PMR 15 - pain

Question 1

Phantom pain is a type of:
a. Neuropathic pain
b. Nociceptive pain
c. Psychogenic pain
d. Somatoform pain

Answer 1

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.

Question 2

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

Answer 2

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.

Question 3

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

Answer 3

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.

Question 4

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

Answer 4

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.

Question 5

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

Answer 5

C) Nonopioids, mild opioids, then strong opioids should be the progression until the patient is free of pain.

Question 6

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

Answer 6

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.

Question 7

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)

Answer 7

C) Indications for SCS include CRPS, inoperable ischemic limb pain, PVD, FBSS, and angina pectoris.

Question 8

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

Answer 8

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.

Question 9

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

Answer 9

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.

Question 10

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

Answer 10

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.

Question 11

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

Answer 11

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.

Question 12

6-monoacetylmorphine is a unique metabolite of which substance?
a. Oxycontin
b. Codeine
c. Heroin
d. Cocaine

Answer 12

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.

Question 13

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

Answer 13

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.

Question 14

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

Answer 14

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.

Question 15

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

Answer 15

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.

Question 16

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

Answer 16

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.

Question 17

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

Answer 17

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.

Question 18

Nociceptors are:
a. Pacinian corpuscles
b. Meissner corpuscles
c. Merkel’s disks
d. Free nerve endings

Answer 18

D) Nociceptors are free nerve endings that transmit the sensation of pain. There are thermal, chemical, and mechanical nociceptors for various stimuli.

Question 19

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

Answer 19

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.

Question 20

is an oral analogue of lidocaine used in the treatment of neuropathic pain.
a. Mexiletine
b. Ketamine
c. Pregabalin
d. Amitriptyline

Answer 20

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.

Question 21

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

Answer 21

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.

Question 22

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

Answer 22

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

Question 23

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

Answer 23

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.

Question 24

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

Answer 24

C) The severity and frequency of migraine attacks tend to decrease with increasing age. The other answers are all true.

Question 25

Opioid receptors belong to the family. a. G-protein-coupled receptor b. NMDA receptor c. AMPA receptor d. GABA receptor

Answer 25

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.

Question 26

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

Answer 26

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.

Question 27

Which of the following is not recommended as a first-line medication for low back pain? a. Acetaminophen b. Naproxen c. Tramadol d. Meloxicam

Answer 27

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.

Question 28

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

Answer 28

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.

Question 29

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

Answer 29

B) Medications such as pregabalin and gabapentin work by blocking calcium channels and have been shown to decrease neuropathic pain.

Question 30

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

Answer 30

A) These two medications affect the sodium channels and help to reduce neuropathic pain, especially trigeminal neuralgia.

Question 31

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

Answer 31

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.

Question 32

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

Answer 32

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.

Question 33

A 60-year-old obese woman presents to you for initial evaluation of left lower extremity pain, associated with numbness and tingling. She states that the pain is located in the posterior thigh and radiates down to the calf. The patient is having a difficult time with toe walking. On the basis of her description, you expect which of the following nerve roots to be involved? a. L4 b. L5 c. S1 d. S2

Answer 33

C) S1 affects sensation in the posterior thigh and calf. Toe walking is affected because the gastrosoleus muscle is affected.

Question 34

A 45-year-old man with diabetes mellitus presents to you complaining of severe pain over his right thigh, difficulty ambulating, and leg weakness. He states that the pain started suddenly around his inguinal area. At first, pain was dull and aching, but then intensified within 2 hours, and became severe and debilitating. He does not recall any trauma to the area. He also complains of associated numbness over the right anterior thigh and medial leg. You make a diagnosis of: a. Lumbar radiculopathy b. Polymyalgia rheumatica C. Avascular necrosis of femoral head d. Diabetic amyotrophy

Answer 34

D) Diabetic amyotrophy is the most common cause of focal femoral neuropathy. The onset is sudden, pain is debilitating, and patients often exhibit difficulty with ambulation.

