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.


Britta said...

I'm almost certain I have CMP too, hopefully, my doctor will agree at my next appointment this Thursday and adjust my treatment plan.

You didn't address twitching and jerking. I thought I read that was a symptom of CMP. I twitch and jerk a lot and it's become very bothersome. Yesterday, my lower jaw twitched and I bit my tongue. Mostly, however it's my limbs, wrists, neck and head that jerk as well as visible muscle twitches in my right arm.

Again great post! I'm really happy to have found your blog!

Dr. Dee said...

Excellent article with lots of new information ...also for doctors and therapists!

Please talk more about what is contained in local anesthetic trigger point injections and how they assist.

How big a role does nutrition play in all this as an effective therapy? What else...?

Again, thanks for an enlightening read.

Muscle Pain said...

Unlike fibromyalgia pain, the pain in myofascial pain syndrome is more localized or regional (along the muscle and surrounding fascia tissues) and is associated with localized small hypersensitive nodules (ie, taut bands), known as myofascial trigger points. Myofascial pain in Taiwan

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