Hey, I'm Hyper Mobile and if you're listening to this, I'm
guessing you might be too. Hi, my name is Alex and I'm your
hyper mobile host and today we are talking all about the bait
and scale. Now for those of you who don't
know what the bait and scale is, trust me, you're going to want
to stick around for this one. There's a love story, there's
travel to distant lands, there's controversy and most excitingly
there's room for improvement. There's something here that we
can certainly look at I think at least and make better, which is
really, really exciting when you're dealing with hyper mobile
connective tissue and sometimes injuries and conditions where if
people can feel often. Quite stuck, so this is exciting
for me in my clinical work as an osteopath based in the UK.
Now the bait and Scale. First we got to talk about what
it is right. Before we go any further, the
bait and Scale is an assessment tool for looking at something
called generalized joint hyper mobility.
Now it's important to note that generalized joint hyper mobility
is not a diagnosis, it's not a diagnosis like for example
Hyperbody Spectrum Disorder or hyper mobile Ehlers Den Loss
Syndrome. Generalized joint hyper mobility
is simply a. And in fact approximately 10% of
the population will demonstrate generalized joint hypermobility.
So it's something which can truly be benign, it can be
harmless. You you see hypermobile people,
they do exist where they're not having issues and they're not in
pain because they don't have a connective tissue disorder.
However, generalized joint hypermobility is a hallmark sign
of conditions like for example hypermobile others animals
syndrome and hyperbility spectrum disorder and whereas
10% of the population. Can demonstrate generalized
joint hyper mobility only approximately one in 500 people
will have the diagnosis of hyper mobility syndrome or hyperbility
spectrum disorder. As always, if you're looking for
my research or sorry the research that I'm citing, it's
certainly not my research, but the research by the wonderful
researchers out there that I am referring to.
You can find it in the show notes.
Now we have this tool which helps us look in theory at
patients and their hyper and their hyper mobility or lack
thereof and. And this tool has become so
ingrained in the assessment of hyper mobile joints that it's
actually even part of the 2017 HEDS diagnostic criteria, in
fact, in that tripartite criteria.
So there's three parts to it. The bait and scale really makes
up the majority of about 1/3 of it.
The part A, there's part A/B and C and the bait and scale really
makes up almost 1/3 of that diagnostic criteria.
So it's something which we all have to deal with whether you
like it or not, but before we. Get into seven of the biggest
problems with with the baton scale, which I can't wait to
talk about and two solutions which may be on the horizon
perhaps if if we keep making progress in this field and keep
improving what we're doing as clinicians, we're going to start
at the very beginning. Because I think to really
understand something you do need to go back to the beginning and
we're going back to 1964. So in 1964 we had something
called the Carter and Wilkinson scale and this was a scale that
was made to assess congenital hip issue.
Using children. So we were actually looking at
the range of motion in joints and infants and this scale was a
paired scale. So in order to get the point on
this scale you had to have both hips for example demonstrated to
be hyper mobile or whatever it was.
I'm not an expert in that scale, OK, but the joints were paired.
You couldn't just have the right side be hyper mobile, you had to
have the left side too. Now at that time there was a
gentleman named Peter Baton and he was actually working.
I believe it was St. Thomas's hospital around that
time and he would later go on to.
Become a geneticist and contribute a huge amount of
research to this hyper mobility field.
He published over 430 medical articles.
Now not to be undone, he had a he had a wife.
They have actually both passed away.
He passed away I believe it was a few weeks ago actually, and
she passed away quite a few years ago now.
But he had a wife named who went on to become named Greta Baton
and she was working as a social worker and a midwife and a nurse
and somehow their paths. Crossed and through their shared
love of the assessment of joint hyper mobility, they went on to
do a lot of amazing things together in this field and the
Baden scale was actually developed as part of their
research looking at semi nomadic tribes people in the Kalahari
Desert. So Greta and Peter needed a
scale that would allow them to assess hyper mobility in this
population of people who probably didn't speak very good,
if any English who didn't really know them they were researchers
going into. Man, that was quite far away.
Trying to collect data on the hyper mobility in that
population. And again I use the word
population because unlike in a clinical setting which is 1 to
one, you have the healthcare provider and the patient.
These were researchers looking at what they probably really
wanted to be a very large sample size because better data will
usually come from a larger sample size.
