pGALS: a novel and simple approach for musculoskeletal examination of children
Submitting InstitutionNewcastle University
Unit of AssessmentClinical Medicine
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Clinical Sciences, Public Health and Health Services
Summary of the impact
pGALS (paediatric Gait, Arms, Legs, Spine) is a quick, accurate and
child-friendly examination technique that identifies children who need to
be referred to a paediatric rheumatology specialist. pGALS has been widely
disseminated since 2008 and integrated into both undergraduate medical
student teaching and the membership examination for the Royal College of
Paediatrics and Child Health. pGALS was developed by Newcastle researchers
in response to their findings of a self-reported lack of confidence among
clinicians when conducting musculoskeletal examinations of children.
Research also showed that delays and inappropriate investigations were
being conducted before the child was referred to a specialist. pGALS is
now taught in at least 15 of the 32 medical schools in the UK and has been
described in a number of leading textbooks. It is becoming known and used
worldwide, adapted for local cultural and social contexts.
The Newcastle University researchers involved throughout the period of
the research were Professor Helen Foster (project lead), Dr Tim Rapley
(social scientist, qualitative methodology) and Dr Sharmila Jandial
(education research fellow, now a consultant in paediatric rheumatology).
Paediatric musculoskeletal problems are extremely common, occurring in up
to 30% of young persons and accounting for 3% of hospital day case
attendances. The challenge for clinicians is identifying those children
who have significant disease and doing so early in its course.
One such disease with significant long term consequences is juvenile
idiopathic arthritis. This is defined as inflammation of one or more
joints for at least six weeks, in a child under the age of 16 years in
whom other known causes of arthritis have been excluded. The inflamed
joint is often swollen, warm, has lost normal movement and is stiff in the
mornings. Pain is not always a major feature and so it can be difficult
for parents and doctors to detect arthritic joints in young children. The
UK annual incidence is approximately 1 in 10,000 and at any one time there
are about 12,000 affected children in the UK. Juvenile idiopathic
arthritis can start at any age from birth to adolescence, but the peak age
of onset is six years. It is more common in girls than boys. Joint damage
occurs early in the disease progression and the risk of associated
blindness (due to associated eye inflammation) is greatest in the first
months of arthritis onset. Evidence supports early and aggressive
intervention to obtain the optimal outcome.
Research conducted by Foster and colleagues (R1, R2) showed that it was
common for many children presenting in primary and secondary care settings
with musculoskeletal complaints to experience delay in being referred to
paediatric rheumatology services. The researchers found complex referral
pathways from their primary care doctor to different secondary care
services, via general paediatrics, orthopaedics, and accident and
emergency. In addition to delaying the critical referral to a paediatric
rheumatologist, such complexity often resulted in children being subjected
to inappropriate, costly and unnecessary invasive investigations, such as
magnetic resonance imaging (for which many young children need a general
anaesthetic) and removal of fluid from the joints (often also requiring
anaesthetic). Further Newcastle-led research (R3) identified a general
lack of assessment of a child's musculoskeletal system by trainee and
consultant general paediatricians, despite other systems, such as
cardiovascular or gastrointestinal, being routinely assessed regardless of
the complaint with which the child presented. This was linked to a,
self-reported, low confidence in their ability to conduct musculoskeletal
assessment of children. Foster and colleagues identified (R4) a lack of
teaching of musculoskeletal clinical skills in medical schools, a
potential explanation for this poor confidence in clinical assessment.
In order to improve the confidence of clinicians conducting
musculoskeletal assessment of children and thus alleviate the delay in
diagnosis of conditions such as juvenile idiopathic arthritis, Newcastle
researchers developed a new method for examination of children's joints.
Foster and colleagues reported the development and validation of pGALS
(paediatric Gait Arms Legs and Spine) in 2006 (R5). This was tested in the
clinic and found to have excellent sensitivity when compared with expert
diagnosis and did not lead to false negative results. Further work by the
group (R6) showed that the pGALS approach can be useful as a diagnostic
tool in the acute (ie non-rheumatological) paediatric setting and can be
used by non-specialists.
References to the research
R1. Foster HE, Eltringham MS, Kay LJ, Friswell M, Abinun M, Myers A.
Delay in access to appropriate care for children presenting with
musculoskeletal symptoms and ultimately diagnosed with juvenile idiopathic
arthritis. Arthritis Care and Research 2007, 57(6), 921-927. DOI:
http://dx.doi.org/10.1002/art.2282. Cited by 19
R2. Myers A, McDonagh JE, Gupta K, Hull R, Barker D, Kay LJ, Foster HE.
More 'cries from the joints': Assessment of the musculoskeletal system is
poorly documented in routine paediatric clerking. Rheumatology
2004, 43(8), 1045-1049. DOI: http://dx.doi.org/10.1093/rheumatology/keh245.
