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

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

  1. Musica

    Musica New Member

    Survey Site Identification

    Follow the numerical sequence:

    1. Forehead (Control)

    Patient position: Seated, head in neutral position.
    Examiner position: Front


    Support the back of the head with the examiner's non-
    dominant hand.
    Press perpendicularly to the center of the forehead.
    2 & 3. Occiput

    Patient position: Seated, head loosely flexed forward approximately thirty degrees
    Examiner position: Beside and behind


    Support the head with the examiner's non-dominant hand on the
    Move the examining thumb up midline of the neck to the nuchal
    ridge, then laterally one thumb width in the insertion of the suboccipital
    muscles on the occiput.
    Press at this point just below the nuchal ridge.
    4 & 5. Trapezius

    Patient position: Seated, head in neutral position
    Examiner position: Beside and behind


    Identify the midpoint of the upper border of the trapezius.
    Press down.
    6 & 7. Supraspinatus

    Patient position: Seated
    Examiner position: Beside and behind


    Press immediately above the scapular spine near the medial border of the scapula.

    8 & 9. Gluteal

    Patient position: Seated
    Examiner position: Beside and behind


    Position one hand loosely on the iliac crest; the thumb falls naturally on the survey site on gluteus medius, just lateral to gluteus maximus.
    Press perpendicularly with the examining thumb.
    10 & 11. Low Cervical

    Patient position: Seated, head in neutral position
    Examiner position: Beside


    Identify the tip of the mastoid process and cricoid cartilage (C6) below the thyroid cartilage.

    Move the thumb straight down from the mastoid process to C5-C7 range (cricoid level).

    Support the other side of the neck.

    Press toward the opposite shoulder.
    12 & 13. Second Rib

    Patient position: Seated
    Examiner position: Beside


    Find the sternal notch; move down to angle of Louis.
    Move to the 1st palpable rib (2nd rib), one thumb width lateral to manubrium sterni.
    Press the upper border.
    Support the patient's back.
    14 & 15. Lateral Epicondyle

    Patient position: Seated, hands on lap
    Examiner position: Beside


    Support the forearm with the examiner's non-dominant hand.
    Press over the muscle 2 cm distal to the lateral epicondyle.
    16. Right Forearm (Control)

    Patient position: Seated
    Examiner position: Beside


    Support the forearm with the examiner's non-dominant hand.
    Press over the muscle at junction of distal and middle 1/3 of forearm.
    17. Left Thumb (Control)

    Patient position: Seated
    Examiner position: Beside


    Support the thumb with the examiner's non-dominant hand.

    Press the entire nail area of the left thumb.

    Do not squeeze the thumb between the examiner's thumb and forefinger.
    18 & 19. Greater Trochanter

    Patient position: Lying on opposite side, leg loosely flexed at the hip and knee
    Examiner position: Beside


    Press perpendicularly one thumb width posterior to the trochanteric prominence.
    20 & 21. Knee

    Patient position: Lying on back, feet slightly apart
    Examiner position: Beside


    Press just above the joint line at the medial fat pad.

    The patient should wear a standard gown for the examination.
    The MTPS instructions are read to the patient before the examination.
    Survey sites are examined in numerical order.
    Each survey site is located first visually and then with light palpation.
    Use the thumb pad of the dominant hand throughout the examination.
    Thumb pad pressure should be applied perpendicularly to each survey site..
    Each survey site is pressed once for a total of 4 seconds.
    The thumb pad force is increased by 1 kg. per second up to 4 kg.
    The patient responds "Yes" or "No" if there is any pain after testing each survey site.
    The patient then rates the intensity of the pain on a scale from 0 to 10. Do not engage in lengthy discussions. Ask the patient to, "Give your best estimate."
    The patient's response to the queries is immediately recorded on a scoring sheet.
    A Fibromyalgia Intensity Score is determined by summing the patient's responses on the 0 to 10 scale for each survey site and dividing by 18.
    Patient's baseline rating of pain is determined by averaging the responses on the 0 to 10 score for each control site (sites 1, 16 and 17) and dividing by 3.
    Variations Encountered & Their Resolution

    Although the standardized protocol for the Manual Tender Point Survey (MTPS) is designed to increase reliability, response to physical examination is inherently liable to variabilities of human perception. Below are listed situations you may encounter in performing the MTPS. They should not significantly confound the MTPS process. Quite the contrary the behavioral characteristics should be noted and the non-verbal communication aspect of the patient's response recognized by the examiner.