So they needed a tool and it was actually Greta who came up with
the idea of modifying and building upon the Carter and
Will. Kinson scale and her major
contribution was unpairing the joints.
So instead of for example having to have the right thumb and the
left thumb be hyper mobile, she said, you know what, we're all a
little bit different side to side and I think people should
get the point even if they're only hyper mobile on the right
hand side for example. So that was the the big step in
terms of progress there. She also changed the card on
Wilkinson scale so you didn't have to have every single finger
be hyper mobile. It just became the pinky that we
were looking at, the pinky and the thumb and so on and there
are a few modifications there, but that's.
How we got to the bait and scale, which we know and some
people love, some people hate, but regardless that's how where
we got to where we are today. Now the bait and scale is is
problematic in nature. If you've seen any of my
contacts online, you know I have some issues with it because so
often I see patients who end up coming to me in my clinical work
as an osteopath who specializes in working with hyper mobile
patients in the UK. And they're telling me, I was
told I failed the bait and scale and that was my whole assessment
and I don't know what to do and firstly the bait and scale.
Should not be used as a comprehensive assessment when
you're looking at someone trying to figure out if they're hyper
mobile or not. As much as there are some good
things about the bait and scale and I'll talk about those for a
minute. There are many, many issues with
it. So in terms of good things about
this bait and scale, it certainly was an improvement
from the Carter and Wilkinson scale and it worked really well
for Greta and Peter's research purposes.
They were dealing with people where they wanted something
quick, something that was really easy.
Something that didn't involve them having to awkwardly touch
people who they didn't know. Assessing someone's hip hyper
mobility passively requires you to touch their hips, right?
So they developed a scale which worked beautifully for their
research purposes. And this scale, again, it was
not made for a 1 to 1 clinical setting.
It was developed for researchers looking at large populations.
They just wanted to get that data so they could then go do
their research and look into the hyper mobility of that
population. This bait and scale was adopted
by the medical community. Some someone must have seen, I
don't know who, but they saw the bait and scale and it started to
be used medically. And that was how it really
became part of the Medical Assessment of Generalized Joint
Hyper Mobility. It was adopted.
However, what's really, really weird is it hasn't been changed
since then, and because I'm I'm just so excited to start
speaking about the problems with the bait and scale, we're just
going to get into it now. OK, so here are these 7
problems, seven of the biggest problems of the bait and scale.
My original list was much longer, but it is a deeply
flawed scale. So firstly, the bait and scale
was initially developed to study large populations as an
epidemiological research tool, and I've already said this
during this podcast. But a tool that is made to look
at a large population is not going to necessarily be really
good at looking at a smaller population or a sample size even
of 1 like we see in a clinical setting.
We need different tools for different things and the bait
and scale all. Though it worked, really, or it
seems to work quite well on larger population sizes, it
seems to have some issues when we're looking at the all of the
quirks and anomalies and unique presentations that we see when
we're looking just at one patient.
Additionally, no rationale was provided for which joints were
chosen from a medical perspective.
So the joints were selected, and the joints that were selected
were the two thumbs, the two elbows, the two pinkies, the two
knees and touching the floor. And Greta and Peter, as far as
I'm aware, never provided a clear justification of why they
chose those joints. We can certainly speculate, and
I do speculate that they chose those joints because they were
easily accessible when dealing with a.
Population which they, you know, they were strangers to.
They were, they were researchers coming there to gather that data
and they chose something that was quick and easy.
However, in healthcare settings, it is essential that we don't
prioritize something being quick and easy over what's actually
best for the patient in terms of assessment.
So the baiting scale, although I think perhaps it became so
popular because it's so quick and it's so easy, it doesn't
necessarily mean that it became popular because it was the best
way of assessing hyper mobility in joints additionally.
There are no explicit instructions on how to do the
bait and scale. There's not even any clear
instruction whether it's to be done actively or passively.
The bait and scale is done differently by different people.
I've observed different healthcare providers in
different clinical settings and everyone will do it a little bit
differently. And this creates problems,
obviously. In terms of replicability, my 7
out of nine bait and scale might not be the same as some other
healthcare providers. 7 out of nine bait and scale and this
introduces. An element of subjectivity into
the medical assessment of patients and again, we need to
remember that part of Healthcare is there are a lot of subjective
things that affect healthcare and that affect clinical
decision making. But whenever possible and
reasonable, we do want to try and reduce how that influences
patient care. The next point is that there's
no real age or ethnicity adjustment.
