PMR 15 - pain Flashcards
Phantom pain is a type of:
a. Neuropathic pain
b. Nociceptive pain
c. Psychogenic pain
d. Somatoform pain
A) Phantom pain is pain from a part of the body that has been lost, or from which the brain no longer receives signals. It is a type of neuropathic pain. Phantom limb pain is a common pain experience of amputees. Whereas phantom sensation is common, phantom pain is not and needs to be treated aggressively. It is often described as shooting, crushing, burning, or cramping.
Allodynia is:
a. Pain resulting from a stimulus that does not normally produce pain
b. An increased painful sensation in response to additional noxious stimuli
c. A decreased sensitivity to painful stimuli
d. The absence of the sense of pain while remaining conscious
A) Allodynia is pain resulting from a ( stimulus that does not normally produce pain. Hyperalgesia is an increased painful sensation in response to additional noxious stimuli. Analgesia is defined as the absence of the sense of pain without losing consciousness and other sensations. Hypoalgesia or hypalgesia is a decreased sensitivity to painful stimuli.
TENS is often used for pain control and is an acronym for:
a. Tension simulator
b. Transcutaneous electrical nerve stimulation
c. Toxic epidermal necrolysis syndrome]
d. Ten stimulation modes
B) TENS stands for transcutaneous electrical nerve stimulation. The TENS unit is a portable device that utilizes electrical stimulation for pain control. It is presumed to decrease pain via the gate controlled theory of pain.
Which type of nerve fibers transmit the first sensation of pain?
a. A delta fibers
b. C fibers
c. A beta fibers
d. B fibers
A) A delta fibers (group Ill fibers) are 2 to
5 mm in diameter, are myelinated, have a fast conduction speed (5-40 meters/sec), and are the first fibers to transmit the sensation of pain.
The World Health Organization (WHO)
recommends a three-step “ladder” for cancer pain relief. In which order should pain medication be administered?
a. Mild opioids, nonopioids, strong opioids
b. Strong opioids, mild opioids, nonopioids
c. Nonopioids, mild opioids, then strong opioids, until the patient is free of pain
d. Mild opioids, strong opioids, surgical intervention
C) Nonopioids, mild opioids, then strong opioids should be the progression until the patient is free of pain.
Complex regional pain syndrome
(CRPS) type lis:
a. Sympathetic-mediated pain limited to a peripheral nerve distribution
b. Reported in 25% of tetraplegic stroke patients
c. Also known as causalgia
d. Also known as reflex sympathetic dystrophy
D) Complex regional pain syndrome
(CRPS) type I is also known as reflex sympathetic dystrophy (RSD) or shoulder-hand syndrome. It is the most common subtype of RSD in stroke patients (reported in about 12%-25% of hemiplegic stroke patients). CRPS type lI, also known as causalgia, is a sympathetic-mediated pain limited to a peripheral nerve distribution.
Which is not an indication for spinal cord stimulator (SCS) implantation?
a. Complex regional pain syndrome (CRPS)
b. Peripheral vascular disease (PVD)
C. Nonischemic nociceptive pain
d. Failed back surgery syndrome (FBSS)
C) Indications for SCS include CRPS, inoperable ischemic limb pain, PVD, FBSS, and angina pectoris.
Which nerve innervates the L4/L5 facet joint?
a. L2 and L3 medial branches
b. L3 and L4 medial branches
C. L4 and L5 medial branches
d. L4 dorsal ramus
B) Each lumbar and thoracic facet joint (except L5/S1 facet joint) is innervated by the medial branches of dorsal rami exiting at the same level and one level above. The LA/L5 facet-joint is innervated by the L3 and L4 medial branches.
Which intervention may be used for diagnosis of facet joint-mediated pain?
a. Fluoroscopically guided facet joint injection
b. Interlaminal epidural injection
c. Fluoroscopically-guided medial branch ablation
d. Transforminal epidural injection
A) Both fluoroscopically guided facet joint injection and fluoroscopically guided medial branch block (not ablation) may be used to confirm the diagnosis of facet joint-mediated pain. After confirmation of the diagnosis, fluoroscopically guided medial branch ablation is usually performed for treatment.