    Patients will vary in their behavior during the MTPS including their response to the pressure application. Although observing the patient's expressions and body language enhances the overall assessment, the objectivity of these responses is difficult to assess reliability. These responses may be recorded along side the individual survey site scores but are not included in the formal scoring.

    On occasion a MTPS may be confounded to the point of being without value. Abandon the survey at least for that visit and note the reason.

    Problem Response
    1. Adipose tissue obscuring landmarks 1. Base survey site location on scoring sheet outline and directions as closely as possible.
    2. Injury present at survey site area 2. Note the finding.
    3. Patient remarks, §Thatïs not where I hurt...¥ 3. Examiner responds, §This is not just a search for sore spots. Itïs a survey of specific locations on your body.¥
    4. Patient announces response before you complete your pressure application. 4. Accept the response and advise the patient to allow the completion of the full pressure application, if possible.
    5. Patient withdraws before you achieve 4 kg. of pressure. 5. Accept this response and record the patientïs numerical score. Note that full pressure was not applied.
    6. Patient grabs your hand to prevent the pressure application. 6. Enlist patient cooperation for maintaining relaxed standardized posture.
    7. Assigning a number for pain may be difficult for a patient. 7. Remind her or him of the scale and say, §Giving your best estimate is sufficient.¥


    It is important to note that the diagnosis of FM requires both (1) the presence of widespread pain of at least three months' duration and (2) at least 11/18 positive survey sites. The presence of 11/18 positive sites alone is not sufficient for the diagnosis of FM.

    The techniques and guidelines outlined in this booklet are designed to facilitate the following:

    Accurate identification of the number of painful survey sites
    Determination of a severity score for each survey site
    Assessment of the patient's baseline pain perception using control points
    Since it is likely that performance of the MTPS protocol will drift from the standard over time, periodic review of these guidelines is recommended.
    Using a standard weight scale or dolorimeter, the examiner should repeatedly familiarize himself or herself with the "Feel of 4 Kilograms" at 4 to 5 week intervals.
    Different procedures to identify survey sites have been described. The MTPS techniques were chosen because of their ease of accurate reproducibility. The MTPS is an assessment of pain at very specific sites; it is not a search for all areas of musculoskeletal soreness.
  2. tigger5

    tigger5 New Member

    Thank you Musica!
  3. Musica

    Musica New Member

    You're welcome, to a fellow Washingtonian!

    Sorry, I did it a bit quickly. Here is a better and more concise description of where the tender points are:

    (1 & 2) Occiput: on both sides (bilateral), at the sub-occipital muscle insertions.
    (3 & 4) Low Cervical: bilateral, at the anterior aspects of the inter-transverse spaces.
    (5 & 6) Lateral Epicondyle: bilateral, 2 cm distal to the epicondyles
    (7 & 8) Knee: bilateral, at the medial fat pad proximal to the joint line.
    (9 & 10) Second Rib: bilateral, at the second costochondral junction, just lateral to the junctions on upper surfaces.
    (11 & 12) Trapezius: bilateral, at the midpoint of the upper border of the muscle.
    (13 & 14) Supraspinatus: bilateral, at origins, above the spine of the scapula (shoulder blade) near the medial border
    (15 & 16) Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.
    (17 & 18) Greater Trochanter: bilateral, posterior to the trochanteric prominence.

    Why Eleven Points?
    Some experts believe that a person does not need to have the required 11 tender points to be diagnosed and treated for fibromyalgia. This criterion was originally intended for research purposes. A diagnosis of fibromyalgia may still be made if a person has less than the 11 of the required tender points so long as they have widespread pain and many of the common symptoms and associated syndromes connected to fibromyalgia, such as sleep disorders and irritable bowel syndrome.

    If a patient has some symptoms but does not meet the tender point criterion, a diagnosis of "possible fibromyalgia syndrome" may be assigned. You should also remember that self-diagnosis is not advised and that you should consult a skilled medical professional to conduct a thorough examination.

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