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I have included a few things from Doctor Starlanyl. Her books have helped me tremendously, especially when I first heard the word Fibromyalgia from my Doctor.

All the information that follows can be found at http://www.sover.net/~devstar/ There is also a lot more information there, that anyone with FMS/MPS should read... along with her book!

Information for Your Rheumatologist & Primary Care Physician Devin Starlanyl & Ken Hoelscher

This information may be freely copied and distributed only if unaltered, with complete original content including: © Devin Starlanyl, 1995-1999

Please read the preceding section "What Everyone on Your Health Care Team Should Know."

Who Gets Fibromyalgia and Myofascial Pain Syndrome?

People of any age can get FMS/MPS, even children. Infant colic is often caused by trigger points (TrPs) that can be relieved with gentle Spray and Stretch and Cranio-Sacral Release. Fibromyalgia (FMS) in youth usually starts with a flu-like illness, and then manifests as "growing pains," which can also be a manifestation of TrPs. Only 25 percent of all patients with FMS are men. There is no gender bias in Myofascial Pain Syndrome (MPS). If you catch FMS/MPS early, and can teach your young patients how to handle it, you can give them a good chance at life.

Undiagnosed, children with developing FMS and/or MPS are often shunted aside as "behavior problems." Once you find the right combination of medications, physical therapy, and coping skills, your patient can avoid many of the absences from school that would otherwise occur. There is a chapter on FMS/MPS in young people in My first book (Starlanyl and Copeland 1996), and I have noted common childhood trigger points (TrPs) in My video, as they are noted in the medical texts Myofascial Pain and Dysfunction: The Trigger Point Manuals, Volume I and Volume II by Travell and Simons (1992; 1983).

Physiological Information

Any patient with diffuse bodywide aches of long duration, coupled with a sleeping disorder (inability to stay asleep, very light sleep, and/or inability to get restorative sleep) should be evaluated for fibromyalgia (FMS). Those sleep problems indicate the presence of the alpha-delta sleep anomaly, which is common in FMS. Patients with specific patterns of referred pain (trigger points), indications of blood vessel, lymph, or nerve entrapment or proprioceptive disturbances should be evaluated for Myofascial Pain Syndrome (MPS).

Once you become familiar with the concepts behind the diagnoses of FMS and MPS, your diagnostic skills will become sharper and you will more easily be able to separate the two conditions, even when they co-exist in the same patient. It is important to understand the differences, as this changes treatment strategies (Borg-Stein and Stein 1996).

Tender Points of FMS Hurt in Place

These tender points are often found in the official "eighteen locations." In cases of traumatic FMS, they may be clustered near trauma sites (including degenerative changes such as those from OA or DDD, or surgical incisions). Muhammad Yunus, M.D., has found that, when testing for tender points of fibromyalgia, a good indicator of proper pressure is that when you use your thumb to press, you notice a blanching of the fingernail. This produces 4 kg of pressure (Yunus 1988).

Trigger Points of MPS Refer Pain to Other Parts of the Body

Trigger points (TrPs) may be active or latent. Latent TrPs restrict movement and cause muscle weakness, but don't cause pain until they are activated by immobility, stress, or one of many possible perpetuating factors. Be gentle when checking for TrPs. Pressing TrPs can aggravate them and cause pain, which can stay with your patient for days. Individual TrPs can be difficult to live with, but they often respond immediately to specific therapy.

It is not unusual in cases of FMS/MPS Complex for the muscles to feel as hard as cement. You may be unable to palpate the TrPs or tender points, or even to feel the ropy bands. Often, it is easier to palpate ropy bands in the forearm if the arm is extended three-quarters of the way. Once electrical muscle stimulation, Spray and Stretch, and other physical therapy modalities have been used to break up the myofascial splinting, and all the perpetuating factors have been brought under control, you will be able to palpate the TrPs.

Perpetuating Factors

If an altered HPA axis, altered metabolism, and reactive hypoglycemia have conspired to create obesity, or if there is extreme muscle guarding, rely on your patient's history to give you an indication of the pattern of possible TrPs. As you know, a careful history is the most important part of the physical exam. Check for perpetuating factors. The most common perpetuating factors of TrPs are the following conditions: Fibromyalgia, impaired sleep, reactive hypoglycemia, paradoxical breathing, hypothyroid, skeletal asymmetry and disproportion. Also consider nutritional inadequacies, anything that impairs muscle metabolism, exposure to toxins, chronic infections, psychological factors, allergies, and inappropriate physical therapy and stress.

