The 'GALS' Locomotor Screen
Total Page：16
File Type：pdf, Size：1020Kb
Annals ofthe Rheumatic Diseases 1992; 51: 1165-1169 1165 NOW AND THEN Ann Rheum Dis: first published as 10.1136/ard.51.10.1165 on 1 October 1992. Downloaded from The 'GALS' locomotor screen Michael Doherty, Jane Dacre, Paul Dieppe, Michael Snaith Abstract musculoskeletal assessment. The screen may The locomotor system is complex and diffi- readily be incorporated into a 'system review' cult to examine. A selective clinical process to clerking, and takes only a minute or so to detect important locomotor abnormalities and perform. Its use should improve the acquisition functional disabiliity could prove valuable. A of further, regionally based locomotor skills via screen based on a tested 'minimal' history and orthopaedic and rheumatology teaching. examination system is described, together Although designed and tested in adults8 the with a simple method of recording. The screen can also be used in children in the screen is fast and easy to perform. As well as context of play. providing a useful introduction to examination of the locomotor system, the screen includes objective observation of functional move- ments relevant to activities of daily living. Its inclusion in the undergraduate clerking reper- toire could improve junior doctors' awareness and recognition of rheumatic disease and general disability. It could also provide a valuable screening test for use in general practice. (Ann Rheum Dis 1992; 51: 1165-1169) Musculoskeletal disorders form a considerable part of the general practitioner workload,' 2 are common in hospital inpatients, 5 and are the single most important factor influencing dis- http://ard.bmj.com/ ability in later life.6 Examination and assess- ment of the locomotor system is therefore a common requirement for doctors in many areas of health care. This requirement is likely to increase as the proportion of elderly patients in the community expands, and as patient percep- tions alter with respect to treatment and health care availability. on October 2, 2021 by guest. Protected copyright. Within medical schools there is increasing emphasis on the acquisition of basic clinical skills at the undergraduate level.7 The ability to Rheumatology Unit, question and examine a patient is a fundamental City Hospital, and Nottingham NG5 1PB, competency on which further education United Kingdom training can be built. Reviews suggest that M Doherty compared with other body systems locomotor Rheumatology history and examination skills are poorly learnt, Department, resulting in inadequate recognition and assess- St Bartholomew's Hospital, London, ment of locomotor disease and disability by United Kingdom junior doctors.34 J Dacre This paper presents one simple approach to Bristol Royal Infirmary, improving the recognition of musculoskeletal Bristol, United Kingdom abnormalities and disability. It summarises a P Dieppe preliminary screening history and examination Bloomsbury for inclusion into the under- Rheumatology Unit, appropriate Middlesex Hospital, graduate curriculum. It is adapted from a London, system that has been shown to have good United Kingdom sensitivity to detect important locomotor M Snaith abnormalities.8 Aspects of this screen overlap Correspondence to: Dr Doherty. with other systems (particularly the nervous Accepted for publication system) and the procedure can be viewed as a Figure 1 Inspectionfrom the sidefor normal spinal 4 June 1992 general functional (disability) as well as basic curvatures. 1166 Doherty, Dacre, Dieppe, Snaith Method features to note at each stage. For convenience SCREENING HISTORY of regional description, the examination can be Ann Rheum Dis: first published as 10.1136/ard.51.10.1165 on 1 October 1992. Downloaded from This comprises three questions: (a) 'Have you broken into gait, arms, legs, and spine ('GALS'). any pain or stiffness in your muscles, joints, or In practice, however, the order of examination back?'; (b) 'Can you dress yourself completely is unimportant and the usual most convenient without any difficulty?'; and (c) 'Can you walk examination sequence is gait, spine, arms, legs, up and down stairs without any difficulty?' with overlap between these components. Positive answers to any of these will obviously (1) Gait. Inspect the patient walking, turning require further enquiry. If all three are negative, and walking back. however, significant musculoskeletal abnor- (2) Spine. Inspect the patient standing from mality or disability is unlikely. three views. (a) From behind-observe normal SCREENING EXAMINATION The patient is examined wearing only under- wear. The table and figs 1-9 list the principal Main features to note during screening inspection Positionlactivity Observation Gait Symmetry, smoothness of movement (legs, arm swing, pelvic tilting) Normal stride length Normal heel strike, stance, toe off, swing through Ability to turn quickly Inspection from behind Straight spine (no scoliosis) Normal, symmetrical paraspinal muscles Normal shoulder and gluteal muscle bulk/symmetry Level iliac crests No popliteal swelling No hindfoot swelling/deformity Inspection from the side Normal cervical and lumbar lordosis Normal (mild) thoracic kyphosis 'Touch toes' Normal lumbar spine (and hip) flexion Inspection from in front Spine 'Head on shoulders' Normal cervical lateral flexion Arms 'Arms behind head' Normal glenohumeral, Figure3 Lateralcervtcalflexion. sternoclavicular, and http://ard.bmj.com/ acromioclavicular joint movement 'Arms straight' Full elbow extension 'Hands in front' No wrist/finger swelling or deformity Ability to fully extend fingers 'Turn hands over' Normal supination/pronation (superior and inferior radioulnar joints) Normal palms (no swelling, muscle wasting, erythema) 'Make a fist' Normal power grip on October 2, 2021 by guest. Protected copyright. 'Fingers on thumb' Normal fine precision pinch/dexterity Legs Normal quadriceps bulk/symmetry No knee swelling or deformity (varus/valgus) No forefoot/midfoot deformity Normal arches Figure 2 Pressure over mid supraspinatus-observefor the Figure 4 Normalpainftee movement ofglenohumer'al, hyperalgesic response offibromyalgia. acromioclavicular, and stemoclavicularjoints. The 'GALS' locomotor screen 1167 spine (and lower limb) features. (b) From the the patient to: 'Place both hands behind your 4); both hands side-observe normal spine contours (fig 1). head, elbows back' (fig 'Place Ann Rheum Dis: first published as 10.1136/ard.51.10.1165 on 1 October 1992. Downloaded from Ask the patient to 'bend forward and touch down by your side, elbows straight'; 'Place toes'. Press over the midpoint of each supra- both hands out in front, palms down, fingers spinatus (fig 2) to elicit hyperalgesia of fibro- straight'; 'Turn both hands over' (fig 5); 'Make myalgia. (c) From in front. Ask the patient to a tight fist with each hand (fig 6); 'Place the tip 'try to place your ear on your left then your of each finger onto the tip of your thumb in right shoulder in turn' (fig 3). turn'. (3) Arms. Still inspecting from in front, ask The examiner then squeezes across the FigureS Normalpronation/supination (proximal and distal radioulnarjoints); normalpalms. Figure 7 No tenderness ofmetacarpophalangealjoints. http://ard.bmj.com/ on October 2, 2021 by guest. Protected copyright. Figure 6 Normalpmoergrip.. Figure 8 Normal internal rotation ofhip inflexion. 1168 Doherty, Dacre, Dieppe, Snaith these regions, the tick is replaced by a cross and further note of the abnormality made. For Ann Rheum Dis: first published as 10.1136/ard.51.10.1165 on 1 October 1992. Downloaded from example in a patient with knee osteoarthritis: G x A M A V V L x x S V V antalgic gait R knee-varus I flexion crepitus effusion Discussion The locomotor system is complex and an extensive history and examination is time con- suming. A screening procedure to detect problems in defined areas is therefore desir- able.8 If the screen is positive then targeted regional examination is undertaken to define the problem. Such a screen is therefore an intro- duction, not a substitution, for the acquisition Figure 9 No tendemess ofmetatarsop halangealjoints. of more detailed locomotor examination skills. The rationale for the selection of screening second to fifth metacarpal (fig 7) to elicit tender- questions and examination tasks is twofold. ness due to metacarpophalangeal joint synovitis Firstly, the principal focus is on symptoms and (which may not be evidenced by swelling). activities of direct relevance to the patient, (4) Legs. With the patient still standing, providing an insight into the patient's cap- inspect from in front for normal lower limb abilities to undertake important daily activities. appearances. The screen is then completed by Secondly, only sufficient history and examina- inspection or examination of the patient lying tion are included to detect significant musculo- on a couch. In this position: (a) flex each hip skeletal abnormality. Pain, for example, is the and knee while holding the knee (confirming principal symptom of locomotor disease and one full knee flexion, no knee crepitus); (b) passively of obvious impact and relevance to the patient. internally rotate each hip in flexion (no pain, Dressing is an important daily event but also a restriction; fig 8); (c) press on each patella for sensitive functional test of most upper and patellofemoral tenderness and palpate for an lower limb joints, requiring in addition reason- http://ard.bmj.com/ effusion; (d) squeeze across the metatarsals for able neuromuscular power and co-ordination. tenderness