Fibromyalgia

and

Myofacial Pain Syndrom

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Still More Opinions

Chronic Myofascial Pain Syndrome

Trigger points cascade down the arm and the neck and shoulders and you lose some mobility. A trigger point cascade results when a primary TrP develops satellite and secondary TrPs, which then develop satellite and secondary TrPs of their own. For example, sternocleidomastoid (SCM) TrPs can result in TrPs developing in other neck muscles, in the chest and shoulders, and in the head and face. The chest and shoulder TrPs can then result in arm/ hand / finger and belly/back/hip TrPs, and so forth. Eventually, you can have TrPs from the top of your head to the tips of your toes. A true "cascade" effect.

Note: A similar cascade of TrPs often takes place in the lower body. For example, painful menses,childbirth, a hysterectomy, or a hernia can activate TrP activity (hips to thighs to knee to lower leg to foot to toe).

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Differences Between FMS and MPS

FMS and MPS are different syndromes. However, the vast majority of physicians tend to lump them together because they see many patients with the FMS/MPS Complex (or at least FMS and individual TrPs). Unless doctors have a thorough knowledge of and familiarity with individual TrPs, they don't stand a chance of sorting out the symptoms. The works of Travell and Simons explain the differences in great detail and supply supporting data.

One interesting difference between the two syndromes is that more women than men have FMS, but MPS affects men and women in equal numbers. Another difference is that muscles in locations that are some distance from the trigger points of MPS have normal sensitivity. In Fibromyalgia, there is a generalized sensitivity. This means there is a bodywide, diffuse achiness with FMS, whereas with MPS there are specific pains in specific areas. In MPS, the areas not affected with TrPs do not hurt; whereas in FMS, the areas outside the tender points still ache (Travell and Simons 1983 and 1992).

Remember that FMS is, among other things, a systemic neurotransmitter dysregulation, and has many biochemical causes. Since neurotransmitters are the means by which the body and brain speak to each other, a systemic dysregulation causes communication breakdowns and failures.

This process somewhat resembles a familiar game that children sometimes play in school. They line up, and whisper a sentence, child to child, down to the end of the line. By the time the last child in the line hears the sentence, its meaning has been garbled. In very simplistic terms, this is similar to what happens to FMS. There are other problems as well, but they are all systemic in nature, such as the alpha-delta sleep anomaly.

Fibromyalgia ia a biochemical disorder. It occurs as part of a biochemical imbalance, and we are far from understanding the "whys" of it. We just know that a number of biochemical balances in the body are in disarray, This is part of the reason why FMS is so complex. There are many neurotransmitters, and they can be disrupted in many ways. Some of these ways influence how other biochemicals, including medications, are metabolized.

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Fibromyalgia symptoms have 11 or more tender points. But a variable proportion of otherwise typical patients may have less than 11 tender points at the time of the examination,"

In addition, the Copenhagen Declaration states that fibromyalgia syndrome is "part of a wider syndrome encompassing headaches, irritable bladder, dysmenorrhea, cold sensitivity,Raynaud's phenomenon, restless legs, atypical patterns of numbness and tingling, exercise intolerance and complaints of weakness." Note: Here the document appears to be referring to the FMS/MPS Complex, which consists of fibromyalgia complicated with Myofasdal Pain Syndrome (MPS). MPS will be explained at a later time.The Copenhagen Declaration goes on to state that the psychological state of FMS patients,which is often one of depression and anxiety, could well be caused by the physical conditions. Chronic pain, especially pain of undiagnosed origin, is a frequent source of depression and anxiety.

Lately, there have been some educational articles about FMS in the popular press. This has alerted many patients to the true nature of their problem. For example, one member of a local support group had been seeing specialist for some time, without receiving a diagnosis. She took one of these articles to her doctor and told him, "This is what I have. It's fibromyalgia" His response was, "I've known that for two years. I didn't tell you, because there's nothing you can do about it anyway." This physician's attitude has no place in the practice of medicine—nor anywhere else. There are effective treatments for FMS, and he owed it to his patient to inform her of her correct diagnosis. Anything short of that is unethical.

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Muscles

The autonomic nervous system tells striated muscle to react to physical or other forms of stress. It can cause us to tense involuntarily, to prepare to fight, or to flee danger. It is also supposed to tell us to relax when the stress is over. Unfortunatley, in FMS, it often forgets the second part and the striated muscles do not relax but remain constricted - that is, they stay tight - ready to deal with a stress that is no longer present. Boths triated and smooth muscles have fibers and bundles of fibers, all individually wrapped in myofascia. Muscles are one of the body's major pain generators, and yet they are the least udnerstood of the body's systems, and are often the most ignored by many physicians.

Glands

In FMS, there is a disrupted HPA axis. This means that the critical balance between hypothalamus, pituitary, and adrenal glands is no longer operating properly. The balance between the hormones that these glands produce is an important key to the proper functioning of the body.

Histamine

Histamine is the neurotransmitter often associated with allergies - we are all familiar with antihistamines. If your cell membranes are broken by trauma, such as a bruise or cut, or exposrure to heat or chemical toxins, histamine is released. Histamine causes the smooth muscle of the bronchial area to constrict, so we become short of breath. It relaxes small blood vessels, but constricts some large ones. IT provokes a generalized dilation of the blood vessels in parts of the brain, as any of us who has ever had a "histamine headache" knows very well. Histamine also causes an increase in the permeability of the capillaries. bruising can result, as well as leakage of intracellular components into the area outside the cells. It causes a drop in blood pressure, secretion of gastric juices, amd may cause nausea and vomiting. When histamine levels become high, swelling, a runny nose, and red eyes result.

Biochemical Factors

People with FMS have unbalanced neuroendocrine systems. Fibromyalgia can start a cascade of neurotransmitter imbalances. Your doctor should be aware that peopel with FMS may need more specific testing than she normally uses. For example, people with FMS often score low-normal on thyroid test, and the BT2 panel (Total T4, Free T4, Total T3 and TSH) is required to get a true picture of the condition of the thyroid. IN some cases, even a thyroid antibody test may be needed. If you are gatigued and your doctor is considering DHEA supplementation, a 25 hour cortisol test may not be useful, because your cortisol may fluctuate wildly through the night and day, although the average value may be fine. As another example, the usual test for anemia may tell yoru doctor that youa re fine, but if your ferratin is checked, it may be discovered that the iron you have is not available to your muscles. Just because standard testing shows normal values does not always mean that everything is fine. It may simply mean that the proper tests have not been run. You may need slightly more specific testing to obtain accurate results.

Metabolic probles such as diabetes or reactive hypoglycemia can perpetuate TrPs. In my experience, reactive hypoglycemia is also very common in FMS. In my last book I discussed the work of Lynne August and R. Paul St. Amand, physicians who independently came to the conclusion that reactive hypoglycemia is a major factor of FMS. There are others who have reached the same conclusion. Standard glucose tolerance tests will not pick up reactive hypoglycemia, but specialized testing is not necessary since the treatment of choice is to stop carbohydrate bingeing and switch to balanced diets such as the Zone diet. this diet may have to be modified to fit each individual, but the Zone books, although not written espressly for people with FMS and MPS, work very well to help those of us who have reactive hypoglycemia as a perpetuating factor. There have also been studies that show supplemental chromium can help patients with reactive hypoglycemia.

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Tender Points

The Copenhagen official Fibromyalgia Syndrome definition states that you must have at least 11 of the 18 specified tender points to be diagnosed with FMS, Tender points hurt where pressed, but they do not refer pain elsewhere—that is, pressing a tender point does not cause pain in some other part of the body. (Note that when examining yourself for tender points, you must use enough pressure to whiten the 'thumbnail.)

The official definition further requires that tender points must be present in all four quadrants of the body—that is, the upper right and left and lower right and left parts of your body. Furthermore, you must have had widespread, more-or-less continuous pain for at least three months. Because tender points can fluctuate and vary from day to day, if you don't have 11 out of the 18 on a given day, your doctor may diagnose "possible FMS" and may need to count the tender points again on future visits.

Tender points occur in pairs on various parts of the body Because they occur in pairs, the pain is usually distributed equally on both sides of the body. On the back of your body, tender points are present in the following places:

On the Back of the body:

• along the spine in the neck, where the head and neck meet

• On the upper line of the shoulder, a little less than halfway from the shoulder to the neck

• Three finger widths, on a diagonal, inward from the last points

• On the back fairly close to the "dimples" above the buttocks, a little less than halfway in toward the spine

• Below the buttocks, very close to the outside edge of the thigh, about three finger widths

On the Front of your body:

• On the neck, Just above inner edge of the collarbone

• Still on the neck, a little further out from the last points, about four finger widths down

• On the inner (palm) side of the lower arm, about three finger widths below the elbow crease

• On the inner side of the knee, in the "fat pad."

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Myofascial Trigger Points

Latent Trigger Points

The trigger point is an exquisitely sore point that not only hurts where it is pressed, like an FMS tender point, but it also "triggers" a referred pain pattern to somewhere else in the body. A latent type of Trp also occurs. The latent Trp doesn't hurt at all, unless it is being pressed. You might not even know it's there, but your body does. It restricts movement, and weakens and prevents full lengthening of the affected muscle. If you press on the latent TrP it does refer pain in its characteristic pattern. A latent TrP may be activated by overstretching, overuse, or chilling the muscle. People who rarely exercise have a much greater chance of developing latent TrPs.

Trigger Point Symptoms

Often, TrP's can be felt as painful lumps of hardened fasda, possibly due to the constriction of blood and other fluids, as discussed in Chapter 2. The ropy bands are often easier to feel along the arms and legs. If you stretch (extend) your muscle about two thirds of the way out, you might be able to feel them. Sometimes the muscles get so tight that you can't feel the lumps, or even the tight, ropy bands. Your muscle simply feels like hardened concrete.

When TrPs are present, muscle strength becomes unreliable. For example, if you have arm and hand TrPs, your grip is weakened so that things may drop unexpectedly from your hand. That's because the pain is translated by the brain as damage—so your body won't allow you to complete acts that cause pain. Your tightest grip just isn't what it used to be.

When a nerve passes through a muscle between the ropy bands, or when a nerve lies between the band and bone, the pressure on the nerve can produce numbness, but only in the area of compression. That's called TrP nerve entrappment. You may have noticed that if one part of your body rests over another part while you are sleeping, the part being compressed goes numb. For example, if you fling one arm over the other arm, the compressed arm will go numb. If you want to be able to distinguish between a TrP with an entrapped nerve and one without such entrappment the following simple test will help:
If ice makes it feel better, that is a sign of nerve entrappment; but if heat relieves the pain and ice makes it worse, then there is no nerve entrappment.

Where trigger points are involved, no two patients' problems are exactly alike. TrPs also can vary in irritability from hour to hour and day to day. The amount of stress needed to activate a latent TrP depends on the conditioning of the muscle, and that also varies. If you have stubborn chronic pain, you should expect multiple causes and perpetuating factors.

Some trigger points refer pain only in close proximity to the TrP itself. Others, such as those in the scaleni muscles, refer symptoms in a very large pattern. This pain pattern is simular from patient to patient, which is a great aid in diagnosis.

A satellite TrP develops in a muscle because that muscle is in the primary TrPs referred pain area. A secondary TrP develops in a muscle that is overloaded because it is compensating or substituting for a muscle that contains the primary TrP. These are important concepts, because they explain how TrPs seem to "spread," It has given rise to the mistaken impression that FMS and/or MPS are "progressive."

There is a large difference between a condition "worsening" and a "progressive" illness. The difference being that a progressive condition cannot be reversed whereas trigger points definitely can be. Often these trigger points produce other symptoms, usually in a referred pain zone. Such a TrP hurts whenever you use the involved muscle. The fact that the referred pain patterns are very similar from patient to patient with TrPs really helps the physician to make a diagnosis. That's why familiarity with TrPs and an ability to take a good medical history are so important. An educated doctor will know where to look for TrPs before the physical exam begins.
Note: There has been some confusion about nomenclature in recent medical literature. A muscle group with many TrPs is often called MPS. The term MPS should refer to chronic, bodywide Myofascial Pain Syndrome. Pain from trigger points is usually steady, dull, deep, and aching.

The intensity can range from mild discomfort to incapacitating torture. If a nerve is trapped, the pain can be burning, sharp, and lightning-like. Trigger point pain, unlike the tender point pain of FMS, is rarely distributed equally on both sides of the body. The effects of low-back pain of Myofascial origin can be as bad as or worse than low-back pain from a herniated disc. If you have a bad back, be sure your doctor is familiar with and understands trigger points. Needless surgery can be avoided, and you will get much better treatment and results.

