Friday, March 8, 2019

Do Tight Muscles Cause You Pain? What You Should Know About Chronic Myofascial Pain

Courtesy Free Photos

This blog post, What You Should Know About Chronic Myofascial Pain, originally appeared on ProHealth, January 7, 2019. Because the article continues to garner attention, I am sharing it in its entirety here on The Pained Ink Slayer with ProHealth’s permission.

If you have questions, be sure to comment.


We have all experienced a tight muscle that causes pain and restriction of motion, such as sleeping on our neck wrong, but this is not myofascial pain syndrome (MPS). So, what is?

Myofascial Pain Syndrome

The primary job of a skeletal muscle is to provide locomotion by attaching to other muscles and to joints. When knotted up pieces of muscle fiber called trigger point/s develop, the muscle is shortened and becomes dysfunctional. Myofascial trigger points (TrPs) prevent normal contraction and relaxation of the muscle involved. These self-sustaining nodules in the hyper-irritable area of the muscle/s cause sensory, motor, and autonomic symptoms.

myofascial = pertaining to the covering (fascia) of muscle

When TrPs are not treated early and appropriately, the tug and pull of the dysfunctional muscle fibers creates stress and leads to development of TrPs in either the same muscle, compensatory muscles on the same or opposite sides of the body, or in all four quadrants of the body as our musculoskeletal system perpetually tries to adjust.


Diagnosis can be complicated if the examiner is not familiar with MPS. Myofascial disorders are generally poorly understood in the medical community. Bourgaize S, et al. (April 2018) allege MPS is confused with fibromyalgia, because both MPS and FM are prominent forms of chronic musculoskeletal pain in their literature review. This delays proper treatment.

A history of chronic myofascial pain and muscle and/or joint dysfunction is what usually gets us to the doctor. As previously noted, MPS pain and dysfunction usually occurs in more than one quadrant of the body and includes: 
  • Pain that lasts three to six months.
  • Trigger point/s that can usually be felt by the examiner.
  • A taut muscle band. (You may or may not be able to feel the TrP in the band depending on the amount of muscle contraction. There may be one or more in the same muscle.)
  • Referred pain. (A referral pattern for the TrP is consistent between patients. Pain can be well away from the primary trigger point.)
  • Twitch response of the muscle by some mechanical method (i.e.: manual pressure or needle insertion).
  • Decreased mobility related to the affected muscle.
  • Weakness in the affected muscle.

Myofascial pain syndrome is known as the great imitator for a reason. For instance, MPS involving the piriformis muscle (a small deep muscle that cuddles the sciatic nerve) may be misdiagnosed as sciatica.

Myofascial Pain Syndrome And Fibromyalgia

Many of the conditions known to cluster with FM, like severe headache, restless leg syndrome, teeth grinding, balance problems, TMJ, chronic pelvic pain, chest wall pain, and more have a myofascial component of their own. Pain specialist, Dr. Karl Hurst-Wicker, MD, explains it like this.

“There is a good deal of overlapping between MPS and fibromyalgia (FMS). Likely this is related to the consistent long-term activation of peripheral pain pathways causing central [nervous system] sensitization and other changes in the nervous system that contribute to the development of FMS. Conversely, it can work in the other direction too; a patient with a primary FMS can develop MPS, in no small part because the FMS can amplify and perseverate even minor myofascial pain and injury to the point where it can propagate and become a regional issue.” (Health Central, Fibromyalgia Centralization and Peripheral Myofascial Pain: Interview with Karl Hurst-Wicker, MD, accessed December 31, 2018)

Unlike FM, MPS is not gender prevalent. Many of the perpetuating factors are genetic, such as short upper arms, short lower legs, one leg shorter than the other, curvature of the spine, or other musculoskeletal deformities. Some metabolic dysfunctions are thought to perpetuate myofascial pain syndrome, too. People with skeletal structural defects, both inherited or the result of injury, surgery, post-polio syndrome, or poor posture, and people who experience undue stress on a muscle, including repetitive motion, can contribute to MPS.

What We Can Do

Treatments for myofascial pain syndrome include manual treatment by a certified myofascial trigger point specialist, a physical therapist or chiropractor that specializes in myofascial therapies, guided self-treatment, electrical stimulation, ultrasound guided trigger point injections by a pain specialist, and more. But, the best treatment is prevention. We should be aware of perpetuating factors, so we can avoid them or manage them.


