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McGraw-Hill Specialty Board Review Pain Medicine

Salahadin Abdi, Pradeep Chopra, Howard Smith

Chapter 6

Types of Pain - all with Video Answers

Educators

Chapter Questions

02:37

Problem 3

Which of the following describes the pathophysiologic changes seen in migraine?
(A) Inflammation of hypothalamic structures leads to low threshold stimulation of vascular and meningeal tissues
(B) Central sensitization mediated by attribution to activation of $\beta$-fibers in the trigeminal system, mediates extracranial hypersensitivity
(C) Large cerebral vessels, pial vessels, large sinuses, and the dura, are innervated by fibers originating from the sphenopalatine ganglion
(D) Activation and threshold reduction of the trigeminocervical complex by its most caudal cells
(E) In acute attacks, a marked reduction in vasoactive substances, including substance $\mathrm{P}$, calcitonin gene related peptide (CGRP), and nitric oxide is commonly seen

Joanna Quigley
Joanna Quigley
Numerade Educator
01:17

Problem 44

Pharmacologic management of $S C D$ pain includes three major classes of compounds: nonopioids, opioids, and adjuvants. Nonopioids include acetaminophen, NSAIDs, topical agents, tramadol, and corticosteroids. The following is true about Tramadol, EXCEPT
(A) it inhibits neuronal reuptake of serotonin and norepinephrine
(B) it acts as a weak $\mu$-receptor agonist
(C) it does not have a "ceiling" effect because of its safe side-effect profile
(D) it is not associated with an addiction potential
(E) it is a centrally acting analgesic

Asma Venkitta
Asma Venkitta
Numerade Educator

Problem 332

A45-year-old patient with metastatic breast carcinoma is prescribed $30 \mathrm{mg}$ of sustained-release morphine (MS Contin) twice a day and one 15-mg tablet of immediate-release morphine (MSIR) every 6 hours as needed for breakthrough pain. On her routine follow-up visit she reports that she routinely uses MSIR four times a day with satisfactory pain control on most days and no major side effects. What would be your best course of action in this situation?
(A) Prescriptions should be left unchanged
(B) MS Contin should be changed to $40 \mathrm{mg}$ of OxyContin twice a day and $5 \mathrm{mg}$ of oxycodone every 6 hours as needed for breakthrough pain
(C) Fentanyl patch of $25 \mu \mathrm{g} / \mathrm{h}$ should replace MS Contin with $15 \mathrm{mg}$ of MSIR every 6 hours as needed for breakthrough pain
(D) MS Contin should be increased to $60 \mathrm{mg}$ twice a day with MSIR $15 \mathrm{mg}$ every 6 hours as needed for breakthrough pain
(E) MS Contin should be increased to $60 \mathrm{mg}$ twice a day, and MSIR should be discontinued

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Problem 333

Approximately in what percentage of patients with malignancies does pain unrelated to cancer occur?
(A) Less than $2 \%$
(B) $3 \%$
(C) $7.5 \%$
(D) $11 \%$
(E) $25 \%$

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Problem 334

There is a significant incidence of neuropathic pain in a cancer patient with brachial plexopathy. The etiology of the brachial plexopathy in such a patient may be caused by direct tumor infiltration or radiation fibrosis. Electrophysiologic evaluation with nerve conduction velocity (NCV) study and electromyography (EMG) helps to distinguish between the two etiologies. Which of the following findings of NCV/EMG is the most helpful to differentiate between the direct tumor infiltration and the radiation fibrosis etiologies of brachial plexopathy?
(A) Segmental nerve conduction slowing
(B) Myokymia
(C) Fibrillation potentials
(D) Positive sharp waves
(E) Decreased amplitude of the compound muscle action potential (CMAP)

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00:45

Problem 335

If bony metastases are present, which primary cancer location has the best 5 -year survival prognosis?
(A) Myeloma
(B) Breast
(C) Prostate
(D) Thyroid
(E) Kidney

Breanna Kloczkowski
Breanna Kloczkowski
Numerade Educator

Problem 336

The most frequent spinal cord symptom or sign in patients with carcinomatous meningitis is
(A) nuchal rigidity
(B) back pain
(C) reflex asymmetry
(D) positive straight leg raise test
(E) weakness

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Problem 337

Which of the following would most likely be responsible for the central pain syndrome?
(A) Epidural spinal cord compression
(B) Metastatic bony destruction of the vertebrae with a nerve root compression
(C) Metastatic involvement of the cranial nerves
(D) Carcinomatous meningitis
(E) Radiation myelopathy

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01:08

Problem 338

The majority of patients with epidural metastasis have the following pattern of pain:
(A) Local
(B) Radicular
(C) Referred
(D) Funicular
(E) All of the above

Cody Delk
Cody Delk
Numerade Educator
01:30

Problem 339

All of the following are true about the World Health Organization (WHO) analgesic ladder, EXCEPT
(A) it is a method for relief of cancer pain based on a small number of relatively inexpensive drugs
(B) it has three steps
(C) step one involves the use of opioids
(D) it suggests to use only one drug from each group at a time
(E) it is a simple and effective method for controlling cancer pain

Maryam Riaz
Maryam Riaz
Numerade Educator

Problem 340

The following are all true about methadone, EXCEPT
(A) it has a highly variable oral bioavailability
(B) it is a low cost medication
(C) it has no known active metabolites
(D) it has $\mathrm{N}$-methyl-D-aspartate (NMDA) receptor agonist properties
(E) it has high lipid solubility

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Problem 341

58-years-old patient with metastatic prostate cancer is taking sustained-release morphine (MS Contin) every 8 hours with a total daily dose of $225 \mathrm{mg}$ with optimal pain control. Because of some circumstances, he has to be converted to transdermal therapeutic system fentanyl (TTS-fentanyl). What is the correct dose of fentanyl patch equivalent to the current dose of MS Contin for this patient?
(A) $25 \mu \mathrm{g} / \mathrm{h}$ every 72 hours
(B) $50 \mu \mathrm{g} / \mathrm{h}$ every 48 hours
(C) $75 \mu \mathrm{g} / \mathrm{h}$ every 72 hours
(D) $100 \mu \mathrm{g} / \mathrm{h}$ every 48 hours
(E) $125 \mu \mathrm{g} / \mathrm{h}$ every 72 hours

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Problem 342

Which of the following is true with respect to central pain syndromes?
(A) The most common cause of central pain state are lesions located in the brainstem
(B) The Wallenberg syndrome (lateral medullar syndrome) is characterized by contralateral facial sensory loss and Horner syndrome
(C) The most common lesions that produce thalamic pain syndrome are infarctions
(D) Spinal cord lesions rarely cause sensory deficits
(E) Central pain syndromes of spinal origin usually respond to epidural steroids

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Problem 343

Peripheral neuropathy is a common pain syndrome characterized by which of the following?
(A) Asymmetric paresthesias and proximal motor impairment
(B) Proximal more than distal sensory impairment
(C) Most peripheral neuropathies may be classified as demyelinating, axonal, or mixed
(D) Peripheral mononeuropathy is the most common peripheral nerve disease in patients with long-standing diabetes mellitus
(E) Nerve conduction studies only measure conduction through small unmyelinated fibers, so impairment of the fast conducting fibers may go undetected

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02:07

Problem 344

Events seen in the development of neuropathic pain are
(A) following nerve injury, there is a decreased activity of the sodium channels which allows for abnormal conduction through pain facilitating fibers
(B) wide dynamic range neurons in the dorsal horn respond with increased frequency as the intensity of the repeated afferent stimulus increases
(C) an increase in potassium channels would facilitate an amplified afferent activity
(D) C-polymodal nociceptors are activated by low-threshold mechanical, thermal, and chemical stimuli
(E) $\gamma$-aminobutyric acid (GABA) and glycine are released in the dorsal horn and augment the response of second order neurons

Christina Sorrentino
Christina Sorrentino
Numerade Educator

Problem 345

Examples of neuropathic pain conditions include all, EXCEPT
(A) complex regional pain syndrome (CRPS)
(B) diabetic peripheral neuropathy
(C) postherpetic neuralgia (PHN)
(D) Raynaud phenomenon
(E) phantom limb pain

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01:07

Problem 346

Which of the following conditions is more likely to be associated with neuropathic pain?
(A) Traumatic nerve injury
(B) Stroke
(C) Syringomyelia
(D) Multiple sclerosis
(E) Large myelinated fiber neuropathy

Joanna Quigley
Joanna Quigley
Numerade Educator

Problem 347

A patient with CRPS responds well to sympathetic ganglion block. The results of this block
can lead you to say which of the following about this particular pain condition?
(A) It is vascularly mediated
(B) It is sympathetically mediated
(C) It is sympathetically maintained
(D) It is less severe than previously thought
(E) It will not respond well to spinal cord stimulation

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01:08

Problem 348

Neuropathic pain can result in which of the following condition?
(A) Central sensitization
(B) Allodynia
(C) Hyperalgesia
(D) B and C
(E) A, B, and C

Cody Delk
Cody Delk
Numerade Educator
01:37

Problem 349

Potential neurophysiologic mechanisms underlying the development of neuropathic pain include
(A) microglial activation in the spinal cord
(B) cytokine production in the spinal cord
(C) decreased glutamate release in the spinal cord
(D) A and C
(E) A and B

Dennis Howard
Dennis Howard
Numerade Educator
04:16

Problem 350

When the stimulus of light touch exerts pain which of the following is exhibited?
(A) Hyperalgesia
(B) Allodynia
(C) Hypereflexemia
(D) Paresthesia
(E) Hypertouchemia

Caroline Jones
Caroline Jones
Numerade Educator
01:08

Problem 351

Phantom pain refers to
(A) any sensation of the missing limb, except pain
(B) painful sensations referred to the missing limb
(C) spontaneous movement of the stump ranging from small jerks to visible contractions (jumpy stump)
(D) pain referred to the amputation stump
(E) B and D

Cody Delk
Cody Delk
Numerade Educator

Problem 352

A 74-year-old male has a left lower extremity amputation after a long bout with uncontrolled diabetes mellitus (DM). What are the chances that this patient will develop phantom pain?
(A) $33 \%$
(B) $49 \%$
(C) $55 \%$
(D) $90 \%$
(E) $75 \%$

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Problem 353

A vascular surgeon consults the pain team on a patient who is scheduled to undergo an amputation secondary to peripheral vascular disease. The patient has read about phantom pain on the Internet and would like to know when it would likely start. You tell the vascular surgeon that
(A) the onset of phantom pain is usually within the first week after amputation
(B) most studies have shown that phantom pain will start between 2 and 4 weeks after an amputation for peripheral vascular disease
(C) the likelihood of her developing phantom pain in the first 6 months after amputation is low, but increases drastically between 6 and 9 months
(D) the onset will likely be delayed for years
(E) none of the above

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Problem 354

The patient mentioned in the previous question develops early and severe phantom pain:
(A) The patient is more likely to suffer from long-standing pain
(B) The patient is less likely to suffer from long-standing pain
(C) The patient is more likely to suffer incapacitating pain for 1 year that will subside rather abruptly
(D) It is likely that the patient will develop neuropathic pain in the extremity contralateral to the amputation
(E) The pain will likely be refractory to treatment with anticonvulsants

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00:37

Problem 355

The number of amputees who have severe phantom limb pain is
(A) $20 \%$ to $30 \%$
(B) $60 \%$ to $80 \%$
(C) $5 \%$ to $10 \%$
(D) $1 \%$ to $2 \%$
(E) $45 \%$ to $55 \%$

Andrei Demkov
Andrei Demkov
Numerade Educator

Problem 356

Preamputation pain
(A) is more likely to lead to phantom pain if the amputation is traumatic
(B) may sensitize the nervous system, explaining why some individuals may be more susceptible to development of chronic phantom pain
(C) is more likely to lead to phantom pain if the amputation is secondary
(D) is similar in character and localization to the subsequent phantom pain in $80 \%$ of patients
(E) is less likely to lead to phantom pain if the amputation is in the upper extremities

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Problem 357

A 25-year-old left lower extremity amputee returns from Iraq. He experiences phantom pain, but is attempting to move forward in life. To ease his transition back into society which of the following is the next best step?
(A) He should take as long as possible to grieve before he finds new employment
(B) He should initially use a cosmetic prosthesis before embarking on the task of learning to use a functional one
(C) He should absolutely refuse to ever have spinal anesthesia as it may worsen phantom pain
(D) He should learn coping strategies as phantom pain is a psychological disturbance
(E) None of the above

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01:08

Problem 358

Stump pain and phantom pain are often confused. There are, however, notable differences. Which of the following is true?
(A) Unlike phantom pain, stump pain occurs in the body part that actually exists, in the stump that remains
(B) Stump pain typically is described as a "sharp," "burning," "electric-like," or "skin-sensitive" pain
(C) Stump pain is usually caused by a neuroma
(D) Surgical revision of the stump or removal of the neuroma is sometimes considered when treating stump pain
(E) All of the above

