AAPM/Anatomy

Question 1

nutrition to the lumbar intervertabral disk is from the

Answer 1

lumbar artery

Question 2

The most common presenting symptom of rheumatoid arthritis is

Answer 2

neck pain

Question 3

The usual site of herniation of a cervical intervertebral disk is

Answer 3

posterolateral

Question 4

The carotid tubercle (chassaignac tubercle) is located at the

Answer 4

transverse process of the C6 vertebra

Question 5

the stellate ganglion is located

Answer 5

anterior to the neck of the first rib and the transverse process of the C7 vertebra

Question 6

A woman with CRPS develops Horner’s after a stellate ganglion block - what is the most likely cause?

Answer 6

Anomalous Kuntz nerves

Question 7

The greater occipital nerve is a branch of

Answer 7

posterior ramus of C2

Question 8

Numbness to the index and middle fingers and weakness in the triceps is most likely caused by

Answer 8

herniated nucleus pulposus of the C6-7 disc causing compression of the C7 nerve root

Question 9

Blood supply to the spinal cord is by

Answer 9

2 posterior spinal arteries and one anterior spinal artery

Question 10

The most common origin of the artery of Adamkiewicz is

Answer 10

between T8 and L3

Question 11

The most common location of the dorsal root ganglion is

Answer 11

directly below the pedicle

Question 12

Absolute central lumbar spinal stenosis is defined as

Answer 12

less than 10mm diameter

Question 13

Absolute central lumbar spinal stenosis is defined as

Answer 13

less than 10 mm diameter

Question 14

The principal action of the quadratus lumborum muscle is

Answer 14

fixation of the 12th rib during respiration

Question 15

Which structure passes under the inguinal ligament

Answer 15

lateral femoral cutaneous nerve

Question 16

The structure that passes under the flexor reticulum of the wrist is

Answer 16

median nerve

Question 17

A boxer complains of pain in his hand after punching bag. What is the most likely cause?

Answer 17

Metacarpal fracture

Question 18

In the dorsal horn of the spinal cord

Answer 18

stimulation of lamina I and II produces pain

Question 19

In a case of an injury of a peripheral nerve the rate of regeneration is

Answer 19

The rate of regeneration is 1mm/d

Question 20

neuropraxia is

Answer 20

loss of conduction of a nerve

Question 21

The following is true about pain except

a) transmitted faster through C fibers
b) some pain may travel through the dorsal column
c) u-receptors when stimulated in the brain produce analgesia
d) intractable pain due to cancer cannot be effectively treated by hypophysectomy
e) transmitted slower by C fibers

Answer 21

a) transmitted faster through C fibers

Question 22

A-d fibers

Answer 22

increase their firing as the intensity of the stimulus increases

Question 23

All of the following statements are true regarding fentanyl as a good agent for transdermal use, except

a) low molecular weight
b) adequate lipid solubility
c) high analgesic potency
d) low abuse potential
e) high molecular wt

Answer 23

e) high molecular weight

Question 24

All of the following are a2 agonists except

a) clonidine
b) antipamezole
c) tizanidine
d) dexmedetomidine
e) baclofen

Answer 24

b) antipamezole

Question 25

The antidepressent with the lowest sedation is

Answer 25

despramine

Question 26

methodone in addition to being a u receptor agonist has been proposed to aslo act as a

Answer 26

NMDA receptor antagonist

Question 27

The cricoid cartilage corresponds with the following vertebra

Answer 27

C6

Question 28

Rotation of the cervical spine occurs at

Answer 28

AA joint

Question 29

The nucleus pulposus in the cervical spine is absent after the age

Answer 29

40 years

Question 30

Kuntz nerves are a contribution from

Answer 30

the T2 sympathetic fibers to the upper extremity

Question 31

Achilles reflex is diminished when which nerve root is affected

Answer 31

S1

Question 32

The dermatome corresponding to the area over the medial malleolus is

Answer 32

L4

Question 33

The medial branch of the dorsal rami innervates

Answer 33

multifdus muscle

Question 34

The psoas major muscle is

Answer 34

hip flexor

Question 35

The principal action of the piriformis muscle is

Answer 35

external rotation of the femur

Question 36

The lumbar facet joint is innervated by

Answer 36

branches from the dorsal ramus at the same level and level above

Question 37

The lumbar facet joints are oriented

Answer 37

45 degrees off the saggital plane

Question 38

The nerve involved in meralgia paresthetica

Answer 38

lateral femoral cutaneous nerve

Question 39

The lumbar sympathetic chain lies

Answer 39

anterolateral border of the lumbar vertebral bodies

Question 40

A 56 yo man presents with pain in the left flank. He gives a history of a rash for 1 week. The pain is burning in character and is sensitive to touch. He most likely has

Answer 40

herpes zoster

Question 41

Pain in the gluteal region produced by hip flexion, adduction, and internal rotation is caused by

Answer 41

piriformes muscle

Question 42

which nerves conduct nociceptive stimuli

Answer 42

a-d and C-fibers

Question 43

Arrange the nerves according to conduction velocity - fastest to slowest

Answer 43

A-a, A-b, A-d, B, C

Question 44

The impulse traveling through the C-fiber terminates in the rexed laminae

Answer 44

1,2,5

Question 45

Some of the naturally occurring chemicals involved in nociceptive input are hydrogen ions, serotonin, and bradykinin. What effect do these have on the nociceptors?

