Screening for signs and symptoms of rheumatoid arthritis by family physicians and nurse practitioners using the Gait, Arms, Legs, and Spine musculoskeletal examination




To evaluate the sensitivity and specificity of the Gait, Arms, Legs, and Spine (GALS) examination to screen for signs and symptoms of rheumatoid arthritis (RA) when used by family physicians and nurse practitioners.


Participating health care professionals (2 rheumatologists, 3 family physicians, and 3 nurse practitioners) were trained to perform the GALS examination by viewing an instructional DVD and attending a training workshop. One week after training, the health care professionals performed the GALS examination on 20 individuals with RA and 21 individuals without RA. All participants were recruited through 2 rheumatology practices, and each participant was assessed by 4 health care professionals. The health care professionals were asked to record whether observed signs and symptoms were potentially consistent with a diagnosis of RA. The health care professionals understood the study objective to be their agreement on GALS findings among one another and were unaware that one-half of the participants had RA. Sensitivity and specificity were calculated to determine the ability of the GALS examination to screen for RA using the rheumatologist as the standard for comparison.


Sensitivity and specificity values varied from 60–100% and 70–82%, respectively, for the 3 family physicians, and 60–90% and 73–100%, respectively, for the 3 nurse practitioners.


Following a very short training period, family physicians and nurse practitioners appeared to be able to use the GALS examination as a screening tool for RA signs and symptoms, particularly for identifying an individual with positive results who will benefit from further investigation or rheumatology referral.


Given the increasing size of the older population and an increasingly prevalent sedentary lifestyle, it is not surprising that the number of musculoskeletal (MSK) conditions is expected to increase. Reports of MSK symptoms comprise 10–30% of patient visits to family physicians' offices (1). It is well recognized that these symptoms are a significant cause of pain and disability for the individual and account for significant financial and health care burdens at the population level (2, 3). Despite this, there are serious concerns regarding the education and training of physicians in the area of MSK medicine, particularly with respect to physical examination of these patients (1, 4–6).

Limited education and training in MSK medicine may be contributing factors for low levels of competency of MSK medicine, a lack of confidence in assessing the MSK system, and physical examinations not being routinely performed by physicians (4–8). It is not surprising that there is a significant underdetection or underdiagnosis of MSK conditions in primary care (9, 10). More specifically, recognition of signs and symptoms of rheumatoid arthritis (RA), which has a prevalence of ∼1% in the Western world, remains a major challenge since RA symptoms can be similar to many other potential causes of pain and joint inflammation (11–13). Approximately 80% of people with RA describe a slow, progressive onset of symptoms over weeks to months typically beginning with pain, swelling, and/or stiffness in multiple joints (13, 14). The joints most commonly affected are those with the highest ratio of synovium to articular cartilage, such as the small joints of the hand (metacarpophalangeal joint, proximal interphalangeal joint) and wrist (14). There is ample evidence suggesting that early identification and treatment of RA attenuate the symptoms and disease progression (15, 16). Given that rheumatologists are typically the specialists who diagnose RA (16), early referral when potential cases are suspected is critical (12), since delayed referrals have been identified as a rate-limiting step in the delay of treatment (15, 17).

The lack of adequate MSK training in medical school coupled with the fact that most people with arthritis address their health needs in primary care is concerning. Approximately 2 decades ago, Doherty et al created the Gait, Arms, Legs, and Spine (GALS) locomotor screening examination to address the high prevalence and underdetection of MSK disorders (8). This 3-minute examination consists of 3 parts: 3 questions addressing pain, difficulty dressing, and difficulty with stairs; assessment of gait; and a physical examination of the appearance and movement of the arms, legs, and spine. In 2006, Dequeker et al noted that the GALS examination is a method for “screening the MSK system quickly with emphasis on rapid identification of significant abnormalities and any physical ability” (18). We have previously shown that the GALS examination can be used by family physicians to detect MSK abnormalities in the general population (19). Although it is not designed specifically to screen for early inflammatory arthritis, we have shown that physiotherapists and physiotherapy students can use the GALS examination to screen for signs and symptoms of RA (20). The use of such a screening examination may enable other health care professionals to thoroughly, accurately, and efficiently identify the signs and symptoms consistent with inflammatory arthritis in the primary care setting to ensure appropriate and timely referral to rheumatologists. The primary objective of this study was to evaluate the sensitivity and specificity of the GALS examination when used by family physicians and nurse practitioners to screen for signs and symptoms of RA.

