Temporal Summation
- Dr. Brian Abelson
- Jun 19
- 6 min read
Updated: 5 days ago
Temporal Summation: A Gateway to Understanding Chronic Pain
Temporal summation refers to the nervous system's tendency to amplify pain when sensory input is repeated in rapid succession. Also known as the "wind-up" phenomenon, this process is central to the concept of central sensitization, where the nervous system becomes hypersensitive to both painful and non-painful stimuli. Think of it like turning up the volume each time you hear the same sound—eventually, even a whisper becomes deafening. In the context of chronic pain, understanding temporal summation can help bridge the gap between tissue pathology and a patient's lived experience of persistent, exaggerated pain.
Article Index
Mechanisms Behind Temporal Summation
Repeated Nerve Fiber Stimulation Rapid activation of C-fiber sensory neurons, before they fully recover, causes signals to accumulate. This repeated input intensifies the central response to stimuli, even when the stimulus remains constant.
Role of NMDA Receptors NMDA (N-methyl-D-aspartate) receptors in the spinal cord are critically involved. When repeatedly stimulated, these receptors become sensitized—removing the normal "brake" (magnesium block) and enhancing signal transmission, leading to amplified pain perception over time.
Normal vs. Pathological Response In acute pain, temporal summation helps detect persistent or dangerous stimuli (e.g., heat or pressure). In chronic conditions, this system malfunctions, so even harmless input (light touch or pressure) can provoke significant pain.
Clinical Relevance and Real-World Examples
Fibromyalgia Patients often show exaggerated temporal summation during simple thermal or pressure testing. A mildly warm stimulus applied repeatedly may feel burning or intolerable in seconds.
Chronic Low Back Pain Those with high wind-up responses during experimental testing often report greater movement-related pain and poorer outcomes in functional assessments.
Osteoarthritis Studies reveal that temporal summation correlates with reported joint pain severity, even when imaging shows minimal structural damage, highlighting the role of central mechanisms.
Post-Surgical Pain Elevated temporal summation before surgery may predict the development of chronic postoperative pain, making it a valuable risk assessment tool.
How Practitioners Assess Temporal Summation
Repeated Stimuli – Apply pressure, pinpricks, or thermal pulses at controlled intervals (usually 0.3–3 Hz).
Subjective Pain Rating – Patients rate pain intensity over time. An increase indicates temporal summation.
Clinical Insight – High temporal summation often reflects central sensitization and may call for treatment beyond tissue-based strategies.
Article Index
Implications for Treatment
Pain Neuroscience Education (PNE) Teaching patients about pain biology helps reconceptualize their experience, reducing fear and improving engagement in active care.
Graded Motor Imagery & Exercise Carefully progressing movement and sensory input can desensitize neural pathways and help restore normal processing.
Manual Therapy Spinal manipulation and myofascial techniques may reduce exaggerated neural responses and restore sensorimotor integration.
Pharmacological Interventions NMDA antagonists have shown short-term benefits in reducing central sensitization in some chronic pain conditions like fibromyalgia.
Conclusion
Temporal summation is more than a laboratory curiosity; it’s a window into how chronic pain behaves in the real world. Recognizing and addressing this phenomenon empowers practitioners to move beyond structural explanations and embrace a more integrated, neurophysiological model of care. For patients, understanding that their heightened pain response is not “in their head” but rooted in genuine nervous system changes provides both validation and hope. Targeting temporal summation opens doors to effective, evidence-informed interventions that go far beyond simply treating the site of pain.
References
Arendt-Nielsen, L., & Petersen-Felix, S. (1995). Wind-up and neuroplasticity in the central nervous system: Implications for the pathophysiology of chronic pain. European Journal of Anaesthesiology Supplement, 10, 17–20.
Staud, R., Vierck, C. J., Cannon, R. L., Mauderli, A. P., & Price, D. D. (2001). Abnormal sensitization and temporal summation of second pain (wind-up) in patients with fibromyalgia syndrome. Pain, 91(1-2), 165–175.
Vierck, C. J., Cannon, R. L., Fry, G., Maixner, W., & Whitsel, B. L. (1997). Characteristics of temporal summation of second pain sensations elicited by brief contact stimuli. Journal of Neurophysiology, 78(2), 992–1002.
Eide, P. K. (2019). Wind-up and the NMDA receptor complex from a clinical perspective. Frontiers in Neuroscience, 13, 1253.
Staud, R., Weyl, E. E., Riley, J. L., & Fillingim, R. B. (2014). Slow temporal summation of pain for assessment of central pain sensitivity and clinical pain of fibromyalgia patients. PLoS ONE, 9(2), e89086.
Overstreet, D. S., et al. (2021). Temporal summation of pain predicts functional disability and pain catastrophizing in chronic low back pain. BMC Musculoskeletal Disorders, 22(1), 325.
Yarnitsky, D. (2010). Role of endogenous pain modulation in chronic pain mechanisms and treatment. Pain, 152(2), S9–S15.
Curatolo, M., Arendt-Nielsen, L., & Petersen-Felix, S. (2006). Central hypersensitivity in chronic pain: Mechanisms and clinical implications. Physical Medicine and Rehabilitation Clinics of North America, 17(2), 287–302.
Moana-Filho, E. J., et al. (2014). Orofacial pain sensitivity does not predict onset of temporomandibular disorder. Journal of Dental Research, 93(7 Suppl), 47S–53S.
Noppers, I. M., et al. (2010). Ketamine for the treatment of chronic non-cancer pain: A review. European Journal of Pain, 14(5), 466–472.
DR. BRIAN ABELSON, DC. - The Author
With over 30 years of clinical experience and having treated more than 25,000 patients, Dr. Brian Abelson is the creator of the Motion Specific Release (MSR) Treatment Systems—a powerful, evidence-based approach designed to achieve effective, lasting results.
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