5,6).
JIA is a common cause of chronic disability in children
(7), and joint damage occurs early (8,9). Emerging evidence
supports early and aggressive intervention to improve
functional outcome (10 –13), which relies on prompt diagnosis and referral to experienced multidisciplinary teams
(7,9,14). However, for many children with suspected JIA,
delay in receiving pediatric rheumatology services is not
uncommon (6,15), with complex referral pathways from
709
710
their primary care doctor to different secondary care services (primarily general pediatrics, orthopedics, and accident and emergency).
Poor clinical skills are a significant barrier to care, with
trainees in pediatrics and primary care reporting poor
self-confidence in their ability to assess a child’s musculoskeletal system (4,16 –19), poor documentation of musculoskeletal assessment (16), and inadequate training in
pediatric rheumatology (4,20,21). These observations may
be explained by the fact that teaching of musculoskeletal
clinical skills involving children is not part of core training in UK medical schools (22), few standard pediatric
textbooks describe musculoskeletal clinical examination
techniques in children (23), and clinical skills are not
reinforced in clinical practice because pediatricians themselves may not have received appropriate training. Furthermore, there is no consensus among pediatric rheumatologists as to best practice in musculoskeletal clinical
examination, and there is no validated screening examination applicable to children (24).
Poor musculoskeletal clinical skills are not unique to
pediatric practice, and musculoskeletal system is often
omitted from routine medical adult patient assessment
(25). Following the General Medical Council (UK) recommendations that musculoskeletal clinical conditions be
emphasized in undergraduate teaching (26), musculoskeletal examination is taught in UK medical schools as part of
core teaching (22), and many students are taught the Gait,
Arms, Legs, and Spine (GALS) screening examination and
are introduced to the basic elements of a more detailed
regional examination (27). The GALS involves simple
questions and procedures that permit rapid and effective
assessment of the musculoskeletal system in adults
(28,29), but it has not been tested in children.
An ideal musculoskeletal screening test for children
must be sensitive (i.e., does not miss significant abnormalities), be acceptable to the child and parent, distinguish
the abnormal child from the normal child, and direct the
assessor to a focused regional examination. Our goal was
to produce a validated pediatric musculoskeletal screening test based on adult GALS that can be successfully
integrated into clinical teaching and will improve pediatric musculoskeletal clinical skills among future doctors.
Ultimately, the goal is that improved pediatric musculoskeletal clinical skills will facilitate diagnosis and, in the
case of children with suspected rheumatic disease, reduce
the delay to pediatric rheumatology care and therefore
optimize outcome. The study was limited to school-age
children because a different examination approach would
be required for younger children.
PATIENTS AND METHODS
Part 1 tested adult GALS in school-age children in comparison with a consultant pediatric rheumatologist’s assessment. Part 2 derived amendments to adult GALS from
expert opinion. Part 3 tested the amended version of adult
GALS.
Foster et al
Part 1: Audit of adult GALS applied in school-age children. Children were recruited from pediatric rheumatology outpatient clinics, with both new and review patients
invited to participate. Participants were examined using
adult GALS by a final-year specialist registrar (AM) in
adult rheumatology experienced in the use of adult GALS
who was blinded to the diagnosis, with no clinical history
being permitted other than the 3 screening questions (i.e.,
“Do you have any pain in your joints, muscles, neck or
back?” “Do you have any difficulty getting dressed without
help?” and “Do you have any difficulty getting up and
down stairs without help?”). On the same day, children
were examined by a consultant pediatric rheumatologist
(HF or MF); this process mirrors clinical practice, with
patients being assessed by the specialist registrar and subsequently by the consultant. The time to perform the examination and findings were recorded on a homunculus.
The consultants, blinded to the specialist registrar’s findings, used their standard clinical approach, and were
asked to record joints as normal or abnormal and also to
document a more detailed description of abnormalities. To
assess interobserver variation, the first 10 patients were
assessed independently by both consultants and the interobserver reproducibility (to distinguish abnormal from
normal joints) was satisfactory, with an intraclass correlation coefficient of 0.81 (⬎0.8 is regarded as satisfactory
[30,31]). The sensitivity, specificity, and positive and negative predictive values of the adult GALS screen were
calculated from comparison with the consultant examination.