Significance & Innovations

  • This is the first time the Gait, Arms, Legs, and Spine (GALS) examination has been introduced to family physicians to determine its utility in screening for signs and symptoms of rheumatoid arthritis.

  • This is the first study to introduce the use of the GALS screening examination to nurse practitioners.

  • Both family physicians and nurse practitioners who were taught the GALS examination using an instructional DVD and a short workshop appeared able to employ the tool to screen for signs and symptoms of rheumatoid arthritis.

Patients and methods

Health care professionals.

The participating health care professionals included 2 rheumatologists, 3 family physicians, and 3 nurse practitioners. Both rheumatologists were practicing physicians with previous clinical experience using the GALS examination. The family physicians and nurse practitioners were active health care professionals at a large urban multidisciplinary health center affiliated with McMaster University (Table 1). All health care professionals participated in a hands-on training workshop and a study day.

Table 1. Training and clinical practice experience of participating health care professionals*
 Clinical practice, yearsPrevious additional MSK trainingProportion of practice with MSK diagnosis, %
  • *

    MSK = musculoskeletal.

Group A   
 Family physician25No15
 Nurse practitioner7No5
 Nurse practitioner25No25
Group B   
 Family physician35Yes50
 Family physician16No15
 Nurse practitioner12No15

One month prior to the training workshop, all health care professionals were given an instructional GALS DVD, endorsed by the Canadian Rheumatology Association, which systematically explains and demonstrates the screening examination. At the training workshop, which was led by the creator of the DVD, the health care professionals viewed the DVD and discussed their issues and concerns. The workshop also included a short presentation on the signs and symptoms of various MSK abnormalities (e.g., osteoarthritis, inflammatory arthritis), a demonstration by an author (AC) of the GALS examination on a volunteer, and a discussion of how to record abnormalities to ensure that all health care professionals would document observations consistently. The health care professionals were divided into groups (1 rheumatologist, 1 family physician, and 1 nurse practitioner per group), and each was given the opportunity to practice the GALS examination on 2 individuals previously diagnosed with RA. The group then reconvened and discussed the findings of each patient to ensure that they had consistently recorded the observations, which included the location (i.e., left hand) and details (i.e., Heberden's nodes) of each abnormality. The health care professionals were also trained to record when the signs or symptoms resembled those of a diagnosis of a bone or joint disorder by indicating the possible condition (e.g., query right knee osteoarthritis, query RA) in the comments section. The health care professionals were then informed about the study day procedures (which took place 1 week following the training session) and were told the objective of the study would be to assess the agreement among each other in their findings of each GALS examination feature on the study participants.


The participants for this study (target n = 50) were recruited from 2 rheumatology practices. Twenty-five individuals previously diagnosed with RA, according to the American College of Rheumatology criteria (16), were identified as eligible by their treating rheumatologists, who were third-party investigators not involved with assessing participants on the study day (16). These RA patients, all ≥50 years of age and capable of giving informed consent, generally had early or mild disease. Recruitment of these participants from specialists' practices ensured that an adequate number of RA patients were included in the study to assess sensitivity and specificity. An additional 25 individuals were randomly selected from one of the previously mentioned rheumatology practices. These participants were eligible if they were ≥50 years of age, capable of giving informed consent, and did not have RA or any other type of inflammatory arthritis. The time elapsed between recruitment and the study day was ∼2 months.

On the study day, the health care professionals and study participants were randomly divided into 2 groups. Group A included 1 rheumatologist, 1 family physician, 2 nurse practitioners, and half of each of the RA and non-RA participants. Group B was comprised of 1 rheumatologist, 2 family physicians, 1 nurse practitioner, and the remaining study participants. Therefore, each participant was assessed by 4 health care professionals. All participating health care professionals and study investigators were blinded to the participants' health status (RA or no RA) and recruitment methods to ensure that they did not know that half of the study participants had previously been diagnosed with RA.

Study procedures.