Question 35

A college football player presents for initial evaluation of left anterior thigh pain. He states that he was hit by a blunt force on his anterior thigh earlier in the day. On exam, you note that his thigh is warm to touch and is swollen, and the patient has difficulty flexing his knee. He had an x-ray of the area that only showed soft tissue swelling. You make the diagnosis of: a. Quadriceps muscle contusion b. Compartment syndrome c. Fracture of the femur d. Hamstrings tear

Answer 35

A) Contusions to muscular structures are common after blunt trauma. X-ray will be negative for acute fractures, but will show soft-tissue swelling. Patients will usually present with pain, swelling, and difficulty with range of motion.

Question 36

The phenomenon when an initial dose of a substance loses its effectiveness over time, requiring a higher dose to achieve that same effect is known as: a. Dependence b. Addiction c. Tolerance d. Withdrawal

Answer 36

C) Tolerance.

Question 37

Occipital neuralgia refers pain in the distribution of the: a. Temporal nerve b. Lingual nerve C. Greater and lesser occipital nerves d. Facial nerve

Answer 37

C) Occipital neuralgia is usually caused by an entrapped nerve root at the neck, usually C2 level, supplying the greater and lesser occipital nerves. At times, the nerve can be entrapped more cephalad, as the nerve courses through muscles in the neck or the posterior scalp. Patients will present with shooting pain and/or scalp hypersensitivity to light touch.

Question 38

A 34-year-old woman with multiple sclerosis presents to your office with facial pain. The pain is described as stabbing, electric pain, is unilateral over the jaw, and is intermittent. What is the most likely diagnosis? a. Occipital neuralgia b. Trigeminal neuralgia c. Osteonecrosis of jaw d. Osteomyelitis

Answer 38

B) The trigeminal nerve supplies sensation over the jaw. Trigeminal neuralgia causes neuropathic pain, is more common in women, multiple sclerosis patients, and is described as a sharp, electric pain. It is usually unilateral and intermittent.

Question 39

A 24-year-old man presents to you with right forearm pain. He states that the pain began 6 months ago, after an elevator door closed on his right forearm. On exam, the right forearm has shiny skin, with decreased hair growth, and the area is very tender to touch. You make a presumptive diagnosis of: a. Cellulitis b. Scleroderma c. Complex regional pain syndrome d. Synovitis

Answer 39

C) Complex regional pain syndrome (CRPS) is a pain syndrome, usually preceded by an inciting event, either trauma or a period of immobilization. It is associated with a hyperactive sympathetic nervous system. It is characterized by intense pain and sensitivity to light touch, with both nociceptive and neuropathic features. Swelling and excessive or lack of hair growth when compared with the other extremity is usually noted.

Question 40

A 30-year-old man presents to you for initial evaluation of intermittent headaches. The headache is unilateral and is associated with lacrimation and ptosis. The most likely diagnosis is: a. Classic migraine b. Cluster headache c. Tension headache d. Shingles

Answer 40

B) Cluster headaches usually present as a sharp unilateral headache, are localized to the orbital area, and are far more common in men than in women. To diagnose cluster headaches, one of the following autonomic signs must be present during the headache on the same side as the headache: lacrimation, ptosis, miosis, rhinorrhea, or conjunctival injection.

Question 41

10 liters of 100% oxygen at the onset of headache has been shown to be effective in treating: a. Classic migraine b. Cluster migraine c. Tension headache d. Shingles

Answer 41

B) Cluster migraine.

Question 42

The most common level of cervical facet joint-mediated pain is: a. C1-C2 b. C2-C3 c. C3-C4 d. C4-C5

Answer 42

B) The most common symptomatic level of cervical facet (zygapophyseal) joint pain determined by controlled diagnostic block is C2-C3. The prevalence of C2-C3 facet joint pain has been estimated to be 50% to 53% in patients whose chief complaint is posterior headache after whiplash injury.