A “sharp,” “burning,” “electric-like,” or
“skin-sensitive” pain at the end of a residual limb is called:
a. Phantom pain
c. Neuroma
b. Stump pain
d. Causalgia
B) Amputation residual limb pain is a
*sharp,” “burning,” “electric-like,” or
“skin-sensitive” pain at the end of an amputated residual limb. Unlike phantom pain, it occurs in the actual existing body part. Residual limb pain is due to a damaged nerve in the residual limb region, sometimes with neuroma formation. A neuroma can cause pain and skin sensitivity. Causalgia should present with other sympathetic-mediated symptoms, such as swelling, hyper- or hypothermia, or sweating in the acute stage.
Which of the following statements is not true regarding facet joint-mediated pain?
a. Rehabilitation should be focused on exercises with neutral or flexion posture to reduce stress
on facet ioints
b. Diagnostic use of facet joint nerve blocks and therapeutic radiofrequency ablation are treatment options
C. To minimize the false-positive response that occurs with one injection, two separate blocks using different-duration aesthetics are recommended
d. Facet joint-mediated pain is likely elicited on flexion or repetitive end-range flexion
D) Rehabilitation exercises are performed primarily with the spine in a neutral posture or in flexion to reduce stress on facet joints. Spine stabilization, core stabilization exercises, posture correction, and a strengthening program to restore functional movements should be initiated. Facet joint-mediated pain is often elicited on extension or with rotation-extension combined movements. Point tenderness may occur in the paravertebral regions. Diagnostic facet ioint nerve blocks and therapeutic radiofrequency ablation are also treatment options, if indicated.
6-monoacetylmorphine is a unique metabolite of which substance?
a. Oxycontin
b. Codeine
c. Heroin
d. Cocaine
C) There are three active metabolites of heroin (diacetylmorphine): 6-monoacetylmorphine (6-MAM), morphine, and the much less active 3-
monoacetylmorphine (3-MAM). 6-MAM is then either metabolized into morphine or excreted in the urine. Since 6-MAM is a unique metabolite of heroin, its presence in the urine confirms that heroin was used by the patient.
Which sympathetic block can be performed for pelvic visceral pain?
a. Stellate-ganglion block
b. Celiac plexus block
c. Hypogastric plexus block
d. Lumbar sympathetic block
C) Hypogastric plexus block can be effective for pelvic visceral pain. Celiac plexus blocks can be used for upper abdominal visceral pain. Stellate-ganglion block is used in sympathetically maintained upper extremity pain. Lumbar sympathetic block is effective in sympathetically mediated lower extremity pain.
The cell bodies of first-order, or primary, thoracic visceral pain fibers are found in:
a. Dorsal root ganglion
b. Trigeminal ganglion
c. Mesenteric ganglion
d. Inferior cervical ganglion
A) The cell bodies of first-order, or primary, pain fibers are located in either the dorsal root ganglia or the trigeminal ganglia. The trigeminal ganglia are A specialized nerves for the face, whereas the dorsal root ganglia provide sensory innervation for the rest of the body.
The initial gate control theory by Melzack and Wall proposed that stimulation of
fibers modulates
the dorsal horn “gate” and therefore reduces the nociceptive input from the periphery.
a. A beta
b. B
c. C
d. A delta
A) The initial gate control theory by Melzack and Wall published in Science in 1965 indicated that stimulation of large diameter A beta fibers modulated the dorsal horn “gate” and therefore reduced the nociceptive input from periphery.
Which of the following is not an application based on the gate control theory?
a. Spinal cord stimulation
b. Massage
C. Transcutaneous electrical nerve stimulation (TENS)
d. Medial branch block
D) The gate control theory was proposed by Melzack and Wall in the mid-1960s. The concept of the gate control theory is that nonpainful input can override painful input by “closing the gate of control,” which results in suppression of pain. In medial branch block, the peripheral pain signal input is simply blocked with injected anesthetic medication.
