Pain is a common complaint. Acute pain comes on suddenly and may be due to trauma, internal obstruction, or an infection. Its onset can be pinpointed. Sometimes, the pain starts so gradually that it is difficult to isolate its time of origin. Pain is considered to be chronic if it has lasted three months or more. Quite often, chronic pain is in one or more of the joints, or the spine, back or hip. It may affect multiple joints as in rheumatoid arthritis, or one or more large joints as with degenerative osteoarthritis. In most acute or chronic conditions, blood tests and imaging studies confirm the diagnosis.

It becomes difficult to arrive at a diagnosis when the pain is all over the body, not just in the joints but symmetrically in the muscles. If the muscles are palpated, tender, large or pea-sized nodules can be felt (but not seen). Pressure on the nodules elicits pain locally and in other sites. It may even cause localised spasm of the muscles and twitching.

This condition is called fibromyalgia and it is a diagnosis of exclusion. It is a debilitating long-term chronic illness that affects up to two per cent of the general population. Females are more frequently affected. it usually starts in middle age. It is often accompanied by other vague symptoms like restlessness, fatigue without physical activity, inadequate and unsatisfactory sleep, tingling and numbness in the hands and feet, and morning stiffness. The lack of restful sleep results in memory problems. The constant pain can cause anxiety and depression.

The exact reason for these symptoms is not known. Imaging tests and blood results are normal. The pain is suspected to be caused by faulty pain perception in the nerves. There is an increase in the levels of neurotransmitters that signal pain. The brain itself becomes more sensitive and overreacts to pain signals.

Painful trigger nodules in the muscles can occur for no apparent reason at all. They are more common in diabetics, especially if they are poorly controlled or if the muscles are strenuously and vigorously overused (athletes and bodybuilders ) without adequate rest or stretching. It can also occur if muscles are kept in a contracted, artificially-shortened position for an inordinate length of time, as with long distance driving, corsets, braces or even sleeping awkwardly.

Once the diagnosis is established, professional physiotherapy may be the fastest way to relief. Therapists are trained in releasing the nodules with massage. They may use the elbow, finger or a special implement. They also have equipment like an ultrasound massager which can "untie" the nodules. They teach flexion and strengthening exercises.

There are certain things that can be done at home.

• Alternating hot and cold applications can be tried

• Cooling sprays can be applied to the affected area in parallel line

• Aerobic activity like walking, jogging, running, cycling and swimming move all the muscles and release chemicals that can prevent the knots from forming

• Life should be strictly scheduled with fixed bedtime to prevent the build-up of stress levels and release of pain chemicals.

Painkillers alone do not work very effectively. If paracetamol or tramadol do not work, it is unlikely that more potent, potentially addictive painkillers will help. Sometimes, it is more effective to combine them with a small dose of antidepressant or anti-epileptic to block the pain perception chemicals.

Alternate therapy like acupuncture, acupressure, or massage therapy are often effective. It is important to go to a qualified professional, otherwise, they may do more harm than good. Exposure to sunlight (to correct any vitamin D deficiency), yoga for stretching and meditation to relieve stress will all contribute to long-term relief.

The writer is a paediatrician with a family practice at Vellore and author of Staying Healthy in Modern India. 
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