Question 43

A patient presents with pain over the lateral aspect of his elbow. The examiner fully extends the patient's elbow, pronates the forearm, and asks the patient to make a fist. He then resists the patient's attempt to extend and radially deviate the wrist, eliciting pain over the lateral elbow. This test is known as: a. Hawkin's test b. Watson's test c. Cozen's test d. Yergason's test

Answer 43

C) Cozen's test.

Question 44

The most common location for an interdigital (Morton's) neuroma is between which of the following metatarsal heads? a. 1st and 2nd b. 2nd and 3rd c. 3rd and 4th d. 4th and 5th

Answer 44

C) 3rd and 4th.

Question 45

The lifetime prevalence of low back pain has been shown to be as high as: а. 95% b. 84% c. 73% d. 66%

Answer 45

B) 84%.

Question 46

Which of the following structures lacks innervation and therefore cannot transmit pain? a. Anterior vertebral body b. Posterior longitudinal ligament C. Anterior longitudinal ligament d. Internal annulus fibrosus

Answer 46

D) The sinuvertebral nerve innervates the anterior vertebral body, the external annulus, and the posterior longitudinal ligament. The anterior longitudinal ligament is innervated by the gray rami communicans, which branch off the lumbar sympathetic chain. The internal annulus fibrosus and nucleus pulposus do not have innervations.

Question 47

Which of the following exercises involve the least amount of force on the low back and are therefore used in the early stages of lumbar rehabilitation? a. Sit ups b. Leg raises c. Curl ups d. Lying prone and extending the spine while extending arms and legs

Answer 47

C) Sit ups cause more than 3,000 Newtons of compressive loads on the spine because of psoas activity. Leg raises also cause relatively high compressive forces. Lying prone and extending the spine while extending the arms and legs cause more than 6,000 Newtons of compression to the spine. Curl-ups cause lower forces on the spine, so they are a better choice for anterior abdominal strengthening in the early stages of rehabilitation, or in those who have increased pain and cannot tolerate increased spinal loading exercises.

Question 48

Which of the following medications is not effective in treating chronic low back pain? a. Tramadol b. Tricyclic antidepressants C. Nonsteroidal anti-inflammatory drugs d. Systemic steroids

Answer 48

D) Multiple studies have found systemic steroids not to be effective for chronic low back pain,

Question 49

A patient presents to you with low back pain, which she attributes to her being diagnosed with osteoporosis. Osteoporosis is usually not visible on conventional radiographs until at least _____% of bone mineral has been lost. a. 10 to 15 b. 15 to 20 C. 25 to 30 d. 35 to 40

Answer 49

C) 25 to 30.

Question 50

Modalities such as paraffin baths, cold packs, and cryotherapy work to alleviate pain through: a. Conduction b. Convection C. Conversion d. Evaporation

Answer 50

A) Conduction is a method whereby energy is transferred by direct interaction of molecules in a different energy state. Cryotherapy is a method of therapeutic cooling by causing the transfer of energy from warmer to cooler particles.

Question 51

Modalities such as whirlpool baths and fluidotherapy work to alleviate pain through: a. Conduction b. Convection c. Conversion d. Evaporation

Answer 51

B) Convection is the act of conveying or transmitting heat in a liquid or gas by, bulk movement of heated particles to a cooler area.

Question 52

Modalities such as ultrasound work to alleviate pain through: a. Conduction b. Convection c. Conversion d. Evaporation

Answer 52

C) Therapeutic ultrasound works by converting electrical energy into high-frequency sound waves, which have the ability to increase tissue temperature and' promote tissue healing.

Question 53

Which of the following medications alleviates pain by inhibiting prostaglandin synthesis, is somewhat selective for cyclooxygenase-2, and has analgesic, antipyretic, and antiinflammatory actions? a. Meloxicam (Mobic) b. Ketorolac c. Diclofenac d. Acetaminophen

Answer 53

A) Meloxicam (Mobic).