Stemocleidomastoid TrPs

Now, lefs take a look at what are called the Sternocleidomastoid (SCM) trigger points to give you a better idea of how important trigger points can be.

Dizziness, ringing of the ears, loss of balance, and other symptoms can all be caused by SCM trigger points. The sternocleidomastold group has a great many functions, one of which is to hold up the head. Receptors m the SCM musde complex transmit nerve impulses that inform the brain of the position of the head and body in the surrounding space. When trigger points are present, the receptors lie. What they tell the brain is not what the eyes tell the brain. If there are TrPs in the muscles surrounding the eyes. The eyes also send incorrect data to the brain — different, incorrect data than the receptors in the neck do. When head movement changes the SCM message, for example, when you turn your head to look around or you look up from changing the kitty litter, you get dizzy. This, coupled with poor balance, can make it seem as though the walls are tilting. In fact, a common symptom of SCM trigger points is called the "drunken" walk, because it causes you to bump into doorways and walls.

People with SCM TrFs often have trouble glancing downward; doing so can cause them to fall forward. They can become so disoriented that they can get nauseated and may even vomit. When you take corners while driving, you get the impression that you're "banking" the turn at a steep angle, as if you were tilted on a motorcycle. This kind of altered perception can occur when you stop the car and you feel as if it were still moving. This can be frightening. These perceptual changes can be very hard to explain to your doctor.

Chronic dry cough, pain deep in the ear canal, pain in the throat and back of the tongue, and pain to a small round area at the tip of the chin also can be part of the SCM trigger point.

Localized sweating and vasoconstriction can be a problem, as well as pain in the cap area of the head. (What SCM TrPs don't cause is a pain in the neck, although they figuratively become one due to their wide-ranging symptoms.)
Note that cold drafts alone can bring on neck TrPs.

Trigger points In the peroneal

You may need to wear warm, loose socks at night during the winter months. (This can be a problem for those of us who need to stick their feet out from under the cover at times during the night, to help equalize the temperature.) Shoes with rigid soles that allow only ankle and no toe movement can perpetuate TrPs in the leg as well as in the foot. Selecting the right sole is important for other reasons, too. Wearing shoes with smooth soles on a hard slippery surface can perpetuate TrPs, as can chilling of the feet. It helps your feet and legs if you soak them in a tub of warm water and then do some gentle stretching.

Intrinsic Foot TrPs

Deep intrinsic foot TrPs can cause pain under the heel, an intolerance to orthotics, a staggering walk, and thickened calluses. Intrinsic foot TrPs can also cause a strange fluffy feeling of numbness, a sense of the side swelling over the region of the metatarsal heads (these are the joints in the toes like the knuckles in the fingers), and a tingling of the great toe.

Active or latent TrPs in the dorsal interosseous muscles can be associated with hammer toes, and any foot deformity will perpetuate TrPs. Note that deformations of the toes may disappear after correction of TrPs.

Foot Structure

Some common varieties of foot structure create additional hazards for the person with FMS/MPS. They are discussed below.

Fallen Arches

People with "fallen arches" often try specially made shoe orthotics without success. The undersurface of the foot near the middle continues to be painful, and the expensive inserts lie in the closet, unused.

Morton's Foot

The name of Dudley J. Morton, M.D. is forever linked with variations on the normal foot structure. One type of variation is hypermobility of the first metatarsal. The second variation is the foot with a relatively short "big toe" metatarsal and longer second toe metatarsal, with a wide web between the second and third toes. These variations are common. In a person with a tendency to develop TrPs, they result in a muscle imbalance stress situation of the whole leg. The peroneus and foot muscles are directly affected. The vastus medialis, gluteus medius, and gluteus mimimus TrPs are perpetuated due to the attempts these muscles make to compensate for the peroneus and foot dysfunction. There is a common callus pattern with this condition that aids diagnosis.

The FMS/MPS Foot

There appears to be no technical term for what I call the FMS/MPS foot. This foot has a broad front, a narrow heel, and a high arch. There is usually a large space between the big toe and the second toe. There is also a typical callus pattern. The callus may wear & hole in your socks about the size of a dime right under the second metatarsal. The big toe is often slanted towards the little toe. All of these are perpetuating factors of foot and leg TrPs.

Morton's Neuroma

Morion's neuroma occurs as a result of entrappment of the nerve between the toes. At the base of the toe, where it joins the foot, there are bones called metatarsals. Nerve branching occurs in this same area. If the metatarsals are crowding the nerves or if the myofasia is tightly wrapped around these nerve branches and the musculature, a neuroma can result.

A neuroma is a swelling of the nerve, with scarring and constriction in the surrounding area. If you have this condition, it feels as though you always have a pebble in your shoe. Your foot hurts whenever you put pressure on it. Gradually this develops into shooting pains that feel like electric shocks originating from the toes. Eventually, your foot hurts all the time, and walking becomes torture. By this point, conservative measures are often not enough. People with FMS/MPS and Morton's neuromas are in severe pain.

Sacroiliac (SI)

Joint Dysfunction

The sacroiliac is one of three joints in the body for which movement can neither be caused by nor opposed by muscles. Abnormal muscle tension from any cause can help to hold this joint in an abnormal, displaced position. It can become locked in place, which is a place that it should not be. For proper functioning, the joint must be mobilized. The onset of sacroiliac (SI) TrPs can be a simple motion of bending forward while tilting the pelvis and twisting. This is common when making a golf swing or while shoveling snow, while stooping and reaching, after a slight fall, or in pregnancy.

What You, the Patient, can Do

As you are learning more about your body, there are steps you can take to eliminate or lessen the effects of perpetuating fac- tors. You will learn more as you continue reading.

Because TrPs are at the heart of FMS/MPS Complex, however, it's important that you always try to prevent more TrPs from developing. You can do so in the following ways:

• Treat injuries aggressively
• Seek crisis intervention when appropriate
• Build proper and sufficient exercise and sleep into your program
• Use your body properly

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Where, Oh Where Are Those Trigger Points?

Travell and Simons warn against thinking of published TrP sites as the only places that trigger points can occur. These published sites are only guides; places to start looking. TrP sites in a given muscle may vary from person to person and many muscle groups may hold multiple TrP locations. Multiple TrPs may create overlapping and differing pain patterns. To add to the diagnostic confusion, TrPs often can overlay FMS tender points. Diagnosis becomes really challenging when FMS and MPS occur together. The hunt for TrPs can seem like a search for lost treasure. Thanks to Drs. Travell and Simons, we have the treasure map.

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No Bones About It

1. Did you have "growing pains" and chronic aches as a child?
Many people with FMS and / or MPS believe that their problems started fairly recently. When closely questioned, however, they often remember "growing pains," especially in the hips

We have found that growing pains are often the first warning sign of a genetic predisposition toward FMS/MPS. A TrP in the gluteus maximus often causes pain in a rapidly growing child.

2. Do you attract blackflies and mosquitoes?
For some reason, blackflies and mosquitoes seem to love people with FMS. There's something about their biochemistry that attracts these insects, (Perhaps you should hire yourself out for lawn parties. It might help pay your medical bills.)

Northern New England blackflies prefer the taste of people with FMS. So do Alaskan blackflies. The attraction may have something to do with abnormal carbohydrate metabolism. It may be electromagnetic. In any case, blackfly bites swell into huge hard lumps that take forever to go away and often leave scars. This symptom does seem to be dimilushed by guaifenesin therapy.

Mosquitoes are attracted to children, people with higher-than-normal body temperatures, anyone wearing bright clothes and scented products, and people with FMS. The best advice is to keep cool and unscented, and to wear white.

3. Do you have bodywide achiness?
Several studies have confirmed the presence of three times the amount of substance P in the spinal fluid of patients with FMS. It is a trammitter that can produce a nerve-generated re- sponse that leads to the dilation of the blood vessels. It can also cause fluid and proteins to migrate from inside the cells to outside the cells. This may be responsible for some of the aches, as well as some of the swollen feeling that FMS patients report.

4. Do you have allergies?
Allergies seem to be part of the FMS/MPS Complex's bag of tricks, and there are many reasons for this, but the chief one may just be that people with FMS/MPS have sensitized nervous systems. Histamine, a familiar name to allergy sufferers, is a neuro transmitter that is regulated in delta level sleep. Multiple chemical sensitivities and sensitivity to odors are also common with FMS. You may be hypersensitive to molds and yeasts. You may also have the "itchies. Add the post-nasal drip common to those with FMS, some Trps, and the already mechanically irritated throat, and you have a perfect set-up for allergies. Note, also, that people with FMS/ MPS don't always react normally to allergy tests. Skin tests are not reliable due to altered biochemical responses. Many of our "allergies" are often really sensitivities without immune components.

5. Do you experience extreme fatigue?
Fatigue and lack of endurance may be part of the disrupted hypothalamic-pituitary-adrenal (HPA) axis found in FMS. The hypothalamus, pituitary, and adrenal glands are tied together in many ways, each affecting the other as well as many other regulatory systems in the body. This interaction of the three glands is called the "HPA axis." If, for some reason, the hypothalamus stops functioning, then the ability to adjust rapidly to environmental change is damaged or lost. The hypothalamus also integrates cardiovascular regulation, food intake, and body temperature. The gland receives its control signals from (you guessed it) neurotransmitters. Fatigue is also exacerbated by sleep deprivation and the constant barrage of disrupted neurotransmitters, which causes an overabundance of mixed messages and sensory overload. Your adrenals, which help to regulate your energy are often overworked because of the adrenaline surges you get — often when you are longing to go to sleep. You may be very tired, "bone weary" even, yet your adrenaline starts pumping and suddenly you are wide awake. Naturally, this is exhausting. The toxic wastes resulting from the constriction of your myofascia also contribute to the energy drain on your resources. Is it any wonder you sometimes feel as if you've been tangling with a vampire?

6. Do vou have mottled or blotchy skin?
Light activates the hypothalamus, which activates the pituitary. The pituitary is also responsible for secreting ineanocyte-stimulating hormone. This influences the mottling on the skin.

7. Do you have loose (hypermobile) joints?
Hypermobility (or loose joints) is often due to rotation of internal musculature. Travell and Simons (1992) say that up to 5 percent of all adults have this problem. Overstretching hypermobile joints can seriously overextend the muscles, thus perpetuating the TrPs.

8. Do you crave carbohydrates or sweets?
Craving for chocolate stems at least partially from a lack of the neurotransmitter serotonin, which can leave you agitated and distressed. Chocolate causes the brain to produce more insulin, which enhances serotonin production. Serotonin is one of the main neurotransmitters in short supply in FMS. Lack of serotonin can also cause a craving for carbohydrates (pasta, bread, and so on).

On the other hand, craving salty things can mean fluctuating hormones, which indicate neurotransmitter dysregulation.

9. Do you have frequent yeast infections, itchiness on the roof of your mouth when you eat tangy cheese, or bloating if you drink beer?
If you have these symptoms, you may have a yeast problem. Many people with FMS/MPS do. And there is a good indication that at least some of the cognitive difficulties you may be experiencing are due to water retention from yeast overgrowth. Often foods that are high in yeast, such as citrus fruits, peanut butter, and cashews, cause bloating or roof-of-the-mouth itch. There is a blood test for the Candida (a common yeast) antibody. This test doesn't measure the Candida yeast, but it looks for antibodies that we would form in response to recurring yeast infections. You may also find that allergy shots for molds are very helpful.

10. Do you have overgrowing connective tissue nail ridges or nails hat curve under, ingrown hairs—and do you scar easily?
Nail ridges or beads and/or nails that curve under; ingrown hairs; adhesions; easy scarring; cuticles that thicken and split painfully resulting in sore hangnails; cysts and fi- broids; pierced ears that overgrow—all of these symptoms may be related. It appears that people with FMS/MPS frequently have overgrowing connective tissue. Also, fibrocystic breasts and fibroid tumors may be related, as they indicate an overgrowth and possible encapsulation of certain types of tissues. Hair loss may also be related, because hair tissue is similar to fingernail tissue.

11. Do you have sleep apnea?
Sleep apnea — temporary cessation of breathing while sleeping is a very dangerous condition that often accompanies snoring. It is common in FMS, especially in men.

