CHROniC LOW BACk PAin
The brain in chronic
low back pain –
A brief stroll through the evidence
Benedict M Wand, Neil E O’Connell, G Lorimer Moseley
Sources of funding:
All three authors currently hold a research
funding grant from BackCare and the ●
The overarching message that arises from the clinical trials
of treatments for chronic low back pain (CLBP) is that current
interventions provide only small short term benefits when compared
Rosetrees Trust. to sham treatment or no treatment, but offer little benefit when compared to
each other.
46,9
Regardless of the type of intervention it seems that patients
Acknowledgements: still exhibit significant levels of pain and disability at the completion of
We would like to acknowledge the treatment.
6
There are numerous potential reasons why the results of clinical
generous support of these organisations trials have been so disappointing.
4
One perspective we have explored
in facilitating our research. previously is that the primary focus of most current therapies on structural
or functional impairments in the spine may to some extent be misdirected.
47

Conflicts of interest: None There is growing evidence of extensive cortical reorganisation
11, 24
as well as
biochemical
44, 18
and structural alterations
2, 42, 8
in the brains of people with
Addresses for correspondence: CLBP. It is possible that these changes may contribute significantly to the
Benedict Wand problem and that treatment may need to be explicitly directed to the brain.
School of Health Sciences
The University of Notre Dame While the clinical implications of these periaqueduactal gray (an important area
Fremantle brain changes on the CLBP experience for descending modulatory control) than
Australia are far from being fully resolved
1
there are normals when exposed to the same
W Australia three areas of consideration which may level of painful stimulus
14
and distressed
email bwand@nd.edu.au be of particular importance to patients CLBP patients have less engagement
and those managing this condition. Firstly, of cortical areas thought to be involved
Neil O’Connell the observed changes may contribute in modulating sensory input than non
Centre for Research in Rehabilitation to enhanced nociceptive responses. distressed CLBP patients when exposed
School of Health Sciences and Decreases in gray matter in areas of the to intense vibratory stimulation of the
Social Care brain that influence pain suppression back.
24

Brunel University such as the midbrain
42
and dorsolateral
Uxbridge prefrontal cortex (DLPFC)
2, 42
could Secondly, psychological features of CLBP
Middlesex UB8 3PH lead to a prolonged state of abnormal such as decision making pertaining to
neil.oconnell@brunel.ac.uk nociceptive modulation
27,15
noted lowered the pain experience, cognitive appraisal
pain thresholds to mechanical stimulation of pain and disorders of mood are likely
Lorimer Moseley of the thumb nail in patients with CLBP to be effected by the demonstrated
Prince of Wales Medical Research and Clauw et al.
10
found significant cortical changes. Apkarian et al.
3
found
Institute & associations between clinical status CLBP patients to be impaired on a task
The University of New South Wales of CLBP patients and tenderness at designed to assess emotional decision
Sydney remote sites. The findings of sensitivity making, others have noted significant
Australia changes well outside the lumbar spine decrements in memory, language skills
lorimer.moseley@gmail.com suggest a central nervous system origin and mental flexibility in older CLBP
of these changes. Importantly, it appears patients
49
and the ability to shift attention
that CLBP patients have significantly away from threatening stimulus seems
lower increase in blood flow to the to be impaired in the CLBP population.
40

8 The Backcare Journal
backcare Winter 2009/10.indd 8 8/1/10 11:18:41
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