Consistent diagnostic criteria that can be used by all healthcare professionals are needed to ensure patients get the right diagnosis and the right treatment in a timely manner. Both MPS and FM cause pain, but that pain is NOT the same. Myofascial pain is a peripheral nerve problem that can usually be isolated; FM is a central nervous system problem that causes body-wide sensitivity.

Perpetuating factors of MPS can, and do, vary among us. Some of us may have a disorder like joint hypermobility. We may have both MPS and FM. Some of us work at computers, and yes, I must remain astutely aware of my body positioning. Maybe you had a surgery that left you with scarring of tissue that puts a strain on normal movement. There are a myriad of things that can lead to development of chronic myofascial pain.  But, the important thing to remember is that trigger points are treatable, and the longer we go without addressing the problem, the greater the risk to developing trigger points that seemingly breed like rabbits and become resistant to treatment.

Additional Reading:

In healing,

Celeste Cooper, RN / Author, Freelancer, Advocate

Think adversity?-See opportunity!

~ • ~ • ~ • ~ • ~ • ~

Learn more about Celeste’s books here. Subscribe to posts by using the information in the upper right hand corner or use the share buttons to share with others. 

Saturday, March 2, 2019

Spring In To Hobbies That Create Presence And Desire

On Stage - Courtesy Celeste's Photography

Spring is a time of reawakening after a long cold winter. It’s a time to explore things that will bring us pleasure as we break through the shell of our own winter cocoon.

I find great strength, comfort, and diversion through poetry and photography, and I am thankful that I have found ways to fill up my thought spaces by writing for others who share this journey with me. My hobbies are huge self-esteem boosters for me as one who lives with chronic pain. 

I am anticipating the opportunities for photo moments as children play, as the flowers bloom, and the wildlife begins to stir.  The canvas of life is limitless. This spring my goal is to use lighting more strategically in my photography, and to write at least two poems before summer.

…Hobbies give us reason to relax and take a break. They are our weapon against boredom and idle hands. They create the presence of desire in our lives and keep our mind open to opportunities for exploring our creativity. Learn to make jewelry, read palms, fish, line dance, take photos, make bird houses, collect antique watches, start a joke book, crochet, or hand glide. Take up scrap booking, wood burning, or calligraphy; it's totally up to you… [Excerpt, day 69, Spring Devotions in the Broken Body, Wounded Spirit: Balancing the See-Saw of Chronic Pain series.]

What hobbies would you like to explore this spring? Write them down and find new ways to be present and fulfilled by your accomplishments.

For more information, see "Writing Your Own Hobby Résumé" in Winter Devotions.

"We simply need to keep an open mind, 
trust our own experience, and believe."

 ~ Pam Grout, author of E-Squared: Nine Do-It-Yourself Energy Experiments 
That Prove Your Thoughts Create Your Reality

In healing,

Celeste Cooper, RN / Author, Freelancer, Advocate

Think adversity?-See opportunity!

~ • ~ • ~ • ~ • ~ • ~

Learn more about Celeste’s books here. Subscribe to posts by using the information in the upper right hand corner or use the share buttons to share with others. 

Friday, February 8, 2019

Does Rare Disease—EDS—Plague Fibromyalgia? #ShareYouAreRare

Many thanks to

 “Living with [Benign Joint Hypermobility Syndrome] BJHS is not without consequences. When I was seven months pregnant, I fell down a flight of stairs because of lax hip joints. (JHS can be especially pronounced during pregnancy.)  After my son was born, I was referred to an orthopedic doctor who diagnosed me with JHS. I have had 4th-degree sprains of both ankles, four shoulder repairs for torn tendons and muscles, and one shoulder has been reconstructed because of JHS. I experience ileo-tibial band laxity causing unstable hips, piriformis syndrome, and a lot of pain. For years, I have lived with sagging and abnormally thin skin that tears easily, like that of someone on long-term steroids. And I battle chronic Achilles tendonitis. But others diagnosed with JHS could have a vastly different experience than I have, because none of us is affected exactly the same.”

Excerpt of part of my story in an article I wrote on joint hypermobility and chronic pain for HealthCentral.

