More ‘cries from the joints’: assessment of the musculoskeletal system is poorly documented in routine paediatric clerking

A. Myers1, J. E. McDonagh3, K. Gupta4, R. Hull5, D. Barker6, L. J. Kay7 and H. E. Foster1,2

1 Departments of Rheumatology and 2 Child Health, University of Newcastle upon Tyne, 3 Institute of Child Health, University of Birmingham, 4 Birmingham Children's Hospital, 5 Rheumatology, Queen Alexandra Hospital, Portsmouth, 6 Paediatrics, St Mary's Hospital, Portsmouth and 7 Rheumatology, Newcastle Hospitals NHS Trust, UK.

Correspondence to: A. Myers. E-mail: andrea.myers{at}ncl.ac.uk


    Abstract
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Objectives. The aim of this study was to describe the assessment of the musculoskeletal (MSK) system in comparison with other systems in routine paediatric medical clerking. Furthermore, to survey trainee paediatricians (SPRs, specialist registrars) about their self-rated confidence in assessing the MSK system.

Methods. Case notes of consecutive general paediatric medical patients admitted to three UK hospitals over a 4-week period were assessed using a standard pro forma. All patients had been assessed by a consultant paediatrician during their admission. A postal questionnaire was sent to all SPRs in training in each of the hospitals, regarding their confidence in assessing the MSK system compared with other systems and their exposure to MSK teaching.

Results. Case notes of 257 patients [117 females, median age 3 yr (range 1–18 yr)] were reviewed. The most common reason for admission was acute infection, although the spectrum of other recorded diagnoses varied between hospitals. Thirteen children (5%) had an acute problem (e.g. infection) against a background of chronic disease. The case note documentation showed that cardiovascular (CVS), respiratory (RS) and gastrointestinal (GI) systems were assessed in the vast majority (>90%) of patients, irrespective of the underlying diagnosis. However, other systems were less well recorded; the trend being the same in each hospital and in descending order, the neurological system (38%), skin (32%), eyes (10%) and musculoskeletal system (4%). Only 2.7% (7/257) patients were documented to have been asked about MSK symptoms, and only 1.6% (4/257) had any documentation of joint examination—in all cases this was limited (e.g. range of movement of the knee only), and no patients had documentation of gait being examined, even in those children presenting with ‘limp’. The response rate to the postal questionnaire was 60% (67/112). The self-rated confidence in MSK assessment was markedly low in comparison with other systems, even though 61/67 recalled some teaching of the MSK system as an undergraduate (61/67) or postgraduate (50/67). Of note none could recall teaching as an undergraduate in paediatric MSK assessment and where there had been postgraduate rheumatology MSK teaching this had been delivered by paediatric rheumatologists in many cases (34/50), reflecting the centres participating in the study.

Conclusions. In routine general paediatric medical in-patient clerking and throughout the admission, MSK assessment was rarely documented, and even where present was limited. This contrasts markedly with other systems which were examined in most children irrespective of the presenting complaint. Self-rated confidence in MSK assessment is low amongst SPRs compared with other systems, despite most recalling some teaching. This discrepancy between teaching and clinical practice needs to be addressed in undergraduate and postgraduate training.

KEY WORDS: Juvenile idiopathic arthritis, Juvenile rheumatoid arthritis, Medical record, Documentation, History and physical examination, Education, Musculoskeletal system