12. Do you have generalized itchiness?
There are many types of itch. Often, when people itch, they look for an allergic reaction as the culprit, but allergies are not always the problem. The skin is the largest organ in the body. Too often if is regarded simply as a passive cover, but your skin is actualy your first line of defense against a frequently hostile outer world. It is the main contact between your inside "world'" and the outer world. However, as most science fiction fans know, problems do tend to occur when two worlds try to communicate, There are pressure plate receptors in the outer skin layer called Merkel's discs. They translate the tactile messages received by the skin to the brain. The brain then responds appropriately to the sensory input. For example, if you touch a thorn, your brain signals "sharp" and you move away. When the receptors don't know what message to send, they initiate a default mechanism. Unfamiliar pressures are translated and sent to the brain as "itch" signals. It may be that because of the dysregulation of neurotransmitters (in FMS) and / or the mechanical constriction of fluids around the Merkel's discs (in MPS), that people with FMS/MPS Complex itch more than most folks. Sometimes, it is enough to drive them to distraction and it often disrupts their meager amounts of sleep. Cold helps to control the itch by numbing the pressure plate receptors, Dryness, which enhances pressure reception by the discs, makes the itch worse.

13. Do you experience frequent frustration?
Those of us with FMS and / or MPS must learn how to cope with chronic frustration in order to survive. On the Internet group, one correspondent commented on how many times she had written a heartfelt reply to someone, only to accidentally delete it instead of sending it. So it goes.

14. Do you experience unusual reactions to medications?
Sometimes just a small portion of a normal dose of medication will have very strong effects on you as a fibromite. Other times you can take whopping doses of the same medication and feel no effects at all. This phenomenon may be connected with altered metabolism.

15. Do you have thick mucus secretions?
A lot of people with FMS/MPS Complex experience thick mucus secretions. There may be times when you have to take off your eyeglasses before you can blow your nose, because the mucus from your nose can gunk up the lenses, and it's hard to remove from your eyeglasses. Guaifenesin ends this problem, and the way it thins secretions may be a part of why it is so effective.

16. Do you have an inability to sweat or extreme night/ morning sweats?
These symptoms seem to come in a specific order. First, there is a period when you hardly sweat at all. This can last for years. Then, later, you may have times when you can become drenched in sweat, even during sleep. Any exertion, even a walk to the mailbox, can cause extreme sweating. Sometimes, this is accompanied by a continual feeling of nerves firing up and down the legs, chest, and arms, although this is not as common as Just sweating. It is likely that the body is trying to eliminate toxins and built-up metabolic waste products in the sweat. Many fibromites have reported that their sweat often smells bad, as does their urine. Additionally, they report having less skin symptomology if they wash off the sweat as soon as possible. Some medications cause sweating as well.

17. Do you have patches of skin with a painful network of fine veins and capillaries?
This is the mysterious "livido reticularis" that is sometimes seen in FMS/MPS Complex patients, usually in the legs, but it also can occur in the arms. Areas of hypersensitive skin are overlain by a visible blue and red network of veins and capillaries.

18. Do you have dennographia (writing with a fingernail on your skin leaves red welts)?
One phenomenon that occurs in FMS/MPS Complex is called the "flare response." The flare response is part of a reaction to the neurotransmitter histamine, and to mast cell release at the trigger points and other trauma sites. One Internet a Family member reported that red welts occurred with acupuncture. This can happen with any kind of trigger point therapy. It is a newegenic (generated by the nerves) flare in response to even mild touch (such as writing on your skin), heat, or chemical contact. Some people with FMS/MPS also experience a profound change in their ability to tolerate heat and cold and an increase in skinfold tenderness. (This is the sensitivity that results when you pinch the upper layer of skin, lifting it off the underlying tissues.) These people respond to touch with what is called "tactile defensiveness, " or muscle tension. For many of us, this means that some types of deep-muscle work, such as Heller-work or Rolfing, can worsen our condition.

19. Do you have night-driving problems?
Many people with FM5/MPS Complex often have a problem driving at night. The lights of the oncoming cars really distress us, Beta-carotene seems to help this somewhat. The effectiveness of beta-carotene depends on how deficient you are at the beginning of supplementation.

20. Do you have an extreme susceptibility to infection?
This symptom can occur in a cycle of immune changes. You may go through a cycle when you don't catch any colds or any other types of germs that may be going around. Later on, the reverse is often true, and your immune system has no success attacking infections at all. At those times, you have to put antibiotic ointment on every scratch to prevent it from becoming infected. Both responses can be signs of immune dysfunction.

The Fibromyalgia Network Newsletter (April 1992) reported two studies that found decreased immune natural killer (NK) cell activity in FMS. These cells are our frontline warriors against outside attack. It seems that they are present in normal amounts in people with FMS, but they do little or nothing. So what gives? Immune natural killer cells require serotonin to activate them, And serotonin is a nerve transmitter regulated in delta sleep, which is in short supply for people with FMS/MPS. When confronted by an "alien invader," our fibromite NK cells respond with "It's not my job."

The thymus is a glandular structure that functions in the development of the immune system. I have found that if I take a thymus extract, which comes In pill form, it makes an important difference in my immune system's ability. Without the extract, I can expect at least one cold a month. With it, I may get one or two colds a year. The extract can be purchased at many health food stores.

21. Do yon have delayed reactions when you are too active physically?
It is a common occurrence in FMS that when you overdo things, the reaction hits hardest the next day or even the day after that.

22. Do you get the shakes?
Perhaps you get the shakes when you are hungry, and they subside as soon as you eat. There is a certain type of hypoglycemia, or low blood sugar, that accompanies many cases of FMS. For some reason, fibromites don't show positive on the normal glucose tolerance test, which, for us, is usually only for ruling out diabetes. If the blood sugar is low, normally the brain receives a signal from the hypothalamus that causes muscles in the stomach wall to contract, but the hypothalamus isn't working normaly. With FMS, the adrenal glands appear to secrete a lot more adrenaline in response to blood sugar changes.

23. Do you bruise easily and do your bruises take a long while to come out and a very long time to go away?
These symptoms may be due to constrictions in the myofasia, or to capillary fragility from medications, or to something else, as yet unknown.

24. Do you have jumpy muscles?
Your muscles may cause you to "jump" when you're nearly asleep. This is often found in combination with teeth grinding (bruxiam) and restless legs. These symptoms are common in both FMS and MPS.

25. Do your hands feel painful in cold water?
This may be due to peripheral vascular spasm, as it is in cases of Raynaud's phenomenon, but we don't really know why it occurs.

26. Have you experienced a recent weight gain or loss?
If you have experienced a recent weight gain, it may in part, be due to the medications you have been taking, Elavil (amitriptyline), for example, has a tendency to give folks the munchies. Sometimes, your eating may be activated by a need to chew. Jaw grinding is a common symptom in FMS/MPS Complex. Carbohydrate craving is another common symptom. So it goes. There is also a subset of fibromites who lose weight and have to struggle to regain it. Many of these people are quite tall.

27. Are you very sensitive to light?
Light sensitivity can be a real problem, Some fibromites can't go anywhere unless they wear dark glasses. Others have Seasonal Affective Disorder (SAD) and need to experience certain amounts of daylight to prevent depression. In the winter they become very depressed when the amount of light dwindles. In FMS, part of this problem may be due to a connection between the hypothalamus and light sensitivity. Often, people with FMS have too little of the neurotransmitter, melatonin, which helps to regulate sleep. This lack may also be connected to light sensitivity. People with SAD have too much melatonin, and they don't always have the necessary night/day fluctuation of melatonin production.

28. Does the noise of fluorescent lights bother you?
The sound a fluorescent light makes can be more than irritating to fibromites. It can be positively disruptive in the workplace. We can get massive headaches or become terribly irritable because of this noise that others rarely notice. Also, the flickering of these lights as they wear out can be hazardous to our peace of mind. People on the Internet have reported varying responses ranging from very mild irritation and disquiet to near seizure.

29. Do some patterns (stripes, checks) make you dizzy?
Some people have reported becoming dizzy and vomiting from looking at patterns. It can cause dizziness to the point of falling over. These people have had to leave fabric stores and avoid using escalators because of it.

30. Do you have electromagnetic sensitivity?
Perhaps you become "wired" by electrical storms, are up all night when the moon is full, and seem to sense the feelings of others. This is part of your empathic connection that is called "electromagnetic sensitivity." Some people with FMS or FMS/MPS Complex appear to be very sensitive to eletromagnetic transmissions, especially when they are experiencing a flare. They have reported stopped watches, computers, phones that come on, and VCRs that are affected, but they have been afraid to mention this to their doctors, which is unfortunate because this can be very important in terms of treatment Russian study on the skin's electromagnetic potential indicated that one-fourth of the people tested were electromagnetically sensitive, one-fourth were electromagnetically null, and the remaining half were considered "average." It seems likely that most people with FMS and FMS /MPS Complex, at least those with extreme dysregulated neurotransmitter activity, are electromagneticaJJy sensitive due to their enhanced autonomic nervous system activity, souped-up receptors, and so forth.

31. Do you experience numbness or tingling?
If electrolytic dysregulation occurs, that may contribute to the symptoms of numbness and tingling. For nerves to conduct sensations, ions such as potassium, chloride, and sodium (called electrolytes) must pass back and forth across the nerves' outer sheath. When a nerve is compressed, this transfer stops. When the pressure is released, the sudden movement causes pain and tingling. Numbness and tingling in referred pain zones are common symptoms with some TrPs.

32. Have you had any serious illnesses, surgeries, or physical traumas?
Illnesses such as diabetes, arthritis, and others, as well as surgeries and physical trauma, can be the original sources for perpetuating factors in FMS/MPS Complex.

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1. Do you have motor coordination problems?
If you have motor coordination problems, that joker, the stemodeidomastoid (SCM) group of muscles, could be a part of your problem (see Figure S-2). SCM trigger points occur in the neck and can cause any (or all) of the following problems:
dizziness, imbalance, neck soreness, a swollen glands feeling, runny nose, maxillary sinus congestion, "tension" headaches, eye problems (tearing, "bug-eyes," blurred or double vision, inability to raise the upper eyelid,and a dimming of perceived light intensity), spatial disorientation, postuial dizziness, vertigo, sudden falls while bending, staggering walk, impaired sleep, nerve impingement, and disturbed weight perception. This last symptom can result in spilling food and drink, and throwing an object across the room when you are just trying to pick it up. People with MFS may seem to have poltergeists. What we really have is disturbed weight perception. If you have SCM TrPs, be careful how you move in bed. When you turn, roll your body with your head remaining flat on the bed, and use your arms to help. Don't lift your head and "lead with it" as you roll. That puts a great strain on your neck area and electrically "loads" the SCM TrPs, Just as climbing steps or walking uphill 'loads' the muscles of your thighs. This means that the electrical potential of your muscles is changed, and the change is not to your benefit. This also adds to the static and electromagnetic sensitivity that you experience.

2. Do you experience an unusual degree of clumsiness?
Many fibromites bump into doorjams, walls, and other stationary objects, and knock things over often. If "klutziness" were an Olympic event, your closet might be filled with gold medals. All of us with FMS and/ or MPS go tripping through life, cleaning up one mess after another, We learn to keep our sense of humor activated and a good supply of absorbent paper towels handy. This clumsineas can be caused by a combination of internal eye muscle TrPs,gluteus minunus TrPs, FMS lack of optical accommodation, and SCM TrPs.

3. Do you have sinus stuffiness?
Sinus stuffiness might well be termed FMS / MPS Nocturnal Sinus Syndrome. Although this is certainly not an official name, It has never been described elsewhere. The symptoms include a nighttime sinus stuffiness on one side, that moves to whichever side of your head is lowest. Gravity drains the congestion to the lower side. This condition goes along with post-nasal drip and, often, a constantly runny nose.

As the muscles tighten, the area becomes more constricted. More fluid backs up. The constant drip into ever-more-restricted vessels uitimately can result in a sinus infection, because anises and bacteria will take advantage of the moist, constricted areas.

4. Do you frequently have a runny nose?
Almost all FM/MPS patients have this form of "vasomotor rhinitis." That's a runny nose without a bacteria or virus.

The side with the worst head and neck rigidity is often the side the person with FMS sleeps on most, arid it is subjected to more of the drip . .. drip . . . drip . .. on the back of the throat, all night. The SCM TrPs and the scaleni become tight in order to "splint" the sore throat and digastric TrPs. Using very warm saltwater for nose drops to clean off the throat and nasopharyngeal area before going to bed will prevent or at least minimize this difficulty without the need for any further medication. Just be careful. If you suspect the area is raw, don't use much salt or too high a temperature.

