Arthritis & Rheumatism (Arthritis Care & Research)

Vol. 55, No. 5, October 15, 2006, pp 709 –716

DOI 10.1002/art.22230
© 2006, American College of Rheumatology
ORIGINAL ARTICLE

Musculoskeletal Screening Examination (pGALS)

for School-Age Children Based on the
Adult GALS Screen
H. E. FOSTER,1 L. J. KAY,2 M. FRISWELL,3 D. COADY,1 AND A. MYERS4

Objective. To develop and validate a musculoskeletal screening examination applicable to school-age children based on
the adult Gait, Arms, Legs, Spine (GALS) screen.
Methods. Adult GALS was tested in consecutive school-age children attending pediatric rheumatology clinics and was
compared with an examination conducted, on the same day, by a pediatric rheumatologist who classified children as
having abnormal or normal joints. Adult GALS was tested for validity compared with the pediatric rheumatologist’s
assessment and deficiencies in adult GALS were identified. Experts proposed amendments to adult GALS, achieving
consensus by modified Delphi techniques. The resultant pediatric screening tool (pGALS) was tested (methodology
identical to the testing of adult GALS) in an additional group of children.
Results. Adult GALS was tested in 50 children (median age 11 years, range 4 –16), of whom 37 (74%) had juvenile
idiopathic arthritis. Adult GALS missed important abnormalities in 18% of children, mostly at the ankle, foot, and
temporomandibular joints. The pGALS was tested in 65 children (median age 13 years, range 5–17 years) and demon-
strated excellent sensitivity (97–100%) and specificity (98 –100%) at all joints, with high acceptability scored by child and
parent/guardian. The median time to perform pGALS was 2 minutes (range 1.5–3 minutes).
Conclusion. The pGALS musculoskeletal screening tool has excellent validity, is quick to perform, and is acceptable to
school-age children and parents/guardians. We propose that pGALS be incorporated into undergraduate and postgrad-
uate medical training to improve pediatric musculoskeletal clinical skills and facilitate diagnosis and referral to
specialists.

KEY WORDS. Musculoskeletal; Children; Pediatric; Screening examination; Clinical skills; GALS; Medical education;
pGALS; Juvenile arthritis; Barriers to care.

INTRODUCTION The differential diagnosis is broad, and although in many

Musculoskeletal symptoms in children and adolescents
are very common, occurring in 4 –30% of young persons
(1–3) and accounting for 3% of day case attendances (4).
Supported by an Educational Project grant from the Ar-
thritis Research Campaign (grant 16067).
1
H. E. Foster, MD, D. Coady, MD: University of Newcastle
upon Tyne, Newcastle, UK; 2L. J. Kay, MA (oxon): University
of Newcastle upon Tyne, Newcastle Hospitals National
Health Service Trust, Newcastle, UK; 3M. Friswell, MBChB:
Newcastle Hospitals National Health Service Trust, New-
castle, UK; 4A. Myers, MD: University of Newcastle upon
Tyne, Newcastle, and Northumbria Healthcare National
Health Service Trust, Northumberland, UK.
Address correspondence to H. E. Foster, MD, Rheumatol-
ogy, Level 4, Catherine Cookson Building, The Medical
School, University of Newcastle upon Tyne, UK NE2 4HH.
E-mail: h.e.foster@ncl.ac.uk.
Submitted for publication November 2, 2005; accepted in
revised form January 19, 2006.
cases the cause is self-limiting, musculoskeletal presenta-
tions are not uncommon in severe, even life-threatening
illnesses such as osteomyelitis, leukemia, juvenile idio-
pathic arthritis (JIA), vasculitis, or nonaccidental injury.
Careful performance of a competent musculoskeletal ex-
amination is vital to the diagnostic process, particularly
because musculoskeletal symptoms are not always easily
volunteered by children, parental observations may be
nonspecific (e.g., “my child is limping”), and joint swell-
ing and abnormal gait (such as limp) rather than reported
pain are the most common presenting features of JIA (5,6).
JIA is a common cause of chronic disability in children
(7), and joint damage occurs early (8,9). Emerging evidence
supports early and aggressive intervention to improve
functional outcome (10 –13), which relies on prompt diag-
nosis and referral to experienced multidisciplinary teams
(7,9,14). However, for many children with suspected JIA,
delay in receiving pediatric rheumatology services is not
uncommon (6,15), with complex referral pathways from