Cited by 31
R3. Jandial S, Myers A, Wise E, Foster HE. Doctors Likely to Encounter
Children with Musculoskeletal Complaints Have Low Confidence in Their
Clinical Skills. Journal of Pediatrics 2009, 154(2), 267-271. DOI:
Cited by 20
R4. Jandial S, Rapley T, Foster H. Current teaching of paediatric
musculoskeletal medicine within UK medical schools — a need for change. Rheumatology
2009, 48(5), 587-590. DOI: http://dx.doi.org/10.1093/rheumatology/kep038.
Cited by 7
R5. Foster HE, Kay LJ, Friswell M, Coady D, Myers A. Musculoskeletal
screening examination (pGALS) for school-age children based on the adult
GALS screen. Arthritis Care and Research 2006, 55(5), 709-716.
http://dx.doi.org/10.1002/art.22230. Cited by 31
Arthritis Research UK. Foster HE, LJ Kay, TR Rapley, CR May. A study
to develop Regional Musculoskeletal examination for use in school aged
children. 2005-2011, £121,758
Arthritis Research UK. Foster HE (Principal Investigator), Rapley TR, Kay
LJ, May CR. Exploring the barriers to care for children with suspected
Juvenile Idiopathic Arthritis. 2008-2012, £141,874
Arthritis Research UK. Jandial S, Kay LJ, Stewart J, Foster HE. Improving
musculoskeletal clinical skills in medical students. 2007 - 2011,
Details of the impact
The pGALS (paediatric Gait, Arms, Legs, Spine) examination
Developed by researchers in Newcastle, pGALS is a quick but sensitive
screening examination of the musculoskeletal system applicable to the
school-aged child, taking less than three minutes to perform. The findings
of the examination need to be considered in the context of a history taken
at the same time. First, a general assessment looks for joint swelling,
any physical asymmetry, flexion deformities or rashes. The child is
observed walking (gait); the arms, legs and spine are then sequentially
examined through a series of specific movements made by the child and
physical examination by the clinician. These tests enable rapid and
accurate assessment of the flexibility and symmetry of joint movements and
indicate whether or not referral to a specialist is in order.
Having developed and validated the pGALS examination, Foster and
colleagues entered into a collaboration with a leading UK charity in order
to disseminate knowledge about pGALS to practicing clinicians, parents
and, importantly, to those teaching medical students.
Collaborations with Arthritis Research UK
Newcastle researchers collaborated with the UK's leading charity in the
field, Arthritis Research UK, on the production of teaching aids.
Both a video of a pGALS examination of a child and a pdf booklet
describing and illustrating the method were developed. Arthritis
Research UK's Education Manager has confirmed that in 2013 around
100 copies of the DVD are requested per month, with 15,600 copies
distributed in total since it was first made. Web-streaming is also
popular: with `5,012 unique views in 2012 and 3,764 unique views in
the first 5 months of 2013' and `pGALS video clips viewed ... on
YouTube — upwards of 40,000 views since April 2012.' (Ev a)
Further collaborations have included surveys (in 2009 and 2013) of
current practice in teaching paediatric musculoskeletal examination. The
methodology and results of the 2009 survey were reported in R3 and R4. The
2013 survey was led from Newcastle and the design was validated by an
independent consultant. Surveys sought the views of lead paediatric
teachers (paediatric rheumatology consultants and trainees who teach (100%
response rate) and general paediatric consultants (39% response rate)).
Additionally, lead adult musculoskeletal teachers were surveyed (62%
response rate). The survey received responses representing 23 UK medical
schools (Ev b).
Impact on medical school teaching
In 2008, pGALS was introduced as a core clinical skill for paediatric
musculoskeletal assessment at Newcastle University Medical School (it is
also taught in Newcastle's NuMed course in Malaysia) and other
institutions in the UK have followed suit. The impact on teaching beyond
Newcastle has been significant and approached through two routes;
awareness raising amongst specialists who teach paediatrics and
contribution to core medical teaching texts.
Raised awareness impacts on teaching. The 2009 survey received
replies from 23 of the 32 UK medical schools (72%) and indicated that only
six medical schools were teaching pGALS.
The 2013 survey also received responses from 23 medical schools and
indicated that pGALS was being taught in 15 medical schools, with all
using the Arthritis Research UK pGALS DVD or web streaming
service. Importantly, a significant improvement since 2009 is that 14
medical schools allowed students to practice pGALS on children and 13
medical schools gave students the opportunity to examine children with
Core clinical skills are acquired at medical school. Since pGALS now
reaches undergraduate students in at least 15 medical schools in the UK,
this begins to address the problem of clinicians' lack of confidence in
musculoskeletal examination identified by Newcastle research.