    Introduction
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
All clinicians caring for children and adolescents should be able to undertake a competent assessment of the musculoskeletal (MSK) system. Firstly, MSK problems are common in children at all ages [1, 2], and although in many cases the course is self-limiting MSK symptoms can be a presenting feature of severe and even life-threatening illness, such as osteomyelitis, leukaemia or non-accidental injury. Children with MSK symptoms present in varied guises to primary care or various specialities in secondary care (including paediatrics, orthopaedics and accident and emergency). Secondly, the diagnosis of most MSK problems in children is essentially clinical as laboratory tests may not be diagnostic and must be interpreted in the clinical context; for example the presence of antinuclear factor in transient benign illnesses is common [3]. Thirdly, symptoms may not be volunteered by younger children. Joint swelling and limp, rather than reported pain, are the most common presenting features of juvenile arthritis [4]. Fourthly, and most importantly, delay in the diagnosis of significant MSK pathology can adversely affect outcome. This is well recognized in the case of childhood malignancy and infection but less so in inflammatory joint disease. Evidence suggests that in juvenile idiopathic arthritis (JIA), the longer the interval from onset of joint symptoms to definitive treatment the worse the outcome—e.g. with knee involvement in JIA, the longer the interval to joint injection and physiotherapy, the greater the risk of otherwise avoidable leg length inequality, muscle wasting and functional disability which may be permanent [5], and the longer the interval to starting disease-modifying drugs (methotrexate) the greater the risk of radiographic joint damage [6]. We have reported that an inappropriately long interval from onset of MSK symptoms to diagnosis and access to the paediatric rheumatology multidisciplinary team is not uncommon [7]. Furthermore many children have evidence of joint restriction and functional disability at presentation [7], and have delayed access to ophthalmological screening to detect potentially blinding uveitis [8].

The performance of a competent MSK assessment including history taking and examination, with an understanding of the age-dependent variation of normal joint appearance, may be the only way to detect important joint abnormalities, and facilitate diagnosis and referral to specialist teams. Many doctors, whether qualified in primary [9, 10] or secondary care [11] or residents in training [12] lack confidence in their clinical examination skills when examining the MSK system in adults. Studies have shown that despite a high frequency of locomotor disorders in the general population, MSK assessment is often omitted from routine medical patient clerking in adults presenting to secondary care [13, 14]. A UK survey of primary care trainees reported that less than 10% received exposure to teaching on MSK problems in children [10] and a survey of UK medical schools shows that MSK assessment in children is not ‘core’ teaching for medical students [15]. It is likely therefore that clinicians are even less confident in the examination of children. The aim of this UK multicentre study was to describe the documentation of the MSK assessment in general paediatric in-patients and to survey trainees’ confidence in their ability to assess the MSK system and their experience of MSK teaching.


    Methods
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
There were three participating UK centres (two teaching hospitals and a district general hospital), all with busy general paediatric units. Exemption from ethical approval for this study was granted as this was deemed an audit of current clinical practice with all information recorded anonymously. The trainee paediatricians (SPRs) were unaware of the study taking place. The reviewers (AM, KG and DB) were not personally involved in the original assessments. Consecutive general paediatric patients admitted to each centre over the same 4-week period were included if they had been assessed by a consultant on at least one occasion during the admission. Case notes were reviewed retrospectively using the same pro forma which included details of the presenting complaint, the systems included in the history and examination, and the findings, whether recorded as normal or abnormal. All entries for the admission were included, i.e. documentation was not restricted to the initial clerking. The mention of any part of a system being examined was deemed as ‘system examined’ irrespective of the amount of detail given and whether normal or abnormal. Whether documentation of a history was obtained from the child or the parent/guardian, this was recorded as ‘history taken’ irrespective of the detail given for each system and the response, e.g. ‘no joint pain’ was recorded for the purpose of this study as ‘MSK history taken’, even if no other questions regarding that system were documented. The primary diagnosis recorded was that given on the discharge summary. Data were collated on a Microsoft Access database and analysed using the statistical software package Arcus Biostat version 1.1 [16] in conjunction with Microsoft Excel. To compare the median scores between the study groups we used the Mann–Whitney test for non-parametric data and for comparison of systems examined between different centres, the {chi}2 test or Fisher's exact test.

A month following the case notes review, a postal questionnaire was sent to SPRs (n = 112) in the three postgraduate regions for each hospital. The questionnaire ascertained the recall of MSK teaching and their self-rated competence in examining the MSK system compared with other systems and details on their teaching of the MSK system. SPRs were asked to grade their confidence on a 1–4 Likert scale (‘no confidence’, ‘some confidence’, ‘confidence in most aspects’ and ‘very confident’) in their examination of the MSK system and to contrast this with their confidence in examining other systems. No objective assessment of competence was made.


