Paediatric musculoskeletal matters (pmm) – collaborative development of an online evidence based interactive learning tool and information resource for education in paediatric musculoskeletal medicine

Musculoskeletal (MSK) complaints in children and young people (CYP) are common with a wide spectrum of causes [1‐4]. In many cases the cause of the symptoms is benign, self-limiting or trauma related but the differential diagnosis is broad and MSK symptoms can be presenting features of serious and potentially life threatening illnesses such as malignancy, vasculitis, sepsis, non-accidental injury and also chronic diseases such as muscle disease, arthritis or neurodisability. Delay in diagnosis and access to care are well reported in childhood diseases that often present with MSK features including cancer, muscular dystrophy and juvenile idiopathic arthritis (JIA) [4‐7]. The reasons for delay are multifactorial [8] including complex pathways, and CYP with MSK concerns invariably present to primary care or various secondary care specialties (usually general paediatrics, orthopaedics or emergency care) [9]; many such doctors report a lack of awareness about MSK disease in CYP, and in particular about arthritis in CYP. Likewise, evidence suggests that many doctors lack confidence and competence in their paediatric MSK clinical skills [5‐7, 10] stemming from a lack of MSK teaching at undergraduate [11] and postgraduate level [12‐15]. Such unmet need is also observed in nurses who may encounter CYP in their clinical practice [16, 17]. Patients and families of CYP with chronic MSK disease report that raising awareness, earlier diagnosis and referral for specialist care are amongst their top priorities to improve clinical outcomes [personal communication Sharon Douglas UK Paediatric Rheumatology Clinical Studies Group (CSG), [18].

We have previously developed novel examination tools to aid joint examination in CYP; paediatric Gait Arms Legs Spine (pGALS) [19] and paediatric Regional Examination of the Musculoskeletal System (pREMS) [20]; and core MSK learning outcomes for primary care doctors [21] and medical students [22]. pGALS is widely taught in medical schools in the UK [23] and internationally. Since publication in 2011, pREMS is increasingly taught albeit targeted at postgraduate training. The interpretation of pGALS and pREMS needs knowledge and context to optimise their utility in clinical practice. This manuscript describes the process to develop Paediatric Musculoskeletal Matters (pmm) – www.​pmmonline.​org - as an online resource designed to host resources to facilitate learning of pGALS, pREMS and core learning needs. pmm was designed originally to target medical students and primary care doctors, although the content is relevant to paediatricians and other clinicians involved in the care of CYP.

Our collaborative and evidence based approach to develop pmm has resulted in an open free e-resource, available using various technologies and targeting non-specialists in paediatric musculoskeletal medicine. This resource – paediatric musculoskeletal matters- pmm- we believe, is the first such resource to target these user groups. User engagement from the start aimed to ensure design and functionality to address their respective needs.

The content of pmm is evidence-based to address learning outcomes for medical students and primary care although the essential knowledge is important to paediatric trainees, general paediatricians and indeed all clinicians involved in the care of CYP. It is envisaged that pmm will be useful to members of the international paediatric rheumatology community who are engaged in the teaching of medical students and non-specialist clinicians. A parallel site – pmm for nurses - is in progress (launch due 2016). We envisage that pmm is an important step to inform a wide target audience, provide knowledge to improve assessment of CYP with MSK presentations and ultimately facilitate earlier diagnosis and referral to specialists.

We acknowledge limitations in our approach. The content of pmm is based on the learning outcomes with the target audience of medical students and primary care doctors working in the UK. The stakeholder representatives were from the UK and mainly recruited from the North of England. However the process of peer review and user feedback since the launch of pmm has involved a wider (UK and international) audience. Feedback confirmed the design and functionality of pmm to be appropriate and english remains the preferred language although translations of key pages (e.g. pGALS instructions) have been requested. Iterations of pmm after peer review have enabled further content to be added (e.g. neuromuscular medicine) and optimised the validity of the resource. pmm is relevant to a spectrum of users (other than medical students and primary care) and regarded as a foundation for further learning; paediatricians who wish to build on their knowledge are encouraged to pursue further training (e.g. EULAR online course in paediatric rheumatology - http://​www.​eular.​org/​edu_​online_​course_​paediatric.​cfm).

Peer review has also suggested further clinical images to reflect ethnic diversity and the spectrum of disease presentations in different parts of the world. pmm for India (September 2015) is an exemplar of partnership between the project team and local paediatricians to develop pmm for their health care context. Further ‘internationalisation’ of pmm is planned as well as a pmm app to aid access to information where Internet access is limited. Future work will focus on evaluating pmm in terms of user experience, real-time access and how pmm influences learning and decision making in the clinical context.