709
710
their primary care doctor to different secondary care ser-
vices (primarily general pediatrics, orthopedics, and acci-
dent and emergency).
Poor clinical skills are a significant barrier to care, with
trainees in pediatrics and primary care reporting poor
self-confidence in their ability to assess a child’s muscu-
loskeletal system (4,16 –19), poor documentation of mus-
culoskeletal assessment (16), and inadequate training in
pediatric rheumatology (4,20,21). These observations may
be explained by the fact that teaching of musculoskeletal
clinical skills involving children is not part of core train-
ing in UK medical schools (22), few standard pediatric
textbooks describe musculoskeletal clinical examination
techniques in children (23), and clinical skills are not
reinforced in clinical practice because pediatricians them-
selves may not have received appropriate training. Fur-
thermore, there is no consensus among pediatric rheuma-
tologists as to best practice in musculoskeletal clinical
examination, and there is no validated screening examina-
tion applicable to children (24).
Poor musculoskeletal clinical skills are not unique to
pediatric practice, and musculoskeletal system is often
omitted from routine medical adult patient assessment
(25). Following the General Medical Council (UK) recom-
mendations that musculoskeletal clinical conditions be
emphasized in undergraduate teaching (26), musculoskel-
etal examination is taught in UK medical schools as part of
core teaching (22), and many students are taught the Gait,
Arms, Legs, and Spine (GALS) screening examination and
are introduced to the basic elements of a more detailed
regional examination (27). The GALS involves simple
questions and procedures that permit rapid and effective
assessment of the musculoskeletal system in adults
(28,29), but it has not been tested in children.
An ideal musculoskeletal screening test for children
must be sensitive (i.e., does not miss significant abnormal-
ities), be acceptable to the child and parent, distinguish
the abnormal child from the normal child, and direct the
assessor to a focused regional examination. Our goal was
to produce a validated pediatric musculoskeletal screen-
ing test based on adult GALS that can be successfully
integrated into clinical teaching and will improve pediat-
ric musculoskeletal clinical skills among future doctors.
Ultimately, the goal is that improved pediatric musculo-
skeletal clinical skills will facilitate diagnosis and, in the
case of children with suspected rheumatic disease, reduce
the delay to pediatric rheumatology care and therefore
optimize outcome. The study was limited to school-age
children because a different examination approach would
be required for younger children.
PATIENTS AND METHODS
Part 1 tested adult GALS in school-age children in com-
parison with a consultant pediatric rheumatologist’s as-
sessment. Part 2 derived amendments to adult GALS from
expert opinion. Part 3 tested the amended version of adult
GALS.
Foster et al
Part 1: Audit of adult GALS applied in school-age chil-
dren. Children were recruited from pediatric rheumatol-