5. Do you have trouble swallowing?
If the post-nasal drip described in Question 4 above isn't treated, trouble with swallowing develops due to the presence of digastric TrPs. This leads to head and neck pain, and a "swollen glands" feeling. Warning—it hurts to work the digastric TrPs. Sometimes it's best to "milk" the area of its excess fluid, using a gentle downward motion from the base of the chin to the base of the throat. Start lightly and listen to your body. It will tell you how much pressure to use.

6. Do you have ear pain?
Medical piterygoid TrPs can cause deep ear pain and also stuffiness in the ear. The sternal portion TrPs of the stemocleidomastoid muscle group can also cause deep ear pain.

7. Do you experience ringing in the ears?
Deep masaeter TRPs may cause a ringing or low roaring sound in the ears. The sound may vary, you may experience a crackling noise, or the sound the phone makes when ifs off the hook.

8. Do you have a chronic dry cough?
A chronic dry cough is often due to a TrP at the lower end of the sternal (breastbone) division of the SCM. The stemodeidomastoid is not a muscle, but a muscle group. Trigger points in different areas of this muscle group cause different symptoms. To further complicate matters, a chronic dry cough can also be caused by esophageal reflux.

9. Do you have fluctuating blood pressure?
This is a symptom currently under study. There are several possible mechanisms involved. One possibility is mechanical. There are blood vessel swellings in your neck called the carotid sinuses. These sinuses, or cavities, in the blood vessels occur where the common carotid artery splits into two parts; one on each side of the neck. These sinuses are lined with pressure receptors that help to control the blood pressure by constricting and dilating the blood vessels. TrPs could affect them. Other physicians are looking at this from the biochemical angle, and we expect to see more research on this published within the next year.

10. Do you have dry eyes, nose, and mouth?
The symptoms of dry eyes, nose, and mouth are called sicca syndrome, which simply means that you have dry eyes, nose, and mouth. With FMS/MPS, all of the mucous membranes can become excessively dry, including the lining of the vagina and the gastrointestinal tract.

11. Do you have problems with swallowing and chewing?
Many people with FMS/MPS Complex have problems swallowing and experience the following symptoms: pain when chewing, jaw clicking, temporomandibular joint dysfunction, soreness inside the throat, excessive saliva secretion, and sinusitis-like pain. They may drool in their sleep and choke on saliva. All these symptoms can be caused by the internal medial pterygoid TrP, which is often overlooked in therapy

12. Do you have a prickling "electric" face?
The pain of a prickling, "electric" face is most often due to the platysma TrP. This TrP refers the prickling pain to the skin that covers the jaw. The platysma is a flat, sort of thin muscle over the throat area

13. Do you have red and/or tearing eyes?
Red and/or tearing eyes can be caused by trPs in the SCM. (Hearing impairment and a disturbed sense of weight perception can also be caused by these TrPs.)

14. Do you experience popping or clicking of the Jaw?
The symptoms of popping or clicking of the jaw are called temporomandibular joint dysfunction (TMJ). Jaw pain and dysfunction are usually caused by the masseter TrP, although the trapezius and temporalis TrPs are often involved, too.

15. Do you have itchy ears?
The masaeter TrP can also cause itchy ears. The itch, which can drive you to distraction, can be relieved by acupressure on the TrP

16. Do you grind and clench your teeth?
You may find that you grind your teeth at night and clench them during the day. Teeth clenching is the brain's default mechanism. When the brain doesn't know what to do in response to the mixed or erratic signals that it often receives from the poorly regulated neurotransmitters and hypersensitive, and occasionally, dysfunctional receptors of those with FMS/MPS, it clenches the jaw. It's sort of a cerebral twiddling of the thumbs. The masseter TrP may be responsible for this symptom.

17. Do have unexplained toothaches?
If you have toothaches that cannot be explained, they may be caused by several TrPs, chiefly the digastric, masseter, and temporalis. Each TrP has its own particular toothache pattern. A TrP-induced toothache is usually intermittent. During a long dental procedure, which often activates these, you should take periodic rests to exercise and relieve your jaw muscles. Anterior digastric TrPs refer pain to the two front lower teeth.

18. Do you have eye pain?
Cutaneous (on the skin) facial TrPs can cause pain in the ears, eyes, nose, and teeth. These TrPs are shallow and can occur in many places on the face. Try some pressure-point work on your face. If the TrPs are there, they will let you know.

19. Do you have double vision, blurry vision, or changing vision?
For vision to be clear, both eyes must take the same picture at the same time. When this doesn't happen, vision problems result. One theory holds that a misalignment of the eyes may be caused by TrPs contracting the muscles that hold the eyeballs in place. If these muscles are being contracted at different amounts of tension, that could cause all the vision irregularities addressed in this question. Muscle fatigue makes things worse. The culprits may be TrPs in the extrinsic eye muscles, or the SCM, trapezius, temporalis, or cutaneous facial muscles. To check your inner eye muscles, stretch them. Put one hand on your head, above your forehead. Then try to look at your hand. This shouldn't hurt. If it does, it's the TrPs in your muscles telling you that they are there. With your eyes still looking upward at your hand, look from one upper corner of your eye to the other. This will probably hurt too, which is a good sign because it signifies the presence of contraction and of possible TrPs. That means you need to stretch these muscles, and they could be causing all or some of your symptoms. Splenius cervices TrPs can also cause blurring of near vision, as well as pain in the side of the head to the eye on same side, and in the eye orbit.

20. Do you have dark specks that float in your vision?
This is a very common symptom for people with FMS/MPS Complex.

21. Do you experience migraines?
Migraines often occur due to constricted blood vessels inside the skull that suddenly expand. There is a strong correlation with food sensitivity, and with neurotransmitter imbalances. Serotonin regulates the constriction and dilation of blood vessels, and serotonin is regulated in delta-level sleep, which is frequently disturbed in people with FMS. The heralding or warning aura of visual disturbances that often precedes a Migraine, which can include zigzag lines and flashes of light, occurs because the trigeminal nerve pathway involved runs very close to the reticulai formation in the eyes. The constant stimulation of both decreased blood flow and increased nerve involvement common in migraines causes the light show. The stemodeidomastoid (SCM) and the di- gastric, cutaneous facial, temporal, trapezius, splenti, and posterior cervical, are all possible migraine-inducing TrPs.

22. Do you ever get a stiff neck?
Levator scapulae TrPs are the most common cause for a stiff neck, although this can also be caused by trapezius and posterior eenical TrPs.

23. Do you experience dizziness when you turn your head or move?
Here's that busy stenwcleidomastoid (SCM) muscle group again. Active TrPs in this group can make heading into traffic miserable. You try to look both ways while holding your head in your hand to avoid dizziness. Or you can be stooping over to change the cat litter, and when you stand up, you can tumble right over backwards. It is important to keep your neck warm and away from drafts if you have an SCM TrP problem. If the TrPs are active, it is a wise precaution to use a soft, triple-folded handtowel pinned as a splint or "chin rest" before riding over bumpy roads.

24. Do you have a sore spot on the top of your head?
This is often caused by the splenius capitis TriP. With FMS/MPS Complex, just the motion of the wind on your hair can produce a tremendous soreness on the crown of your head.

25. Do you experience extreme discomfort when you wear heavy clothing and/or discomfort or pain mid-shoulder when you carry a purse?
This is caused by the upper trapezius Trp. The trapezius muscle is the most common muscle to get TrPs. It can get many TrPs, and each one has its own pain pattern or symptoms. One trapezius TrP, for example, can cause a queer shivery feeling with gooseflesh appearing on your arm or leg.

26. Do you have pain when you write, a changing signature, and/or illegible handwriting?
These problems can be most frustrating if you work with your hands and depend on them. Pain is caused by the lack of blood flow to the muscles, which causes severe disruption of handwriting skills. This can be due to many shoulder and arm TrPs. Thumb pain and tingling numbness are often due to brachialis entrapment of the radial nerve and adductor and opponens pollids TrPs.

Adductor and opponens polias TrPs also can cause "trigger thumb," "weeder's thumb," clumsiness, and handwriting that is both painful and illegible, The brachioradialis is most often responsible for writer's cramp and for the weak grip that allows objects to slip out of your hand or causes spills from a cup when you're trying to drink something, and you end up wearing it instead.

27. Do your fingers turn color with the cold?
If your fingers and/ortoes turn red, then white, and then a bluish color when the weather outside is icy, ask your physician to investigate Raynaud's phenomenon, a peripheral vascular condition, common in FMS. This condition is caused by spasms of the blood vessels in response to cold—or stress.

28. Do you have esophageal reflux?
Reflux means a backwards flow, which is exactly what happens to the contents of the stomach in this condition. It starts with Just the stomach gases—hydrochloric add fumes—which can cause severe heartburn, sore throat, and TrPs. The next phase of this process involves the stomach juices. If you lean over, or strain at a bowel movement, or put pressure on the stomach, in any way, some of the fluid—also highly acidic—comes up to burn your esophagus and throat. The next stage, vomiting, occurs with the same actions. Sometimes, even lying down after a big meal can cause vomiting. There are many over-the-counter medications now available for reflux. Reflux perpetuates TrPs. This is a thoroughly irritating condition. It often starts as simple heartburn after you eat. Back pressure from the stomach opens the muscular valve between the top of the stomach and the bottom of the esophagus, which is called the cardiac sphincter. The acidic gas from the stomach begins to irritate the end of the esophagus, causing heartburn. If this continues, stomach gases are burped up, which are damaging to delicate throat tissues. You then might get a sore throat which might give you a headache. Bending over or lying down often adds just enough gravitational pressure to cause reflux. In severe form, the actual stomach contents are regurgitated. A hiatal hernia adds to the pressure, as does obesity. More than 30 percent of people with FMS have a hiatal hernia. Overeating, some medications, certain foods, and heavy drinking will aggravate reflux. Raising the head of your bed about six inches may help. Limiting coffee (regular or decaf), and other caffeine-containing liquids, stopping bedtime snacks, quitting smoking, avoiding certain foods such as chocolate and fried foods also helps, as does avoiding peppermint, spearmint, and onions. If a food makes you belch, it probably can give you heartburn, Avoid eating too fast, chew carefully, and eat small portions. The external oblique muscle TrP often aggravates reflux.

29. Do you experience shortness of breath?
This symptom, often due to TrPs in the serratus anterior muscle, is commonly identified as a "stitch" in the side. This TrP can contribute substantially to the pain of a heart attack. It can also cause a "catch" in the lower inner side of the shoulder blade. The pectorals are often involved as well. There is a reduced tidal volume in the lung due to restricted chest expansion, which means that less air is taken into the lung because the breath is shallower.

30. Do you have hypersensitive nipples and/or breast pain?
This is commonly due to TrPs in the pectorals muscles. Many of us have latent pectorals and stemalia TrPs. You can do "doorway stretches" to help these points.

31. Do YOU have A "frozen shoulder"?
Subscapularis TrPs can cause what is termed "frozen shoulder." This TrP severely restricts rotation movement of the arm at shoulder level. Hanging curtains, folding sheets, throwing a ball overhand, raising your arm at school to answer a question — these things are out of the question. Driving long distances aggravates this TrP, as does anything that causes your arms to remain in a shortened position.

32. Do you have a painful, weak grasp that sometimes just lets go? This is the result of infraspinatus, scaleni, hand extensors, and brachioradialis TrPs. The pain felt when turning a door knob or using a screwdriver can be intense if you have these TrPs. Vou may also experience extreme weakness in your hands. Loss of control when drinking, pouring liquids, and so forth is common. People with FMS and/or FMS / MPS Complex really have a "drinking problem"—there are days when you'll just have to rely on straws to get liquids to your mouth. Trigger points in the scalenemuscles also can cause hands to drop objects,numbness, or tingling (usually in the little finger and the finger next to it), and hand swelling (noticeable when wearing rings). This muscle group causes compression of arteries and sensorynerves, shoulder pain, and pain in the upper half of the arms. It is also responsible for sleep disturbance and ulner and median nerve numbness, and in addition, can entrap some of the spinal nerves in the neck.

33. Do you have chest tightness?
This is usually due to the pectoral TrPs. Often these will pull down the sternocleidomastoid (SCM) muscle group and work to perpetuate Trps there. If involved, the pectorals' TrPs must be treated before the SCM TrPs can be successfully treated.

34. Do you have a hiatal hernia?
This is a protrusion of the stomach upward through the diaphragm in the space where the esophagus goes through. Symptoms of a hiatal hernia are reflux and heartburn. The abdominal oblique TrP can produce a "stitch" in the side and hiatal hernia symptoms.

