15. pain - msk 6 · a.k.a. interdigital neuroma most common location: between _____ metatarsal...

PAIN

1. Patients with chronic pain can display:

A) Sleep fragmentation

B) Difficulty falling asleep

C) Decreased quality of sleep

D) All of the above

Chronic pain and Sleep

Studies have shown that patients suffering from chronic pain can suffer from:

❍ sleep disturbances

❍ ↑time to fall asleep

❍ sleep fragmentation

❍ ↓quality of sleep

2. All of the following are goals of chronic pain management EXCEPT:

A) Elimination of all pain

B) Return to work

C) Maximize activity and function

D) Restoration of a normal sleep cycle

Goals of chronic pain management

Return to work, Maximize activity and function, Restoration of a normal sleep cycle → The others are realistic goals

and will hopefully lead to normalization of function

Although elimination of all pain is a noble and desirable goal, it is not a realistic goal in patients with chronic pain.

3. What is the goal of chronic pain management?

A) Decrease the use of medications

B) Enable people with pain to function better and enjoy daily activities

C) Eliminate pain

D) Help people with pain return to their previous work

Goal of chronic pain management

To help people with pain _________ better and live rewarding lives.

Often the pain can be reduced, but not eliminated.

4. The majority of burns result from:

A) Fire/flame injuries

B) Scald injuries

C) Electrical injuries

D) Chemical injuries

Burns

60% of burns result from ________________.

Scald, electric, and chemical injuries only make up a minority of burn injuries.

5. Nociceptors are:

A) Pacinian corpuscles

B) Meissner corpuscles

C) Merkel’s disks

D) Free nerve endings

Nociceptors

________________ that transmit the sensation of pain.

There are thermal, chemical, and mechanical nociceptors for various stimuli.

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HB Kim, www.AcupunctureMedia.com

6. Phantom pain is a type of:

A) Neuropathic pain

B) Nociceptive pain

C) Psychogenic pain

D) Somatoform pain

Phantom pain

Pain from a part of the body that has been lost, or from which the brain no longer receives signals.

It is a type of neuropathic pain.

Phantom limb pain is a common pain experience of amputees.

Whereas phantom sensation is common, phantom pain is not and needs to be treated aggressively.

It is often described as shooting, crushing, burning, or cramping.

Nociceptive Pain Mixed Type Neuropathic PainCaused by activity in neural pathways in

response to potentially tissue‐damaging stimuli

Caused by a combination of both

primary injury and secondary effects

Initiated or caused by primary lesion or

dysfunction in the nervous system

Postoperative pain

Mechanical low back pain

Sports/exercise injuries

Sickle cell crisis

Arthritis

Postherpetic neuralgia

Neuropathc low back pain

Distal polyneuropathy (eg, diabetic, HIV)

Central post‐stroke pain

Trigeminal neuralgia

CRPS

7. Neuropathic pain, itchiness, and impaired sensation can occur as a result of burn injury involving nerve endings in which of the

following layers?

A) Epidermal

B) Dermal

C) Subcutaneous fat

D) Deep fascia

Neuropathic pain

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

8. A “sharp,” “burning,” “electric‐like,” or “skin‐sensitive” pain at the end of a residual limb is called:

A) Phantom pain

B) Stump pain

C) Neuroma

D) Causalgia

___________ pain (Amputation residual limb pain)

“sharp,” “burning,” “electric‐like,” or “skin‐sensitive” pain at the end of an amputated residual limb.

Unlike phantom pain, it occurs in the actual existing body part.

Due to a damaged nerve in the residual limb region, sometimes with neuroma formation.

A neuroma can cause pain and skin sensitivity.

Causalgia: present with other sympathetic‐mediated symptoms, such as swelling, hyper‐ or hypothermia, or

sweating in the acute stage.

9. The first line of treatment for bothersome phantom limb sensation, phantom limb pain, and residual limb pain is:

A) Desensitization techniques

B) Pharmacologic techniques

C) Biofeedback techniques

D) Use of transcutaneous electrical nerve stimulation (TENS) unit

____________________ techniques

Such as tapping, slapping, wrapping, and massaging the residual limb

Have been shown to ↓phantom limb pain and abnormal sensations.

Many patients find that wearing a prosthesis diminishes their phantom pain.

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10. TENS is often used for pain control and is an acronym for:

A) Tension simulator

B) Transcutaneous electrical nerve stimulation

C) Toxic epidermal necrolysis syndrome

D) Ten stimulation modes

TENS = ________________________________

A portable device that utilizes electrical stimulation for pain control.

Presumed to decrease pain via the gate controlled theory of pain.