Each health care professional was allotted 6 minutes to conduct the GALS examination and record any observed abnormalities for each participant. Each health care professional assessed participants sequentially by rotating from one examination room to the next. The study participants wore a gown during the examinations to ensure adequate exposure of the back. The GALS examination commenced with 3 questions followed by a physical assessment of the gait and the appearance and movement of the arms, legs, and spine as abnormal or normal (Table 2). If or when an abnormality was observed, the health care professional recorded the location of the abnormality (e.g., left hand), type of abnormality (e.g., Heberden's nodes), and if RA was suspected. After completing each GALS examination, each health care professional submitted their recording sheet to a research assistant before moving to the next examination room to assess the next participant. The health care professionals were blinded to the observations of the other health care professionals.

Table 2. Individual features assessed in the Gait, Arms, Legs, and Spine examination
 Symmetry and smoothness of movement
 Stride length and mechanics
 Ability to turn normally and quickly
  Wrist/finger swelling/deformity
  Squeeze across second to fifth metacarpals to check tenderness (indicates synovitis)
  Turn hands over to inspect muscle wasting and assess forearm pronation and supination
 Grip strength
  Power grip (tight fist)
  Precision grip (oppose each finger to thumb)
  Full extension
  Abduction and external rotation of shoulders
  Squeeze across metatarsals for tenderness (indicates synovitis)
  Knee swelling/deformity, effusion
  Quadriceps muscle bulk
  Crepitus during passive knee flexion
  Check internal rotation of hips
 Inspection from behind
  Shoulders and iliac crest height symmetry
  Paraspinal muscle
  Shoulder, buttock, thigh, and calve muscles bulk
  Popliteal or hindfoot swelling or deformity
 Inspection from the front
  Quadriceps bulk and symmetry
  Swelling or varus or valgus deformity at knee
  Forefoot of midfoot deformity, action normal
  Ear against shoulder on either side to check lateral cervical spine flexion
  Hands behind head with elbows back (check rotator cuff muscles, acromioclavicular joints, sternoclavicular joints, and elbow joints)
 Inspection from the side
  Normal thoracic and lumbar lordosis
  Normal cervical kyphosis
  Normal flexion (lumbosacral rhythm from lumbar lordosis to kyphosis) while touching toes
 Trigger point
  Supraspinatus muscle tenderness (exaggerated response)

Ethics approval was obtained from the Hamilton Health Sciences/McMaster University Faculty of Health Sciences Research Ethics Board.

Statistical analyses.

Statistical analyses were performed to assess the sensitivity and specificity of the GALS examination for screening for RA. The rheumatologists' assessments on the study day were considered the standard for comparison. Therefore, the observations of each family physician and nurse practitioner were compared with those of the rheumatologist in their group, specifically whether or not a query of RA was documented. Sensitivity and specificity with associated 95% confidence intervals were calculated using the VassarStats Clinical Calculator 1 web site ( A 1-sided 95% confidence interval was calculated where the estimate of sensitivity or specificity was 100%.


Of the 50 study participants scheduled to participate, 41 were assessed on the study day (21 RA participants, 20 non-RA participants). Despite 2 reminder phone calls in the prior week, 9 individuals scheduled to participate did not attend because of scheduling conflicts or illness. Of the 41 study participants, 20 were assessed by a rheumatologist as having signs and/or symptoms consistent with RA (10 per group) for a 95% sensitivity. Sensitivity and specificity of the family physicians and nurse practitioners when compared to the respective rheumatologist in each circuit were calculated (Table 3). For family physicians, sensitivity and specificity varied from 60–100% and 70–82%, respectively. For nurse practitioners, sensitivity varied from 60–90% and specificity varied from 73–100%. In participants who were not queried as having RA signs or symptoms by family physicians or nurse practitioners, observations that were missed included positive squeeze tests of the hand and foot, ulnar deviation, and hallux valgus.

Table 3. Sensitivity and specificity of family physicians and nurse practitioners compared to rheumatologist assessment in each circuit*
  • *

    Values are the percentage (95% confidence interval).

  • One-sided 95% confidence interval.