ogy outpatient clinics, with both new and review patients
invited to participate. Participants were examined using
adult GALS by a final-year specialist registrar (AM) in
adult rheumatology experienced in the use of adult GALS
who was blinded to the diagnosis, with no clinical history
being permitted other than the 3 screening questions (i.e.,
“Do you have any pain in your joints, muscles, neck or
back?” “Do you have any difficulty getting dressed without
help?” and “Do you have any difficulty getting up and
down stairs without help?”). On the same day, children
were examined by a consultant pediatric rheumatologist
(HF or MF); this process mirrors clinical practice, with
patients being assessed by the specialist registrar and sub-
sequently by the consultant. The time to perform the ex-
amination and findings were recorded on a homunculus.
The consultants, blinded to the specialist registrar’s find-
ings, used their standard clinical approach, and were
asked to record joints as normal or abnormal and also to
document a more detailed description of abnormalities. To
assess interobserver variation, the first 10 patients were
assessed independently by both consultants and the inter-
observer reproducibility (to distinguish abnormal from
normal joints) was satisfactory, with an intraclass correla-
tion coefficient of 0.81 (⬎0.8 is regarded as satisfactory
[30,31]). The sensitivity, specificity, and positive and neg-
ative predictive values of the adult GALS screen were
calculated from comparison with the consultant examina-
tion.
Part 2: Derivation of amended version of adult GALS.
The amendments required for adult GALS were derived
through consultation with members (doctors and allied
health professionals) of the British Society for Pediatric
and Adolescent Rheumatology (BSPAR), with invitations
to participate being distributed at BSPAR national meet-
ings. The respondents (termed experts) were involved in
subsequent dialogue to reach consensus. The proposed
amendments were derived through a modified Delphi
technique (32) that involved 2 iterative cycles, with ques-
tionnaires incorporating feedback from discussion groups
of experts. Survey 1 followed presentation, at a national
BSPAR meeting, of the results of adult GALS testing in
children (33). Experts were asked by questionnaire to
judge whether, in their opinion, each of the components of
adult GALS was essential, desirable, or not necessary.
They were also asked to suggest amendments for joints
where adult GALS performed less well. A subsequent
questionnaire (survey 2) asked the experts to judge
whether, in their opinion, each of the proposed amend-
ments to adult GALS was essential, desirable, or not nec-
essary. The results were then discussed in an expert group
to derive consensus.
Part 3: Testing of pGALS in school-age children. The
proposed amended version of adult GALS was termed
pediatric GALS (pGALS), which was tested, using meth-
odology identical to the testing of adult GALS, on an
additional group of consecutive outpatient attendees. A
power calculation (80% power, P ⫽ 0.05) required 60
Pediatric Musculoskeletal Screening (pGALS) 711

