Thursday, March 24, 2011

Fibromyalgia (FM) and Myofascial Pain Syndromes (MPS) by Dr. John Whiteside

Intro, by Celeste

I became interested in Dr. John Whiteside’s work when on my quest to find out what was happening to my musculoskeletal system. In an effort to learn all I could on how to make myself better, which as you all know eventually ended up in the book, I Goggled trigger point and Travell and Simons and I read nearly everything I could get my hands on. One of those things was what Dr. Whiteside had to say about treating myofascial trigger points (MTrPs) in his practice in Australia.

I knew there was more to my pain than the tender point model of fibromyalgia. I was concerned as to why I had these “knots” in my muscles that were referring pain, and numbness and wondered if all patients diagnosed with fibromyalgia were experiencing this same painful phenomenon.

I consider Dr. John Whiteside a friend, an advocate, and a true healer. He has been kind enough to offer up the following information for me to share with you.

Fibromyalgia (FM) and Myofascial Pain Syndromes (MPS).

By Dr John Whiteside, MBBS, BSc, FACNEM.

I became aware of the work of Dr Travell when I was working in general practice medicine in 1987. I began to treat patients using trigger point injections and soon confirmed her teachings that myofascial pain syndromes were common. Dr Travell told me in 1988 that in her experience myofascial pain was more common than the common cold. She said that Family Medicine doctors, each day, saw more MPS than any other condition, but it remained undiagnosed.

In the latter half of 1987 I learned that many medical illnesses were partly caused by myofascial trigger points. Trigger points in the sternocleidomastoid muscle frequently produce dizziness, trigger points in the chest wall can produce exercise induced asthma, trigger points in the erector spinae are a common cause of heavy, painful periods. It was clear that the work of Dr Travell revealed a totally new paradigm for general medicine. I began to refer to this work as Myofascial Medicine.

It was this recognition that myofascial trigger points were ubiquitous, and that they contributed so much to many named medical illnesses, that forced me out of Family Medicine. I found it impossible to continue writing prescriptions for pharmaceutical drugs to treat the symptoms of illness, when there was a way available to treat the cause. I opened my specialty practice in Myofascial Medicine in 1988.

To further understand the importance of perpetuating factors I completed my training at the Australasian College of Nutritional and Environmental Medicine (ACNEM), obtaining a Fellowship in 1996 (FACNEM).

Over the past 23 years I have worked full time doing trigger point injections as taught by Dr Travell. I have treated over 20,000 patients with local and regional MPS and FM. I present to you the following information generated from my hands on practical experience.


Fibromyalgia is just a word, a collective noun, coined to group together the symptoms of patients with chronic widespread pain. Myofascial Pain Syndrome refers to an actual physical entity.

Some 20 years ago the leading rheumatologists in the world met to tidy up the nomenclature related to chronic pain. “How can we share our research if we are all speaking about different things? Let us all agree on one definition. “So they discussed this and came to an agreement that the new term would be Fibromyalgia, and that it would be defined as “widespread pain lasting more than three months and when examined by a health practitioner the patient would exhibit local tenderness at eleven of eighteen specific sites.” The specific sites were chosen in an arbitrary fashion to be inclusive of the four body quadrants.

From this point on, when patients presented to doctors with widespread pain and tenderness they would be told that they had fibromyalgia. Many were grateful to at last be given a diagnosis but when they asked what caused it, they were told “we do not know”. When they asked what can be done to cure it they were told, “there is no cure, but you may be helped with certain pharmaceutical medication.”

The more astute patient would ask,” what does fibromyalgia mean?” only to be told that it means you have widespread pain and tenderness. If they had the courage they would tell the doctor that is what they told him in the first place, and all the doctor had done was give it a medical name. But most were happy to have a name that they could give to friends and family, join a local fibromyalgia self help group, and take their drugs.

Fibromyalgia is only a name. It is only a word. Like the word intuition, some people have it, some do not. We know what it is, but do not know where it comes from.

Myofascial pain

Myofascial pain is totally different. It is based on real palpable entities; trigger points existing along taut bands within skeletal muscles.

In the early 1940’s Dr Travell developed chronic right arm pain as a result of handwriting research papers. She suffered with this for many months because all treatment options available to her failed. She returned to the scientific literature, and found, across the previous 100 years, a very small number of scattered reports describing trigger points in muscles. These trigger points were palpable entities, with observable physical properties. They actually existed. They could be felt beneath the examining fingers. They exhibited specific observable behavior; they exhibited a twitch response when plucked, they referred pain to another anatomical region when pressed, and when injected with local anesthetic they briskly twitched then became inactive.