Group A  
 Family physician100 (74–100)70 (42–98)
 Nurse practitioner80 (55–100)80 (55–100)
 Nurse practitioner60 (30–90)100 (74–100)
Group B  
 Family physician60 (30–90)82 (59–100)
 Family physician80 (55–100)82 (59–100)
 Nurse practitioner90 (71–100)73 (46–99)


This is the first study to investigate the use of the GALS examination as a screening tool for RA when used by primary care physicians and nurse practitioners. The sensitivity and specificity for the family physicians were 60–100% and 70–82%, respectively. For the nurse practitioners, the corresponding values of sensitivity and specificity were 60–90% and 73–100%, respectively. These values are similar to those from a previous study where physiotherapists and physiotherapy students used the GALS examination to detect RA signs and symptoms using a similar study design (20). Although statistical tests were not performed to determine whether one group of health care professionals was better at detecting RA signs and symptoms than the other, both family physicians and nurse practitioners appeared able to identify signs and symptoms and, importantly, distinguish abnormalities from what is otherwise normal. A high sensitivity reflects few false-negative results and is important so as to not miss those who may actually have the condition. Patients recognized as having these signs and/or symptoms would likely be referred for subsequent testing or to a rheumatologist. Likewise, a high specificity is important so as to minimize the number of patients without the condition who are subjected to subsequent referral and/or diagnostic tests, resulting in unnecessary burdens to the patient and the health care system.

A review article discussing educational issues in rheumatology (18) noted that the use of the GALS screening tool by rheumatologists, orthopedic surgeons, and neurologists could aid in the early detection or even the diagnosis of MSK conditions. It is important to note that the GALS examination is a widely used and published MSK screening examination (10). While focused physical examinations have been reported, such as the Regional Examination of the Musculoskeletal System (10), these examinations are more thorough and typically target a specific anatomic region after an abnormality has been detected. Although primary health care professionals currently practicing in Canada do not routinely perform the GALS screening examination, it has been integrated into the curricula of most Canadian medical schools and throughout the UK. The GALS examination is not currently taught in nurse practitioner curricula. Despite the participating health care professionals never having been exposed to the GALS examination during their training, our results support the potential for the GALS examination to be taught to health care professionals and implemented as a quick screening tool to aid in the identification of the signs and symptoms of early inflammatory arthritis. The GALS screening examination is not meant to be used as a definitive diagnostic tool, and given the prevalence of RA (13), it is likely to pick up MSK problems that are not consistent with RA. However, the potential remains for the early identification and referral of suspected cases of RA to reduce joint destruction and increase the likelihood for disease-modifying antirheumatic drug–free remission in those patients with RA (11, 15).

A limitation of this study is that each health care professional's ability to screen for signs and symptoms of RA was not assessed prior to the training session due to feasibility issues. In addition, the participating health care professionals had variable prior medical training and years of experience working in primary care. It was unknown if or how often the participating health care professionals reviewed the GALS DVD on their own time, a factor that may have contributed to variability in results. It is also important to note that all of the participating health care professionals worked in the same family practice clinic, and all of the family physicians had an academic affiliation. Participation in the study may have influenced the manner in which practitioners undertook the learning and application of the GALS examination. Also, participants with RA may have behaved differently than naive patients who would be assessed in a normal clinical setting.

Three limitations noted in our previous study (20) were addressed here: the time interval between the training workshop and the study day was shortened to 1 week, each study participant was assessed by 3 health care professionals plus a rheumatologist, and it was clarified during training how to document a suspected case of RA. We were unable to address the challenge of recruiting participants with early RA who were not yet treated. We selected the most feasible alternative and recruited those whose disease was in the early stages and/or being well controlled with medications.

To summarize, following a short training period, family physicians and nurse practitioners appeared able to employ the GALS examination to screen for possible RA signs and symptoms. Warranting further investigation is a comparison of the accuracy of the GALS examination when performed by individuals taught using only the instructional DVD with that of individuals taught using the DVD in combination with a workshop. The potential for including the GALS screening examination in the curricula for nurse practitioner training in the same way that it has been incorporated into undergraduate medical training is worthy of exploration.


All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. Dr. Beattie had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study conception and design. Beattie, MacIntyre, Cividino.

Acquisition of data. Beattie.

Analysis and interpretation of data. Beattie, MacIntyre, Cividino.