Chronic Back Pain: Brain Circuitry

After the spinal cord receives the signals from the muscles, it then sends signals along the spinal cord up to your brain. Your brain then must make meaning of the pain. If your spinal cord has amplified a minor “achy muscle” pain into an unbearable pain, then it is still up to your brain to override these signals. Some conditions like chronic pain, anxiety and depression all activate similar parts of the brain. Certain parts of the brain are linked through biological and electrical circuits. We also know that untreated depression can increase medical symptoms, decrease a person’s pain threshold and increase the intensity of pain. Up to 70% of people consulting a doctor about depression have physical aches and pains.

Musculoskeletal pain, depression and anxiety are so strongly linked that health care providers should be on the lookout for all three. It has been commonly believed that if doctors can just get rid of the physical pain, then depression and/or anxiety will also go away; however, there has been no clinical or research evidence that treating only a person’s pain gets rid of depression and/or anxiety. In fact, this approach commonly leads to misdiagnosis, frustration and over-treatment of non-painful, age-appropriate structural “normal” abnormalities in the spine.

Remember - not all abnormal-looking spines are painful.

Spine researchers also think that some people who have a history of depression, stressful life events, anxiety and considerable fears or misunderstandings of their pain may have increased sensitivities to pain. All of these conditions are likely to stimulate the spinal cord to start this central amplification process. And despite all our advanced medical imaging and testing, we still cannot analyze your spinal cord signals to block these signals in any meaningful way.

However, because pain, anxiety and depression are so interconnected, we can take advantage of that. We know that depression and anxiety can be treated successfully with medications and cognitive behavioral therapy. Our psychologists have also successfully taught hundreds of people mental relaxation techniques and breathing exercises to alleviate and manage their chronic pain.

Studies have also proven that exercise is an effective treatment for depression. Meditation, yoga and stress management exercises also all help with managing stress. If each of these interventions leads to a small improvement alone, then trying several items on the “menu” of treatments should result in more improvement. The sooner you learn how to recognize the elements of pain, the sooner you can learn how to manage your pain. Understanding the sources of life stressors will allow you to make new life choices that diminish depression, anxiety or stress, and begin to eliminate misunderstandings or fears about your pain.

Studies have shown that workers who have a combination of pain, depression and anxiety are out of the workforce much longer than those who complain of pain alone. The best pain rehabilitation programs understand and address all of these problems.

man running from  bear

A part of the brain involved in pain control is called the amygdala. This area deep within the brain is also thought to control a person’s fear. This may explain why many people with chronic back pain have a magnified fear of physical activity causing injury or re-injury, and why pain can occur after actual damage or even perceived damage to an area of the body occurs. Neuroscientists are doing studies to see if the amygdala’s fear response can be switched on and off but any successful treatment wouldn’t be available for decades. What you CAN do, however, is to first understand which movements cause pain, and then work towards not being afraid of that movement. Physical therapists work on getting patients accustomed to the typical and not-harmful pain associated with normal day-to-day movements. By understanding that some movements will stretch a painful muscle, or activate a painful group of muscles, but not injure you, you can slowly train your brain to not over-respond to the pain associated with these physical activities. We teach our patients that “hurt does not always mean harm.”

Another deep area of the brain that is involved in chronic pain is the hypothalamus and pituitary gland. These areas of the brain produce stress hormones that circulate throughout our bodies. Some researchers suspect that early childhood or previous trauma or stressors can lead to long-lasting impact on our hypothalamus and pituitary gland’s ability to control production of these stress hormones. We don’t yet know how to “reset” these hormone levels using any of the medications that are currently available. We hope that by doing these cognitive-behavioral stress management exercises you will be able to decrease the levels of these hormones.