Dr Travell examined her own muscles and found trigger points in her right arm and shoulder. Her father was a physician. She asked him to inject these physical entities with procaine, and after a sufficient course of therapy she obtained a complete recovery. Her career path changed and she spent the second half of her life documenting the properties of these real palpable physical entities.

Side note from Celeste:

MPS=myofascial pain syndrome
CMP=chronic myofascial pain

Devin Starlanyl, my mentor, saw MPS being used interchangeably with conditions of the mouth and jaw, which no doubt are related to myofascial trigger points, however, it was leading to confusion. Myofascial trigger points (MTrPs) can exist anywhere there is muscle tissue from the smallest to the largest, from the deepest to the most superficial to the end where muscle attaches to bone. To avoid confusion, she, and I following in her footsteps refer to the disease at the neuromotor endplate (excessive release of acetylcholine, a chemical that relays information to the brain) as chronic myofascial pain, CMP. Most still refer to the disease as MPS.

The acceptance of FM and MPS

Why is FM accepted so easily in the medical community and MPS considered so “alternative”? The answer is that FM is easy and is treated with drugs, while MPS is difficult and requires hard earned practical skills to treat.

Any doctor can learn all that is needed to treat FM in one hour. The patient tells you that they have widespread pain and tenderness, normally together with disturbed sleep, fatigue, and depression. A quick physical examination allows you to elicit tenderness at eleven or more of eighteen specific anatomical sites. You confidently give the patient a diagnosis of FM, together with a prescription for a drug, and a referral to the local FM network group. Consultation completed, next patient please. This is easy to do in the busy day of Family Medicine.

To further support this process the Medical Benefit Organizations have an item number for FM, so you get paid, the patient gets reimbursed, and the Medical Board supports your action in prescribing the drug. The entire protocol is underwritten by the senior specialists and the research is heavily supported by the pharmaceutical industry.

Existing institutions have inertia, and large institutions are almost stationary

Myofascial Medicine is different. Although it is based on real physical entities, it is strangely hard to see. The most effective way of seeing it is to use local anesthetic trigger point injections. These can only be done by medical practitioners and to see the results the doctor has to do them. Doing them takes practice. It is time consuming. It does not have an item number so the extra time devoted to the procedure cannot be financially reimbursed until the doctor becomes so good at the work that he can bill privately an appropriate fee.

To convince busy doctors already earning good incomes from fast drug based medicine to take time out to learn Myofascial Medicine is like reciting Shakespeare in a storm. It may make the actor feel good, but no one can hear him.

Most of the advance work is being done by a devoted number of non doctor therapists; nurses, physiotherapists, occupational therapists, masseurs etc. These people are well educated in the area of Myofascial Medicine but have less ability to effect major therapeutic change because they are denied access to the most powerful tool, local anesthetic trigger point injections. They are also limited by the same things noted above, no item numbers, and poor financial return.

My professional experience

In the early years I was puzzled by the ubiquitous nature of myofascial trigger points. Why were they there? Why were they in such well localized anatomical locations? Why did they refer their pain, or more correctly, their pattern of influence?

The sternocleidomastoid muscles in particular harbored a deep and important mystery. Here were two muscles attached to take maximum advantage of the vectors associated with the movement of the head on the neck. They were fast muscles with intimate neural connections to balance, sight, hearing, and the health of the mucous membranes in the nose and paranasal sinuses (smell). When they developed trigger points they produced dysfunction in these senses. Those of us trained in myofascial medicine noted these symptoms and were drawn to examine the muscles to find the trigger points and then to treat them. But what did this mean?

The long muscles of the back, the erector spinae, when they develop trigger points, refer their pattern of influence to the muscles of the pelvis. Treating these causes a reduction in the intensity and the pain of the menstrual period by relaxing the uterine muscle. Women with endometriosis very frequently suffer low back pain. Do the trigger points in the erector spinae contribute to retrograde peristalsis of the Fallopian tubes and allow for movement of endometrial tissue to the peritoneal cavity and thus cause this common medical condition? Do they also, separately, by the same mechanism impede the normal passage of the egg from ovary to uterus, and contribute to the problem of infertility? What does this mean?

The puzzle was solved, in my mind, when it dawned on me that we were looking at the pathological manifestation of something physiological within the muscle. The ubiquitous nature of the trigger points, together with their reliable pattern of influence (so meticulously documented by Dr Travell), must mean we were looking at an abnormal expression of a fundamental physiological system of truly wondrous importance to our understanding of life.

