Arthritis & Rheumatism, Volume 60,
October 2009 Abstract Supplement

The 2009 ACR/ARHP Annual Scientific Meeting
Philadelphia October 16-21, 2009.

An Evidence and Practice Based Regional Musculoskeletal Examination for School Aged ChildrenpREMS

Foster1,  Helen, Rapley1,  Tim, Heaven1,  Ben, Kay2,  Lesley, May1,  Carl

Newcastle University, Newcastle upon Tyne, United Kingdom
Newcastle Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom


Competent examination of the paediatric musculoskeletal (pMSK) system is essential in the process of making a diagnosis in children presenting with MSK complaints. The aim of this project was to develop a regional examination for school-aged children that is evidence based, age appropriate and brings together primary research on clinical technique, systematic review, and expert consensus in a similar format to REMS [Coady 2004].


Video observations of 89 MSK examinations by staff (doctors n=11; therapists n=8) of school-aged children attending outpatient clinics in 7 UK paediatric rheumatology centres, and 14 semi-structured review interviews with clinicians. Qualitative and quantitative analyses revealed descriptions, frequencies and variations in technique for joint regions in various clinical scenarios. Systematic literature review and data from clinical observation were combined to derive a proposed regional MSK examination with feedback from a further group of 37 pMSK experts through a web-based survey. All results were collated and discussed by consensus development groups to derive pREMS (paediatric Regional Examination of the MSK system).


Systematic review revealed little evidence about pMSK examination. Video observation showed variation in examination techniques used between therapists and doctors between orthopaedics and rheumatology, especially at the hip and the knee in the context of mechanical and inflammatory clinical scenarios and with differences from those techniques used in adult REMS. pREMS is based on "look, feel, move" similar to adult REMS but with the addition of a "measure" option (e.g muscle strength) with reference given to age specific range of joint movement. Further manoeuvres were added based on the clinical scenario (such as suspected hypermobility, mechanical knee pain) and including specific tests as appropriate (e.g patella apprehension test). Where there was variation in technique the consensus group proposed a test based on the study results and, where available, the literature. The consensus group decided that pREMS in entirety was aimed at trainees in paediatric rheumatology although some components of pREMS (e.g hip abduction and adduction) are essential for medical students and others were aimed at paediatric orthopaedics (e.g foot and thigh angle).


pREMS is the first evidence and consensus based regional examination for school aged children based on clinical practice, and gives a series of clinical manoeuvres that are relevant to clinical scenarios. A structured approach with guidance on the level of skills required for undergraduate and postgraduate medicine is an important step towards improved pMSK clinical skills relevant to clinical training.

To cite this abstract, please use the following information:
Foster, Helen, Rapley, Tim, Heaven, Ben, Kay, Lesley, May, Carl; An Evidence and Practice Based Regional Musculoskeletal Examination for School Aged ChildrenpREMS [abstract]. Arthritis Rheum 2009;60 Suppl 10 :253
DOI: 10.1002/art.25336

Abstract Supplement

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