Answer 45

activates the nociceptors

Question 46

substance P release from the dorsal horn neuronal elements is blocked by

Answer 46

both type of opioids

Question 47

arrange the visceral structures - hollow viscera, solid vescera, serosal membranes - in the order of increasing sensitivity to noxious stimuli

Answer 47

solid viscera, hollow viscera, serosal membranes

Question 48

visceral pain is typically felt as

Answer 48

dull and vague

Question 49

hollow viscera can be painful during which type of contractions

Answer 49

isometric

Question 50

silent nociceptors were first identified in

Answer 50

joints

Question 51

visceral referred pain with hyperalgesia can be explained by which of the following

Answer 51

viscerosomatic convergence

Question 52

enkephalins and somatostatin - are these types of neurotransmitters

Answer 52

inhibitory

Question 53

There are several subtypes of NMDA receptors, they are

Answer 53

NR1, NR2 (A, B, C, D)

Question 54

Sodium channels are also important in neurotransmission through the dorsal root ganglion. How many different types of sodium channels have been identified?

Answer 54

9

Question 55

ziconotide, found in snail venom, acts primarily on which type of calcium channel?

Answer 55

N-type

Question 56

Pretreatment with an NMDA antagonist prior to inflammation has been shown to

Answer 56

attenuate central centization

Question 57

NMDA receptor channels are usually inactive and blocked by zinc and magnesium ions. A depolarization of the cell membrane removes these ions and allows influx of which ions?

Answer 57

Sodium and calcium

Question 58

nociceptive stimuli cause increased activity in the cerebral cortex in

Answer 58

widespread areas in the temporal cortex

Question 59

Gaba receptors are these types of ion channels

Answer 59

chloride

Question 60

nociceptors are present in

Answer 60

skin, subcutaneous tissue, joints and visceral tissue

Question 61

substance P is released by the activation of nociceptors and has the following effects

Answer 61

vasodilation and mast cell activation

Question 62

visceral pain terminates in the following Rexed lamina(e)

Answer 62

Laminae 1, 2,5, 10

Question 63

The visceral pain may be felt as pain in

Answer 63

the midline, unilateral, bilateral, multiple patterns

Question 64

which of the following induce pain in hollow viscera

Answer 64

ischemia, distension

Question 65

viscera are supplied by sympathetic nerves which contribute to pain generation and transmission. The release serveral chemical substances including the following

Answer 65

norepinephrine, histamine, serotonin,

Question 66

neurotransmitters in the CNS are classified into which of the following

Answer 66

excitatory, inhibitory and neuropeptides

Question 67

excitatory neurotransmitters

Answer 67

glutamate, aspartate

Question 68

NMDA receptor blockade in the spinal cord causes

Answer 68

inhibition of pain transmission | reduction in pain transmission

Question 69

The subunit most relevant in nociception is

Answer 69

NR2B and NR1

Question 70

RA vs. osteoarthritis

Answer 70

RA is an inflammatory polyarthritis that typically affects young to middle-aged women. They present with a joint pain and stiffness in the hands. Typically the first metacarpophalanegeal joint is affected whereas in osteoarthritis the carpometacarpal joint is affected. They have a history for morning stiffness.

Question 71

uncinate processes

Answer 71

bony protrusions located laterally from the C3-C7 vertebrae. They prevent the disk from herniating laterally.

Question 72

fracture of what bone after falling on an outstretched hand

Answer 72

scaphoid bone in wrist or | fracture of the distal radius is also known as a Colles fracture

Question 73

ketamine and memantine are NMDA receptor

Answer 73

blockers

Question 74

the most important substanaces found in the descending inhibitory pathways of the CNS include

Answer 74

serotonin and NE

Question 75

The most relevant calcium channel to pain impulse transmission in the spinal cord is

Answer 75

N-type

Question 76

N-type calcium channels are highly concentrated in the

Answer 76

DRG and dorsal horn

Question 77

windup is a phenomenon that occurs due to constant input of C-fiber activity to the spinal cord. This phenomenon defines

Answer 77

increase in excitability of spinal neurons in the dorsal horn

Question 78

primary inhibitory neurotransmitters include

Answer 78

glycine and GABA

Question 79

excitatory neuropeptides in the CNS include

Answer 79

substance P and neurokinin A

Question 80

Serotonin is released as mediator as a result of tissue injury from

Answer 80

platelets and mast cells

Question 81

protease-activated receptors were detected in

Answer 81

platelets, endothelial cells, fibroblasts, nervous system

Question 82

Increased nerve growth factor (NGF) levels observed after inflammatory stimuli result from increased synthesis and release of NGF from cells in the affected tissue. Large number of stimuli can alter NGF production including

Answer 82

2IL-1b, IL-4, IL-5 tumor necrosis factor a and transforming growth factor b platelet derived growth factor epidermal growth factor

Question 83

endogenous opioid peptides are important in nociceptive perception and modulation and include

Answer 83

leucine-enkephalin, dynorphin, methionine-enkephalin, nociception

Question 84

Nociceptors are specific receptors within the superficial layers of the skin

Answer 84

False

Question 85

Conduction verlocity of A-d fibers is faster than the c-fibers

Answer 85

true

Question 86

Nociceptive impulse terminates in nociceptive-specific as well as wide dynamic range neurons

Answer 86

true

Question 87

hyperalgesia can only occur with somatic nociceptive stimuli and not visceral stimuli

Answer 87

false

Question 88

nmda receptor in the spinal cord dorsal horn is essential for central sensitization, the central facilitation of pain transmission produced by peripheral injury

