on 2 individuals previously diagnosed with RA. The group
then reconvened and discussed the findings of each patient to
ensure that they had consistently recorded the observations,
which included the location (i.e., left hand) and details (i.e.,
Heberden’s nodes) of each abnormality. The health care
professionals were also trained to record when the signs or
symptoms resembled those of a diagnosis of a bone or joint
disorder by indicating the possible condition (e.g., query right
knee osteoarthritis, query RA) in the comments section. The
health care professionals were then informed about the study
day procedures (which took place 1 week following the training
session) and were told the objective of the study would be to
assess the agreement among each other in their findings of
each GALS examination feature on the study participants.
Participants.The participants for this study (target n 50)
were recruited from 2 rheumatology practices. Twenty five
individuals previously diagnosed with RA, according to
the American College of Rheumatology criteria (16), were
identified as eligible by their treating rheumatologists, who
were third-party investigators not involved with assessing
participants on the study day (16). These RA patients, all 50
years of age and capable of giving informed consent, generally
had early or mild disease. Recruitment of these participants
from specialists’ practices ensured that an adequate number of
RA patients were included in the study to assess sensitivity and
specificity. An additional 25 individuals were randomly selected
from one of the previously mentioned rheumatology practices.
These participants were eligible if they were 50 years of age,
capable of giving informed consent, and did not have RA or
any other type of inflammatory arthritis. The time elapsed
between recruitment and the study day was 2 months.
On the study day, the health care professionals and study
participants were randomly divided into 2 groups. Group
A included 1 rheumatologist, 1 family physician, 2 nurse
practitioners, and half of each of the RA and non-RA
participants. Group B was comprised of 1 rheumatologist, 2
family physicians, 1 nurse practitioner, and the remaining
study participants. Therefore, each participant was assessed
by 4 health care professionals. All participating health care
professionals and study investigators were blinded to the
participants’ health status (RA or no RA) and recruitment
methods to ensure that they did not know that half of the study
participants had previously been diagnosed with RA.
Study procedures. Each health care professional was allotted
6 minutes to conduct the GALS examination and record any
observed abnormalities for each participant. Each health care
professional assessed participants sequentially by rotating from
one examination room to the next. The study participants wore
a gown during the examinations to ensure adequate exposure
of the back. The GALS examination commenced with 3
questions followed by a physical assessment of the gait and
the appearance and movement of the arms, legs, and spine as
abnormal or normal (Table 2). If or when an abnormality was
Table 2. Individual features assessed in the Gait, Arms,
Legs, and Spine examination
Gait
Symmetry and smoothness of movement
Stride length and mechanics
Ability to turn normally and quickly
Arms
Hands
Wrist/finger swelling/deformity
Squeeze across second to fifth metacarpals to check
tenderness (indicates synovitis)
Turn hands over to inspect muscle wasting and
assess forearm pronation and supination
Grip strength
Power grip (tight fist)
Precision grip (oppose each finger to thumb)
Elbows
Full extension
Shoulders
Abduction and external rotation of shoulders
Legs
Feet
Squeeze across metatarsals for tenderness (indicates
synovitis)
Calluses
Knees
Knee swelling/deformity, effusion
Quadriceps muscle bulk
Crepitus during passive knee flexion
Hips
Check internal rotation of hips
Spine
Inspection from behind
Shoulders and iliac crest height symmetry
Scoliosis
Paraspinal muscle
Shoulder, buttock, thigh, and calve muscles bulk
Popliteal or hindfoot swelling or deformity
Inspection from the front
Quadriceps bulk and symmetry
Swelling or varus or valgus deformity at knee
Forefoot of midfoot deformity, action normal
Ear against shoulder on either side to check lateral
cervical spine flexion
Hands behind head with elbows back (check rotator
cuff muscles, acromioclavicular joints,sternoclavicular joints,
and elbow joints)
Inspection from the side
Normal thoracic and lumbar lordosis
Normal cervical kyphosis
Normal flexion (lumbosacral rhythm from lumbar lordosis to
kyphosis) while touching toes
Trigger point
Supraspinatus muscle tenderness (exaggerated response)
Current Pedorthics
January/February 2014
37