Cross-cultural validation of the paediatric Gait, Arms, Legs, Spine (pGALS) tool for the screening of musculoskeletal disorders in Mexican children

The development of pGALSplus: evaluating feasibility and acceptability of an assessment to facilitate the identification and triage of children with musculoskeletal presentations

Objectives

Healthcare professionals (HCPs) need to identify potentially serious musculoskeletal (MSK) presentations in children and refer them to specialists appropriately. Our aim was to develop 'pGALSplus' (paediatric gait, arms, legs and spine plus) to support clinical assessment, aid decision-making and assess feasibility and acceptability in exemplar MSK pathologies.

Methods

We used a three-phase mixed methods approach: phase 1, preliminary stakeholder engagement and scoping review to propose pGALSplus; phase 2, iterative development of pGALSplus involving an expert working group; and phase 3, testing the feasibility of pGALSplus in exemplar MSK conditions [JIA, mucopolysaccharidoses (MPS), muscular dystrophy (MD), developmental coordination disorder (DCD) and healthy controls (HCs)]. The final pGALSplus was derived from analysis of phase 3 data and feedback from HCPs, families and expert consensus input from an international e-survey (n = 22) and virtual event (n = 13).

Results

Feasibility was tested in 45 children (JIA, n = 10; MPS, n = 6; MD, n = 9; DCD, n = 10; HCs, n = 10). Overall the assessment was achievable in the target age range (2-10 years) and quick to complete [median 12 min (range 8-20)], with high acceptability from families. Expert feedback deemed pGALSplus to be very useful and of particular use to non-specialists in MSK paediatrics. The final pGALSplus comprises 26 clinical observations/skills with a colour-coding approach to aid decision-making and identification of more serious MSK presentations and additional resources to support its use in clinical practice.

Conclusions

pGALSplus is a novel evidence- and consensus-based assessment building on pGALS, with high acceptability and feasibility. As community-based MSK assessment in children becomes more established, we propose that pGALSplus will facilitate and inform decision-making to promote access to specialist care.

Implementation and assessment of a structured curriculum for a 4-week pediatric rheumatology rotation for pediatric residents

BACKGROUND

General pediatricians often initially address children's musculoskeletal (MSK) issues and play a crucial role in triaging and managing patients' rheumatologic conditions. This study assessed the effectiveness of a structured curriculum in enhancing pediatric residents' knowledge, MSK examination skills, and confidence during a 4-week pediatric rheumatology rotation.

METHODS

Pediatric residents in their either second or third year who participated in the 4-week rheumatology rotation once across three academic years (July 2020-June 2023) were enrolled. Residents' knowledge, MSK examination skills, and confidence were assessed at pre- and post-rotation by using 25 multiple-choice questions, the Thai pediatric Gait Arms Legs Spine examination, and a questionnaire, respectively. The curriculum comprised instruction on MSK examinations, interactive lectures, case-based discussion, topic reviews, MSK radiology conference, clinical experience in rheumatology clinic and consultations, with self-guided learning with educational resources.

RESULTS

Fifty-eight pediatric residents (48 females, 10 males) with a mean age of 28.9 ± 0.8 years participated. Significant improvements were noted postrotation. Knowledge scores rose from 63.0 ± 12.2 to 79.7 ± 9.1 (mean difference 16.7 ± 10.3, p < 0.001). Similarly, MSK examination scores increased from 67.5 ± 14.4 to 93.6 ± 8.7 (mean difference 26.1 ± 14.6, p < 0.001). Residents also reported a marked increase in confidence across all evaluated areas, including history taking, MSK examination, arthrocentesis, and diagnosing and treating rheumatologic conditions (p < 0.001).

CONCLUSIONS

The 4-week structured curriculum in the pediatric rheumatology rotation significantly enhanced pediatric residents' knowledge, MSK examination skills, and confidence. These findings support the integration of pediatric rheumatology rotations into pediatric residency training programs.

Reliability of the tunisian pediatric gait, arms, legs, and spine: toward a valid screening tool for tunisian children with musculoskeletal conditions

BACKGROUND

Pediatric musculoskeletal disorders account for 10% of first-line consultations in Tunisia. Referral delay and deficiencies in musculoskeletal screening raise a challenge to the early diagnosis and management of rheumatic conditions in children. The pGALS (Pediatric Gait Arms Legs Spine) was developed and translated into many languages to overcome these deficiencies. Our study aimed to adapt and validate pGALS to the Tunisian dialect for school-age children.

