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 due to metatarsophalangeal disease Walking is another important functional activity (fig 9); and (e) inspect both soles for callosities, that may be affected by lower limb joint, reflecting abnormal weight bearing (spine, hip, lumbar spine, neurological, or muscular knee, or foot abnormality). abnormality: walking up and down stairs is a more stringent test of lower limb (and cardio-

vascular and respiratory) function than walking on October 2, 2021 by guest. Protected copyright. SUGGESTED METHOD OF RECORDING FINDINGS on the flat, and therefore a more appropriate If the three screening questions are negative screen. Similarly, with respect to examination then of selected movements, 'hands behind head' screens the patients ability to get their hands to pain 0 their face, head, and mouth (relevant to dress V washing, eating, etc) but is also a sensitive test walk V of glenohumeral abnormality (abduction and external rotation being the first affected move- is briefly recorded in the notes. If positive, ments at this joint). By inference, if this further questions and responses will be required. movement is normal the patient will also be able If the patient's gait (G) is normal and there is to get their hands round behind their back (for no abnormal appearance (A-that is, no swel- example, to wipe their bottom). Observation of ling, deformity, wasting, abnormal attitude, or power grip and fine precision pinch is a quick, skin change) or movement (M) of their arms sensitive screen of hand function and dexterity (A), legs (L), or spine (S), the following relevant to many daily activities; both are template may usefully be written in the notes affected early by local joint or periarticular with respect to examination: disease. A further relevant aspect of the screen is that G V A M most rheumatological abnormality is detected A V V by inspection at rest and during movement. In L V V other words, if a joint looks normal, assumes a S V V normal resting position, and moves smoothly through its range of movement without facial If abnormality is detected at one or more of evidence of discomfort, then it probably is The 'GALS' locomotor screen 1161169

normal. Palpation in the screen is restricted to large, potentially complex system. The screen is

joints commonly targeted by inflammatory quickly learnt by undergraduates8 and post- Ann Rheum Dis: first published as 10.1136/ard.51.10.1165 on 1 October 1992. Downloaded from arthropathy (metacarpophalangeal joints, meta- graduates,'0 and its regular application can tarsophalangeal joints, knees), and briefly to improve junior doctor's recognition of patient screen for paim associated with fibromyalgia disability and locomotor disease. 0 Its inclusion syndrome which is easily overlooked.3 If the in the undergraduate programme could enhance screening history or examination is positive student awareness and clinical skills relating to then more detailed questioning and regional the locomotor system and to disability in examination will be warranted. general. Consideration of such a screen is The order of examination is unimportant and particularly germane at a time when the under- the summary is intended as a guide rather than graduate curriculum is under review with major as doctrine. Each individual will develop their emphasis on clinical skills and attitudes. For own sequence, combining certain elements with these reasons the 'GALS' screen has been tests of other systems. For ease of description endorsed by the education committees of the observations relating to gait, spine, arms, and Arthritis and Rheumatism Council and the legs are described separately, though in practice British Society for Rheumatology (autumn there is considerable overlap during certain 1991). The screen might also be useful to allied manoeuvres (for example, observation of health professionals, particularly those working the standing patient from in front and from with elderly patients. behind). With respect to recording in the notes, however, 'GALS' is an easy, concise system to We are grateful to the Education Committees of the Arthritis and employ. It can stand on its own as a combined Rheumatism Council and the British Society for Rheumatology objective record of functional disability and for considering and endorsing this procedure. musculoskeletal system examination, or readily be incorporated within the neurological ('CNS') 1 Arthritis and Rheumatism Council field unit. Digest of data clerking with which there is particular overlap. on the rheumatic diseases I. Ann Rheum Dis 1974; 33: 93-105. Although currently practised systems reviews 2 Wright V. The epidemiology ofdisability. JR Coll Physicians may include questions relating to activities of Lond 1982; 16: 178-83. 3 Doherty M, Abawi J, Pattrick M. Audit of medical inpatient daily living, objective observation of functional exanination: a cry from the joint. J R Coll Physicians Lond capabilities (for example, walking, ability to 1990; 24: 115-8. 4 Spencer M A, Dixon A S. Rheumatological features of grip, ability to get hands to mouth) are often patients admitted as emergencies to acute general medical omitted, though often relevant, particularly in wards. Rheumatol Rehabil 1981; 20: 71-3. 5 Ahern M J, Schultz D, Soden M, Clark M. The musculo- older patients. In presenting the 'GALS' screen skeletal examination: a neglected clinical skill. Aust N Z J we are not necessarily supporting the traditional Med 1991; 21: 303-6. 6 Robine J M, Ritchie K. Healthy life expectancy: evaluation of 'systems review' clerking.9 If more focused global indicator of change in population health. BMJ 1991; questioning and examination relating to the 302: 457-60. 7 Report of the GMC working party to review the 1980 presenting problem is undertaken the 'GALS' recommendations [consultation paper]. London: General procedure will still be useful in selective situa- Medical Council, 1991. 8 Jones A, Ledingham J, Regan M, Doherty M. A proposed http://ard.bmj.com/ tions as a rapid test of functional performance minimal rheumatological screening history and examination: and to screen out regional locomotor abnor- the joint answers back. J7 R Coll Physicians Lond 1991; 25: 111-5. malities that merit closer scrutiny. 9 Hoffbrand B I. Away with the systems review: a plea for This brief 'screen' is sensitive to important parsimony. BMJ 1989; 298: 817-9. 10 Jones A, Regan M, Ledingham J, Doherty M. Can we alter locomotor abnormality and functional impair- doctors' awareness of locomotor problems? BrJ Rheumatol ment8 and forms a useful introduction to a 1991; 30 (suppl 2): 1. on October 2, 2021 by guest. Protected copyright.