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Fibromyalgia (FMS) and
Chronic Myofascial Pain (CMP)
Information for Patients, Supporters
Doctors and Other Health Care Providers

with Devin Starlanyl

David G. Simons: The Wind Beneath My Wings

 

Readers may ask why I have dedicated this website to David G. Simons, M.D.  Other articles in this section concern his early life as a flight surgeon in the pre-astronaut program, “Project Man High.”  In my books, on this website and in my other writings I frequently mention the medical texts he co-authored, “Myofascial Pain and Dysfunction: The Trigger Point Manual,” (TPM), volumes I and II and the 2nd edition of volume I.  These big red books are the definitive texts of myofascial medicine.  Without them, and without Dr. Simons, my works, including this website, would not exist.  Through much of my own voyage of medical discovery, he has been my mentor, and he still is. 

 

When Dr. Simons took charge of the flight program, his goal was to clarify previous animal experiments that explored the medical hazard of heavy cosmic radiation as a threat to manned space flight. This required that a human being ascended as high as then possible and remained aloft for as long as possible at latitude at least as far north as the northern border of the USA.  He wasn’t interested in setting records.  When he volunteered to make his flight, he had no guarantee he’d even survive but expected to because of the expertise of his boss, Col. John Paul Stapp, in exploring the limits of human tolerance safety.  He knew direct observation and experiments were required to discover what was out there and what was needed to protect the human body during space flight.  He was driven to explore.  He confirmed that the effects observed in experimental animals were not prohibitive for relatively short exposures like those experienced in the moon journeys.  However, relatively recent research makes it now clear that a manned trip to Mars and back is absolutely prohibitive with known technology for protection from those cosmic rays.  His flight took courage, determination, consuming curiosity and perseverance.  Later in his life he embarked on a different path, and his discoveries are still making a world of difference.

 

The concept of myofascial trigger points (MTPs) requires a practitioner to make a paradigm shift from medicine-as-usual.  It takes a new way of thinking and a special group of skills that don’t come easy to many in the medical community.  Yet Dr. Simons was immediately able to grasp the significance of MTPs and began to expand the understanding of the trigger point.  He and Janet G. Travell, M.D., President John F. Kennedy's White House physician, co-authored the first Trigger Point Manual (TPM) on the MTPs in the upper body in 1983.  In so doing, they propelled the field of myofascial medicine that she had launched.  People may know about Kennedy’s specially designed (by Janet Travell) rocking chair, but they don’t know that J.F.K. had MTPs that required the specially designed chair.  Most TPM readers also don’t know that the second TPM (volume II, lower body) published in 1992 was written primarily by Dr. Simons, with help from Lois Statham Simons because of Dr. Travell’s advanced age.  This fact was not told to me by Dr. Simons, but became evident during my research on the development of that volume at the Travell Archives.

 

Dr. Simons once mentioned to me that as soon as he learned about MTPs his biggest surprise was that they are so common.  They are ubiquitous.  Individual MTPs can occur, but if there are no perpetuating factors and the MTPs are treated, they resolve.  If they are not treated, they may become latent.  Finding a single MTP is unusual, and this may be due to the fact that so few people recognize and treat them promptly.  Most chronic illness has a myofascial component adding to the pain and dysfunction.  Dysfunction caused by MTPs includes restricted range of motion and muscle weakness, and these can occur before any pain is noticed. 

 

The TPMs show the approximate locations of the most common MTPs.  They also explain common causes and perpetuating factors of individual MTPs and describe in detail a variety of treatments.  At the end of volume II there is a very brief chapter on chronic myofascial pain (CMP); describing some of the disastrous consequences when primary MTPs and their perpetuating factors remain untreated and uncontrolled.  The authors still didn’t have all the answers as to the biochemistry of MTP formation, but they made careful observations and tests and explained what they had found.  They continued to research, and, slowly, others took to the hunt for answers.  Yet the medical establishment long considered myofascial medicine “controversial” because there wasn’t a simple blood test or imaging technique to define it.  Myofascial medicine wasn’t tried and found wanting; it was tried and found difficult.  There are many possible common MTP locations and their common referral patterns and associated symptoms to learn, and many potential perpetuating factors.  Both TMP texts are huge.  Palpation of MTPs takes a fine touch and skill that comes with practice and experience.

 

During my search to figure out what was wrong with my own body and mind, I had access to some of the best medical libraries in the world.  This was in the pre-Internet days when that was crucial.  Teachers weren’t teaching myofascial medicine in most medical schools.   I had already discovered fibromyalgia (FM), but none of my doctors or professors could explain the sketched pain patterns I carried around with me.  When I opened those big red books, there were the specific patterns I had been told were “impossible!”  So now I knew about individual MTPs.  Yet I had every MTP in both texts, plus others that weren’t even in there.  So I contacted Dr. Simons.  I had a lot of questions, and I received so much more than answers: David Simons supplied me with a new set of questions and an invitation to journey into uncharted realms of medicine. 