There are many theories regarding joint hypermobilty and the connection to Ehler’s Danlos Syndrome (EDS), a genetic collagen disorder.  Some researchers consider Benign Joint Hypermobility Syndrome (BJHS) to be a milder form of one of the many types of EDS. (1) According to NORD, there are thirteen subdivisions. 

NORD established the annual awareness day for rare diseases on the last day of February. tells us to #ShareYouAreRare and more.

Last year, the following appeared on ProHealth and with ProHealth’s permission, I am sharing it in its entirety here on The Pained Ink Slayer.


According to the National Organization for Rare Disorders (NORD), there are many Ehlers Danlos Syndromes and related disorders caused by different genetic defects in collagen. We will focus on the most common type of Ehlers-Danlos syndrome in this article.

hEDS = EDS hypermobile type, previously known as EDS type III or joint hypermobility syndrome.

Characterized by joint hypermobility, skin extensibility and tissue fragility, this type of EDS can co-occur in fibromyalgia and myofascial pain syndrome even though it is thought to be a rare condition. Fibromyalgia and EDS also share connections you might not have considered.

The EDS Connection

Gastrointestinal problems are noted in both hEDS and fibromyalgia, and myofascial pain syndrome has been noted in both hEDS and fibromyalgia.

A 2014 study, A Prospective Evaluation of Undiagnosed Joint Hypermobility Syndrome in Patients with Gastrointestinal Symptoms (2), found upper and lower GI symptoms increased with the severity of joint hypermobility type. Upper GI symptoms were dependent on autonomic and chronic pain factors.

 A 1993 study published in the Annals of the Rheumatic Diseases (3) suggests there is a strong association between joint hypermobility and fibromyalgia in schoolchildren and joint hypermobility may play a role in developing fibromyalgia. Keep in mind, in 1993, few understood the incidence of myofascial pain syndrome in chronic pain conditions, which could be true in this case. It would be interesting to see a follow up study on the participant group to see how many of these children would meet today’s suggested fibromyalgia criteria.

In 2013, a French study, Fibromyalgia: an unrecognized Ehlers-Danlos syndrome hypermobile type? (4), reports some patients suffering from fibromyalgia present with clinical signs and alterations in tissues, changes in antibodies that test for certain markers found in tissue, and alterations to the microscopic structure of skin that is similar to hEDS. They also suggest some types of fibromyalgia could represent undiagnosed joint hypermobility.

A 2017 case study (5) highlights that patients with EDS type III [hEDS] may suffer from pain due to myofascial trigger points around the affected hypermobile joints, not a surprise to me. I have been writing about this for years. Myofascial pain syndrome is a chronic pain condition caused by myofascial trigger points and it appears to perpetuate pain in both fibromyalgia and hEDS.


Symptoms may vary, but there are general symptoms. Don’t be surprised by the number similar to fibromyalgia and/or myofascial pain syndrome.

·        Loose, unstable joints prone to injury
·        Easy bruising.
·        Dysautonomia
·        High and narrow palate with teeth crowding
·        Small fragile blood vessels
·        Velvety-smooth skin which may be stretchy
·        Abnormal wound healing and scar formation
·        Low muscle tone and weakness
·        Muscle and joint pain
·        Joint pain associated with exercise

Other criteria may include:

·        Family history
·        Headaches caused by resulting Arnold-Chiari malformation (noted in some FM patients)
·        Low bone density
·        Not knowing where body parts are in relation to space, loss of proprioception
·        Difficulty processing information rapidly
·        Functional gastrointestinal disorders, such as delayed stomach emptying, inflammation of the stomach, and irritable bowel syndrome 
·        Vascular skin conditions, such as Raynaud’s and skin moddling due to a sympathetic nerve response known as livedo reticularis

What about you?

I was born with lax joints, just like my maternal grandmother and aunt. Well into adulthood, I sat with my legs splayed as if chicken wings, or crossed the other direction, yoga style. I have gotten myself into some precarious positions that result in pain, and like fibromyalgia, I can’t always predict when that will happen. I continue to struggle with the effects. Whether joint hypermobility is benign (without genetic markers), or genetic (as seen in hEDS), it is not without consequences. Because of lax hip joints, I fell down a flight of stairs; I was seven months pregnant. I have had 4th-degree sprains of both ankles, several bouts of Achilles tendonitis, inflammation of multiple joints, four shoulder repairs for torn tendons and muscles due to dislocation, knee surgery, and I experience ileo-tibial band inflammation caused by unstable hips, compensatory piriformis syndrome, and a lot of pain. And I am not alone. There are many like me. Are you?