Part 2: Derivation of amended version of adult GALS.
The amendments required for adult GALS were derived
through consultation with members (doctors and allied
health professionals) of the British Society for Pediatric
and Adolescent Rheumatology (BSPAR), with invitations
to participate being distributed at BSPAR national meetings. The respondents (termed experts) were involved in
subsequent dialogue to reach consensus. The proposed
amendments were derived through a modified Delphi
technique (32) that involved 2 iterative cycles, with questionnaires incorporating feedback from discussion groups
of experts. Survey 1 followed presentation, at a national
BSPAR meeting, of the results of adult GALS testing in
children (33). Experts were asked by questionnaire to
judge whether, in their opinion, each of the components of
adult GALS was essential, desirable, or not necessary.
They were also asked to suggest amendments for joints
where adult GALS performed less well. A subsequent
questionnaire (survey 2) asked the experts to judge
whether, in their opinion, each of the proposed amendments to adult GALS was essential, desirable, or not necessary. The results were then discussed in an expert group
to derive consensus.
Part 3: Testing of pGALS in school-age children. The
proposed amended version of adult GALS was termed
pediatric GALS (pGALS), which was tested, using methodology identical to the testing of adult GALS, on an
additional group of consecutive outpatient attendees. A
power calculation (80% power, P ⫽ 0.05) required 60
Pediatric Musculoskeletal Screening (pGALS)
711
Table 1. The performance of the adult Gait, Arms, Legs, Spine screen (GALS) in
children compared with examination performed by a pediatric rheumatologist*
Neck
Shoulders
Elbows
Wrists
Hands
Lumbar spine
Hips
Knees
Ankles
Feet
Temporomandibular joints
Sensitivity
Specificity
Positive
predictive value
Negative
predictive value
100
100
100
100
100
100
100
100
0
0
0
97
98
94
86
97
100
97
97
0
0
0
66
87
55
30
90
100
93
93
0
0
0
100
100
100
100
100
100
100
100
0
0
0
* Values are the percentage.
children to test the amendments to adult GALS, including
96 normal joints and 24 abnormal joints at each anatomic
site. Acceptability of pGALS according to the child and
parent/guardian was recorded on a Likert scale (range 0 –5)
for their opinion on 1) the time taken to perform pGALS,
with a scale of 5 options (ranging from “far too short” to
“far too long”), and 2) the level of discomfort experienced
during the examination, with a scale of 5 options (ranging
from “lots of pain” to “no pain”).
The study had ethical approval, with informed consent
obtained from parents/guardians and assent obtained from
older children. All information was recorded anonymously.
RESULTS
Patients used to test adult GALS and pGALS. Adult
GALS was tested in 50 consecutive school-age children (25
girls, median age 11 years [range 4 –16 years]). Of these, 42
had inflammatory joint disease (37 had JIA, 2 had systemic
lupus erythematosus, 2 had reactive arthritis, and 1 had
juvenile dermatomyositis) and 8 had noninflammatory
joint disease (5 had benign joint hypermobility and 3 had
anterior knee pain). The testing of pGALS involved 65
children (42 girls, median age 13 years [range 5–17 years])
with the following diagnoses: inflammatory joint disease
(40 had JIA, 1 had systemic lupus erythematosus, 5 had
juvenile dermatomyositis, and 3 had systemic sclerosis),
mechanical joint problems (8 had benign joint hypermobility and 5 had anterior knee pain), primary Raynaud’s
disease (2 patients), and idiopathic pain syndrome (1 patient).
The expert group to derive amendments to adult GALS.
From the membership of BSPAR (n ⫽ 124), 36 members
(representing 20 pediatric rheumatology units within the
UK) agreed to participate, with larger centers nominating 1
representative consultant. All experts responded to the
surveys and most (32 of 36) attended a minimum of 1
discussion group. The expert group included 25 pediatric
rheumatologists, 6 of whom were trainees; 6 physiothera-
pists; 1 occupational therapist; 3 clinical nurse specialists;
and 1 pediatric orthopedic surgeon.
