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Spatial summation of pain and its meaning to patients

  • Michele Curatolo EMAIL logo
Published/Copyright: October 1, 2017
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 17 Issue 1

Neuro-physiologically, spatial summation occurs when subliminal inputs arising from multiple afferents induce action potentials in neurons. When applied to human pain physiology, this notion supports the observation that non-painful stimuli can induce pain when applied to larger body areas. Accordingly, painful stimuli that are applied to small areas become more painful when the stimulation area is enlarged. The likely pathophysiologic mechanism underlying spatial summation of pain is the convergence of low-intensity input from multiple afferents to common nociceptive pathways, ultimately eliciting a pain sensation after innocuous stimulation or amplifying pain after painful stimulation.

Spatial summation of pain has been extensively studied in human research using different experimental models. Most investigations have confirmed the aforementioned phenomenon of increasing pain sensation with increasing stimulation area [1,2,3]. Interestingly, while spatial summation is particularly strong with stimuli applied within the same dermatome [4], it occurs also when stimuli are applied to different and even contralateral dermatomes [5]. This suggests that spatial integration of nociceptive stimuli occurs not only at spinal cord level, but also at supraspinal centres.

The clinical significance of spatial summation is obvious. Nociceptive input from wide areas or multiple sources are more likely to lead to uncontrolled pain with all related consequences, including disability, mental health co-morbidities and more need for treatment, among others.

The notion of spatial summation is useful for both the health care provider and the patient. Both of them are interested in explanations on the nature of the symptoms. However, knowing this hardly satisfies the need to improve pain management. The next question is therefore: how to make use of this knowledge to improve patient-related outcomes?

The paper by Holbert et al., published in this issue of the Scandinavian Journal of Pain, is an attempt to better understand the role of spatial summation in the pathophysiology of specific pain syndromes [6]. The hypothesis was that spatial summation is more pronounced at the back, compared with other body regions, which would contribute to the higher prevalence of back pain. The hypothesis was not confirmed by the results, indicating that the back is not a particularly vulnerable region in terms of facilitation of spatial summation. Therefore, facilitated spatial summation is an improbable explanation for the high prevalence of back pain.

Translational studies on spatial summation are sparse. One open question is whether high degrees of spatial summation are associated with poor outcomes. Better prediction of outcomes may support clinical decision-making. For instance, one could hypothesize that the higher the spatial summation, the more likely the occurrence of persistent post-surgical pain. The literature on other biomarkers of nociceptive processes is equivocal [7], but studies have shown that facilitated temporal summation is a risk factor of persistent pain after knee surgery [8,9].

Spatial summation reflects central integration of nociceptive stimuli and is attenuated by ketamine [10]. Other centrally-active medications, such as antidepressants and anticonvulsants, have the potential to modulate spatial summation. Therefore, another area of potential research is whether the efficacy of these medications is correlated with the degree of spatial summation. This may allow more targeted treatments. In this regard, the concept of mechanism-based pain treatment has recently received much attention [11]. Unfortunately, also this research has not produced convincing results. Studies on the prediction of drug effects based on sensory phenotypes have not been consistent [12,13,14,15]. Whether spatial summation can contribute to better patient phenotyping for a more individualized pain treatment remains to be determined.

In conclusion, spatial summation of pain likely contributes to the magnitude of pain. Therefore, it has probable clinical relevance. So far, this remains “good to know”. The challenge of future research is to determine whether this knowledge can be used to improve the life of patients with chronic pain.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2017.07.017.

University of Washington – Department of Anesthesiology & Pain Medicine, Box 356540 – 1959 NE Pacific Street, Room BB1421, Seattle, WA 98195-6540, USA

  1. Conflict of interest: None declared.

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Published Online: 2017-10-01
Published in Print: 2017-10-01

© 2017 Scandinavian Association for the Study of Pain

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https://doi.org/10.1016/j.sjpain.2017.07.018