Cody Delk
Cody Delk
Numerade Educator

Problem 359

A neuroma is an inflammation of a nerve that is seen universally after a nerve has been cut (ie, during an amputation). They show spontaneous and abnormal evoked activity following mechanical or chemical stimulation from the periphery. This results from
(A) an increased and novel expression of sodium channels
(B) hyperexcitability changes and reorganization of the thalamus
(C) an increase in potassium efflux
(D) increased activity in afferent $C$ fibers
(E) A and D

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05:01

Problem 360

Some amputees show an abnormal sensitivity to pressure and to repetitive stimulation of the stump, which can provoke attacks of phantom pain. Which of the following is the case in humans?
(A) It can be reduced by giving the NMDA antagonist, ketamine
(B) It can only be reduced by terminating the stimulation
(C) It can be attributed to the general excitability of spinal cord neurons, where only $\mathrm{C}$ fibers gain access to secondary pain-signaling neurons
(D) Sensitization of the dorsal horn may be mediated by glycine and serotonin
(E) All of the above

Rikhil Makwana
Rikhil Makwana
Numerade Educator
00:50

Problem 361

Of the following, which does not play a role in the mechanism for generating phantom pain?
(A) Peripheral sensitization
(B) Central sensitization
(C) Cortical reorganization
(D) Increased thalamus response to stimulation
(E) Sympathetic inhibition

Hunza Gilgit
Hunza Gilgit
Numerade Educator

Problem 362

Pharmacologically treating phantom pain is not easy. Which of the following medications has not proven to be effective in well-controlled trials?
(A) Tramadol
(B) Gabapentin
(C) Memantine
(D) Amitriptyline
(E) A and C

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Problem 363

A 65-year-old Vietnam War veteran with a left below the knee amputation and phantom pain has surgery on an amputation neuroma. He should expect
(A) excellent resolution of his phantom pain
(B) short-term pain relief
(C) a likely infection and subsequent complicated hospital course
(D) decreased pain only if he receives a 40-minute infusion of diphenhydramine within 24 hours of the surgery
(E) none of the above

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Problem 364

A patient has tingling sensations in a phantom limb that are uncomfortable and annoying but do not interfere with activities or sleep. According to the Sunderland classification of patients with phantom pain, what group is this patient in?
(A) Group I
(B) Group II
(C) Group III
(D) Group IV
(E) None of the above

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01:14

Problem 365

The gate-control theory of pain has been used to explain phantom limb pain. It states that
(A) following significant destruction of sensory axons by amputation, wide dynamic range neurons are freed by inhibitory control
(B) self-sustaining neuronal activity may occur in spinal cord neurons
(C) if spontaneous spinal cord neuronal activity increases by any amount, pain may occur in the phantom limb
(D) A and B
(E) A, B, and C

Stacy Storey
Stacy Storey
Numerade Educator
01:23

Problem 366

All of the following are true about primary dysmenorrhea, EXCEPT
(A) pain is transmitted via the thoracolumbar spinal segments and pelvic afferents
(B) the etiology of pain includes myometrial contractions leading to intense intrauterine pressure and uterine hypoxia
(C) prostaglandins and leukotriene production that sensitizes afferent pelvic nerves is part of its pathogenesis
(D) endometriosis and adenomyosis are its most common causes
(E) altered central receptivity of the afferent input from the pelvis is thought to be relevant in its development

Shubham Kumar
Shubham Kumar
Numerade Educator
01:21

Problem 367

All of the following are true about chronic endometriosis, EXCEPT
(A) ovaries, cul-de-sac, uterine tubes, surface of the bowel are among the most common sites of pathologic implantation of the functioning endometrial tissue
(B) retrograde menstruation, lymphatic spread, and hematogenous spread of the endometrial tissue are all thought to play a role in endometriosis etiology
(C) pain occurs only with menses
(D) definitive diagnosis can be made by visualization of the characteristic lesions without a mandatory histologic confirmation
(E) leuprolide acetate (Lupron) may be an effective treatment of the symptoms of chronic endometriosis

Courtney Burson
Courtney Burson
Numerade Educator

Problem 368

All of the following are correct, EXCEPT
(A) pudendal nerve takes origin from $\mathrm{S} 2, \mathrm{~S} 3$, and $\mathrm{S} 4$ roots bilaterally
(B) bilateral denervation of the inferior hypogastric nerves is as effective as a lumbar epidural block with respect to sensory input from the uterus and cervix
(C) many patients with hymenal neuropathy are so emotional and complain so violently that the pelvic examination is not possible
(D) patients with sympathetic pelvis syndrome have a deep pain in the pelvis not associated with physically detectable abdominal wall or muscle tenderness
(E) ilioinguinal and iliohypogastric neuropathy is rarely associated with the surgeries in the lower abdominal wall area

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Problem 369

All of the common reasons for the inadequate management of acute pain in a hospital setting are true, EXCEPT
(A) the common idea that pain is merely a symptom and not harmful in itself
(B) the fact that opioids have no potential for addiction when administered strictly for acute pain
(C) lack of understanding of the pharmacokinetics of various agents
(D) lack of appreciation of variability in analgesic response to opioids
(E) prescription of inappropriately low doses of opioids and thinking that opioids must not be given more often than every 4 hours

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Problem 370

The following are true about pathologic (nonphysiological) pain, EXCEPT
(A) it occurs in the context of central sensitization
(B) it occurs in the context of peripheral sensitization
(C) it outlasts the stimulus
(D) it spreads to nondamaged areas
(E) it is elicited by $\mathrm{A}-\delta$ and $\mathrm{C}$ fibers, but not A- $\beta$ fibers, which transmit touch sensation

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Problem 371

Perioperative administration of NSAIDs
(A) does not reduce the demand for opioids during and after the surgery
(B) is contraindicated because of increased possibility of bleeding
(C) has synergistic effect with opioids
(D) has its analgesic effect only through peripheral mechanisms
(E) is not associated with the concerns for postoperative bleeding

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05:30

Problem 372

All of the following are true about the NMDA receptors, EXCEPT
(A) they are involved in development of "windup" facilitation
(B) NMDA agonists reduce development of tolerance to opioids
(C) NMDA receptors are involved in development of central sensitization
(D) NMDA receptors are involved in changes of peripheral receptive fields
(E) NMDA receptors are involved in induction of oncogenes and long-term potentiation

Rikhil Makwana
Rikhil Makwana
Numerade Educator
02:56

Problem 373

As compared with somatic pain, all of the following are true about visceral pain, EXCEPT
(A) it may follow the distribution of a somatic nerve
(B) it is dull and vague
(C) it is often periodic and builds to peaks
(D) it is often associated with nausea and vomiting
(E) it is poorly localized

Cody Delk
Cody Delk
Numerade Educator

Problem 374

The following statements are true regarding preemptive analgesia, EXCEPT
(A) preemptive analgesia is helpful in reducing postoperative pain in part by reducing the phenomenon of central sensitization
(B) early postoperative pain is not a significant predictor of long-term pain
(C) local anesthetics, opioids, and NSAIDs can be used for preemptive analgesia
(D) preemptive analgesia may have the potential to prevent the development of chronic pain states
(E) preemptive analgesia is thought to reduce neuroplastic changes in the spinal cord

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Problem 375

The following statements are true regarding multimodal analgesia, EXCEPT
(A) it may include NSAIDs, acetaminophen, local anesthetics, and opioids in the same patient
(B) it is beneficial because of the synergistic action of the individual medications with different sites of action along the pain pathways
(C) it is not very valuable owing to an increase in the incidence of side effects
(D) it facilitates early mobilization of the postsurgical patient
(E) it expedites return to normal parenteral nutrition

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02:38

Problem 376

All of the following statements about PHN are correct, EXCEPT
(A) midthoracic dermatomes is one of the most common sites for PHN
(B) men are affected more often than women in a ratio of $3: 2$
(C) ophthalmic division of the trigeminal nerve is one of the most common sites for PHN
(D) PHN may occur in any dermatome
(E) PHN has an incidence of $9 \%$ to $14.3 \%$

Asma Venkitta
Asma Venkitta
Numerade Educator
00:59

Problem 377

PHN is defined as
(A) any pain associated with the herpes zoster
(B) pain caused by herpes zoster for more than 1 month
(C) persistent pain with a significant neuropathic component in a dermatomal distribution
(D) pain caused by herpes zoster for more than 3 months
(E) neuropathic pain in midthoracic dermatomes caused by herpes simplex virus

Emily Terlap
Emily Terlap
Numerade Educator
00:59

Problem 378

Which of the following is true about the management of PHN?
(A) Approximately $40 \%$ of patients with PHN have either incomplete or no relief from treatment
(B) Prevention of herpes zoster is not nearly as important as a multimodal treatment of PHN
(C) Current multimodal treatment of PHN is nearly $100 \%$ effective, independent of the duration of the symptoms
(D) Current multimodal treatment of $\mathrm{PHN}$ is nearly $100 \%$ effective as long as it is started within the first month of the symptoms of $\mathrm{PHN}$
(E) Current multimodal treatment of $\mathrm{PHN}$ is nearly $100 \%$ effective as long as it is started immediately after the first symptoms of herpes zoster

Emily Terlap
Emily Terlap
Numerade Educator
02:21

Problem 379

The following are true about the use of antidepressants in treatment of PHN, EXCEPT
(A) amitriptyline has been shown to be effective in treatment of $\mathrm{PHN}$, but has significant limitations in the long term because of its side effects
(B) selective serotonin reuptake inhibitors (SSRIs) have been found to be equally or more effective in treatment of PHN than the older generation of tricyclic antidepressants (TCAs) or selective norepinephrine reuptake inhibitors (SNRIs)
(C) SNRIs have been shown to be more effective than placebo in treatment of $\mathrm{PHN}$
(D) antidepressant therapy in $\mathrm{PHN}$ is built on sound, scientific basis
(E) one of the significant side effects of TCAs is their anticholinergic properties

Nick Johnson
Nick Johnson
Numerade Educator

Problem 380

Which of the following is true about use of opioids in the treatment of PHN?
(A) The use of opioids is not justified for nonmalignant pain
(B) Opioids tend to be less effective for the treatment of neuropathic pain than nonneuropathic pain
(C) Opioids were not found to be useful in the treatment of $\mathrm{PHN}$
(D) The use of opioids should be avoided in combination with antidepressants because of the risk of excessive central nervous system (CNS) suppression
(E) The use of opioids in PHN should be avoided owing to the increased potential of addiction

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01:04

Problem 381

Which of the following is the most common cause of autonomic neuropathy in the developed world?
(A) Leprosy
(B) Diabetes mellitus (DM)
(C) Human immunodeficiency virus (HIV) infection
(D) Heavy metal poisoning
(E) Idiopathic etiology

Carlene Jimenez
Carlene Jimenez
Numerade Educator
01:03

Problem 382

Diabetic amyotrophy
(A) has a poor prognosis
(B) has better prognosis when it involves upper extremities
(C) usually resolves within 1 to 2 years spontaneously
(D) has better prognosis when the symptoms do not involve pain
(E) it is directly related to hyperglycemia

Charles Machakwa
Charles Machakwa
Numerade Educator

Problem 383

The following are true about the distal sensorimotor polyneuropathy, EXCEPT
(A) it is the most common neuropathic manifestation of both type 1 and type 2 diabetes
(B) it starts distally and spreads proximally
(C) initial symptoms may involve numbness and tingling in the toes or feet
(D) it is a length-dependent neuropathy
(E) it is usually asymmetrical

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Problem 384

The prevalence of diabetic neuropathy in DM patients is
(A) less than $1 \%$ at diagnosis of DM, rising to $10 \%$ in patients diagnosed for longer than 5 years
(B) about $10 \%$ at diagnosis of DM, rising to more than $50 \%$ in patients diagnosed for longer than 5 years
(C) about $50 \%$ at diagnosis of $\mathrm{DM}$, rising to almost $100 \%$ in patients diagnosed for longer than 5 years
(D) about $50 \%$ at diagnosis of DM, and does not change significantly with time
(E) no such studies have been done so far

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Problem 385

Patients with diabetic distal sensorimotor polyneuropathy initially may complain of numbness and tingling in the toes or feet, which then slowly spreads proximally over months to years. Eventually, numbness and tingling appear in the fingertips, as the symptoms of diabetic polyneuropathy progress to
(A) ankle
(B) knee
(C) mid-thigh
(D) buttock and groin
(E) abdomen

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01:08

Problem 386

Which of the following is the most widely accepted cause of trigeminal neuralgia?
(A) Demyelinating conditions, as trigeminal neuralgia is most common in patients with multiple sclerosis
(B) Direct trauma of the trigeminal ganglion at the level of the foramen ovale, before branching into its three branches
(C) Arterial cross-compression of the trigeminal nerve in the posterior fossa
(D) Tumors of the posterior fossae
(E) Poor vascular supply to the affected trigeminal branch