METHODS

Using the Delphi method, we carried out a cross-cultural adaptation of the pGALS to the Tunisian dialect. This consensual version was validated in a cross-sectional study, in two pediatric centers.

RESULTS

Ninety-two patients were enrolled, 43 females (46.7%) and 49 males (53.3%), mean age was 9.4 ± 2.6 years. The mean test duration was 3.4 ± 2.3 min, and the acceptability and comprehension of the test were good. Six patients had a musculoskeletal complaint, 19 had positive pGALS, and 14 were diagnosed with musculoskeletal disease. The internal consistency score (Cronbach's α) was 0.852. The sensitivity of the test was 92.8%, the specificity was 92.3%, the positive likelihood ratio was 2.16, and the negative likelihood ratio was 0.01.

CONCLUSION

The pGALS test adapted to the Tunisian dialect is a relevant, quick, and valid tool for screening musculoskeletal abnormalities in school-age children.

Screening utility and acceptability of the Kiswahili-pGALS (paediatric Gait, Arms, Legs, Spine) at a tertiary referral hospital in Kenya-A diagnostic accuracy study

BACKGROUND

Paediatric rheumatic diseases cause considerable disease burden to children and their families (Moorthy LN, Peterson MGE, Hassett AL, et al, Pediatric Rheumatology 8:20, 2010). Delayed diagnosis is a significant determinant of severity and mortality attributed to these conditions (Foster HE, Eltringham MS, Kay LJ, et al, Arthritis Care Res 57(6):921-7, 2007). pGALS is a simple clinical tool used to assess joints and identify musculoskeletal (MSK) conditions in school-going children to enable early referral to paediatric rheumatologists.

OBJECTIVES

This study aimed to translate and determine the diagnostic accuracy and acceptability of a Kiswahili version of the pGALS screening tool among Kiswahili-speaking children.

METHODS

The pGALS screening questions were translated into Kiswahili according to the World Health Organisation (WHO) standard for translation of a tool. The validity of the Kiswahili PGALS was ascertained and acceptability rated (time taken, discomfort). Using systematic random sampling, we enrolled children aged 5-16 years presenting at the Aga Khan University Hospital's (AKUH) emergency department in Kenya, who spoke Kiswahili and had symptoms suggestive of an MSK condition. Those already under follow-up at the paediatric rheumatology service at AKUH were excluded. MSK assessment was undertaken by two resident doctors using the newly translated Kiswahili-pGALS and findings were compared with a paediatric rheumatologist examination ('gold-standard') on the same day, and who was blinded to the pGALS findings. We analysed demographic details of the participants and determined the diagnostic accuracy by cross tabulation of the index test results by the results of the reference standard.

RESULTS

One hundred children with a median age of nine years (IQR 7-11) were enrolled. The sensitivity and specificity of the Kiswahili-pGALS screening tool were 76.8% (95%CI 63.6-87.0%) and 40.0% (95%CI 23.9-57.9%), respectively. The diagnostic accuracy was 62.7% (95%CI 52.1-72.1%), area under the ROC was 0.58 (95%CI 0.48-0.68). The median time to perform the Kiswahili-pGALS was 5.0 min (IQR 3.5-6.0 min). Ninety percent of the guardians found the practice of Kiswahili-pGALS to have none, or only some discomfort.

CONCLUSIONS

The Kiswahili-pGALS's was found to be a useful screening tool to aid early identification of MSK conditions in Kiswahili-speaking settings. However, the low specificity implies that relatively large number of false positives would still need to be reviewed by a rheumatologist if the tool is adapted for use.

Acceptability and Practicality of a Quick Musculoskeletal Examination into Sports Medicine Pre-Participation Evaluation

BACKGROUND

Child musculoskeletal (MSK) diseases are common and, even if often benign, sometimes can lead to significant impairment in the future health of children. Italian pre-participation evaluation (PPE), performed by a sports medicine physician, allows for the screening of a wide range of children every year. Therefore, this study aims to evaluate the feasibility and the acceptability of pGALS (pediatric Gait, Arms, Legs and Spine) screening, a simple pediatric MSK screening examination, when performed as part of a routine PPE.

