Screening for Signs and Symptoms of Rheumatoid Arthritis
Significance & Innovations
• This is the first time the Gait, Arms, Legs, and Spine
(GALS) examination has been introduced to family
physicians to determine its utility in screening for signs and
symptoms of rheumatoid arthritis.
• This is the first study to introduce the use of the GALS
screening examination to nurse practitioners.
• Both family physicians and nurse practitioners who were
taught the GALS examination using an instructional DVD
and a short workshop appeared able to employ the tool to
screen for signs and symptoms of rheumatoid arthritis.
contributing factors for low levels of competency of MSK
medicine, a lack of confidence in assessing the MSK system,
and physical examinations not being routinely performed by
physicians (4–8). It is not surprising that there is a significant
underdetection or underdiagnosis of MSK conditions in
primary care (9,10). More specifically, recognition of signs and
symptoms of rheumatoid arthritis (RA), which has a prevalence
of 1% in the Western world, remains a major challenge since
RA symptoms can be similar to many other potential causes of
pain and joint inflammation (11–13). Approximately 80% of
people with RA describe a slow, progressive onset of symptoms
over weeks to months typically beginning with pain, swelling,
and/or stiffness in multiple joints (13,14). The joints most
commonly affected are those with the highest ratio of synovium
to articular cartilage, such as the small joints of the hand
(metacarpophalangeal joint, proximal interpha- langeal joint)
and wrist (14). There is ample evidence suggesting that early
identification and treatment of RA attenuate the symptoms
and disease progression (15,16). Given that rheumatologists
are typically the specialists who diagnose RA (16), early referral
when potential cases are suspected is critical (12), since delayed
referrals have been identified as a rate-limiting step in the delay
of treatment (15,17).
Table 1. Training and clinical practice experience of
participating health care professionals*
Clinical
practice,
years
Previous
additional
MSK
training
Proportion
of practice
with MSK
diagnosis, %
Group A
Family physician
Nurse practitioner
Nurse practitioner
25
7
25
No
No
No
15
5
25
Group B
Family physician
Family physician
Nurse practitioner
35
16
12
Yes
No
No
50
15
15
* MSK musculoskeletal.
36
Pedorthic Footcare Association www.pedorthics.org
The lack of adequate MSK training in medical school coupled
with the fact that most people with arthritis address their health
needs in primary care is concerning. Approximately 2 decades
ago, Doherty et al created the Gait, Arms, Legs, and Spine
(GALS) locomotor screening examination to address the high
prevalence and underdetection of MSK disorders (8). This
3-minute examination consists of 3 parts: 3 questions addressing
pain, difficulty dressing, and difficulty with stairs; assessment
of gait; and a physical examination of the appearance and
movement of the arms, legs, and spine. In 2006, Dequeker et
al noted that the GALS examination is a method for “screening
the MSK system quickly with emphasis on rapid identification
of significant abnormalities and any physical ability” (18). We
have previously shown that the GALS examination can be
used by family physicians to detect MSK abnormalities in the
general population (19). Although it is not designed specifically
to screen for early inflammatory arthritis, we have shown that
physiotherapists and physiotherapy students can use the GALS
examination to screen for signs and symptoms of RA (20). The
use of such a screening examination may enable other health
care professionals to thoroughly, accurately, and efficiently
identify the signs and symptoms consistent with inflammatory
arthritis in the primary care setting to ensure appropriate and
timely referral to rheumatologists. The primary objective of
this study was to evaluate the sensitivity and specificity of the
GALS examination when used by family physicians and nurse
practitioners to screen for signs and symptoms of RA.
Patients and methods
Health care professionals. The participating health care
professionals included 2 rheumatologists, 3 family physicians,
and 3 nurse practitioners. Both rheumatologists were
practicing physicians with previous clinical experience using
the GALS examination. The family physicians and nurse
practitioners were active health care professionals at a large
urban multidisciplinary health center affiliated with McMaster
University (Table 1). All health care professionals participated
in a hands-on training workshop and a study day.
One month prior to the training workshop, all health care
professionals were given an instructional GALS DVD,
endorsed by the Canadian Rheumatology Association, which
systematically explains and demonstrates the screening
examination. At the training workshop, which was led by the
creator of the DVD, the health care professionals viewed the
DVD and discussed their issues and concerns. The workshop
also included a short presentation on the signs and symptoms
of various MSK abnormalities (e.g., osteoarthritis, inflammatory
arthritis), a demonstration by an author (AC) of the GALS
examination on a volunteer, and a discussion of how to record
abnormalities to ensure that all health care professionals
would document observations consistently. The health care
professionals were divided into groups (1 rheumatologist, 1
family physician, and 1 nurse practitioner per group), and each
was given the opportunity to practice the GALS examination