Question 54

Which of the following medications alleviates pain by inhibiting cyclooxygenase in the central nervous system and has analgesic and antipyretic, but not anti-inflammatory actions? a. Meloxicam (Mobic) b. Ketorolac c. Diclofenac d. Acetaminophen

Answer 54

D) Acetaminophen.

Question 55

Which of the following medications alleviates pain by inhibiting prostaglandin synthesis and release and inhibits platelet aggregation, and its therapeutic response may take 2 weeks for arthritis treatment? a. Meloxicam (Mobic) b. Ketorolac c. Diclofenac d. Aspirin

Answer 55

D) Aspirin.

Question 56

Which of the following nonsteroidal anti-inflammatory drugs (NSAIDs) does not inhibit platelet aggregation? a. Celecoxib (Celebrex) b. Ketorolac c. Diclofenac d. Aspirin

Answer 56

A) Studies have shown that celecoxib, a selective COX-2 inhibitor, does not inhibit platelet aggregation.

Question 57

Which of the following opioid analgesics has the longest half-life, producing longer periods of pain relief? a. Morphine b. Codeine c. Oxycodone d. Oxymorphone

Answer 57

D) Morphine, codeine, and oxycodone have a half-life of 2.5 to 3.5 hours. Oxymorphone has a half-life of 7 to 9 hours.

Question 58

Which of the following opioid analgesics has the longest half-life, producing longer periods of pain relief? a. Morphine C. Methadone b. Codeine d. oxymorphone

Answer 58

C) Methadone has a half-life of 13 to 47 hours. Morphine and codeine have a half-life of 2.5 to 3.5 hours. Oxymorphone has a half-life of 7 to 9 hours.

Question 59

Which of the following side effects has been seen with long-term use of high-dose opioids? a. Increased lactation b. Decreased libido c. Increased cortisol response to stress d. Hostility and anxiety

Answer 59

B) Chronic use of high-dose opioids has been shown to decrease libido in men and women, and to cause amenorrhea and a reduced cortisol response to stress.

Question 60

Mirtazapine, venlafaxine, and duloxetine are ____________ and are used to treat, depression and chronic pain. a. Tricyclic antidepressants b. Benzodiazepines C. Selective serotonin reuptake inhibitors (SSRIs) S d. Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Answer 60

D) Serotonin-norepinephrine reuptake inhibitors (SNRIs).

Question 61

Amitriptyline (Elavil) is a __________ and is used to treat depression and neuropathic pain. a. Tricyclic antidepressant (TCA) b. Benzodiazepine c. Selective serotonin reuptake inhibitor (SSRI) d. Serotonin-norepinephrine reuptake inhibitor (SNRI)

Answer 61

A) Tricyclic antidepressant (TCA).

Question 62

This therapeutic technique uses many forms of both auditory and visual physiologic monitoring in an attempt to educate patients to alter physiologic functions that are usually not under conscious control. This technique has been used in chronic pain conditions, including headaches, low back pain, and fibromyalgia. a. Pilates c. Biofeedback b. Yoga d. tai chi

Answer 62

C) A commonly used form of biofeedback in chronic pain is EMG biofeedback, but there are other types.

Question 63

To diagnose fibromyalgia, widespread musculoskeletal pain must be present over a period of at least months. a. 2 c. 6 b. 3 d. 9

Answer 63

B) The definition also includes at least 11 positive tender points out of 18 locations.