Asma Venkitta
Asma Venkitta
Numerade Educator

Problem 387

Which of the following is true regarding medical management for the treatment of trigeminal neuralgia?
(A) Anticonvulsant medications are usually considered as the second line of treatment
(B) Beneficial effects of carbamazepine are better in elderly patients
(C) Risk of side effects of carbamazepine increase with age
(D) Carbamazepine has proven to be the most effective treatment for trigeminal neuralgia, independently of the sideeffect profile
(E) Because of the unlikelihood of serious side effects with surgery, all patients should consider this option first

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00:23

Problem 388

The gasserian ganglion
(A) receives exclusively proprioceptive information from the muscles of mastication
(B) the mandibular branch is located medial to the ophthalmic branch
(C) the two medial branches are sensory while the lateral branch is partially motor
(D) the ganglion lies out of the cranium, in the Meckel cave
(E) the foramen rotundum is used as landmark for the blockage of the trigeminal ganglion

Chinwe Abaraoha
Chinwe Abaraoha
Numerade Educator

Problem 389

Which of the following is true regarding the diagnosis of trigeminal neuralgia?
(A) The diagnosis must be confirmed with magnetic resonance imaging (MRI) to detect vascular trigeminal nerve compression
(B) Sensory evoked potentials is the most sensitive test to perform the diagnosis
(C) The diagnosis is clinical and tests are only necessary to rule out associated conditions
(D) To accurately diagnose the condition, it is necessary to correlate clinical findings with MRI and sensory evoke potential tests
(E) None of the above

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Problem 390

Giant cell arteritis is characterized by which of the following?
(A) Affects almost exclusively Asian population
(B) As other forms of vasculitis, giant cell arteritis commonly involves skin, kidneys, and lungs
(C) Males are more commonly affected
(D) It is more common in older patients, with a peak incidence between 60 to 75 years of age
(E) Visual loss is the presenting symptom in over $50 \%$ of the patients

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11:59

Problem 391

According to the International Headache Society Diagnostic Criteria, analgesic rebound headache is
(A) headache that resolves or reverts within 2 weeks after discontinuation of the suspected medication
(B) headache that worsens after intake of analgesics and reduces in intensity and frequency with reduction in the analgesic dose
(C) the intensity of the headache decreases in intensity proportionally to the decrease in the dose of analgesic
(D) headache greater than 15 days per month that has developed or markedly worsened during medication overuse
(E) headache that increases in intensity with the use of morphine, most likely because of the cerebral vasodilation mediated by histamine release

Erin Moser
Erin Moser
Numerade Educator

Problem 392

Cluster headaches are characterized by
(A) lancinating unilateral headache that is commonly triggered by stress factors
(B) the pain is strictly unilateral and autonomic symptoms occur ipsilateral to the pain
(C) the onset is slow with progressive worsening of the pain over several hours with an attack usually lasting 3 to 4 days
(D) melatonin is commonly indicated as therapy for the acute attack
(E) cluster headaches are more common in elderly patients

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Problem 394

Which of the following is correct regarding headache?
(A) Migraine is the most common form of headache
(B) Tension-type headache (TTH) is commonly aggravated by physical exercise
(C) The presence of nausea, vomiting, photophobia, or phonophobia excludes the diagnosis of TTH
(D) The most common form of migraine is associated with aura
(E) Comorbid conditions associated with chronic migraine include depression, anxiety, and panic disorders

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Problem 395

Hundred precent oxygen inhalation is a safe and effective method for acute treatment of
(A) chronic daily headache
(B) $\mathrm{TTH}$
(C) migraine with aura
(D) cluster headache
(E) glossopharyngeal neuralgia

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00:45

Problem 396

The Ramsay Hunt syndrome is caused by the infection of the varicella-zoster virus of the
(A) sphenopalatine ganglion
(B) gasserian ganglion
(C) geniculate ganglion
(D) glossopharyngeal ganglion
(E) stellate ganglion

Tate Hilken
Tate Hilken
Numerade Educator

Problem 397

Which of the following characterizes the spontaneous intracranial hypotension $(\mathrm{SIH})$ ?
(A) Is the same entity as post-dural puncture headache (PDPH)
(B) Headache is consistently unilateral
(C) Orthostatic headache is pathognomonic
(D) Patients complain of bitemporal headache
(E) To confirm the diagnosis, it is required that cerebrospinal fluid (CSF) opening pressures be below $60 \mathrm{~mm} \mathrm{H}_2 \mathrm{O}$

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Problem 398

A 20-year-old male presents to the clinic with complaints of moderate headaches located bilateral in the forehead, parietal, and occipital areas. The pain is dull and continuous and not associated with nausea, vomiting, photophobia, and phonophobia. The patient recalls that the symptoms started 1 year ago and have been constant since they started. No abnormalities where observed on physical examination, sinus computed tomography (CT), or brain MRI. The patient has occasionally tried over-the-counter analgesics with no relief. Which of the following is the most likely diagnosis?
(A) Status migrainosus
(B) Rebound headache
(C) New daily persistent headache
(D) Cluster headache
(E) Classical migraine

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02:01

Problem 399

Which of the following is a theory that may explain the presence of aura?
(A) Cortical spreading depression
(B) The vascular theory
(C) Hormonal fluctuation
(D) Estrogen withdrawal
(E) Cerebral idiopathic hypertension

Dennis Howard
Dennis Howard
Numerade Educator

Problem 400

Chronic low back pain and neck pain persists 1 year or longer in what percentage of patients?
(A) $5 \%$ to $10 \%$
(B) $15 \%$ to $20 \%$
(C) $20 \%$ to $25 \%$
(D) $25 \%$ to $60 \%$
(E) $60 \%$ to $75 \%$

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00:55

Problem 401

The prevalence of zygapophysial (facet) joint involvement in low back pain is
(A) $5 \%$ to $10 \%$
(B) $10 \%$ to $15 \%$
(C) $15 \%$ to $45 \%$
(D) $50 \%$ to $60 \%$
(E) $65 \%$ to $70 \%$

Andrei Demkov
Andrei Demkov
Numerade Educator

Problem 402

A 58-year-old with metastatic lung cancer suddenly complains of severe back pain. Symptoms of early spinal cord compression include all of the following, EXCEPT
(A) rapid onset
(B) symmetric and profound weakness
(C) spasticity
(D) increased deep tendon reflexes
(E) urinary retention and constipation

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Problem 403

Specific indications for discography include all of the following, EXCEPT
(A) further evaluation of abnormal discs to assess the extent of abnormality
(B) patients with persistent, severe symptoms in whom other diagnostic tests have revealed clear confirmation of a suspected disc as the source of pain
(C) assessment of patients who have failed to respond to surgical procedures to determine if there is possible recurrent disc herniation
(D) assessment of discs before fusion to determine if the discs within the proposed fusion segment are symptomatic
(E) assessment of minimally invasive surgical candidates to confirm a contained disc herniation or to investigate contrast distribution pattern before intradiscal procedures

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Problem 404

The following signs and symptoms are consistently found with cervical radiculopathy, EXCEPT
(A) gait disturbances
(B) normal muscle tone
(C) negative Babinski test
(D) weak tendon reflexes
(E) positive axial compression test (Spurling maneuver)

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01:33

Problem 405

All of the following are reasons associated with smoking as a risk factor for low back pain, EXCEPT
(A) mineral content of the lumbar vertebrae is decreased
(B) fibrinolytic disc activity is altered
(C) blood flow and nutrition to the disc are diminished
(D) disc $\mathrm{pH}$ is higher
(E) increased degenerative changes of the lumbar spine

Asma Venkitta
Asma Venkitta
Numerade Educator
02:39

Problem 406

All of the following treatments have strong evidence to back their use when treating acute low back pain, EXCEPT
(A) muscle relaxants effectively reduce low back pain
(B) bed rest is effective for treating low back pain
(C) continuing normal activity gives equivalent or faster recovery from acute low back pain
(D) NSAIDs prescribed at regular intervals are an effective treatment for acute low back pain
(E) different types of NSAIDs are equally effective at treating low back pain

Sophie Knight
Sophie Knight
Numerade Educator

Problem 407

Age-related changes in the intervertebral discs include all of the following, EXCEPT
(A) the dimensions of the lumbar intervertebral discs decrease with age
(B) collagen lamellae of the annulus fibrosis increases in thickness
(C) distinction between the nucleus pulposus and annulus fibrosis becomes less apparent
(D) the nucleus pulposus is less able to transmit weight directly
(E) $80 \%$ of nucleus pulposus cells in the elderly exhibit necrosis

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Problem 408

Radiculopathy is a neurologic condition associated with all of the following characteristics, EXCEPT
(A) numbness
(B) weakness
(C) pain
(D) compression of axons
(E) ischemia of axons

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01:55

Problem 409

Adverse effects of epidurally administered steroids include all of the following, EXCEPT
(A) Cushing syndrome
(B) osteoporosis
(C) avascular bone necrosis
(D) hypoglycemia
(E) suppression of the hypothalamus-pituitary axis

Qudsiya Anis
Qudsiya Anis
Numerade Educator

Problem 410

Relative contraindications to epidural steroid injections include
(A) preexisting neurologic disorder (ie, multiple sclerosis)
(B) sepsis
(C) therapeutic anticoagulation
(D) localized infection at injection site
(E) patient refusal

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Problem 411

L4-L5 disk herniation with L5 nerve root involvement includes
(A) numbness over the medial thigh and knee
(B) weakness with dorsiflexion of great toe and foot
(C) difficulty walking on toes
(D) pain in lateral heel
(E) quadriceps weakness

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Problem 412

In patients with chronic low back pain, the prevalence of sacroiliac joint pain is
(A) $10 \%$
(B) $15 \%$
(C) $20 \%$
(D) $25 \%$
(E) $30 \%$

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02:22

Problem 413

Match the following terms with the correct definitions.

Spondylolysis

Joanna Quigley
Joanna Quigley
Numerade Educator
02:22

Problem 414

Match the following terms with the correct definitions.

Spondylolisthesis

Joanna Quigley
Joanna Quigley
Numerade Educator
01:01

Problem 415

Match the following terms with the correct definitions.

Kissing spines

Joanna Quigley
Joanna Quigley
Numerade Educator
02:22

Problem 416

Match the following terms with the correct definitions.

Radiculopathy

Joanna Quigley
Joanna Quigley
Numerade Educator
02:38

Problem 417

Match the following terms with the correct definitions.

Radicular pain
(A) Neurologic condition in which conduction is blocked to the axons of a spinal nerve or its roots. It results in numbness and weakness
(B) An acquired defect caused by fatigue fracture of the pars interarticularis
(C) Pain that arises as a result of irritation of a spinal nerve or its roots
(D) Displacement of a vertebrae or the vertebral column in relationship to the vertebrae below it
(E) Periostitis of spinous processes or inflammation of the affected ligament

CP
Cassandra Pelkey
Numerade Educator
02:02

Problem 418

Evidence regarding the value of epidural injections for the management of chronic spinal pain demonstrates the following:
(A) Limited with interlaminar lumbar epidural steroid injections for short-term relief of lumbar radicular pain
(B) Strong with interlaminar lumbar epidural steroid injections for long-term relief of lumbar radicular pain
(C) Moderate for lumbar transforaminal epidural steroid injections for short-term relief of lumbar radicular pain
(D) Strong for lumbar transforaminal epidural steroid injections for long-term relief of lumbar radicular pain
(E) Strong for caudal epidural steroid injections for short-term relief of lumbar radiculopathy and post-lumbar laminectomy syndrome

Jerrah Biggerstaff
Jerrah Biggerstaff
Numerade Educator
02:39

Problem 419

All of the following statements regarding intervertebral disc innervation are true, EXCEPT
(A) nerve plexuses that innervate the intervertebral discs are derived from dorsal rami
(B) in normal lumbar intervertebral discs, nerve fibers are only found in the outer third of the annulus fibrosis
(C) discs painful on discography and removed with operation have nerve growth deep into the annulus and into the nucleus pulposus
(D) disc fissuring is a trigger for neoinnervation of a disc
(E) the anterior and posterior nerve plexuses accompany the anterior and posterior longitudinal ligaments

Qudsiya Anis
Qudsiya Anis
Numerade Educator

Problem 420

Three days after a lumbar epidural steroid injection was given, a 57-year-old male complains of fever and severe back pain over the site where the injection was given. Two days later, the back pain has progressively worsened, and a severe radiating pain goes down the right leg and knee. Which of the following is the most likely complication of the epidural steroid injection?
(A) Epidural abscess
(B) Epidural hematoma
(C) Arachnoiditis
(D) Anterior spinal artery syndrome
(E) Cauda equina syndrome

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01:26

Problem 421

X-ray imaging is recommended for which of the following cause of low back pain?
(A) Disc bulging
(B) Cauda equina syndrome
(C) Spondylolisthesis
(D) Lateral disc herniation
(E) Spinal cord tumors

Joanna Quigley
Joanna Quigley
Numerade Educator
00:35

Problem 422

Which of the following nerve root and muscle motion combinations is correct?
(A) L2-leg extension
(B) L3-heel walking
(C) LA-toe walking
(D) L5-first toe dorsiflexion
(E) $\mathrm{S} 1$ - hip flexion

