The Cinderella Hypothesis postulates that damage to the muscles can occur when the muscle fibers which are activated first are also the last to deactivate. Like Cinderella, they are always working, and not given adequate amounts of time to recover. These damaged muscle fibers can be a source of pain.

Low intensity, continuous activation of the fibers can be initiated consciously, for example while typing, or subconsciously, due to tension. Some studies have found that damage to the muscles can occur in as little as 30 minutes during continuous typing.

Though continuous activation without release does not happen for all patients during low intensity, sustained activity, the Cinderella Hypothesis presents a compelling case for taking breaks throughout the work day to participate in some brief stretching, which may help relax and lengthen the muscles.

Impairment is the clinical term for a loss of function due to pain or injury.  Being unable to lift more than 10 lbs because of low back pain is an example of impairment.  Disability is closely related to impairment, but is distinct because it involves choice.  Though your impairment may not allow you to lift heavy objects you may still able to sit at a desk. You can take on a job in which lifting isn’t necessary.  In this view, though you are impaired, you are not disabled for a desk job.

I once met a young woman who was employed as a secretary working the switchboard at a rehabilitation center.  She was quadriplegic (paralyzed in her arms and legs), and operated the switchboard and her wheelchair by blowing through a tube. She had help in the morning getting ready to go to work and during the day for meals and personal needs. She worked 9-5, 5 days a week.  Though this young woman was 100% impaired, and could have easily made the choice to be permanently and totally disabled, she chose to work.  She was fortunate to be able to have a job that would accommodate her impairment. Even if that is not possible, her story highlights the fact that impairment does not have to equate to disability.  Though you may be impaired, you can still participate in your life in many different capacities– whether that be through employment, engaging with loved ones, taking up a hobby, or other activities that bring fulfillment.

For people suffering chronic pain, pain intensity is not the only factor that should be considered when treating the patient. Many assume that once the pain is reduced, the patient will go back to living their normal life. However, this is often not the case.

Many chronic pain patients have decreased muscle flexibility and strength, and in addition psychological problems (Schofferman, 2006). Therefore, multi-disciplinary rehabilitation may be an important part of their treatment.

Successful treatment may be reflected as much by improvement in function as in reduction in pain intensity. The capacity for increased activity allows a pain patient to do things otherwise prevented by pain. A patient who was unable to work due to his severe low back pain could after treatment, despite persistent pain,  sit, stand, and walk for longer periods of time. He returned to work to a desk job. Despite residual pain the treatment was still considered successful by the patient because he was able to return to work.

Many chronic pain patients report frustration with the attitudes they face from friends, family, and health care practitioners.  Most often, patients report feeling stigmatized for experiencing pain that doesn’t have a readily identifiable cause.

Pain can have a variety of causes, and there is currently no set standard for diagnosing and treating chronic pain.  This lack of standard creates a confusing and frustrating experience for the patient, and a puzzling case for physicians.  For some, a lack of known etiology causes the patient to place blame on themselves, when in fact, the lack of knowledge is a result of the limits of medical knowledge (http://bit.ly/HFXzhm). 

Blaming oneself can have destructive consequences, including avoiding getting necessary professional help and actively participating in rehabilitation(http://bit.ly/17Supp1).  A strong social support base can reduce feelings of stigmatization and improve coping (http://bit.ly/10chj3G).  Support groups for pain patients can be effective in developing coping skills for depressive symptoms that are frequently experienced in patients living with pain, and boosting self-appraised problem-solving confidence (http://bit.ly/1bfJIFK).

You may have read or heard on the news about the new healthcare laws being put into place.  I have met many people who have said that they have no idea what will happen, so I thought I would provide some information. I am not an expert, nor am I placing an opinion on it. Any or all of this can change tomorrow, so before making any decisions consult your HR administrator, insurance broker, or whoever handles your health insurance needs.

As of January 1, 2014, you will be required to have health insurance. If you do not have health insurance, you will be fined a specific amount (based on your income) every year until you get coverage. The fines increase every year.  However, there are exceptions to this rule, including hardship exemptions, for which you can apply.

Many plans are changing because they don’t meet the minimum requirements set by the law. This may mean that your policy may change as of January 1, 2014. Even if it doesn’t apply to your needs and desires, the new standards require inclusion of items like prescription drugs, maternity leave, and pediatric dental care. Although pre-existing healthcare conditions will no longer be a reason for denying coverage or charging higher premiums, there are a few exceptions to this rule.

For more information, please visit https://www.healthcare.gov/

Studies have shown that obese patients have more problems with musculoskeletal pain than the general population (http://bit.ly/Hh3usQ).  Obesity and pain show a strong relationship even when insulin resistance, inflammation, and pain-related comorbidities are accounted for (http://1.usa.gov/17jGHqj).

