The GALS Screen (12.02.2020) Flashcards
What does GALS stand for?
Gait
Arms
Legs
Spine
What key questions would you ask in the GALS examination?
- Have you any pain or stiffness in your muscles, joints or back?
- Can you dress yourself completely without any difficulty?
- Can you walk up and down stairs without any difficulty?
What do you want to find out in the locomotor examination?
What is the nature of the joint abnormality?
What is the extent (distribution) of the joint involvement?
Are any other features of diagnostic importance present?
-> If you ask the questions and nothing is wrong the person is probably okay.
What would you look for when assessing gait in the GALS examination?
observe patient walking, turning and walking back
look for:
- smoothness and symmetry of leg, pelvis and arm movements
- normal stride length
- ability to turn quickly
What would you assess in the GALS examination in terms of spine?
- Is paraspinal and shoulder girdle muscle bulk symmetrical?
- Is the spine straight?
- Are the iliac crests level?
- Is the gluteal muscle bulk normal?
- Are the popliteal swellings?
- Are the Achilles tendons normal?
- Are there signs of fibromyalgia?
- Are spinal curvatures normal? (cervical lordosis, thoracic kyphosis, lumbar lordosis)
- Is lumbar spine and hip flexion normal?
- Is cervical spine normal?
How would you assess for fibromyalgia?
Fibromyalgia: does mild pressure over either mid-point of each supraspinatus or gentle squeezing of skinfold over trapezius muscles elicit tenderness? (in fibromyalgia these are trigger points).
What is an early sign of AS?
- straight lumbar spine
- lacks normal curvature (lumbar lordosis)
Assessment of arms in the GALS examination
- Look for normal girdle muscle bulk and symmetry
- Look to see if there is full extension at the elbows
- Are shoulder joints normal?
- Shoulder movement: place both hands behind the head,
then push elbows back - Examine hands palms down with fingers straight
- Observe supination, pronation, grip and finger movements
- place tip of each finger on to the tip of the thumb
to assess normal dexterity and precision grip - Test for synovitis at the metacarpo-phalangeal joints (MCP joints) -> MCP joints will be tender in early RA, tenderness suggests synovitis
What can you observe in early RA?
MCP joints can be tender (also MTPs)
Assessment of legs in the GALS screen
- Look for knee or foot deformity
- Assess flexion of hip and knee
- Look for knee swellings ( examine each knee for presence of fluid using ‘bulge’ sign and ‘patella tap’ sign)
- Test for synovitis at the metatarso-phalangeal joints (MTP joints) -> should not be painful if you don’t have the disease
- Inspect soles of the feet (for rashes and/or callosities)
Detailed examination of any abnormal joint(s) identified in the GALS screen might show…
Inspection: swelling, redness, deformity
Palpation: warmth, crepitus, tenderness
Movement: active, passive, against resistance
Function: loss of function
What do you want to fund out in terms of the nature of the joint abnormality?
Is there inflammation?
Is there irreversible joint damage?
Is there a mechanical defect?
=> basically, is it inflammation to mechanical?
What are the signs of inflammation?
- Swelling (tumor)
- Warmth (calor)
- Erythema (rubor) = redness
- Tenderness (dolor) = pain
- Loss of function (functio laesa)
Define arthritis
Arthritis - refers to definite inflammation of a joint(s) i.e. swelling, tenderness and warmth of affected joints
Define arthralgia
Arthralgia - refers to pain within a joint(s) without demonstrable inflammation by physical examination
It is a classic connective tissue disease.
Define dislocation
Dislocation - articulating surfaces are displaced and no longer in contact
Define subluxation
Subluxation - Partial dislocation
Define varus deformity
Varus deformity - lower limb deformity whereby distal part is directed towards the midline e.g. varus knee with medial compartment osteoarthritis
Define valgus deformity
Valgus deformity - lower limb deformity whereby whereby distal part is directed away from the midline e.g. hallux valgus
Gout
- Acute gout is a good example of arthritis
- painful!
- tissue deposition of monosodium urate (MSU) crystals occurs as a result of hyperuricaemia and leads to one or more of the following:
- Gouty arthritis
- Tophi (aggregated deposits of MSU in tissue)
Gouty arthritis commonly affects the metatarsophalangeal joint of the big toe (‘1st MTP joint’) -> podagra
- Abrupt onset
- Extremely painful
- Joint red, warm, swollen and tender
- Resolves spontaneously over 3-10 days
What is the most common cause of gout?
diet
=> foods rich in purine
- Uric acid is produced in the body during the breakdown of purines – chemical compounds that are found in high amounts in certain foods such as meat, poultry, and seafood.