Answer 88

true

Question 89

neuropeptides are only excitatory in nature

Answer 89

false

Question 90

common causes of actue abdominal pain in adults include

Answer 90

diabetic ketoacidosis in an elderly paitent without a previous history of diabetes

Question 91

The ulnar nerve is commonly compressed

Answer 91

at the cubital tunnel

Question 92

The most convincing evidence of a cluster headache is

Answer 92

the headaches are occurring at the same time each night

Question 93

recent evidence as shown that migrain headaches involve the mechanism of

Answer 93

cortical spreading depression

Question 94

zygapophysial joint arthropathy

Answer 94

cadaveric studies of the facet joints in patients have revealed histologic changes

Question 95

postmastectomy neuromas

Answer 95

neuromas are most likely the cause of a painful scar

Question 96

fibromyalgia syndromes

Answer 96

both primary and secondary

Question 97

endometriosis

Answer 97

if diagnosed a the time of laparoscopy, laparoscopic surgery should be the first choice of treatment

Question 98

upper extremity symptoms and thoracic outlet syndrome

Answer 98

symptoms following a fractured clavicle

Question 99

psoriatic arthritis - which joints typically involved

Answer 99

distal interphalangeal joints

Question 100

pain and HIV

Answer 100

distal symmetrical polyneuropathy is the most common peripheral nerve disorder associated with HIV

Question 101

first symptom of syringomyelia

Answer 101

central pain

Question 102

primary burning mouth syndrome

Answer 102

chronic, idiopathic intraoral pain condition that is not accompanied by clinical lesions; some consider it a painful neuropathy

Question 103

cervical carotid artery dissection and pain

Answer 103

most commonly presents with neck, head or facial pain

Question 104

causative agents of pain in pseudogout

Answer 104

calcium pyrophosphate crystals

Question 105

tarsal tunnel syndrome

Answer 105

compression of the posterior tibial nerve as it passes by the medial malleolus

Question 106

most common cause of pelvic pain in women

Answer 106

endometriosis

Question 107

nociception and pleura

Answer 107

parietal pleura does not contain any nociceptive innervation, the visceral pleura does

Question 108

repetitive strain injury

Answer 108

controversial diagnosis partially because there are few studies showing an associateion between physical risk factors and injury

Question 109

axillary dissection from a mastectomy may cause chest pain because

Answer 109

axillary dissection poses risks to the intercostobrachial nerve and the medial cutanous nerve of the arm

Question 110

post herpetic neuralgia is pain that persists more than

Answer 110

120 days

Question 111

chronic pancreatitis

Answer 111

excessive alcohol use plays a role in up to 70% of adults, whereas genetic and structural defects predominate in children Pain is commonly described as mid-epigastric postprandial pain that radiates to the back and can sometimes be relieved by sitting upright or leaning forward autoimmune pancreatitis accounts for 5%

Question 112

The most common presenting complaint of a tumor affecting the brachial plexus is

Answer 112

pain

Question 113

withdrawal syndromes from intrathecal baclofen can be

Answer 113

fatal

Question 114

phantom sensations are more vivid in the

Answer 114

distal extremity

Question 115

a complaint along the deltoid has been shown to correlate with the

Answer 115

rotator cuff

Question 116

L4 nerve involvement

Answer 116

weakness of leg extension and loss of patellar reflex

Question 117

S1 nerve involvement

Answer 117

loss of sensation over the bottom of the foot, achilles reflex is normal

Question 118

part of the brain that mediates drug craving

Answer 118

amygdala

Question 119

one of the brain's rewards centers

Answer 119

nucleus accumbens

Question 120

nucleus locus ceruleus

Answer 120

arousal attention and anxiety

Question 121

anterior cingulate cortex

Answer 121

functional part of the limbic system

Question 122

seizure activity is more likely seen with which opioid

Answer 122

meperidine - especially in elderly patients

Question 123

respiratory depression and opioids

Answer 123

apneic threshold is decreased

Question 124

what would likely give you the greatest incidence of delayed respiratory depression

Answer 124

epidural morphine

Question 125

opioids in general reduce the sympathetic output and produce a dose dependent bradycardia except

Answer 125

meperidine

Question 126

what is the main mechanism by which opioids produce analgesia

Answer 126

coupling of opioid receptor to potassium and calcium channels, inhibiting neurotransmitter release (presynaptic) and inhibiting neuronal firing (post synaptically)

Question 127

main mechanism of spinal opioid analgesia is via

Answer 127

activation of presynaptic opioid receptrs

Question 128

opioids act on what receptors

Answer 128

u, d, k, ORL, voltage-dependent sodium channels, a2b-adrenoreceptors and NMDA receptors

Question 129

one important characteristic of methadone that has to be considered when prescribing it on an outpatient basis

Answer 129

sedation and respiratory depression outlast the analgesic action

Question 130

what property of methadone makes it a good option for opioid rotation, when tolerance develops

Answer 130

NMDA antagonist

Question 131

which is the only opioid with prolonged activity not achieved by controlled release formulation

Answer 131

methadone

Question 132

which opioid is used in the treatment of addiction

Answer 132

buprenorphine

Question 133

pharmacologc properties of fentanyl that make it an ideal drug for transdermal and transmucosal administration

Answer 133

high lipid solubility, low molecular weight, high potency

Question 134

what is a long and cumbersome research tool for substance abuse and is very good but not ver practical in the setting of a busy pain clinic

