Annals ofthe Rheumatic Diseases 1992; 51: 1165-1169

NOW AND THEN

The 'GALS' locomotor screen

Michael Doherty, Jane Dacre, Paul Dieppe, Michael Snaith

AbstractThe locomotor system is complex and diffi-cult to examine. A selective clinical process todetect important locomotor abnormalities andfunctional disabiliity could prove valuable. Ascreen based on a tested 'minimal' history andexamination system is described, togetherwith a simple method of recording. Thescreen is fast and easy to perform. As well asproviding a useful introduction to examinationof the locomotor system, the screen includesobjective observation of functional move-ments relevant to activities of daily living. Itsinclusion in the undergraduate clerking reper-toire could improve junior doctors' awarenessand recognition of rheumatic disease andgeneral disability. It could also provide avaluable screening test for use in generalpractice.

(Ann Rheum Dis 1992; 51: 1165-1169)

musculoskeletal assessment. The screen mayreadily be incorporated into a 'system review'clerking, and takes only a minute or so toperform. Its use should improve the acquisitionof further, regionally based locomotor skills viaorthopaedic and rheumatology teaching.Although designed and tested in adults8 thescreen can also be used in children in thecontext of play.

Rheumatology Unit,City Hospital,Nottingham NG5 1PB,United KingdomM DohertyRheumatologyDepartment,St Bartholomew'sHospital, London,United KingdomJ DacreBristol Royal Infirmary,Bristol, United KingdomP DieppeBloomsburyRheumatology Unit,Middlesex Hospital,London,United KingdomM SnaithCorrespondence to:Dr Doherty.Accepted for publication4 June 1992

Musculoskeletal disorders form a considerablepart of the general practitioner workload,' 2 arecommon in hospital inpatients, 5 and are thesingle most important factor influencing dis-ability in later life.6 Examination and assess-ment of the locomotor system is therefore acommon requirement for doctors in many areasof health care. This requirement is likely toincrease as the proportion of elderly patients inthe community expands, and as patient percep-tions alter with respect to treatment and healthcare availability.Within medical schools there is increasing

emphasis on the acquisition of basic clinicalskills at the undergraduate level.7 The ability toquestion and examine a patient is a fundamentalcompetency on which further education andtraining can be built. Reviews suggest thatcompared with other body systems locomotorhistory and examination skills are poorly learnt,resulting in inadequate recognition and assess-ment of locomotor disease and disability byjunior doctors.34

This paper presents one simple approach toimproving the recognition of musculoskeletalabnormalities and disability. It summarises apreliminary screening history and examinationappropriate for inclusion into the under-graduate curriculum. It is adapted from asystem that has been shown to have goodsensitivity to detect important locomotorabnormalities.8 Aspects of this screen overlapwith other systems (particularly the nervoussystem) and the procedure can be viewed as ageneral functional (disability) as well as basic

Figure 1 Inspectionfrom the sidefor normal spinalcurvatures.

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Doherty, Dacre, Dieppe, Snaith

MethodSCREENING HISTORYThis comprises three questions: (a) 'Have youany pain or stiffness in your muscles, joints, orback?'; (b) 'Can you dress yourself completelywithout any difficulty?'; and (c) 'Can you walkup and down stairs without any difficulty?'

Positive answers to any of these will obviouslyrequire further enquiry. If all three are negative,however, significant musculoskeletal abnor-mality or disability is unlikely.

SCREENING EXAMINATIONThe 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 ofmovement (legs, arm swing,pelvic tilting)

Normal stride lengthNormal heel strike, stance, toe off,

swing throughAbility to turn quickly

Inspection from behind Straight spine (no scoliosis)Normal, symmetrical paraspinal

musclesNormal shoulder and gluteal muscle

bulk/symmetryLevel iliac crestsNo popliteal swellingNo hindfoot swelling/deformity

Inspection from the side Normal cervical and lumbar lordosisNormal (mild) thoracic kyphosis

'Touch toes' Normal lumbar spine (and hip)flexion

Inspection from in frontSpine

'Head on shoulders' Normal cervical lateral flexionArms

'Arms behind head' Normal glenohumeral,sternoclavicular, andacromioclavicular joint movement

'Arms straight' Full elbow extension'Hands in front' No wrist/finger swelling or

deformityAbility to fully extend fingers

'Turn hands over' Normal supination/pronation(superior and inferior radioulnarjoints)

Normal palms (no swelling, musclewasting, erythema)

'Make a fist' Normal power grip'Fingers on thumb' Normal fine precision

pinch/dexterityLegs Normal quadriceps bulk/symmetry

No knee swelling or deformity(varus/valgus)

No forefoot/midfoot deformityNormal arches

features to note at each stage. For convenienceof regional description, the examination can bebroken into gait, arms, legs, and spine ('GALS').In practice, however, the order of examinationis unimportant and the usual most convenientexamination sequence is gait, spine, arms, legs,with overlap between these components.