- causes excess uric acid in blood which can lead to gout
Examiing joint swelling as a part of the locomotor examination
- look at site
- look at tissue involved
- conclude what it is likely to be indicative of:
Articular soft tissue - joint synovial or effusion -> inflammatory joint disease
Periarticular soft tissue p> subcutaneous tissue -. inflammatory joint disease
non-articular synovial -> bursa/tendon sheath -> inflammation of structure
Bony areas -> articular ends of bone -> osteoarthritis
Enthesis
- pathology at the enthesis i.e. the site where ligament or tendon inserts into bone
examples include: - plantar fasciitis
- Achilles tendinitis
Locomotr examination of any abnormal joints identified in the GALS screen
- Inspection (swelling, redness, deformity)
- palpation (warmth, crepitus, tenderness)
- movementL active, passive, against resistance
- function: loss of function
What is the nature of the joint abnormality?
- inflammation?
- irreversible joint damage?
- mechanical defect?
What are the signs of irreversible joint damage?
Joint deformity
- malalignment of two articulating bones
Crepitus
- audible and palpable sensation resulting from movement of one roughened surface on another
- classic feature of osteoarthritis e.g. patello-femoral crepitus on flexing the knee
Loss of joint range or abnormal movement
ANKYLOSING SPONDYLITIS
- chronic condition where joint deformity may occur
Affects:
Sacroiliac joints (sacroiliitis) and spine
May lead to spinal fusion (ankylosis) and deformity
Entheses resulting in chronic enthesopathy
Non-axial joints – hips and shoulders (common), others less frequently involved
Strong association with HLA-B27
Rheumatoid factor is
- Flat lumbar spine, rigid exaggerated thoracic kyophosis
- It’s all about catching it early before patients get to that stage.
negative
What is part of the group pf zero-negative spondyloarthropathies?
- Ankylosing spondylitis
- Reiter’s syndrome and reactive arthritis
- Arthritis associated with psoriasis (psoriatic arthritis)
- Arthritis associated with GI inflammation (enteropathic synovitis)
Signs of mechanical defect as a joint abnormality
May be due to inflammation, degenerative arthritis or trauma and identified by
- painful restriction of motion in absence of features of inflammation e.g. knee ‘locking’ due to meniscal tear or bone fragment
- instability e.g. side-to-side movement of tibia on femur due to ruptured collateral knee ligaments
What do you want to find out when assessing the joints?
Are any of the joints abnormal?
- we can rapidly determine this by performing the GALS screen
What is the nature of the joint abnormality?
What is the extent (distribution) of the joint involvement?
Are any other features of diagnostic importance present?
How to assess the pattern of arthritis?
determine number of joints involved:
- polyarthritis > 4 joints
- oligoarthritis. 2-4 joints
- monoarthritis single affected joint
- symmetrical?
- size of joints involved
- is there axial involvement?
This is very helpful in the differential diagnosis e.g.
- bilateral and symmetrical involvement of large and small joints is typical of rheumatoid arthritis
- lower limb asymmetrical oligoarthritis and axial involvement would be typical of reactive arthritis
- exclusive inflammation of the first metatarsophalangeal joints is highly suggestive of gout
RA: which joints are commonly affected and spared
Involved:
PIP, MCP, wrist, elbow, shoulder, c-spine, hip, knee, ankle, tarsal MCP
Spared:
DIP, t- and l-spine
in RA you may also see subcutaneous nodules!
OA: which joints are generally involved and spared?
Involved:
- 1st CMC, DIP, PIP. c-spine, tl-spine, hip, knee, 1st MTP, toe IP
Spared:
- MCP, wrist, elbow, shoulder, ankle, tarsal joints
Pattern of joint disease in rA
- asymmetric oligoarthritis
What is synovial fluid?
- Viscous fluid present in joint space of synovial joints (diarthroses)
- Colourless or pale yellow transparent viscous film covering synovium and cartilage with few cells
How is synovial fluid made?
- Synthesized by synovial lining cells
- Synovium consists of lining cells 1-3 cells deep in a matrix mainly containing type I collagen and proteoglycans
- Two types of synovial lining cells:
- type A = macrophage-like and type B = fibroblast-like
- Type B cells secrete the hyaluronic acid which results in the increased viscosity of synovial fluid
Synovial effusion
- abnormal increase in synovial fluid volume
Abnormal mechanical stimulation e.g. in osteoarthritis with damage to cartilage and bone - Increase production of hyaluronic acid by synovial fibroblasts due to mechanical forces
- Excess hyaluronic acid increases oncotic pressure and increases synovial volume – normal composition
- In synovitis due to inflammation the effusion is inflammatory exudate – abnormal composition: inflammatory cells and mediators, reduced hyaluronic acid
What are the different types of synovial effusions?
