These overworked muscles develop secondary TrPs. Satellite TrPs develop in the areas of pain referred from the primary TrP. These additional TrPs cause the false impression of a progressive disease process, unless the TrPs are recognized. Nearly everyone who sees the cover of my last book (15) recognizes some TrP referred pain patterns as their own. They don't always recognize that the patterns are not FMS.
Secondary and satellite TrPs can spread until overlapping pain patterns cover three or all four quadrants of the body. (13) At that point, although they are still regional in nature, the TrPs may seem be misdiagnosed as FMS. In a study of 96 patients, seventy-two per cent had both FMS and CMP. (5) This study was done by a doctor who understood the difference between FMS and TrPs. Thirty-five percent of the myofascial pain patients in this study had generalized pain in three or four quadrants, but they had chronic myofascial pain and not FMS.

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Among the FMS patients in this study, twenty-eight per cent had FMS with no TrPs. Some clinicians mistakenly think that all FMS patients also have TrPs and that these conditions are the same. This is not a difference of opinion. This is an error that can have significant impact on the quality of patient care.
For example, you can't strengthen a muscle that has a TrP. People with TrPs who are sent to work hardening and weight training get worse because TrPs cause muscle fibers to be shortened even when they are at rest. Muscles with TrPs are contractured (physiologically shortened.) This means that you cannot voluntarily relax these muscles fully unless something occurs to change the physiology. That means TrP specific treatment. The area around the TrP is in severe energy crisis and is releasing sensitizing substances that irritate, aggravate and modify surrounding sensory and autonomic nerves. (14) "Strengthening" exercise causes them to shorten and tighten even more Inappropriate exercise is one of the most avoidable of TrP perpetuating factors. (14) It can be harmful to a patient if a doctor, physical therapist, occupational therapist or other care provider does not recognize a TrP for what it is, and know how to treat it.

A muscle that harbors a TrP cannot be strengthened because it is physiologically inhibited. You must be out of pain with normal range of motion for two weeks before strengthening exercise is initiated, and then it must be gentle and introduced very gradually. (14) Stretch slowly to full range of motion once only for each muscle. This single stretch must be repeated many times at intervals during the day. The stretch should be within the limits of pain and should not produce a lasting ache. When such an exercise produces only mild soreness which disappears on the first day, you can repeat the exercise the next day. When the TrPs cause only mild soreness that disappears quickly, you can add more muscle lengthening exercises gradually. (14)

When you can do 10 lengthening contractions easily, this daily exercise can be replaced with one muscle shortening contraction per muscle. (Holding a muscle in maximal contraction for 5 to 10 seconds daily is sufficient to maintain the strength of the muscle.) TrPs must be gone (not just latent) for two weeks before strengthening exercises are attempted. Then you can add one additional repetition each day if the exercise soreness disappears that day. Exercise must be prescribed very carefully and monitored closely to see that it is done properly.

Enough time must be allowed between exercise and/or bodywork sessions. TrP-involved muscle fibers are under substantially increased tension when at rest.(14) You don't want to increase that tension. This means stair stepping, rowing machines, stretch band exercises, and Nautilus-type machine exercises are contraindicated if there are TrPs in the involved muscles. All the TrPs in the muscle function group must be gone first, and the perpetuating factor brought under control. All exercises require coordination with proper breathing techniques. You can't properly perform "abdominal breathing" if your respiratory muscles are inhibited by TrPs. TrPs in the respiratory and accessory muscles must be treated to allow for deep breathing.

Fibromyalgia is not associated with unexplained toothaches; carpal-tunnel like symptoms; localized aching or pain in the coccyx, shin, back, hands, pelvis, neck, fingers or eyes; tight muscles; trouble swallowing; weak or painful grip, numbness or swelling in the hands, pain or itching in the ears, frequent eye correction changes, unexplained toothaches, spatial disorientation, appendicitis-like pain, weak ankles or knees, restricted range of motion, angina-type pain, or dizziness. Specific TrPs can and do cause these symptoms. Information on some of these and other symptoms are given in The Survival Manual. (15, Chapter 8)