Dee Anne
Dee Anne
Numerade Educator

Problem 423

Which of the following is the most frequent complication of a laminotomy with discectomy?
(A) Recurrent disc herniation
(B) Infection
(C) Dural tear
(D) Neural injury
(E) Failed back surgery syndrome (FBSS)

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Problem 424

Which of the following includes conservative treatment for FBSS?
(A) Discectomy
(B) Chemonucleolysis
(C) Rehabilitation
(D) Laminectomy
(E) Fusion

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Problem 425

Favorable prognostic indicators for patients undergoing repeated lumbosacral surgery include all of the following, EXCEPT
(A) female sex
(B) satisfactory outcome from prior surgeries
(C) operative findings of disk herniation
(D) epidural scarring requiring lysis of adhesions
(E) radicular pain

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02:56

Problem 426

Waddell signs were developed to help identify nonorganic causes of low back pain. They include all of the following, EXCEPT
(A) tenderness
(B) stimulation
(C) distraction testing
(D) regional disturbance
(E) underreaction

Cody Delk
Cody Delk
Numerade Educator

Problem 427

A 25-year-old male presents with progressively worsening neck and back pain and stiffness over 4 months that improves with light exercise and warm showers. Which of the following is the most likely diagnosis?
(A) Rheumatoid arthritis
(B) Ankylosing spondylitis
(C) Psoriatic arthritis
(D) Klippel-Feil syndrome
(E) Reiter syndrome

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Problem 428

Which of the following is a major criteria for cervicogenic headache?
(A) Bilateral head or face pain without sideshift
(B) Pain is superficial and throbbing
(C) Restricted neck range of motion
(D) Pain relief with digital pressure to cervical vertebrae
(E) Lack of relief from anesthetic blockade

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00:35

Problem 429

Neurogenic claudication can be distinguished from vascular claudication by which of the following?
(A) Leg tightness
(B) Pain alleviated with standing
(C) Pain exacerbated with lumbar flexion
(D) No change in pain with exercise
(E) Pain exacerbated with lying supine

Dee Anne
Dee Anne
Numerade Educator

Problem 430

Neck pain has been suggested to have a multifactorial origin. Which of the following statements regarding neck pain is true?
(A) Workplace interventions are not effective at reducing neck pain
(B) Normal degenerative changes in the cervical spine are a risk factor for pain
(C) Physical activity does not protect against neck pain
(D) Precision work does not increase the risk of neck pain
(E) Social support in the workplace does not affect neck pain

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Problem 431

In patients with neck pain, what is more predictive at excluding a structural lesion or neurologic compression than at diagnosing any specific etiologic condition?
(A) MRI
(B) Discography
(C) Blood tests
(D) Physical examination
(E) Electrophysiology

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Problem 432

All of the following characteristics are associated with a poor prognosis for neck pain, EXCEPT
(A) prior neck pain
(B) pain resulting from an accident
(C) passive coping techniques
(D) middle age
(E) compensation

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Problem 433

Which of the following is the most common complication of fluoroscopically guided interlaminar cervical epidural injections?
(A) Nonpositional headache
(B) Vasovagal reactions
(C) Increased neck pain
(D) Fever
(E) Dural puncture

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Problem 434

A 54-year-old female complains suddenly of inability to move her legs after a transforaminal epidural steroid injection. On further examination, she is found to have intact light touch sensation, sphincter disturbance, and loss of pain and temperature sensation. What is the most likely diagnosis?
(A) Cauda equina syndrome
(B) Epidural hematoma
(C) Epidural abscess
(D) Transient paraplegia
(E) Anterior spinal artery syndrome

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Problem 435

A57-year-old diabetic male presents with a new onset of neck pain over the past several hours; the pain is beginning to move down each arm equally. Two days ago he had a cervical epidural injection which he receives periodically for a herniated disc. On physical examination, his temperature is $102.4^{\circ} \mathrm{F}$, his cervical spine is exquisitely tender to palpation and he complains of radicular pain down both arms. The most likely organism causing this presentation is
(A) Pseudomonas
(B) Escherichia coli
(C) Streptococcus pneumoniae
(D) Hemophilus influenza
(E) Staphylococcus aureus

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01:51

Problem 436

The following statements are true regarding the pathologic mechanism in HIV-related neuropathy, EXCEPT
(A) HIV is found within endoneurial macrophages
(B) HIV is found within Schwann cells
(C) antisulfatide antibodies are one of the humoral factors responsible for demyelinating diseases in AIDS patients
(D) secretion of cytokines by the HIVinfected glial cells may generate tissuespecific autoimmune attack
(E) the pathologic mechanisms in HIV-related neuropathies are not well understood

Joanna Quigley
Joanna Quigley
Numerade Educator

Problem 437

Pain syndromes of neuropathic nature occur in approximately $40 \%$ of AIDS patients with pain. Several types of peripheral neuropathies have been described in patients with HIV and AIDS. The most common painful neuropathy encountered in patients with HIV and AIDS is
(A) mononeuritis multiplex
(B) polyradiculopathy
(C) cauda equina syndrome
(D) painful toxic neuropathy
(E) predominantly sensory neuropathy of AIDS

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02:04

Problem 438

The most important pathophysiologic event in sickle cell anemia, which explains most of its clinical manifestations, is vascular occlusion. The following are the pathophysiologic processes that lead to vascular occlusion in patients with sickle cell disease (SCD), EXCEPT
(A) erythrocyte dehydration
(B) distortion of the shape of erythrocytes
(C) polymerization of the sickle cell hemoglobin on deoxygenation
(D) decreased deformability of erythrocytes
(E) decreased stickiness of erythrocytes

Anitha Mary
Anitha Mary
Numerade Educator

Problem 439

A physician has to exercise extra caution when attributing SCD patient's complaints of pain to behavioral deviations, such as drug-seeking behavior, because
(A) patients in real pain, such as sickle cell pain, do not develop addiction to opioids
(B) most patients with SCD have substance abuse and addiction, as they are exposed to opioids early in life
(C) there is a higher incidence of controlledsubstance diversion in SCD patients
(D) sickle cell pain could be the prodrome of a serious and potentially fatal complication of SCD
(E) severe pain, such as sickle cell pain, should only be managed by an experienced physician subspecializing in pain management

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Problem 440

What makes the pain of SCD unique in its acuteness and severity?
(A) SCD patients tend to have a decreased threshold to pain because of prolonged and early exposure to severe pain in life
(B) SCD patients have increased tolerance to opioids and opioid-related hyperalgesia
(C) SCD pain pathophysiology involves a combination of ischemic tissue damage and secondary inflammatory response
(D) Repetitive SCD crises lead to ischemic damage of the CNS and subsequent central sensitization to pain
(E) SCD patients tend to anticipate and respond with a spectacular behavioral manifestation to pain, because of its cyclic feature

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01:58

Problem 441

At initial presentation, objective signs of a painful SCD crisis, such as fever, leukocytosis, joint effusions, and tenderness, occur in
(A) less than $10 \%$ of patients
(B) about $25 \%$ of patients
(C) about $50 \%$ of patients
(D) about $75 \%$ of patients
(E) more than $90 \%$ of patients

Alexa Moschella
Alexa Moschella
Numerade Educator
03:22

Problem 442

What percentage of hospital admissions in adult SCD patients result from acute sickle cell pain?
(A) Less than $10 \%$
(B) About $25 \%$
(C) About $50 \%$
(D) About $75 \%$
(E) More than $90 \%$

Cody Delk
Cody Delk
Numerade Educator
01:30

Problem 443

Which of the following is true regarding treatment of sickle cell pain with NSAIDs?
(A) They should be completely avoided because of potential side effects
(B) They should not be administered continuously for more than 5 days
(C) They should be administered only in combination with opioids
(D) They should not be administered continuously for more than 1 month
(E) Potential morbidity from their side effects in SCD patients is the same as in the general population

Maryam Riaz
Maryam Riaz
Numerade Educator

Problem 445

All of the following are true about chronic pain in the spinal cord injury (SCI) patient, EXCEPT
(A) approximately two-thirds of all SCI patients suffer from chronic pain
(B) approximately one-third of $\mathrm{SCl}$ patients with pain have severe pain
(C) pain in $\mathrm{SCI}$ patients may lead to severe depression and even suicide
(D) because of the overwhelmingly significant impairment of other important functions, pain is only a minor consideration in an SCI patient
(E) pain in SCI interferes with rehabilitation and activities of daily living (ADLs)

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Problem 446

In an $\mathrm{SCl}$ patient, chronic pain secondary to overuse is common in
(A) neck
(B) lower back
(C) shoulders and arms
(D) hips and thighs
(E) knees and feet

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Problem 447

Autonomic dysreflexia usually occurs after an $\mathrm{SCI}$ at
(A) any level
(B) above $\mathrm{C} 4$
(C) above C7
(D) above T6
(E) above L1

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Problem 448

The following is true regarding the visceral pain in an SCI patient, EXCEPT
(A) it is unlikely that visceral pain may occur in the absence of any abdominal organ dysfunction
(B) the pattern of visceral pain is not affected in an SCI patient, because it is transmitted through the sympathetic system, which usually bypasses the site of injury
(C) autonomic dysreflexia cannot be triggered by visceral pain
(D) visceral pain is always present in an $\mathrm{SCI}$ patient as part of the central pain syndrome
(E) increases in spasticity or autonomic reactions may be the only indications of abdominal organ dysfunction

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Problem 449

Neuropathic pain in $\mathrm{SCl}$ is divided into abovelevel, at-level, and below-level types. Depending on the type of pain, nerve root injury (peripheral component), and/or SCI (central component) may contribute to the pain. Which of the following is true?
(A) Below-level pain has only peripheral component
(B) At-level pain has only peripheral component
(C) Below-level pain is usually caused by compressive mononeuropathy
(D) Below-level pain is usually caused by CRPS
(E) At-level pain may have both peripheral and central components

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02:56

Problem 450

One of the characteristics of stimulus-evoked neuropathic pain in SCI can be temporal summation of pain. Temporal summation of pain is defined as
(A) elicitation of pain by nonnoxious stimulation
(B) pain continuing after stimulation has ceased
(C) an increased pain response to a noxious stimulus
(D) abnormal increase in pain with each repetitive stimulation
(E) pain felt in a place apart from the stimulated area

Cody Delk
Cody Delk
Numerade Educator
05:01

Problem 451

An axonal injury triggers a Wallerian degeneration, which is defined as
(A) degeneration of the portion of the axon separated from the neuronal body by the injury
(B) degeneration of the injured neuron dis$\mathrm{tal}$ and proximal to the level of injury
(C) atrophy of the motor unit supplied by the injured neuron
(D) dying of the body of the neuron, which lost its axon
(E) degeneration of the secondary afferent neuron because of the absence of the input from the injured primary afferent neuron

Rikhil Makwana
Rikhil Makwana
Numerade Educator
03:04

Problem 452

Which of the following is true about the central cord syndrome?
(A) It is the injury of the mid-portion of the spinal cord, usually around T6 level
(B) Upper extremities are affected more than lower
(C) It is very uncommon
(D) Patient usually presents with absent perianal sensation
(E) It is usually associated with complete SCI

Jessica Wolf
Jessica Wolf
Numerade Educator
02:56

Problem 453

A common sensory symptom in patients with CRPS is hyperpathia which may be defined as
(A) normally innocuous stimuli are perceived as painful
(B) exaggerated pain perception after a noxious stimulus at the site of injury
(C) exaggerated pain perception after a noxious stimulus in the area surrounding the primary affected skin
(D) exaggerated delayed painful perception after a noxious stimulus
(E) unpleasant abnormal sensation, whether spontaneous or evoked

Cody Delk
Cody Delk
Numerade Educator

Problem 454

Common findings in patients with CRPS I include
(A) symmetrical distal extremity pain
(B) pain intensity that is usually proportional to the intensity of the initiating event
(C) nearly all patients with CRPS I having sweating abnormalities
(D) sensory abnormalities that are most often proximal
(E) consistency between the inciting lesion and the spatial distribution of the pain

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02:05

Problem 455

Late changes observed in patients with CRPS I include
(A) sensory abnormalities
(B) warm extremities
(C) distal swelling
(D) trophic changes
(E) increased dermal blood flow

Rikhil Makwana
Rikhil Makwana
Numerade Educator

Problem 456

Which of the following is true in relation to CRPS?
(A) Males are more commonly affected than females
(B) CRPS II is more common than CRPS I
(C) Three bone scan showing unilateral periarticular uptake is mandatory to confirm CRPS diagnosis
(D) The diagnosis of CRPS is mainly clinical
(E) The mean age group is between 15 and 25 years

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Problem 457

Which of the following is the diagnostic criteria that differentiates CRPS II from CRPS I?
(A) Triple-phase bone scan showing diffuse spotty osteoporosis
(B) Weakness of all muscles of the affected extremity
(C) Sweating abnormalities
(D) Lesion of a peripheral nerve structure is mandatory
(E) Paresis