I have seen too many patients with active TrPs who were put into weight-training and work-hardening programs, which changed them from injured people into totally disabled people. Listen to your patient.

Because of their healthy appearance, FMS patients are frequently denied the support that other handicapped patients take for granted. Ask your patient to set realistic vocational, social, and recreational goals. Prescribing exercise should be considered as carefully as writing a prescription. You need the right dose, the right timing, and the right kind.

It's not uncommon for patients to feel nausea or a dramatic increase in muscle aches, especially headaches, and/or exhaustion after any physical therapy has moved a large amount of toxins and wastes from their constricted muscles. Warn patients to take it easy after physical therapy. Some people blame FMS on deconditioning. This has been shown to be a fallacy.

Everyone who is physically deconditioned does not get FMS. Conversely, some extremely athletic people have developed FMS as a result of traumas received while they were in peak physical condition. As TrPs are inactivated, the patient should begin carefully graded exercises to increase strength and endurance. You need to work with a good physical therapist who is knowledgeable about both FMS and MPS. Initially, the patient may be able to tolerate only one short session once a week. The body needs time to process released toxins and waste. There is good evidence that continuing exercise in spite of pain simply aggravates the abnormal pain filter (Bennett 1997).

Fibromyalgia amplifies the pain and other symptoms of myofascial trigger points. FMS/MPS Complex is not to be taken lightly.

Neither are individual trigger points. Travell and Simons say, "A swimmer may drown from a muscle cramp produced by a myofascial trigger point. Myofascial pain has driven some patients to suicide. Myofascial back pain is a major, unrecognized source of industrial disability" (1983, 18). Pain is a large factor in FMS and MPS and is also a major perpetuating factor for both conditions. FMS sensitivity amplifies the pain of MPS.

The general diffuse aching that is characteristic of FMS should not be confused with the specific trigger point sites and other symptomology of MPS. If TrPsrecur after effective treatments, there are hidden perpetuating factors.

If the pain recurs but the TrP is gone, look for another cause, including cancer and other systemic diseases.

Delayed-onset muscle soreness, which appears a day or two following overexertion, is a function of FMS and not of TrPs. Above all, doctors must believe that their patients hurt as much as they say they do. To take a good history, the physician must first be willing to believe the patient. Undiagnosed FMS/MPS pain can be all-consuming, and even though the patient may look fine, many patients have been driven to suicide. Three FMS patients have made the news in the last three years because they chose the "Kevorkian option." Chronic pain can kill (Liebeskind 1991; Fishbain, Goldberg, Rosomoff, et al. 1991).

Psychological Information Your patients may become confused or extremely stressed during office visits. They may have been misdiagnosed previously, perhaps several times. They may have been accused of malingering or of being neurotic psychosomatics. On the Internet, we call it the "It's All In Your Head" syndrome, or IAIYH. If you do have such patients, they should ask a family member or a trusted friend to accompany them to your office.

Depression is often a result of chronic pain syndromes. This is especially true when patients have had a long period of undiagnosed illness, or when their doctors and family have repeatedly said to them, "It's all in your head." It is true that some patients do have emotional problems, and these can worsen the physical symptoms of MPS.

Often, the constant effort of dealing with their so-called "untreatable pain" has reduced physical activity, limited social life, impaired sleep, caused loss or change of family role, and perhaps been responsible for loss or change of job.

Think about it. Suppose you had lost your ability to practice medicine because you could no longer trust your fine motor control, and your ankles buckled. Suppose pain had become your constant companion and you felt confused and inarticulate most of the time. Yet through it all you continued to look just fine, and no one believed your account of your symptoms. How would you feel? Depressed? Misunderstood?

Acute pain that diminishes in the course of a natural healing process is generally manageable psychologically, but recurrent or persistent pain caused by an unrecognized cause threatens future function and well-being. It can lead to frustration, depression, and progressive disability. When patients mistakenly believe that they must live with and endure undiagnosed TrP pain because they have been told it is arthritis, they restrict their activities to avoid the pain. Then, their TrPs become latent. Patients must learn that TrPs are responsive to proper treatment. Conversations with patients should be about empowerment, not invalidation.