Answer 134

addiction severity index

Question 135

An opioid specific five-minute self administered tool which can be completed in less than 5 minutes to help predict patients at high risk for exhibiting aberrant opioid related behavior is

Answer 135

opioid risk tool

Question 136

the opioid which is largely metabolized by CYP3A4 is

Answer 136

fentanyl

Question 137

an opioid specific instrument which may be useful in predicting opioid misuse and is available as a 5, 14, or 24 item questionnaire as well as a revised version designed to be less susceptible to overt deception than the original version is

Answer 137

screener and opioid assessment for patients with pain

Question 138

a classic example of an opioid partial agonist is

Answer 138

buprenex

Question 139

a popular nmemonic for following relevant domains of outcome in pain management for patients on long term opioid therapy is the so called 4 As which include all the following

Answer 139

analgesia, activities of daily living, adverse events, aberrant drug taking behaviors

Question 140

a popular pain assessment scale which is utilized by preverbal toddler and nonverbal children through age 7 who may be treated with opioids is

Answer 140

FLAC C

Question 141

the opioid which as some component of metabolism of CYP1A2 is

Answer 141

methadone

Question 142

the opioid which is a metabolite of oxycodone via 3-0 demthylation is

Answer 142

oxymorphone

Question 143

oral transmucal fentanyl citrate against the buccal mucosa - bioavailability is... total dose absorbed from gI tract is...

Answer 143

50% bioavailability | 25 % GI absorption, escaping hepatic and intestinal first pass effect

Question 144

fentanyl buccal tablet

Answer 144

utilizes effervescent drug delivery system and achieves a bioavailability of 65%

Question 145

after IM administration of fentanyl - time to onset of analgesia

Answer 145

7-15 minutes

Question 146

oral bioavailability of morphine is

Answer 146

25-35%

Question 147

methadone acts as a

Answer 147

pure U agonist

Question 148

A tool which documents a uantitative assessment of various opioid adverse effects is the

Answer 148

numerical opioid side effect (NOSE)

Question 149

most prescribed opioid in the US, which also undergoes O-desmethylation to dihydromorphine and its major metabaolites excreted into the urine are dihydrocoidein and nordihydrocodeine

Answer 149

hydrocodone

Question 150

which receptor is responsible for opioid induced respiratory depression

Answer 150

u-receptor

Question 151

propoxyphene napsylate has a higher maximum daily dose than propoxyphene hydrochloride because

Answer 151

the napsylate salt tends to be absorbed more slowly than the hydrochloride

Question 152

when considering opioid rotation to methadone which of the following is the most appropriate next step

Answer 152

reduce the dose by 75-90%

Question 153

when considering opioid rotation to fentanyl, which is the most appropriate next step

Answer 153

maintain equianalgesic dose

Question 154

the equianalgesic conversion ratio of oral oxymorphone to iv morphine is

Answer 154

1 to 1

Question 155

by approximately what percentage is codein ineffective as an analgesic in the caucasion population owing to genetic polymorphisms in cyp2d6 (the enzyme necessary to o-methylate codein to morphine)

Answer 155

10%

Question 156

NSAIDS act mainly in the

Answer 156

periphery

Question 157

what are the advantages of CoX-2 inhibitors vs. NSAIDs

Answer 157

less GI effects

Question 158

MOA of traditional NSAIDs

Answer 158

inhibition of prostaglandin G/H synthase enzymes

Question 159

the main role of prostaglandins in pain is

Answer 159

sensitization of peripheral nociceptors

Question 160

the effect of NSAIDs on renal function may include

Answer 160

chronic interstitial nephritis

Question 161

What laboratory value is most compatible with of platelet dysfunction caused by NSAIDs

Answer 161

below the upper limits of normal to mildly prolonged bleeding time

Question 162

the duration of aspirin effect is related to the turnover rate of cox in different target tissues because aspirin

Answer 162

irreversibly inhibits cox activity

Question 163

the unique sensitivity of platelets to inhibition by low doses of aspirin is related to

Answer 163

presystemic inhibition of platelets in the portal circulation

Question 164

how long before surgery are NSAIDs advised to be stopped

Answer 164

2-3 days

Question 165

which of the following NSAID is as effective as morphine

Answer 165

ketorolac

Question 166

rare side effect of NSAID is

Answer 166

potentially fatal hepatic necrosis

Question 167

oxycarbazepine is

Answer 167

a sodium channel blocker

Question 168

adverse effects of pregabalin

Answer 168

constipation, dizziness, blurred vision, dry mouth

Question 169

gabapentin

Answer 169

first line drug for PHN and diabetic neuropathy - reduce dose in renal insufficiency - thought to inhibit voltage dependent calcium channels - chemical structure similar to GABA

Question 170

zonisamide

Answer 170

sulfonaminde drug - sodium channel blocker - 40-50% protein bound - may potentially lead to renal calculi

Question 171

what is the best way to use aed to treat pain

Answer 171

combine with anti-depressants

Question 172

the antidepressant with the least anticholinergic and least sedating effect is

Answer 172

desipramine

Question 173

which antidepressant selectively inhibits serotonin reuptake with minimal effect on norepinephrine reuptake

Answer 173

paroxetine

Question 174

the most common adverse effects associated with TCAs are

Answer 174

anticholinergic effects

Question 175

The least common adverse effects associated with TCAs are

Answer 175

seizure

Question 176

compared to TCAs, SSRIs

Answer 176

have less side effects

Question 177

tramadol

Answer 177

- opioid characteristics - dose limit of 400mg/d - centrally acting analgesic - inhibits reuptake of NE and serotonin

