Poor sensitivity of musculoskeletal history in children
Newcastle upon Tyne NHS Foundation Trust, Rheumatology, Newcastle upon Tyne NE7 7DN, UK. Archives of Disease in Childhood
(Impact Factor: 2.9).
04/2012; 97(7):644-6. DOI: 10.1136/archdischild-2011-300853
To demonstrate the sensitivity of musculoskeletal (MSK) history taking.
Prospective study: consecutive children attending outpatient clinics.
Paediatric rheumatology clinic (n=45; girls n=28; median age 12 years, range 3-18), acute general paediatric assessment unit (n=50; girls n=21; median age 8 years, range 3-16).
Pro forma recording abnormal joint involvement from history taking and then following MSK examination completed by clinicians.
Sensitivity of MSK history taking compared with clinical examination.
Paediatric rheumatology clinic: 135 abnormal joints identified in 34 children; 53/135 (39%) by history alone, 82/135 (61%) detected on examination resulting in MSK history sensitivity 53%, specificity 98%. Acute paediatric unit: 29 abnormal joints identified in 17 children; 18/29 identified on history (sensitivity 62%).
MSK history taking failed to identify a large number of abnormal joints which were detected on physical examination, emphasising the need for all joints to be examined as part of a screening examination as a minimum.
Available from: Ethan Sen
- "The pGALS examination was originally developed in the context of paediatric rheumatology clinics but has been shown to be useful to detect pathology other than rheumatic disease in acute general paediatric assessment [14,15]. Furthermore pGALS has been shown to detect joint abnormalities that may not be apparent from history alone . Our study suggests that pGALS may be a useful adjunct to facilitate earlier recognition of MPS and this is of clinical importance as a large number of children in this study had attenuated MPS type 1. "
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Children with mucopolysaccharidoses (MPS) often have musculoskeletal (MSK) abnormalities. Paediatric Gait, Arms, Legs, and Spine (pGALS), is a simple MSK assessment validated in school-age children to detect abnormal joints. We aimed to identify MSK abnormalities in children with MPS performing pGALS.
Videos of children with a spectrum of MPS performing pGALS were analysed. A piloted proforma to record abnormalities for each pGALS manoeuvre observed in the videos (scored as normal/abnormal/not assessable) was used by three observers blinded to MPS subtype. Videos were scored independently and rescored for intra- and inter-observer consistency. Data were pooled and analysed.
Eighteen videos of children [12 boys, 6 girls, median age 11 years (4–19)] with MPS (13 type I [5 Hurler, 8 attenuated type I]; 4 type II; 1 mannosidosis) were assessed. The most common abnormalities detected using pGALS were restrictions of the shoulder, elbow, wrist, jaw (>75% cases), and fingers (2/3 cases). Mean intra-observer Κ 0.74 (range 0.65–0.88) and inter-observer Κ 0.62 (range 0.51–0.77). Hip manoeuvres were not clearly demonstrated in the videos.
In this observational study, pGALS identifies MSK abnormalities in children with MPS. Restricted joint movement (especially upper limb) was a consistent finding. Future work includes pGALS assessment of the hip and testing pGALS in further children with attenuated MPS type I. The use of pGALS and awareness of patterns of joint involvement may be a useful adjunct to facilitate earlier recognition of these rare conditions and ultimately access to specialist care.
Available from: PubMed Central
- "‘my child is limping’) and young children may have difficulty in localising or describing pain in terms that adults may understand. In children, it is not uncommon to find joint involvement that has not been mentioned as part of the presenting complaint ; it is essential to perform all components of pGALS, followed up with more detailed physical examination as appropriate. "
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ABSTRACT: We describe pGALS (paediatric Gait, Arms, Legs and Spine) - a simple quick musculoskeletal assessment to distinguish abnormal from normal joints in children and young people. The use of pGALS is aimed at the non-specialist in paediatric musculoskeletal medicine as a basic clinical skill to be used in conjunction with essential knowledge about red flags, normal development and awareness of patterns of musculoskeletal pathologies. pGALS has been validated in school-aged children and also in the context of acute general paediatrics to detect abnormal joints. We propose that pGALS is an important part of basic clinical skills to be acquired by all doctors who may be involved in the care of children. The learning of pGALS along with basic knowledge is a useful way to increase awareness of joint disease, facilitate early recognition of joint problems and prompt referral to specialist teams to optimise clinical outcomes. We have compiled this article as a resource that can be used by the paediatric rheumatology community to facilitate teaching.
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