The future

We need more research on this connection. Folks can’t seem to agree on diagnostic criteria or terms for hEDS or fibromyalgia, which is extremely confusing and frustrating. Most likely this is because of the lack of robust research. Funding for research on rare diseases is grossly lacking. We need to raise awareness.

(Edited February, 2019) This year February 28th is Rare Disease Day in the United States. The U.S. Pain Foundation has provided various ways to engage within our community. Check out the awareness events taking place and share the word in your communities.

You can find more information on Ehlers-Danlos Syndromes at NORD, and the NIH, Genetic and Rare Diseases Information Center (GARD).


The amount of research of this painful rare disorder over the past two decades is limited, but what we do have suggests more investigation is needed and many more people may be affected than realized. Symptoms of EDS can overlap with FM and could present as a mimicking or co-existing condition. Joint hypermobility and skin disorders have been more frequently observed in children with FM (6) than in otherwise healthy children, skin ultrastructural similarities between FM and EDS hypermobility type have been noted (7), and some types of EDS can perpetuate the development of myofascial trigger points that cause chronic myofascial pain (8).

Research Resources:

(1) Hermanns-Lê T, Reginster MA, Piérard-Franchimont C, Delvenne P, Piérard GE, and Manicourt D. (2012). Dermal ultrastructure in low Beighton score members of 17 families with hypermobile-type Ehlers-Danlos syndrome. Journal of Biomedicine and Biotechnology; 2012:878107.

(2) Fikree A, Grahame R, Aktar R, Farmer AD, Hakim AJ, Morris JK, Knowles CH, Aziz Q. (2014). A prospective evaluation of undiagnosed joint hypermobility syndrome in patients with gastrointestinal symptoms. Clinical Gastroenterology and Hepatology; (10):1680-87.

(3) Gedalia A, Press J, Klein M, and Buskila, D. (1993). Joint hypermobility and fibromyalgia in schoolchildren. Annals of the Rheumatic Diseases; 52(7): 494–496.

(4) Hermanns-Lê T, Piérard GE, Angenot P. (2013). Fibromyalgia: an unrecognized Ehlers-Danlos syndrome hypermobile type? [Article in French]
La Revue Médicale de Liège; 68(1):22-4.

(5) Tewari S, Madabushi R, Agarwal A, Gautam SK, Khuba S. (2017). Chronic pain in a patient with Ehlers-Danlos syndrome (hypermobility type): The role of myofascial trigger point injections. Journal of Bodywork and Movement Therapies; 21(1):194-196.

(6) Ting TV, Hashkes PJ, Schikler K, Desai AM, Spalding S, Kashikar-Zuck S. (2012). The role of benign joint hypermobility in the pain experience in Juvenile Fibromyalgia: an observational study. Pediatric Rheumatology Online Journal;10(1):16.

(7) Hermanns-Lê T and Pierard GE. (2016). Skin ultrastructural similarities between Fibromyalgia and Ehlers-Danlos syndrome hypermobility type.
International Journal of Clinical Rheumatology; 11(2), 019-022.

(8) Fernández-de-Las-Peñas C. (2009). Interaction between Trigger Points and Joint Hypomobility: A Clinical Perspective. Journal of Manual and Manipulative Therapy;17(2):74-7.
In healing,

Celeste Cooper, RN / Author, Freelancer, Advocate

Think adversity?-See opportunity!

~ • ~ • ~ • ~ • ~ • ~

Learn more about Celeste’s books here. Subscribe to posts by using the information in the upper right hand corner or use the share buttons to share with others. 

Wednesday, January 30, 2019

Deadline To Comment On New Federal Recommendations On Pain April 1st – Read Mine

If you have had your pain care jeopardized because of the opioid crisis, please refer to the US Pain Foundation toolkit. You can access the full report and find the toolkit HERE. Or you can comment at Write as little or as much as you would like. The important thing is that we use our voice.

Comments on the task force proposal due by April 1, 2019.