Medical research, throughout history, has largely started with disease. It is by investigating the illness that we learn about the normal physiology beneath. The manifestations of diabetes have been known for thousands of years. The research into the illness allowed us to understand how the regulation of the pancreas functions in healthy life. The documentation of the effects of a blood clot or bleed in the brain can be found in the very earliest medical text books. The investigation of this pathology contributed to our understanding of normal neural pathways. So, I believe, must be the case with Myofascial Medicine.

Time after time, case after case, I released myofascial trigger points using the techniques taught by Dr Travell, and observed the pattern of influence of that specific focal point within that muscle disappear. The skeletal muscles contained a patterned system of communication. They talked to each other. They were intimately connected to all the elements in the body that allowed for normal function.

The answer to the puzzle was what happened when the myofascial trigger point was not pathologically “active.”

When the sternocleidomastoid muscles were healthy the balance and coordination of the special senses in the head and neck was optimal. The primitive animal or man could see and hear more clearly, had better balance and coordination, could hunt better, fight better, and survive better.

When the erector spinae muscles were healthy in the primitive female the individual had a more reliable menstrual cycle, lost less blood, and was more fertile.

I reflected on the evolution of biological systems and noted the appearance of the skeletal muscle proteins at the very origin of single cell life, the prokaryotes, appearing some 3,500 million years ago. Within these cells exists a cytoskeletonof microtubules together with a network of filaments that connect them. These are made up of complex polymers of many different proteins, including actin and myosin, the two proteins that dominate the skeletal muscle system in man. And what do these primitive structures do? The interior of the cell is in continuous motion, and the cytoskeleton provides the machinery for intracellular movement.

At the very beginning of life, the ancestor of our skeletal muscle system appeared as an intrinsic component of the movement of life. They appeared together. At that point, and onward, the skeletal muscle system was intimately and continuously aware of all other processes occurring in that living organism.

For 2,000 million years this was the only form of life. Then came the eukaryotes, still single cell organisms, but now they had a nucleus. These appeared some 1,400 million years ago and remained the most complex form of life on earth for the next 600 million years before the first and simplest multi cellular organisms developed, about 800 million years ago. At this point the nervous system begins to develop and by 600 million years ago the chordates appear with the primitive notochord.

If we reflect on this we see that the origins of the skeletal muscle system are in existence and functioning intimately with all the other systems of the living organism some 3,500 million years ago. It is only some 600 million years ago that multicellular organisms appeared and made it necessary for evolution to develop a nervous system. In other words the nervous system only appeared in the last 15% of the evolutionary process. It only appeared when the muscular system alone could not process all the information required by the gradually larger and more complex multicellular organisms. If you like, the skeletal muscle system called upon evolution to create a nervous system to help it do its work.

It is for these reasons; I believe with Myofascial Medicine, we are looking at a fundamental body of knowledge so deep and profound that when we fully understand it, and it is incorporated into daily mainstream use by medical practitioners, it will change the whole paradigm of medicine. I believe, in time, the work of Travell will be seen in the same light as that of other great pioneers, such as Darwin. I believe she will be seen as the greatest medical pioneer of the 20th century.

Wednesday, March 9, 2011

Chronic Pain Thoughts, Tidbits, and Insight: Response to an article

THIS WAY IN: How to Use Pain Meds Safely
Neurology Now
February/March 2011; Volume 7(1); p 10–11,15

Click on Download article, PDF or view each hyperlink

This is a good article on the benefits and pitfalls of opioids. I believe, opioids should be considered for treatment of pain with medications, especially when other treatment modalities have failed. I have to disagree that doses must be elevated due to tolerance, because some research shows that is not true for all people. Antidepressants and anti-seizure medications are also abused and people die from them, but we don’t hear about these cases because BIG pharma somehow keeps these incidents undercover. The FDA doesn’t go after the data on incidents regarding these type of medications. Most of what we hear is what can be sensationalized by reporters. Reporters want headlines that sell. The political money band plays on.

Any medication/drug taken for a reason other than intended is abuse. Improving function is the goal, obtaining enough pain relief to participate in myofasical therapy, get out of a chair, bathe, comb your hair, put on makeup, smile at yourself in the mirror, participate in the day, and interact with family and friends without having to painfully force air over the vocal cords in an effort to talk.

The Pain Patient (Pseudo-addiction) (Cooper and Miller, pg.171-172)

*Medications improve their quality of life. They are in control of their medications.
*The pain patient will want to decrease the medication if side effects are present.
*The pain patient is concerned about physical problems.
*The pain patient follows the contract for the use of opioids. (Pain specialists
will most likely have you sign a contract with them stating that you will follow
their prescribing instructions.)
*The pain patient will have medication left over.

