tender points vs trigger points, whats the difference?

Discussion in 'Fibromyalgia Main Forum' started by shelby319, Jan 6, 2007.

  1. shelby319

    shelby319 New Member

    I saw something here where someone mentioned there was a difference between trigger points and tender points, does anyone know what the difference is and how you treat the tender points compared to the trigger points? I'm now confused totally!!

    Thank you to anyone who can help me understand the difference! I need this information for my pain management Dr's visit coming up. Which I'm a nervous wreck over!!
    Gentle hugs,
    Shelby
  2. lenasvn

    lenasvn New Member

    Trigger Points and Tender Points:
    Why the Difference Is Important to You


    by Devin J. Starlanyl 12/2004

    There is general confusion and lack of information concerning chronic
    myofascial pain (CMP). Many of the symptoms mistaken for fibromyalgia
    syndrome (FMS) may actually be due to myofascial trigger points (TrPs)
    instead. TrPs are easily treated if they caught early. Understanding the
    differences between FMS and CMP and how they can interact may be
    necessary before the most effective therapies for your symptom control can
    be chosen. There is no such thing as a fibromyalgia trigger point. You
    may have read about them in articles and even books written by respected
    physicians, but they do not exist. FMS tender points and myofascial trigger
    points (TrPs) are different in fundamental and significant ways. (1, 4, 7, 11, 14, 18)
    Failure to differentiate myofascial pain from TrPs may lead to unnecessary
    tests and procedures that may cause harm as well as unnecessary expense.

    (9)
    Fibromyalgia is not progressive.(4) If FMS is getting worse, there is at least
    one perpetuating factor that is out of control. This factor is often co-existing
    myofascial pain. Medical case reports indicate that even if a patient has
    been diagnosed only with FMS, identification and treatment of coexisting
    myofascial TrPs and adequate FMS support can provide considerable
    symptom relief (3) and restore function. Yet many people have never heard
    of myofascia or of TrPs.

    One type of myofascia, the fascia (a type of connecting tissue) you can see,
    is the thin, translucent material that covers chicken breasts at the grocery.
    You have myofascia too. Imagine “...a gauze-like network that shapes the
    entire body. Make that network three-dimensional, covering all of the
    interior, and then fill the gauze with structures including blood vessels,
    nerves, and lymph.”(15) That’s one form of fascia. Your muscles are infiltrated
    with fascia down to the cellular level. Myofascia tightens in response to
    stressors like trauma or infection. It can entrap blood and lymph vessels or
    nerves, causing diagnostic confusion. Fascia surrounds your heart and holds
    other organs in place.

    Myofascial TrPs are extremely sore points that can occur in taut ropy bands
    throughout the body. They may feel like painful lumps or nodules, and they
    restrict range of motion. They are not part of FMS. Because it is found so
    many places in the body, tight myofascia can cause a vast array of
    symptoms. Single myofascial TrPs can occur in anyone. If there are one or
    more TrP perpetuating factors out of control, TrPs may seem to spread. TrP
    perpetuating factors include anything that will perpetuate stress on the
    muscle, including trauma, body asymmetry, or co-existing conditions.

    Trigger Points and Tender Points: Why the Difference Is Important to You
    by Devin J. Starlanyl © 2004 Page 1


    When you have a TrP in a muscle, it causes pain at the end of range of
    motion when you stretch that muscle, and it weakens the muscle even
    before it causes pain. Your ankle, knee or hip may buckle, or your grip may
    fail, depending on which muscle is involved (these symptoms are not part of
    FMS). You then avoid stretching this muscle because it hurts. Muscles are
    designed to work best with motion. Since you don’t stretch the muscle, it
    becomes less healthy and your range of motion lessened. Circulation in
    your capillaries, your microcirculation, becomes impaired around the TrP.
    Nutrients and oxygen can’t be delivered easily, nor wastes removed. Your
    lymph system depends on muscle movement to move lymph, so that system
    begins to stagnate as well. Other muscles do the work of the TrP-weakened
    muscle. 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 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. Among the FMS patients in this study, twenty-eight
    percent 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

