GALS locomotor screen Annals of the Rheumatic Diseases BMJ by alicejenny


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Annals ofthe Rheumatic Diseases 1992; 51: 1165-1169                                                                                     1165


                             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
                             (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-
                             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.
                                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,               competency on which further education and
Nottingham NG5 1PB,
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             ment of locomotor disease and disability by
Hospital, London,
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                   appropriate for inclusion into the under-
Rheumatology Unit,           graduate curriculum. It is adapted from a
Middlesex Hospital,
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:           with other systems (particularly the nervous
Dr Doherty.
Accepted for publication     system) and the procedure can be viewed as a         Figure 1 Inspection from the side for normal spinal
4 June 1992                  general functional (disability) as well as basic     curvatures.
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1166                                                                                                   Doherty, Dacre, Dieppe, Snaith

           Method                                                             features to note at each stage. For convenience
           SCREENING HISTORY                                                  of regional description, the examination can be
           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

           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
                                       Normal shoulder and gluteal muscle
                                       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)
           Inspection from in front
               'Head on shoulders'     Normal cervical lateral flexion
               'Arms behind head'      Normal glenohumeral,                   Figure3 Lateralcervtcalflexion.
                                         sternoclavicular, and
                                         acromioclavicular joint movement
                  'Arms straight'      Full elbow extension
                  'Hands in front'     No wrist/finger swelling or
                                       Ability to fully extend fingers
                  'Turn hands over'    Normal supination/pronation
                                         (superior and inferior radioulnar
                                       Normal palms (no swelling, muscle
                                       wasting, erythema)
                  'Make a fist'        Normal power grip
                  'Fingers on thumb'   Normal fine precision
             Legs                      Normal quadriceps bulk/symmetry
                                       No knee swelling or deformity
                                       No forefoot/midfoot deformity
                                       Normal arches

           Figure 2 Pressure over mid supraspinatus-observe for the           Figure 4 Normal painftee movement ofglenohumer'al,
           hyperalgesic response offibromyalgia.                              acromioclavicular, and stemoclavicularjoints.
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The 'GALS' locomotor screen                                                                                                             1167

                              spine (and lower limb) features. (b) From the        the patient to: 'Place both hands behind your
                              side-observe normal spine contours (fig 1).          head, elbows back' (fig 4); 'Place both hands
                              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) toelicit 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

                              Figure S Normal pronation/supination (proximal and
                              distal radioulnarjoints); normal palms.              Figure 7 No tenderness of metacarpophalangealjoints.

                              Figure 6 Normal pmoer grip..                         Figure 8 Normal internal rotation ofhip inflexion.
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1168                                                                                          Doherty, Dacre, Dieppe, Snaith

                                                                       these regions, the tick is replaced by a cross and
                                                                       further note of the abnormality made. For
                                                                       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

                                                                       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-
           Figure 9 No tendemess of metatarsop halangealjoints.
                                                                       duction, not a substitution, for the acquisition
                                                                       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-
           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
           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
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The 'GALS' locomotor screen                                                                                                                   1169

                              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-
                              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:
                              Although currently practised systems reviews              93-105.
                                                                                    2 Wright V. The epidemiology of disability. J R Coll Physicians
                              may include questions relating to activities of          Lond 1982; 16: 178-83.
                              daily living, objective observation of functional     3 Doherty M, Abawi J, Pattrick M. Audit of medical inpatient
                                                                                        exanination: a cry from the joint. J R Coll Physicians Lond
                              capabilities (for example, walking, ability to            1990; 24: 115-8.
                              grip, ability to get hands to mouth) are often        4 Spencer M A, Dixon A S. Rheumatological features of
                                                                                        patients admitted as emergencies to acute general medical
                              omitted, though often relevant, particularly in           wards. Rheumatol Rehabil 1981; 20: 71-3.
                              older patients. In presenting the 'GALS' screen       5 Ahern M J, Schultz D, Soden M, Clark M. The musculo-
                                                                                        skeletal examination: a neglected clinical skill. Aust N Z J
                              we are not necessarily supporting the traditional        Med 1991; 21: 303-6.
                              'systems review' clerking.9 If more focused           6 Robine J M, Ritchie K. Healthy life expectancy: evaluation of
                                                                                       global indicator of change in population health. BMJ 1991;
                              questioning and examination relating to the              302: 457-60.
                              presenting problem is undertaken the 'GALS'           7 Report of the GMC working party to review the 1980
                                                                                       recommendations [consultation paper]. London: General
                              procedure will still be useful in selective situa-       Medical Council, 1991.
                              tions as a rapid test of functional performance       8 Jones A, Ledingham J, Regan M, Doherty M. A proposed
                                                                                       minimal rheumatological screening history and examination:
                              and to screen out regional locomotor abnor-              the joint answers back. J7 R Coll Physicians Lond 1991; 25:
                              malities that merit closer scrutiny.                      111-5.
                                                                                    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.
                              locomotor abnormality and functional impair-         10 Jones A, Regan M, Ledingham J, Doherty M. Can we alter
                                                                                       doctors' awareness of locomotor problems? BrJ Rheumatol
                              ment8 and forms a useful introduction to a                1991; 30 (suppl 2): 1.
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                                  The 'GALS' locomotor screen.
                                  M Doherty, J Dacre, P Dieppe, et al.

                                  Ann Rheum Dis 1992 51: 1165-1169
                                  doi: 10.1136/ard.51.10.1165

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