The Manual Tender Point Survey

By: David Sinclair, MD, Terence W Starz, MD, Dennis C Turk, PhD (Jointly sponsored with the University of Pittsburgh School of Medicine Center For Continuing Education in the Health Sciences.)

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.

Survey Site Identification

Follow the numerical sequence:

1. Forehead (Control)

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

Procedure:

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

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

Procedure:

1. Support the head with the examiner's non-dominant hand on the 
   forehead.
2. 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.
3. 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:

1. Identify the midpoint of the upper border of the trapezius.
2. Press down.

6 & 7. Supraspinatus

Patient position: Seated
Examiner position: Beside and behind

Procedure:

1. 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:

1. Position one hand loosely on the iliac crest; the thumb falls naturally on the survey site on gluteus medius, just lateral to gluteus maximus.
2. Press perpendicularly with the examining thumb.

10 & 11. Low Cervical

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

Procedure:

1. Identify the tip of the mastoid process and cricoid cartilage (C6) below the thyroid cartilage.
2. Move the thumb straight down from the mastoid process to C5-C7 range (cricoid level).
3. Support the other side of the neck.
4. Press toward the opposite shoulder.

12 & 13. Second Rib

Patient position: Seated
Examiner position: Beside

Procedure:

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

14 & 15. Lateral Epicondyle

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

Procedure:

1. Support the forearm with the examiner's non-dominant hand.
2. Press over the muscle 2 cm distal to the lateral epicondyle.

16. Right Forearm (Control)

Patient position: Seated
Examiner position: Beside

Procedure:

1. Support the forearm with the examiner's non-dominant hand.
2. 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:

1. Support the thumb with the examiner's non-dominant hand.
2. Press the entire nail area of the left thumb.
3. 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:

1. 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:

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

Review

1. The patient should wear a standard gown for the examination.
2. The MTPS instructions are read to the patient before the examination.
3. Survey sites are examined in numerical order.
4. Each survey site is located first visually and then with light palpation.
5. Use the thumb pad of the dominant hand throughout the examination.
6. Thumb pad pressure should be applied perpendicularly to each survey site.
7. Each survey site is pressed once for a total of 4 seconds.
8. The thumb pad force is increased by 1 kg. per second up to 4 kg.
9. The patient responds "Yes" or "No" if there is any pain after testing each survey site.
10. 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."
11. The patient's response to the queries is immediately recorded on a scoring sheet.
12. 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.
13. 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.

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:

1. Accurate identification of the number of painful survey sites
2. Determination of a severity score for each survey site
3. Assessment of the patient's baseline pain perception using control points
4. Since it is likely that performance of the MTPS protocol will drift from the standard over time, periodic review of these guidelines is recommended.
5. 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.
6. 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.

The authors are grateful for the advice and criticism of the many people who contributed to the creation of this document. For more information on "The Manual Tender Point Survey" contact:

University of Pittsburgh Medical Center
Center for Continuing Education in the Health Sciences
522 Nese-Barkan Building
200 Lothrop Street
Pittsburgh, PA 15213
Attn. Linda Levine

Dennis C Turk, PhD
John and Emma Bonica Professor of Anesthesiology and Pain Research
Department of Anesthesiology
University of Washington
Seattle, WA 98195

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