Beyond pGALS: the need for a multifaceted musculoskeletal decision-making tool ('pGALSplus') in community-based clinical practice

Musculoskeletal (MSK) problems in children are common, and health-care professionals must identify those requiring onward referral. Paediatric gait, arms, legs and spine (pGALS) is an MSK assessment to discern abnormal joints. We aimed to identify MSK assessments to add to pGALS (pGALSplus) to facilitate decision-making in the context of exemplar conditions representing a spectrum of MSK presentations, namely JIA, mucopolysaccharidoses, muscular dystrophy and developmental co-ordination disorder. A literature review identified 35 relevant articles that focused on clinical assessments [including questionnaire(s), physical examination and functional tests] used by health-care professionals in the context of the exemplar conditions. We provide a description of these assessments and the rationale regarding how they, or components of such tools, might be useful within pGALSplus. This process provides a foundation for further work to develop and validate pGALSplus. What does this mean for patients?Children can develop a range of problems affecting their joints, muscles and bones, such as pain or weakness. Although most of these are not likely to cause a long-term problem and get better by themselves, some will have a more serious cause. To our knowledge, there is no agreement regarding which assessments are best to help non-specialist health professionals identify signs of serious disease or to help them to refer patients to the right specialty. We wanted to develop an assessment tool (which we called pGALSplus) to help professionals identify such children with potentially more serious diagnoses, thereby improving their access to care and treatment. As a first step, we wanted to find out which assessments are currently being used in clinical practice to identify those children who have a more serious condition or to assess further those already diagnosed, and we chose to look at this in four different conditions that affect everyday life (juvenile idiopathic arthritis, mucopolysaccharidoses, muscular dystrophy and developmental co-ordination disorder). We researched whether these assessments are effective and whether they would be useful to include as part of pGALSplus. We used a range of resources, including research literature and national guidelines, and we propose that pGALSplus should include physical assessment, a questionnaire and testing of skills involving movement and function (e.g. standing up from the floor).