Medical Screening

For our Osteopaths to use WITH patients - PLEASE READ BELOW

This page is a reference for our Osteopaths to work through with their patients. It is NOT meant as a reference for patients to use by themselves. Working through these screening questions without an appropriate healthcare professional can be misleading and fuel unnecessary anxiety.

Osteoporosis Screening

This work is based on the FRAX tool.

Risk factors in osteoporosis & related fractures include:

Female risk factors (low oestrogen)

  • Early menopause <45 yoa.

  • Hysterectomy <45 yoa.

  • Absent periods >6months from increased exercise or extreme dieting.

Male risk factors (low testosterone)

  • Steroids.

  • Alcohol misuse.

  • Hypogonadism.

 Hormone related disorders (undiagnosed)

  • Hyperthyroid.

  • Adrenal glands (increase glucocorticoids) e.g. Cushing’s syndrome.

  • Decrease Oestrogen & Testosterone.

  • Pituitary gland disorders e.g. Hypopituitarism.

  • Overactive parathyroid glands.

  • Type one diabetes.

Other risk factors

  • Sex: female > male.

  • Age: old > young. Bone loss starts between 20 & 40 but increases in later life.

  • Previous fracture: Previous fracture either spontaneously or from a trauma, which, in a healthy individual, would not normally result in a fracture then there’s a greater risk of it happening again.

  • Alcohol: No safe level of alcohol consumption but exceeding 14 units a week, 3+ units a day increases likelihood of developing osteoporosis.

  • Smoking.

  • Steroids (glucocorticoids). Daily dose of 5+mg prednisolone for more than 3 months.

  • Family history of osteoporosis.

  • Parental history of hip fracture.

  • BMI < 19.

  • History of eating disorders e.g Anorexia or Bulimia.

  • Rheumatoid Arthritis.

  • Malabsorption problems e.g. Coeliacs Disease or Crohn’s.

  • Some breast & prostate cancer medications.

  • Long term bed rest or inactivity (reduced chance with increased activity).

  • Chronic Liver Disease.

  • Local bone pathologies e.g. Osteogenesis Imperfecta.

Axial Spondyloarthritis (AxSpa) Screening

This work is based on the SPADE tool. The text is adapted from Zoe Clark, Osteopath.

  • Did your back pain & stiffness start before the age of 45?

  • Did your pain & stiffness develop gradually, with symptoms persisting at least three months?

  • Does your pain & stiffness tend to ease with physical activity & exercise?

  • Do you find there is no improvement in your back pain when you rest?

  • Do you suffer from increased back pain & discomfort when immobile during sleep, & start to feel better once up & moving?

  • Does the pain improve with NSAIDs?

  • Do you experience fatigue?

  • Do you have/have you had heel pain (enthesitis)?

  • Do you have peripheral arthritis/other joint pains or swellings? Do you have/have you had dactylitis?

  • Do you have a history of iritis/uveitis?

  • Do you have psoriasis?

  • Do you have inflammatory bowel disease (Crohn’s or Ulcerative Colitis)?

  • Do you have a family history of: - Axial SpA? - Reactive Arthritis? - Psoriasis? - IBD (Crohn’s or Ulcerative Colitis)? - Uveitis?

  • Have you had a blood test for ESR or CRP? If so, were they raised?

  • Are you HLA-B27 positive?

  • Do you have sacroiliitis shown by MRI?

Polymyalgia Rheumatica (PMR)

  • Inflammatory changes in capsules, bursa (<interspinous bursa Lsp and Csp & subacromial-subdeltoid buristis) & connective tissue surrounding tendons in hip, groin (<rectus femoris & adductor longus) & shoulders (<bicep tenosynovitis & glenohumeral synovitis).

  • Bilateral (may start unilateral) shoulder 95% of cases > neck & pelvis.

  • Systemic inflammation: distal arthritis < asymmetric knees & wrists, distal tenosynovitis (sometimes causing pitting oedema) & CTS.

  • Age: 50+ yoa <70+yoa ? age-related adrenal insufficiency (endocrinosenescene)

  • Sex: women > men.

  • Genetics: northern Europe > southern europe > africa.

  • Environmental: ?sunlight

  • Infection: virus e.g. Covid-19

  • Morning stiffness & pain on inactivity.

  • Rheumatological red flags: fatigue, malaise, weight loss from loss of appetite & nocturnal pain; fever associated with GCA.

  • Depression.

Giant Cell Arteritis (GCA)

  • Diplopia (double vision).

  • Pain around the eyes.

  • Flashing lights.

  • Colour changes.

  • Blurred vision.

  • Temporary loss of vision in one eye.

  • Sudden blindness in one or both eyes.


Hypermobility Screening

Risk factors: family history of EDS or hypermobility, Just GAPE questions: Joints & (U)other Soft Tissues, Gut, Allergy/atopy/autoimmune, Postural Symptoms, Exhaustion.