Table 1. The performance of the adult Gait, Arms, Legs, Spine screen (GALS) in
children compared with examination performed by a pediatric rheumatologist*

Positive Negative
Sensitivity Specificity predictive value predictive value

Neck 100 97 66 100

Shoulders 100 98 87 100
Elbows 100 94 55 100
Wrists 100 86 30 100
Hands 100 97 90 100
Lumbar spine 100 100 100 100
Hips 100 97 93 100
Knees 100 97 93 100
Ankles 0 0 0 0
Feet 0 0 0 0
Temporomandibular joints 0 0 0 0

* Values are the percentage.

children to test the amendments to adult GALS, including pists; 1 occupational therapist; 3 clinical nurse specialists;
96 normal joints and 24 abnormal joints at each anatomic and 1 pediatric orthopedic surgeon.
site. Acceptability of pGALS according to the child and
parent/guardian was recorded on a Likert scale (range 0 –5)
Testing of adult GALS in school-age children (part 1).
for their opinion on 1) the time taken to perform pGALS,
The median time for the specialist registrar to perform
with a scale of 5 options (ranging from “far too short” to
adult GALS was 2 minutes (range 1–2.5 minutes). Adult
“far too long”), and 2) the level of discomfort experienced
GALS had good sensitivity and specificity for the joints
during the examination, with a scale of 5 options (ranging
that are included in the screen, and the negative predictive
from “lots of pain” to “no pain”).
values at each of these sites were high, suggesting that the
The study had ethical approval, with informed consent
adult GALS screen did not miss significant abnormalities
obtained from parents/guardians and assent obtained from
in the areas examined (Table 1). However, adult GALS
older children. All information was recorded anony-
rated 19 of 50 children as normal, but the pediatric rheu-
mously.
matologist’s examination detected abnormalities in 9 of
these 19 children (5 had JIA and 4 had benign hypermo-
RESULTS bility); adult GALS therefore had a false negative rate of
18% (9 out of 50). A total of 55 joint abnormalities were
missed by adult GALS, the majority of which involved the
Patients used to test adult GALS and pGALS. Adult
foot and ankle (namely, restricted range of movement of
GALS was tested in 50 consecutive school-age children (25
ankle joint [n ⫽ 20], subtalar joint/midfoot [n ⫽ 13], teno-
girls, median age 11 years [range 4 –16 years]). Of these, 42
synovitis/tendinitis [n ⫽ 6], arthritis of an individual toe
had inflammatory joint disease (37 had JIA, 2 had systemic
[n ⫽ 4], and abnormal foot posture [n ⫽ 8]). Four patients
lupus erythematosus, 2 had reactive arthritis, and 1 had
with JIA had temporomandibular joint (TMJ) abnormali-
juvenile dermatomyositis) and 8 had noninflammatory
ties that were missed, which included limited jaw open-
joint disease (5 had benign joint hypermobility and 3 had
ing/deviation. The positive predictive value of adult GALS
anterior knee pain). The testing of pGALS involved 65
was low at the wrist, elbows, and neck (30%, 55%, and
children (42 girls, median age 13 years [range 5–17 years])
66%, respectively), with loss of range of movement being
with the following diagnoses: inflammatory joint disease
the main abnormality missed. Significant amendments to
(40 had JIA, 1 had systemic lupus erythematosus, 5 had
adult GALS were therefore needed to incorporate the foot,
juvenile dermatomyositis, and 3 had systemic sclerosis),
ankle, and TMJ, and improvement in the specificity of the
mechanical joint problems (8 had benign joint hypermo-
adult GALS screen at the wrist, elbow, and neck was
bility and 5 had anterior knee pain), primary Raynaud’s
needed.
disease (2 patients), and idiopathic pain syndrome (1 pa-
tient).
Development of pGALS by expert opinion (part 2).
The expert group to derive amendments to adult GALS. Survey 1 suggested amendments for the foot and ankle,
From the membership of BSPAR (n ⫽ 124), 36 members and following survey 2, there was consensus for “walk on
(representing 20 pediatric rheumatology units within the tip toes and then heels” (as desirable or essential) as the
UK) agreed to participate, with larger centers nominating 1 screening test (Figure 1). In survey 1, the suggested amend-
representative consultant. All experts responded to the ments for the TMJ were “open jaw” and “move jaw side to
surveys and most (32 of 36) attended a minimum of 1 side.” Following survey 2, there was consensus to refine
discussion group. The expert group included 25 pediatric this as “open (your) mouth and insert 3 fingers” (child’s
rheumatologists, 6 of whom were trainees; 6 physiothera- own fingers) as the screening test for the TMJ. Most com-
712 Foster et al