Testing of adult GALS in school-age children (part 1).
The median time for the specialist registrar to perform
adult GALS was 2 minutes (range 1–2.5 minutes). Adult
GALS had good sensitivity and specificity for the joints
that are included in the screen, and the negative predictive
values at each of these sites were high, suggesting that the
adult GALS screen did not miss significant abnormalities
in the areas examined (Table 1). However, adult GALS
rated 19 of 50 children as normal, but the pediatric rheumatologist’s examination detected abnormalities in 9 of
these 19 children (5 had JIA and 4 had benign hypermobility); adult GALS therefore had a false negative rate of
18% (9 out of 50). A total of 55 joint abnormalities were
missed by adult GALS, the majority of which involved the
foot and ankle (namely, restricted range of movement of
ankle joint [n ⫽ 20], subtalar joint/midfoot [n ⫽ 13], tenosynovitis/tendinitis [n ⫽ 6], arthritis of an individual toe
[n ⫽ 4], and abnormal foot posture [n ⫽ 8]). Four patients
with JIA had temporomandibular joint (TMJ) abnormalities that were missed, which included limited jaw opening/deviation. The positive predictive value of adult GALS
was low at the wrist, elbows, and neck (30%, 55%, and
66%, respectively), with loss of range of movement being
the main abnormality missed. Significant amendments to
adult GALS were therefore needed to incorporate the foot,
ankle, and TMJ, and improvement in the specificity of the
adult GALS screen at the wrist, elbow, and neck was
needed.
Development of pGALS by expert opinion (part 2).
Survey 1 suggested amendments for the foot and ankle,
and following survey 2, there was consensus for “walk on
tip toes and then heels” (as desirable or essential) as the
screening test (Figure 1). In survey 1, the suggested amendments for the TMJ were “open jaw” and “move jaw side to
side.” Following survey 2, there was consensus to refine
this as “open (your) mouth and insert 3 fingers” (child’s
own fingers) as the screening test for the TMJ. Most com-
712
Foster et al
micrognathia) and jaw opening (checking for asymmetry of
movement or deviation) using the child’s own 3 fingers to
gauge the degree of opening. Inability to walk on the heels
may be a feature of tendinitis, enthesitis or arthritis of the
ankle/foot, and osteochondroses (e.g., Sever’s disease).
Toe walking alerts the observer to possible neuromuscular
disease but has been reported as a presenting feature of JIA
(34). Inability to walk on the toes may be a feature of
arthritis (metatarsalgia) or local trauma of the foot. The
appearance of flat feet but normal arches on tip-toe is
normal in young children until ⬃5 years of age. Persistence of flat feet beyond this age or a nonmobile flat foot
warrants further investigation. In the school-age child with
mechanical lower limb pain (e.g., anterior knee pain), abnormal foot posture (including flat feet, excessive pronation/supination of the feet) may be found.
Testing of pGALS for validity and acceptability (part 3).
The pGALS screen had excellent sensitivity and specificity at all joints (Table 3). There were no false negatives;
pGALS did not miss any children with significant joint
Table 2. The components of pediatric Gait, Arms, Legs,
Spine screen (pGALS)*
Figure 1. The results of expert opinion in the development of the
pediatric Gait, Arms, Legs, Spine (pGALS) screen. A, Survey 1:
the value of each component of adult GALS in a pediatric musculoskeletal screen (pGALS). B, Survey 2: the proposed amendments to adult GALS to be included in pGALS to screen the foot
and ankle, temporomandibular joints, wrist and elbow. Black
bar ⫽ not necessary; gray bar ⫽ desirable; white bar ⫽ essential;
MCP ⫽ metacarpophalangeal joint; MTP ⫽ metatarsophalangeal
joint.
ponents of adult GALS were scored as desirable or essential (survey 1), with consensus to keep the format of
pGALS as similar to adult GALS as possible, except for
“put your arms by your side” being replaced by “reach for
the sky” as a more effective screening test for elbow extension. Another proposed amendment for the wrists was
“palms together and hands together back to back,” and a
proposed amendment for the neck was “look at the ceiling.”
