The Tender Point Test for healthcare professionals

Fri, 30 May 2008 12:00:00 +0100

The Tender Point test is the only test for Fibromyalgia Syndrome (as opposed to for excluding differential diagnoses) that is routinely carried out in the clinical setting. However little or no training in performing the test is often given and variations in carrying it out impact heavily on its effectiveness as a diagnostic tool.

It should be noted that the choice of 11 out of the standard 18 tender points as a diagnostic for Fibromyalgia Syndrome was originally devised as an inclusion test for research and that 11 is an arbitary number. Examiners should also take into account that tender point test scores are typically lower in men than in women. [1]

According to the 1990 ACR Criteria for the Classification of Fibromyalgia, "digital palpation should be performed [on the standard tender point sites] with an approximate force of 4 kg. For a tender point to be considered "positive" the subject must state that the palpation was painful. "Tender is not to be considered "painful." [2]

The thumb pad of the examiner's dominant hand can be used to apply pressure to the evaluation sites during the tender-point examination. This allows the examiner to detect important tactile cues, such as the existence of myofascial trigger points around a tender point site which can lead to a false positive.

There are some common sense guidelines, based on the requirements of the ACR Criteria, for conducting a tender point examination, including:

Taking into account that the patient's position during examination, the amount of force applied at the evaluation site, the number of times the evaluation site is palpated, and the method of applying force (instrument vs finger pad) may influence tender-point sensitivity.
Ensuring that they (the examiner) know how to recognise myofascial trigger points so as to differentiate between these and tender points. The most obvious signs are that a myofascial trigger point, unlike a tender point, will likely feel like a knot in the muscle and should refer pain or other symptoms elsewhere.
Telling the patient before beginning the examination that they need to respond to each tender point examination. The patient should respond with a “yes” or “no” if they have any pain at the site being examined. If the patient's response is “yes,” the examiner should ideally get them to rate the pain on a scale of 0 (no pain) to 10 (worst pain), and record each response.
Only palpating each tender point once. It will be easier for the examiner if the patient is in a standard, easy access hospital gown and is in a comfortable position, either sitting or lying down. The examiner should locate the tender point position visually before applying any pressure and should then apply a force equivalent to 4kg, which should be sufficient to blanch the nail bed of the thumb used. The tender point should be palpated for long enough for the patient to respond: some doctors recommend a constant palpation for 4 seconds.
There are control sites that can be palpated and recorded to provide baseline documentation of the patient's pain perception. These sites should be less painful and include the nail of the thumbs and the forehead.

The 1990 ACR criteria for the location of tender points are as follows:

Occiput: Bilateral, at the suboccipital muscle insertions.
Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7.
Trapezius: bilateral, at the midpoint of the upper border.
Supraspinatus: bilateral, at origins, above the scapula spine near the medial border.
Second rib: bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces.
Lateral epicondyle: bilateral, 2 cm distal to the epicondyles.
Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.
Greater trochanter: bilateral, posterior to the trochanteric prominence.
Knee: bilateral, at the medial fat pad proximal to the joint line.

References:

Clauw, DJ. Fibromyalgia: Update on Mechanisms and Management. Journal of Clinical Rheumatology: Volume 13(2)April 2007pp 102-109.
Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum 1990;33:160---72.

EULAR Guidelines for Fibromyalgia

Sun, 08 Jun 2008 12:00:00 +0100

In July 2007, the European League Against Rheumatism (EULAR) published the first set of evidence based recommendations for the management of Fibromyalgia Syndrome. E-published in July 2007, the article describing the development of these recommendations then appeared in the April 2008 edition of the Annals of the Rheumatic Diseases.