Beighton score >4:

  • Passive hyperextension of the 5th MCP beyond 90 degs.

  • In wrist flexion the thumb touches the forearm.

  • Hyperextension of the elbow 10+ degs.

  • Passive extension of the knee 10+ degs.

  • In forward flexion the hands touch the floor.

Cervical artery dissection (CAD) Vertebral Artery dissection (VAD)

Tear in the internal artery —> intramural haematoma &/or an aneurysmal dilatation.

CAD: 2.9/100,000 individuals per year.

ICAD 3–5 x > VAD.

Vascular pain < throbbing, pounding, pulsing, &/or beating.

CAD

Male: 46 yoa. Femae 41 yoa. Male 55% > female 45%. Extremely rare in children & > 65 yoa.

Most common symptom: h/a &/or neck (<sudden, sharp, severe) pain. H/a new & unilateral, sudden o/s, & may resemble a migraine or cluster h/a (unilateral).

Other symptoms: Horner’s & lower cranial nerve palsy. The time from initial symptoms to ischaemic stroke minutes to a few weeks.

Onset: spontaneous, neck trauma <hyperextension & rotation (VAD > CAD & ICAD as VA abruptly transitions from a vertical to horizontal path in C1 TP).

CAD <extension. No excess risk of CAD stroke in manipulation.

Risk factors for CAD:

  • Recent acute respiratory infection.

  • Vitamin B6, B9, B12 deficiency.

  • Low body mass index & low cholesterol.

  • Smoking.

  • Pulsating tinnitus.

  • Medical &/or family history of arterial anomalies &/or CAD.

  • Connective tissue disorders i.e. Ehlers–Danlos syndrome type IV, Marfan’s syndrome, Osteogenesis Imperfecta, or Loeys–Dietz syndrome. 

ICA

ICA: < blood to brain < anterior portion including retina. ECA: face, scalp, skull & meninges.

Symptoms (ipsilateral to affected artery) often mild. Unilateral neck pain (including  upper anterior cervical) commonly with h/a (periorbital, frontal). ICA upper cervical pain with no other migraine or cluster h/a symptoms.  

Anterior circulation: retinal &/or cerebral ischaemic symptoms:

  • Hemiparesis.

  • Hemisensory loss.

  • Neglect.

  • Aphasia.

  • Gaze deviation.

  • Dysarthria.

  • Monocular visual loss.

Extracranial ICA aneurysm: CNXII>CNIX-XI due to proximity of ICA in neck.

Intracranial ICA rupture: Subarachnoid Haemorrhage (SAH) (sudden o/s severe h/a).

ICA location = unlikely neck manipulation complications. 

VAD

Symptoms VAD:

  • Stroke: 67%.

  • TIA: 10%.

  • Unilateral occipital/nuchal line &/or neck pain (ipsilateral): 12%. H/a can mimic ICAD (periorbital, frontal) but with occipital pain.

  • SAH (sudeen o/s severe h/a) without ischaemia: 2%.

  • Sensorimotor cervical radiculopathy C5/C6: 1%. 

VA strains in contralateral neck rotation. VA>CA & ICA physical injury as VA abruptly transitions from a vertical to a horizontal path in C1 TP. Neck manipulation does not exceed failure strains of VA. No changes in blood flow in VA of healthy young male adults during neck manipulation.

VA: posterior portion of the brain —> brainstem ischaemic symptoms:

  • Cerebellar ischaemia: ataxia, vertigo, &/or nystagmus. Lateropulsion > dizziness in VA pathology. Loss of balance with no proprioception or visual disorders = not vestibular/unconscious proprioceptive systems.

  • Ipsilateral loss of pain & contralateral temperature sensation.

  • Ipsilateral hemiparesis.

  • Nausea/vomiting.

  • Vertigo.

  • Nystagmus (III, IV, VI, cerebellar, vestibular), diplopia (III, IV, VI), dysphagia (IX<X) & dysarthria (V, VII, IX, X, XII & spinal nerves), dysphonia (X).

VA stenosis uncommon in healthy people. VAD risk factors:

  • Most common: CVS risk factors —> VA atherosclerotis: dizziness, visual dysfunction, or cognitive dysfunction > neck pain

  • Arterial hypoplasia.

  • Rotational occlusion.

  • Coagulopathy.

  • Drug abuse.

  • Migraine

Chaibi A, Russell MB (2019). A risk-benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review.

Chu EC, Trager RJ, Tao C, Lee LY (2022). Chiropractic Management of Neck Pain Complicated by Symptomatic Vertebral Artery Stenosis and Dizziness

Li H, Wei N, Zhang L, Liu X, Han J (2020). Body lateropulsion as the primary manifestation of medulla oblongata infarction: a case report