If you have chronic low back pain, you may feel like you are fighting a losing battle. This is because historically, in the medical field, there has been no consensus on how to treat chronic low back pain for good. The majority of treatments focus on the wrong end of pain; the physical site of discomfort (muscle, skin, etc.); rather than the top of the top-down processing system: the brain (1). 
As we’ve talked about in prior articles about the motor homunculus and the fear center, the brain is capable of changing itself over time as a result of chronic pain. Many of these changes are believed to have a role in enhancing pain perception. If this mechanism is correct, then it partially explains the lack of success in the development of treatment for chronic low back pain so far.
Seeing the Brain Like Never Before
One of the most recent developments in research that has impacted this cause is functional magnetic resonance imaging, also known as fMRI. As its name suggests, fMRI measures how the brain functions. It combines images of activation energy levels in the brain in order to determine what regions are activated at what time, and by what cue.
Several studies focus on observing patients with chronic low back pain using fMRI, and evidence collected so far seems to support the theory of top-down processing. Researchers are able to record and track cortical changes, as well as calculate how the magnitude of these changes relates to the intensity of the pain.
What Changes, and What are the Effects?
The human brain is highly evolved and is designed to be able to react to environmental changes. These reactions can even involve structural changes, where the brain can reduce or expand particular areas depending on what circuits are being activated. As we talked about in our central sensitization article, chronic pain amplifies regions implicated in pain processing, resulting in worsened pain.
In reality, pain perception is so pervasive in the brain that many of its cortical effects do more than influence the pain itself. There are mental effects associated that may need medical attention of their own, or to be a considered factor in the treatment of your chronic pain.
Changes that worsen pain.
The key detail in this section, as well as regarding pain processing in general, is that pain is a subjective experience. Our brains receive the stimulus as input, and its processing of the pain is what tells us how to feel. As we feel more pain, more often, the associated routes can become strengthened, exaggerating our pain perception as a consequence.

The dorsolateral prefrontal cortex, or DLPFC, is a cortical region that moderates the pain response. It is a section of the prefrontal cortex, which is where conscious thought and decision-making occur. Imaging studies have shown that in individuals with chronic low back pain, the DLPFC experiences neurodegeneration — a reduction in volume and activity (2). The less active the DLPFC becomes, the higher the perceived intensity of pain (3).
Changes that affect psychological and cognitive functioning
While the changes that enhance pain processing are considered cognitive in nature, there are additional changes beyond pain perception that influence how we think and feel. For example, as chronic low back pain intensifies, patients are less able to regulate emotions during decision-making, a result of amygdala overactivation and dampened prefrontal cortex activity (4).

Patients also experience increasing impairments in memory, as the amygdala is capable of reducing activity in the hippocampus, which is associated with memory storage, during times of stress (5).

A comparable effect was observed using language-learning studies, as the ability to learn a new language involves flexibility of key brain regions. Patients with chronic pain are less able to acquire new languages and have been shown to experience reduced brain plasticity (6).
If you have chronic low back pain or chronic pain in any area, there is more to consider than the physical location of the pain. As time goes on, the likelihood that your brain will be influenced increases, as well as the magnitude of these changes. Being aware of what’s causing and maintaining your pain is one of the biggest favors you can do for yourself. More information is gathered every day, and staying updated can help you manage your pain and find relief. 
In health,
Dr. Joe Tatta, DPT, CCN