METHODS

Consecutive school-aged children attending a sports medicine screening program were assessed with the addition of pGALS to the routine clinical examination. Practicability (time taken) and patient acceptability (discomfort caused) were recorded.

RESULTS

654 children (326 male, mean age 8.9 years) were evaluated through pGALS. The average time taken was 4.26 min (range 1.9-7.3 min). Acceptability of pGALS was deemed high: time taken was "adequate" (97% of parents) and caused little or no discomfort (94% of children). Abnormal MSK findings were common.

CONCLUSIONS

pGALS is a practical and acceptable tool to perform in sports medicine PPE, even if performed by a non-expert in MSK medicine. Although common, abnormal MSK findings need to be interpreted in the global clinical context and assessment.

The Thai Translation of the Pediatric Gait, Arms, Legs, Spine Tool is Useful for Pediatric Residents in Detecting Musculoskeletal Abnormalities in Children

BACKGROUND

The pediatric Gait, Arms, Legs, Spine (pGALS) tool is used to screen musculoskeletal (MSK) abnormalities in children. This study aimed to evaluate the application of the Thai translation of pGALS tool in outpatient clinical settings.

METHODS

This cross-sectional study included patients aged 4 to 16 years, recruited from the Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. Pediatric residents performed the Thai pGALS tool, and a pediatric rheumatologist performed the MSK examination.

RESULTS

One hundred Thai patients were enrolled with a mean age of 9.87 ± 3.01 years. Forty percent of patients had MSK complaints. The median duration of the assessment was 3.96 minutes (interquartile range, 2.07-5.84 minutes). Abnormal pGALS examination by pediatric residents was found in 43 patients, all of which had abnormal MSK examination by a pediatric rheumatologist. Seventeen patients did not have abnormal pGALS examination by pediatric residents, but had abnormal MSK examination confirmed by a pediatric rheumatologist; these patients all had noninflammatory/mechanical conditions. The 3 screening questions of the Thai pGALS tool had a sensitivity and specificity of 71.67% and 77.5%, respectively; the examination had a sensitivity and specificity of 74.14% and 100%, respectively. For acceptability, 99% of parents and 89% of patients reported no discomfort. For practicality, 99% of parents and 89% of patients reported the highest level of practicality.

CONCLUSIONS

The Thai pGALS tool is useful for MSK screening in children performed by pediatric residents in outpatient clinical settings. Adding maneuvers to the pGALS examination to detect more common noninflammatory MSK conditions would be beneficial.

A mixed methods evaluation of the Paediatric Musculoskeletal Matters (PMM) online portfolio

BACKGROUND

The PMM Portfolio is comprised of the Paediatric Musculoskeletal Matters (PMM) website, the paediatric Gait, Arms, Legs and Spine (pGALS) app and e-learning modules (ELM). The target audiences are non-specialists in paediatric musculoskeletal medicine. Our study aimed to evaluate impact on learning and clinical practice.

METHODS

Mixed methods (analytics, online survey, interviews) were used with PMM and ELM registered users and purposive sampling of users using international contacts within paediatrics and paediatric rheumatology. Data was analysed using descriptive statistics and qualitative techniques. A Paired T-Test compared self-rated confidence before and after use of the PMM Portfolio.

RESULTS

There has been wide reach for all the e-resources; PMM website (662,827 hits, 262,476 users, 214 countries, data 31st July 2020); pGALS app (12,670 downloads, 70 countries, data 31st July 2020); ELM (150 users, 30 countries, data 30th May 2019). There were 164 responses (students, trainees and health care professionals) to the survey from 25 countries. Most responders deemed the PMM Portfolio useful / very useful for their learning with significantly increased self-rated confidence in their clinical examination and reasoning skills following access to the PMM website, p = < 0.01, pGALS app, p = < 0.01 and ELM, p = < 0.01. The most popular PMM website pages related to clinical assessment techniques (especially pGALS). There was high uptake of the pGALS app and pGALS ELM especially from trainees and allied health professionals. Many clinicians reported the PMM Portfolio to be useful when used to teach others. User feedback reported that easy navigation, open access, clinical images and cases were the most valued features. User feedback highlighted need to increase awareness of the e-resources through training programmes.

