For Tigger and others: The 18 Point Test - Part I

Discussion in 'Fibromyalgia Main Forum' started by Musica, Dec 2, 2005.

  1. Musica

    Musica New Member

    This is from the FM Aware site. I believe it is under the Health Professionals tab. It describes how it is done. There are pictures on the site as to where the tender points are, but you probably know those! LOL However, here are the names of where they are. I don't know how many actually ask patients to rate the degree of pain.


    Widespread musculoskeletal pain has long plagued humankind. It made its appearance in past epochs as lumbago, muscular rheumatism, and fibrositis. Most recently the condition has been labeled as fibromyalgia (FM).

    Although etiology and pathophysiology of FM are widely debated, the clinical entity described as FM is estimated to affect from three to six million people in the United States. Historically, there has been great variability in the criteria used for diagnosing FM. The American College of Rheumatology (ACR) conducted a multicenter study published in 1990 that specified two primary criteria that characterized FM: (1) three or more months of widespread pain defined as pain present above and below the waist on the right and left side of the body and along the midline and (2) report of pain at a minimum of 11/18 specified locations (tender points - TPs) throughout the body when palpated with 4 kilograms of digital pressure. These two criteria were selected from a number of variables examined as they were shown to reliably discriminate FM from other musculoskeletal disorders in the multicenter study.

    TPs are widely distributed throughout the musculoskeletal system. They are typically located in the muscle bodies, over tendinous insertions and at bony prominences. The anatomic and physiological mechanisms accounting for the presence of TPs have received great attention but explanation for their origin remains unclear.

    A number of factors may influence the sensitivity of TPs during an examination: (1) the amount of force applied at the survey site, (2) the number of times (single versus repeated) and method (finger pad, dolorimeter) by which the force is applied, (3) the patient's position, which affects muscle tone and survey site localization. The sequence of site examination may influence the patient's response based on the anchoring effect of sensations experienced at prior survey sites. A standardized examination procedure enhances the reliability of survey site reporting, interobserver reproducibility, the comparability of research studies and the direction of treatment modalities.

    The Manual Tender Point Survey (MTPS) outlined in this document describes a technique requiring approximately 5-10 minutes to perform. It is based on the 1990 American College of Rheumatology tender point protocol for FM. This guide will (1) describe the pressure application technique, (2) discuss the precise identification of survey sites, and (3) review the complete Manual Tender Point Survey examination including the standardized examination procedure and patient instructions.

    Pressure Application Techniques

    The standard procedure for applying pressure in the Manual Tender Point Survey (MTPS) uses the thumb pad of the examiner's dominant hand. This method was adopted because it has been shown to be as reliable as the use of a dolorimeter (strain gauge). Also, it allows the examiner to make use of important tactile cues.

    Survey sites are first located visually (see figure at right) and then with light palpation.
    Then apply thumb pad pressure perpendicular to each survey site.
    Each survey is pressed for a total of 4 seconds only once to avoid sensitization that may occur with repeated palpation.
    The force is increased by 1 kg. per second until 4 kg. of pressure is achieved.
    Whitening of the examiner's nail bed usually occurs when applying the 4 kg. force.
    Learning the Feel of 4 Kilograms

    A simple method to learn the feel of 4 kilograms can be developed by using a standard weight scale.

    The examiner stands behind the practice subject.
    The scale is first set at the weight of the subject.
    4 kg. is then added to the subject's balanced weight.
    At the trapezius survey site, enough pressure is applied perpendicularly with the thumb pad of the dominant hand to return the scale into balance.
    A dolorimeter may also be used to assist the examiner to acquire the feel of 4 kg of force.
    Procedural Guidelines & Patient Instructions

    The MTPS should be performed at the beginning of the physical examination because other examination procedures may sensitize the specified points to the palpation pressure.
    The patient should wear a standard gown to permit easy access to palpation sites.
    A scoring sheet is used to record the results of the examination.

    Read the statement from the scoring sheet:
    "Various areas of your body will be examined for pain. Please say 'Yes' or 'No' if there is any pain when I press a specific point."

    If a patient responds, "Yes" to indicate a site is painful, the examiner should assess the patient's perception of the pain severity by asking her/him to rate the pain on a 0 to 10 scale.
    Explanation of the scale is also read to the patient:

    "I want you to rate the intensity of the pain on a scale from 0 to 10. 0 is no pain and 10 is the worst pain that you have ever experienced." ( After testing survey site 9, the patient should be reminded of the meaning of the pain scale to reinforce their understanding of the range.)

    The 18 survey sites and 3 control sites are examined in the designated numerical order. The figure above shows the general location of survey sites.

    Individuals vary in their judgment of what constitutes a painful sensation. The purpose of the control sites is to reveal the baseline of the patient's pain perception.
    For survey sites 1-17, the patient should sit on the end of the exam table.

    Survey sites 18 and 19 are tested with the patient lying on her/his contralateral side from the site to be tested.
    The patient should lie on her/his back with feet slightly apart for survey sites 20 and 21.

    Following the testing at each survey site, the examiner asks the patient, "Is that painful?" After the response, the examiner will ask her/him to "Please rate the pain from 0 to 10." The response is immediately recorded on the scoring sheet where indicated.

    Some patients may have difficulty following the instructions. When this happens, repeat the instructions and reassure the patient that "Giving your best estimate is sufficient." Avoid lengthy discussions or explanations.
    The Fibromyalgia Intensity Score is obtained by averaging the scores of the 18 survey sites (sum of the pain severity ratings divided by 18). The scores of the control sites may be averaged. These values may be helpful when following patients through serial examinations over time and to make comparisons among patients.

    ***Specific testing sites will follow in Part II***
  2. justjanelle

    justjanelle New Member

    back onto page 1.

    Best wishes,

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