(1) Gait. Inspect the patient walking, turningand walking back.

(2) Spine. Inspect the patient standing fromthree views. (a) From behind-observe normal

Figure3 Lateralcervtcalflexion.

Figure 2 Pressure over mid supraspinatus-observefor thehyperalgesic response offibromyalgia.

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Figure 4 Normalpainftee movement ofglenohumer'al,acromioclavicular, and stemoclavicularjoints.

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The 'GALS' locomotor screen

spine (and lower limb) features. (b) From theside-observe normal spine contours (fig 1).Ask the patient to 'bend forward and touchtoes'. Press over the midpoint of each supra-spinatus (fig 2) to elicit hyperalgesia of fibro-myalgia. (c) From in front. Ask the patient to'try to place your ear on your left then yourright shoulder in turn' (fig 3).

(3) Arms. Still inspecting from in front, ask

FigureS Normal pronation/supination (proximal anddistal radioulnarjoints); normal palms.

the patient to: 'Place both hands behind yourhead, elbows back' (fig 4); 'Place both handsdown by your side, elbows straight'; 'Placeboth hands out in front, palms down, fingersstraight'; 'Turn both hands over' (fig 5); 'Makea tight fist with each hand (fig 6); 'Place the tipof each finger onto the tip of your thumb inturn'.The examiner then squeezes across the

Figure 7 No tenderness ofmetacarpophalangealjoints.

Figure 8 Normal internal rotation ofhip inflexion.

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Figure 6 Normalpmoer grip..

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Doherty, Dacre, Dieppe, Snaith

these regions, the tick is replaced by a cross andfurther note of the abnormality made. Forexample in a patient with knee osteoarthritis:

G x AALS

xV

antalgic gaitR knee-varus

I flexioncrepituseffusion

Figure 9 No tendemess ofmetatarsop halangeal joints.

second to fifth metacarpal (fig 7) to elicit tender-ness due to metacarpophalangeal joint synovitis(which may not be evidenced by swelling).

(4) Legs. With the patient still standing,inspect from in front for normal lower limbappearances. The screen is then completed byinspection or examination of the patient lyingon a couch. In this position: (a) flex each hipand knee while holding the knee (confirmingfull knee flexion, no knee crepitus); (b) passivelyinternally rotate each hip in flexion (no pain,restriction; fig 8); (c) press on each patella forpatellofemoral tenderness and palpate for aneffusion; (d) squeeze across the metatarsals fortenderness due to metatarsophalangeal disease(fig 9); and (e) inspect both soles for callosities,reflecting abnormal weight bearing (spine, hip,knee, or foot abnormality).

SUGGESTED METHOD OF RECORDING FINDINGSIf the three screening questions are negativethen

pain 0dress Vwalk V

is briefly recorded in the notes. If positive,further questions and responses will be required.

If the patient's gait (G) is normal and there isno abnormal appearance (A-that is, no swel-ling, deformity, wasting, abnormal attitude, orskin change) or movement (M) of their arms(A), legs (L), or spine (S), the followingtemplate may usefully be written in the noteswith respect to examination:

GALS

V A MV V

V V

V V

If abnormality is detected at one or more of

DiscussionThe locomotor system is complex and anextensive history and examination is time con-suming. A screening procedure to detectproblems in defined areas is therefore desir-able.8 If the screen is positive then targetedregional examination is undertaken to define theproblem. Such a screen is therefore an intro-duction, not a substitution, for the acquisitionof more detailed locomotor examination skills.The rationale for the selection of screening

questions and examination tasks is twofold.Firstly, the principal focus is on symptoms andactivities of direct relevance to the patient,providing an insight into the patient's cap-abilities to undertake important daily activities.Secondly, only sufficient history and examina-tion are included to detect significant musculo-skeletal abnormality. Pain, for example, is theprincipal symptom of locomotor disease and oneof obvious impact and relevance to the patient.Dressing is an important daily event but also asensitive functional test of most upper andlower limb joints, requiring in addition reason-able neuromuscular power and co-ordination.Walking is another important functional activitythat may be affected by lower limb joint,lumbar spine, neurological, or muscularabnormality: walking up and down stairs is amore stringent test of lower limb (and cardio-vascular and respiratory) function than walkingon the flat, and therefore a more appropriatescreen. Similarly, with respect to examinationof selected movements, 'hands behind head'screens the patients ability to get their hands totheir face, head, and mouth (relevant towashing, eating, etc) but is also a sensitive testof glenohumeral abnormality (abduction andexternal rotation being the first affected move-ments at this joint). By inference, if thismovement is normal the patient will also be ableto get their hands round behind their back (forexample, to wipe their bottom). Observation ofpower grip and fine precision pinch is a quick,sensitive screen of hand function and dexterityrelevant to many daily activities; both areaffected early by local joint or periarticulardisease.A further relevant aspect of the screen is that

most rheumatological abnormality is detectedby inspection at rest and during movement. Inother words, if a joint looks normal, assumes anormal resting position, and moves smoothlythrough its range of movement without facialevidence of discomfort, then it probably is