35. Do you experience heart attack-like pains, rapid heartbeat, and/or a illittety heartbeat?
This alarming set of symptoms can be caused by pectoral and stemalis TrPs. Trigger point pain following recovery from a heart attack can often be eased by using a vapocoolant spray, such as Fluori-Methane

36. Do you have mitral valve prolapse?
This valve in the heart consists of connective tissue. When connective tissue loses its elasticity, the valve doesn't flex as it should, and thus doesn' t fit as it should. This allows some of the blood to flow backward in the heart. This is not a desirable condition.

37. Do you have intestinal cramps, bloating, etc.?
Active TrPs in the abdominal muscles may cause a lax, pendulous abdomen filled with gas. The gut can't be pulled in because the TrPs inhibit contraction. A fat pad forms right over the abdomen. This fat pad is hard to get rid of, due to the TrPs. The first thing to do is to find and eliminate the back muscle TrPs that refer pain to the abdomen. These can cause burning, fullness, bloating, and swelling. Only then can you hope to eliminate the abdominal muscle TrPs in the gut.

38. Do you experience nausea?
The abdominal TrPs and multifidi TrPs can cause severe nausea. Vomiting can be caused by the upper rectus abdominis TrPs.

39. Do you experience appenditis-like pains?
This is another symptom that can have you running to a hospital's emergency department. It can be caused by TrPs in the iliopsoas, rectus abdominis, piriformis, or iliocostalis muscle groups. There is one TrP that forms right at McBume/s point, which can cause pseudo-appendicitis or can refer pain to the pelvis or to the penis. Note that pain caused by TrPs in the iliopsoas muscle may seem like appendicitis, but it often radiates down the leg.

40. Do you have an irritable bladder and/or bowel?
This can be due to the pyramidalis, multifidi, and abdominal TrPs, as well as to yeast overgrowth in the gastrointestinal tract. Trigger points in the upper rim of the pubis appear to add to the irritability and spasming of the genital-urinary tract. This is as least part of the reason why so many of us have to urinate so often. With FMS/MPS Complex, not only is the bladder hypersensitive, it won't hold as much. In addition, we can't empty our bladders totally. Below normal electrical activity in the muscles of the gut, common in FMS, can lead to constipation and intestinal cramps, as well. There are specific TrPs that may cause or intensify diarrhea, nausea, vomiting, food intolerance, colic, burping and/or painful menstrual periods.

41. Do you have burning or foul-smelling urine?
This is a fairly common symptom for people with FMS and can intensify with MPS. It also occurs with guaifenesin treatment. This symptom can mimic a true urinary infection.

42. Do you experience pain with intercourse?
This symptom may be caused by vaginal TrPs and pelvic floor TrPs. In addition, abdominal and low-back TrPs may be the cause of aching discomfort and cramps during sex. Where there is sharp pain, the culprit may be the piriformis TrP with pudendal nerve entrapment. 43. Do you have menstrual problems such as severe cramping, delayed periods, irregular periods, long periods with a great deal of bleeding, late periods, missed periods, membranous flow, and/or blood clots?
Some of these problems can be caused by coccygeus, iliocostalis, rectus abdominis, pyramidalis, and other pelvic and vaginal TrPs, as well as the adductor magnus. There may also be thick secretions to deal with, and a lot of hormone problems. (These hormone problems are due to faulty neurotransmitter functioning, which is common among people with FMS.)

44. Do you experience impotence?
This problem can be created by piriformis entrapment of the pudendal nerve. Piriformis TrPs can also create sciatic radiating pain, lumbago, and low-back pain. Pain from the entrapped nerve may extend down to the sole of foot. Blood vessels may also be entrapped by this small but very busy muscle.

45. Do you have low-back pain?
This is a tiger with many claws. The quadratus lumborumTrP is usually the main claw. It causes pain when walking, when turning in bed, when getting up from a chair, and when coughing or sneezing. It (along with the iliopsoas) is often the cause of failed low-back postsurgical syndrome". You can get a deep "lightning bolt" pain from the quadratus lumborum to the front of the thigh. Pain may extend to the groin, testes, scrotum, or down the leg like sciatica pain. If this tiger gets its main claw in your back, you may feel a heaviness in your hips, a cramping of your calves, and burning sensations in your legs and feet. This can cause TrPs in those areas, which then become additional claws for the tiger. Sleeping conditions can affect the quadratus lumborum very strongly.

Devider

Lower Body Problems

1. Do you have sciatica?
This throbbing ache can feel like a "toothache" festering in the hip. There are a lot of muscles in the hip, and it's hard to be sure you have found the precise culprit. Often the TrPs work as a team, egging each other on. The thoracolumbar paraspinals, gluteus minimus, hamstrings, piriformis, and iliopsoas TrPs are often the villains of sciatic pain. The other gluteals are also often involved. Using pillows under your knees during the night, if you sleep on your back, or between your knees, if you sleep on your side, will prevent overextension of the hip muscles.

2. Do you have weak ankles?
The peroneus and tibialis (see Figure 8-26) TrPs are the most common TrPs that can cause the anide to buckle outward, often causing soft-tissue damage and even falls. The problem can begin with some kind of trauma, such as immobilization of the leg in a cast, or with variations of foot structure, such as in Morton's foot. The inner ankle pain is usually due to the tibialis TrP.

3. Do you get shin splints? The same TrPs that cause weak anides are responsible for the sharp pain you get when you kneel or get up from kneeling. The pain travels like electricity up your lower leg. Sometimes this pain can be avoided if you make sure your feet stay at right angles to your legs, that is, your toes stay bent while kneeling and the top of your foot is not touching the floor. If your muscles are rigid, it can be difficult to feel the peroneal and tibialis TrPs.

4. Do you "stumble over your own feet"?
The tibialis TrP is often responsible for what is called "foot slap" and '"foot drop." This is the loss of foot clearance when one takes a step. The brain doesn't receive the proper feedback signals from the body that tell it how high to raise the foot in order to clear the ground. The tibialis TrP can also cause big toe pain.

5. Do you have upper/lower leg cramps?
Trigger points in the sartorius muscle are mostly responsible for upper leg cramps, and TrPs in the gastroenemius muscleare usually the culprits in calf cramps. Note, however, that these cramps can be caused by other problems, as well. For example, dehydration, electrolytic imbalance, and heat stress can all cause calf cramps. Also some drugs, such as lithium or cimetidine, can cause leg cramping. There is a muscle "pump" in the legs, the soleus muscle; it helps the heart by returning blood from the lower legs. This soleus pump "sleeps" when you do, which contributes to pooling of blood in the lower legs and to circulatory insufficiency in the calf muscles. This is one reason that calf cramps often occur when we lie down, or when we first arise from sleep. When there are TrPs in the soleus muscle, this problem becomes more common.

Note: Soleus TrPs usually cause referred heel pain and tenderness, but there is one most unusual pain pattern that refers pain from the soleus to the jaw. Travell and Simons (1992) mention that they have seen this twice. In one occurrence of this pattern, the patient had jaw pain but no typical jaw TrPs, and had been tooth grinding at night. There was no leg pain, but when the soleus TrP was touched, the jaw pain was activated. It isn't clear why this connection exists, but, in this case, at least, the leg bone's connected to the jaw bone.

Most people are unaware that the soleus is so important to good circulation. Military professionals, however, learn that if they alternately tense and relax their lower legs while standing at attention for any length of time, they will avoid fainting. (Cadets often learn this the hard way.) The central nervous system also plays a role in nocturnal cramps by dictating the dilation of the blood vessels. Even TrP-induced cramps are worsened by impaired circulation. With these TrPs, there is difficulty in walking fast or on uneven ground. Vitamin C may help. At night, placing a firm pillow or blanket roll under your feet to keep them in a neutral position may help. (Do not point your toes, as in ballet; keep your feet at right angles to your legs.) When you make the bed, try tucking in the bottom end of the cover sheet very loosely, to allow room for your feet. Don't ever sacrifice function for packaging. Your feet will become riddled with TrPs.

6. Do you experience muacle cramps and twitches elsewhere?
Check the trigger point charts for a pain referral pattern that is in the area of the cramp or twitch. Then, find the location of a TrP affecting that area. Check your body to see if a TrP is causing the cramp or twitch. Muscles function in groups, but the TrPs must be treated one at a time. Ordinary muscle cramps are caused by overstimulation of a muscle by nerves, unlike spasms, which are caused by a chemical imbalance in the muscle.

7. Do you have a buckling knees?
This "falling failing" is often due to a combination of vastus mediali and quadriceps TrPs, and adductor longus TrPs. This can arrive as a secondary symptom to abdominal congestion and pelvic pain, often during the menstrual period. The knee will ache, fre- quently on the inner side, and then will "give out," specially when walking over rough ground. Phantom limb pain can be induced by residual (meaning "left over" from before amputation) muscles in the thigh. When treating these TrPs, it is important to treat the hamstrings also, as they are usually tight because of deep TrPs. Avoid prolonged immobility, which will worsen the budding knee.

8. Do you have difficulty climbing stairs?
This can be due to sartorius, quadriceps femoris, and/or vastus medialis Tips. The first two muscles ache in the thigh. The vastus medialis usually causes pain in the knee. One way to avoid aggravating these TrPs is to climb steps with your feet and body held at a 45-degree angle to the steps. Don't face them head on. Trigger points in the thoracolumbar paraspinals can also cause difficulty walking up stairs. They produce a form of sciat- ica that is aggravated by prolonged immobility. for example, during and after airplane or auto trips, sitting at a computer, or sitting during long meetings without moving around.

9. Do you have foot pain?
This can come from a variety of causes. Heel pain is often caused by TrPs in the soleus. The soleus muscle is an important one. Frequently people are treated suigically for a heel spur. There may be a heel spur on the other heel, too, but it gives the patient no problem, and is usually ignored. After the painful heel spur is removed, however, the pain often remains, because the TrP which is the actual cause of the heel pain, has not been treated. The pain remains until the TrP is defused and the perpetuating factors are remedied. Pain in the sole of your foot when running or walking can also be caused by TrPs in the tibiaUs posterior, although the intrinsic foot muscles are also implicated m sole pain. Pain from the tibialis posterior is usually most severe in the arch of the foot, but it can also occur in the heel, toes, and calf. Tibialis posterior weakness causes severe pronation. Pronstion means that when you stand, your feet point out at an angle rather than straight ahead. The pronation is a symptom, not the cause, of the TrP. Too often, expensive orthotics (inserts) are placed inside the shoes to correct pronation, and the cause of the pronation is overlooked.

10. Do you have feet that are wide in front and narrow in the back, with a high arch?
We call this the "FMS/ MPS foot," for want of a better term. The great toe is often slanted in toward the little toe, and the space between the big toe and the second toe is wide. This is apperpetuating factor of foot and leg TrPs, as is Morton's foot, another foot shape variant. Morton's foot has a second toe longer than the big toe, with a wide web between the second and third toes.

11. Do you have tight hamstrings?
If back pain is a tiger, then the hamstrings are an enraged pit bull. The hamstring complex, adductor magnus, quadriceps femoris, iliopsoas, and gastrocnemius are often involved with TrPs. Defusing the TrPs in this area is a very complex procedure. As with many areas of thick musculature, there is one layer of muscle after another, crossing over each other, and layers of TrPs.

12. Do you experience strange sensations—numbness, hypersensitivity, "ants crawling under your skin," and so forth, on the outer thigh area?
This condition is called meralgia pares the tica. It occurs because of a very large, superficial nerve on the outer thigh, called the lateral femoral cutaneous nerve. This nerve can be entrapped by several muscles as it leaves the pelvic area "e quadriceps femoris, vastus lateralis, sartorius, and tensor fasda latae. Meralgia paresthetica is often associated with a lax, pendulous abdominal wall.

13. Do you experience burning or redness on the inner thigh?
This is another TrP in a muscle that very few people are familiar with, (It is mind-boggling how little we know about our own bodies, until they start malfunctioning.) The gradlis muscle TrP causes a superficial hot, stinging pain in the middle thigh, and no change of position reduces the pain. Walking tends to relieve it, but one of our local support group members found that taking long walks actually caused the pain.

14, Do you have restless leg syndrome?
This is the name used to describe a constantly moving leg. The movement can happen just at night, when the jiggling will drive your spouse or "significant other" up the wall, and/or it can occur during the day, when it will drive just about everyone else up the wall. It can be caused by TrPs in the gastrocnemius or soleus muscles.