11. A patient presents with pain over the lateral aspect of his elbow. The examiner fully extends the patient’s elbow, pronates the

forearm, and asks the patient to make a fist. He then resists the patient’s attempt to extend and radially deviate the wrist, eliciting pain

over the lateral elbow. This test is known as:

A) Hawkin’s test

B) Watson’s test

C) Cozen’s test

D) Yergason’s test

Lateral epicondylitis

_______ test positive

Medial epicondylitis Lateral epicondylitis

12. The most common location for an interdigital (Morton’s) neuroma is between which of the following metatarsal heads?

A) 1st and 2nd

B) 2nd and 3rd

C) 3rd and 4th

D) 4th and 5th

Morton’s neuroma

A.k.a. Interdigital neuroma

Most common location: between _________ metatarsal heads.

13. Allodynia is:

A) Pain resulting from a stimulus that does not normally produce pain

B) An increased painful sensation in response to additional noxious stimuli

C) A decreased sensitivity to painful stimuli

D) The absence of the sense of pain while remaining conscious

Allodynia

Hyperalgesia increased painful sensation in response to additional noxious stimuli

Analgesia absence of the sense of pain without losing consciousness and other sensations

Hypoalgesia decreased sensitivity to painful stimuli

14. Pain caused by a stimulus that does not normally provoke pain is known as:

A) Anesthesia

B) Allodynia

C) Hyperesthesia

D) Hyperalgesia

pain from a stimulus that ordinarily will not provoke pain

Anesthesia Loss of sensation

Hyperesthesia ↑sensation or sensitivity

Hyperalgesia ↑pain response from a normally painful stimulus (the degree of pain is disproportionate to the stimulus)

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15. An increased response to a stimulus that is normally painful is known as:

A) Anesthesia

B) Allodynia

C) Hyperesthesia

D) Hyperalgesia

Allodynia pain from a stimulus that ordinarily will not provoke pain

↑pain response from a normally painful stimulus (the degree of pain is disproportionate to the stimulus)

16. An unpleasant abnormal sensation, whether spontaneous or evoked, is known as:

A) Anesthesia

B) Allodynia

C) Dysesthesia

D) Hyperalgesia

unpleasant abnormal sensation, whether painful or evoked

Anesthesia loss of sensation

Dys Aesthesis

Not‐normal Sensation

17. Spondylolysis, a common cause of low back pain, is thought to arise secondary to:

A) Repetitive hyperflexion of the lumbar spine

B) Repetitive hyperextension of the lumbar spine

C) Repetitive side bending of the lumbar spine

D) Repetitive rotation of the lumbar spine

Spondylolysis

Refers to a defect of the pars interarticularis.

If a child, adolescent, or young adult presents with low back pain, spondylolysis should be high on the differential diagnosis.

It is thought to arise from _______________________________.

Sports such as football and gymnastics increase the risk of developing spondylolysis.

18. The most common level affected in a degenerative spondylolisthesis is:

A) L2‐L3

B) L3‐L4

C) L4‐L5

D) L5‐S1

Spondylolisthesis

Refers to the slippage of one vertebra relative to the one above it.

Can result from many causes.

In older patients who develop spondylolisthesis, most are degenerative in nature (usually caused by disc or facet disease).

Most commonly affects the _______ level.

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19. Fibromyalgia is characterized by:

A) Chronic widespread pain and tenderness

B) An elevated sedimentation rate

C) A rapid resolution with antibiotics

D) Bilateral median neuropathies at the wrist (CTS)

Fibromyalgia

Chronic ____________ pain and tenderness.

The specific diagnostic criterion is the presence in 11 or more of 18 characteristic tender points.

20. Which of the following is NOT true regarding fibromyalgia?

A) The peak prevalence is age 55 to 64

B) Tenderness to finger pressure must be present in at least 5 of 10 tender point sites

C) No specific etiology has been identified

D) Fibromyalgia is more common among women than men

Fibromyalgia

More common among women than men.

The average age of onset of fibromyalgia is between 30 and 50, with peak prevalence among women age 55 to 64.

No specific etiology has been identified.

Tender points (tenderness to approximately 4 kg/square inch which is about the pressure required to blanch the

examiner’s nail bed) must be present in at least _____ of _____ specific sites.

21. To diagnose fibromyalgia, widespread musculoskeletal pain must be present over a period of at least ______ months.

A) 2

B) 3

C) 6

D) 9

Fibromyalgia

Widespread musculoskeletal pain must be present over a period of at least ___ months.

