GALS Screening OSCE Examination

1. Introduction
2. General Inspection
3. Gait
4. Spine
5. Arms
6. Legs
7. Recording Your Findings
8. Completing the Examination
9. Quiz

Wash your hands and don personal protective equipment if appropriate.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient's details taking 3 points of identification usually; full name, date of birth and NHS/hospital number.

Briefly explain the examination and obtain consent. A useful way to explain GALS is to say you would like to watch them walk and then check the joints in their arms, legs and back to make sure everything is moving as it should.

Position the patient standing in their underwear where possible, as adequate exposure is essential for inspecting the spine, joints and muscle bulk. You will need space for the patient to walk a few metres away from you and back.

Before touching the patient, ask the three GALS screening questions, which quickly flag up the presence of musculoskeletal disease and its functional impact:

• "Do you have any pain, stiffness or swelling in your muscles, joints or back?" This screens for symptoms common to almost all joint pathology, such as osteoarthritis, rheumatoid arthritis and the inflammatory spondyloarthropathies. The pattern matters: early-morning stiffness lasting more than 30 minutes points towards an inflammatory cause, whereas pain that worsens with use and eases with rest is more typical of degenerative disease.
• "Can you dress yourself completely without any difficulty?" This screens for restricted joint range of movement and fine motor impairment in the upper limbs, both of which interfere with tasks such as doing up buttons.
• "Can you walk up and down stairs without any problem?" This screens for gross motor function and lower-limb joint disease, since climbing stairs demands good hip, knee and ankle movement together with adequate proximal muscle power.

Always ask whether the patient is currently in any pain before you begin, so you avoid causing distress and can interpret guarding correctly.

Begin with a general inspection of the patient and the surrounding area. Look at the patient as a whole for clues to an underlying rheumatological or neurological condition. Note any obvious asymmetry, muscle wasting, joint swelling or deformity, and observe whether the patient appears comfortable or is holding a limb protectively.

Scan the bedside and the patient's belongings for objects that hint at their functional status, such as walking aids (sticks, frames or crutches), wheelchairs, splints or orthotics, and any analgesia or disease-modifying medication packaging. These items give an immediate impression of how much the patient's mobility and independence are affected, which is exactly what GALS is designed to detect.

Ask the patient to walk a few metres away from you, turn, and walk back, then observe a few cycles. Watching gait is one of the most informative parts of the screen because normal walking requires the hips, knees, ankles and spine to move smoothly and in coordination, so almost any significant lower-limb or spinal problem will alter it.

Assess the gait for symmetry and smoothness, a normal stride length, normal heel strike and toe off, good arm swing, and the ability to turn quickly and steadily. Patients with joint disease often turn slowly and in several small steps because of pain, stiffness or instability.

Several abnormal gait patterns are worth recognising:

• An antalgic gait develops in response to pain. The patient spends as little time as possible bearing weight on the painful leg, shortening the stance phase on that side and producing a limp.
• A Trendelenburg gait is caused by weakness of the hip abductors (gluteus medius and minimus), often due to a superior gluteal nerve lesion, hip joint disease or an L5 radiculopathy. The pelvis drops towards the unsupported (swinging) side during stance because the abductors cannot stabilise it.
• A waddling gait arises from bilateral proximal muscle weakness, classically in the myopathies and muscular dystrophies, giving a broad-based, rolling pattern.
• Reduced or absent arm swing on one side is an early clue to Parkinson's disease, and is typically accompanied by short shuffling steps and difficulty initiating movement.

Also note any obvious leg-length discrepancy or reduced range of movement, both of which commonly accompany chronic joint disease.

With the patient standing, inspect the spine and posture from behind, from the side and from the front, then assess a small number of key movements.

From behind, the spine should appear straight with no lateral curvature. A sideways curvature is termed scoliosis and may be postural or structural. Check that the paraspinal muscles are symmetrical, that the shoulders and gluteal muscle bulk are equal, and that the iliac crests are level, since pelvic tilt can indicate a leg-length discrepancy or hip pathology. Asymmetrical muscle bulk may reflect wasting from disuse or a neurological lesion.

Image - Scoliosis seen on inspection of the spine from behind. The lateral curvature of the spine and the resulting asymmetry are key findings in the spinal component of GALS

Creative commons source by Lucien Monfils [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]

From the side, confirm the normal sagittal curves: a gentle cervical lordosis, a thoracic kyphosis and a lumbar lordosis. An exaggerated thoracic curve (a hyperkyphosis) may result from osteoporotic vertebral wedge fractures in older patients, while a fixed question-mark posture with loss of lumbar lordosis is characteristic of ankylosing spondylitis.

Image - The normal sagittal curves of the vertebral column: cervical lordosis, thoracic kyphosis and lumbar lordosis. Inspecting the spine from the side allows you to spot an exaggerated kyphosis or a lost lumbar lordosis

SimpleMed original image, credit 'SimpleMed original'

To assess lumbar flexion, ask the patient to bend forward and try to touch their toes while you rest two fingers on adjacent lumbar spinous processes. Your fingers should separate as the spine flexes; if they stay together the lumbar spine is moving as a stiff block, which suggests inflammatory back disease such as ankylosing spondylitis. This is a quick bedside version of Schober's test, in which a more formal measurement is made by marking a point over the L5 spinous process and a second point 10 cm above it: with full flexion the distance between the two marks should increase to at least 15 cm, and a smaller increase indicates restricted lumbar flexion.

From the front, assess cervical lateral flexion by asking the patient to tilt each ear towards the corresponding shoulder. Restriction here is common in cervical spondylosis and inflammatory neck disease. You can also confirm there is no obvious facial or limb asymmetry from this view.

To assess the temporomandibular joints, ask the patient to open their mouth fully and then move the jaw from side to side. Watching the jaw open in the midline checks for restricted range of movement and any deviation, while listening and feeling for clicking or crepitus can reveal joint involvement, which occurs in conditions such as rheumatoid arthritis.

Preview the GALS Screening OSCE Examination quiz