15. Do you have a staggering walk and balance problems?
If caused by MPS, these symptoms are usually due to stemocleidomastoid (SCM) and/or gluteus minimus TrPs. The use of flexible shoes with good support will aid in controlling some of the balancing problem.

16. Do your first steps in the morning feel as if you are walking on nails?
This can also happen after a meal or at other times when you stand up after sitting for a while. In Travel I and Simons' Trigger Point Manual, Volume Q, this condition is listed as commonly occurring with flat feet, but it also occurs with cases of the wedge-shaped FMS / MFS foot, which is characterized by high arches as well. The condition occurs as the foot first flattens during the stride, due to the weight of body. When the plantar fasda (fasdal tissue on the bottom of the feet) stretches more than it should, it starts to contract whenever you are off your feet for any length of time. It sometimes shortens to the point that walking can become very painful. This condition is usually caused by TrPs in the Jong flexor muscles of the toes. These TrPs are to be found in the calf area, not the foot itself. Morion's foot or any other foot deformity that causes hyperonation (walking with toes pointing further out than normal) can become perpetuating factors for these TrPs. Check your calf, toward the inner side of the knee and about a handsbreadth down from the knee. The TrP pain will radiate down the calf over the ankle and to the underside of the foot. Toe cramps can be caused by intrinsic flexors in the foot itself.

17. Do others in your family have these symptoms?
FMS runs in families. It isn't uncommon to have several generations in a family represented at a support meeting, or many members of one family with FMS. People with FMS seem to be born with the tendency to develop it.

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By reading the answer/question sections above I have come to the conclusion that my problem with Pseudotumor is a FMS/MPS problem and no other. Especially if you look at question 9 in the second secition above, it makes sense to believe that if the muscles can mess with your blood-pressure they can mess with the flow of the spinal fluid and therfore cause Idiopathic Intracranial Hypertension (Pseudotumor).

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In Conclusion: The signs and symptoms described in this chapter are by no means all of the possible symptoms associated with FMS and/or the FMS /MPS Complex. There are many more trigger points than have been shown. You have your own story to tell and your own pieces of the puzzle to add to the growing body of information. You just need to find doctors who will listen.

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Medications for FMS/MPS

Types of Medications for Chronic Pain

It's normal to be depressed when you have chronic pain, but that doesn't mean the depression is causing the pain. Maintenance with mild narcotics (Darvocet, Tylenol #3, Vicodin, Lorcet, Lortab) for nonmalignant (noncancerous) chronic pain conditions offers humane alternatives if other reasonable attempts at pain control have failed. The main problem with raising the dosages of these medication's is not only with the narcotic components, per se, but with the aspirin or acetaminophen that is often compounded with them. These NSAIDS (nonsteroidal anti-inflammatory drugs) can create more toxidty and can have more disastrous side effects than the narcotics themselves. Note that neither FMS nor MPS is an inflammatory condition. Sometimes narcotic analgesics are more easily tolerated than NSAIDs are. Prolonged use of these narcotics may result in physiological changes of tolerance or physical dependence, but these are not the same as psychological dependence. Undertreatment of the chronic pain of FMS/MFS Complex results in worsening contractions of the myofascia, which results in even more pain.

Note: Amitriptyline, ibuprofen, and other medications, as well as FMS itself, can cause water retention.

Psychoactive drugs, that is, medications that affect the mental state such as Atarax, BuSpar, Elavil, and Xanax, influence neurotransmitters. Jf your doctor prescribes these "antianxiety" drugs, it is not an indication that your symptoms are "all in your head." These medications extend the amount of sleep and may ease day time symptom flares. They don't, however, stop the alpha-wave intrusion into delta-level sleep. Many medications are prepared using lactose fillers. This is the case with some over-the- counter drugs, as well as with prescription medications, such as Effexor. If you have lactose intolerance, check with your pharmacist.

Common FMS/MPS Complex Medicines

The list of medications presented here is only a partial listing. Check with your doctor about these medicines and others. Stay tuned, to the fM Network Newsletter for news of newer medications that may be of use in FMS or FMS/MPS Complex. Ambieni is a hypnotic — a sleeping pill for short-term use for insomnia. However, there have been some reports of serious depression when using this medication.

Atarax (hydroxyzmellQ): This suppresses activity in some areas of the central nervous system to produce an antianxiety effect. This antihistamine and anxiety-reliever may be useful when itching is a problem.

Benadryl (diphenhydramineh) This is a helpful nonprescription sleep aid/antihistamine that is safe to take during pregnancy. The starting dose is 50 mg, taken I hour before bed. The medicine can be increased as tolerated until symptoms are controlled, or to about 300 mg. About 20 percent of patients react with excitation rather than becoming sedated when taking Benadryl.

BuSpar (buspirone HQ): This drug may improve memory, reduce anxiety, and help regulate body temperature. It is not as sedating as many other antianxiety drugs.

Desyrel (trazodone): This antidepressant helps with sleep problems. Note that it must be taken with food.

Diflucan (fl-aconazole): This antifungal medication penetrates all of the body's tissues, even the central nervous system. Very short-term use can be considered if cognitive problems and/or depression are present and yeast is suspected. Yeast may also be at the root of irritable bowel syndrome, sleep dysfunction (muramyl dipeptides from bowel bacteria induce sleep), and other common FMS problems. Diflucan is very expensive.

Effexor (venlafaxine HCI): This is an antidepressant and serotonin and norepinephrine reuptake inhibitor. The suggested trial dosage is 25 Trig. taken in the morning. Food has no effect on its absorption.
Warning: When discontinuing this medication, taper off slowly.

Elavil (amitriptyline): This antidepressant is inexpensive and useful. It often generates a deep stage-four sleep. It can cause photosensitivity and morning grogginess. It often causes weight gain and dry mouth, as well as stopping the normal movements of the intestine. It may cause Restless Leg Syndrome.

Chromhim picolinate taken in conjunction with Elavil often relieves "carbocraving" and minimizes weight gain.

EMlai: This prescription-only topical cream may help cutaneous (skin) trigger points. It is a mixture of topical anesthetics. Flexeril (cyclobenzaprine): This tricyclic medication can sometimes stop spasms, twitches, and some tightness of the muscles. It is chemically related to Elavil. It generates stage-four sleep, but it may cause gastric upset and a feeling of detachment from life.

Fluori-Methanc: This vapocoolant spray is manufactured by the Gebauer Company for "spray and stretch" treatment to inhibit pain impulses and to allow for passive stretching. There are some environmental concerns about the use of fluorocarbons.

Hismanal (astemizole aucdnate): This is a potent antihistamine often given for allergies. Warniny Do not take this medication at the same time as ketaconazole, an antifungal medication.

Imitrex (sumatriptan): This medication is available in pill form or in a self-injectable solution. It will not prevent migraines, but in many cases it is effective for migraine pain. Using a different mechanism of action than other migraine medications, it acts directly on specific serotonin receptors, and it constricts specific blood vessels in the brain. Dilation of these blood vessels is often responsible for migraine symptoms. It may provide relief in less than 20 minutes as it alleviates nausea, head pain, and light sensitivity.
Warning: Imitrex should not be used within 24 hours of taking ergot (a com-mon migraine medicine). It may increase blood pressure. It may cause muscle spasm in the jaw, neck, shoulders, and arms. Also reported were tingling sensations, rapid heartbeat, and "the shakes." It is very expensive.

Inderal (propranolol HC): This medication sometimes helps in the prevention of migraine headaches, although blood pressure may drop with its use. Antacids will block its effect and should not be used.

Klonopin (klonazepam): This is not only an antianxiety medication, but also an anticonvulsive/ antispasmodic. It is useful in dealing with muscle twitching. Restless Leg Syndrome, and nighttime grinding of teeth.

LibraK: This medication is often used for irritable bowel syndrome. It is a combination of antispasmodic plus tranquilizer that helps to modulate bowel action.

Pamelortnortriptylin HCVi: This tricydic antidepressant is used to help those with insomnia problems fall asleep. Note that some people find it stimulating and must take it in the morning. Others can use it before bedtime.>br> Warning: There have been some reports of depression with its use.

Paxil (paroxetine HCI): This serotonin and norepinephrine reuptake inhibitoTOTay also reduce pain. Paxil should not be used with other medications that also increase brain serotonin. Suggested dosage is 10 mg (half of a scored tablet). It may need to be taken in the morning, as sometimes it causes insomnia if taken before bed.

Potaba (aminobenzoate potassium): This is a member of the B-vitamin complex. It is used to dimmish fibrotic tissue. Travell and Simons (1992) p. 278, recommend it for stubborn cases of myofascial pain syndrome.
Waning; Do not use Potaba with sulfa drugs. The suggested dosage is 500 mg three times a day for five months.

Procaine injection for trigger points: This is to be used as a last resort. Trigger Point Inlection protocols can be found in Travell and Simons' Trigger Point Manual (1983). Note that this procaine injection is not as effective for people with FMS/MPS Complex as it is for those with MPS only.

Prozac (fluoxetine HCI): This SSRi (Specific Serotonin Re-uptake Inhibitor) antidepressant incresaes the availability of serotonin. It is useful for those patients who sleep excessively, have severe depression, and overwhelming fatigue. It may cause insomnia. It has a relatively slow elimination (two to three days). It may be taken with or without food and is metabolized in the liver.
Warning: FMS patients sometimes become worse on Prozac, because it disrupts stage-four delta sleep.

Relafen (nabumetoneh): This is a nonsteroidal anti-inflammatory drug that is often well-tolerated because it is absorbed in the intestine, thus sparing the stomach.

Sinequan (doyepin HCI): This Tricyclic antidepressant and antihistamine combination can produce marked sedation effect.

Soma (carisoprodol): This central nervous system "muffler" is greatly underutilized. It acts on the nervous system to relax muscles, not on the muscles themselves. It works rapidly, and the effects last from four to six hours. Except for the extremely rare patient with sensitivity to it, it is well-tolerated. It helps patients to detach themselves from their pain and modulates erratic neurotransmitter traffic, damping the sensory overload of FMS. It should first be tried in a half-pill dose. When taking this medication, some people feel as if they are in a meditative state. Soma raises the seizure threshold. It may cause drowsiness. It is not recommended for children under 12-years old.

Tagamet (dineliaine), Zantac (Tanitidine HCI): These medications are often used to counter esophageal reflux. Tagamet may increase stage-four sleep and enhance Elavil.

Tlazadone (Desyrel); This medication is often given to people with FMS to promote sleep and elevate mood. This medication should not be used in women who may be or may become pregnant. Animal studies show it can cause birth defects.

Ultram (tiamadol HCI): This medication for moderate to severe pain acts on the central nervous system. It is one of a new class of analgesics called CABAs (Centrally Acting Binary Agents). It has a "low-abuse potential," so doctors may prescribe it more liberally than other strong painkillers.
Warning: Frequent side effects of Ultram are constipation, nausea, dizziness, headaches, weariness, tightening of jaw and neck muscles, and vomiting. More than one Internet doctor has switched all FMS patients to Ultram. One doctor reported that 70 percent of those taking Ultram gained enough control over the pain they experienced so that they resumed more active lifestyles. Ultram is not a controlled substance. Reports say it doesn't work well on an "as needed" basis—you have to take it regularly for best benefits. Many people said it brought more alertness for longer times and less "fibrofumble" of the fingers. It has also been reported to have success as a migraine treatment.
Warning: One case of seizures has been reported with its use. This medication can lower the seizure threshold.

Wellbutrin: This weak Specific Serotonin Re-uptake Inhibitor (SSRI) and antidepressant is sometimes used in FMS/MPS in place of Elavil
Warning: Wellbutrin can promote seizures.

Xanax (alprazolam): This anti-anxiety medication may be enhanced by ibuprofen. It enhances the formation of blood platelets, which store serotonin, and also, raises the seizure threshold.
Warnings: (1) When stopping Xanax medication, you must taper off it Very gradually. (2) Xanax must not be used during pregnancy.

Zoloft (sertraline HCI): This is an SSRI and antidepressant. It is commonly used to help with sleep problems.

Most people who find Benedryl stimulating rather than sedating will have the same response to Pamelor, Paxil, and Ultram.

In Conclusion: Because physicians' understanding of FMS, MPS, and FMS / MPS Complex has been so slow and is still so incomplete, information about effective medications is also incomplete. It is essential to find a physician who understands that your pain is real and should be addressed with appropriate medications. Every patient's medications must be tailored to that person's specific symptoms, and must also be monitored to meet that person's changing needs.