    Results
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Two hundred and fifty-seven patients (117 females) in the three centres were identified and all case notes reviewed. The median age of the patients was 3 yr (range 0–18), with no significant differences in the age and gender distribution between the hospitals (Table 1). There were statistically significant differences (Kruskal–Wallis, P = 0.0001) in the spread of primary diagnoses between the centres (Table 2), with acute infections (notably respiratory) being the most common reason for admission followed by asthma, abdominal pain, headache, rash, accidental poisoning and problems relating to chronic diseases, e.g. diabetes, cystic fibrosis. Thirteen children had more than one diagnosis: six children were admitted with an acute infection with a background chronic disease [including cystic fibrosis (n = 1), Down's syndrome (n = 1), diabetes (n = 1), asthma (n = 2) and eczema (n = 2)].


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TABLE 1. Demographics of study groups

 

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TABLE 2. Recorded diagnoses in each hospital—figures given as %

 
The frequency of documented history and examination for each system is shown in Table 3. There was considerable variation between hospitals but the documentation of history was poor compared with examination for all systems, with all but respiratory (RS) and gastrointestinal (GI) having documented history taken in <50% of patients. Eyes and musculoskeletal (MSK) systems fared worse, with less than 5% of patients having a documented history. However, documentation of examination was evident in the vast majority (>90%) of patients for the cardiovascular (CVS), RS and GI systems, whereas the examination of other systems was less well recorded; namely the neurological system (CNS, 38% of case notes), skin (32%), eyes (10%) and MSK (4%). Where there was documentation of history been taken in the CVS, RS and GI systems, there was invariably (99%) documentation of the respective examination. For other systems, however, documentation of the examination was evident in only a proportion of those with documented history (CNS 40/56, skin 33/58, MSK 4/5 and eyes 3/9). There were only eight patients documented to have been asked about MSK symptoms, of whom three had a positive response. Eleven patients (4.2%) had documented evidence of an MSK examination being performed, three of whom had documented MSK symptoms. Three patients (1.4%) had a rheumatological diagnosis [‘limp’ (n = 1), back pain (n = 1), reactive arthritis (n = 1)]; the recorded MSK examination was in each case very limited, e.g. hips only (n = 1), range of movement at hip only (n = 1), palpation of knee only (n = 1) and none had their gait documented. A further eight patients had documentation of MSK examination (albeit very limited, e.g. MSK ‘tick’, or MSK ‘NAD’, presumably meaning no abnormality detected); the recorded diagnoses in these patients were asthma (n = 1), impetigo (n = 2), diarrhoea (n = 2), idiopathic thrombocytopenic purpura (n = 1), haemolytic uraemic syndrome (n = 1) and gingivitis (n = 1).


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TABLE 3. Frequency of recorded history and examination in case notes (figures given as %)

 
With regard to confidence in MSK assessment skills amongst SPRs, 67/112 (60%) responses were received. All SPRs were general professional trainees in paediatrics (year 1, n = 21; year 2, n = 8; year 3, n = 10; year 4, n = 10; year 5, n = 11), as well as locum appointments for training (n = 4), clinical research fellows (n = 3) and two on maternity leave (with non-specified year of training). The majority of respondent SPRs (61/67) had received some formal teaching in the MSK examination as undergraduates, and 50/67 respondents (75%) had received rheumatology teaching as a postgraduate. The undergraduate teaching had been delivered by adult rheumatologists on adult patients but none of the trainees could recall training in paediatric MSK assessment. Postgraduate rheumatology MSK teaching for many of the SPRs (34/50) had been delivered by paediatric rheumatologists either during clinical attachments or formal teaching days, reflecting the centres taking part in the study. With regard to MSK assessment, 6/67 felt they had ‘no confidence’, 35/67 had ‘some confidence’, 24/67 had confidence ‘in most aspects’ and 2/67 felt ‘very confident’. This was in contrast to other systems in which most rated themselves as being confident ‘in most aspects’ or ‘very confident’ for CVS, RS and GI systems. Confidence in MSK examination ranked lowest behind CNS, eyes and skin (Fig. 1). There was a higher proportion of SPRs who rated themselves as being confident in ‘most aspects’ who had undertaken a clinical attachment in paediatric rheumatology (13/24) compared with those who had attended a study day (5/24). Self-rated confidence was higher in ‘senior’ SPRs (years 4 and 5), who were confident ‘in most aspects’ (12/21) or ‘very confident’ (1/21) compared with junior SPRs (years 1–3) who rated themselves as being confident ‘in most aspects’ (10/43) and ‘very confident’ (1/43).



