workshop gals

OSCE-Aid Revision Workshops: GALS

2015 www.osce-aid.co.uk

GALS Screen

Overview: The GALS screen is derived as a brief screening examination (taking less than 3 minutes) for use in routine clinical assessment. This has been shown to be highly sensitive in detecting significant abnormalities of the musculoskeletal system. It involves inspecting carefully for joint swelling and abnormal posture, as well as assessing the joints for normal movement. GALS stands for Gait Arms - Legs Spine. Some may find it easier to conduct the GALS screen as gait spine arms legs; so that you can get patient to walk, stand then lie down in a smoother and more comfortable manner. Format of the exercise:

5 minutes warm-up o Introduce self. o Discuss GALs: Each student suggests an item on the GALS screen in a

logical and sensible order in turn. o Tutor asks whether students think GALS is easy or difficult exam to perform

and why. o Stress its importance as a screening tool and its common place in clinical and

also exam settings. o Stress the importance of conducting GALS in succinct manner as student will

be required to conduct an additional joint exam in seven minutes

10 minutes tutor demonstration o Go through GALS with a volunteer, provide tips along the way e.g. the spiel

for each inspection and test, significance of certain abnormalities. Encourage questions.

10 minutes of practicing on each other

5 minutes round up for questions key points to take home Practice lots, also learn hand and foot exam back to front

Extra time: o See below for notes on the hand examination and picture round



Ideal GALS screen format

The three screening questions before you start

1. Do you have any pain or stiffness in your muscles, joints or back? 2. Can you walk up and down the stairs without any difficulty? 3. Can you dress yourself completely without any difficulty?

And of course ask about pain and comfort during the examination.

Inspection

With the patient standing in the anatomical position, observe from behind, from the side, and from in front for:

o bulk and symmetry of the shoulder, gluteal, quadriceps and calf muscles o limb alignment o alignment of the spine o equal level of the iliac crests o ability to fully extend the elbows and knees (carrying angle) o popliteal swelling o abnormalities in the feet such as an excessively high or low arch profile,

clawing/retraction of the toes and/or presence of hallux valgus



Gait

Ask the patient to walk a few steps, turn and walk back. Observe the patients gait for symmetry, smoothness and the ability to turn quickly.

You should also note and comment on use of a walking aid, speed, stride length or arm swing

Spine

With the patient standing, inspect the spine from behind for evidence of scoliosis, and from the side for abnormal lordosis or kyphosis.

Ask the patient to tilt their head to each side, bringing the ear towards the shoulder. Assess lateral flexion of the neck (this is sensitive in the detection of early neck problems - e.g. in Rheumatoid arthritis).

Ask the patient to bend to touch their toes. This movement is important functionally (for dressing) but can be achieved relying on good hip flexion, so it is important to palpate for normal movement of the vertebrae. Assess lumbar spine flexion by placing two or three fingers on the lumbar vertebrae. Your fingers should move apart on flexion and back together on extension (see Figure 8). If not - think Ankylosing Spondylitis!

Arms

Ask the patient to put their hands behind their head and push their elbows back. Assess shoulder abduction and external rotation, and elbow flexion (these are often the first movements to be affected by shoulder problems).

With the patients hands held out, palms down, fingers outstretched, observe the backs of the hands for joint swelling and deformity.

Ask the patient to turn their hands over. Look at the palms for muscle bulk and for any visual signs of abnormality.

Ask the patient to make a fist. Visually assess power grip, hand and wrist function, and range of movement in the fingers.

Ask the patient to squeeze your fingers. Assess grip strength.

Ask the patient to bring each finger in turn to meet the thumb. Assess fine precision



pinch (this is important functionally).

Gently squeeze across the metacarpophalangeal (MCP) joints to check for tenderness suggesting inflammatory joint disease. (Be sure to watch the patients face for non-verbal signs of discomfort.)

Legs

With the patient lying on the couch, assess full flexion and extension of both knees, feeling for crepitus.

With the hip and knee flexed to 90, holding the knee and ankle to guide the movement, assess internal rotation of each hip in flexion (this is often the first movement affected by hip problems).

Perform a patellar tap to check for a knee effusion. Slide your hand down the thigh, pushing down over the suprapatellar pouch so that any effusion is forced behind the patella. When you reach the upper pole of the patella, keep your hand there and maintain pressure. Use two or three fingers of the other hand to push the patella

down gently (see Figure 7). Does it bounce and tap? This indicates the presence of an effusion.

From the end of the couch, inspect the feet for swelling, deformity, and callosities on the soles.