The Addict

*The medications cause a decreased quality of life. An addict is out of control with
*The addict will want to continue medication regardless of side effects.
*The addict is in denial.
*The addict doesn’t follow the contract for the use of opioids.
*The addict doesn’t have medication left over. Addicts lose prescriptions and always
have a story.

The preceding lists are an excerpt from Fibromyalgia Network, April, 2001, based on Dr. Heit’s work at the Georgetown University School of Medicine (2001) and Dr. Heit’s presentation, “Opioid Prescribing: An Update on Clinical, Ethical and Legal Guidelines” from the Journal of Law, Medicine & Ethics, 22(3) 252–56, (Fall) 1994.

The laws currently written are to protect us, however, the shenanigans of drug seekers and physicians who feed their habit to make a dollar, helping them rid their addiction, keeps the patient in debilitating pain, wallowing in misery and emotionally handicapped. And then they have the gall to insinuate we are to blame for our pain state.

On the other hand, more patient education regarding the pitfalls of opioid therapy is needed. With conditions such as ours it takes a multimodal treatment course to feel better. When our pain in not under control it is impossible to tolerate treatments and activity known to help. It is unreasonable for us to expect, even with pain meds, to be pain free. It is not, nor should it be the main goal. What we need from any of our medications is enough relief to participate in activities and treatments. We are entitled to have enough pain control to avoid the snare of a hypersensitive state, which will keep our brain in a constant wind up. Once this wind-up phenomenon takes place, it takes twice the effort to bring the pain response back under our watchful supervision. We know, or should know, what aggravates our pain (Chapter 2 – Communicating Your Healthcare Needs, pgs. 65-132). It should be up to us to decide what enough is and what too much is. The road to a more productive life is paved with pain medications that afford us the opportunity to move, one step at a time. The golden brick is that one with the face of, movement, thought, physical therapies and emotional support engraved with your name.

A course of treatment that has worked for some is a tapered opioid vacation every couple of months for about a week, so the body doesn't get used to craving more and more. They are called mini med vacations and are supplemented with other meds to help and it is supervised and administered by a qualified physician. More studies need to be done on this because my biggest fear is that we don’t know the end place on opioid dosing until it is too late. Why take unnecessary risk? I understand pain only too well, but as most of us who have been on opioid therapy will tell you, it never takes the pain completely away, and still allows you to get up and move about. We must participate and have our own plan. We need to be empowered. And, we need control over what medication helps us. If the government continues to walk hand and hand with pharmaceuticals, one day our rights pain relief, will be completely stripped. As honest chronic pain patients we need to take this responsibility seriously.

I understand that what works for me, may not work for someone else. For me, it is about balance of spiritual, mental, physical and emotional, collaboration with my healthcare provider, and acceptance. I like to think that because of chronic life altering pain, I have learned the importance of appreciating days I might otherwise take for granted.

I think the alternative drugs, the Savellas, Lyrica, Cymbalta come with their own package of unwanted side effects and alter the brain chemistry and interact with many other medications we take for comorbid conditions such as migraine and IBS. The pharmaceutical industry has financial and political power beyond our comprehension. If a patient ONLY needs one medication and these class of drugs work for them, I am all over it. It is about improving function, but it should be our option, not something dictated to us by our government, putting themselves between the patient and the physician for profitability.

Give us the right to choose what is best for us. Let us have the medication that promotes enough pain relief so we can participate in trigger point therapies, Yoga, T’ai Chi, acupuncture, myofascial release, active release therapy, or even a light massage. Shouldn’t that be a right, not a privilege?

We are intelligent people here. Our goal is to feel well enough to wake up to a bright day. We must not ignore the pitfalls of opioid use, but we have proven over and over again that the pain patient is NOT going to abuse their medications. If one man steals in a community does that mean it is a community of thieves? Even if I do start to abuse my opioid, one in ten will, can’t you inform me of this possibility? Will you offer a remedy for me so that I may live one day with manageable pain? We admit we need to be better educated in what can happen with escalating doses and medication interactions. THAT is what the physician should be giving us when we are on opioid or any medication therapy. If they cannot provide that information for us, then they need to make appropriate referrals.

Harmony and Hope, Celeste

Written by Celeste Cooper, RN, author, Integrative Therapies for Fibromyalgia, Chronic Fatigue Syndrome, and Myofascial Pain: The Mind-Body Connection (co-author, Jeff Miller, PhD).

Celeste's Website

Celeste's Website
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