With the objective of developing evidence-based recommendations for the management of Fibromyalgia Syndrome, a multidisciplinary task force was formed representing 11 European countries. The researchers, including a number of Britons, said that:

"Although effective treatments are available no guidelines exist for management of [Fibromyalgia Syndrome]"

The task force carried out a systematic review of the literature with the keywords "fibromyalgia", "treatment or management" and "trial". Studies were excluded from consideration if they did not use the American College of Rheumatology (ACR) criteria for the classification of Fibromyalgia Syndrome, were not clinical trials, or included patients with chronic fatigue syndrome or myalgic encephalomyelitis. The primary outcome measures looked for were change in pain assessed by visual analogue scale and fibromyalgia impact questionnaire. The task force categorised the quality of the studies based on randomisation, blinding and allocation concealment and only the highest quality studies were used to base recommendations on.

One hundred and forty-six studies were found to be eligible for the review and 39 pharmacological intervention studies and 59 non-pharmacological were included for the final recommendations after those of a lower quality or with insufficient data were separated.

Identified categories of treatment were antidepressants, analgesics, and "other pharmacological" and exercise, cognitive behavioural therapy, education, dietary interventions and "other non-pharmacological". Nine recommendations for the management of fibromyalgia syndrome were developed using a systematic review and expert consensus. However, in many studies the sample size was small and the quality of the study was insufficient for strong recommendations to be made. EULAR intends to update the recommendations every 5 years, incorporating findings from good-quality clinical trials that will add to the currently available evidence.

The task force said in summary that:

"These recommendations are the first to be commissioned for FMS, although previous reviews have addressed the area ... [they] should assist health care providers, with asecondary intention to incorporate information into materials for patients."

Specific recommendations in these guidelines regarding general considerations for management of FMS are as follows:

Comprehensive evaluation of pain, function, and psychosocial context is needed to understand FMS completely, because it is a complex, heterogeneous condition involving abnormal pain processing and other secondary features (level of evidence, IV D).

Optimal treatment of FMS mandates a multidisciplinary approach, which should include a combination of nonpharmacologic and pharmacologic interventions. After discussion with the patient, treatment modalities should be specifically tailored based on pain intensity, function, and associated features such as depression, fatigue, and sleep disturbance (level of evidence, IV D).

Specific recommendations on nonpharmacologic management of FMS are as follows:

Heated pool treatment, with or without exercise, is effective (level of evidence, IIa B).

For some patients with FMS, individually tailored exercise programs can be helpful. These may include aerobic exercise and strength training (level of evidence, IIb C).

For certain patients with FMS, cognitive behavioral therapy may be beneficial (level of evidence,IV D).

Based on the specific needs of the patient, relaxation, rehabilitation, physiotherapy, psychological support, and other modalities may be indicated (level of evidence, IIb C).

Specific recommendations on pharmacologic management are as follows:

Tramadol is recommended for management of pain (level of evidence, Ib A). Although other treatment options may include simple analgesics (eg, paracetamol) and other weak opioids, corticosteroids and strong opioids are not recommended (level of evidence, IV D).

Antidepressants are recommended for the treatment of FMS because they decrease pain and often improve function (level of evidence, Ib A). Appropriate options may include amitriptyline, fluoxetine, duloxetine, milnacipran, moclobemide, and pirlindole.

Tropisetron, pramipexole, and pregabalin are recommended for the treatment of FMS because they reduce pain (level of evidence, Ib A).

The limits of the recommendations include the small size of some studies and the use of other outcome measures in studies meaning that they were excluded from consideration. The assessment of strength of evidence tends to favour pharmacological studies as double blinding and placebo controls are impossible in many non-pharmacological studies. However, most non-pharmacological interventions are safe and have other health benefits and these important factors were taken into account. In some areas evidence was lacking due to the poor quality of the studies and expert opinion had to be used as a factor.

Reference: Carville SF, Arendt-Nielsen S, Bliddal H, Blotman F, Branco JC, Buskila D, Da Silva JA, Danneskiold-Samsøe B, Dincer F, Henriksson C, Henriksson KG, Kosek E, Longley K, McCarthy GM, Perrot S, Puszczewicz M, Sarzi-Puttini P, Silman A, Späth M, Choy EH; EULAR. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008 Apr;67(4):536-41. Epub 2007 Jul 20.

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The Tender Point Test for healthcare professionals

EULAR Guidelines for Fibromyalgia