RE: The Inter-Agency Task Force Draft Report on Pain Management Best Practices.
Docket Number: HHS-OS-2018-0027

To those concerned,

The IOM report and the National Pain Strategy have addressed the stigma of chronic pain, yet here we are nearly a decade later in worse shape than ever. I appreciate your efforts to take integrative therapies mainstream, educate others on the benefits of responsible opioid treatment, and stop the lunacy that is driving pain patients to suicide as the “opioid epidemic” (which should read ILLEGAL, BLACK MARKET FENTANYL, thank you.) continues to rise. We need factually driven reports, not those that sensationalize inaccurate data to make money at our expense. I wish there was a plan to engage with the media that includes the unintended consequences of addressing the drug problem we have in the United States. 

I could use better pain control, but I would have no life if I had to plan it around monthly all-day visits to a pain doctor to get 60 pills. Thank you for thinking of people like me. It would be great if you could get Medicare to pay for monthly therapeutic trigger point massage and my TENS unit supplies. It would be nice if I had help with the cost of a new PEMF device, pay for my EEG biofeedback device, or pay for unlimited visits to my physical therapist to get active release therapy. Thank goodness I have access to interventional care such as ultrasound guided trigger point injections, cervical nerve ablations, and occipital nerve blocks, but they only provide temporary/partial relief and Medicare won’t pay for me to have them when they wear off. Instead, I have to wait the six months as my pain escalates out of control and tethers me to my recliner, draped in warm compresses and ice packs, praying my TENS adhesive doesn't cause blistering too quickly. I pay an extraordinary Medicare premium (NO! Medicare is NOT free, and tie-in plans rate chronic pain patients up for their “pre-existing” chronic pain condition). My pain specialist does not take Medicare Advantage plans, but even if he did, their would be co-pays. I am grateful that the task force is addressing this. This is a good start, but I have reservations.

Over the long-term, I hope things will be easier for the patient and reduce the justified fear of physicians to prescribe. Patients have become unpaid guinea pigs for Big Pharma as pharmaceutical companies push physicians to prescribe other “newer” central acting agents that come with their own basket of interactions and abuse risk. I have permanent damage to my esophagus and stomach and have suffered the consequences for twenty years. Obviously, there was a time Feldene was my drug of choice.

In closing, I appreciate all those on the task force for providing a report that considers many of my personal concerns; it is comprehensive. We need reliable research that is not paid for by parties who will benefit from the outcome. Let us all hope there is forward motion for making pain care individualized, compassionate, accessible and effective.

Sincerely, Celeste Cooper, Retired RN

In healing,

Celeste Cooper, RN / Author, Freelancer, Advocate

Think adversity?-See opportunity!

~ • ~ • ~ • ~ • ~ • ~

Learn more about Celeste’s books here. Subscribe to posts by using the information in the upper right hand corner or use the share buttons to share with others. 

Monday, January 21, 2019

How Can A Pea Cause So Much Pain? Defining Myofascial Trigger Points

Pain generators of things like headache, pelvic muscle and organ dysfunction, spinal disease, joint dysfunction, TMJ, and much more can often be attributed to the presence of myofascial trigger points in over-stressed or injured muscles. So what are they, how are they classified, and why are the stages of a trigger point (TrP) important?


A myofascial trigger point (MTrP) is a “self-sustaining” hyper-irritable area of muscle fiber in a taut band of muscle that is felt as a nodule or bump. This aggravated spot causes gradual shortening of the muscle involved and interferes with normal muscle function. Myofascial TrPs can also put pressure on the surrounding nerves, lymph and blood vessels, causing other symptoms in addition to pain.

Common abbreviations:

MTrP = myofascial trigger point
TrP = trigger point

Trigger points can usually be felt unless the muscle is too tight, they are buried under other large muscles or they are located behind bone. They radiate pain in a consistent pattern according to their location in the muscle affected and hidden TrPs are often located by their pain referral pattern. Additionally, TrP/s can be well away from the pain referral zone. 

National Association of Myofascial Trigger Point Therapists handy 

It’s important to know what a trigger point feels like, so get familiar with your body. Feel around to see if you find any lumps or bumps that reproduce your pain. In average size muscles, TrPs are about the size of a pea and there can certainly be more than one. If a muscle is too tight, massage may be necessary to relax the muscle so we can isolate the TrP. Muscles around the face are very tiny. In this case, they may feel like a tight string, while larger muscles feel like a tight rope. 
Acute myofascial pain from trigger points differs from chronic myofascial pain. You can read more in our book, Integrative Therapies forFibromyalgia, Chronic Fatigue Syndrome, and Myofascial Pain and in an article I wrote for HealthCentral, What YouShould Know About Chronic Myofascial Pain.
Trigger points that are adequately stimulated by compression or needle insertion exhibit a visible local twitch response. However, Perreault T, Dunning J, and Butts R, 2017, report "several studies show that eliciting a local twitch response does not correlate with changes in pain and disability, and multiple systematic reviews have failed to conclude whether the twitch response is relevant to the to the outcome of TrP dry needling."

