Name: Demonstration of Cutaneous Allodynia in Association with Chronic Pelvic Pain (Video) | JoVE Journal
Uploaded: 2009-06-23T00:00:00.000+00:00
Duration: 6 min 44 s
Description: Learn a bedside test for cutaneous allodynia to identify chronic pain states in patients with pelvic conditions. This method helps distinguish chronic pain from disease recurrence using simple clinical assessment.

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5 minutes

Introduction
In most cases the areas of cutaneous allodynia will be identified in the dermatomes of the abdomen and perineum that innervate the intra-pelvic structures &ndash; T11-L1 and S3,4,5 respectively. The term allodynia refers to the presence of a painful sensation as a consequence of a stimulus that is not normally painful, in this case a cotton-tipped culture stick.
1. Abdomen
<ol>
<li>An explanation of the test is undertaken and permission to procede is obtained.</li>
<li>The woman exposes the abdomen from the rib cage to the region of the pubic bone.</li>
<li>A cotton-tipped culture stick is shown to the woman and brushed against her hand to demonstrate how the light pressure will feel.</li>
<li>The woman is asked to note the point at which light pressure applied to the skin becomes sharp as the cotton-tipped culture stick is drawn down the abdominal wall.</li>
<li>The cotton-tipped culture stick is then lightly drawn down the abdomen and the woman will either note the presence of no change in sensation or will note a sudden and discrete sharpness in sensation. The process is repeated until the entire area of cutaneous allodynia has been identified. A positive test is defined by the presence of this sudden sharp sensation.</li>
<li>In some cases the areas are large but in others they will be small. They can be unilateral but usually will be bilateral.</li>
</ol>
2. Perineum
<ol>
<li>An explanation of the test is undertaken and permission to procede is obtained.</li>
<li>The woman exposes the perineum in the lithotomy position.</li>
<li>A cotton-tipped culture stick is shown to the woman and brushed against her hand to demonstrate how the light pressure will feel.</li>
<li>The woman is asked to note the point at which light pressure applied to the skin becomes sharp as the cotton- tipped culture stick is drawn across the perineum.</li>
<li>The cotton-tipped culture stick is then drawn across the buttocks horizontally in a direction from the lateral aspect of the buttock to toward the anus to cut across the S3 dermatome. The process is repeated on the contralateral side. Additionally the cotton-tipped applicator can be drawn from the region of the labia majora in a directly posterior direction, avoiding the vaginal area. A positive test is defined by the presence of a sudden sharp sensation.</li>
<li>On the perineum, the area usually describes the S# dermatome when positive. Positive results can be seen unilaterally as well but less commonly.</li>
</ol>

<ol><li>Giamberardino, M. A., Affaitati, G., Lerza, R., Lapenna, D., Costantini, R., Vecchiet, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Relationship+between+pain+symptoms+and+referred+sensory+and+trophic+changes+in+patients+with+gallbladder+pathology%5BTitle%5D)+AND+%22Pain%22%5BJournal%5D)">Relationship between pain symptoms and referred sensory and trophic changes in patients with gallbladder pathology.</a> Pain. 114 (1-2), 239-249 (2005).</li>
<li>Giamberardino, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Women+and+visceral+pain%3A+are+the+reproductive+organs+the+main+protagonists%3F+Mini-review+at+the+occasion+of+the+%26quot%3BEuropean+Week+Against+Pain+in+Women+2007%5BTitle%5D)+AND+%22Eur+J+Pain%22%5BJournal%5D)">Women and visceral pain: are the reproductive organs the main protagonists? Mini-review at the occasion of the &quot;European Week Against Pain in Women 2007.</a> Eur J Pain. 12 (3), 257-260 (2008).</li>
<li>Baranauskas, G., Nistri, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Sensitization+of+pain+pathways+in+the+spinal+cord%3A+cellular+mechanisms%5BTitle%5D)+AND+%22Prog+Neurobiol%22%5BJournal%5D)">Sensitization of pain pathways in the spinal cord: cellular mechanisms.</a> Prog Neurobiol. 54 (3), 349-365 (1998).</li>
</ol>

The presence of cutaneous allodynia indicates the woman has had severe pain in the past to the extent that neuropathic changes have occurred. Although the problem may have originated from dysmenorrhea or endometriosis, a new condition has emerged &ndash; Chronic Pelvic Pain. The original condition may be active or quiescent. Recognition of this new development is important for patient education and to initiate processes of rehabilitative care. Recognition of the development of this state may also permit the clinici...

