Dr. Devin Starlanyl, MD
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Your success on the road to healing depends on identifying as many perpetuating factors as you can, and dealing with them.

No matter what you do to relieve the TrPs, they will come back if you have perpetuating factors. If you have chronic MPS, or FMS&MPS Complex, you DO have perpetuating factors, and if you want to feel better, you can't ignore them. They won't simply go away, and neither will your TrPs.

Don't let the number of perpetuating factors be daunting to you. Become a detective. Think of perpetuating factors as clues to why you feel bad. David Simons, in his monograph "Myofascial Pain Syndrome Due to Trigger Points" (1987), says that effective TrP therapy should last indefinitely unless there are perpetuating factors. Factors which perpetuate TrPs, by doing so, perpetuate FMS. Whatever you can do to give yourself better health will decrease the stress load on your body.

One of the best ways to start on your healing process is to get a good complete physical examination. Have your possible perpetuating factors listed and discuss any required testing with your doctor. Have your TrPs mapped by a physical therapist who KNOWS Travell and Simons' medical. Don't be fooled by someone who says, "I know trigger points. You have all 18." This person doesn't know tender points (FMS)from trigger points (MPS).

Metabolic problems such as diabetes or reactive hypoglycemia (RHG)can perpetuate TrPs. RHG is common in FMS. The standard glucose tolerance test will not show RHG. You need a high carbohydrate challenge meal, and blood sampling for glucose and adrenalin levels, as we get adrenalin spikes at unusual times. Usually, such a test is not necessary.

The way to get this condition under control is by a balanced diet, avoiding meals and snacks with unbalanced carbohydrates and avoiding excess carbohydrates. If you have the symptoms, try the diet. There is nothing special to buy, just healthy food. If, on the other hand, healthy food is special to you, that should tell you something right there.

You and your doctor should also consider the possibility that you may have a malabsorptive condition in the gut, especially if you have been on NSAIDS. This is worsened if you have vitamin and mineral insufficiency. You may require extra supplementation
People with FMS have unbalanced neuroendocrine systems. This can start a neurotransmitter cascade of imbalances. Your doctor should be aware that people with FMS often score low normal on a thyroid test, and the BT2 panel--Total T4, Free T4, Total T3 and TSH, are needed to get a true picture of the thyroid. A thyroid antibody test may be needed in some cases. A 24 hour cortisol may not be relevant, since your cortisol may swing wildly through the night and day, but the median may be fine. You may need slightly more specific testing to get accurate results.
Paradoxical breathing is a major perpetuating factor, and it is often overlooked. Your belly should expand when you inhale, and go in when you exhale.

Paradoxical breathing is shallow breathing, and causes oxygen starvation. Focus on breathing correctly to flood your body with life-giving oxygen to help you heal. Air hunger can be compounded if the neurotransmitter histamine is in overabundance, and other neurotransmitters are creating extra mucus or constriction in the air passages.

Anything which cuts down the available oxygen to the muscles can perpetuate TrPs. This can be in the form of a metabolic problem, such a hypoglycemia, a deficiency, such as anemia, or even a mechanical factor, such as tight or restrictive clothing.
Poor posture and poor body mechanics develop when we're not looking. Our shoulders try to creep up around our neck as we sit typing at a keyboard. We forget how to stand up straight. Our chest muscles get tight because it hurts to breathe, so we hunch down. This contracts the neck muscles, which rolls the shoulder forward. You can almost see the TrPs developing those satellites and secondaries. We get this head-forward posture.

Good posture means good posture ALWAYS. This means no slouching when you relax and watch tv at night, or when you read. Right now, take note of your body. What areas of your body are being stressed? You can learn to relax MINDFULLY, being aware of your posture. You can even learn to sleep mindfully.

Allow enough room in the sheets for your feet when you make the bed. When you're on your back, try to keep your arms so that the hands face palm inward, rather than palm to the bed surface, which would roll the shoulders. Avoid having your chin scrunched down toward your chest if you're on your side, so that the neck muscles don't contract. If you are having sole pain with your first steps in the morning, roll up a large towel and put it under the covers at the bottom of the bed, to keep your feet in a neutral position. It will take time to develop new habits.
Be aware of how you move in bed. When you turn, roll with your head flat on the pillow, and use your arms to help you turn. Don't lift your head and "lead with it" as you roll on to your side. Practice this. Turning in bed the wrong way is a great stressor to the SCM muscles, and a common perpetuating factor. Ask your physical therapist to help you learn how to turn in bed, get up from lying down, and get up from sitting, without stressing your body. This is called "body mechanics".

You need sleep. Not just 8 hours of sleep, but sufficient RESTORATIVE sleep. You must wake up feeling like you have slept, NOT like trained elephants spent the night flamenco dancing on your body!

If you were awake many times during the night, if you had no dreams, or if you woke up more tired than you were when you went to sleep, you didn't get restorative sleep. You and your doctor must work together to find out what medications or combination of medications work to provide you this blessing that so many people take for granted.

Often, a good first choice to try is Benedryl. I have observed that there is a subset of FMS patients that are stimulated by Benedryl, Paxil, Pamelor and Ultram. Start by trying Benedryl.

