The GALS (Gait, Arms, Legs, Spine) screen is a quick and reasonably sensitive way to detect common musculoskeletal (MSK) abnormalities as part of a general medical assessment (1). However, for a person with MSK complaints a detailed assessment is required to determine the diagnosis and the impact of the condition on that person. The key starting point is the history. This needs to be holistic and individualised as the enquiry proceeds since the impact of any condition is person specific and influenced by many factors (e.g. psychosocial factors, illness perceptions, sleep, comorbidity etc.). A thorough history alone usually suggests the single most likely cause for the patient's problem(s). The history should then guide the subsequent physical examination – an efficient targeted “rapier” approach is recommended in which the practitioner selects the appropriate skills from a range of competencies according to specific elements in the history. This contrasts with a more lengthy hypothesis-free “general screen” in which the same set of uniform procedures is undertaken in each patient.
This presentation will cover key principles and considerations of assessment and illustrate how the history guides the subsequent “rapier” examination (2). Examples include:
(1) in the history: determination of pain localisation and features that associate with radiated pain; important pain and stiffness characteristics that differentiate mechanical usage-related pain, inflammatory pain, acute crystal synovitis pain, destructive bone pain and neurogenic pain; non-specific symptoms of inflammation
(2) in the examination: usual order of inspection at rest, inspection during movement, then palpation at rest and during movement of symptomatic regions; contrasting clinical findings that quickly differentiate joint and peri-articular problems; initial selection of the movement(s) that is affected first and most severely by arthropathy - the tight pack position(s); detection of “stress pain” (pain worse in tight-pack positions but reduced/absent in loose-pack positions - the most sensitive sign of inflammation); examination for effusion, soft-tissue and firm swelling; use of resisted active movements and stress tests for peri-articular lesions; a targeted screen for asymptomatic disease prompted by main diagnosis.
EULAR learning resources available at http://www.eular.org/edu_training_dvd.cfminclude: (1) The “GALS” screen and (2) Principles of the musculoskeletal history and examination.
Disclosure of Interest None declared