Question 178

the benzodiazepine which is used to treat various neuropathic pain syndromes is

Answer 178

clonazepan

Question 179

carisoprodol antidote

Answer 179

flumazenil

Question 180

tizanidine is an

Answer 180

a 2 agonist

Question 181

ziconotide

Answer 181

- derived from conus sea snail venom - a synthetic form of cone snail peptide (conotoxin) - N-type calcium channel blocker - common side effects are dizziness, confusion and headache

Question 182

Capsaicin

Answer 182

- member of the vanilloid family which binds to the TRPV1 receptor - commercially available in 0.025% and 0.075% concentrations - active component of chili peppers - depletes presynaptic substance P

Question 183

side effects of lidocaine 5% patches

Answer 183

edema erythema abnormal sensation exfoliation

Question 184

calcitonin can be used as an adjuvant drug for

Answer 184

phantom limb pain sympathetically maintained pain cancer bone pain osteoporosis pain

Question 185

Regarding the effects produced by different subtypes of opioid receptors

Answer 185

opioid receptors mostly affect phosphorylation through G protein coupling opioid receptors act both presynaptically and post synaptically

Question 186

The use of pure opioid agonists are preferred in chronic pain patients because of their

Answer 186

superior analgesic efficacy | easier titratable nature

Question 187

Systemic administration of opioids exerts its analgesic effects at what levels

Answer 187

brain cortex brainstem, medulla dorsal horn of the spinal cord sensory neuron (peripheral nervous system)

Question 188

Which conditions increase the liklihood of opioid-related toxicity

Answer 188

renal disease | cirrhotic liver disease

Question 189

epidural morphine

Answer 189

initial phase within 2 hours of the bolus dose and the second phase 6-12 hours later -patients should be closely monitored for 24 hours after the administration of epidural morphine

Question 190

opioids should be used with caution in which disease states

Answer 190

emphysema kyphoscoliosis COPD obstructive sleep apnea

Question 191

what part differs largely among the u, d, k, ORL receptors

Answer 191

extracellular loops | N or C terminal tails

Question 192

Opioids modify and relieve the perception of pain without detriment of other sensory mode types. While the pain is still present there is a dissociation of the emotional and sensory aspects of pain, making the patients feel more comfortable. This is because

Answer 192

- action of opioids on supraspinal structures, brainstem (PAG) and the RVM (rostroventral medulla) - enhanced inhibitory activity on descending controls terminating in the the dorsal horn of the spinal cord

Question 193

Opioids exert their analgesic effects through

Answer 193

- their central action within the CNS, inhibiting directly the ascending transmission of painful stimuli from the dorsal horn at the spinal cord - their central action within the CNS activating pain control circuits descending from the midbrain via the RVM to the spinal cord dorsal horn - their peripheral action on opioid receptors andthe release of endogenous opioid-like substances

Question 194

pharmacologic characteristics of opioids

Answer 194

- they are primary pain mediators with ceiling effects | - there are sex related differences to opioid -mediated responsiveness

Question 195

tramadol is different than other opidos because

Answer 195

- risk of respiratory depression is lower | - low abuse potential

Question 196

transdermal fental vs. SR morphine

Answer 196

- can be used when the oral route cannot be - 80 times more potent than morphine - causes less constipation

Question 197

use of meperidine

Answer 197

- should be limited to 1-2 days in the mgt of acute pain - normeperidine is a neurotoxic metabolite of meperidine - should be avoided in the mgt of chronic pain

Question 198

opioid distribution and biotransformation (metabolism)

Answer 198

fentanyl is highly protein bound - fentanyl distributes to fat tissue and redistributes from there into the systemic circulation opioids are metabolized by the liver

Question 199

what are the neuroendocrine effects produced by opioids

Answer 199

hypogonadism | decreased cortisol levels

Question 200

what drugs may have interactions with nsaids /cox-2 inhibitors

Answer 200

ACE inhibitors furosemide warfarin lithium

Question 201

which nsaid is contrainticated in patients allergic to sulfonamides

Answer 201

valdecoxib and celecoxib

Question 202

anti-inflammatory agents which may possess advantages when GI side effects are a concnern

Answer 202

nabumetone and coxibs

Question 203

coxibs vs. NSAIDs

Answer 203

- coxibs are associated with less GI side effects - coxibs have similar renal effects - coxibs are not associated with platelet dysfunction

Question 204

which NSAIDs have higher potency compared to ASA

Answer 204

diflunisal indomethacin ketorolac diclofenac

Question 205

scenarios in which the adjunct use of NSAIDS can be beneficial in postoperative pain

Answer 205

use of opioids | preexisting ventilatory compromise

Question 206

options that can be offered to patients with increased risk of GI toxicity

Answer 206

NSAIDs combine with GI prophylaxic | coxibs

Question 207

NSAIDs and cancer

Answer 207

synergistic effect of NSAIDs and opioids | ability to reduce the side effects of opioids

Question 208

anti-inflammatory agents which do not interfere with the cardioprotective effects of low dose aspirin

Answer 208

celecoxib

Question 209

carbamazepine

Answer 209

- blocks voltage-dependent sodium channels - bicuculline antagonizes its antinociceptive effect - it was first used for trigeminal neuralgia