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Problem 458

Patients with CRPS exhibit significant psychologic findings, including
(A) the most common psychiatric comorbidities are anxiety and depression
(B) increased incidence of somatization in patients with CRPS than to patients with chronic low back pain
(C) psychiatric problems are the cause of CRPS
(D) CRPS is a psychogenic condition
(E) maladaptive behaviors in CRPS patients indicate the presence of psychopathology

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01:37

Problem 459

The Lewis triple response consists of the following, EXCEPT
(A) activation and sensitization of cutaneous $C$ fibers elicit local edema
(B) reddening of the skin at the site of the stimulus
(C) spreading flare
(D) local peripheral vasoconstriction mediated by the release of substance $\mathrm{P}$

Zachary Papazian
Zachary Papazian
Numerade Educator

Problem 460

The diagnosis of myofascial pain syndrome is confirmed when
(A) the myofascial trigger point is identified by palpation
(B) a patient has a widespread muscle condition
(C) a patient is diagnosed with fibromyalgia first
(D) regional muscle spasms are noted
(E) none of the above

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Problem 461

Four experienced physicians examine a patient. They all identify the same precise localization of trigger points within a muscle. The minimum criteria that must be satisfied in order to distinguish a myofascial trigger point from any other tender area in muscle are
(A) a taut band and a tender point in that taut band
(B) a local twitch response
(C) referred pain
(D) reproduction of the person's symptomatic pain
(E) A and C

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02:48

Problem 462

A 23 -year-old female is found to have a trigger point in the left trapezius muscle. With regard to electrical characteristics of the trigger point, which of the following is false?
(A) A characteristic electrical discharge emanates from the trigger point
(B) Spontaneous EMG activity typical of end-plate noise occurring in myofascial trigger points has been further confirmed in a study of young subjects with chronic shoulder and arm pain
(C) The sympathetic nervous system does not have a modulating effect on the motor activity of the trigger point
(D) End-plate noise without spikes was found at trigger point sites to a significantly greater degree than at end-plate zones outside of trigger points, and not at all in taut band sites outside of an end-plate zone
(E) All the above statements are true

Danielle Ashley
Danielle Ashley
Numerade Educator

Problem 463

Manual therapy is one of the four basic treatment options used for inactivating trigger points. Some practitioners also incorporate the stretch and spray technique. It is therapeutic
(A) because like with other soothing sprays, the placebo effect is extremely high
(B) because the vapocoolant spray stimulates thermal and tactile A- $\beta$ skin receptors, thereby inhibiting $\mathrm{C}$ fiber and $\mathrm{A}-\delta$ fiber afferent nociceptive pathways and muscle spasms, myofascial trigger points, and pain when stretching
(C) because the vapocoolant is focused specifically on the trigger point
(D) because therapists don't have to be as liberal when passively stretching patients
(E) B and D

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Problem 464

Which of the following is not an effective myofascial release technique?
(A) Strumming
(B) Perpendicular and oscillating mobilizations
(C) Therapeutic ultrasound
(D) Connective tissue massage
(E) Pétrissage

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00:35

Problem 465

Trigger points can theoretically be related to underlying articular dysfunction. Joint and muscular dysfunction is closely related and should be considered as a single functional unit. It has been noted that
(A) restrictions in joint capsules inhibit function for those muscles overlying the particular joint, but muscle dysfunction does not result in joint capsule restrictions
(B) restrictions in joint capsules do not inhibit adjacent muscles, nor does muscular dysfunction result in joint capsule restrictions
(C) restrictions in joint capsules inhibit muscle function for those muscles overlying the particular joint. Conversely, muscle dysfunction results in joint capsule restrictions
(D) restrictions in joint capsules do not severely limit the overlying muscles; however, muscle dysfunction does regulate joint capsule range of motion
(E) muscle dysfunction does not result in joint capsule range of motion

Alexander Burbelo
Alexander Burbelo
Numerade Educator

Problem 466

An administrative assistant presents with a number of upper back trigger points. She is scheduled for dry needling. What is the most common indication for this therapeutic modality?
(A) Relief of an acute myofascial pain syndrome
(B) To identify a myofascial trigger point as the cause of a particular pain
(C) To eliminate a trigger point permanently
(D) Inactivation of myofascial trigger points to facilitate physical therapy
(E) None of the above

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Problem 467

Randomized, double-blind, controlled studies have shown that adding which of the following medications to local anesthetics increases the pain relief obtained from myofascial trigger point injections?
(A) Steroids
(B) Ketorolac
(C) Vitamin $\mathrm{B}_{12}$
(D) Diphenhydramine
(E) None of the above

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00:29

Problem 468

Which of the following is not a complication of trigger point injections?
(A) Local hemorrhage into muscle
(B) Infection
(C) Transient nerve block
(D) Syncope
(E) Torticollis

Chinwe Abaraoha
Chinwe Abaraoha
Numerade Educator

Problem 469

Two days after a trigger point injection, a patient presents to your office irate. He claims that the trigger point injection has not helped him whatsoever. Which one of the following is not a likely reason why you are having this problem?
(A) You missed the trigger point during needling
(B) The patient is not motivated to improve
(C) You injected the secondary or satellite trigger point and not the primary trigger point
(D) Insufficient muscle stretching in the clinic after the injection
(E) Not enough stretching by the patient at home

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Problem 470

Mechanical precipitating factors can cause unrelenting musculoskeletal pain. The major mechanical factors that practitioners must consider in treating myofascial pain syndrome include anatomic variations, poor posture, and work-related stress. Of the anatomic variations, which of the following are the most common?
(A) Leg length discrepancy and small hemipelvis
(B) Short femur syndrome
(C) Long great toe syndrome
(D) Kyphosis
(E) All of the above

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Problem 471

What nutritional or hormonal factors have repeatedly been found to be low in persons with persistent myofascial pain?
(A) Iron
(B) Folic acid
(C) Vitamin $\mathrm{B}_{12}$
(D) Thyroid hormone
(E) All of the above

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Problem 472

Biologic aberrations seen in most patients with fibromyalgia indude all of the following, EXCEPT
(A) lowered pain thresholds to pressure induced pain
(B) disordered sleep as evidenced by polysomnography
(C) increased spinal fluid levels of substance $\mathrm{P}$
(D) decreased spinal fluid levels of nerve growth factor (NGF)
(E) no physiological or biochemical evidence for central sensitization

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02:00

Problem 473

Of the following criteria, which are absolutely necessary for the classification of fibromyalgia syndrome?
(A) Widespread pain for at least 3 months
(B) Pain sensitivity to $4 \mathrm{~kg}$ of digital pressure at a minimum of 11 of 18 anatomically defined tender points
(C) Diagnosis after the age of 18 years
(D) A and B
(E) A, B, and C

James Kiss
James Kiss
Numerade Educator

Problem 474

Which of the following is not one of the 18 potential locations for tender points in fibromyalgia?
(A) Occiput, at the suboccipital muscle insertion
(B) Low cervical, at the anterior aspects of the intertransverse spaces at $\mathrm{C} 5-\mathrm{C} 7$
(C) Lumbar paraspinal musculature, from the level of L 3 to L5
(D) Lateral epicondyle, extensor muscle, $2 \mathrm{~cm}$ distal to the epicondyle
(E) Knees, at the medial fat pad proximal to the joint line and condyle

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Problem 475

A 60-year-old female recently diagnosed with fibromyalgia has been exhibiting signs of anxiety and depression and is now in treatment. This situation
(A) makes perfect sense because fibromyalgia is a psychogenic disorder
(B) relates to the fact that a subgroup of fibromyalgia patients concurrently have depression and anxiety, although an affective disorder is unlikely to cause fibromyalgia
(C) demonstrates a patient who is less likely to exhibit signs of depression than one who has not sought out medical care
(D) exhibits a patient who was probably abused as a child
(E) none of the above

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Problem 476

Which of the following does not occur often as a clinical manifestation of the fibromyalgia syndrome?
(A) Irritable bladder syndrome
(B) Irritable bowel syndrome
(C) Urinary urgency
(D) Dizziness and light-headedness
(E) A and D

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Problem 477

A 50-year-old female with fibromyalgia complains of trouble sleeping. You are not surprised as it is well-known that these patients
(A) awaken in the morning feeling stiff, cognitively sluggish, and unrefreshed by their sleep
(B) commonly awaken feeling distressingly alert after only a few hours of sleep (mid insomnia) and then are unable to sleep soundly again until near morning (terminal insomnia)
(C) don't have trouble napping during the day
(D) A and B
(E) A, B, and C

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Problem 478

Which one of the following statements is false regarding fatigue in fibromyalgia?
(A) It should always be attributed to the fibromyalgia itself
(B) It is rarely induced by medications
(C) It manifests as a feeling of weakness as opposed to the feeling of tiredness felt in chronic fatigue syndrome
(D) A and B
(E) A, B, and C

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Problem 479

Secondary fibromyalgia refers to
(A) fibromyalgia that does not interfere with a patient's functioning
(B) fibromyalgia that occurs in the setting of another painful condition or inflammatory disorder
(C) a multifocal pain syndrome that occurs only after a patient has been diagnosed with dysthymia
(D) fibromyalgia that meets all the other characteristics of the disease but only produces between 8 and 10 tender points
(E) none of the above

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Problem 480

A very inquisitive 40-year-old female, recently diagnosed with fibromyalgia, states that she has been reading about her condition on the Internet. She wants to know about substance P. You tell her that
(A) substance $\mathrm{P}$ is a pronociceptive neurochemical mediator of pain because it carries or amplifies afferent signals
(B) substance $\mathrm{P}$ levels in the patients with fibromyalgia have been found to be significantly higher in the CSF, serum, and urine
(C) the elevation of substance $\mathrm{P}$ in the CSF is a result of lowered CSF substance $P$ esterase
(D) the elevation in CSF substance $\mathrm{P}$ is indicative of fibromyalgia
(E) A and B

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03:34

Problem 481

The management objectives for fibromyalgia are
(A) not specific because there is still no cure
(B) reestablish emotional balance
(C) improve sleep
(D) restore physical function
(E) all of the above

Melissa Geisel
Melissa Geisel
Numerade Educator
02:00

Problem 482

The shared decision concept
(A) is a method where half of the treatment decisions come from the physician and half come from the ancillary staff (physical therapists, massage therapists, etc)
(B) improves both patient and physician satisfaction
(C) must be used on selective patients because cultural background, beliefs, and religion can all inhibit its effectiveness
(D) A and B
(E) A, B, and C

Keronhica Desir
Keronhica Desir
Numerade Educator

Problem 483

A 60-year-old female recently diagnosed with fibromyalgia wants to discuss her treatment options. She is adamant about not taking medications. Which one of the following statements is false regarding her alternatives?
(A) Relaxation techniques like progressive muscle relaxation, self-hypnosis, or biofeedback have been recommended
(B) Cognitive behavioral therapies and support groups are efficacious is some patients
(C) Aerobic exercise can yield positive outcomes
(D) Heat and cold applications can provide relief
(E) Deep massage does more harm than good

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Problem 484

A PhD student comes with questions. She wants to know how dopamine and serotonin play a role in fibromyalgia pathogenesis. You tell her that
(A) dopamine levels directly correlate with pain levels
(B) tryptophan, serotonin, 5-hydroxytryptophan, and 5-hydroxyindole acetic acid have been found to be decreased in fibromyalgia patients
(C) the number of tender points in fibromyalgia patients have not been found to correlate with the concentration of serotonin in the serum
(D) dopamine agonists have been found to decrease pain in fibromyalgia patients
(E) B and D

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Problem 485

No treatments seem to be working for a 45year-old female with a 5-year history of fibromyalgia. She has talked to a relative who told her that oxycodone/acetaminophen works for all pain. How do you respond?
(A) Opioids work but only when a shortacting medication is combined with a long-acting medication
(B) In combination with pregabalin and duloxetine, hydromorphone has displayed incredible synergy in extremely depressed fibromyalgia patients
(C) Women with fibromyalgia have reduced $\mu$-opioid receptor availability within regions of the brain that normally process and dampen pain signals
(D) Fibromyalgia is so difficult to treat that you are willing to try anything that she thinks may help
(E) You are not opposed to trying opioids, but the potential hyperalgesia has been found to be significantly worse in patients with fibromyalgia

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Problem 486

Numerous medications have been used to treat the insomnia associated with fibromyalgia. Which one of the following has not been used?
(A) Amitriptyline
(B) Cyclobenzaprine
(C) Fluoxetine
(D) Clonazepam
(E) Pregabalin

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Problem 487

Pathophysiologic components of cancer pain can be
(1) somatic (nociceptive) pain
(2) sympathetic pain
(3) neuropathic pain
(4) central pain

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00:50

Problem 488

The skeletal sites most commonly involved in osteolytic metastatic processes are
(1) ribs
(2) humerus
(3) femur
(4) tibia

Grant Castaneda
Grant Castaneda
Numerade Educator
03:16

Problem 489

The primary compression of the spinal cord from metastatic deposits occurs in
(1) the thoracic spine in $70 \%$ of patients
(2) the lumbar spine in $20 \%$ of patients
(3) the cervical spine in $10 \%$ of patients
(4) multiple sites of the spine in $60 \%$ of patients