The pGALS maneuvers are listed in Table 2 and illustrated in Figure 2. The TMJ screening test is the observation of facial profile (looking for asymmetry of growth or
Screening questions
Do you have any pain or stiffness in your joints,
muscles or your back?
Do you have any difficulty getting yourself dressed
without any help?
Do you have any difficulty going up and down stairs?
Gait
Observe the child walking
“Walk on your tip-toes/walk on your heels” (A,B)†
Arms
“Put your hands out in front of you” (C)
“Turn your hands over and make a fist” (D)
“Pinch your index finger and thumb together”
“Touch the tips of your fingers with your thumb” (E)
Squeeze metacarpophalangeal joints (F)
“Put your hands together/put your hands back to back”
(G,H)†
“Reach up and touch the sky” (I)†
“Look at the ceiling” (I)
“Put your hands behind your neck” (J)
Legs
Feel for effusion at the knee (K)
“Bend and then straighten your knee” (active
movement of knees and examiner feels for crepitus)
(L)
Passive flexion (90 degrees) with internal rotation of
hip (M)
Spine
“Open your mouth and put 3 of your (child’s own)
fingers in your mouth” (N)†
Lateral flexion of cervical spine: “try and touch your
shoulder with your ear” (O)
Observe spine from behind (P)
“Can you bend and touch your toes?” observe curve of
spine from side and behind (Q)
* See Figure 2 for illustrations of individual movements (A–Q).
† Additions and amendments to the original adult Gait, Arms, Legs,
Spine screen.
Pediatric Musculoskeletal Screening (pGALS)
713
Figure 2. Illustration of movements in the pediatric Gait, Arms, Legs, Spine screen (pGALS). See Table 2 for detailed
description of movements (A–Q).
abnormalities that were detected by the pediatric rheumatologist examination. A positive response to ⱖ1 of the 3
screening questions (i.e., “there was pain and/or stiffness,”
“difficulty in dressing independently,” or “difficulty with
stairs”) gave the following results as compared with the
consultant’s assessment: sensitivity 49%, specificity 82%,
positive predictive value 85%, and negative predictive
value 37%. The median time to complete pGALS was 2
minutes (range 1.5–3 minutes). The acceptability questionnaires were completed by 49 of 65 children (the nonresponders being very young children) and by 45 of 65
parents/guardians (the nonresponders not having witnessed the examination performed on older children/
young persons who opted to be examined by the doctor on
714
Foster et al
Table 3. The performance of pediatric Gait, Arms, Legs, Spine screen (pGALS) in children compared with assessment
performed by a pediatric rheumatologist*
Cervical spine
Shoulders
Elbows
Wrists
Hands
Temporomandibular joints
Lumbar spine
Hips
Knees
Ankles and feet
Abnormal joints
tested, no.†
Normal joints
tested, no.†
Sensitivity,
%
Specificity,
%
Positive
predictive
value, %
Negative
predictive
value, %
5
6
25
42
26
27
3
16
33
29
60
124
105
88
104
103
62
114
97
101
100
100
100
100
100
100
100
100
100
97
100
100
100
100
99
98
100
100
100
99
100
100
100
100
96
93
100
100
100
97
100
100
100
100
100
100
100
100
100
99
* A total of 65 children were tested.
† Joints deemed abnormal or normal by the pediatric rheumatologist.
their own). For the responders, most children (98%) and
most parents/guardians (91%) thought pGALS was acceptable for the time taken. For acceptability of comfort, most
children/adolescents (95%) deemed pGALS as causing no/
slight discomfort. None of the parents/guardians scored
pGALS as being uncomfortable for their child.