Question 210

pregabalin is FDA approved for

Answer 210

diabetic neuropathy postherpetic neuralgia fibromyalgia

Question 211

gabapentin

Answer 211

- chemical structure similar to gaba | - inhibits voltage-dependent calcium channels

Question 212

clonazepan

Answer 212

benzodiazepine effective as anxiolytic and muscle relaxing agent may be useful for phantom limb pain

Question 213

lamotrigine

Answer 213

anticonvulsive | rapid titration may result in skin rash

Question 214

tertiary amine TCAs are

Answer 214

imipramine, doxepin

Question 215

analgesics and TCA

Answer 215

- analgesic effects of TCA are independent of their effects on clinical depression - onset of analgesia with TCA ranges from 3-7 days - analgesia tends to occur at lower doses and plasma levels than that needed for antidepressent effects - TCAs analgesic property is superior to that of SSRI

Question 216

TCAs

Answer 216

do not have potential for addiction | can cause insomnia, restlessness and dry mouth

Question 217

TCA toxicity

Answer 217

hyperthermia, tachycardia, seizures

Question 218

when prescribing antidepressants for pain

Answer 218

- explain to the patient that you are primarily treating the pain and not depression - explain to the patient that it will not work immediately - explain to the patient that it may help sleep

Question 219

acetominophen

Answer 219

- analine derivative - induced analgesia is centrally mediated - peripheral mechanism of action - drug of choice for relieving mild to moderate musculoskeletal pain

Question 220

acetaminophen toxicity

Answer 220

the liver gets the major insult | n-acetylcysteine is beneficial for treatment

Question 221

baclofen

Answer 221

good for muscle rigidity and spacticity used for neuropathic pain Gaba-b receptor agonist

Question 222

botulinum toxin a

Answer 222

last for about 3-6 months

Question 223

steroids produce analgesia by

Answer 223

anti-inflammatory effects suppressing ectopic discharge from injured nerves reducing edema

Question 224

what may potentially facilitate or perpetuate myofascial trigger points in some patients

Answer 224

low vitamine B12 or folate

Question 225

piriformis syndrome

Answer 225

-trauma -pain in the muscle with sciatic and difficulty in walking worsening with squatting or lifting -a sausage-like mass within the muscle -positive Laseque sign -gluteal atrophy

Question 226

weaver's bottom (ischiogluteal bursitis)

Answer 226

pain while sitting that goes away when standing or lying on their contralateral side - pain promptly returns when sitting

Question 227

tarsal tunnel

Answer 227

located behind and inferior to the medial malleolus. It is bounded laterally by the tibia and medially by the flexor retinaculum. It contains the tibial nerve, posterior tibial tendons, flexor digitorum longus tendon, flexor hallucis longus tendon, tibiai artery and vein

Question 228

tarsal tunnel syndrome

Answer 228

arises from trauma and is characterized by foot pain and paresthesi, as well as potentially by sensory loss and Tinel sign at the ankle

Question 229

a march fracture

Answer 229

a stress fracture of the metatarsal bone | the second and third metatarsals are the most common sites

Question 230

pronator syndrome

Answer 230

may result from compression of the median nerve proximal to the branching of the anterior interosseous nerve. -generally complain of an aching discomfort of the forearm, numbness in the thumb and index finger, and weakness in the hand. PE - tenderness over the proximal part of the pronator teres muscle that is exacerbated by pronation of the forearm against resistance.

Question 231

CRPS 1 and 2

Answer 231

clinically indistinguishable | evidence of major nerve damage in type 2

Question 232

temp range to test warm temp sensation

Answer 232

40-45 C. Temperatures higher than 45 are generally perceived as painful

Question 233

what may potentially facilitate or perpetuate myofascial trigger points in some patients?

Answer 233

low vitamin B12 or folate

Question 234

Tietze syndrome (costochondritis)

Answer 234

- diagnosis by excludion - unilateral, involving the second and third costal cartilages and is characterized by mild to moderately severe anterior chest wall pain - typically in the region of the costal cartilages, but may radiate to the arm and shoulder - under 40

Question 235

spontaneous osteonecrosis of the knee (SONK)

Answer 235

well-localized pain without trauma or inciting event - unilateral and spontaneous wihtpredilection for the medial femoral condyle - typically elderly patients >60 - woman x3 more likely

Question 236

meralgia paresthetica

Answer 236

painful mononeuropathy of the lateral femoral cutaneous nerve. - commonly caused by focal entrapment of the LFCN as it passes through the inguinal ligament - wt change, pregnance, seat belts, trauma, tumors and strenuous walking or cycling

Question 237

chronic exertional compartment syndrome (anterior tibial compartment)

Answer 237

runners, soccer players, racers exacerbation of pain on passive dorsiflexion of the great toe, weakness of the extensor hallucis longus m, and decreased sensation in the first web space. -symptoms are bilateral 75-90 % of the time

Question 238

symptoms of L5-S1 herniated disk

Answer 238

S1 nerve root distribution - pain/sensory changes in the calf, latreal border of the foot, heel, sole, and sometimes 4th and 5th toes - weakness in gastroc, soleus, peroneus longus and brevis mm

Question 239

symptoms of L4-5 disk

Answer 239

L5 symptomis | -diminished sensation in the lateral leg, dorsum of the foot and 1st 2 toes

Question 240

CRPS

Answer 240

- diagnosed by hx and PE - diagnostic criteria include 1. an initiating noxious event 2. spontaneous pain and/or allodynia occur outside the territory of a single peripheral nerve and is disproprotionate to the inciting event 3. evidence of edema, cutaneous perfusion, abnormal sudomotor activity 4. exclude any other cause of pain/dysfunction