If relevant, order tests to identify coexisting conditions that might be contributing factors. Look for indications of reactive hypoglycemia. It is very common in FMS/MPS Complex and often does not show up on the gtt.

Take the time to talk with your patient. Take the time to listen. If you ask the right questions, you'll find out what you need to know.

TENS units are not the best electrical unit for breaking up trigger points, because they don't create the necessary muscle contraction. Microstim, neuromuscular electrical stimulation, and galvanic stimulation work well. Home units are available with a prescription.

Trigger point injections can be part of an overall therapy regimen, but they do not stand alone, and they must be done properly, with proper positioning of the patient for each muscle, range of motion exercises during the injection session, and other myotherapy indicated by Travell and Simons. You must still identify and deal with the perpetuating factors.

Stretched and injected muscles are likely to be sore for two to three days following treatment. Strenuous activities should be avoided while the muscles are sore, including shopping, gardening, and traveling.

Patients with FMS/MPS Complex may not find injections as effective as will patients with just MPS. The injections may hurt more, and their effects may last for shorter periods of time. See the Travell and Simons Trigger Point Manuals (1998, 1992). Each specific trigger point injection technique is described in detail in those books. If you get a chance to attend a seminar on FMS and/or MPS, do so. I'm sure you will find it worth your time:

Contact Robert Gerwin, M.D., for information on Travell Myofascial Pain Seminars at (301) 656-0220.

Contact Mary Maloney, P.T., at (203) 723-0533, for information on trigger point seminars.

Contact Richard van Why, R.N., M.Div., M.L.S., for information on FMS regional seminars at (301) 698-0932.

Myofascial Pain and Dysfunction: The Trigger Point Manual Volume I edition 2 by Simons, Travell and Simons 1998 and Volume II by Travell and Simons 1992 should be in your library and in your hospital library. The causes, perpetuators, and remedies for trigger points are all there. Keep the manuals on your desk and refer to them often.

The Journal of Musculoskeletal Pain is an excellent source of new information, and don't neglect the Fibromyalgia Network Newsletter. It is a quick read, and summarizes much of the current ongoing research. It also provides you with a patient's-eye view of FMS, with tips on coping mechanisms. The treatment of FMS/MPS can be a "throw away your crutches and walk" kind of experience that is all too rare in a physician's life.

It is not that unusual to have an undiagnosed patient come to you on crutches, or even in a wheelchair, and within a few months of treatment to see that patient walk again.

Bennett, R. M. 1997. Fibromyalgia Network Newsletter. (July, p. 5) P. O. Box 31750. Tucson, AZ 85751-1750.

Borg-Stein, J. and J. Stein. 1996. Trigger points and tender points: One and the same? Does injection treatment help? Rheum Dis Clin N Am 22 (2):305–322.

Consensus Document on Fibromyalgia: The Copenhagen Declaration. 1992. Published in Lancet, vol. 340, Sept. 12, 1992, and J Musculoskel Pain 1(3/4) 1993.

Fishbain, D. A., M. Goldberg, R. S. Rosomoff and H. Rosomoff. 1991. Completed suicide in chronic pain. Clin J Pain 7(1):29–36.

Liebeskind, J. C. 1991. Pain can kill. Pain 44(1):3–4.

Simons, D. G., J. G. Travell and L. S. Simons. 1998. Travell and Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume I: The Upper Body. Baltimore: Williams and Wilkins.

Starlanyl, D. J. and M. E. Copeland. 1996. Fibromyalgia & Chronic Myofascial Pain Syndrome: A Survival Manual. Oakland: New Harbinger Publications.

Travell, J. G. and D. G. Simons. 1992. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume II: The Lower Body. Baltimore: Williams and Wilkins.

Yunus, M. B. 1988. Diagnosis, etiology and management of fibromyalgia syndrome:An update. Compr Ther 14(4):8-20.

*Anti-candida antibody test:

Immunodiagnostic Laboratory

San Leandro CA 94577

IgG levels indicate a chronic problem. IgA reading indicates problems in mucous lining of sinus, lung, gut, vagina. IgM reading indicates recent yeast problem.

**Total T4 and T3 uptake often gives false negatives for thyroid. We need B2T panel -- Total T4, Free T4, total T3 and TSH to indicate true state of thyroid. Patients with low-normal thyroid often respond well to T3 therapy.