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Other Options—Some Helpful Nonprescription Medications

As part of the job of taking control over your own health, investigate alternative health aids. There are over-the-counter (OTC), or nonprescription, medications you can take. You may need less prescription medication if you take OTC. Note that the side effects and bioequivalency of OTC medications and health food nutrients often have not been studied as extensively as PDA-approved medications. Be sure to check with your doctor or pharmacist before you use them with your prescription medications.

Vitamin C

The body eliminates vitamin C, even in large doses, in 12 hours. Time-release vitamin C is eliminated in 16 hours. For these reasons it is better to take 2 doses of 500 mg vitamin C, 12 hours apart, than to take one 1000 mg tablet.

CoQIO

CoQIO is a bioenzyme. Its proper name is Coenzyme QIO, and it is available in many health food stores and drug stores. It may help clear the cognitive (fibrofog) difficulties during a flare. Effective dosage varies. Note: CoQIO's use is still experimental.

Chromium Picolunate

This mineral supplement is often effective in decreasing the "carbo-craving" some fibromites experience. It seems to improve the efficiency of insulin in the body. Dosage varies.

Melatonin

Melatonin is a neurotrammitter secreted by the pineal gland, which is located in the center of the brain. It is eventually changed in the body to serotonin, another neuiotransmitter. Studies on melatonin have just begun. A potent antioxidant and possible age-retarder, it also triggers sleep. It is nontoxic, and may make Elavil more active or effective. In normal individuals, melatonin induces sleepiness, decreases alertness, and slows reaction time.
Warning: As many as one-third of those who try melatonin become depressed. If depression occurs, stop taking it. Seasonal Affective Disorder (SAD) (winter depression) is thought to be due to an overabundance of melatonin that does not wry with the daily cycle. It is this lack of variety,that is responsible. SAD patients often need extra melatonin at night to provide the difference in the sleep/wake cycle. Melatonin is sometimes helpful in resetting the sleep / wake cycle after a time change, or for shift workers. Melatonin secretion in humans can be acutely suppressed by light if the light is of sufficient intensity. Research on the Internet indicates there is a wide variety of melatonin among brands. Note: Synthesized melatonin seems more likely to cause depression and often does not help with sleep problems.

Raw Thymus

The thymus gland governs the body's immune system, which is the system that decides what is "self" and what is "invader," It is a spongy, pinkish-gray gland located behind the breastbone. At one time, not many years ago, doctors thought that the thymus gland was a useless relic. Today, we know that it is the "master gland" of the immune system. It is present at birth, and continues to grow until puberty. It produces the hormone, thymoxin, which activates T-cells that protect us from invading substances. When you reach adulthood, the thymus shrinks and no longer produces T-cells, although it is believed to secrete hormones that keep the T-cells working. Premier Labs produces a thymus extract made from animals that are fed without antibiotics, hormones, or food supplements. It has been helpful for AIDS patients and for patients with FMS or CFS (Chronic Fatigue Syndrome)—all patients who have impaired immune systems.

L-Threonine

Several people on the Internet have reported that Threonme, anamino acid, helps with the Restless Legs Syndrome. Dosage and types available vary.

Calms Forte

Calms Porte is a mix of herbs, calcium, and magnesium, available over the counter in many health food and drug stores. It may be effective as an alternative medicine to take to promote sleep before going to bed.

Peppermint Oil

This oil, in enteric-coated capsules, often helps Irritable Bowel Syndrome (IBS). If broken down in the stomach, however, it causes flatulence, and you don't need to add more gas to your gut. Look for the brand "Peppermint Plus".

Phasyme

Phazyme and other brands of simethicone may be useful when bloating is a problem. Try taking it before eating foods that normally cause extra bloating.

Salt Water

Using warm salt water for nose drops before going to bed can decrease nocturnal post-nasal drip. It can also stop morning sore throats and aggravated neck trigger points.

In ConclusionFor people with FMS and PMS/MPS Complex, finding the best medications can be a difficult task. Once you've established what works for you, though, you can take steps to maximize the medications' intended effects and minimize their side effects.

Devider

Fibromyalgia (or FMS/MFS Complex). Some gout medications that prevented the formation of uric acid had no effect on fibromyalgia. He tested the urine of his patients on the medications, and found that they were urinating large quantities of phosphoric acid. By then, he had also noticed an obvious family clustering of fibromyalgia cases, and he began to suspect that an inherited defect in phosphate metabolism was the basis of at least some of the fibromyalgia problem.
There were problems with the gout medications. They had side effects, and some people couldn't tolerate them. He still didn't know why they worked the way they did, but he began searching for a kinder, gentler alternative. When he found that guaifenesin, an over-the-counter (OTC) medicine generally used as an expectorant to loosen phlegm and mucus in the lungs, also had the ability to remove excess uric acid, he tried it. Although he had been taking the gout medication for his "rheumatism" (fibromyalgia), he quickly found out that he still had excess phosphorus remaining in his body. The guaifenesin did an even better job than the gout medication at ridding his body of the phosphorus.

St. Amand uses as his working hypotheses the notion that in fibromyalgia, the mitochondria (our cells' energy factories), are affected. This is the possible cause of the decrease in the body's main fuel, adenosine triphosphate (ATP), in the muscles. This decrease has often been noted in fibromyalgia (Fibromyaigia Network Newsletter April 1994). Increased amounts of inorganic phosphates in the mitochondria depress the formation of ATP. The phosphates remain in solution, but in excess amounts. Areas with the greatest need for ATP, the brain and the muscles, would be most severely affected. And excess phosphates would enter various cells of the body.

Note: Guaifenesin is the active ingredient in many cough medication/expectorants. Unfortunately, most of these same medications also contain large amounts of sugar and alcohol, and often other medications such as pseudoephredine. For a reason known only to the Food and Drug Administration, the pill form is available only by prescription. Mucus Secretions and Guaifenesin As a rule, fibromites produce unusually thick mucus secretions. If they wear glasses, their lenses may become gunked up from nasal secretions when they blow their noses, They may need more toilet paper or wet wipes than most to cleanse themselves of extra heavy vaginal or anal secretions. Guaifenesin thing all of these thick, sticky secretions.

Guaifenesin Treatment

Guaifenesin treatment for fibromyalgia is not simple. Doctors can't just prescribe the medication and expect symptom remission. St. Amand begins treatment by taking a careful medical history of the patient, noting when the symptoms first appeared. He examines the patient for tender points and nodules, which he maps on a chart. He notes the degree of soreness, and the shape and size of the area. He has found that as patients progress, the symptoms tend to disappear in the reverse order in which they first appeared. His patients keep a careful record of their symptoms, including emotional ones. During treatment with guaifenesm, their symptoms are often more intense than the original ones, but they occur for briefer spans of time. He has found that two months at the proper dosage reverses about one year of symp- toms. He also checks his patients for reactive hypoglycemia, which is a perpetuating factor.

Nutrition
Keeping It Natural. If you have reactive hypoglycemia as a perpetuating factor, you MUST be on a balanced "Zone" diet for the reversal to take place. Dr. St Amand has found less patients needing the diet, but his patients appear to be more sensitive to "blocking" factors. Remember, we are trail-blazing here. No salicyclates are allowed during guaifenesm therapy. Salicylates are found in some medications and herbs. Map your pain patterns before starting this therapy, and mark each area from one to ten in pain intensity to help you monitor therapy progression. Sometimes guaifenesm works on feeder deposits. These feeder deposits, in my opinion, are large lumps of biochemical debris trapped in myofacial trigger points (TrPs). Over time, these trapped waste materials can become quite toxic. I feel that some of the myofascial TrP structure is formed of the excess phosphates. As the guaifenesin releases some of the phosphates, the matrix loosens and the toxic wastes are released into the bloodstream. Because the liver and kidneys can process only a limited amount of wastes at one time, some of the material redeposits, temporarily. Sometimes these transient deposits even form on the teeth, until eventually the liver and kidneys can catch up with the elimination process. Whether this is the mechanism or not, expect plateaus in the reversal process. Don't become discouraged. We are all different. Allow your body to find the best pace for your own healing.

Dosage
St. Amand has found three subsets of patients in his clinic practice. One subset, about 20 percent of all patients, goes through FMS reversal relatively quickly at 300 mg twice a day. If the "cyclic process" hasn't started in two weeks, the patients are raised to 600 mg twice a day. Fifty percent of all patients experience reversal on 600 mg twice a day. Another 20 percent need 1800 mg a day. The final 10 percent requires 2400 mg or more of guaifenesin per day.

When the first cycle begins, there is usually a period of flu-like fatigue as stored toxins and excess phosphates start releasing. Sleep as much as you can. Your liver and kidneys are working hard to process toxins and excess materials so that they can be excreted. You may have to cutback on bodywork during this time, as this also breaks up TrP material. For the first few months on guaifenesin, expect to be spitting out mucus that has been clogging your airways. Headaches are very common. You may find some "ouch spots" on the back of your neck, or on your hairline, that hurt even with moderate pressure. Putting ice on these spots sometimes helps people to endure.

Symptoms You May Experience during Guaifenesin Treatment

Among the symptoms you may experience are nausea, fatigue, increased aches, eye irritation, abnormal sensations and abnormal taste sensations (foul or metallic). Odd skin rashes can be common during the reversal period. These can be scaly rashes, such as eczema, blistering, adult acne, or skin cracking. St. Amand has found that at some time after the adequate dosage for reversal has been reached, the patient may lose a large amount of "inferiorly formed" hair that is replaced with healthy hair.

You may also have a burnt taste in your mouth, pimples, guricy eyes, an acidy smelling perspiration unique to guaifene- sin reversal (fortunately), burning on urination (excess phos- phates are excreted as phosphoric acid), bladder infections, and very strong smelling urine. Your urine may become very dark—deep yellow, or even brown. Vaginal secretions also turn acidy. Women may get rashes and burning sensations in the vagina] area. Male partners sometimes also feel the effects. You may experience soreness in the crease between your buttocks. "Bag Balm'" or another protective ointment is helpful. With most people, guaifenesin therapy seems to result in remission of symptoms. When your symptoms are in remis- sion and you have resumed activities, it is time to tiry cutting down or stopping your other medications one at a time. Try this only after discussing it with your doctor. When you are symptom-free and medication-free, slowly start to taper off the guaifenesin. At some point your symptoms may reappear. You may need a maintenance dose of guaifenesin, as some diabetics need insulin, to help you eliminate excess phosphates. Otherwise they will start to build up again. It is important to remember that the signs and symptoms described here are not side effects of guaifenesin. They are from the toxins and excesses being released by the guaifenesin and are a good sign, although it won't feel like it at the time. At least you'll understand why you often felt "toxic." You were.

A Theory

Knowing that guaifenesm thins secretions and works at a cellular level, I believe, at least in part, that guaifenesin may work mechanically, cleaning off gummy cellular membranes. It may be that the nature of one's reversal depends on the nature of one's deposits: how many, how dense they are, how much and what kind of tissue is displaced, and how good one's body is at detoxifying. Thinner secretions also allow more efficient breathing.

Guidelines for Taking Guaifenesin

You can do a number of things to make taking guaifenesin safer and more effective for yourself.
Here are some guidelines:

• Drink a lot of water with the guaifenesin. You may feel very thirsty all the time and choose to carry some water around with you.

• As described above, keep the dosage of guaifenesin low at first. It may cause stomach upset or nausea, which will probably disappear in a few days, as your body adjusts to it.

• Store guaifenesin in an environment between 59 and 86 degrees Fahrenheit, not in the refrigerator, nor in a very warm room.

• During guaifenesin therapy, avoid adding phosphoric acid to your body. Cola drinks, for instance, are loaded with it. It makes no sense to add phosphoric acid to your metabolism when your body is already working hard to get rid of its excess. Read your labels.

• Get plenty of rest.

• Eat healthy food, but not too much of it.

• Pay attention to your posture, and stretch when you can.

• Keep a positive attitude.

• Take 15- to 20-minute warm baths (not hot).

Allow enough time between bodywork sessions to recover from one before the next one begins.

• Allow some time for your body to adjust to healing. It will be finding a new balance every day.

• Remember, you are under stress and going through the trauma of change and rebalancing. Your biochemistry is changing. Baby yourself.