C fibers are:
a. Small myelinated fibers responding to high-intensity mechanical stimulation
b. Large myelinated fibers that transmit temperature sensation
c. Small unmyelinated fibers that transmit burning pain
d. Large unmyelinated fibers that transmit noxious information from a variety of modalities
C) A sharp, pricking, stinging pain sensation caused by a needle, pin prick, or a skin cut is transmitted by the A delta fibers. Burning pain caused by inflammation or burned skin is transmitted by C fibers.
Nociceptors are:
a. Pacinian corpuscles
b. Meissner corpuscles
c. Merkel’s disks
d. Free nerve endings
D) Nociceptors are free nerve endings that transmit the sensation of pain. There are thermal, chemical, and mechanical nociceptors for various stimuli.
What is the pain wind-up phenomenon?
a. Increased pain intensity by repeated stimulation
b. Recruitment of silent nociceptors after tissue injury causing increased pain intensity
c. Increased muscle tone caused by severe pain
d. Central sensitization caused by repeated stimulation of nociceptive C fibers
D) Pain wind-up is a phenomenon caused by repeated stimulation of peripheral nerve fibers, leading to progressively increasing electrical response in the second-order neurons. The process is also termed as central sensitization, which leads to hyperalgesia, allodynia, and spontaneous pain.
is an oral analogue of lidocaine used in the treatment of neuropathic pain.
a. Mexiletine
b. Ketamine
c. Pregabalin
d. Amitriptyline
A) Mexiletine is an orally active local anesthetic, antiarrhythmic agent, that is structurally similar to lidocaine and considered an oral analogue of lidocaine for neuropathic pain treatment. Ketamine is the most commonly used NMDA antagonist for neuropathic pain.
Pregabalin (Lyrica), similar to gabapentin (Neurontin), binds to the alpha2delta subunit of the voltage-dependent calcium channel in the central nervous system. It decreases the release of neurotransmitters such as glutamate, noradrenaline, and gamma-aminobutyric acid. Amitriptyline (Elavil) is a tricyclic antidepressant (TCA) used for neuropathic pain.
Which of the following statements is not true regarding central poststroke pain (CPSP)?
a. CPSP develops in 8% of stroke patients
b. Functional magnetic resonance imaging (fMRI) is required for the diagnosis of CPSP
c. Pain is characterized most often as a burn
d. There is no intervention proven to alter the development of CPSP
B) CPSP is a central neuropathic pain syndrome that can occur after stroke in the part of the body that corresponds to the cerebrovascular lesion. It develops in 8% of stroke patients. Elimination of other causes of pain after stroke must occur before diagnosing CPSP, since CPSP is a diagnosis of exclusion. Pain is characterized most often as a burn; however, aching, pricking, lacerating, shooting, squeezing, throbbing, and heaviness are all possible qualitative descriptors.
Which of the following is not true regarding fibromyalgia?
a. The peak prevalence is age 55 to 64
b. Tenderness to finger pressure must be present in at least 5 of 10. tender point sites
c. No specific etiology has been identified
d. Fibromyalgia is more common among women than men
B) Fibromyalgia is more common among women than men. The average age of onset of fibromyalgia is between 30 and 50, with peak prevalence among women age 55 to 64. No specific etiology has been identified. Tender points (tenderness to approximately 4 kg/ square inch which is about the pressure required to blanch the examiner’s nail bed must be present in at least 11 of 18 specific sites
Which of the following is true regarding discogenic lumbar pain?
a. There is strong familial predisposition to discogenic lumbar pain
b. Intradiscal pressures increase when one changes his/her position from sitting to standing
c. There is a strong association between discogenic lumbar pain and alcoholism
d. For non-radicular low back pain with degenerative disk disease, fusion appears to have a superior outcome when compared with standard nonsurgical therapy and also be better than intensive interdisciplinary rehabilitation
A) There is strong familial
predisposition to discogenic lumbar pain.
Discogenic pain is also associated with , advanced age, male sex, and smoking.
Intradiscal pressure is higher in the sitting position than in the standing position. For nonradicular low back pain with degenerative disk disease, fusion does not appear to be better than intensive interdisciplinary rehabilitation.