So we know that different people with different ethnic
backgrounds or different ages are going to have different
joint mobility. It's well.
Documented that mobility can vary depending on the population
that we're looking at and that for example the mobility of
joints in children is going to be different than the mobility
of the joints that we see in a quote UN quote normal 60 year
old. Now recently in the 2017 HGDS
diagnostic criteria they did actually for what I believe is
the first time put in age guidelines for what constitutes
a positive or what do you what do you call a successful
maintenance score but that's the first time that's happened.
And it's it shouldn't. It's surprising that it takes us
so long to see very sensible things like that start to make
their appearances. And although good science is
slow science, it's surprising that it does take that long to
see what I consider to be relatively straightforward and
basic changes start to become. Official In terms of how things
are meant to be done, continuing with problems, there is no
explicitly agreed upon and validated Positive score for a
score of four out of nine is typically considered to be
indicative of generalized joint hyper mobility.
But there nobody has come out. No research consortium or group
of individuals, no no particular authority.
You know, Greta and Peter didn't offer this either.
No one said this is what this is what needs to be counted as
positive for generalized joint. Vulnerability.
There are some people who will count to 3, some people who will
count to 5. Four is for the most part what
you see in terms of clinical practice.
But again there is no official this a score of this or greater
is hyper mobile. It really doesn't seem to be the
case. And again this can lead to a lot
of confusion in patients and variability in terms of how this
scale is scored by healthcare providers.
It's also important to note that six out of the nine points.
So remember, every single joint is a point, and touching the
floor is the weird point that gives gets us to #9.
But anyways, out of the nine points available, six of those
points are found in the upper extremities, which is the
technical term for your arms. Six of the points are in the
upper extremities. I cannot tell you how often I
see patients who have, for example, hypermobile hips.
Which are not counted or acknowledged by the bait and
hypermobile ankles, Which again, are not counted or acknowledged
by the bait and scale. Hypermobile toes, again, they
don't matter. Hypermobile jaws, hypermobile
spines, all. None of those joints matter.
None of those joints are taken into account in the bait and
scale. And this is deeply problematic
because there are some hyperbole, people who don't have
that much upper extremity hypermobility, but who do have
more of the hyperability in their lower extremities or their
spine, and they are a completely neglected patient group.
And that's these are the people who most often I end up seeing
in clinic, who have tried to do everything right, but they're
hitting walls. And it's simply because their
body was not part of the thought process and the development and
adoption of the scale by the wider medical community.
And it's not their fault. They're just getting stuck.
Because they're hitting a wall. And my final problem with the
bait and scale is that there is no such thing as 1/2 point.
It is a binary scale. It is a yes or no scale.
So for example, I will see patients whose thumbs can almost
touch their forearms, but because they don't touch, they
don't get the point. There's no room for discretion.
There's no room for for anything other than a binary yes, no
outcome in this scale. And that does, certainly.
Problems for patients, especially for patients who may
have been more hypermobile in, for example, a joint like their
thumb when they were younger but who have now aged.
And as a part of the natural aging consequence, natural aging
consequence, they are no longer hypermobile in that joint.
So we have people again who are perhaps being told that they
fail the bait and scale when actually they don't.
And in this type of situation what we're seeing is someone
who. Really is hyper mobile.
Who would have had those points maybe a decade ago but who now
as due to the natural consequences of aging has lost
that mobility in those joints and is going to be missed if
they are only assessed using the bait and scale.
Now before I talk about alternatives to the bait and
scale and what I think we can do better as a field and I say this
is a healthcare provider myself, right?
And I want to believe that we can do better and we must do
better. I want to give you a tip now
there's a brilliant research paper which I'm going to link in
the show notes. If you're someone who's having
issues with the bait and scale you feel like you're hyper
mobile, you're a medical provider or healthcare provider.
They're they're saying you're not and you're really really
confused by all of this. You must go read that research
paper. It's from the 2021 Rheumatology
International Journal and it's called the Bait and Score as a
measure of generalized joint Hyper mobility and it's by Malik
Reinhold and Pierce and it is the best discussion of the bait
and scale that I've seen ever possibly And what's really
interesting is after their analysis of the bait and.