    Trigger Points and Tender Points: Why the Difference Is Important to You
    by Devin J. Starlanyl © 2004 Page 2


    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)

    Fibromyalgia is associated with central sensitization, including: general,
    diffuse (not localized) pain; hyperalgesia (pain amplification) and allodynia
    (pain from non-pain stimuli such as noise and light).(17) To control FMS pain
    amplification, you need to control the pain generators.(1) FMS amplifies pain.
    Myofascial TrPs generate pain and other symptoms. The differences are
    important, because these conditions are treated differently, even when they

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    co-exist in the same patient and have some perpetuating factors in common.
    Some factors that can perpetuate a myofascial TrP (such as short upper
    arms or Morton’s foot) will not, of themselves, perpetuate nor initiate FMS.

    TrPs in the sternocleidomastoid muscle (in the neck) alone can cause:
    clumsiness; blurred or double vision; tension headaches; runny nose;
    maxillary sinus congestion; spatial disorientation; unintentional veering; or
    cause patterns of light and dark (such as shadows along the road or
    escalator treads) or head motion to result in dizziness (among many other
    symptoms), and if you know this, you may save worry and unnecessary
    testing and be able to do something to relieve the symptoms. If the bottom
    of your feet feel like you’re walking on broken glass as you take your first
    steps in the morning and you know this may be due to TrPs, you can do
    something. Roll up a big towel and put it under your blanket at the bottom
    of the bed so that your feet can rest on it. That avoids allowing the plantar
    fascia to remain shortened overnight. (Keeping muscles in a shortened
    position is a common TrP perpetuating factor.) Chronic pelvic pain that feels
    like it comes from organ disease can come from TrPs.(2) If you believe that
    these symptoms come from FMS, there is nothing to do for them but
    attempt to control the pain. Understanding TrPs and their perpetuating
    factors can give you some measure of control over your symptoms and your
    life.

    We know what TrPs cause specific symptoms, what their perpetuating factors
    are, and what to do about them. These topics are discussed in detail in
    medical texts such as Travell and Simons’ Myofascial Pain and Dysfunction:
    The Trigger Point Manuals. For example, the prickling tingling painful
    sensation along the jaw line that can move upward across the cheeks is
    caused by specific TrPs in a muscle called the platysma (15 p 82) and not by
    FMS. If the TrPs are treated and the perpetuating factors brought under
    control, the symptom will go away. If the perpetuating factors cannot all be
    identified or controlled, the TrP can still be treated and minimized.

    When active (pain causing) TrPs become latent, they no longer cause pain,
    but they still cause restricted movement and muscle weakness. The latent
    TrPs still electrically inhibit the muscle.

    Some people don’t exercise because if they don’t move they don’t hurt as
    much. This is false reasoning. Their TrPs have merely become latent. Even
    a minor stressor can become a life-altering event if you have latent TrPs.
    Myofascial TrPs can cause: bloating, incontinence, impotence, rectal pain,
    sore throat, tender neck and armpit “swollen glands” feeling, muscle pain,
    headaches, pain in joints without swelling, dizziness, autonomic symptoms,
    weak muscles, ear pain, restricted range of motion, knee pain, shoulder
    pain, wrist pain, hand pain, neck pain, back pain, abdominal pain, pelvic
    pain, pain in the outer or inner vaginal area, stiffness in the morning (and
    after any immobility), shortness of breath, chest pains, tightness in the

    Trigger Points and Tender Points: Why the Difference Is Important to You
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    chest, frequent nighttime urination, inability to empty the bladder fully, stiff
    neck, nasal congestion, trouble swallowing, hoarseness of voice, tearing
    eyes, gastroesophageal reflux, vomiting, heart arrythmias, ringing ears,
    painful or itching ears, growing pains, painful menstrual periods, irritable
    bladder or bowel, belching, diarrhea, rapid racing heartbeat, painful
    intercourse, and many, many more symptoms.

