Musculoskeletal assessment of general medical in-patients—joints still crying out for attention

M. S. Lillicrap, E. Byrne and C. A. Speed

Department of Rheumatology, Addenbrookes Hospital, Cambridge, UK


    Abstract
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Objectives. The aim of this study was to assess the extent of musculoskeletal assessment (history and examination) amongst medical in-patients and to determine the effects that GALS (gait, arms, legs, spine) teaching has had on this.

Methods. General medical in-patients were interviewed and examined. Case notes were reviewed to determine diagnoses and assess documentation of clinical signs and/or symptoms. Doctors were interviewed to determine whether they had been taught the GALS locomotor screen, assess their confidence in examining the musculoskeletal system and explore their attitudes to musculoskeletal problems.

Results. The presence or absence of locomotor symptoms was recorded in 50% of the 100 patients, whilst signs were recorded in 20%; 63% of all the patients had locomotor symptoms and/or signs. Relevant musculoskeletal history was missed in 49% of the patients, whilst signs were missed in 78%; 42% of those with musculoskeletal conditions would have benefited from additional treatment. Teaching of the GALS screen significantly increased doctors' confidence in examination of the locomotor system.

Conclusions. Active musculoskeletal problems are seen frequently amongst medical in-patients. There is a significant discrepancy between the number of patients with clinical symptoms and signs and the frequency with which they are detected and treated.

KEY WORDS: GALS screen, Musculoskeletal assessment, Medical in-patients.


    Introduction
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Musculoskeletal complaints are common amongst the general population and are a source of significant pain and disability [1]. They can also impact on the presentation of other diseases, as well as affecting rehabilitation and discharge planning. Furthermore, a significant number of medical conditions are associated with locomotor manifestations [2]. Musculoskeletal assessment is therefore a standard component of medical undergraduate curricula. However, in an audit undertaken in 1990, locomotor symptoms and signs were recorded in medical notes in only 14.5 and 5.5%, respectively [3]. The aim of the present study was to assess the current extent of musculoskeletal assessment in general medical in-patients, in a teaching hospital, and to assess the confidence with which musculoskeletal assessment is undertaken by medical staff.

Following a previous study [3], a practical method was developed for screening the locomotor system (the GALS—gait, arms, legs, spine—locomotor screen) [4, 5]. The GALS screen is a simple approach to improving the recognition of musculoskeletal abnormalities and disability. It involves three screening questions: (1) do you have any pain or stiffness in your muscles, joints or back? (2) Can you dress yourself completely without difficulty? (3) Can you walk up and down the stairs without difficulty? This is followed by a brief structured screening examination (Table 1Go). Although the system is a screen and does not substitute for more detailed locomotor examination, it is easily taught, and potentially dispels the preconception that musculoskeletal assessment is inherently difficult. Medical students taught the GALS screen are able to examine the locomotor system more confidently and effectively [6]. However, it is unknown how teaching the GALS screen impacts in routine medical clerkings. The GALS screen is included in the curriculum of the clinical medical students at Addenbrookes Hospital. By repeating the original audit, the current study allowed an assessment of the impact that this teaching has had in clinical practice.


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TABLE 1. Main features of the GALS screening musculoskeletal examination (after Doherty et al. [4])—the order given is the order in which the examination is undertaken (GSAL)

 


    Patients and methods
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Evaluation of patients
All patients admitted through the medical take (either via casualty or from GP referrals) on selected days over a 3-month period (August–October 2001) were assessed. A total of 43 men and 57 women (out of 196 consecutive patients approached) (mean age 70 yr; range 18–93 yr) capable and willing to give written informed consent were recruited. Each patient was assessed, by a rheumatology specialist registrar (SpR) (ML), at least 48 h after admission to hospital. Patients were asked the GALS screening questions. A GALS examination was then undertaken, with further assessment of abnormal joints performed as required.

Case notes were reviewed to see whether locomotor symptoms and/or signs had been recorded at any time during their admission. Notes were reviewed for the recording of cardiovascular, respiratory, gastrointestinal and neurological symptoms and signs, as well as documentation of fundoscopy, skin assessment and breast examination (in females). The age, sex and cause of admission were also noted.

The study was approved by the Cambridge Local Research Ethics Committee and was undertaken with the written consent of all the consultants involved with the acute medical take.