Vikash Ranjan
Vikash Ranjan
Numerade Educator

Problem 490

In a patient with skeletal metastases, bisphosphonates
(1) inhibit recruitment and function of osteoclasts
(2) stimulate osteoblasts
(3) have greatest effect in breast cancer and multiple myeloma
(4) have an acute pain-relieving effect

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Problem 491

The following substance(s) may be useful in treating a patient with a malignant disease:
(1) Gabapentin
(2) Amitriptyline
(3) Samarium 153
(4) Hydromorphone

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Problem 492

The following is (are) the possible compilation(s) of a neurolytic celiac plexus block:
(1) Persistent diarrhea
(2) Aortic pseudoaneurysm
(3) Intradiscal injection
(4) Damage to the artery of Adamkiewicz

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Problem 493

In a cancer pain patient, the following agent(s) can be used effectively via implantable intrathecal delivery system:
(1) Opioids
(2) $\alpha_2$-Adrenergic agonists
(3) Local anesthetics
(4) Ziconotide

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Problem 494

Which of the following conditions are the possible complications of chemotherapy in a cancer patient?
(1) Toxic peripheral neuropathy
(2) $\mathrm{PHN}$
(3) Avascular necrosis
(4) Pseudorheumatism

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Problem 495

As compared to younger subjects which of the following is correct about older people with pain?
(1) There may be difficulties in determining the etiology of pain in older people
(2) Older people generally receive significantly lower amounts of opioid analgesia
(3) There may be increased potency of opioids
(4) The majority of older people choose quantity of life over quality of life

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02:20

Problem 496

The goals of palliative care can be summarized as follows:
(1) To help those who need not die to live, and to live with the maximum of freedom from constraints on their quality of life arising from acute and chronic conditions of the body
(2) To help those who can no longer live to die on time - not too early and not late
(3) To help the dying, whether in hospital, nursing home, hospice, or at home, to die with dignity and in peace
(4) To administer euthanasia only to the patients who truly understand the fact that their condition is terminal and who personally request it

Sharon Edamala
Sharon Edamala
Numerade Educator

Problem 497

Peripheral neuropathy(ies) is (are) characterized by
(1) sensory loss
(2) fasciculations
(3) dysesthesias
(4) chronic pain

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11:32

Problem 498

Area(s) of acute pain processing in cortical and subcortical regions of the brain as determined by functional MRI include
(1) anterior cingulate cortex
(2) parietal cortex
(3) prefrontal cortex
(4) hypothalamus

NU
Noor Ul Ain
Numerade Educator

Problem 499

Small-diameter peripheral neuropathies are commonly painful. Example(s) of these neuropathies include
(1) Ross syndrome (segmental anhidrosis)
(2) Fabry disease
(3) Charcot-Marie-Tooth disease type 1
(4) diabetic neuropathy

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Problem 500

Chronic renal failure neuropathy is commonly manifested with
(1) restless leg syndrome
(2) painful neuropathy
(3) distal weakness
(4) selective loss of small nerve fibers

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Problem 501

Animal studies in neuropathic pain conditions have shown
(1) intraplantar injections of interleukin 1 (IL-1) reduces mechanical nociceptive threshold
(2) IL-1 hyperalgesia is mediated by bradykinin B-1 receptors
(3) effects of IL-1 on mechanical hyperalgesia seems to be mediated by prostaglandins
(4) IL-1 effects on nociceptions may be mediated by vagal afferents

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Problem 502

Potential complication(s) of stellate ganglion block include
(1) pneumothorax
(2) lesion of the recurrent laryngeal nerve
(3) neuritis
(4) Horner syndrome

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Problem 503

Important factor(s) involved in the development of neuropathic pain include
(1) behavioral studies have shown that NMDA is involved in the induction and maintenance of pain-related behaviors
(2) the spinal N-type voltage-dependent calcium channels are the predominant isoform involved in the pre-and postsynaptic processing of sensory nociceptive information
(3) tactile allodynia in the spinal nerve ligation model may be blocked by intrathecal $\mathrm{N}$-type $\mathrm{Ca}^{2+}$ blockers like ziconotide
(4) after nerve injury there is upregulation of the NMDA receptors

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Problem 504

Which of the following is (are) effect(s) of $\mu$-opioid agonists in neuropathic pain conditions?
(1) Decrease dynamic allodynia
(2) Decrease temperature threshold for cold pain
(3) Decrease static allodynia
(4) $\mu$-Opioid agonists do not have any beneficial effects in patients with neuropathic pain conditions

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04:53

Problem 505

Effect(s) of GABA in the modulation of afferent nociceptive input include
(1) $\mathrm{GABA}_{\mathrm{A}}$ produces postsynaptic inhibition via metabotropic receptors, which are ligand-gated $\mathrm{Cl}^{-}$channels
(2) the dominant type of inhibition of glutaminergic excitatory postsynaptic action potential is produce by GABA and/or glycine
(3) $\mathrm{GABA}_{\mathrm{B}}$ and adenosine produce postsynaptic hyperpolarization by activation of $\mathrm{K}^{+}$channels
(4) GABA and glycine produce slow activation of postsynaptic potentials

Prashant Bana
Prashant Bana
Numerade Educator
01:51

Problem 506

During the windup process
(1) sustained depolarization may recruit $\mathrm{K}^{+}$ channels, leading to decrease in the intracellular $\mathrm{Ca}^{2+}$ levels
(2) cumulative recruitment of NMDAreceptor current leads to progressive relief of the $\mathrm{Mg}^{2+}$ blockade of the NMDA-receptor pore
(3) more intense or sustained noxious peripheral stimulation induces a decrease in the release of neuromodulator peptides, leading to an excitatory state
(4) intracellular calcium levels play a major role in the development of windup

Lottie Adams
Lottie Adams
Numerade Educator
01:59

Problem 507

In patients with $\mathrm{PHN}$
(1) histopathologic studies in patients with PHN commonly show ganglion cell loss and fibrosis
(2) sensory loss function in the affected dermatome with increase heat pain perception is an almost universal finding
(3) antiviral drugs used in chronic PHN usually are ineffective in alleviating pain
(4) cold stimuli-evoked pain is more common than heat-evoked pain

Caroline Jones
Caroline Jones
Numerade Educator
03:09

Problem 508

The Special Olympics has brought together thousands of people with disabilities. Often enough, the race times in these events are significantly better than those of participants in the traditional games. In addition to undergoing the same type of grueling training regimens, however, participants in the Special Olympics often have to deal with difficulties performing activities of daily living as well as comorbidities associated with their primary disease. The likelihood that an amputee in a wheelchair race has phantom limb pain would be decreased if the
(1) participant is a young child
(2) participant is a male
(3) participant is a congenital amputee
(4) amputation is a below the knee amputation versus an above the knee amputation

Supratim Pal
Supratim Pal
Numerade Educator

Problem 509

A triple amputee (bilateral lower extremities, left upper extremity) presents to the pain clinic for work-up and treatment of phantom limb pain. This patient's pain most likely
(1) occurs intermittently
(2) is primarily localized to the fingers or palm of the hand in the upper extremity or toes, feet, or ankles in the bilateral lower extremities
(3) is of stabbing, shooting, or pins and needles character
(4) presents with attacks that last several minutes to an hour

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Problem 510

True statement(s) about phantom sensations is (are):
(1) They are less frequent than phantom pains
(2) They usually appear 1 month after the amputation
(3) The phantom sensation usually manifests as enlargement of the missing limb
(4) A common position of the phantom for upper limb amputees is the fingers clenched in a fist

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03:04

Problem 511

Which of the following is (are) example (s) of how the peripheral nervous system may play a role in phantom pain modulation?
(1) Dorsal root ganglion (DRG) cells display an altered expression pattern of different sodium channels
(2) Generation, but not maintenance of phantom pain by the sympathetic nervous system
(3) Long after limb amputation, injection of noradrenaline around a stump neuroma is reported to be intensely painful
(4) Phantom pain is directly related to the skin temperature of the stump

Bryan Valdivia
Bryan Valdivia
Numerade Educator
01:08

Problem 512

Phantom pains are often a replica of preamputation pain. It has also been noted that amputees with phantom pain have more often suffered from intense and long-lasting preamputation pain than have patients without phantom pain. These observations led to the premise that preemptive analgesia may help decrease postamputation pain. Of the studies done on this subject matter
(1) most have been of very poor methodological quality
(2) the two which included blinding and randomization showed no significant differences versus controls
(3) the aim has been to thwart spinal sensitization by blocking the cascade of intraneuronal responses that take place after peripheral nerve injury
(4) the sample size was always greater than 100

Cody Delk
Cody Delk
Numerade Educator

Problem 513

Which of the following dietary modification(s) should be made to alleviate symptoms of interstitial cystitis?
(1) Restrict spicy foods
(2) Eliminate alcohol intake
(3) Cease smoking
(4) Increase orange juice intake

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Problem 514

Sodium pentosan polysulfate (Elmiron)
(1) is an antispasmodic medication
(2) is an oral analogue of heparin
(3) alleviates symptoms of interstitial cystitis by relaxing smooth musculature
(4) increases antiadherent surface of the bladder lining

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02:47

Problem 515

Which of the following substance(s) is (are) thought to be involved in descending inhibition?
(1) GABA
(2) Serotonin
(3) Endogenous opioid peptides
(4) Norepinephrine

Cody Delk
Cody Delk
Numerade Educator

Problem 516

Which of the following is (are) the psychological factor(s) affecting pain response?
(1) Fear and helplessness
(2) Sleep deprivation
(3) Anxiety
(4) Cultural differences

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01:10

Problem 517

Which of the following is (are) psychological method(s) for reducing pain?
(1) Placebo and expectation
(2) Psychological support
(3) Procedural and instructional information
(4) Cognitive coping strategies

Asma Venkitta
Asma Venkitta
Numerade Educator

Problem 518

Gastrointestinal (GI) impairment in a postsurgical patient can be
(1) worsened by increased sympathetic activity because of severe pain
(2) contributed to by administration of opioids
(3) mitigated by early mobilization of the patient
(4) worsened by epidural blockade with local anesthetic

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Problem 519

Which of the following feature(s) suggest neuropathic pain?
(1) Pain in the area of sensory loss
(2) Good response to opioids
(3) Pain in response to nonpainful stimuli
(4) Absence of Tinel sign

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Problem 520

The correct corresponding vertebral levels for optimal epidural catheter placement for various surgical procedures are
(1) T10-12 for lower abdominal surgery
(2) T8-10 for upper abdominal surgery
(3) L2-4 for lower extremity surgery
(4) C7-T2 for upper extremity surgery

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Problem 521

Which of the following medications are useful in an inpatient management of a post-burn injury pain?
(1) Opioids
(2) Ketamine
(3) Benzodiazepines
(4) Nitrous oxide

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Problem 522

In patients with a traumatic chest injuries thoracic epidural analgesia has been shown to significantly improve inspiratory effort, negative inspiratory force, gas exchange, ability to cough, and ability to clear bronchial secretions. The following finding may be considered relative contraindications for epidural analgesia in a patient with posttraumatic chest injury:
(1) Inadequate coagulation function
(2) Spine fractures
(3) Inadequate intravascular volume resuscitation
(4) Concomitant head injury

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Problem 523

The most common characteristics of pain in PHN include
(1) steady burning or aching
(2) dull and poorly localized
(3) paroxysmal and lancinating
(4) usually not aggravated by contact with the affected skin

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01:21

Problem 524

Which of the following group(s) of medications was found to be useful in treatment of PHN?
(1) Opioids
(2) Antiepileptic drugs
(3) Topical agents
(4) Antidepressants

Maryam Riaz
Maryam Riaz
Numerade Educator

Problem 525

Which of the following is (are) true about interventional therapy for PHN?
(1) No proven surgical cure for PHN has been found
(2) Cryotherapy is likely to bring only short-term relief
(3) Topical lidocaine may provide effective analgesia for PHN
(4) Transcutaneous nerve stimulation (TENS) has been shown to give an effective symptomatic relief in some patients

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01:22

Problem 526

Antiviral agents in the acute phase of herpes zoster
(1) competitively inhibit DNA polymerase, terminating DNA synthesis and viral replication
(2) are generally well tolerated
(3) hasten healing of the rash
(4) may reduce the duration of $\mathrm{PHN}$

Shazia Naz
Shazia Naz
Numerade Educator
00:59

Problem 527

Oral steroids for acute herpes zoster
(1) are not currently recommended
(2) may provide pain relief in the acute phase
(3) have no benefit in prevention of $\mathrm{PHN}$
(4) have almost no side effects in patients with herpes zoster

Emily Terlap
Emily Terlap
Numerade Educator
01:46

Problem 528

Which of the following statement(s) is (are) true about diabetic amyotrophy?
(1) It is commonly associated with pain
(2) It responds well to a complicated multimodal treatment
(3) Involves weakness and atrophy of the involved muscles
(4) Sciatic nerve and its supplied muscles are most commonly affected