A study of 215 fibromyalgia (FMS) patients found that obese patients had greater pain sensitivity, poorer sleep quality, and reduced physical strength and flexibility (http://bit.ly/18TVYy4).  If you are in pain and overweight, losing weight may help reduce your symptoms.  Though this can be achieved through simply taking in fewer calories than you expend, studies have shown that diet and exercise are significantly more effective together than either intervention alone (http://bit.ly/1ezkOEP).

Adjusting your lifestyle doesn’t have to be drastic!  Start by making healthy swaps in your diet: try replacing white bread with whole wheat bread, or try using olive oil or canola oil instead of butter.  Pick up a fruit or vegetable that you wouldn’t normally buy and figure out ways to incorporate it into your meals for the week.

Exercise habits can evolve with a little time and effort.  If you normally walk five blocks in one day, see if you can increase that to six or seven.  Though weight training can be beneficial in building muscle strength and bone density, aerobic exercise is more likely to be helpful if your goal is weight loss.  Simply increasing your physical activity and making smarter food choices can help you lose weight and decrease your pain.

Last week, we discussed some of the psychological components of pain, and the potent effect emotion and attitude can have on the day-to-day management of your pain.  Many patients coping with chronic pain experience kinesiophobia, an irrational fear of reinjuring oneself or exacerbating pain by participating in physical activity.

One study of patients with foot and ankle pain found that out of movement-related fear, pain intensity, and range of motion deficit, fear was by far the greatest predictor of disability status (http://1.usa.gov/1fXzxN5).  Clearly, fear of movement plays an important role in the quality of life of patients living with pain.

Managing pain more successfully as reflected in continuing to work and be involved in life  is associated with less fear than those with lower levels of functioning when all other metrics are also considered.  A review of seven studies which examined patients with chronic musculoskeletal pain who chose to continue working found that these patients were significantly more likely to have low scores for both emotional distress and perceived disability (http://1.usa.gov/H4v9gc).

Treatments that address both the physical and emotional aspects of pain can produce better outcomes.  A study of 130 patients who had undergone a spinal fusion found that patients who participated in a rehabilitation program that included cognitive-behavioral therapy to address  kinesiophobia and catastrophizing as well therapeutic exercise faired significantly better than those who participated in a program consisting only of therapeutic exercise.  The psychological intervention was found to reduce dysfunctional thoughts and enhance quality of life for up to one year after treatment ended (http://1.usa.gov/17M2T91).

It is apparent that attitude – especially beliefs about movement – impacts the quality of life for patients in pain.  Those who maintain a positive outlook and a healthy perspective on movement, though not necessarily reporting reduced levels of pain, do show an increase in function.

Several different variables have been studied: Catastrophizing, depression, kinesiophobia, and self-efficacy.

Catastrophizing is a type of dysfunctional thought in which the patient exaggerates the severity of a situation. Examples of catastrophizing are thoughts like “I can’t take it!” “What did I do to deserve this?” “What’s the use?”  “I might as well be dead!” One study of patients entering a multidisciplinary pain treatment center found that the extent to which a patient catastrophized was a better predictor of disability status than pain intensity (http://bit.ly/1aVCGa6).  A separate study of fibromyalgia patients found that pain catastrophizing was correlated with an increase in brain activity in areas related to attention to pain, anticipation of pain, and motor control (http://bit.ly/17y4Up8).  This suggests that catastrophizing affects the intensity with which patients perceive pain.

Depression and chronic pain often coexist.  Both conditions can markedly affect a patient’s health, motivation, and overall quality of life.  Patients with depression often experience feelings of helplessness, fatigue, and hopelessness – all feelings which can impair treatment outcome.  Depression and pain are also linked biologically through 2 common pathways:  the serotonergic and noradrenergic systems (http://bit.ly/1gqi29f).  The neurotransmitters serotonin and norepinephrine modulate pain transmission and also play key roles in the development of depression.  Therefore, treatments that target these neurotransmitters, such as tricyclic antidepressants, and SNRIs (serotonin/norepinephrine reuptake inhibitors) can be helpful for both conditions (http://bit.ly/1fID6GQ).

Kinesiophobia is fear of movement based on the belief that activity will result in re-injury or exacerbation of pain. Hi kinesiophobia scales result in less activity and interfere in effective rehabilitation (http://bit.ly/19RClca).  Depression often co-exists with kinesiophobia.

Self-efficacy in the context of chronic pain refers to confidence in one’s ability to cope and function despite persistent pain.   A study of patients with an acute whiplash injury found that patients with less belief in their ability to manage their life in the face of pain were significantly more likely to have their injury develop into a chronic condition (http://bit.ly/1bylac/).  A separate study of 45 low back pain patients found that higher self-efficacy predicted better overall functioning and decreased levels of pain at 6 month follow-up (http://bit.ly/19RClca).

Psychological factors play an important role in evaluating and treating pain.  When usual treatment is not progressing well, assessment and treatment of emotional factors may help the patient succeed in finding pain relief.