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- PATIENTS AND METHODS
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). 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 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.
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- PATIENTS AND METHODS
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 ) 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 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.