Question 64

A patient presents with pain and paresthesias in the first three fingers of the hand and the skin over the thenar eminence. The pain does not awaken the patient at night. Pain can be provoked by resisted elbow flexion and pronation, as well as by resisted finger flexion. You make the diagnosis of: a. Carpal tunnel syndrome (CTS) b. Pronator syndrome c. C5 radiculopathy d. C8 radiculopathy

Answer 64

B) Pronator syndrome refers to median nerve compression as the nerve passes between the two heads of the pronator teres. It often mimics carpal tunnel syndrome (CTS), as it presents with numbness over the first three digits. Whereas pain in CTS patients can wake patients from sleep, pain from pronator syndrome usually does not. Weakness is seen in median nerve innervated muscles distal to the pronator teres.

Question 65

A patient presents with numbness and pain in a well-circumscribed distribution on the anterolateral thigh. These symptoms are exacerbated by walking or extending of the hip. No weakness of the lower limb is noted. You make the diagnosis of: a. Peripheral neuropathy b. Peroneal nerve entrapment c. Lateral femoral cutaneous neuropathy d. Sciatic neuropathy

Answer 65

C) Lateral femoral cutaneous neuropathy (also known as meralgia paresthetica) refers to entrapment of the lateral femoral cutaneous nerve. Patients will present with anterior lateral thigh numbness and pain. It is a purely sensory nerve entrapment, so there should be no muscle weakness.

Question 66

The first line of treatment for bothersome phantom limb sensation, phantom limb pain, and residual limb pain is: a. Desensitization techniques b. Pharmacologic techniques c. Biofeedback techniques d. Use of transcutaneous electrical nerve stimulation (TENS) unit

Answer 66

A) Desensitization techniques such as tapping, slapping, wrapping, and massaging the residual limb have been shown to reduce phantom limb pain and abnormal sensations. Many patients find that wearing a prosthesis diminishes their phantom pain.

Question 67

Functional instability, leading to low back pain, is thought to be the result of: a. Tissue damage b. Poor muscular balance C. Poor muscular control d. All of the above

Answer 67

D) Tissue damage, poor muscular balance, and poor muscular control are thought to lead to functional instability of the low back. These cause the joints to become lax and alter the anatomy of the lumbar spine, leading to a feeling of instability.

Question 68

Spondylolysis, a common cause of low back pain, is thought to arise secondary to: a. Repetitive hyperflexion of the lumbar spine b. Repetitive hyperextension of the lumbar spine c. Repetitive side bending of the lumbar spine d. Repetitive rotation of the lumbar spine

Answer 68

B) Spondylolysis refers to a defect of the pars interarticularis. If a child, adolescent, or young adult presents with low back pain, spondylolysis should be high on the differential diagnosis. It is thought to arise from repetitive hyperextension of an immature spine. Sports such as football and gymnastics increase the risk of developing spondylolysis.

Question 69

The most common level affected in a degenerative spondylolisthesis is: a. L2-L3 C. L4-L5 b. L3-L4, d. L5-S1

Answer 69

C) Spondylolisthesis refers to the slippage of one vertebra relative to the one above it. Spondylolisthesis can result from many causes. In older patients who develop spondylolisthesis, most are degenerative in nature (usually caused by disc or facet disease). Spondylolisthesis most commonly affects the L4-L5 level.

Question 70

A 20-year-old man presents to you for initial evaluation of low back pain and morning stiffness. He denies trauma to the area. On physical examination, there is decreased spinal mobility and decreased chest expansion. You make a diagnosis of: a. Spinal stenosis b. Reactive arthritis c. Ankylosing spondylitis d. Psoriatic arthritis

Answer 70

C) Ankylosing spondylitis is three times more common in men than in women, usually presents in the late teens, and is associated with morning stiffness and aching pain in the lower back (at times affecting the buttocks). On physical examination, one can find tenderness to palpation over the sacroiliac joints and decreased spinal mobility.

Question 71

What type of exercise should be avoided in patients with osteoporotic compression fractures? a. Walking for 40 minutes, three times a week b. Spinal flexion exercises C. Progressive resistive back extension exercises d. Swimming

Answer 71

B) The best type of exercises for patients with osteoporosis is progressive resistive spinal extension exercises. Studies have shown that patients with osteoporosis have weaker back extensors than the general population. Spinal flexion exercises should be avoided, as these can aggravate compression fractures in patients with osteoporosis.