micrognathia) and jaw opening (checking for asymmetry of

movement or deviation) using the child’s own 3 fingers to
gauge the degree of opening. Inability to walk on the heels
may be a feature of tendinitis, enthesitis or arthritis of the
ankle/foot, and osteochondroses (e.g., Sever’s disease).
Toe walking alerts the observer to possible neuromuscular
disease but has been reported as a presenting feature of JIA
(34). Inability to walk on the toes may be a feature of
arthritis (metatarsalgia) or local trauma of the foot. The
appearance of flat feet but normal arches on tip-toe is
normal in young children until ⬃5 years of age. Persis-
tence of flat feet beyond this age or a nonmobile flat foot
warrants further investigation. In the school-age child with
mechanical lower limb pain (e.g., anterior knee pain), ab-
normal foot posture (including flat feet, excessive prona-
tion/supination of the feet) may be found.

Testing of pGALS for validity and acceptability (part 3).

The pGALS screen had excellent sensitivity and specific-
ity at all joints (Table 3). There were no false negatives;
pGALS did not miss any children with significant joint

Table 2. The components of pediatric Gait, Arms, Legs,

Spine screen (pGALS)*

Screening questions
Do you have any pain or stiffness in your joints,
muscles or your back?
Do you have any difficulty getting yourself dressed
without any help?
Do you have any difficulty going up and down stairs?
Gait
Observe the child walking
“Walk on your tip-toes/walk on your heels” (A,B)†
Arms
“Put your hands out in front of you” (C)
“Turn your hands over and make a fist” (D)
“Pinch your index finger and thumb together”
“Touch the tips of your fingers with your thumb” (E)
Squeeze metacarpophalangeal joints (F)
“Put your hands together/put your hands back to back”
(G,H)†
Figure 1. The results of expert opinion in the development of the “Reach up and touch the sky” (I)†
pediatric Gait, Arms, Legs, Spine (pGALS) screen. A, Survey 1:
“Look at the ceiling” (I)
the value of each component of adult GALS in a pediatric mus-
culoskeletal screen (pGALS). B, Survey 2: the proposed amend- “Put your hands behind your neck” (J)
ments to adult GALS to be included in pGALS to screen the foot Legs
and ankle, temporomandibular joints, wrist and elbow. Black Feel for effusion at the knee (K)
bar ⫽ not necessary; gray bar ⫽ desirable; white bar ⫽ essential; “Bend and then straighten your knee” (active
MCP ⫽ metacarpophalangeal joint; MTP ⫽ metatarsophalangeal movement of knees and examiner feels for crepitus)
joint. (L)
Passive flexion (90 degrees) with internal rotation of
ponents of adult GALS were scored as desirable or essen- hip (M)
tial (survey 1), with consensus to keep the format of Spine
pGALS as similar to adult GALS as possible, except for “Open your mouth and put 3 of your (child’s own)
“put your arms by your side” being replaced by “reach for fingers in your mouth” (N)†
the sky” as a more effective screening test for elbow exten- Lateral flexion of cervical spine: “try and touch your
shoulder with your ear” (O)
sion. Another proposed amendment for the wrists was
Observe spine from behind (P)
“palms together and hands together back to back,” and a “Can you bend and touch your toes?” observe curve of
proposed amendment for the neck was “look at the ceil- spine from side and behind (Q)
ing.”
The pGALS maneuvers are listed in Table 2 and illus- * See Figure 2 for illustrations of individual movements (A–Q).
† Additions and amendments to the original adult Gait, Arms, Legs,
trated in Figure 2. The TMJ screening test is the observa- Spine screen.
tion of facial profile (looking for asymmetry of growth or
Pediatric Musculoskeletal Screening (pGALS)
Figure 2. Illustration of movements in the pediatric Gait, Arms, Legs, Spine screen (pGALS). See Table 2 for detailed
description of movements (A–Q).
abnormalities that were detected by the pediatric rheuma-
tologist examination. A positive response to ⱖ1 of the 3
screening questions (i.e., “there was pain and/or stiffness,”
“difficulty in dressing independently,” or “difficulty with
stairs”) gave the following results as compared with the
consultant’s assessment: sensitivity 49%, specificity 82%,
positive predictive value 85%, and negative predictive
713
value 37%. The median time to complete pGALS was 2
minutes (range 1.5–3 minutes). The acceptability question-
naires were completed by 49 of 65 children (the nonre-
sponders being very young children) and by 45 of 65
parents/guardians (the nonresponders not having wit-
nessed the examination performed on older children/
young persons who opted to be examined by the doctor on
714 Foster et al

Table 3. The performance of pediatric Gait, Arms, Legs, Spine screen (pGALS) in children compared with assessment
performed by a pediatric rheumatologist*

Positive Negative
Abnormal joints Normal joints Sensitivity, Specificity, predictive predictive
tested, no.† tested, no.† % % value, % value, %

Cervical spine 5 60 100 100 100 100

Shoulders 6 124 100 100 100 100
Elbows 25 105 100 100 100 100
Wrists 42 88 100 100 100 100
Hands 26 104 100 99 96 100
Temporomandibular joints 27 103 100 98 93 100
Lumbar spine 3 62 100 100 100 100
Hips 16 114 100 100 100 100
Knees 33 97 100 100 100 100
Ankles and feet 29 101 97 99 97 99

* A total of 65 children were tested.

† Joints deemed abnormal or normal by the pediatric rheumatologist.