Headaches Due to Myofascial Trigger Points

Devin Starlanyl, MD

This information may be freely copied and distributed only if unaltered, with complete original content.

There are many possible causes of headache. For people with the hyper aroused autonomic nervous system of FMS, sensitivity to noise, cold, heat and light can add to our headache woes.

Allergies, fatigue, hormonal imbalances, reactive hypoglycemia, congestion, vasomotor rhinitis, and neurotransmitter dysregulation can also be factors. By far, however, the most common cause of headaches is referred pain from myofascial trigger points (TrPs). All the before-mentioned factors often activate and/or perpetuate TrPs. Since TrPs can entrap blood and lymph vessels as well as nerves, TrP pain is often confused with neurological, rheumatic, or inflammatory pain, especially with some of the more bizarre autonomic symptoms that can occur. TrP headache pain is often variable, and may change with body position or muscular activity. It may be so severe at times that you can't function or even think clearly. TrPs refer pain elsewhere in specific patterns, so it is important to become familiar with the pattern and any possible accompanying symptoms, as well as the location of the instigating trigger point. All of these TrPs are documented in the detailed medical texts "Myofascial Pain and Dysfunction: The Trigger Point Manuals" Vol I and II by Janet G. Travell and David G. Simons.

The frontalis muscle is part of the broad musculo-fibrous layer of the occipito-frontalis muscle, which stretches across the forehead, top and back of the skull. The frontalis portion is -- you guessed it -- in the front. TrPs in the frontalis muscle remain local, causing pain over the forehead, often radiating upwards over the scalp. The TrPs will let themselves be known to you, they aren't shy. When you press them, they scream at you, "HERE I AM!" You usually feel like screaming right back at them, "GO AWAY!" These TrPs are often activated by overwork, especially in tense people who have a lot of facial expression.

Occipitalis TrPs cause local pain over the area of the rest of the skull, but also refer pain to the back of the head, pain through the skull, and to the back of the eyeball. You often can feel the lumps and bumps of the TrPs with your fingers. These may become so severe that you cannot bear weight of back of your head on a pillow. TrPs in the head and neck region respond to moist heat, unless there is nerve entrapment. Then, ice will help. Massage is beneficial, as well as CranioSacral Release (CSR) and Spray and Stretch (S&S), but you also must check for perpetuating factors such as stress, eye strain and overwork.

Temporalis TrPs occur in a line a little beyond the outer edge of the eye to just behind the tip of the ear. Each temporalis TrP refers pain in a different pattern. The one closest to the eye refers pain over eyebrow, straight up the side of the head, and the front upper teeth. TrPs further back along the line to the ear refer pain to different teeth. The further back the TrP, the further back the tooth or teeth. They also refer pain upwards of their position, causing headache.

TrPs in the extrinsic eye muscles are a frequent contributor to headaches. For your vision to be clear, both eyes must take the same picture at the same time, and all the muscles of each eye must work together in harmony. A misalignment of the eyes can be caused by TrPs in any of these muscles. Double vision, blurry vision and/or changing vision can result if these muscles are being contracted at different tension. Put one hand on your head, above your forehead. Then, keeping your head still, try to look at your hand. This shouldn't hurt. If it does, the TrPs are calling to you, letting you know they're around. Move your eyes from one upper corner to the other, but do this gently. This may activate the TrPs and cause a headache. This does not mean you shouldn't do the exercise -- it is a warning letting you know how badly these stretches are needed. Start slowly, and go gently, but keep at it. Remember to vary your gaze -- look up and out once in a while when you are doing close work. Poorly fitting glasses or improperly corrected vision can contribute to your headaches. This is especially tiresome if your vision is changing constantly due to these extrinsic TrPs. TrPs around the eyes are also likely to be involved. Get into the habit of doing acupressure work on your face and neck for brief periods, whenever you have the time. Check for masseter TrPs along the lower border of the jaw just after the "corner". These TrPs, by no means the only possible ones in the masseter, refer pain along the eyebrow line, as well as to an area along the side of the lower jaw, contributing to headaches. TrPs in the lateral pterygoid muscle are found about an inch in front of the center of the outer ear, and about an inch below that. These TrPs refer pain in front of the ear and pain deep in the TMJ and the maxillary sinuses. Both of these, especially the sinus pain, can add to headache misery. There is a TrP in the back of the digastric muscle that sometimes refers pain to the back of the skull. You can find this TrP right off the corner of the lower jaw, immediately next to it in the throat. It also radiates to the upper part of the sternocleidomastoid (SCM) -- which is an exceedingly complex muscle we'll tackle later. The spillover pain can be from the front of the throat under the chin along the line of the jaw, much worse under the ear, and continuing to extend upward and backward in a diagonal nearly to the back of the head.