Question 241

causes for initial pain relief from a back surgery, followed by worsening back pain and new onset leg pain several weeks later

Answer 241

epidural fibrosis, arachnoiditis, discitis, battered root syndrome, recurent disc,

Question 242

why do patients with low back pain present with sitting intolerance

Answer 242

sitting bent forward subjects the lumbar intervertebral discs to greater stress than standing, sitting with one's back straight, or lying down

Question 243

leading cause of central pain in the industrialized world

Answer 243

stroke

Question 244

disorder with highest incidence of central pain

Answer 244

syringomyelia (60-80%)

Question 245

selective nerve blocks

Answer 245

sometimes used to diagnose nerve root pathology prior to surgery, but there is little evidence as to whether or not this improves outcomes

Question 246

chronic renal failure (pain?)

Answer 246

associated with large, myelinated fiber loss that is rarely painful

Question 247

celiac disease (pain?)

Answer 247

chronic inflammatory enteropathy resulting from sensitivity to gluten. 10% have peripheral neuropathy and ataxia.

Question 248

HIV (pain)

Answer 248

peripheral neuropathies are reported in up to 35% of AIDS patients. Typically distal sensory, but toxic from medications or co-infections and B12 deficienty as well.

Question 249

Fabry disease (pain)

Answer 249

x-linked, lysosoma storage disease. Usually presents in adulthood, if occurs in childhood is a painful neuropathy

Question 250

amyloidosis and pain

Answer 250

may result in a painful peripheral or autonomic neuropathy secondary to deposition of amyloid in nervous tissue.

Question 251

Guillain-barre

Answer 251

acute inflammatory demyelinating polyneuropathy | Patients usually present with diffuse muscular or radicular pain followed by sensorimotor dysfunction.

Question 252

MS

Answer 252

demylinating disease that typically presents in early adult life - ocular compaints are the most common presenting symptom - central dystethic pain affects approximately 20% of MS patients

Question 253

Chronic fatigue syndrome

Answer 253

- acute radiculopathy | - pain or sensory changes in a lower extremity

Question 254

diabetic neuropathy

Answer 254

distal, symmetrical polyneuropathy | -predominantly a sensory disturbance, occurring in a stocking-glove distribution

Question 255

SI joints

Answer 255

large, paired, diarthrodial synovial joints whose primary functions are stability and dissipating truncal loads - most accurate diagnosis is through local blocks - from MVA, falls, athletic injuries, spondyloarthropathy and pregnancy

Question 256

diagnosis of cervicogenic headache

Answer 256

- the precipitation of head pain by neck movement or external pressure over the upper cervical or occipital region - restricted range of motion of the neck - unilaterality of head pain with or without shoulder or arm pain - diagnostic anesthetic blocks

Question 257

which is more common - migraine with or without aura

Answer 257

without

Question 258

chronic tension type headache

Answer 258

average headache frequency is equal to or greater than 15 days per month or 180 days per year

Question 259

cluster headaches

Answer 259

a series of intense unilateral headaches occurring over a period of 2 weeks to 3 months - associated with unilateral autonomic features such as nasal congestion, rhinorrhea, miosis or lacrimation - brief attacks 15-180 min, occur in orbital, supraorbital and/or temporal regions

Question 260

phantom breast pain

Answer 260

occurs in 20% or mastectomy patients

Question 261

phantom limb pain

Answer 261

60-80% of amputees phantom sensations >90% generally worse in the distal limb

Question 262

indications of acute pain in a young child

Answer 262

palmar sweating and reduced cutanous oxygenation | FACS and COMFORT scale

Question 263

pain score in preschool children

Answer 263

FACES scale and Charleston pain pictures

Question 264

FACS

Answer 264

comprehensive coding system based on a wide range of facial actions

Question 265

COMFORT

Answer 265

eight-item scale designed to measure distress (including pain) that includes alertness, calmness, respiratory response, physical mvt, bp, muscle tone and facial tension

Question 266

most common way to diagnose AHZ

Answer 266

clinically | rash +/- PCR

Question 267

quantitative sensory test

Answer 267

evaluate function of individual nerves - vibratory thresholds and von frey filaments - large myelinated fibers more vulnerable to injury

Question 268

fibromyalgia

Answer 268

common pain condition, 2.4% in general population | -widespread MS pain, sleep disturbance, psychologic distress and comorbidity with other pain syndromes

Question 269

diagnostic criteria for CRPS 1

Answer 269

- presence of an initiating noxious event or a cause of immobilization - continuing pain, allodynia, or hyperalgesia with which the pain is disproportionate to any inciting event - evidence oat some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of the pain - diagnosis is excluded by the existence of condition that otherwise would account for the degree of pain and dysfunction

Question 270

CRPS 2

Answer 270

a known injury to a major nerve | and all the type 1 criteria

Question 271

glossopharyngeal neuralgia

Answer 271

intense pain in the tonsils, middle ear and back of tongue - intermittent or persistent - swallowing, chewing, talking, sneezing, or eating spicy foods may trigger the disorder - often result of compression of 9th or 10th nerve

Question 272

S1 radiculopathy

Answer 272

pain, sensory, and motor changes - shooting and aching and burning on the back of the thigh radiating to the plantar aspect of foot - decreased ankle reflex

