When Visualization Hurts!

Several years ago, I honestly believed that the only cause of low back pain (LBP) was injury to muscles, ligaments, discs and/or facet joints. As a caring PT, I would try so hard to unload, stabilize, stretch and strengthen those structures, and hoping my patients’ pain would go away.


Although treating structures worked on many patients, some of them continued to have pain despite my efforts. I certainly did not spend as much time discussing with my patients their fears and worries about their LBP as I do today.

This study aimed to determine if visualization of a painful event would trigger painful memories. Call me a geek but I find these brain studies absolutely fascinating.


It seems silly: why would our brain make us feel pain when we are not in real danger? Why would just perceiving a potential threat cause pain?


Eleven subjects with LBP and 11 subjects with no LBP were exposed to virtual LBP stimuli by having them view images of a man carrying luggage in a half-crouching position. While viewing the image, all subjects had whole brain functional MRIs.


Result #1: All 11 subjects with LBP reported of experiencing either pain or discomfort while viewing the virtual image.


Result #2: None of the 11 asymptomatic subjects reported of discomfort while viewing the virtual image.

Result #3: Unlike the asymptomatic subjects, the fMRIs of individuals with LBP showed activation of the cortical areas related to pain and emotions such as the…

Insula, Premotor area


Thalamus, Gyrus

Pulvinar, Hippocampus

Posterior cingulate cortex

Fusiform, Cerebellum

Could it be that the virtual LBP stimuli can retrieve the memories of unpleasant experiences and therefore contribute to prolonged chronic LBP conditions?

Here is an example of how our brains can easily be fooled. The lines above are definitely straight yet even though I have told you this and you can take out a ruler to confirm this; still your brain can not help but perceive the lines as being crooked. Our brain rationalizes this because of the particular way the black boxes are stacked on top of each other. How is this related to feeling pain?


Sometimes our brain stacks up experiences and memories in a particular way and automatically perceives our body as being “damaged” (crooked). Even if there is, in fact no damage and the tissues have healed (and are straight), if the brain believes the body is still injured, no matter how much you are told otherwise, the pain can persist.

Reference: Shimo K1, et al Visualization of painful experiences believed to trigger the activation of affective and emotional brain regions in subjects with low back pain. PLoS One. 2011;6(11):e26681.

a back bend
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