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FIG. 1. Self-perceived confidence of SPRs in their ability to assess the MSK system compared with other systems.

 

    Discussion
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
This is the first study of case note documentation of MSK assessment in routine paediatric medical in-patient clerking in the UK. We have shown that MSK history and examination is rarely recorded in children admitted acutely to hospital, irrespective of the presenting complaint. This contrasts markedly with other systems (namely CVS, RS and GI), which were examined in the vast majority of children. We also show that trainee paediatricians (SPRs) lack confidence in their ability to assess the MSK system compared with other systems. These results suggest that poor assessment of the MSK system in children is not uncommon.

The poor assessment of the MSK system described here is likely to reflect current clinical practice in general paediatrics in the UK as the same trends were seen in the three hospitals in geographically distinct areas, each with different paediatricians who have diversity in their undergraduate and postgraduate training. It was interesting to note the significant variation in the documented clinical assessments by body system between the hospitals (Table 3)—this may reflect the previous clinical experiences of the junior staff who may have rotated from a given speciality (e.g. neurology) and therefore have greater confidence in examining the respective system (i.e. CNS in the given example). Alternatively the discrepancies may reflect the different specialist interests and care pathways locally—two of the hospitals were large teaching hospitals and this may influence the in-patient case mix, the subsequent clinical experiences, teaching and confidence (and competence) of the junior clinical staff.

Biases in our results are possible—a potential to overestimate MSK assessment skills as all entries in the case notes were included irrespective of the detail given, and conversely a potential to underestimate MSK assessment skills as we have taken the medicolegal perspective that the absence of a record in the notes indicates that the history was not taken and the examination was not done [17]. However, we suggest that any potential underestimate is likely to be small, as even in those patients with MSK symptoms the documented examination was limited. In reality, therefore, MSK assessment skills may be worse than we describe. As MSK symptoms are not an uncommon presentation of significant illness in children, poor MSK assessment may result in delayed diagnosis and adversely affect outcome.

We acknowledge that in the acute presentation of illness in children initial MSK assessment may not be appropriate in all cases, but would argue that during the course of an admission all systems should at least be screened, especially as all children are assessed on several occasions, and usually by senior clinicians (SPRs and consultants) as part of current clinical practice. MSK symptoms are common (approximately 14% of school age children in the community [1, 2] and 1.2% of acute hospital admission in this study), may be presenting complaints of severe and potentially life-threatening conditions (including leukaemia, non-accidental injury, JIA and vasculitis) and are a common source of morbidity in chronic diseases of childhood, e.g. cystic fibrosis, inflammatory bowel disease. Despite variation in the frequency of primary diagnoses in the three hospitals (which may reflect different specialist interests and care pathways), infection was the commonest primary diagnosis. MSK complications from infection are common, ranging from arthralgia and reactive arthritis to osteomyelitis and septic arthritis. Although no recorded MSK diagnoses were identified during the course of this study, our results show that MSK assessment was universally poor. In view of the reported prevalence of MSK problems in children and adolescence [1, 2], the results from this study are of concern. It may be expected that clinicians assessing children presenting with MSK complaints (e.g. limp, painful knee, etc.) may be more focused and therefore the case note documentation of the clinical assessment would be more complete that we have observed in our current study. However, as part of an on-going study of referral pathways for children with suspected JIA [7], case note documentation of clinical assessment prior to paediatric rheumatology was noted to be poor (Eltringham, personal communication).