their own). For the responders, most children (98%) and
most parents/guardians (91%) thought pGALS was accept-
able for the time taken. For acceptability of comfort, most
children/adolescents (95%) deemed pGALS as causing no/
slight discomfort. None of the parents/guardians scored
pGALS as being uncomfortable for their child.
DISCUSSION
This is the first description of a validated musculoskeletal
screening test for school-age children. The pGALS test
performs very well; it is sensitive, quick to perform, and is
acceptable to children and parents/guardians. The pGALS
screen was derived from adult GALS, which has been used
as part of core teaching in UK medical schools since 1991,
is widely accepted by teachers in rheumatology, and ef-
fectively improves musculoskeletal clinical competence
among junior doctors assessing adults (25,35,36). It is en-
visioned that pGALS, being similar to adult GALS in for-
mat and content, will be equally effective in the improve-
ment of clinical competence in the musculoskeletal
assessment of children. We believe that competent pedi-
atric musculoskeletal clinical skills will facilitate accurate
diagnosis, referral to specialist teams, and, most impor-
tantly for children with suspected rheumatic disease, re-
duce delay in referral to pediatric rheumatology care and
ultimately improve these children’s outcome.
Adult GALS is not adequate, in its original form, as a
musculoskeletal screening tool for use in school-age chil-
dren. The majority of the abnormalities that were missed
were at the foot and ankle and the TMJ, which are not
specifically tested in the original description of adult
GALS (28). These sites are commonly involved in JIA,
especially at presentation (6,37,38). Gait observation can-
not be relied upon to detect significant foot and ankle
abnormalities (such as restriction of the subtalar joints),
particularly because the observer must be aware of the
development of gait and normal variants in children (39).
TMJs need to be specifically screened because they are
often involved in children with JIA, may be subclinical,
and cause significant morbidity (40).
The pGALS screen had excellent sensitivity and speci-
ficity compared with the consultant assessment, which is
all the more impressive given the lack of detailed clinical
history included in the screen. The screening questions,
however, have low sensitivity (but high specificity and
high positive predictive value), demonstrating that clinical
history alone may be unhelpful as a musculoskeletal
screening tool. Nonetheless, these questions are helpful
prompts to the history taker and help focus the examiner’s
attention if a positive response is obtained.
The methodology to propose amendments to adult
GALS (based on the Delphi process [32]) has been used
effectively in health care research, development of guide-
lines for best practice and content of curricula (41), and in
pediatric rheumatology (42). There is no published con-
sensus on musculoskeletal clinical examination tech-
niques in children (24) and yet the expert group, repre-
senting different training backgrounds, had considerable
agreement on the amendments to adult GALS, which were
invariably simple maneuvers commonly used in clinical
practice. Poor reliability of detailed clinical musculoskel-
etal assessment among pediatric rheumatologists has been
reported (43), but in this study the consultants were com-
pared only on their ability to dichotomize children’s joints
as normal or abnormal and showed good level of agree-
ment.
The components of pGALS are demonstrated in Table 2
and Figure 2. The vast majority of children and their
parents or guardians deemed pGALS to be acceptable. We
did not ascertain the acceptability and discomfort of the
pediatric rheumatologists’ examination as part of this
study; the few children who deemed pGALS uncomfort-
able may have also had a similar discomfort when exam-
ined by the consultant.
This study involved the testing of pGALS in a pediatric
rheumatology clinic and the performance of pGALS by an
experienced specialist registrar in adult rheumatology. As-
sessment of pGALS in routine general pediatric and pri-
mary care settings is clearly important, and is planned by
our group.
The influence of pGALS on improving clinical skills is