Articles in the same Issue

  1. Observational study
  2. Perceived sleep deficit is a strong predictor of RLS in multisite pain – A population based study in middle aged females
  3. Clinical pain research
  4. Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation
  5. Clinical pain research
  6. The Functional Barometer — An analysis of a self-assessment questionnaire with ICF-coding regarding functional/activity limitations and quality of life due to pain — Differences in age gender and origin of pain
  7. Clinical pain research
  8. Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain
  9. Observational study
  10. Chronic disruptive pain in emerging adults with and without chronic health conditions and the moderating role of psychiatric disorders: Evidence from a population-based cross-sectional survey in Canada
  11. Educational case report
  12. Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study
  13. Clinical pain research
  14. Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain
  15. Observational study
  16. Comparison of patients diagnosed with “complex pain” and “somatoform pain”
  17. Original experimental
  18. Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic
  19. Topical review
  20. New evidence for a pain personality? A critical review of the last 120 years of pain and personality
  21. Clinical pain research
  22. A multi-facet pain survey of psychosocial complaints among patients with long-standing non-malignant pain
  23. Clinical pain research
  24. Pain patients’ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity, and treatment outcome
  25. Observational study
  26. Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy
  27. Clinical pain research
  28. COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients
  29. Original experimental
  30. Quantitative sensory tests fairly reflect immediate effects of oxycodone in chronic low-back pain
  31. Editorial comment
  32. Spatial summation of pain and its meaning to patients
  33. Original experimental
  34. Effects of validating communication on recall during a pain-task in healthy participants
  35. Original experimental
  36. Comparison of spatial summation properties at different body sites
  37. Editorial comment
  38. Behavioural inhibition in the context of pain: Measurement and conceptual issues
  39. Clinical pain research
  40. A randomized study to evaluate the analgesic efficacy of a single dose of the TRPV1 antagonist mavatrep in patients with osteoarthritis
  41. Editorial comment
  42. Quantitative sensory tests (QST) are promising tests for clinical relevance of anti–nociceptive effects of new analgesic treatments
  43. Educational case report
  44. Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl
  45. Editorial comment
  46. Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations
  47. Editorial comment
  48. Opioids in chronic pain – Primum non nocere
  49. Editorial comment
  50. Finally a promising analgesic signal in a long-awaited new class of drugs: TRPV1 antagonist mavatrep in patients with osteoarthritis (OA)
  51. Observational study
  52. The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain
  53. Clinical pain research
  54. Opioid tapering in patients with prescription opioid use disorder: A retrospective study
  55. Editorial comment
  56. Sleep, widespread pain and restless legs — What is the connection?
  57. Editorial comment
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  59. Observational study
  60. Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic
  61. Editorial comment
  62. The burden of central anticholinergic drugs increases pain and cognitive dysfunction. More knowledge about drug-interactions needed
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  64. A case-history illustrates importance of knowledge of drug-interactions when pain-patients are prescribed non-pain drugs for co-morbidities
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  66. Why can multimodal, multidisciplinary pain clinics not help all chronic pain patients?
  67. Topical review
  68. Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics
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  73. Clinical pain research
  74. Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain
  75. Editorial comment
  76. Towards a structured examination of contextual flexibility in persistent pain
  77. Clinical pain research
  78. Context sensitive regulation of pain and emotion: Development and initial validation of a scale for context insensitive avoidance
  79. Editorial comment
  80. Is the search for a “pain personality” of added value to the Fear-Avoidance-Model (FAM) of chronic pain?
  81. Editorial comment
  82. Importance for patients of feeling accepted and understood by physicians before and after multimodal pain rehabilitation
  83. Editorial comment
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  86. Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain
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  97. Clinical pain research
  98. The cognitive impact of chronic low back pain: Positive effect of multidisciplinary pain therapy
  99. Clinical pain research
  100. Central sensitization associated with low fetal hemoglobin levels in adults with sickle cell anemia
  101. Topical review
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  103. Original experimental
  104. What constitutes back pain flare? A cross sectional survey of individuals with low back pain
  105. Original experimental
  106. Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
  107. Clinical pain research
  108. Chronic low back pain and the transdiagnostic process: How do cognitive and emotional dysregulations contribute to the intensity of risk factors and pain?
  109. Original experimental
  110. The impact of the Standard American Diet in rats: Effects on behavior, physiology and recovery from inflammatory injury
  111. Educational case report
  112. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series
  113. Original experimental
  114. Hyperbaric oxygenation alleviates chronic constriction injury (CCI)-induced neuropathic pain and inhibits GABAergic neuron apoptosis in the spinal cord
  115. Observational study
  116. Predictors of chronic neuropathic pain after scoliosis surgery in children
  117. Clinical pain research
  118. Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital
  119. Clinical pain research
  120. A novel miniature, wireless neurostimulator in the management of chronic craniofacial pain: Preliminary results from a prospective pilot study
  121. Clinical pain research
  122. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending
  123. Original experimental
  124. Unpredictable pain timings lead to greater pain when people are highly intolerant of uncertainty
  125. Original experimental
  126. Initial validation of the exercise chronic pain acceptance questionnaire
  127. Clinical pain research
  128. Exploring patient experiences of a pain management centre: A qualitative study
  129. Clinical pain research
  130. Narratives of life with long-term low back pain: A follow up interview study
  131. Observational study
  132. Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption
  133. Clinical pain research
  134. Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
  135. Original experimental
  136. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
  137. Observational study
  138. Impact of analgesics on executive function and memory in the Alzheimer’s Disease Neuroimaging Initiative Database
  139. Clinical pain research
  140. Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [11C]-D-deprenyl PET/CT
  141. Original experimental
  142. Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
  143. Topical review
  144. Psychoneuroimmunological approach to gastrointestinal related pain
  145. Letter to the Editor
  146. Do we need an updated definition of pain?
  147. Narrative review
  148. Is acetaminophen safe in pregnancy?
  149. Book Review
  150. Physical Diagnosis of Pain
  151. Book Review
  152. Advances in Anesthesia
  153. Book Review
  154. Atlas of Pain Management Injection Techniques
  155. Book Review
  156. Sedation: A Guide to Patient Management
  157. Book Review
  158. Basics of Anesthesia
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