    If you have back pain that worsens with sitting but it improves with
    appropriate therapy, check for iliopsoas and quadratus lumborum TrPs. If
    the pain is in the hip and radiates down the back of the leg, check the
    piriformis muscle in the buttock for TrPs. If pain radiates down the side of
    the leg, check the side of the hip for the gluteus minimus TrPs. Myofascial
    TrPs can refer symptoms a good distance away from their location. TrPs in
    the scalene muscles of the neck can entrap lymph and blood vessels, causing
    swelling in the hands in the morning. They can cause tightness and pain in
    the chest and down the back of the arm in a specific pattern, including the
    top of the thumb and index finger. You and your care providers need to
    become familiar with the common TrP referral pain patterns. They can be
    very specific and are generally similar from person to person, so if you can
    identify the pain pattern, you can find the TrP. Don’t work on the area of
    pain. Your jaw may be sore, but the source of the pain may be a TrP in your
    calf. Your doctor and dentist need to know this, and so do you for self-
    preservation. Innocent teeth have been pulled because dentists were
    unaware that TrPs can cause tooth pain and sensitivity to cold, heat and
    pressure. Teeth have been ground to adjust the bite, only to have a TrPladen muscle contracture change, causing the bite to change as well.

    Treating TrPs without treating the perpetuating factors means that the same
    TrPs will keep coming back. Treating the perpetuating factors is the key to
    both FMS and CMP, but it won’t make existing TrPs go away. Latent TrPs are
    like land mines waiting to explode. If you fall, or catch a cold, or are hit
    with any other stressor, they may all activate at once. This may be
    mistaken for or even cause an FMS “flare.”

    Multiple latent TrP activation often happens in the elderly. Much of the
    aches and pains and muscle weakness of old age may be due to unsuspected
    TrPs and may respond to proper treatment.(14) People who have been
    incontinent or have had sexual dysfunction for years due to myofascial TrPs
    may be relieved – and astonished – at their response to adequate TrP
    treatment. Then they often become angry as they realize that they have
    suffered needlessly because their doctors did not understand TrPs. TrPs
    cause muscle weakness and other dysfunction before they cause pain, so
    they may be unsuspected even by some doctors who have TrP medical texts.
    Some care providers just look at TrP diagrams. That is insufficient preparation to treat myofascial TrPs. Myofascial medicine requires study, and it
    is well worth the time spent on it. Many patients endure needless pain and
    medical tests due to lack of recognition and treatment of myofascial TrPs.(9)

    Trigger Points and Tender Points: Why the Difference Is Important to You
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    Some researchers lump FMS and CFIDS together and ignore myofascial
    pain. We won’t have clear research results until we distinguish these
    conditions. It is frustrating to see medical research that claims to be on
    FMS/CFS patients (written by researchers who lump these conditions
    together) and yet it describes nodules, ropy bands and restricted range of
    motion of myofascial pain. The authors of the article did not know better,
    and neither did their peer reviewers! This is a sad state.

    Many dentists, psychologists and others use the terms “temporomandibular
    dysfunction” and “myofascial pain syndrome (MPS)” to describe the same
    jaw dysfunction. Their research conclusions may be honestly but
    erroneously used by other researchers to apply to MPS due to TrPs. Further
    research may build on those faulty conclusions. An article attempting to
    prevent this clarified the issue (13), yet this potentially misleading research
    still comes out in quantity.

    An enormous amount of research has also been done on FMS patients with
    no regard for co-existing TrPs. Much of this research is suspect because
    some of the symptoms described could be due to myofascial TrPs instead. I
    believe it would reduce FMS clinical study variables considerably if patients
    in FMS studies were routinely screened for co-existing myofascial TrPs.
    Researchers may find that some symptoms now associated with FMS are
    more commonly due to myofascial TrPs, and some may not be associated
    with FMS at all. This may also be true for CFIDS. Many experts believe that
    one way deal effectively with these conditions is to separate them into
    meaningful subgroups that might give clues to effective treatment.