Aparna Shakti
Aparna Shakti
Numerade Educator

Problem 529

Charcot joint
(1) affects primarily weight-bearing joints
(2) can be caused by multiple causes other than DM
(3) is related to the destruction of afferent proprioceptive fibers
(4) is related to the destruction of efferent neural fibers

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01:46

Problem 530

Which of the following statement(s) about treatment of diabetic peripheral neuropathic pain (DPNP) is (are) true?
(1) Most of the antidepressants are Food and Drug Administration (FDA) approved for the treatment of DPNP
(2) Most therapies for DPNP result in more than $90 \%$ reduction in pain
(3) Most of the anticonvulsant drugs are FDA approved for the treatment of DPNP
(4) NSAIDs are the most commonly utilized medications

Aparna Shakti
Aparna Shakti
Numerade Educator

Problem 531

Treatment of painful diabetic neuropathy (PDN) rests on modification of the underlying disease and control of pain symptoms. In turn, the modification of the underlying disease includes strict glycemic control. Which of the following is (are) true?
(1) Tight glycemic control can halt or slow the progression of distal sensorimotor neuropathy
(2) Hemoglobin $\mathrm{A}_{1 c}$ target should be $<6 \%$
(3) Euglycemia is the ideal goal
(4) Weight loss and exercise program is an important part of glycemic control in a diabetic patient

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Problem 532

The current treatments of the PDN include
(1) antiepileptic drugs
(2) antidepressants
(3) opioids
(4) aldose reductase inhibitors

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Problem 533

The convulsive tic
(1) is more severe in males
(2) may indicate the presence of a tumor, vascular malformation, or ecstatic dilation of the basilar artery
(3) is because of presence of bilateral facial spasms
(4) is a result of painful periodic unilateral facial contractions

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Problem 534

Which of the following support(s) the diagnosis of idiopathic trigeminal neuralgia?
(1) Periods of weeks or months without pain
(2) Increase pain by commonly benign stimuli, like talking, eating, or washing
(3) Pain often alleviated by sleep
(4) Bilateral pain in the distribution of the trigeminal nerve, described as shooting or lancinating

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Problem 535

Which of the following is (are) true regarding trigeminal neuralgia?
(1) Very often, trigeminal neuralgia is the presenting symptom in patients affected with multiple sclerosis
(2) Trigeminal neuralgia is 20 times more common in patients with multiple sclerosis
(3) Trigeminal neuralgia tends to occur in the early stages of multiple sclerosis
(4) Bilateral trigeminal neuralgia is seen more often than expected in patients with multiple sclerosis

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Problem 536

The retrogasserian glycerol injection
(1) is a selective neurolytic agent with preference for sensory fibers, leaving intact motor neurons
(2) recurrence rates are the highest of all ablative techniques
(3) sensory loss is almost unseen in patients after this procedure
(4) sensory loss is less common than with radiofrequency thermocoagulation

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Problem 537

Which of the following is (are) true for trigeminal neuralgia?
(1) Trigeminal neuralgia is the most common cranial neuralgia
(2) It is more common in females
(3) The highest incidence is in elderly patients
(4) The disease most frequently linked with trigeminal neuralgia is multiple sclerosis

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Problem 538

Potential factors involved in the development of trigeminal neuralgia include
(1) ion channel upregulation in the area of the trigeminal injury
(2) focal demyelination
(3) up to $30 \%$ of patients with trigeminal neuralgia have arterial cross compression at the level root entry zone
(4) cell body degeneration in the trigeminal complex of the mesencephalon

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Problem 539

Spontaneous intracranial hypotension (SIH)
(1) the most common site of idiopathic dural tears is the lower lumbar region
(2) congenital subarachnoid or Tarlov cysts are a potential site for dural weakness and rupture
(3) the most obvious difference between PDPH and SIH, is the lack of postural symptoms in the second
(4) are no characteristic findings on MRI

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Problem 540

A common treatment for patients with $\mathrm{PDPH}$ is epidural blood patch (EBP). Which of the following is (are) true regarding this therapy?
(1) Maintenance of supine position for 2 hours after the patch provides higher chances for success
(2) As a result of the predominant caudad spread of the blood after EBP, a level of placement above the suspected dural tear is recommended
(3) The effectiveness of EBP is reduced when the dural tear was caused by a large-size needle
(4) The long-term relief of an initial EBP is close to $98 \%$

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Problem 541

The incidence of PDPH is between $1 \%$ and $75 \%$. Factor(s) that prevent its development at the time of dural puncture include
(1) use of an interlaminar approach
(2) use of intrathecal catheter
(3) bed rest after the puncture
(4) use of small-gauge spinal needle

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01:43

Problem 542

Diagnostic criteria for cervicogenic headache by the International Headache Society and the International Association for the Study of Pain (IASP) include
(1) unilateral headache
(2) relief of acute attacks by blocking the greater occipital nerve with local anesthetic
(3) aggravation of the headache with neck movements
(4) decrease range of neck motion

Anna Miller
Anna Miller
Numerade Educator
01:43

Problem 543

The cervicogenic headache
(1) has a prevalence of $0.4 \%$ to $2.5 \%$ in the general population and may account for up to $15 \%$ to $20 \%$ of patients with chronic headache
(2) is more common in females; a female to male ratio of 4 to 1
(3) mean age is the beginning of the fourth decade
(4) is aggravated by neck movement, and alleviated by occipital nerve block

Anna Miller
Anna Miller
Numerade Educator
01:30

Problem 544

The cortical spreading depression
(1) may produce the aura symptoms
(2) produces activation of the trigeminal nerve endings
(3) consist of decreased cerebral blood flow spreading forward from the occipital cortex
(4) is followed by generalized cerebral vascular dilation that explains the headache

Rikhil Makwana
Rikhil Makwana
Numerade Educator

Problem 545

In terms of migraine which of the following is (are) true?
(1) Migraine with aura is associated with an increase of cerebral blood flow that happens after the headache begins
(2) In migraine with aura there is a decrease of cerebral blood flow that starts after the headache begins
(3) In migraine without aura there is no change in cerebral blood flow
(4) In migraine without aura there is increase of cerebral blood flow before the headache begins

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03:04

Problem 546

Migraine is a risk factor for
(1) major depression
(2) manic episodes
(3) anxiety disorders
(4) panic disorders

Dennis Howard
Dennis Howard
Numerade Educator
01:50

Problem 547

Migraine happens in $18 \%$ of women, $6 \%$ of men, and $6 \%$ of children. Migraine usually
(1) begins in the first three decades of life
(2) is of higher prevalence in the fifth decade
(3) decrease symptoms in the last trimester of their pregnancy in most females
(4) is improved, common after surgical menopause

Nick Johnson
Nick Johnson
Numerade Educator
01:43

Problem 548

Tension-type headache
(1) is the result of sustained contraction of the pericranial muscles with subsequent ischemic pain
(2) has more common onset during adolescence and young adulthood
(3) has increased EMG activity in muscles with tenderness
(4) reduces CNS levels of serotonin that may be responsible for abnormal pain modulation

Anna Miller
Anna Miller
Numerade Educator
02:39

Problem 549

For any structure to be deemed a cause of low back pain, it must have the following characteristic(s):
(1) A nerve supply
(2) Be capable of causing low back pain in healthy volunteers
(3) Be susceptible to disease or injuries known to be painful
(4) Be shown to be a source of pain in a patient using diagnostic techniques of known reliability and validity

Sophie Knight
Sophie Knight
Numerade Educator
01:26

Problem 550

Randomized controlled trials (RCTs) have generated evidence-based conclusions for preventive interventions back and neck pain. Which of the following statement(s) is (are) true based on the evidence of RCTs?
(1) Lumbar supports are not effective in preventing neck and back pain
(2) Exercise may be effective in preventing neck and back pain
(3) Back schools are not effective in preventing back and neck pain
(4) Ergonomic interventions are effective in preventing back and neck pain

James Kiss
James Kiss
Numerade Educator

Problem 551

Anomalies of lumbar nerve roots include which of the following?
(1) Two pairs of nerve roots arise from a single dural sleeve
(2) A dural sleeve arises from a lower position in the dural sac
(3) The vertebral foramen is unoccupied by a nerve or contains a supernumerary set of roots
(4) Extradural anastomoses between roots in which a bundle of nerve fibers leaves one dural sleeve to enter an adjacent one

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14:16

Problem 552

Low back pain is defined as pain perceived within a region bounded
(1) superiorly by an imaginary line through the T12 spinous process
(2) inferiorly by a transverse line through the posterior sacrococcygeal joints
(3) laterally by the lateral borders of the erector spinae
(4) within the region overlying the sacrum

Paul A.
Paul A.
California State Polytechnic University, Pomona

Problem 553

Complications of cervical transforaminal injections include which of the following?
(1) Cerebellar infarction
(2) Cerebral infarction
(3) Spinal cord infarction
(4) Anterior spinal artery syndrome

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Problem 554

Discographic stimulation (formally known as discography) is considered positive if
(1) adjacent disc stimulation causes pain
(2) thermal stimulation with a wire electrode causes pain
(3) pain is reproduced at pressures greater than 80 psi
(4) pain is reproduced at pressures less than 50 psi and preferably less than 15 psi

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Problem 555

The use of chemonucleolysis for lumbar disc herniations is indicated for which of the following?
(1) Contained disc protrusions
(2) Extruded disc herniations
(3) Herniations unresponsive to nonsurgical management
(4) Sequestered disc herniations

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Problem 556

Causes of FBSS include which of the following?
(1) Inappropriate selection of patients
(2) Irreversible neural injury
(3) Inadequate surgery
(4) New injury to nerves and spine

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Problem 557

Selection criteria for elective lumbosacral spine surgery include
(1) radicular pain with corresponding dermatomal segmental sensory loss
(2) abnormal imaging study showing nerve root compression
(3) signs of segmental instability consistent with symptoms
(4) success of conservative therapy

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04:13

Problem 558

The main types of cervical involvement in rheumatoid arthritis include
(1) atlantoaxial subluxation
(2) cranial settling
(3) subaxial subluxation
(4) occipital condyle fractures

Mariana Roldan
Mariana Roldan
Numerade Educator
01:10

Problem 559

Whiplash and whiplash-associated disorders (WAD) comprise a range of injuries to the neck caused by or related to a sudden distortion of the neck. Characteristics include
(1) spinal cord injury (SCI)
(2) referred shoulder pain
(3) sensory deficits
(4) headaches

Mayukh Banik
Mayukh Banik
Numerade Educator

Problem 560

Distraction testing allows an examiner to identify neurologic and mechanical abnormalities in the cervical spine. It is characterized by
(1) relief of neck pain
(2) lifting head from the chin and occiput
(3) relief of pressure on zygapophyseal joints
(4) examiner standing in front of a standing patient

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Problem 561

A 45-year-old male with complaints of cervical neck pain radiating down his left arm is examined by a physician. With one particular maneuver, his pain is exactly reproduced. The test(s) that can reproduce his symptoms include
(1) distraction testing
(2) Valsalva test
(3) spurling maneuver
(4) Adson test

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01:10

Problem 562

The following are true about HIV infectionrelated neuropathies, EXCEPT
(1) inflammatory demyelinating polyneuropathies occur early in the course of HIV infection
(2) vasculitis-related neuropathies occur midcourse in HIV infection
(3) distal sensory neuropathies occur late in HIV infection
(4) HIV-related neuropathies tend to be nonspecific to the stage of HIV infection

Christina Sorrentino
Christina Sorrentino
Numerade Educator

Problem 563

Which of the following is (are) true about the predominantly sensory neuropathy of AIDS?
(1) The predominant symptom is pain in the soles of the feet
(2) Ankle jerks are often absent or reduced
(3) As symptoms of the neuropathy progress, they usually remain confined to the feet
(4) EMG demonstrate sensory, but not motor involvement

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Problem 564

Which of the following group(s) of medication(s) is (are) useful in treatment of pain in HIV and AIDS patients?
(1) Opioids
(2) Anticonvulsants
(3) Psychostimulants
(4) Antidepressants

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Problem 565

Pathophysiologic tissue injury in SCD generates multiple pain mediators. The facilitators of the pain transmission include
(1) bradykinin
(2) serotonin
(3) substance $P$
(4) dynorphin

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Problem 566

Which of the following established four components of SCD is responsible/associated with the patient's pain?
(1) Anemia and its sequelae
(2) Organ failure
(3) Comorbid conditions
(4) Pain syndromes

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Problem 567

Which of the following statement(s) is (are) true about avascular necrosis (AVN) and SCD?
(1) Core decompression is an effective treatment of late stages of the AVN
(2) Treatment of AVN is mostly symptomatic
(3) AVN affects mostly femoral head
(4) AVN is the most common complication of SCD in adults

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Problem 568

Which of the following statement(s) is (are) true about leg ulceration and SCD?
(1) Leg ulcers occur in $5 \%$ to $10 \%$ of the adult SCD patients
(2) Skin grafting is a very effective treatment for chronic leg ulcers in SCD patients
(3) Many leg ulcers heal within a few months with good localized treatment
(4) Regranex, used to treat leg ulcers, contains an autologous platelet-derived growth factor