Squeeze across the metatarsophalangeal (MTP) joints to check for tenderness suggesting inflammatory joint disease. (Be sure to watch the patients face for signs of discomfort.)

Report positive and negative findings of each aspect of GALS (appearance and movement), then offer to examine the relevant joint. Picture and GALS screen courtesy of Arthritis Research UK



Mark scheme

You are a Foundation Year 1 Doctor at the GP surgery. Mrs Green is complaining of some wrist pain recently. Please examine her musculoskeletal system and examine the relevant joint as appropriate Wash hands Introduce self Good morning my name is _______ and I am a junior doctor in the surgery.

Permission & explanation Can I check your name and date of birth? I heard that you have some problems with your hands. Is it okay if I examine your joints and movements today? This will involve me observing your walking then getting you to do a few movement with me.

Expose For this examination please roll up your sleeves (actors would be in shorts usually) please let me know if there is any pain at any point and I will stop.

Three questions Inspect gait Inspect spine

Neck lateral flexion, flexion and extension Assess lumbar spine flexion modified Schobers test Assess shoulder abduction and external rotation, elbow flexion

Inspect arm and hand muscles Fist Precision grip Palpate MCP joints

Inspect legs Assess full flexion & extension of both knees, feels for crepitus Internal and external rotation of hips Patella tap Palpate MTP joints Inspect foot for ulcers or calluses

Conclude examination, thank patient, offer to help re-dress Summarise finding, offer to examine a relevant joint Overall impression satisfied Passed by actor



Extra notes: hand exam + special tests

Examining the hand is a common rheumatoid and orthopaedic examination. Make sure you ensure adequate exposure up to the elbow, and make sure patient is comfortable by putting a pillow beneath the hands. As per any joint exam the principles are LOOK FEEL MOVE + SFS (sensation, function and special tests) LOOK Hands Nails: clubbing, psoriatic changes (pitting, onycholysis) Skin: Palmar erthythema, Dupuytrens contracture, rheumatoid nodules, shiny skin (sclerosis) Muscle: Wasting (especaily in 1st dorsal interossei, thenar and hypothenar eminences) Joints: any swellings - Hebedens nodes (DIP) and Bouchards nodes (PIP), synovitis (bogginess and swelling around joint) or deformities swan neck, Boutonnieres deformity and z-shaped thumb in rheumatoid arthritis Then go on to Wrists for swellings, ganglion and carpal tunnel scars And Elbows for psoriatric plaques, gouty tophi, rheumatoid nodules FEEL Run the back of your hands to feel patients forearm, wrist and hand to feel for difference in temperature There are quite a few things to palpate in the hand/wrist area, starting proximally -

1. Wrists for tenderness 2. Palms for contractures and muscle buik 3. Get patient to their hands over, palpate for anatomical snuffbox (optional) 4. Palpate/move each small joint using a two-hand technique, looking for

tenderness, hotness or limited range of movement MOVE Test range of movements (both actively and passively) by

1. Prayers sign wrist extension 2. Reverse prayers sign wrist flexion 3. Fingers flexion 4. Fingers extension 5. Test thumb abduction by asking patient to point their thumbs to the ceiling and

holding them against resistance of your finger 6. Test opposition by asking patient to make a ring with thumb and the tip of little

fingers and do not let you break it with your ring (assessment of median nerve) SENSATION Test little finger (ulnar nerve), index finger (median nerve) and skin over anatomical snuff box (radial nerve) with your light touch or wisp of cotton if available FUNCTION You can ask patient to write a sentence, pick up/transfer a coin or do a button. If you are short of time in exam settings you can always suggest to the examiner what you would ideally do and move on. SPECIAL TESTS There are endless special tests one could do on the hands. For exam purposes, here are some suggestions of quicker special tests that are easy to do and easy to explain.



Tinels test tap on median nerve (carpel tunnel) to reproduce pain and tingling in the distribution of median nerve Phalens test hold wrists in reverse prayer sign (fully flexed for 1-2minutes) to reproduce pain and tingling in the distribution of median nerve Finkelstein test ask patient to bend thumb down across the palm of their hand, and bend the wrist toward their little finger. If this is painful it suggests patient has de Quervain's tenosynovitis (affecting their thumb tendons)



Picture round Rheumatoid hand

Rheumatoid nodules

Osteoarthritic hand



Nail pitting

Onycholysis

Ankylosing spondylitis resulting in a loss of lumbar lordosis, buttock atrophy, and an exaggerated thoracic kyphosis with a stooped posture

Picture credit: www.studyblue.com / www.pathologyoutlines.com / www.pixgood.com / www.nailsmag.com / www.images.rheumatology.org



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