The musculoskeletal examination: GALS

GALS - 步态，手臂，腿部和脊柱 - 屏幕由三个简单的问题组成，并进行了简短的检查，以检测明显的肌肉骨骼异常^（1）。在进行更集中的检查之前，它也可以用作筛选工具。

^（1）Doherty M, Dacre J, Dieppe P and Snaith M, 1992.The 'GALS' locomotor screen。Annals of the Rheumatic Diseases, 51(10), pp.1165-1169.

Screening questions that assess the musculoskeletal system should be incorporated into the routine systemic enquiry of every patient. As discussed, the main symptoms arising from disorders of the musculoskeletal system are pain, stiffness, swelling, and associated functional problems. The screening questions we use to directly address these areas are:

问题	Rationale
Do you have any pain, swelling or stiffness in your muscles, joints or back?	focuses on the common symptoms of a musculoskeletal problem
Can you dress yourself completely without any difficulty?	focuses on upper limb function
您可以在毫无困难的情况下上下楼梯上走来走去吗？	focuses on lower limb function

没有疼痛或僵硬的患者，穿衣或爬楼梯没有困难的患者不太可能患有任何明显的肌肉骨骼疾病。如果患者确实有疼痛或僵硬，或者在这两项活动中都有困难，则应采用更详细的病史。

该检查设计用于常规临床评估，需要1-2分钟才能进行。它涉及仔细检查关节肿胀和异常姿势，并评估正常运动的关节。

If an abnormality of an individual area is noted in the GALS screen, that area should be examined in more detail using the relevant regional examination routine (REMS). The GALS screen is not designed to tell you what the problem is, only that there is a problem that requires further assessment.

这四个要素的顺序（步态，手臂，腿和脊柱）评估可以变化 - 实际上，在要求患者躺在沙发上之前，完成患者站立的元素通常更方便。

Introduction

It is important to introduce yourself, explain to the patient what you are going to do, gain verbal consent to examine, and ask the patient to let you know if you cause them any pain or discomfort at any time. In all cases it is important to make the patient feel comfortable about being examined and this extends to the clothing they wear and level of exposure.

A good musculoskeletal examination relies on patient cooperation, in order for them to relax their muscles, but also the ability to view and compare joints and muscle groups if important clinical signs are not to be missed.

• 要求患者走几步，转过身。观察患者的步态以保持对称性，平滑度和快速转动的能力。
• With the patient standing in the anatomical position, observe from behind, from the side, and from in front for:
  • bulk and symmetry of the shoulder, gluteal, quadriceps and calf muscles
  • 肢体对齐
  • alignment of the spine
  • equal level of the iliac crests
  • ability to fully extend the elbows and knees
  • popliteal swelling
  • 脚部异常，例如过高或低的拱形轮廓，脚趾的爪/缩回和/或胆管外翻的存在（见图6）。

• 请病人把手放在头后。这评估了肩部绑架（受肩袖问题影响的第一运动）和外旋转（受藻类问题影响的第一运动）。它还评估肘部屈曲。
• 要求患者完全伸直手臂，以评估全肘部伸展（受肘部问题影响的第一乐章）。
• With the patient’s hands held out, palms down, fingers outstretched, observe the backs of the hands for joint swelling and deformity. Inspect the nails and skin at the same time.
• Ask the patient to turn their hands over (the movement of supination assesses both wrist and elbow movement).
• Look at the palms for muscle bulk and for any visual signs of abnormality.
• Ask the patient to make a fist. Visually assess power grip, hand and wrist function, and range of movement in the fingers.
• 请病人挤压手指。评估握力强度。
• 要求患者依次携带每只手指以满足拇指。评估精细的精密捏合（在功能上很重要）。
• Gently squeeze across the metacarpophalangeal (MCP) joints (see image below) to check for tenderness suggesting inflammation within the joints. (Be sure to watch the patient’s face for non-verbal signs of discomfort.)

• With the patient lying on the couch, assess full flexion and extension of both knees, feeling over the tibiofemoral joint line for crepitus during the movements.
• With the hip and knee flexed to 90°, holding the knee and ankle to guide the movement, assess internal rotation of each hip in flexion (this is often the first movement affected by hip problems).
• Perform a check for a knee effusion using either a patellar tap or a sweep/bulge test:
  • For a patellar tap, slide your hand down the thigh, pushing down over the suprapatellar pouch so that any effusion is forced behind the patella. When you reach the upper pole of the patella, keep your hand there and maintain pressure. Use two or three fingers of the other hand to push the patella down gently (see image below). Does it bounce and ‘tap’? This indicates the presence of a relatively large effusion.
    
    
    
    
    
    
    
    
    
    
    
    
    
  • 可能无法通过tap tap测试检测到小积液，并且扫描/凸起测试可能很有用。要进行扫描/凸起测试，请向上抚摸膝盖的内侧（朝向肩部小袋）清空液体的内侧隔室，然后向下（远端）抚摸侧面（请参见下图）。内侧可能会补充并产生大量表明积液的液体。
    
    
    
    
    
    
• 从沙发的尽头，检查脚是否有局部或普遍的肿胀，畸形，例如术语，脚趾爪，以及通常发生在metatrangepherangeal关节（MTP）下的鞋底上的call骨。
• 挤在质量法（MTP）关节上，以检查暗示炎症性关节疾病的压痛。（请务必观看患者的脸是否有不适的迹象。）

• 在患者站立的情况下，从后面检查脊柱，以证明脊柱侧弯的证据，并从侧面检查异常的神经病或脑膜炎。请注意，最初从后面看肩膀，然后是骨盆，膝盖的背部，然后是脚踝，请注意任何明显的不对称性。
• Ask the patient to tilt their head to each side, bringing the ear towards the shoulder. This assesses lateral flexion of the neck, which is sensitive in the detection of early neck problems.
• 要求患者弯下腰触摸他们的脚趾。该运动是受腰椎问题影响的第一运动，在功能上很重要（对于敷料）。但是，可以通过依靠良好的臀部屈曲来实现这一点，因此触诊椎骨的正常运动很重要。通过在腰椎上放置两个或三个手指来评估腰椎屈曲。您的手指应在屈曲中分开，然后在延伸中返回（请参见下图）。

重要的是正面和negati记录ve findings in the notes. The presence or absence of changes – in appearance or movement – in the gait, arms, legs or spine should be recorded. For a normal result ‘GALS: NAD’ is sufficient. If there are abnormalities such as swelling or restriction of movement, these should be recorded with a brief descriptive note.

如果您因筛查问题，检查或患者的自发抱怨而被警告，您将需要详细的病史（如上所述）。您还应该对相关关节进行区域检查 - 可以在其中找到有关如何执行此操作的详细信息肌肉骨骼检查：REMS页面。