Confidence of medical staff in musculoskeletal examination
Following completion of the patient assessments, all medical pre-registration house officers (PRHOs) (n=16), senior house officers (SHOs) (n=18) and SpRs (n=10) involved with the acute medical take were interviewed. They were asked whether they had been taught the GALS screen and asked to grade their responses to the statements: ‘I feel confident to examine the musculoskeletal system’, ‘musculoskeletal assessment should be part of routine patient clerking’ and ‘musculoskeletal issues are of great importance to health-care provision’. Responses were scored using a 5-point Likert scale [ranging from ‘definitely not confident’ or ‘strongly disagree’ (score=1) to ‘extremely confident’ or ‘strongly agree’ (score=5)].


    Results
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 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Comparison of routine assessment of different clinical systems
The frequencies of assessment of different systems, irrespective of the primary reason for admission, are illustrated in Fig. 1Go. The presence or absence of cardiovascular, respiratory and gastrointestinal symptoms was documented in the medical notes in 99, 96 and 93% of the patients, respectively. Examination of these systems was documented in 99, 98 and 95% of cases, respectively. Neurological symptoms and signs (positive or negative) were recorded in 75 and 63%, respectively. Locomotor symptoms (positive or negative) were recorded in the medical notes in 50% of the patients, whilst locomotor signs (positive or negative) were only recorded in 20%.



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FIG. 1. Locomotor symptoms and signs are less frequently documented than those of other major systems. Case notes were reviewed for the documentation of history and examination of different system. Black bars illustrate the frequency with which symptoms (cardiovascular, respiratory, gastrointestinal, neurological and locomotor) were recorded. Grey bars illustrate the frequency with which signs [cardiovascular, respiratory, gastrointestinal, neurological, fundoscopy, skin, breast (women only) and locomotor] were recorded.

 
Sixty-three per cent of the patients admitted, irrespective of primary admission diagnosis, had active musculoskeletal complaints. Common musculoskeletal diagnoses were osteoarthritis (37% of all patients), inflammatory arthritis (8%), cervical/lumbar spondylosis (8%), soft tissue lesions (6%) and fibromyalgia (5%). Thirteen per cent had more than one locomotor diagnosis. In those patients with musculoskeletal symptoms an appropriate musculoskeletal history was documented in 49%. Musculoskeletal signs were documented in 22% of the cases where signs were subsequently found (although not all the signs subsequently demonstrated were recorded). These frequencies were not significantly different to those found in patients without musculoskeletal symptoms or signs. Furthermore, even if positive musculoskeletal symptoms were documented, this did not affect the frequency with which a musculoskeletal examination was undertaken.

Medical staff confidence in, and attitudes toward, musculoskeletal assessment
Confidence in eliciting a musculoskeletal history and examination was good. Furthermore, there was no significant difference between PRHOs, SHOs and SpRs (mean confidence ratings—scale 1–5 with S.D.): history taking: PRHOs 3.2±0.8, SHOs 3.3±0.9 and SpRs 4.1±0.9; examination: PRHOs 3.1±0.8, SHOs 3.0±0.9 and SpRs 4.0±0.9. However, those doctors, of whatever grade, who had been taught the GALS screen had a significantly greater confidence (P < 0.01; {chi}2) in examining the musculoskeletal system (Fig. 2Go). All the groups agreed, to a similar extent, that musculoskeletal assessment should be part of the routine patient clerking (mean Likert score of agreement 3.3±0.9). Likewise there was agreement that musculoskeletal issues are of great importance to health-care provision (mean Likert score of agreement 4.1±0.7).



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FIG. 2. Medical staff taught the GALS locomotor screen show significantly more confidence in the examination of the locomotor system. All medical PRHOs (n=16), SHOs (n=18) and SpRs (n=10) were interviewed and asked to grade their response to the statement ‘I feel confident to examine the musculoskeletal system’ on a Likert scale of 1 (not at all confident) to 5 (extremely confident). Scores were grouped into not confident (1 or 2), intermediate confidence (3) or confident (4 or 5). Respondents were grouped according to whether or not they had ever been taught the GALS musculoskeletal screen and the results are illustrated graphically. There is a significant difference between the responses of the two groups with those taught the GALS screen showing significantly greater confidence (P < 0.01; {chi}2).

 


    Discussion
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 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
This study demonstrates that the musculoskeletal system is still assessed much less commonly, amongst medical in-patients, than other systems. This is despite a high frequency of active musculoskeletal complaints in this population (63% of the patients). Furthermore, 42% of the patients demonstrated to have musculoskeletal problems (28% of the total general medical intake) would have benefited from additional treatment. Implementation of appropriate therapy for these musculoskeletal complaints could have potentially prevented disability, improved quality of life and reduced a potentially significant socio-economic burden, although this study did not seek to address the impact treatment might have had. The findings none the less reiterate the importance of not overlooking assessment of the musculoskeletal system.

