Survey Site Identification Follow the numerical sequence: 1. Forehead (Control) Patient position: Seated, head in neutral position. Examiner position: Front Procedure: 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 Procedure: Support the head with the examiner's non-dominant hand on the forehead. 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 Procedure: Identify the midpoint of the upper border of the trapezius. Press down. 6 & 7. Supraspinatus Patient position: Seated Examiner position: Beside and behind Procedure: Press immediately above the scapular spine near the medial border of the scapula. 8 & 9. Gluteal Patient position: Seated Examiner position: Beside and behind Procedure: 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 Procedure: 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 Procedure: 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 Procedure: 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 Procedure: 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 Procedure: 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 Procedure: Press perpendicularly one thumb width posterior to the trochanteric prominence. 20 & 21. Knee Patient position: Lying on back, feet slightly apart Examiner position: Beside Procedure: Press just above the joint line at the medial fat pad. Review 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.¥ Afterward 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.