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.

Update: Now Available - Myofascial Pain Syndrome 
(In header of The Pained Ink Slayer)

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. 

Sunday, January 6, 2019

5 Things You Should Know About Dysautonomia If You Have Fibromyalgia

This blog post, 5 Things You Should Know About Dysautonomia If You Have Fibromyalgia, originally appeared on ProHealth. Because the article continues to garner attention, I am sharing it in its entirety here on The Pained Ink Slayer.


Published on ProHealth October 11, 2018

When I started looking at a way to raise awareness for dysautonomia this month, I realized it was in 2015 that I wrote about dysautonomia and fibromyalgia. So, I thought it was time for an update.

What is dysautonomia?

Dysautonomia is a term used to describe a disruption in the way our autonomic nervous system regulates, communicates, and adjusts our body functions so we maintain balance.

As reported in the above-mentioned article, the autonomic nervous system (ANS) consists of two branches:  the sympathetic and the parasympathetic.

The sympathetic nervous system prepares our body for fight or flight in stressful situations and sometimes seems to give us superhuman powers in fearful or dangerous situations. Certain functions take place, like the release of adrenaline, which cause other things such as an increase in our heart rate so that more oxygen is delivered to our muscles when it’s needed.

It is the parasympathetic arm of our ANS that normalizes things after a threat is gone. Both branches of the autonomic nervous system work “automatically” to provide the body balance and well-being, referred to as homeostasis.

5 scientific advances in understanding dysautonomia and fibromyalgia
1.     The American College of Rheumatology posed at their annual meeting, Dysautonomia may be the pathogenesis behind fibromyalgia (December 23, 2015). Two groups of patients were part of a study:  those with fibromyalgia and those with rheumatoid arthritis. Martinez-Martinez LA, et al., discovered a strong correlation between dysautonomia and the fibromyalgia group. Shirley Pulawski had this to say about the paper.

“A consistent line of investigation suggests that dysautonomia may explain the multisystem fibromyalgia features, and that fibromyalgia is a sympathetically maintained neuropathic pain syndrome,” the researchers wrote. “The sympathetic nervous network is the main component of the stress response system.”

Her reference:
Martinez-Martinez LA, et al. Paper #71. Presented at: American College of Rheumatology Annual Meeting; Nov. 7-11, 2015; San Francisco.

2.     Small fiber neuropathy has been implicated in fibromyalgia dysautonomia once again. In September 2018, Fibromyalgia and small fiber neuropathy: the plot thickens, Martinez-Lavin suggests "The recent recognition of small fiber neuropathy in a large subgroup of fibromyalgia patients reinforces the dysautonomia-neuropathic hypothesis and validates fibromyalgia pain... Skin biopsy and corneal confocal microscopy will probably become useful fibromyalgia diagnostic tests. Dorsal root ganglia sodium channel blockers are potential fibromyalgia analgesic medications. Subgroups of young girls with ‘autoimmune neuropathic fibromyalgia’ may respond to immunoglobulin therapy."

Side note: In light of the FDA approved clinical trial on the BCG vaccine for fibromyalgia, the plot does indeed thicken and the characters at play are biological. The FM/a test is a multi-biomarker-based blood test that looks specifically at immune system white blood chemokine and cytokine patterns.  The paper by Kenney, M.J.  and Ganta, C.K., Autonomic Nervous System and Immune System Interactions Autonomic Nervous System and Immune System Interactions (2014, July), states that cytokines and other immune factors affect the level of activity and responsivity of discharges in sympathetic and parasympathetic nerves innervating diverse targets. I am in no way a scientist, but I take this to mean immune influences such as those identified in the FM/a test could be a player in our dysautonomia symptoms.

3.     Reyes-Manzano CF, et al., Multifractal Analysis Reveals Decreased Non-linearity and Stronger Anticorrelations in Heart Period Fluctuations of Fibromyalgia Patients, concluded in August 2018, "When compared to healthy controls, fibromyalgia patients display decreased nonlinearity and stronger anti-correlations in heart period fluctuations.” This reinforces dysautonomia and loss of heart rate variability in fibromyalgia as reported in my 2015 article.

4.     Autonomic nervous system dysfunction may contribute to poor sleep in fibromyalgia and vice versa according to a 2017 study. The investigators describe it as a vicious circle.

5.     I found the study, Dermatological Manifestations of Postural Tachycardia Syndrome Are Common and Diverse (2016, Jan.), particularly interesting since many of us experience POTS (a type of dysautonomia called chronic orthostatic intolerance). I suspect I am not alone in this one since so many of us also complain of unusual rashes, Raynaud’s, and livedo reticularis. Note: Raynaud’s and livedo reticularis are thought to be dysfunctions in the sympathetic arm of our autonomic nervous system.


There is sufficient evidence to correlate dysautonomia and fibromyalgia. If you have symptoms of dysautonomia, discuss it with your physician. Diagnosis needs to be made in order to explore possible treatments that will ease your symptoms and improve your health.

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
Click on the picture