demonstration of cutaneous allodynia in association with chronic pelvic pain

Demonstration of Cutaneous Allodynia in Association with Chronic Pelvic Pain

Pelvic pain is a common condition that is associated with dysmenorrhea and endometriosis. In some women the severe episodes of cyclic pain change and the resultant pain becomes continuous and this condition becomes known as Chronic Pelvic Pain. This state can be present even after the appropriate medical or surgical therapy has been instituted. It can be associated with pain and tenderness in the muscles of the abdomen wall and intra-pelvic muscles leading to severe dyspareunia. Additional symptoms of irritable bowel and interstitial cystitis are common. A common sign of the development of this state is the emergence of cutaneous allodynia which emerges from the so-called viscero-somatic reflex. A simple bedside test for the presence of cutaneous allodynia is presented that does not require excessive time or special equipment. This test builds on previous work associated with changes in sensation related to gall bladder function and the viscera-somatic reflex(1;2).
The test is undertaken with the subject s permission after an explanation of how the test will be performed. Allodynia refers to a condition in which a stimulus that is not normally painful is interpreted by the subject as painful. In this instance the light touch associated with a cotton-tipped applicator would not be expected to be painful. A positive test is however noted by the woman as suddenly painful or suddenly sharp. The patterns of this sensation are usually in a discrete pattern of a dermatome of the nerves that innervate the pelvis.
The underlying pathology is now interpreted as evidence of neuroplasticity as a consequence of severe and repeating pain with changes in the functions of the dorsal horns of the spinal cord that results in altered function of visceral tissues and resultant somatic symptoms(3). 
The importance of recognizing the condition lies in an awareness that this process may present coincidentally with the initiating condition or after it has been treated. It also permits the clinician to evaluate the situation from the perspective that alternative explanations for the pain may be present that may not require additional surgery.

A demonstration of the bedside test for cutaneous allodynia and its clinical implications.

Pelvic pain is a common condition that is associated with dysmenorrhea and endometriosis.  In some women the severe episodes of cyclic pain change and the ...

Hi, I am John Gerald. I'm a professor of obstetrics and Gynecology at the Calgary Chronic Pain Center in the Department of Obstetrics and Gynecology at the University of Calgary in Calgary, Canada. Today we'll show you a procedure for identifying the presence of cutaneous allodynia on the abdomen and perineum.We use this test to identify when a patient has developed a chronic pain state. This chronic pain state can occur after the development of a disease and after the treatment of the disease. And it's helpful for us to recognize this chronic pain state as it may indicate that it doesn't necessarily mean that there's been a recurrence of the disease that's causing the patient's pain.Our patient today is a 22-year-old mother of one who's had pain for approximately 10 years from severe dysmenorrhea before she came to the clinic. This patient has had nine laparoscopies, including a laparoscopically assisted vaginal hysterectomy. These were all done for endometriosis, although she has had endometriosis.This patient's problem now is primarily chronic pain state as evidenced by the cutaneous allodynia. She's currently on MS.Contin 75 milligrams twice a day, and gabapentin 1200 milligrams three times a day. And we're in the process of shifting her from the MS contin to methadone.So today we're going to show you how to use the simple instrument that's available in any doctor's office to assess cutaneous allodynia. So let's get started. To begin the testing procedure, a cotton tipped culture stick is shown to the patient and brushed against her hand to demonstrate how the light pressure will feel on the abdomen.Next, the patient is asked to note the point at which light pressure applied to the skin on the abdomen becomes painful. Okay, so I'm gonna run this Q-tip down your tummy, and you tell me when it gets sharp.Okay? Okay.The culture stick is then lightly drawn down the abdominal wall.As the culture stick is drawn down the abdomen, the patient will either note the presence of no change in sensation or a sudden and discreet sharpness in sensation. This process is repeated until the entire area of cutaneous allodynia has been tested. A positive test is defined by the presence of a sudden sharp sensation.Well, Stacey's layer used to run about here, which is about T 11, but it's now moving up and it's becoming higher in the level in the thoracic dermatome section. It extends down as far as probably L two in this, in the lower segment, and that's expanded as well. It used to run about in this duration in this area like this, but as her pain's been getting worse, so the areas of cutaneous adenia, The areas that test positive on the abdomen can be large or small and are most commonly bilateral in nature.Okay, so this area is quite large in this patient's abdomen, but it's highly variable. In some cases, individuals will have only dime shaped areas, usually around here that are quite painful to touch. They can be unilateral or they can be bilateral.They can be dumbbell shaped, but ordinarily they're sort of semi-circular and down to about L one. And they also are variable, depending upon whether or not there's a scar present as well. But ordinarily, they can start as very small areas and then expand to include both sides.With abdominal testing completed, we can begin testing the peroneum. When the patient is ready to proceed. The cotton tipped culture stick is again shown to the patient and brushed against her hand to demonstrate how the light pressure will feel on the perineum.The patient is then asked to note the point at which light pressure applied to the skin becomes painful, and the culture stick is lightly drawn across the perineum. Okay, I'm just gonna run this across your bottom and just tell me when it becomes sharp.Okay. Right There.During testing of the perineum, the culture stick is drawn across the buttocks in a horizontal direction, going from the lateral aspect of the buttock toward the anus to cut across the S3 dermatome, the process is repeated On the contralateral side, the culture stick is then drawn in a posterior direction from the region of the labia majora, avoiding the vaginal area. A positive test is defined by the presence of a sudden sharp sensation on the perineum. A positive result is most commonly seen bilaterally.On the S3 dermatome, We've just shown you how to identify the presence of cutaneous allodynia and the emergence of a chronic pain state. It's important to remember that this chronic pain state can occur as a consequence of active pelvic disease, such as endometriosis, or it may actually be present after the endometriosis has been treated. It can also be present with a reactivation of endometriosis.The value of a positive test is that it may offer an alternative explanation for the cause of the patient's pain that does not necessarily require surgery. So that's it. Thanks for watching and good luck with your approach to chronic pelvic pain.

demonstration-cutaneous-allodynia-association-with-chronic-pelvic

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Learn a bedside test for cutaneous allodynia to identify chronic pain states in patients with pelvic conditions. This method helps distinguish chronic pain from disease recurrence using simple clinical assessment.

Demonstration of Cutaneous Allodynia in Association with Chronic Pelvic Pain

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