- normal
- non-inflammatory (OA, mechanical defects)
- inflammatory (gout, RA)
- infection (e.g. bacterial infections)
appearance goes from clear to very turbid in this list.
Synovial fluid examination
When? mandatory when joint infection is suspected; useful to confirm crystal arthritis
How? needle aspiration under aseptic conditions (arthrocentesis)
Relative contraindications?
Arthrocentesis
synovial fluid aspiration
Risks of arthrocentesis
- all are rare
- introducing infection (i.e. septic arthritis)
- bleeding into joint (haemarthrosis)
- damage to structures within the joint (e.g. cartilage)
What are synovial fluid samples examined for?
- Rapid Gram stain followed by culture and antibiotic sensitivity assays
- Polarising light microscopy to detect crystals which can be seen in arthritis due to gout or pseudogut
Gout vs. Pseudogout on a synovial fluid examination
Gout: urate, needle shaped, birefringence negative (polarising light microscopy)
Pseudogout: CPPD (calcium pyrophosphate dihydrate; brick shaped and birefringence positive
CPPD arthropathy is similar to gout
Key points about connective tissue disorders
- Arthralgia and arthritis is typically non-erosive
= Serum autoantibodies are characteristic and…- May aid diagnosis
- Correlate with disease activity
- May be directly pathogenic
- Raynaud’s phenomenon is common in these conditions
- Intermittent vasospasm of digits on exposure to cold
- Typical colour changes – white to blue to red
- Vasospasm leads to blanching of digit
- Cyanosis as static venous blood deoxygenates
- Reactive hyperaemia
- Raynaud’s phenomenon is most commonly isolated and benign condition (‘Primary Raynaud’s phenomenon’)
Raynaud’s phenomenon
- most commonly isolated and benign condition (Primary Reynaud’s pehnomenon)
- it is common in connective tissue disorders however osteoporosis people with it don’t have a connective tissue disorder
- doesn’t tend to affect the thumb
- not symmetrical
Key points about overlap syndrome
- When features of more than 1 connective tissue disorder are present e.g. SLE and inflammatory muscle disease we can use the term overlap syndrome
- When incomplete features of a connective tissue disease are present we can use the term undifferentiated connective tissue disease
- In one instance a group of patients with features of seen in SLE, scleroderma, rheumatoid arthritis, and polymyositis were identified by the presence of an autoantibody:
- Anti-U1-RNP antibody (U1-RNP are uridine-rich small nuclear ribonucleoproteins)
….this condition was termed Mixed Connective Tissue Disease (‘MCTD’)
- Anti-U1-RNP antibody (U1-RNP are uridine-rich small nuclear ribonucleoproteins)
Key points in systemic sclerosis
- Thickened skin with Raynaud’s phenomenon
Dermal fibrosis, cutaneous calcinosis and telangiectasia - Skin changes may be limited or diffuse
- Diffuse systemic sclerosis
- Fibrotic skin proximal to elbows or knees (excluding face and neck)
- Anti-topoisomerase-1 (anti-Scl-70) antibodies
- Pulmonary fibrosis, renal (thrombotic microangiopathy) involvement
- Short history of Raynaud’s phenomenon
- Limited systemic sclerosis*
- Fibrotic skin hands, forearms, feet, neck and face
- Anti-centromere antibodies
- Pulmonary hypertension
- Long history of Raynaud’s phenomenon
Key points about inflammatory muscle disease
- Proximal muscle weakness due to autoimmune-mediated inflammation either with (dermatomyositis) or without (polymyositis) a rash
- Skin changes in dermatomyositis:
- Lilac-coloured (heliotrope) rash on eyelids, malar region and naso-labial folds
- Red or purple flat or raised lesions on knuckles (Gottron’s papules)
- Subcutaneous calcinosis
- Mechanic’s hands (fissuring and cracking of skin over finger pads)
- Associated with autoantibodies:
- Antinuclear antibody – Anti-tRNA synthetase antibodies (e.g. anti-Jo-1 = histidyl)
- Elevated CPK, abnormal electromyograpghy, abnormal muscle biopsy (polymyositis = CD8 T cells; dermatomyositis = CD4 T cells in addition to B cells)
- Associated with malignancy (10-15%) and pulmonary fibrosis