Raised awareness through textbooks. Foster and Jandial were
invited in 2008 to contribute a chapter on children's musculoskeletal
problems, including a description of pGALS, to one of the most popular
paediatrics student textbooks, `The Illustrated textbook of Paediatrics',
Lissauer and Clayden (eds). Amazon.co.uk report that this textbook
is its best seller in paediatrics texts (Ev c). Evidence from a
number of medical school libraries indicated that this text is also
generally the most frequently borrowed by students (Ev d).
The pGALS examination has been described in several other textbooks. `Training
in Paediatrics: The Essential Curriculum' (2009) Gardiner, Eisen and
Murphy (eds), `MRCPCH Clinical: Short Cases, History Taking and
Communication Skills' (2011) Bedwani, Anderson and Beattie, `Rheumatology
in Primary Care' (2012) Wagh (ed) and the `Pocket Tutor
Paediatric Clinical Examination' (2012) Brugha, Marlais and
Abrahamson (eds). In February 2012 Oxford University Press
requested permission to use photographs of the pGALS examination produced
by Arthritis Research UK in their `Oxford Specialist Handbooks
on Paediatric Rheumatology'.
Impact on paediatrician training
Foster is Chair of the Royal College of Paediatrics and Child Health
(RCPCH) College Advisory Committee for higher specialist training in
paediatric rheumatology in the UK. She was able to use her position to
lobby the Board of Examiners, backed by the evidence-base provided by the
Newcastle research, to address the lack of confidence and competence in
the paediatric musculoskeletal examination skills reported by
paediatricians in the UK. In 2009, Foster was successful in persuading the
RCPCH to include paediatric musculoskeletal assessment in the competency
framework for training and also, most importantly, included in the
clinical part of the MRCPCH examination (a mandatory examination for all
paediatricians in the UK) and pGALS was included as a minimum basic skill
(Ev e). Consequently, all paediatricians trained in the UK are now aware
of pGALS. Supplementary resources for trainees and examiners have also
been developed by Foster and Jandial at the request of the RCPCH and are
available on the RCPCH website (Ev f).
In May 2013 the Intellectual Property coordinator for the American
Academy of Family Physicians sought copyright permission to use the pGALS
materials and the Arthritis Research UK Education Manager has
confirmed that, `Examples of recent requests to reproduce the
description of how to perform the screening examination [pGALS] include:
... "The Pediatric Clinics of North America" (Canadian request, November
2011) [and] "General Practice at a Glance" textbook (request
from Wiley-Blackwell, July 2011).' (Ev a)
The Director of Paediatrics of a major hospital in Mumbai, India, has
confirmed the use of pGALS in practice there, stating, `[pGALS] is
routinely used in clinical practice in our country ... Hands On — a
document prepared by the authors [Foster and Jandial] and the
video demonstrating pGALS are popular teaching tools and are routinely
used by my colleagues and me in our training and teaching sessions.'
(Ev g). An Emeritus Professor of Pediatric Rheumatology in Canada has also
noted that pGALS `has filled a significant gap in medical education
and has been widely adopted world-wide' (Ev h).
Sources to corroborate the impact
Ev a. Information supplied by the Education Manager of Arthritis Research
UK, whose contact details are available on request. The video is available
Ev b. The survey was undertaken in June/July 2013 using Survey Monkey and
the methodology was similar to the previous study by Newcastle
researchers. The response rate was acceptable for a questionnaire of this
type and the instrument was validated and optimized by established
strategies. Contact details for the independent consultant are available
Ev c. Data from Amazon.co.uk shows `The Illustrated textbook of
Paediatrics', Lissauer and Clayden (eds), published by Mosby, to be
the bestseller in the category Books > Scientific, Technical &
Medical > Medicine & Nursing > Medical Sciences A-Z >
Ev d. Lending data provided by Newcastle University library staff who
conducted a survey amongst colleagues. Data from five English medical
school libraries was obtained indicating that only a `Crash course'
paediatrics text was more frequently borrowed.
Ev e. The Royal College of Paediatrics and Child Health have produced a
guide for candidates and examiners that references pGALS on page 33. It is
available at the RCPCH website or a pdf copy can be provided on request. http://www.rcpch.ac.uk/training-examinations-professional-development/assessment-and-examinations/examinations/clinical-e-3
Ev f. Supplementary resources are available at http://www.rcpch.ac.uk/training-examinations-professional-development/postgraduate-training/sub-specialty-training/paediatr
Ev g. Correspondence is available from the Director of Paediatrics Jaslok
Hospital and Research Centre, Mumbai, India. Contact details are available
Ev h. Correspondence is available from the Professor Emeritus, Division
of Rheumatology, Department of Pediatrics, University of British Columbia,
and British Columbia's Children's Hospital, Vancouver, Canada. Contact
details are available on request.