CONCLUSIONS

The PMM Portfolio was developed to aid learning for clinicians who are not specialists in paediatric MSK medicine. Our evaluation demonstrates wide international reach and positive feedback on learning. The PMM Portfolio is a highly useful e-resource for paediatric rheumatologists in their teaching of others to raise awareness, facilitate early diagnosis and referral of children with suspected disease. The wide user engagement informed future PMM Portfolio development and the mixed method of evaluation is transferable to other e-resources.

Cross-cultural adaptation and validation of the Gait, Arms, Legs, Spine locomotor screening test for detecting musculoskeletal disorders in Mexican adults

AIM

Developed in the United Kingdom, the Gait, Arms, Legs and Spine (GALS) sensitive screening test enables doctors to examine joints and positions at rest and during motion. Therefore, patients with an early diagnosis for musculoskeletal (MSK) disorders, can enjoy a better quality of life than those diagnosed at a later stage. The objective was to adapt and validate a Mexican-Spanish version of the GALS measurement instrument for MSK disorders in Mexican adults.

MATERIALS AND METHODS

We conducted a cross-sectional diagnostic test study among 18- 60-year-old adults in a hospital in the city of Guadalajara, Mexico. Based on international guidelines, we divided our work into 2 phases: first, we developed and adapted a cross-cultural, Mexican-Spanish version of the GALS; second, we validated the instrument as a diagnostic test among Mexican patients.

RESULTS

The adapted version yielded the following scores as a measurement instrument: 0.92 under Cronbach's alpha, 0.695 (95% CI, 0.592-0.797) in the kappa index, 98.2% (95% CI, 90.3%-100%) in sensitivity, 80.6% (95% CI, 72.9%-86.9%) in specificity, and 5.06 for positive likelihood ratio. It also covered an area of 0.89 (95% CI, 0.85-0.93) under the receiver operating characteristic curve.

CONCLUSIONS

The GALS diagnostic test proved valid for detecting MSK disorders among Mexican adults. It can be used by specialized physicians, family doctors, general practitioners and even physicians in training.

Acceptability and Practicality of the Turkish Translation of Pediatric Gait Arm Legs and Spine in Turkish Children

BACKGROUND

The pediatric Gait, Arms, Leg, and Spine (pGALS) is a practical questionnaire for musculoskeletal (MSK) system evaluation in school-age children.

OBJECTIVE

The aim of this study was to evaluate the acceptability/practicality of pGALS Turkish translation in Turkey (cross-sectional study).

METHODS

The Turkish translation of pGALS was administered to children (4-18 years) who attended to the Pediatric Emergency Department of Hacettepe University, Ankara, Turkey, and the outpatient clinic of the Physical Therapy and Rehabilitation Department of Marmara University, Istanbul, Turkey, during 1 month in 2016. The demographics, complaints, final diagnoses, and pGALS parameters were noted. The acceptability of pGALS was evaluated using visual analog scale.

RESULTS

Ninety-five patients (median age, 108 months; male/female, 1.1) were enrolled. Sixteen patients (16.8%) had MSK diagnosis, whereas 79 (83.2%) had non-MSK diagnoses. Musculoskeletal diagnoses were as follows: scoliosis (n = 4), metatarsus adductus (n = 4), soft tissue injury (n = 3), lumber disk herniation (n = 2), muscle spasm (n = 1), Achilles tendinitis (n = 1), and tibia torsion (n = 1). The sensitivity was 64.7%, and specificity was 89.7% for positive response to 1 or more pGALS screening questions to detect abnormal pGALS. The most sensitive question was pain question. The most common abnormal pGALS components were spine and posture. The sensitivity and specificity of pGALS for detecting MSK diagnosis were 93.7% and 97.4%, respectively. The median duration of pGALS examination was 4 minutes. Most patients/parents found the duration acceptable (94.7%/97.9%, respectively) and reported that pGALS caused little/no discomfort (97.9%/96.8%, respectively).

CONCLUSION

This is the first study showing the Turkish version of pGALS as a valid, acceptable, and practical screening test in Turkey.