Saliylates and Other Concern

Salicylates are compounds found in medications such as aspirin, some suscreens, aloe vera, Pepto-Bismol, wait arid callus removers, Listermene, some Alka-Selzers, and some muscle rubs. Salicylates block the bodys efforts to excrete the excess phosphates. Mentholatum, found in many menthol-containmg OTC topical medications, contains many ingredients, but one of the major ones is methyl-salicylate, Ifsalicylates are taken during guaifenesin therapy, the body's toxins will be liberated from the myofascia but will circulate in the blood without being excreted. Ask your pharmacist to help you find nonsalicylate alternatives, Salicylic add is currently being added to some ultrasound and galvanic stimulator physical therapy mineral gels and electrode gels. Some of these gels may contain aloe, which will also block the gualfenesin action. Note also that the presence of aloe can be difficult to ascertain, because it is in so many cosmetics. Again, read your labels. Avoid large quantities of herbs and herbal teas, since many are rich in salicylates, unless you can be sure the herbs have none. Many herbal medications, such as pycnogenol, contain large amounts of salicylates. Small amounts of herbs for seasoning are acceptable. St. Amand has found that food materials, with the exception of herbs, do not block the guaifenesin action.

Note: It is interesting that in addition to its expectorant qualities, guaifenesin has been used to help women become pregnant. It thins the cervical secretions, which makes it easier for the sperm to penetrate the egg. Guaifenesin seems to have a strange side effect. A few of the women trying guaifenesin therapy had had previous breast implants. Every one of them had previously developed hard shell-like capsules around the implants, Guaifenesin therapy eliminated, or at least minimized, these shell-like capsules.

In Conclusion

Controlled studies measure group response, not individual response, each of us is unique. The only double-blinded study on FMS guaifenesin therapy was done by Robert Bennett M.D. at Oregon Health Sciences University. This study of 20 women showed guaifenesin equal to placebo. This response is not uncommon when attempting to design experiments for old medications with new usages. The study is flawed by no fault of Dr. Bennett, who has done great work.

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Chirocpractic Work

When the body is in proper alignment, the inherent recuperative powers of the body will take over, and the body will heal itself. Your first visit to a chiropractor should include careful, detailed medical history, a thorough physical examination, and sometimes X-rays. Only then can a treatment plan be formed. Chiropractors use many methods to coax the bones back into their proper position. They also work on the muscles to ease the tightening that caused the problem in the first place. Sometimes only a few visits to the chiropractor are needed to realign your body. However, if you have FMS, MPS, or FMS/ MPS Complex, after each chiropractic adjustment, your tight muscles will pull your bones slightly out of alignment again. Your body has limited means for restoring function when parts of it are busy fighting other parts, This kind of internal warfare can cause other symptoms to develop throughout your entire body. Of course, just as in all professions, there are chiropractors and there are chiropractors. When looking for a chiropractor to work with you for treatment of FMS, MPS, or FMS/MPS Complex ask others at your support group for recommendations. When you find one with a good reputation, try calling. Ask him or her about myofascial trigger points and Drs. Travail's and Simons' work. Most chiropractors are far ahead of M.D.s regarding this area of knowledge. You will even find chiropractors with well- thumbed volumes of the Trigger Point Manual close at hand in their offices.

Spine Manipulation

The central focus of chiropractic medicine is the manipulation of the spine to relieve pain and body imbalances. Manual adjustment (the familiar "cracking") of body manipulation can line up the spine, although this method is not recommended for people with MPS or FMS/MPS Complex. Manual adjustment can cause great pain if there is nerve entrapment, especially with TrPs in the neck. Activator methods of chiropractic adjustment usually work very well, however, Blocking, or straightening out the spine by placing blocks under the hips and coaxing the spine into alignment, is a gentle method that many chiropractors use. Blocking is especially good for those of us with MPS or FMS / MPS Complex. Traction usually doesn't work with MPS or FMS/MPS Complex, since the muscles revert to the same tightness and misalignment after the treatment. Chiropractors use heat, cold, and other types of bodywork. Electrical stimulation is especially effective in eliminating or minimizing TrPs. Many chiropractors can also help with exercises and nutritional advice.

Chiropractic treatment can be frustrating at first. Bones are coaxed into alignment, only to have tight and contracting muscles pull them right back out of alignment. Liberated toxins and wastes can cause you to feel toxic and exhausted after a treatment, as do most successful treatments of other kinds of physical therapy. However, the results are worth the effort. It can be an ironic comfort to know that if you are hurting, you are working with someone who is getting you back on the healing path.

The Activator and Other Treatment Methods:
One of the kindest innovations in chiropractic medidne is the Activator. The Activator is a small (about the size of a pen), handheld instrument that delivers a low-force tap where directed. It is the most widely used low-force technique in chiropractic practice. Some people have described it as looking like a "mini-pogo stick." (Others think that it looks like a metal hypodermic, without a needle, but with a spring attachment). The chiropractor aims one end of the Activator at a vertebra or other misaligned bone, and lightly taps the other end. This engages the spring mechanism, which immediately realigns the bone. When used expertly by a Doctor of Chiropractic, it can realign the skeleton almost instantly. It can be used on all types of patients, and has different settings. The Activator works faster than the body's ability to tense and resist. It appears that very few people are unable to tolerate Activator adjustment. It is important to remember that it cannot be handled by the patient and should be used only by an expert practitioner.

Massage Therapists

There are many forms of massage, and books have been written about most of them, from aielaia, (an ancient form of massage, practiced with the hands barely touching the body, which works on energy fields) to andent Zen forms. Massage can be a relaxing, powerful, healing tool, but it must be respected and carefully man- aged. The wrong kind of massage, too vigorous a massage, or too short a time between massages can be detrimental to your healing. The type and duration of massage must be decided on a person-to-person basis and is best left to the discretion of a skilled massage therapist and to what feels best and works best for you. You must be in control of your healing path, once you are educated in the types of treatment that are possible. The first few times you experience massage, it may leave you exhausted, and you may feel the need to go home and sleep. This is a common occurrence with FMS, MPS, and FMS/MPS Complex massage patients. It's a sign that toxins and blockages in the body are being released into the bloodstream. Your liver and kidneys will be working overtime, so help them all you can. Drink plenty of pure water, avoid toxins such as secondhand smoke and alcohol and eat lightly, but nutritiously. After a massage, just as with any other physical therapy, plan to take it easy for a while. You may have a sore body the day after a massage, especially if you have a lot of TrPs. This soreness should disappear by the following day If it does not, tell your massage therapist to take things a little easier the next time. Your body needs time to adjust to the new balance it has found. Some types of deep muscle massage, such as skin-rolling, Rolfing, and HellerworK may be beyond your endurance and will usually worsen your symptoms by triggering rebound contraction. This causes your muscles to tighten up much worse than they were before the massage, and your condition will continue to deteriorate. Other types of bodywork, such as the Alexander Technique and Bowen therapy, can be extremely gentle and effectively provide some relief from symptoms

Alexander Technique

The Alexander Technique focuses on correcting body mechanics. It improves posture and movement styles, thus relieving muscle tensions. The patient's thought processes and body movements are both retrained and the patient learns to move with greater ease, avoiding perpetuating factors that can lead to tense muscles and TrPs. It is an exceedingly gentle method of relief for tense muscles. Alexander Technique practitioners are trained to teach their method to their clients. Their relationship with their clients is that of teacher and student. At first, the teacher may observe the student lying on a table, fully clothed. Then obser- vation takes place as the student stands, walks, and performs daily activities. Lessons are usually on a one-to-one basis, because the teacher must touch and adjust the student's movements, although group classes are becoming more common. Lessons usually run from half an hour to a full hour, once a week, for a minimum of 15 weeks. Generally, the lessons continue for 30 or more weeks.

Bowen Therapy

Bowen therapy is a very gentle, noninvasive form of bodywork that doesn't require a long series of treatments. Some therapists using Bowen therapy treat people only once a week for a month. It's a light, specific touch with a rolling motion on an out-of-alignment muscle. This touch signals the nerves beneath to signal the brain to move the muscle back to where it belongs, like a reset button. In Bowen therapy, some of the areas that are worked on are TrP locations, and some are acupressure meridians. It often takes five to ten days for the muscles to respond after a treatment.

Craniosacral Release (CSR):

The craniosacral system is composed of the brain, spinal cord, cerebrospinal fluid, a membrane that separates the brain from the skull, the cranial bones, and the sacrum. (The sacrum is a group of five fused vertebrae at the base of the spinal column, right above the cortex.) The fluid in this system moves with a rhythm all its own. But the rhythm of any patients with chronic conditions, such as those with FMS/MPS Complex, is often very low and fast. Craniosacral release (CSR) can normalize these rhythms. CSR is based on the premise that the brain expands and contracts with a very gentle pumping that circulates cerebrospinal fluid throughout the brain and spine. This very gentle method of bodywork releases tensions and blocks that have developed in the crainosacral system. Many people with FMS and FMS/MPS Complex are electromagnetically sensitive because of their dysfunctional neurotransmitters. When the practitioner is also electromagnetically sensitive, even if the practitioner's hands move the patient's skin only fractions of an inch, it can seem to the patient as though the whole of her or his body is moving. That's because the whole of the myofascia is adjusting; and this is what the patient feels. Layer after layer of tightness can be released with the proper application of this bodywork technique. Often, emotional releases accompany craniosacral work, as well as physical releases. CSR practitioners use the term "energy cysts." These form in the craniosacral system and block energy flow. They are described as emotional blockages that often present an electromagnetic blockage to healing.

Feldenkrais Method

The Feldenkrais method is a bodywork/ mindfulness technique that enhances the communication between the body and brain. It is based on movement and postural mechanics and uses movement and structural training through the use of patterning. The movements are very slow and gentle, and the focus is on correcting postural misalignments. The practitioner guides the patient in muscle movement patterns to retrain them.

Jin Shin Do Bodymind Acupressure

Jin Shin Do bodymind accupressure is an integrated healing method that uses gentle, deep finger pressure to liberate physical and emotional tensions. It also employs Taoist breathing techniques.

Manual Lymphatic Drainage

This massage technique "milks" the lymphatic ducts, removing blockages. This reduces tightness and swelling and stimulates lymphatic components. Most people performing these procedures are trained massage therapists.

Proprioceptor Neuromuscular Facilitation (PNF)

Proprioceptors are sensory receptors that tell your subconscious mind how your body is moving in relation to its environment. They tell the brain which muscles are contracting, and which ones are relaxed, With FMSor FMS/MPS Complex, because ofneurotransmitter dysfunction, proprioceptors often lie. Their information superhighway is cluttered with roadkill, and the messages don't get through or become garbled during the journey. Proprioceptor neuromuscular facilitation (FNF) can trick the proprioceptors by retraining them. The PNF therapist puts the patient in a comfortable position and then has the patient try to push out of that position. Each time this exercise is repeated, the muscle stretches a little further. Oniy specially trained massage therapists can perform this technique.

Reiki

Reiki is a Japanese form of one type of chi gung (Bodywork You Can Do Yourself). The term "reiki" translates as universal life energy. Reiki method was founded by a Japanese-Christian monk, Mikao Usui, in the mid-1800s. This therapy is founded on the premise that Id (universal life force) energy is everywhere and can be focused, channeled, and applied to others, promoting harmony balance, and healing. Reiki practitioners are available at several levels. A reiki master can rebalance the universal life force within a patient by the laying on of hands.

Spray and Stretch

In spray and stretch massage, after your massage therapist takes a detailed history and performs an examination to find your trigger points, you learn to release tightened muscles with the use of a vapocoolant spray that cools only the myofascia—-not the muscle underneath. The massage therapist sprays the vapocoolant in very precise patterns and directions. This cooling inhibits muscle-tensing reflexes. Then, the practitioner stretches the muscle, a little at a time between specific sprays. The patient must give the practitioner constant feedback since the patient is in control of the treatment, and her or his comfort must be ensured. The movement of the spray, the timing of the spray, and the stretch of the muscle are critical to the release of the muscle tissue. This method can also use ice, as long as the ice is kept covered and prevented from directly touching the patient's skin. After the muscle has been released, the muscle group is passively stretched several times, through its normal range of motion. The muscle group is then rewarmed.

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Strictly limit alcohol and sugar consumption.
Avoid fruit juice, dried fruit, baked beans, black eyed peas, lima beans, potatoes, corn/popcorn, bananas, barlye, rice, pasta or other heavy starches.

Eat protein as part of every meal. When starting a meal, it is wise to eat some protein as your first course. Excercise regularly to decrease the amount of insulin in your blood.

Drink at least 8 ounces of water with every meal.
Avoid caffein and nicotine.
Use chromium supplements.

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