Pediatric Musculoskeletal Screening (pGALS)
likely to be greatest if it is taught as a core skill at the
undergraduate level. The appropriate interpretation of
pGALS requires knowledge of musculoskeletal problems
in children and adolescents and awareness of age, devel-
opmental changes, and normal variants. This requires sup-
plementary teaching and clinical experience in pediatric
rheumatology. Competent performance of pGALS will fa-
cilitate a problem-orientated regional examination using
an approach similar to adult patients (27). We propose that
pGALS be incorporated in routine assessment of all well
children and be attempted in unwell children, because
significant musculoskeletal problems can manifest in dis-
eases such as sepsis or inflammatory bowel disease. This
strategy will raise awareness of musculoskeletal problems
in pediatric practice and will facilitate appropriate man-
agement, thus optimizing patient care.
ACKNOWLEDGMENTS
We are grateful to the children and their families for their
participation in this study, to members of the British So-
ciety for Pediatric and Adolescent Rheumatology, to the
healthy volunteer for the filming of pGALS, and to the
Television Services, University of Newcastle for the pho-
tographs.
REFERENCES
1. Goodman JE, McGrath PJ. The epidemiology of pain in chil-
dren and adolescents: a review. Pain 1991;46:247– 64.
2. Symmons DP, Jones M, Osborne J, Sills J, Southwood TR, Woo
P. Pediatric rheumatology in the United Kingdom: data from
the British Pediatric Rheumatology Group National Diagnos-
tic Register. J Rheumatol 1996;23:1975– 80.
3. De Inocencio J. Epidemiology of musculoskeletal pain in pri-
mary care. Arch Dis Child 2004;89:431– 4.
4. Foster HE, Everett S, Myers A. Rheumatology training in the
UK: the trainees’ perspective [letter]. Rheumatology (Oxford)
2005;44:263– 4.
5. McGhee JL, Burks FN, Sheckels JL, Jarvis JN. Identifying chil-
dren with chronic arthritis based on chief complaints: ab-
sence of predictive value for musculoskeletal pain as an in-
dicator of rheumatic disease in children. Pediatrics 2002;110:
354 –9.
6. Eltringham ME, Myers A, Friswell M, Abinun MA, Kay LJ,
Foster HE. Referral delays for children with juvenile idio-
pathic arthritis [abstract]. Clin Exp Rheumatol 2003;21:532.
7. White PH, McPherson M, Levinson JE. Community programs
for children with rheumatic diseases. Pediatr Clin North Am
1986;33:1239 – 49.
8. Levinson JE, Wallace CA. Dismantling the pyramid. J Rheu-
matol Suppl 1992;33:6 –10.
9. Wallace CA, Levinson JE. Juvenile rheumatoid arthritis: out-
come and treatment for the 1990s. Rheum Dis Clin North Am
1991;17:891–905.
10. Sherry DD, Stein LD, Reed AM, Schanberg LE, Kredich DW.
Prevention of leg length discrepancy in young children with
pauciarticular juvenile rheumatoid arthritis by treatment with
intraarticular steroids. Arthritis Rheum 1999;42:2330 – 4.
11. Flato B, Aasland A, Vinje O, Forre O. Outcome and predictive
factors in juvenile rheumatoid arthritis and juvenile spondy-
loarthropathy. J Rheumatol 1998;25:366 –75.
12. Hudson B, Clarke M, Strong N, Abinun M, Craft AW, Foster
HE. An audit of screening for chronic anterior uveitis in
715
juvenile chronic arthritis [abstract]. Br J Rheumatol 1997;36
Suppl 1:17.
13. Cabral DA, Petty RE, Malleson PN, Ensworth S, McCormick
AQ, Shroeder ML. Visual prognosis in children with chronic
anterior uveitis and arthritis. J Rheumatol 1994;21:2370 –5.
14. Arthritis and Musculoskeletal Alliance. Standards of care for
people with inflammatory arthritis. URL: http://www.arma.
uk.net/pdfs/ia_b&w.pdf.
15. Manners PJ. Delay in diagnosing juvenile arthritis. Med J Aust
1999;171:367–9.
16. Myers A, McDonagh JE, Gupta K, Hull R, Barker D, Kay LJ, et
al. More ‘cries from the joints’: assessment of the musculo-
skeletal system is poorly documented in routine paediatric
clerking. Rheumatology (Oxford) 2004;43:1045–9.
17. Glazier RH, Dalby DM, Badley EM, Hawker GA, Bell MJ,
Buchbinder R. Determinants of physician confidence in the
primary care management of musculoskeletal disorders.
J Rheumatol 1996;23:351– 6.
18. Hergenroeder AC, Chorley JN, Laufman L, Fetterhoff AC. Pe-
diatric residents’ performance of ankle and knee examina-
tions after an educational intervention [abstract]. Pediatrics