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01:17

Problem 569

Management of painful vasoocclusive crises in SCD patients frequently employs supplemental oxygen. Which of the following is (are) true about the supplemental oxygen administration in SCD patients?
(1) Supplemental low-flow oxygen is often given to patients with SCD painful crisis in efforts to diminish the number of reversibly sickled cells
(2) There is little supportive data for the use of supplemental oxygen in SCD patients
(3) Routine oxygen administration in the absence of hypoxemia may impair reticulocytosis in SCD patients
(4) Routine oxygen administration in the absence of hypoxemia has no proven benefit in SCD patients

Niamat Khuda
Niamat Khuda
Numerade Educator

Problem 570

Which of the following statement(s) is (are) true about epidemiology of SCD?
(1) It is the most common hemoglobinopathy in the United States
(2) The prevalence is significantly higher in the African American population than in the general population
(3) It occurs in $0.3 \%$ to $1.3 \%$ of the African American population
(4) The prevalence of SCD does not depend on the ethnic background of the population

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Problem 571

Which of the following is (are) the measure(s) used to treat vasoocclusive crises of SCD during pregnancy?
(1) Aggressive hydration
(2) Supplemental oxygen in patients with hypoxemia
(3) Partial exchange transfusions
(4) Prophylactic transfusions

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Problem 572

When an opioid-tolerant patient in a sickle cell vasoocclusive crisis is admitted to a hospital, which of the following step(s) should be taken?
(1) A baseline opioid infusion should be started immediately at an equianalgesic dose to patient's home opioid requirement
(2) A baseline infusion should be supplemented with a patient-controlled analgesia (PCA) on demand for breakthrough pain
(3) As patient's new opioid requirement becomes known from the PCA history, conversion to a combination of longand immediate-release opioid can be undertaken
(4) Fast opioid dose increases may lead to hypoxemia and/or hypercarbia, which may exacerbate sickling of erythrocytes

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Problem 573

Autonomic dysreflexia
(1) is usually triggered by a spontaneous sympathetic discharge above the $\mathrm{SCl}$ level
(2) is rarely associated with headache
(3) is never life-threatening
(4) manifests itself with increased blood pressure

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Problem 574

Which of the following is (are) true about the anterior cord syndrome?
(1) It is characterized by complete sensory loss
(2) Prognosis for motor function recovery is very poor
(3) It is a complete SCI syndrome
(4) It is characterized by complete motor function loss

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Problem 575

Which of the following is (are) true about the posterior cord syndrome?
(1) It is characterized by preservation of temperature sensation
(2) It is characterized by preservation of normal gait
(3) It is uncommon
(4) It is characterized by preservation of proprioception

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Problem 576

Which of the following is (are) true feature(s) of Brown-Séquard SCI syndrome?
(1) Ipsilateral motor deficit
(2) Contralateral pain sensation deficit
(3) Contralateral temperature sensation deficit
(4) Uncommonness

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Problem 577

Anticonvulsants are commonly used for the treatment of neuropathic pain in the $\mathrm{SCI}$ patients. Which of the following correctly describe(s) their pharmacologic actions?
(1) Modulation of calcium channels
(2) Modulation of sodium channels
(3) Increase of GABA inhibition
(4) Blockade of reuptake of norepinephrine

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Problem 578

Which of the following is (are) the usual symptom(s) of the autonomic dysreflexia?
(1) Dramatic rise in blood pressure
(2) Flushing and sweating in areas above the SCI
(3) Marked reduction in peripheral blood flow
(4) Decline in heart rate

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01:38

Problem 579

Heterotopic ossification (HO) is commonly seen in patients with traumatic brain injury (TBI), cerebral vascular accident, burns, trauma, total joint arthroplasty, and SCI. Which of the following is (are) true about $\mathrm{HO}$ in $\mathrm{SCl}$ patients?
(1) It is always painful
(2) Hip is the most commonly affected
(3) It is defined as ossification inside the joint capsule
(4) Osteoclast inhibitors are use for both treatment and prophylaxis of $\mathrm{HO}$

Christina Sorrentino
Christina Sorrentino
Numerade Educator

Problem 580

CRPS in the initial stages may be associated with
(1) neurogenic inflammation
(2) higher local levels of tumor necrosis factor alpha
(3) high systemic CGRP levels
(4) Increase in protein concentration in fluid of affected joints

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Problem 581

Which of the following is true about motor abnormalities in CRPS?
(1) Dystonia of the hand or affected foot occurs in about $30 \%$ of the patients in the acute stages
(2) Decrease active range of motion and increase amplitude of physiological tremor is seen in about $50 \%$ of the patients
(3) They are likely related to an abnormal peripheral process
(4) They may be explained by abnormalities in the cerebral motor processing

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Problem 582

In terms of CRPS which of the following is (are) true?
(1) Incidence of CRPS is $20 \%$ after brain lesion
(2) Affected extremities after brain injury are at higher risk of developing CRPS than unaffected
(3) CRPS following SCI is frequent
(4) Upper extremities are more commonly affected than lower extremities

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Problem 583

Which of the following is true regarding bone scintigraphy?
(1) The three stages of the three-phase bone scan include the perfusion, blood-pool, and mineralization phases
(2) Homogeneous unilateral hyperperfusion in the perfusion phase is consistent with CRPS
(3) Homogeneous unilateral hyperperfusion in the blood-pool phase is consistent with CRPS
(4) Patients with CRPS show increase unilateral periarticular trace uptake in the mineralization phase

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01:18

Problem 584

Which of the following is true regarding $C$ fiber impulses?
(1) After sensitization, antidromic impulses to peripheral $\mathrm{C}$ fiber terminals release vasoactive substance
(2) Neurally released substances trigger neurogenic inflammation
(3) Neurogenic inflammation includes axonal reflex, vasodilation, and plasma extravasation
(4) C fiber activation peripherally releases CGRP and substance $\mathrm{P}$

Parvati Devi
Parvati Devi
Numerade Educator

Problem 585

The major peripheral pathologic finding(s) in patients with CRPS is (are)
(1) patch atrophy of some muscle cells
(2) capillary microangiopathy
(3) Wallerian degeneration
(4) generalized osteopenia

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Problem 586

Which of the following is (are) true regarding CRPS?
(1) Medical procedures are the second most common cause of CRPS
(2) Decrease deep tendon reflexes are a result of muscle atrophy
(3) Cutaneous dynamic mechanical allodynia is a hallmark of central sensitization
(4) Hypoesthesia may be rarely seen in patients with CRPS

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Problem 587

Characteristics of CRPS I in pediatrics include
(1) CRPS I is more common in girls
(2) the lower extremity is more often affected
(3) CRPS may have genetic predisposition
(4) CRPS is more common in Hispanics

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Problem 588

Characteristics of CRPS II in pediatrics include
(1) the incidence is similar in boys and girls
(2) brachial plexus injury during delivery commonly leads to chronic pain
(3) Erb palsy do not generally develop CRPS
(4) patients with Erb palsy need a comprehensive treatment to avoid the development of CRPS II

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Problem 589

To confirm the diagnosis of CRPS:
(1) There are no laboratory tests to confirm the diagnosis
(2) Disturbed vascular scintigraphy is necessary to make the diagnosis of CRPS
(3) Bone scan is nonspecific for the diagnosis of CRPS
(4) There is no utility in ordering bone scan in patients with CRPS

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Problem 590

Which of the following is true regarding movement disorders in CRPS patients?
(1) Motor dysfunction is the result of voluntary defensive response to protect the limb from painful stimuli
(2) Deep tendon reflexes in these patients are normal to brisk
(3) Movement disorders often happen in early stages of the disease
(4) Akinesia is a prominent finding in CRPS patients

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01:10

Problem 591

In terms of CRPS and dystonia, which is characterized by involuntary contractions of one or more muscles, it can be said that
(1) dystonia is a prominent feature of CRPS
(2) dystonia in patients with CRPS typically presents with flexure postures
(3) tonic dystonia often spares the first two digits
(4) extensor postures occur early in the development of dystonia

Joanna Quigley
Joanna Quigley
Numerade Educator
02:32

Problem 592

Supraspinal regulatory mechanisms that may explain some of the features of CRPS include
(1) spread of cortical representation of the affected limb
(2) patients with generalized dystonia have increased intracortical excitability to sensory stimuli
(3) motor cortical disinhibition
(4) early increase activity of the thalamus contralateral to the affected limb

Anand Jangid
Anand Jangid
Numerade Educator

Problem 593

Which of the following is (are) myofascial trigger point characteristic(s)?
(1) Weakness with muscle atrophy
(2) Referral of pain to a distant site upon activation of the trigger point
(3) Range of motion not restricted
(4) Autonomic phenomenon, such as piloerection or changes in local circulation (regional blood flow and limb temperature) in response to trigger point activation

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Problem 594

The definitive goal of treatment of persons with myofascial pain syndrome is (are)
(1) restoration of function through inactivation of the trigger point
(2) restoration of normal tissue mobility
(3) relief of pain
(4) increased range of motion

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Problem 595

Inactivation of the myofascial trigger point can be accomplished
(1) manually
(2) by direct injection of a local anesthetic into the muscle
(3) by dry needle intramuscular stimulation of the myofascial trigger point
(4) by correcting structural mechanical stressors

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Problem 596

With regard to trigger point injections, botulinum toxin which of the following is true?
(1) Has been tried unsuccessfully in myofascial trigger point inactivation
(2) Can cause a flulike myalgia
(3) Occasionally causes weakness that is confined to the area of injection
(4) Is a long-lasting trigger point injection capable of about a 3 month inactivation of the trigger point

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02:21

Problem 597

A 40-year-old female with chronic myofascial neck pain wants to go to an acupuncturist. She should know that
(1) in one study it was found that shallow needling reduced the pain of chronic myofascial neck pain
(2) in a randomized, double-blind, shamcontrolled study, acupuncture was found to be superior to dry needling in improving range of motion
(3) in a randomized, double-blind, shamcontrolled study, acupuncture was found to be better than placebo when treating trigger points in chronic neck pain
(4) in a randomized, double-blind, controlled study, acupuncture was found to be better than control only when it was followed by transcutaneous electrical stimulation

Gus Steppen
Gus Steppen
Numerade Educator

Problem 598

598. A 40-year-old woman comes to the pain clinic for initial evaluation. After a thorough history and physical examination, the patient is diagnosed with fibromyalgia. Which symptom(s) would support your diagnosis of fibromyalgia as opposed to myofascial pain syndrome?
(1) Widespread pain
(2) Irritable bowel syndrome
(3) Distal paresthesias
(4) Occipital headaches

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Problem 599

Which of the following is (are) true of fibromyalgia?
(1) Adult women are twice as likely to be affected as adult men
(2) Prevalence peaks in the fourth decade of life
(3) Many children diagnosed with fibromyalgia will have worsening of their symptoms as they reach adulthood
(4) Affects all ethnic groups

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03:25

Problem 600

Risk factors for the development of fibromyalgia syndrome include
(1) physical trauma
(2) febrile illness
(3) family history of fibromyalgia
(4) history of sexual abuse

Alyssa Mae L.
Alyssa Mae L.
Numerade Educator
01:44

Problem 601

Sleep disturbances are common in patients with fibromyalgia. Difficulties the patient may encounter include
(1) problems initiating sleep
(2) awakening in the middle of the night
(3) light, unrefreshing sleep
(4) difficulty napping throughout the day

Emily Himsel
Emily Himsel
Numerade Educator

Problem 602

Pathophysiologically, fibromyalgia
(1) is a disorder of abnormal processing of sensory information within the CNS
(2) exhibits a narrow array of recognized objective physiological and biologic abnormalities
(3) patients demonstrate abnormally low regional cerebral blood flow in thalamic nuclei and other pain-processing brain structures that is inversely correlated with spinal fluid substance $P$ levels
(4) demonstrates abnormal spinal cord windup

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Problem 603

That same patient (who happens to be a neurobiology graduate student) starts to ask about the role that cytokines play in fibromyalgia. You tell her that
(1) IL- 8 has been found to be significantly higher in the serum of fibromyalgia patients, especially in depressed patients
(2) IL-6 was not found to be increased in the blood of fibromyalgia patients
(3) the production of IL-8 in vitro is stimulated by substance $P$
(4) cytokines do not play a role in the pathogenesis of fibromyalgia

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Problem 604

Which of the following medications are FDA approved for the treatment of fibromyalgia?
(1) Cyclobenzaprine
(2) Duloxetine
(3) Tramadol
(4) Pregabalin

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03:29

Problem 605

The pain in fibromyalgia is, at least in part, mediated by central sensitization. Studies have shown that
(1) dextromethorphan and ketamine may improve pain and allodynia in fibromyalgia patients
(2) the majority of patients with fibromyalgia that tried ketamine benefited
(3) ketamine's efficacy was limited because of its side effects
(4) dextromethorphan had a similar sideeffect profile

Ian Kaigh
Ian Kaigh
Numerade Educator