MV V

xV

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The 'GALS' locomotor screen 116

normal. Palpation in the screen is restricted tojoints commonly targeted by inflammatoryarthropathy (metacarpophalangeal joints, meta-tarsophalangeal joints, knees), and briefly toscreen for paim associated with fibromyalgiasyndrome which is easily overlooked.3 If thescreening history or examination is positivethen more detailed questioning and regionalexamination will be warranted.The order of examination is unimportant and

the summary is intended as a guide rather thanas doctrine. Each individual will develop theirown sequence, combining certain elements withtests of other systems. For ease of descriptionobservations relating to gait, spine, arms, andlegs are described separately, though in practicethere is considerable overlap during certainmanoeuvres (for example, observation ofthe standing patient from in front and frombehind). With respect to recording in the notes,however, 'GALS' is an easy, concise system toemploy. It can stand on its own as a combinedobjective record of functional disability andmusculoskeletal system examination, or readilybe incorporated within the neurological ('CNS')clerking with which there is particular overlap.Although currently practised systems reviewsmay include questions relating to activities ofdaily living, objective observation of functionalcapabilities (for example, walking, ability togrip, ability to get hands to mouth) are oftenomitted, though often relevant, particularly inolder patients. In presenting the 'GALS' screenwe are not necessarily supporting the traditional'systems review' clerking.9 If more focusedquestioning and examination relating to thepresenting problem is undertaken the 'GALS'procedure will still be useful in selective situa-tions as a rapid test of functional performanceand to screen out regional locomotor abnor-malities that merit closer scrutiny.

This brief 'screen' is sensitive to importantlocomotor abnormality and functional impair-ment8 and forms a useful introduction to a

large, potentially complex system. The screen isquickly learnt by undergraduates8 and post-graduates,'0 and its regular application canimprove junior doctor's recognition of patientdisability and locomotor disease. 0 Its inclusionin the undergraduate programme could enhancestudent awareness and clinical skills relating tothe locomotor system and to disability ingeneral. Consideration of such a screen isparticularly germane at a time when the under-graduate curriculum is under review with majoremphasis on clinical skills and attitudes. Forthese reasons the 'GALS' screen has beenendorsed by the education committees of theArthritis and Rheumatism Council and theBritish Society for Rheumatology (autumn1991). The screen might also be useful to alliedhealth professionals, particularly those workingwith elderly patients.

We are grateful to the Education Committees of the Arthritis andRheumatism Council and the British Society for Rheumatologyfor considering and endorsing this procedure.

1 Arthritis and Rheumatism Council field unit. Digest of dataon the rheumatic diseases I. Ann Rheum Dis 1974; 33:93-105.

2 Wright V. The epidemiology of disability. JR Coll PhysiciansLond 1982; 16: 178-83.

3 Doherty M, Abawi J, Pattrick M. Audit of medical inpatientexanination: a cry from the joint.J R Coll Physicians Lond1990; 24: 115-8.

4 Spencer M A, Dixon A S. Rheumatological features ofpatients admitted as emergencies to acute general medicalwards. Rheumatol Rehabil 1981; 20: 71-3.

5 Ahern M J, Schultz D, Soden M, Clark M. The musculo-skeletal examination: a neglected clinical skill. Aust N ZJMed 1991; 21: 303-6.

6 Robine J M, Ritchie K. Healthy life expectancy: evaluation ofglobal indicator of change in population health. BMJ 1991;302: 457-60.

7 Report of the GMC working party to review the 1980recommendations [consultation paper]. London: GeneralMedical Council, 1991.

8 Jones A, Ledingham J, Regan M, Doherty M. A proposedminimal rheumatological screening history and examination:the joint answers back. J7 R Coll Physicians Lond 1991; 25:111-5.

9 Hoffbrand B I. Away with the systems review: a plea forparsimony. BMJ 1989; 298: 817-9.

10 Jones A, Regan M, Ledingham J, Doherty M. Can we alterdoctors' awareness of locomotor problems? BrJ Rheumatol1991; 30 (suppl 2): 1.

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