2001;107:E52.
19. Bonds DE, Mychaleckyj JC, Watkins R, Palla S, Extrom P.
Ambulatory care skills: do residents feel prepared? Med Educ
Online [serial online] 2002;7:7. URL: http://www.med-ed-
online.org/pdf/res00037.pdf.
20. Dubey SG, Roberts C, Adebajo AO, Snaith ML. Rheumatology
training in the United Kingdom: the trainees’ perspective.
Rheumatology (Oxford) 2004;43:896 –900.
21. Lanyon P, Pope D, Croft P. Rheumatology education and
management skills in general practice: a national study of
trainees. Ann Rheum Dis 1995;54:735–9.
22. Kay LJ, Deighton CM, Walker DJ, Hay EM, and the Arthritis
Research Campaign Undergraduate Working Party of the ARC
Education Sub-committee. Undergraduate rheumatology
teaching in the UK: a survey of current practice and changes
since 1990. Rheumatology (Oxford) 2000;39:800 –3.
23. Kay LJ, Baggott G, Coady DA, Foster HE. Musculoskeletal
examination for children and adolescents: do standard text-
books contain enough information? Rheumatology (Oxford)
2003;42:1423–5.
24. Foster HE, Kay LJ. Examination skills in the assessment of the
musculoskeletal system in children and adolescents. Curr
Paediatr 2003;13:341– 4.
25. Lillicrap MS, Byrne E, Speed CA. Musculoskeletal assessment
of general medical in-patients: joints still crying out for atten-
tion. Rheumatology (Oxford) 2003;42:951– 4.
26. General Medical Council. Good Medical Practice. URL: http://
www.gmc-uk.org/guidance/good_medical_practice/index.asp.
27. Coady D, Walker D, Kay L. Regional Examination of the Mus-
culoskeletal System (REMS): a core set of clinical skills for
medical students. Rheumatology (Oxford) 2004;43:633–9.
28. Jones A, Ledingham J, Regan M, Doherty M. A proposed
minimal rheumatological screening history and examination:
the joint answers back. J R Coll Physicians Lond 1991;25:
111–5.
29. Doherty M, Dacre J, Dieppe P, Snaith M. The ‘GALS’ locomo-
tor screen. Ann Rheum Dis 1992;51:1165–9.
30. Kramer MS, Feinstein AR. Clinical biostatistics. LIV. The
biostatistics of concordance. Clin Pharmacol Ther 1981;29:
111–23.
31. Kramer MS, Boivin JF. Directionality, timing, and sample
selection in epidemiologic research design. J Clin Epidemiol
1989;42:827– 8.
32. Delbecq A, Gustafson D. Group techniques for programme
planning: a guide to nominal group and Delphi processes.
Glenview (IL): Scott, Foresman and Co; 1975.
33. Myers A, Kay LJ, Friswell M, Foster HE. Application of the
adult GALS screening examination in school age children
[abstract]. Rheumatology 2003;39 Suppl 1:103.
34. Dyet L, Pilkington C, Raffles A. A novel presentation of juve-
nile idiopathic arthropathy. Arch Dis Child 2003;88:1015– 6.
35. Fox R, Dacre JE, Clark CL, Scotland AD. Impact on medical
716
students of incorporating GALS screen teaching into the med-
ical school curriculum. Ann Rheum Dis 2000;59:668 –71.
36. Plant MJ, Linton S, Dodd E, Jones PW, Dawes PT. The GALS
locomotor screen and disability. Ann Rheum Dis 1993;52:
886 –90.
37. Guillaume S, Prieur AM, Coste J, Job-Deslandre C. Long-term
outcome and prognosis in oligoarticular-onset juvenile idio-
pathic arthritis. Arthritis Rheum 2000;43:1858 – 65.
38. Huemer C, Malleson PN, Cabral DA, Huemer M, Falger J, Zidek
T, et al. Patterns of joint involvement at onset differentiate oli-
goarticular juvenile psoriatic arthritis from pauciarticular juve-
nile rheumatoid arthritis. J Rheumatol 2002;29:1531–5.
39. Beresford MW, Cleary GA. Evaluation of a limping child. Curr
Paediatr 2005;15:15–22.
Foster et al
40. Walton AG, Welbury RR, Foster HE, Thomason JM. Juvenile
chronic arthritis: a dental review. Oral Dis 1999;5:68 –75.
41. Broomfield D, Humphris GM. Using the Delphi technique to
identify the cancer education requirements of general practi-
tioners. Med Educ 2001;35:928 –37.
42. Ruperto N, Ravelli A, Murray KJ, Lovell DJ, Andersson-Gare
B, Feldman BM, et al. Preliminary core sets of measures for
disease activity and damage assessment in juvenile systemic
lupus erythematosus and juvenile dermatomyositis. Rheuma-
tology (Oxford) 2003;42:1452–9.
43. Guzman J, Burgos-Vargas R, Duarte-Salazar C, Gomez-Mora P.
Reliability of the articular examination in children with juve-
nile rheumatoid arthritis: interobserver agreement and
sources of disagreement. J Rheumatol 1995;22:2331– 6.