PART B – The musculo-skeletal system Acute symptoms and signs Symptoms in the acute phase are severe pain in the neck and shoulder girdle and in the shoulder joints, and loss of function in the upper extremity. Occasionally, one or both shoulder joints may dislocate during the torture (Forrest, 2002). Neurological complaints indicative of plexus lesion are frequent: irradiating pain and reduced muscle strength in the upper extremities, accompanied by sensory disturbances, typically in the form of paraesthesia and reduced sensibility. At neurological examination, common findings are reduced muscle strength, most prominent distally, loss/reduction of tendon reflexes and sensory disturbances along the sensory nerve pathways (Allden et al., 2001). Symptoms and signs in the chronic phase Many torture victims who have been exposed to suspension by the arms, in particular Palestinian hanging, develop chronic disability with pain, reduced shoulder function and permanent neurological deficit, indicative of partial lesion of the brachial plexus, most often involving sensory modalities. Systematic studies – including radiodiagnostic evaluation of possible lesions in the shoulder joint caused by suspension – are, however, not available, and the pathogenesis of the long-lasting symptoms and shoulder dysfunction are therefore not fully understood. Neurogenic pain due to plexus lesion may, however, play an important role (Moreno & Grodin, 2002; Thomsen, Eriksen & SmidtNielsen, 2000). In the late stages, typical complaints are pain in the neck and shoulder girdle, deep pain in the shoulder joints during activity, especially in connection with overhead movements (abduction, inward rotation) and lifting, reduced range of movements in 19 the shoulder joints, feeling of instability in the shoulder joints or popping, locking sensations on movement. Neurological symptoms are likewise frequent: irradiating pain, muscle weakness with a feeling of heaviness in the upper extremities and various sensory disturbances, including vasomotor and sudomotor changes. At clinical examination, most of the findings are unspecific and confined to the soft tissues: typical findings are tender and trigger points in the neck and shoulder girdle, muscular imbalance with musculo-tendinous inflammation in dynamic shoulder stabilisers and shoulder impingement. At joint examination, a reduced range of active movement in the shoulder joint is common. Signs of habitual luxation/subluxation are rare, but upon specific testing, various degrees of instability may be present. At neurological examination, brachial plexus injury will manifest itself as sensory and motor deficit, depending on the severity of the nerve lesion. Reduced muscle strength, which often is asymmetrical and most pronounced distally as well as reduction/loss of tendon reflexes are signs of motor involvement. Sensory disturbances, which might involve different sensory modalities, are signs of sensory involvement. Clinical examination A clinical examination of torture victims submitted to suspension by the arms should include: 1. Examination of shoulder function: passive and active range of movement, joint stability, function of accessory shoulder joints, including scapula function 2. Examination of soft tissues: muscle relief, muscle tone and stretch range, tender and trigger points, tendinitis, shoulder impingement