There is a subset of us who react oddly to Benadryl, Ultram, Pamelor, Paxil and some other medications which usually product drowsiness. We become wired. 10 mg of Paxil helps me sleep, but only if I take it in the morning.

What constitutes a comfortable bed is different for us all. Some of us require a firm mattress or futon. Many of us need a water bed or air mattress. Some, like the "Princess and the Pea", find that even those bedding choices are to hard.

Finding the right pillow can be a challenge. Due to neck TrPs, many of us have hardly any curvature in our neck. The standard cervical pillow doesn't work. It is a trial and error procedure to find out what worked best. Some people prefer a small pillow that is soft enough to mold the way they want it. Some use a water pillow. Sometimes, when we find out what works well, our body changes, and we must begin the search again.
Infections and infestations can run down your body and reduce its ability to recover. When you are already struggling with FMS&MPS Complex, facing yet another illness seems unsurmountable. Do everything within reason to minimize your chances of developing additional medical problems, including bacterial, viral and/or yeast infections, and protozoal or parasite infestations. Remember that your immune system may be down due to sleep deprivation, or hyperactive due to neurotransmitters.

Previous surgeries and previous physical traumas can create adhesions and weak areas which are targets for TrP formation. As your body tries to compensate for extra tissue or lack of mobility in tissue, these areas become perpetuating factors.

Certain behaviors, particular things you do, whether voluntarily or involuntarily, can be perpetuating factors. Do you use a heavy shoulder bag? Do you smoke? Do you drink too much alcohol? Do you stay up too late or get up too early? Do you keep irregular hours? Do you work shifts? Do you perform repetitious exercise or work? Do you procrastinate and then have to double up your work load to catch up? Do you blame others for your problems? Do you have a great amount of negativity and stress in your life? Do you promise to do things for others and then half-kill yourself trying to fulfill your promises? Are you continually trying to push yourself beyond your limits? All of these are stressors that you don't need. We all have them.

The "good-sport" syndrome can destroy us. By nature, many of us are helping, giving people. We like to lend a hand, even when both of ours are tied behind out backs. We need to cultivate a sense of enlightened self-interest. Otherwise we overextend ourselves when we feel well, and then we crash.

Physical imbalance is also a perpetuating factor. Perhaps you were born with one leg shorter, or one side of the pelvis smaller. You may have proportionally short upper arms so you tilt sideways to lean one side on an armrest when you sit. You could have short lower legs, so that most chairs automatically cut off the circulation of the hamstring muscles. Imbalance can come with age, as we lose teeth, or our body wears down unevenly.

Be sure that you and your physical therapist consider both sides of the body when doing stretching and bodywork. You may have active TrPs on one side of the body only, but both sides need work. The body is designed to be a functional whole.
Anything which causes you to hold your muscles in a tightened or unnatural condition for a period of time can be a perpetuating factor. Anxiety, grief, chronic pain, depression, repetitive action, dental work, needle work, or constant computer mouse use are examples of stressors which perpetuate trigger points.

If you constantly look in one area, the muscles of your eyes may develop TrPs. Every once in a while, look around. Look up and down, and then roll your eyes, stretching the muscles up and to each corner of the eye, clockwise and then counter clockwise. Deliberately stretch those eye muscles.

Some perpetuating actions, such as chewing gum, may seem harmless, but you can pay for them with TrPs. Mouth breathing, constant facial expressions such as squinting, ill-fitted or rigid-soled shoes, and poorly designed furniture can all contribute to the stresses on your body.
Obesity, Morton's foot or FMS&MPS Complex foot(see "Fibromyalgia and Chronic Myofascial Pain Syndrome: A Survival Manual"), overwork, immobility (even that due to prolonged bed rest or casts), and inappropriate physical therapy are also common TrP perpetuators.
We are creatures of habit. Being so, we don't tolerate change well. Even so slight a change as the switch to Daylight Savings Time can affect FMS and MPS temporarily.

If you live in a time zone with seasonal changes, you may notice that your health declines in the spring and the fall, with more rapid temperature, moisture and barometric extremes.
At all times, consider your attire preventative medicine. Dress in layers, and be especially mindful of drafts. Avoid sitting under air conditioner or heater ducts.

Our ability to tolerate change is often faced with an insurmountable obstacle when we travel. New schedules, the immobility of travel itself, new foods, new surroundings and being without your "life support" can be devastating. They all add to sensory overload, and your brain can't keep up with the rapid changes and input. You may find yourself in flare after every trip.

One perpetuating factor which will require us all to work together to remedy is the increasing burden of pollution that impacts our lives. No matter how carefully we eat, move and live, the growing amount of toxins in the air, water and soil will affect our lives. As the Earth become less healthy, so shall we all. It is in your own self-interest to become an environmentalist, and be aware of your impact on nature, and it on you. The story of life is a closed circle. Be mindful of it.

Excerpted from "The Fibromyalgia Advocate: Guide to Fibromyalgia and Chronic Myofascial Pain Syndrome", Devin Starlanyl, coming from New Harbinger in October 1998.