DISCUSSION
This is the first description of a validated musculoskeletal
screening test for school-age children. The pGALS test
performs very well; it is sensitive, quick to perform, and is
acceptable to children and parents/guardians. The pGALS
screen was derived from adult GALS, which has been used
as part of core teaching in UK medical schools since 1991,
is widely accepted by teachers in rheumatology, and effectively improves musculoskeletal clinical competence
among junior doctors assessing adults (25,35,36). It is envisioned that pGALS, being similar to adult GALS in format and content, will be equally effective in the improvement of clinical competence in the musculoskeletal
assessment of children. We believe that competent pediatric musculoskeletal clinical skills will facilitate accurate
diagnosis, referral to specialist teams, and, most importantly for children with suspected rheumatic disease, reduce delay in referral to pediatric rheumatology care and
ultimately improve these children’s outcome.
Adult GALS is not adequate, in its original form, as a
musculoskeletal screening tool for use in school-age children. The majority of the abnormalities that were missed
were at the foot and ankle and the TMJ, which are not
specifically tested in the original description of adult
GALS (28). These sites are commonly involved in JIA,
especially at presentation (6,37,38). Gait observation cannot be relied upon to detect significant foot and ankle
abnormalities (such as restriction of the subtalar joints),
particularly because the observer must be aware of the
development of gait and normal variants in children (39).
TMJs need to be specifically screened because they are
often involved in children with JIA, may be subclinical,
and cause significant morbidity (40).
The pGALS screen had excellent sensitivity and specificity compared with the consultant assessment, which is
all the more impressive given the lack of detailed clinical
history included in the screen. The screening questions,
however, have low sensitivity (but high specificity and
high positive predictive value), demonstrating that clinical
history alone may be unhelpful as a musculoskeletal
screening tool. Nonetheless, these questions are helpful
prompts to the history taker and help focus the examiner’s
attention if a positive response is obtained.
The methodology to propose amendments to adult
GALS (based on the Delphi process [32]) has been used
effectively in health care research, development of guidelines for best practice and content of curricula (41), and in
pediatric rheumatology (42). There is no published consensus on musculoskeletal clinical examination techniques in children (24) and yet the expert group, representing different training backgrounds, had considerable
agreement on the amendments to adult GALS, which were
invariably simple maneuvers commonly used in clinical
practice. Poor reliability of detailed clinical musculoskeletal assessment among pediatric rheumatologists has been
reported (43), but in this study the consultants were compared only on their ability to dichotomize children’s joints
as normal or abnormal and showed good level of agreement.
The components of pGALS are demonstrated in Table 2
and Figure 2. The vast majority of children and their
parents or guardians deemed pGALS to be acceptable. We
did not ascertain the acceptability and discomfort of the
pediatric rheumatologists’ examination as part of this
study; the few children who deemed pGALS uncomfortable may have also had a similar discomfort when examined by the consultant.
This study involved the testing of pGALS in a pediatric
rheumatology clinic and the performance of pGALS by an
experienced specialist registrar in adult rheumatology. Assessment of pGALS in routine general pediatric and primary care settings is clearly important, and is planned by
our group.
The influence of pGALS on improving clinical skills is
Pediatric Musculoskeletal Screening (pGALS)
likely to be greatest if it is taught as a core skill at the
undergraduate level. The appropriate interpretation of
pGALS requires knowledge of musculoskeletal problems
in children and adolescents and awareness of age, developmental changes, and normal variants. This requires supplementary teaching and clinical experience in pediatric
rheumatology. Competent performance of pGALS will facilitate a problem-orientated regional examination using
an approach similar to adult patients (27). We propose that
pGALS be incorporated in routine assessment of all well
children and be attempted in unwell children, because
significant musculoskeletal problems can manifest in diseases such as sepsis or inflammatory bowel disease. This
strategy will raise awareness of musculoskeletal problems
in pediatric practice and will facilitate appropriate management, thus optimizing patient care.
715
13.
14.
15.
16.
17.
18.
19.
ACKNOWLEDGMENTS
We are grateful to the children and their families for their
participation in this study, to members of the British Society for Pediatric and Adolescent Rheumatology, to the
healthy volunteer for the filming of pGALS, and to the
Television Services, University of Newcastle for the photographs.
20.
21.
22.
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