In the neck, as in many other parts of the body, TrPs can occur in many layers of muscles. The splenius capitis muscles are wide bands that run from the back of the skull at the sides to the upper vertebrae. TrPs here feel like sore areas on either side of the back of the head, directly under the skull. These TrPs transmit pain to the top of the head. Splenius cervicis muscles are thinner muscles connecting vertebrae. TrPs in the upper splenius capitis muscles send pain to the back of the head and diffusely throughout the skull, with intense pain behind the eyeballs. They can cause blurring of near vision in the eye on the same side as the TrP. TrPs in the lower splenius cervicis muscles are found on either side of the neck below where it joins the trunk, above the shoulder blades. Referred pain flows down to the shoulder, collar bone, and angle of the neck. You may not be able to rotate your neck due to pain. There are several types of posterior cervical muscles. A TrP in the semispinalis cervicis, alongside the spine right below the skull, creates pain up the back of the head toward the top. A TrP in the semispinalis capitis muscle just above the base of the skull, on the back of the side of the head, creates a headache like half a headband, with the highest intensity in the temple and over the eye. If you have TrPs on both sides, the pain can be incapacitating. A TrP in between these two other TrPs sends pain up to the base of the skull. It may also cause neck pain, spilling over to the top of the collar bone and upper inward border of the shoulder blade. Posterior cervical TrPs below the skull can also produce pain in the hands and feet on both sides, or to the body below the shoulder on the same side as the TrP. Place your hand alongside your head, with the heel of your hand directly under your ear, resting against the square of your jaw. Your outstretched fingers should be wrapping diagonally around to the back of your head. Find suboccipital TrPs on a diagonal line (the higher side is toward the back of the skull) under your palm. These TrPs initiate deep head pain that radiates from the back of your head to the cavity of your eye. The pain seems to penetrate inside your skull, because these muscles are deeply placed, just below the base of the skull on the side.

Multifidi run along the entire spine. Neck multifidi are often headache inducers. These muscles are short and deep, and go from one vertebra to another. Pain is transmitted in different patterns depending on which multifidi muscle has TrPs. Activation is usually caused by prolonged bending of your neck doing close work, by stooped posture, or by gross trauma. If you have trigger points in the multifidi of the neck vertebrae, pressure from your pillow at night can be intolerable. In addition to pain, there can be a tingling, numbness, or burning pain over the back of your head on the same side as the TrPs. This is an indication that the TrPs are causing nerve entrapment. Check to see that your workstation is ergonomically correct. Don't slump. Avoid tight hats and headbands, heavy glasses, heavy overcoats and tight collars. To relieve these symptoms, sit backwards in a hot shower while you stretch your neck muscles downward.

The trapezius muscle may have TrPs in many locations. There is one spot that sends pain up the same side of the neck and head, in a hook shape. Follow a line about an inch behind your ear down the side of your neck above the collar bone about halfway to the start of the shoulder. There is often spillover pain in the neck region, beneath the ear, and well as under the eyebrow. This is a major source of tension headache and neck aches. There can also be a mild pain at top of head, lower back teeth and outer ear. One or both ears can burn, turn red, or lose all color as blood vessels dilate or contract in response to this TrP. The sternocleidomastoid (SCM) muscle connects to the head, but separates into two parts. One connects to the collar bone, and one to the breastbone. TrPs in the breastbone (sternal) part, in the front, can refer pain to top or back of head, over the eye. Midlevel TrPs send pain arching across the cheek and jaw, over the eyebrow ridge, and deep inside eye, as well as pain to the ear on the same side. TrPs in the upper sternal SCM cause pain behind but not close to the ear, and to the back of the head. SCM TrPs also affect the eyes and sinuses, and can cause tearing, reddening or drooping of eye, as well as inability to raise the upper eyelid. You may experience visual disturbances. Patterns from window blinds and escalator treads can cause an out-of-control, seizure-like feeling. Stripes, checks and polka dots can be a problem -- anything with strongly contrasting light and dark spaces. You may experience dizziness, runny nose and sinus congestion on the involved side, as well as ringing in ear and deafness. TrPs in the collar bone (clavicular) section cause a frontal headache and earache. Middle TrPs in this section also cause pain to the front of the head, which can extend across the forehead to other side. Anything which hyper extends the neck, such as sleeping on two pillows, can aggravate these TrPs. Mechanical stresses such as doing overhead work, writing on a blackboard, or hanging curtains, aggravate these TrPs.