Which statement is not true regarding migraine?
a. Analgesic overuse is associated with an increased risk of chronic pain
b. Migraine can be induced by sildenafil
c. The severity and frequency of attacks tend to increase with increasing age
d. Migraine is associated with an increased risk of developing myocardial infarction in men
C) The severity and frequency of migraine attacks tend to decrease with increasing age. The other answers are all true.
Opioid receptors belong to the family.
a. G-protein-coupled receptor
b. NMDA receptor
c. AMPA receptor
d. GABA receptor
A) There are three distinct opioid receptors-mu, delta, and kappa. All of these receptors belong to the G-protein-coupled receptor family, with cAMP acting as an intracellular second messenger.
What is the goal of chronic pain management?
a. Decrease the use of medications
b. Enable people with pain to function better and enjoy daily activities
c. Eliminate pain
d. Help people with pain return to their previous work
B) The goal of chronic pain management is to help people with pain function better and live rewarding lives. Often the pain can be reduced, but not eliminated.
Which of the following is not recommended as a first-line medication for low back pain?
a. Acetaminophen
b. Naproxen
c. Tramadol
d. Meloxicam
C) For most patients with low back pain, regardless of the duration of symptoms, acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line options for pain relief.
A 70-year-old man presents to you 1 year after a stroke with complaint of severe, persistent, paroxysmal, often intolerable pain on the hemiplegic side, which is not responsive to any analgesic treatment. Before looking at his old imaging studies, you suspect that the patient’s stroke affected which of the following areas of his brain:
a. Medulla
b. Substantia nigra
c. Thalamus
d. Globus pallidus
C) Central pain syndrome (CPS; also called thalamic pain syndrome or Dejerine-Roussy syndrome) is most commonly preceded by numbness on the affected side, which is later replaced by a burning and tingling sensation. CPS can be severe and debilitating, presenting at times with hypersensitivity to touch. Less commonly, some patients develop severe ongoing pain with little or no stimuli. The thalamus is thought to play a major role in relaying sensory/ pain information between a variety of subcortical areas and the cerebral cortex.
Pregabalin (Lyrica) and gabapentin (Neurontin) work by blocking specific _________ channels on neurons and are preferred first-line medications for
diabetic neuropathy.
a. Sodium
b. Calcium
c. Potassium
d. Magnesium
B) Medications such as pregabalin and gabapentin work by blocking calcium channels and have been shown to decrease neuropathic pain.
The anticonvulsants carbamazepine (Tegretol) and oxcarbazepine (Trileptal) are especially effective in trigeminal neuralgia. The actions of these two drugs are mediated principally through _________ channels.
a. Sodium
b. Calcium
c. Potassium
d. Magnesium
A) These two medications affect the sodium channels and help to reduce neuropathic pain, especially trigeminal neuralgia.
A 75-year-old man presents to you 3 months after sustaining a stroke, with resulting right-sided weakness. He complains of pain over his right shoulder and decreased range of motion. Scarf sign is positive. The patient is noted to have decreased range of motion in all planes. The most likely diagnosis is:
a. Rotator cuff syndrome
b. Adhesive capsulitis
c. Shoulder dislocation
d. Glenohumeral subluxation
B) Adhesive capsulitis occurs when the connective tissue around the glenohumeral joint becomes inflamed. This leads to pain, stiffness, and decreased range of motion. People with a history of a stroke, diabetes, lung and heart disease are at a higher risk for developing adhesive capsulitis.
A 55-year-old man who works in construction presents with pain over his upper back. He states that he bent over to lift a heavy object and felt a sharp pain midline. On examination, he has obvious spasm with tenderness to palpation over his paravertebral muscles in the region of T7-T9. Neurological examination is within normal limits. You make the diagnosis of:
a. Discitis
b. Thoracic radiculopathy
C. Vertebral fracture
d. Thoracic sprain/strain
D) Thoracic sprain/strain usually occurs with heavy lifting or excessive repetitive motion. Sprain refers to injury to ligaments, whereas strain refers to injury to muscle. Sprain/ strain commonly presents with pain and muscle spasm. The neurological examination should be normal.