    An important step to symptom control is to deal with the causes of the
    symptoms. When you have chronic unrestorative sleep, it is logical that you
    also have chronic fatigue. This is not the same as CFIDS. If pain from
    myofascial TrPs is disrupting sleep, or you waken often with urinary urgency
    or diarrhea caused by TrPs, you need to take care of the TrPs (and other
    factors disrupting your sleep). If you take care of the TrPs and their
    perpetuating factors, it will be much easier to deal with the remaining
    symptoms. It’s not as easy for doctors as throwing a pill at the problem (and
    the patient), but it is good medical practice. The medical dictum “do no
    harm” is often lost in the field of chronic pain because care providers are
    unaware of the pervasiveness of myofascial TrPs.

    Some symptoms once linked with FMS may not be. Carbohydrate cravings,
    weight fluctuations and some swelling may be due to insulin resistance.
    Research indicates that insulin resistance may be a common perpetuating
    factor of FMS.(18) It can perpetuate TrPs. Sleep dysfunction, prevalent in
    FMS, may adversely affect glucose tolerance (10), and may unbalance the
    hypothalamic-pituitary-adrenal (HPA) axis.(8) Treating the insulin resistance
    through diet, especially if it is the main FMS perpetuating factor, may ease
    the symptom load considerably and may make co-existing TrPs more treatable.

    Trigger Points and Tender Points: Why the Difference Is Important to You
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    The concept of perpetuating factors is as valid for FMS as it is for myofascial
    TrPs, in my opinion. Many identified myofascial TrP perpetuating factors
    may also be perpetuating factors, aggravating factors, or even initiating
    factors of FMS. This has caused many clinicians to erroneously believe that
    FMS and myofascial pain are the same. This confusion must be eliminated.
    Common perpetuating factors need to be brought under control, but that is
    not enough.

    For example, an intestinal bug can set up TrPs that will perpetuate
    symptoms of diarrhea and vomiting that will persist even after the virus is
    gone. The TrPs have to be identified and treated first (and not with
    antibiotics). Doctors must learn to identify TrPs. “Most of the six million
    Americans with fibromyalgia have at least one associated syndrome which
    mandates specialized attention in addition to traditional therapeutic
    approaches.”(12) In the vast majority of chronic pain patients, including FMS
    and arthritis patients, myofascial pain is a co-existing condition.

    It is important to learn individual TrPs to learn their specific referral
    patterns, but it is also important to understand that complex overlapping
    pain patterns may exist in chronic pain patients. Body-wide TrPs may cause
    widespread pain, with TrPs in many areas and layers of many muscles. (The
    TrPs in the text diagrams are common, but they can occur anywhere.) As
    the perpetuating factors are addressed, single muscle pain patterns will
    eventually become apparent and then those TrPs can be treated.

    Spray and stretch and TrP injections are part of therapy for myofascial TrPs,
    not for FMS. One study showed that patients with both FMS and myofascial
    TrPs find TrP injections more painful, they have less effect (although they
    are still worthwhile to treat the TrPs), and the post-injection soreness would
    be worse than if the patient only had TrPs.(6) This is often the case with
    bodywork as well. Physical therapy, other bodywork, exercise and other
    therapies must proceed carefully and gradually if FMS and TrPs coexist. The
    amount of pain involved should not be underestimated. Any treatment will
    be more complicated and less successful than if the patient had only one of
    the conditions, and some bodywork may require extra medication to prevent
    added central sensitization. Each patient can vary in many ways. In the
    chronic myofascial pain component there is a wide variety of TrP
    combinations plus there may be different nerves, blood and lymph vessels
    entrapped. There may be different perpetuating factors. In the FMS
    component, there may be different biochemicals affected in different ways,
    and they may be affecting other biochemicals in different ways. Each case is
    different. Care providers and patients must understand both of these
    conditions to ensure adequate medical care. Insurance companies must
    understand that they will save money in the long run if the TrPs are treated
    promptly and adequately by trained providers, and the perpetuating factors
    controlled. Once the TrPs are appropriately treated and their perpetuating
    factors brought under control, you may find that remaining FMS symptoms

    Trigger Points and Tender Points: Why the Difference Is Important to You
    by Devin J. Starlanyl © 2004 Page 7


    are more easily managed. Some people may even find that they do not
    even have FMS after all.