Note: The size of the muscle involved, whether it is an active primary or active secondary TrP is not relative to pain intensity. Sometimes, TrPs in small muscles can cause more pain than those found in larger muscles. Such is the case of TrPs in the piriformis muscle, which is a small deep muscle in the buttocks that cradles the sciatic nerve. Trigger points in the piriformis muscle mimic sciatica pain which is created by compression of the sciatic nerve as it exits the spine.  The treatments are very different. 


The three familiar classifications of TrPs are primary, secondary, and/or satellite. Knowing the classification of a TrP is important to the person providing treatment, including us.  

Primary TrP

A primary TrP is the one that starts the painful event. A primary TrP can be active or latent. (More coming on what that means.)

Secondary TrP

A secondary trigger point is born when compensatory muscles, on the same side of the body, the opposite side, or even in the same group, also become overloaded in an attempt to temporarily help muscles that are affected by primary TrPs.

As we sit at a computer our neck bends as our head drifts forward from its weight. Before long we find ourselves rubbing the back of our neck. Our uncorrected posture has put undue stress on muscles that are trying to lift our head to a neutral anatomical position. We are in pain because muscle fibers have abnormally shortened in an effort to keep our face from smashing into the keyboard. You can imagine how much work is placed on ancillary muscles that have also been pulled out of their normal functioning position. For me, not continually adjusting my posture or taking frequent breaks will trigger a migraine attack because of the presence of occipital neuralgia and the pressure on my occipital nerve. That leads to a predictable cascade of events. My nose begins to run on the right side, my eyelid droops, my right eye crosses, and more. 

After note: Muscles on the front, back, and sides of our neck not only hold up our head, they also contribute to other muscles that support function of things like our jaw, shoulders, scapula, and so on. The opportunity for secondary TrPs to develop is extensive.  

Secondary TrPs can also be active or latent.


Trigger point charts you can download


Satellite TrP

A satellite trigger point is a type of secondary TrP that is located in the referral zone of the primary trigger point. 


Active Trigger Point

Active TrPs hurt without being touched, radiate pain, restrict motion, and can cause other symptoms depending on the surrounding nerves, lymph system, and blood vessels. They call for our attention.

Latent Trigger Point

A latent trigger is a dormant TrP that causes pain only when it is compressed or manipulated. Latent TrPs do all the same things as active TrPs and cause stiffness and weakness that persist for years after apparent recovery. They can go unnoticed only to be reactivated from a seemingly minor overstretching, repetitive use, overuse, or injury. In some people, a harmless event can cause dormant TrPs to light up like a firecracker instigating a cascade of events including referral of pain, and other symptoms.


My interview with myofascial trigger point specialist, Frank Gresham



Myofascial trigger points restrict muscle movement and cause weakness that can persist for years after apparent recovery, so don't be lured into thinking you can only treat active TrPs.  A latent primary TrP can remain dormant wreaking havoc on our musculoskeletal system and unless it is also treated, it will remain in the same state. This means secondary TrPs will redevelop and present in the active stage (causing pain without pressing on it), leaving us to think treatment doesn’t work. Have patience, it's difficult to define a primary from a secondary trigger point, even for experts and especially when multiple muscles are dysfunctional. But, with the help of a professional trained in myofascial medicine, such as physician, physical therapist, chiropractor and/or myofascial therapist, we can conquer these unruly pieces of muscle fiber that cause us so much pain.

Coming soon: Prevention and treatment

Additional Reading:

In healing,

Celeste Cooper, RN / Author, Freelancer, Advocate

Think adversity?-See opportunity!

~ • ~ • ~ • ~ • ~ • ~

Learn more about Celeste’s books here. Subscribe to posts by using the information in the upper right hand corner or use the share buttons to share with others. 

Celeste's Website

Celeste's Website
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