 

The word “mentor” comes from Greek classics.  Mentor was the wise counselor of Odysseus and Telemachus.   What I found in Dr. Simons was a mentor of the highest order.  I remember sitting near him at a breakfast table with eight or ten people at a Focus on Pain conference in the ‘90s.  He was discussing his work with someone next to me, and his whole body became animated.  His eyes lit up, and he leaned forward, the whole force of his being behind the phrase, “I love to teach.”  This love of teaching has been my good fortune, and, since you are on this website, it is yours as well.  For some of us, it's not enough just to discover something.  We need to understand it, find out why and how it happens and what to do about it, and then teach what we know so that others can understand it also.  We immediately begin thinking about the next set of questions that arise with each discovery.   

 

The second edition of TPM volume II, published in 1999, contained more about how MTPs formed.  By then, Dr. Simons and colleagues did the critical research to develop the integrated hypothesis that was scientifically logical.  There were some weak links, because all of the answers were yet to be found.  His hypothesis has since been shown to be correct, and it has been expounded upon and detailed in current research.  Some of that research is in the Myopain Overview elsewhere on this website. Myofascial pain due to MTPs is a true disease, a myopathy, and is no longer only a syndrome. 

 

Chronic myofascial pain is much more common than originally thought.  Research in myofascial medicine is starting to expand exponentially, yet even though most physicians have patients with MTPs in their practice, the doctors seldom understand the reasons for their patient’s symptoms.  I asked Dr. Simons once long ago how he was able to deal with this and persevere in his work.  Research in myofascial medicine has been ongoing for nearly sixty years, and patients who see the few MTP referral pain patterns on the front of my books often recognize them as their own (and often consider them caused by FM, to my great frustration), yet many doctors in practice know nothing of this common source of musculoskeletal pain and dysfunction.  I asked Dr. Simons how he was able to deal with this and persevere in his work.  He reminded me of the need to change what we can, accept what we can’t, and the wisdom to know the difference.  And he keeps exploring, looking for answers, and teaching what he knows to those of us who will listen and learn. 

 

For more than a decade I have been honored to have Dr. Simons as my mentor.  He has challenged me and guided me as I have attempted to bring a basic understanding of myofascial medicine to patients through my own books.  One of his earliest challenges was to distinguish those symptoms caused by MTPs from those caused by FM.  Now we understand that some of these symptoms have components of both FM and MTPs and may be impacted by other interactive co-existing conditions.  Although FM is very real, it is often misunderstood.  At the International Myopain Congress in 2007 it was a “given” that FM patients have at least one MTP.  Much that the medical world “knows” about FM may be suspect, because co-existing MTPs were not taken into account during the research and undoubtedly contribute an unknown amount to a lot of the findings.  

 

Dr. Roland Staud and others have shown that pain from peripheral tissues, such as pain caused by MTPs, can be enough to sensitize the central nervous system or maintain this sensitization.  Thus, at least some cases of FM may be caused by MTPs, and even more cases of FM may be maintained by pain from MTPs.  At least some of what are called “growing pains” in the young and even much of the restricted range of motion, stiffness and “rheumatism” of old age are very likely caused or contributed to by MTPs.

 

Research by Dr. Jay Shah of the National Institutes of Health includes analysis and identification of over 30 biochemicals released by the local twitch response of MTPs.  Just recently, the Mayo Clinic issued a press release about a new imaging technique, magnetic resonance elastography.  This technique can image a taut band, and thus document the presence of a MTP.   For some of us, palpation skills, range of motion, recognizable pain patterns and the like were enough to accept the reality of MTPs and learn how to find and treat them; now the rest of the medical world has proof available that MTPs have been there all along!   Once they realize the ubiquity of MTPs, they will also recognize the lack of health care professionals who can treat them.  

 

We presently have a growing cadre of educated patients, available resource materials, a small but treasured group of MTP therapists and other manual practitioners, and an even smaller group of physicians specializing in myofascial medicine.  We still desperately need more care providers who are trained in myofascial medicine, but we are moving ever more rapidly in the right direction.  Now we must raise awareness in the medical world of the prevalence of MTPs, CMP and the importance of interactive diagnoses in chronic illness.  There is a new TPM in progress that will eventually present updated information and the best of both earlier volumes.  When I started looking for the sources of chronic pain and associated symptoms, I had the TPMs.  It was Dr. David G. Simons who guided me in my quest, and I have been honored to share in the exciting voyage of exploration and discovery.  He is, indeed, the wind beneath my wings.  

 

Devin J. Starlanyl

(with gratitude to Nye Ffarrabas for proofreading)

 

 

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