    Trigger Points and Tender Points: Why the Difference Is Important to You
    by Devin J. Starlanyl © 2004 Page 8


    References

    1. Borg-Stein J. 2002. Management of peripheral pain generators in
    fibromyalgia. Rheum Dis Clin North Am 28(2):305-17.
    2. Doggweiler-Wiygul R, 2004. Urological myofascial pain syndromes.
    Curr Pain Headache Rep 8(6):445-451.
    3. Donelly JM. 2002. Physical therapy approach to fibromyalgia with
    myofascial trigger points: a case report. J Musculoskel Pain 10(1/
    2):177-190.
    4. Gerwin RD. 1999. Differential diagnosis of myofascial pain syndrome
    and fibromyalgia. J Musculoskel Pain 7(1-2):209-215.
    5. Gerwin R. 1995. A study of 96 subjects examined both for fibromyalgia
    and myofascial pain. J Musculoskel Pain 3(Suppl 1):121 (Abstract).
    6. Hong CZ, Hsueh TC. 1996. The difference in pain relief after trigger
    point injections in myofascial pain in patients with and without
    fibromyalgia. Arch Phys Med Rehabil 77:1161-1166.
    7. Jain AK, Carruthers BM, van de Sande MI et al. 2004. Fibromyalgia
    Syndrome: Canadian Clinical Working Case Definition, Diagnostic and
    Treatment Protocols – A Consensus Document. J Musculoskel Pain
    11(4):3-107.
    8. Meerlo P, Koehl M, van der Borght K et al. 2002. Sleep restriction alters
    the hypothalamic-pituitary-adrenal response to stress. J Neuroendocrinol 14(5):397-402.
    9. Meyer HP. 2002. Myofascial pain syndrome and its suggested role in the
    pathogenesis and treatment of fibromyalgia syndrome. Curr Pain
    Headache Rep 6(4):274-83.
    10. Scheen, Byrne, Plat et al.1996. Relationships between sleep quality
    and glucose regulation in normal humans. Am J. Physiol. 271 (2 Pt
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    11. Schneider M J. 1995. Tender Points/fibromyalgia vs. trigger points/
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    differential diagnosis. J Manip. Physiol Ther 18(6):398-406.
    12. Silver DS, Wallace DJ. 2002. The management of fibromyalgiaassociated syndromes. Rheum Dis Clin North Am 28(2):405-17.
    13. Simons DG. 1995. Myofascial pain syndrome: One term but two
    concepts; a new understanding. J Musculoskeletal Pain 3(1):7-14.
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    14. Simons DG, Travell JG, Simons LS. 1999. Travell and Simon’s Myofascial
    Pain and Dysfunction: the Trigger Point Manual: Volume I, edition 2: The
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    15. Starlanyl DJ, Copeland ME. 2001. Fibromyalgia and Chronic Myofasical
    Pain: The Survival Manual, edition 2. Oakland. New Harbinger
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    16. Staud R. 2004. Fibromyalgia pain: do we know the source? Curr Opin
    Rheumatol 16(2):157-63.
    17. Staud R. 2002. Evidence of involvement of central neural
    mechanisms in generating fibromyalgia pain. Curr Rheumatol Rep.
    4(4):299-305.
    18. Vicennati V, Pasquali R. 2000. Abnormalities of the hypothalamic-
    pituitary-adrenal axis in nondepressed women with abdominal obesity
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    Trigger Points and Tender Points: Why the Difference Is Important to You
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  3. NyroFan

    NyroFan New Member

    Shelby:

    Why not check with google? I learned about fibromyalgia
    trigger points , so then you know which is which, you can identify if is is fibro relate or not.

    I found it a while back and it helped me.

    nyrofan
  4. blizotte

    blizotte New Member

    Here is how it was explained to me.

    In FMS you have tender points that hurt when touched or pressed but you have no pain in any other part of your body because of this touching.

    In Chronic Pain Syndrome you have trigger points that when touched or depressed cause pain, not only in the touched area, but all in other parts of the body and sometimes throughout the entire body as with my daughter who has suffered with this ever since an automobile accident.

    This is a very simplistic definition but it made it clearer to me when explained this way. I hope it helps you too.

    blizotte