pGALSplus: Informed decision-making for children with musculoskeletal presentations

Kindly written by Vicky Mercer, Paediatric Physiotherapist and Lecturer in Physiotherapy

A new clinical assessment, called pGALSplus (paediatric Gait, Arms, Legs and Spine), aims to support healthcare professionals to identify children who may require onward referral to specialist services and ultimately facilitate earlier recognition of more serious musculoskeletal (MSK) conditions.

Whilst MSK presentations in children and young people are common and mostly self-limiting, there are a minority with more serious underlying conditions, including inflammatory joint disease or neuromuscular disease. Often children will present to healthcare professionals in primary or community care, whose experiences in the field of MSK paediatrics may be variable. Referrals to specialist services can be complex and delay in access to care for children with serious MSK conditions is well reported. Timely referral to the appropriate specialist can be critical; influencing early access to treatments and interventions, and ultimately improving clinical outcomes.

pGALS is a simple, quick MSK assessment already validated and well established in clinical practice. Whilst the pGALS assessment has been shown to detect joint and functional problems within the context of rheumatology, orthopaedics and neuromuscular medicine, alone it is unlikely to be specific enough to be indicative of any particular condition.

The findings need to be interpreted in the clinical context and this will invariably entail further enquiry and physical or functional assessment. We aimed to widen the scope of pGALS to develop an assessment (called pGALSplus) to further facilitate the identification and triage of children with serious MSK presentations. pGALSplus was created iteratively with stakeholder engagement and expert consensus, resulting in pre-school (aged 2-4 years) and school-age (aged 5-10 years) versions to reflect developmental norms.

pGALSplus assumes a similar ‘top-toe’ approach to pGALS, and includes further physical examination (testing lower limb reflexes and checking for leg length discrepancy) and testing of functional skills (standing from the floor, hopping and jumping). pGALSplus was then piloted in groups of children aged between 2 and 10 years, with exemplar MSK presentations (children with Juvenile Idiopathic Arthritis, Muscular Dystrophy, Mucopolysaccharidoses and Developmental Co-ordination Disorder) as well as a healthy control group, to test feasibility and acceptability.

pGALSplus was found to be quick to complete (average time taken 12 minutes) with high satisfaction from families. Expert feedback deemed pGALSplus likely to be very useful particularly to non-specialists in MSK paediatrics both in the UK and also in the wider context.

The pGALSplus assessment and accompanying resources, which include assessment proformas (editable/standard PDFs), ‘Top Tips’ and basic instructions, and a visual demonstration animation are freely available via the Paediatric Musculoskeletal Matters website.

This investigator-sponsored study funded by Sanofi has been submitted for peer review and publication. Work was led by the research team based at Newcastle University with collaborators from Newcastle upon Tyne, South Tyneside and Sunderland and Manchester University Hospitals.

We are grateful to all the healthcare professionals, patients and families who participated in this study, and co-authors Dr Nicola Smith, Dr Sharmila Jandial, Emerita Professor Helen Foster, Professor Michela Guglieri, Dr Simon Jones and Professor Jeremy Parr, and to Dr Gabriel Okugbeni, Professor Tim Rapley and Mrs Pauline Hensman for acting as collaborators.

For further information please email Vicky Mercer, Paediatric Physiotherapist and Lecturer in Physiotherapy.