Question 72

Pain caused by a stimulus that does not normally provoke pain is known as: a. Anesthesia c. Hyperesthesia b. Allodynia d. Hyperalgesia

Answer 72

B) Allodynia is pain from a stimulus that ordinarily will not provoke pain. Anesthesia is a loss of sensation. Hyperesthesia is an increased sensation or sensitivity. Hyperalgesia is increased pain response from a normally painful stimulus (the degree of pain is disproportionate to the stimulus).

Question 73

An increased response to a stimulus that is normally painful is known as: a. Anesthesia C. hyperesthesia b. Allodynia d. hyperalgesia

Answer 73

D) Allodynia is pain from a stimulus that ordinarily will not provoke pain. Anesthesia is a loss of sensation. Hyperesthesia is an increased sensation or sensitivity. Hyperalgesia is increased pain response from a normally painful stimulus (the degree of pain is disproportionate to the stimulus).

Question 74

An unpleasant abnormal sensation, whether spontaneous or evoked, is known as: a. Anesthesia b. Allodynia c. Dysesthesia d. Hyperalgesia

Answer 74

C) Dysesthesia is an unpleasant abnormal sensation, whether painful or evoked. Allodynia is pain from a stimulus that ordinarily will not provoke pain. Anesthesia is a loss of sensation. Hyperesthesia is an increased sensation or sensitivity. Hyperalgesia is increased pain response from a normally painful stimulus (the degree of pain is disproportionate to the stimulus).

Question 75

Methadone hydrochloride works as: a. Antagonizing N-methyl-D-aspartate (NMDA) receptor b. A gamma-aminobutyric acid (GABA) agonist c. An acetylcholine receptor blocker d. A blocker of release of calcium from the sarcoplasmic reticulum

Answer 75

A) Methadone hydrochloride is a relatively potent NMDA receptor antagonist, allowing activation of NMDA, largely responsible for central sensitization. Methadone is cheap, has no active metabolites, and has a half-life varying from 7 hours to 5 days.

Question 76

Patients with chronic pain can display: a. Sleep fragmentation b. Difficulty falling asleep c. Decreased quality of sleep d. All of the above

Answer 76

D) Studies have shown that patients suffering from chronic pain can suffer from sleep disturbances, including longer time to fall asleep, sleep fragmentation, and decreased quality of sleep.

Question 77

Neuropathic pain, itchiness, and impaired sensation can occur as a result of burn injury involving nerve endings in which of the following layers? a. Epidermal C. Subcutaneous fat b. Dermal d. deep fascia

Answer 77

B) Nerve endings in the dermal layer are responsible for transmitting sensation and pain back to the central nervous system.

Question 78

The majority of burns result from: a. Fire/flame injuries b. Scald injuries c. Electrical injuries d. Chemical injuries

Answer 78

A) 60% of burns result from fi re/flame injuries. Scald, electric, and chemical injuries only make up a minority of burn injuries.

Question 79

Fibromyalgia is characterized by: a. Chronic widespread pain and tenderness b. An elevated sedimentation rate c. A rapid resolution with antibiotics d. Bilateral median neuropathies at the wrist (CTS)

Answer 79

A) Fibromyalgia is characterized by diffuse tenderness and pain. The specific diagnostic criterion is the presence in 11 or more of 18 characteristic tender points. The others are not characteristic of fibromyalgia.

Question 80

All of the following are goals of chronic pain management except: a. Elimination of all pain b. Return to work c. Maximize activity and function d. Restoration of a normal sleep cycle

Answer 80

A) Although elimination of all pain is a noble and desirable goal, it is not a realistic goal in patients with chronic pain. The others are realistic goals and will. hopefully lead to normalization of function.