The explanation for the MSK system not being assessed as part of routine paediatric in-patient clerking is likely to be multifactorial. Firstly, teaching how to examine the MSK system in children is not a ‘core’ requirement in UK medical schools for undergraduates [15]; this is corroborated by the fact that none of the SPRs surveyed in this study had received any teaching of MSK assessment in children as an undergraduate. Secondly, there is little information in standard paediatric textbooks to reinforce clinical skills [18], although more recent additions have updated the sections on clinical assessment in children [19, 20]. Thirdly, there is no consensus as to what constitutes a ‘competent’ MSK assessment and how it should be documented and there is no screening MSK examination validated for use in children and adolescents taking into account normal age-dependent variation [21]. Many of the SPRs surveyed in this study had been exposed to teaching of MSK assessment, including that of children given by paediatric rheumatologists at postgraduate level, but nevertheless many still lacked confidence in examining the MSK system compared with other systems and this finding was the same in all three hospitals and respective training regions (i.e. deaneries). This suggests that these results, albeit showing poor documentation of MSK clinical assessment, may in fact be an overestimate of the general UK situation, where many hospitals do not have a paediatric rheumatology unit which may provide clinical teaching to paediatric trainees. Self-rated confidence in MSK assessment was greater in more senior trainees, but case note documentation was generally poor and this discrepancy between clinical practice, confidence and teaching warrants further investigation. The documented assessment of other systems, namely CNS, skin and eyes, was also poor compared with CVS, RS and GI, which suggests that problems with clinical teaching are not unique to the MSK system. Such discrepancy between self-reported ability in assessing different systems has been reported from a US residents’ survey [12], where ability to assess GI, CVS and RS systems were rated most highly and MSK was rated as the most difficult system to assess and there was no correlation between the seniority of trainee and their confidence in assessing the MSK system. We suggest that poor MSK assessment skills in general paediatrics reflect the paucity of paediatric rheumatology and orthopaedic teaching in medical education, a lack of clinical experience and reinforcement by senior staff in paediatrics, many of whom will not have received teaching in MSK assessment in their own training.

There is optimism, however, that the situation is improving. A recent study showed that the competence in MSK examination of adult patients was better in junior doctors who had received specific training in MSK assessment [11, 14]. MSK examination is now taught in all UK medical schools [15] in two parts; firstly the ‘GALS’ locomotor screen examination and secondly introducing the student to the basic elements of regional examination. The GALS acronym stands for Gait, Arms, Legs and Spine and the screen involves a series of simple questions and procedures that permit rapid assessment of the locomotor system in adults [22, 23]. The GALS screening examination was designed and tested in adults. We have shown that the GALS screen performs well when applied to children with rheumatic disease, is well tolerated and is quick (takes less than 2 min to do) but requires further refinement and validation [24]. The ‘shorthand’ notation of the GALS assessment is simple and quick to complete, therefore facilitating the case note documentation of MSK assessment—a similar format would be envisaged for a paediatric MSK screening examination.

In conclusion we have shown that MSK assessment is rarely recorded in paediatric medical in-patient clerking, which suggests that it is rarely performed. Paediatricians in training are not confident in their ability to assess the MSK system compared with other systems. There is a need for a validated screening MSK examination suitable for children which can be taught at undergraduate level as a ‘core’ skill. We propose that such a validated MSK screening examination be incorporated in the general assessment of all children, and included in the routine clerking in all cases in the ‘well-child setting’. In the ‘acutely unwell-child setting’, the MSK clinical assessment may need to be truncated depending on the clinical context (e.g. omission of gait observation in the child with gastroenteritis). However, given that MSK symptoms are common and may be the presenting feature of severe (even life-threatening disease), or a complication of acute paediatric problems (e.g. arthralgia following a viral infection), we propose that during the course of an admission, MSK screening examination should be performed on at least one occasion—i.e. as per the situation for all other body systems. This strategy will raise awareness of MSK problems in routine paediatric practice and ultimately improve clinical competency and facilitate prompt diagnosis and appropriate management, thus optimizing patient care.

The authors have declared no conflicts of interest.


    References
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

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Submitted 20 February 2004; revised version accepted 29 April 2004.