The apparent reluctance of medical staff to assess the musculoskeletal system is in spite of a reportedly good level of confidence in its evaluation, and recognition that musculoskeletal assessment should be part of routine clerking. The explanation is likely to be multifactorial. It may reflect time constraints and the perception that assessment is time consuming. Assessment also requires patient co-operation and it is of note that the neurological assessment, which likewise involves more active patient involvement, is similarly less frequently documented than other systems. It may reflect a need to treat the primary admission problem and the increased pressure on general medical beds. However, this study was undertaken after 48 h of admission when, whatever the cause of admission, a more general assessment of patients' problems should have been undertaken and incorporated into ongoing management plans. The comparable frequency of breast examinations in females (Fig. 1Go) might support an omission of such routine assessments. Despite the GALS screen this study may reflect the perceived complexity of examining the locomotor system, which in turn causes doctors to feel less confident (despite their reported confidence), as compared with other systems. It was not possible to assess whether those patients in whom assessment was undertaken were more likely to be seen by confident doctors or by those taught the GALS screen. Finally, there may be a failure to recognize the health impact of musculoskeletal complaints despite the agreement that musculoskeletal issues are of importance to health-care provision.

It is possible to compare this study with that undertaken in 1990. Both were undertaken in similar-sized teaching hospitals. The spectrum of medical admissions, the frequency of active musculoskeletal problems and the frequency of the individual musculoskeletal disorders in the two study populations were very similar. Although still inadequate, the frequency with which locomotor symptoms and signs are documented is increased in the current study. Two factors may have contributed to the increased frequency of locomotor examination in the current study (20 vs 5.5%). The first is the improved confidence relating to the teaching of the GALS locomotor screen. The second is the use, in our hospital, of a medical admission proforma that includes a section for assessment of locomotor symptoms. Although nothing subsequently prompts examination of the musculoskeletal system, it is possible that this section not only increased the frequency of documentation of musculoskeletal symptoms (50 vs 14.5% in the previous study) but also increased awareness of the need to assess musculoskeletal problems when examining patients. By contrast, however, reported symptoms did not necessarily prompt subsequent examination. Additionally, despite the history prompt, 50% of the patients still had nothing recorded, either positive or negative.

The potential impact of the findings of this study in terms of health-care provision may be significant. Relevant musculoskeletal history was missed in 49% of the patients with symptoms whilst signs were missed in 78%.

In conclusion, over the past 10 yr the recognition of musculoskeletal problems has generally improved. Teaching of the GALS locomotor screen has probably contributed significantly to this. This teaching increases the confidence with which doctors assess locomotor problems. However, despite this, there is still a significant discrepancy between the number of patients with symptoms and signs and the frequency with which they are detected and treated.


    Acknowledgments
 
The authors wish to express their gratitude to all the consultants involved with the acute medical take at Addenbrooke's Hospital who kindly agreed for their patients to be involved in this study. We are also grateful to all the junior staff and patients who agreed to be involved with the study.


    Notes
 
Correspondence to: M. S. Lillicrap. E-mail: mark.lillicrap{at}nnuh.nhs.uk Back


    References
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 

  1. Leistner K, Wessel G, Allander E. Medium-term trends in the occurrence of rheumatic diseases in European countries. Results of an inquiry on statistical data. Scand J Rheumatol 1986;15:206–18.[ISI][Medline]
  2. Munro J, Edwards C. Macleod's clinical examination, 8th edn. Edinburgh: Churchill Livingstone, 1990.
  3. Doherty M, Abawi J, Pattrick M. Audit of medical inpatient examination: a cry from the joint. J R Coll Physicians Lond 1990;24:115–8.[ISI][Medline]
  4. Doherty M, Dacre J, Dieppe P, Snaith M. The ‘GALS’ locomotor screen. Ann Rheum Dis 1992;51:1165–9.[Abstract]
  5. Plant MJ, Linton S, Dodd E, Jones PW, Dawes PT. The GALS locomotor screen and disability. Ann Rheum Dis 1993;52:886–90.[Abstract]
  6. Fox RA, Dacre JE, Clark CL, Scotland AD. Impact on medical students of incorporating GALS screen teaching into the medical school curriculum. Ann Rheum Dis 2000;59:668–71.[Abstract/Free Full Text]
Submitted 23 September 2002; Accepted 20 December 2002