Scale and looking at a lot of studies which have used it and
how it works or doesn't work, They go on to say this in the
conclusion. The evidence presented here
brings into question the validity of the Baden scale as a
direct and indirect indicator of generalized joint hyper mobility
and disputes its continued use as a diagnostic tool.
Now, if you're someone who doesn't do a lot of scientific
writing, you might not be aware of how strongly worded that is
for a scientific paper. So scientific writing is always
measured, it's always precise. That's how it has to be.
And to see 3 researchers in a major journal writing from that,
from a from a position of such strength where they feel
confident enough to say that means that there there are
issues with the scale. At least that's how I interpret
this. These researchers went on to say
that the current use of a negative bait and scale score to
exclude the presence of generalized joint hyper mobility
is a practice that must be discontinued and again very,
very strong rooting there. What they're trying to
communicate is that a bait and score that's found to be
positive, so typically that's going to be a great four or
greater out of nine, that that score does accurately identify
people who have generalized joint hyper mobility.
However, there are some people who really should qualify as
having generalized joint hyper mobility who are scoring.
In less than four out of nine on the bait and scale, and those
people are being missed. So in patients who are scoring
less than four out of nine, the bait and scale is potentially
creating harm. These researchers go on to say
that ultimately this is not only diagnostically inaccurate, but
could also deny a patient their fundamental right to a correct
diagnosis and hence access to appropriate support.
Instead, the bait and scale should be used as intended, IE
as an initial screening method after which other notable
joints, for example the shoulder, hips, ankles and
remaining digits could be examined.
So what these researchers are saying is look the bait and
scale. It's not bad for a kind of quick
and dirty initial assessment, but it by number means is
perfect. And this is the attitude that we
really need to adopt in this field.
Field is OK, we can talk about a bait and scale.
You know, we can give patients a bait and score, but is it good
enough? And I really think it's not.
Now, there are alternative scales, but unfortunately
they're not used very often and there's not much information on
them. Three that you might want to try
and look up are the Hospital Del Mar criteria, the Rotez Carol
criteria, and I'm sorry if I mispronounced that I've tried my
best, and the lower limb assessment score.
The problem with these different scoring systems and why they're
not used as often is precisely that because they're not used as
often, they haven't been used in published research as much.
And we don't really know. Not enough about them to know if
they work well or not. However, from my position as
someone who has looked a little bit into them, they seem to be
better in some ways. For example, the Hospital Del
Mar criteria does look at people's hips, which I think is
really important. It includes a more comprehensive
assessment which which is really what we need.
Another reason why I think that these alternative scales are not
used very often is simply because they're time consuming
and I hate doing this, but we always have to think of the
business side of healthcare and whether that would be time
constraints in a public healthcare setting or in a
private healthcare setting. Because remember, clinicians
want to get you in and out because it's they're trying to
see as many patients as possible, right?
And again, that's that's just how it works, OK.
We always have to think of the system of the healthcare system
in which we are existing. Patients.
But if you have something that's really quick, do you want to do
something that takes longer? Potentially not as a community.
It seems like there's always so much discussion about genetics
research and looking for gene therapies.
And while that's all wonderful and I think it's great that
we're looking into those types of treatment options, I really
think that improving the bait and scale would be such a
wonderful place to start and I think it would do so much good
for so many people. The bait and scale has existed
for 50 years. It was first made in 19. 73
We're in 2023 now and I believe it's time for a change.
My hope is that we will start to see more and more healthcare
providers doing a holistic assessment of patients and
looking at all their joints and looking at the ranges of motion
and using that to inform their understanding of that patients
generalized joint hyper mobility or lack thereof.
But I hope that you leave today's episode knowing a bit
more about the bait and scale, why it's something that's used
so widely today and why it is far from perfect now if you
found today's. Episode helpful.
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Obviously it's not medical advice, it cannot be medical
advice, but it can be so helpful sometimes to hear what other
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And you know some of the Physiology behind hypermobility
and how living in a hypermobile body can make sense sometimes
when you think about some of the science behind it.
Anyways, if you want to join, be sure to check that out the link.
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