For more information and diagrams see "Fibromyalgia and Chronic Myofascial Pain Syndrome: A Survival Manual" by Devin J. Starlanyl M.D. and Mary Ellen Copeland MA,MS. New Harbinger Oakland California USA 800-748-6273 Canada 800-561-8583.

Weird Neurological symptoms?

What Your Neurologist Should Know

Devin Starlanyl This information may be freely copied and distributed only if unaltered, with complete original content including: © Devin Starlanyl, 1995-1999.

Please read “What Everyone on Your Health Care Team Should Know.” Please also read the section “Reactive Hypoglycemia”.

Neurotransmitters are your field. You know more than most physicians how fast the information is being updated in neurology and endocrinology. Neuroendocrine disorders are complex, and fibromyalgia (FMS) compounded with Myofascial Pain Syndrome (MPS) can leave you shaking your head in confusion. What‘s worse, most of the FMS/MPS Complex patients will come to you undiagnosed or misdiagnosed (Buskila, Neumann, Sibirski, et al. 1997).

Many of your patients may suffer from allodynia or hyperesthesia, but there are specific symptoms of FMS/MPS Complex besides pain in specific trigger point (TrP) patterns that should send up a red flag. Some of these symptoms mimic neurological disorders (Travell and Simons 1992, 1983; Simms and Goldenberg 1988).

Stiffness

FMS/MPS morning stiffness is primarily due to the immobility of the night, as well as to the lack of restorative sleep. It isn’t so much the amount of sleep we get as the poor quality of sleep (Branco, Atalaia and Paiva 1994; Drewes, Gade, Nielsen, et al. 1995; Horne and Shackell 1991). Also, any time we stay in one position for any length of time, our bodies stiffen in that position due to inflexible myofascia. This stiffness may take hours to work out.

Twitching

Eyelid twitching is often the first noticeable symptom in FMS/MPS Complex, and it’s very common. Check the periorbital TrPs, especially around the upper eye ridge. You will probably find some real screamers. Check the hollow slightly back from the outside corner of the eye. Also check the sternocleidomastoid, the temporalis, and the trapezius TrPs for possible causes of the eye twitch. You may also find other head TrPs. Other muscles twitching can become bothersome. Sometimes there can be a continuous twitch of many muscles. In other cases, one or two muscles will fire off now and then. This may be intensified by mineral insufficiency and/or neurotransmitter dysregulation. It may also be a sign of folic acid deficiency.

Fasiculations and waves of twitches can be caused by low-level TrPs. This has been described as having your nerves plugged in to twinkling Christmas lights. Other people have severe twitches that disrupt their functioning. These can in time become painful cramping. Check for vitamin and mineral insufficiencies.

Sleep Problems

Trouble falling asleep, trouble staying asleep, light sleeping, interrupted sleep, waking up feeling tired and unrefreshed are often symptoms of the alpha-delta sleep disorder, which often occurs with FMS/MPS. The K-alpha sleep anomaly is also sometimes found in FMS.

Neurogenic Problems

Raynaud’s syndrome is often present with FMS (Bennett 1991), and nerve, blood and lymph vessel entrapment by myofascial TrPs can compound the symptoms (Travell and Simons 1992; 1983). There may be increased neurogenic inflammation (Littlejohn, Weinstein and Helme 1987), sensory dysfunction (Kosek, Ekholm and Hansson 1996), qualitatively altered nociception (Bendtsen, Norregaard, Jensen, et al. 1997), and altered sympathetic nerve activity (Elam, Johansson and Wallin 1992) in FMS. There can also be orthostatic sympathetic derangement (Martinez-Lavin, Hermosillo, Mendoza, et al. 1997; Bou-Holaigah, Calkins, Flynn, et al. 1997).

