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.

P27 A scoping review to support the development of pGALSplus: a multi-professional tool and educational resource

Poster presentation Tuesday 8 October

Background

Musculoskeletal (MSK) problems in children and young people (CYP) are common. The majority will present to healthcare professionals in the community but it can be challenging to identify those with serious disease requiring onward referral. pGALS (paediatric Gait, Arms, Legs and Spine) was developed as a simple, quick MSK clinical assessment to discern abnormal joints, initially within paediatric rheumatology and later targeted at non-specialists. Anecdotally, pGALS can detect joint and functional problems in CYP with other serious conditions, but alone is unlikely to be specific enough. It is unknown whether a pGALSplus assessment is practical. Our aim was to scope the literature about MSK assessments applicable to CYP used in clinical practice, focusing on evidence of validity in the context of diagnosis and assessment of juvenile idiopathic arthritis (JIA), mucopolysaccharidoses (MPS), Muscular dystrophy (MD) and developmental coordination disorder (DCD) to develop an extended pGALS.

Methods

Scoping review using the Newcastle University Library search tool (which includes several databases) and Google Scholar, and consulting NICE guidance/pathways. Search terms included dyspraxia, paediatric MSK assessment, screening tools, balance, and rheumatology, assessment tools for MD, MPS, and JIA. Studies cited within relevant articles uncovered through searches were also checked. The search was conducted between 1 October and 1 December 2018. Publication date was limited to post-1998, language did not constitute as exclusion criteria unless translation was unavailable.

Results

32 journal articles were deemed appropriate, describing specific assessment or screening tools in the context of diagnosis of our target conditions. Within DCD, motor co-ordination test batteries aid diagnosis as part of specialist assessment, but are regarded as too lengthy for the purpose of screening; a questionnaire may be useful as a first-step diagnostic tool, along with an assessment of static balance (found to be significantly worse in children with DCD). In paediatric rheumatology, pGALS is the only validated screening tool to discern normal from abnormal. Other tools to assess health and wellbeing, disability and function are validated in the context of established disease only. For neuromuscular conditions the North Star Ambulatory Assessment is valid, reliable and practical as a functional assessment, and includes activities that are necessary to remain functionally ambulant. With regards to MPS, searches did not reveal specific MSK tests, but evidence suggests that skeletal malformations and joint problems were the most frequently presenting signs. pGALS performs well to identify abnormal joints with restriction within an MPS group.

Conclusion

This review supports the development of pGALSplus; a toolkit to facilitate identification and assessment of CYP with potentially serious MSK disease. pGALSplus will be targeted at community-based clinicians and will likely include physical examination, questionnaire(s) and appropriate adjuncts. Our group is currently developing pGALSplus, aiming to describe feasibility and acceptability, and develop educational and training resources, aimed at multi-professionals.

Conflicts of Interest

The authors declare no conflicts of interest.

Chronic pain and head injury following motor vehicle collisions: a double whammy or different sides of a coin

Chronic pain and head injury are common and burdensome sequelae of motor vehicle collisions. The aim of this study was to compare differences in physical injury and functional impairment, psychological distress and pain coping in head injured and non-head injured chronic pain persons subsequent to motor vehicle collisions. Two groups of 54 participants matched in terms of age, gender, and years of formal education underwent a psychological-legal assessment. As part of the assessment, participants completed the Multidimensional Pain Inventory, Sickness Impact Profile, Minnesota Multiphasic Personality Inventory-2, and Coping Strategies Questionnaires. Select scales from questionnaires were combined and underwent multivariate analyses of covariance to test the effects of pain sites at the time of psychological-legal assessment (low, high) and head injury status (head injured and non-head injured chronic pain). Overall, some differences between the two groups were noted but the results did not strongly support the hypothesis that head injured chronic pain participants have a greater physical or psychological burden than non-head injured chronic pain participants. The results suggest the import of assessing and managing pain sites and pain severity in persons injured in motor vehicle collisions.

Detecting altered postural control after cerebral concussion in athletes with normal postural stability

OBJECTIVE

To determine if approximate entropy (ApEn), a regularity statistic from non-linear dynamics, could detect changes in postural control during quiet standing in athletes with normal postural stability after cerebral concussion.

METHODS

The study was a retrospective, case series analysis of centre of pressure (COP) data collected during the Sensory Organization Test (SOT) from NCAA Division I (USA) athletes prior to and within 48 h after injury. Subjects were 21 male and six female athletes from a variety of sports who sustained a cerebral concussion between 1997 and 2003. After injury, athletes displayed normal postural stability equivalent to preseason levels. For comparison, COP data also were collected from 15 male and 15 female healthy non-athletes on two occasions. ApEn values were calculated for COP anterior-posterior (AP) and medial-lateral (ML) time series.

RESULTS

Compared to healthy subjects, COP oscillations among athletes generally became more regular (lower ApEn value) after injury despite the absence of postural instability. For AP time series, declines in ApEn values were much larger in SOT conditions 1 and 2 (approximately three times as large as the standard error of the mean) than for all other conditions. For ML time series, ApEn values declined after injury in all sensory conditions (F(1,55) = 6.36, p = 0.02).

CONCLUSIONS

Athletes who demonstrated normal postural stability after concussion nonetheless displayed subtle changes in postural control. Changes in ApEn may have represented a clinically abnormal finding. ApEn analysis of COP oscillations may be a valuable supplement to existing concussion assessment protocols for athletes.

Role of a clinical facilitator in introducing an integrated care pathway for the care of the dying

Integrated care pathways (ICPs) have been developed as a tool for improving end-of-life care. The Liverpool Care Pathway for the Dying (LCP) is a multidisciplinary and evidence-based approach to caring for the dying person. At Wythenshawe hospital a clinical facilitator was appointed to facilitate the introduction of the LCP. This full-time post, which existed for 18 months, involved supporting and educating staff about the pathway. The LCP is now used through the general surgical and medical wards and acute and regional coronary care units. This article reflects on the different aspects of the role and the development of the project.