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

22. Which of the following is true regarding discogenic lumbar pain?

A) There is strong familial predisposition to discogenic lumbar pain

B) Intradiscal pressures increase when one changes his/her position from sitting to standing

C) There is a strong association between discogenic lumbar pain and alcoholism

D) For non‐radicular low back pain with degenerative disk disease, fusion appears to have a superior outcome when compared with

standard nonsurgical therapy and also be better than intensive interdisciplinary rehabilitation

Discogenic lumbar pain

Pain syndrome that originates from a lumbar disc.

Broadly degenerative disc disease (DDD) is a cause of discogenic back pain

Most common cause of lower backache.

There is strong familial predisposition to discogenic lumbar pain.

Associated with advanced age, male sex, and smoking.

Intradiscal pressure is higher in the sitting position than in the standing position.

For non‐radicular low back pain with degenerative disk disease, fusion does not appear to be better than

intensive interdisciplinary rehabilitation.

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23. The lifetime prevalence of low back pain has been shown to be as high as:

A) 95%

B) 84%

C) 73%

D) 66%

Lower back pain

The lifetime prevalence of low back pain has been shown to be as high as _____.

24. Which of the following structures lacks innervation and therefore CANNOT transmit pain?

A) Anterior vertebral body

B) Posterior longitudinal ligament

C) Anterior longitudinal ligament

D) Internal annulus fibrosus

___________________

The sinuvertebral nerve innervates the anterior vertebral body, the external annulus, and the posterior longitudinal ligament.

The anterior longitudinal ligament is innervated by the gray rami communicans, which branch off the lumbar sympathetic chain.

The internal annulus fibrosus and nucleus pulposus do not have innervations.

25. A 60‐year‐old obese woman presents to you for initial evaluation of left lower extremity pain, associated with numbness and tingling.

She states that the pain is located in the posterior thigh and radiates down to the calf. The patient is having a difficult time with toe

walking. On the basis of her description, you expect which of the following nerve roots to be involved?

A) L4

B) L5

C) S1

D) S2

S1

S1 affects sensation in the posterior thigh and calf.

walking is affected because the gastrocsoleus muscle is affected.

L4 L5 S1

Motor weakness Extension of quadriceps Dorsiflexion of great toe and foot Plantar flexion of great toe and foot

Screening Exam Squat & rise _______ walking _______ walking

Reflexes Knee jerk diminished None reliable Ankle jerk diminished

26. Which of the following side effects has been seen with long‐term use of high‐dose opioids?

A) Increased lactation

B) Decreased libido

C) Increased cortisol response to stress

D) Hostility and anxiety

Chronic use of high‐dose opioids

Has been shown to _______________ in men and women, and to cause amenorrhea and a reduced cortisol response to stress.

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27. Which of the following medications is not effective in treating chronic low back pain?

A) Tramadol

B) Tricyclic antidepressants

C) Nonsteroidal anti‐inflammatory drugs

D) Systemic steroids

Chronic low back pain

Effective treatments: Tramadol, TCA, NSAID

Multiple studies have found systemic steroids NOT to be effective for chronic low back pain.

28. A 55‐year‐old man who works in construction presents with pain over his upper back. He states that he bent over to lift a heavy

object and felt a sharp pain midline. On examination, he has obvious spasm with tenderness to palpation over his paravertebral muscles

in the region of T7‐T9. Neurological examination is within normal limits. You make the diagnosis of:

A) Discitis

B) Thoracic radiculopathy

C) Vertebral fracture

D) Thoracic sprain/strain

_________________________

Usually occurs with heavy lifting or excessive repetitive motion.

Sprain refers to injury to ligaments, whereas strain refers to injury to muscle.

Sprain/strain commonly presents with pain and muscle spasm.

The neurological examination should be normal.

Ligament Tendon

bone to bone muscle to bone

↓ ↓

29. Occipital neuralgia refers pain in the distribution of the:

A) Temporal nerve

B) Lingual nerve

C) Greater and lesser occipital nerves

D) Facial nerve

Occipital neuralgia

Usually caused by an entrapped nerve root at the neck, usually C2 level, supplying the _______________________.

At times, the nerve can be entrapped more cephalad, as the nerve courses through muscles in the neck or the posterior scalp.

Patients will present with shooting pain and/or scalp hypersensitivity to light touch.

30. The phenomenon when an initial dose of a substance loses its effectiveness over time, requiring a higher dose to achieve that same

effect is known as:

A) Dependence

B) Addiction

C) Tolerance

D) Withdrawal

_______________

The phenomenon when an initial dose of a substance loses its effectiveness over time, requiring a higher dose to

achieve that same effect is known as Tolerance.

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15. pain - msk 6 · a.k.a. interdigital neuroma most common location: between _____ metatarsal...

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