Difficulty getting out known words, especially nouns and pronouns, is part of the “cognitive deficits” package we often get with FMS. Names and nouns become awfully hard to find. It’s very frustrating. In addition, TrPs in speech muscles can create slow, “halted” speech pattern, or garbled sounds.

Difficulty distinguishing right from left and/or difficulty finding places or following directions is common. They say that there will never be a rally for fibromyalgia because none of us could find where it was held, and we’d all come on the wrong day anyway.

Short-term memory problems and confusional states are common. We may have difficulty multitasking, or performing a number of steps in sequence. You may have to arrange for your office to call your FMS patients an hour beforehand, to be sure that they remember. This behavior is common in chronic pain states (Gritchnik and Ferrante 1991; Grigsby, Rosenberg and Busenbark 1995). Long-term memory may disappear.

Your patient may have severe problems estimating distance and depth perception. This can lead to a feeling of unreality. Sternocleidomastoid TrPs can cause severe proprioceptor disturbances, including dizziness when the field of vision is changing rapidly, and many other proprioceptor disturbances. Any pattern on light and dark, such as window blinds, escalator steps, trees along a road, or patterns in fabrics can cause dizziness or even a seizure-like feeling.

Psychological Problems

Free-floating anxiety, panic attacks, rapid mood swings, irritability with unknown cause, trouble concentrating, inability to recognize familiar surroundings—this is all part of what we term “fibrofog,” and can be part of the neurotransmitter imbalances. This can be worsened by reactive hypoglycemia (Hvidberg, Fanelli, Hershey et al. 1996; Christensen 1997; Lindgren, Eckert, Stenberg, et al. 1996), a common perpetuator of FMS and MPS, which must be modified by diet.

Expect severe headaches, which may be modified considerably by specific trigger point therapy if they are due to MPS (Travell and Simons 1983; Krabak, Borg-Stein, Oas, et al. 1996; Dunteman, Turner and Swarm 1996; Graff-Radford, Jaeger and Reeves 1986).

“Sensory overload” is what I call the feeling that information and stimulation are coming at you so fast you can’t deal with it. We either go into a “fugue” state, and stare into space for a while until our brain catches up (this can happen mid-sentence)—or we learn to close down some sensory input. In the latter case, we shut off car radios, and avoid noisy rooms and cities. There are times we need our “space.”

Depression is often caused by chronic pain states (Faucett 1994; Hendler 1984). Too little serotonin may trigger depression. Neurotransmitters are imbalanced in FMS (Russell 1996), and in the endocrine system as well (Pillemer, Bradley, Crofford, et al. 1997). Acute pain that diminishes in the course of a natural healing process is something that most of us can live with. Recurrent or persistent pain, especially due to an unrecognized untreatable cause, can threaten our future function and well-being, which can lead to frustration, depression, and progressive disability.

Physical Sensitivity

Sensitivity to cold, heat, humidity, barometric pressure, and approaching storms, light, noise, and odors may all be a part of body “thermostat” regulation problems. One minute we’re hot, and the next minute we have chills. The hypothalamus at the base of the brain is our thermostat, so this is part of the disrupted HPA axis (Griep, Boersma and de Kloet 1994). The hypothalamus sends a message to the body to contract or dilate blood vessels, via neurotransmitters. Some of us run a low-normal temperature and some of us have chronic low-grade fevers. Check for hypothyroid and other metabolic dysfunctions.

Take a good history. We often have abnormal electromyographic results due to nerve entrapment by TrPs, and even abnormal EEGs, although these vary, like the symptoms, from hour to hour and day to day. Please use only surface EEGs. Remember that there is considerable pain amplification in FMS (Lautenbacher and Rollman 1997; Yunus 1992).

Neuorplasticity plays a significant role in chronic pain states (Coderre, Katz, Vaccarino, et al. 1993). There are often white blotches in the MRIs. We don’t yet understand their significance. Regional cerebral blood flow abnormalities have been documented in FMS (Mountz, Bradley, Modell 1995; Johansson, Risberg, Rosenhall, et al. 1995). Once you see this pattern of signs and symptoms and understand the concepts behind the diagnoses of FMS and MPS, they will become easier to recognize.

References

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