Question 273

C6 radiculopathy

Answer 273

pain in the neck, shoulder, lateral arm, radial forearm, dorsum of hand, tip of thumb, index and long finger

Question 274

celiac plexus block

Answer 274

diagnostic and therapeutic tool to help with upper abdominal pain from viscera - pancreas -complications - diarrhea, hypotension, genitofemoral neuralgia, infection, bleeding, damage to surrounding structures and rarely paralysis

Question 275

factitious disorder

Answer 275

the patient produces symptoms of illness

Question 276

malingering

Answer 276

a clearly defined external goal

Question 277

hypochondriasis

Answer 277

6 month preoccupation with fear that one has a serious disease

Question 278

ilioinguinal neuralgia

Answer 278

sharp, electrical sensation in the groin area, exacerbated by light toch or rubbing of clothes

Question 279

what is the most common complication from a celiac plexus block

Answer 279

hypotension

Question 280

celiac plexus/ganglia

Answer 280

dense network of pre and postganglionic fibers. The three splanchnic nerves, greater, lesser and least synapse there

Question 281

migraine headaches are directly related to

Answer 281

estrogen decrease

Question 282

approaches to the celiac plexus block include

Answer 282

retrocrural transcrural transaortic intercrural

Question 283

Hoffmann sign is indicative of

Answer 283

upper motor neuron lesion

Question 284

H-reflex

Answer 284

- limited to calf muscle - recorded in gastroc and soleus m by stimulating the posterior tibial nerve in the popliteal fossa - recorded from the soleus muscle mediated by the S1 nerve root - normal in L5 radiculopathy

Question 285

The arteria radicularis magna (arter of Adamkiewicz) arises from the aorta at which spinal levels

Answer 285

T9-12

Question 286

what is the most common inherited neuropathy

Answer 286

charcot-marie-tooth disease

Question 287

patients diagnosed with cubital tunnel syndrome may have

Answer 287

pain and numbness in the ulnar border of the forearm and hand - clawing of the small finger - Wartenberg sign

Question 288

paroxysmal hemicranias are rare benign headache disorders that may typically be associated with

Answer 288

conjunctival injection rhinorrhea ptosis eyelide edema

Question 289

characteristics of conus medullaris syndrome include

Answer 289

symmetric paraplegia | UMN signs

Question 290

central pain of spinal cord origin

Answer 290

- most commonly traumatic - steady, burning, dysesthetic pain in 96% - bowel and bladder dysfunction can be seen - most will develop signs within 1-6 months after causitive lesion, but can be up to 5 years

Question 291

A positive froment sign indicates?

Answer 291

- weakness of the first dorsal interosseous - weakness of flexord pollicis brevis - weakness of adductor pollicis

Question 292

drugs that can cause a painful neuropathy?

Answer 292

amiodarone metronidazole pyridoxine vincrisitine

Question 293

spinal cord stimulation has been used for the treatment of

Answer 293

failed back surgery syndrome crps angina peripheral vascular disease

Question 294

plantar fascitis

Answer 294

inflammation of the tendons and fascia of the foot as the insert into the calcaneal periosteum. Typically seen in people who stand on hardwood floors for a prolonged period of time. Pain is elecited with plantar compression over the anterior calcanius and also may radiate along plantar fascia

Question 295

metatarsalgia

Answer 295

characterized by pain in the plantar surface of the metatarsal heads caused by prolonged weight-bearing. It can also be replicated with manual compression over the metatarsal heads. Pain is most commonly increased in combined pronation and eversion.

Question 296

etiology and diagnosis of tarsal tunnel

Answer 296

involves compression or inflammation of the posterior tibial nerve that provides sensory innervation to medial aspect of the calcanius, motor supply to small lateral musculature of the foot and to the medial and lateral plantar branches. Usually related to activity

Question 297

morton neuroma (interdigital)

Answer 297

compression of the interdigital nerves in between the metatarsal heads and deep transverse metatarsal ligaments. The third interspace (between the third and 4th metatarsal) is most frequently involved, it is believed to be so because lateral plantar nerve sends a branch to the medial plantar nerve to form a larger third common digital nerve making it less mobile. -usually unilateral and affects females more commonly

Question 298

calcaneal spur

Answer 298

seen in mobidly obese people or those who stand or walk excessively.

Question 299

interscalene block of brachial plexus

Answer 299

especially effect for surgery of the shoulder or upper arm

Question 300

a baker (popliteal) cyst

Answer 300

represents balooning of the synovium-lined joint capsule usually on the posteromedial aspect of the knee. -

Question 301

posterior cruciate ligament

Answer 301

usually damaged violently - high kinetic injury

Question 302

anterior cruciate ligament

Answer 302

most common injured ligament in knee injuries | -anterior drawer, lachman or pivot shift test

Question 303

meniscal tear

Answer 303

will block terminal knee flexion or extension mcmurray test apley grind test

Question 304

pes anserine bursa

Answer 304

lies between the medial hamstring tendones and proximal medial tibia

Question 305

brachial plexitis

Answer 305

an acute disorder that always begins with unilateral diffuse pain in the shoulder follwed by weakness in the proximal muscles

Question 306

pancoast tumor

Answer 306

tumor of the apex of the lung that typically involves the brachial plexus.

Question 307

thoracic outlet syndrom

Answer 307

impingement of the subclavian vessels and lower trunk of brachial plexus resulting in various decrees of vascular or neurologic compromise

Question 308

golfers elbow

Answer 308

medial epicondylitis | pain and tenderess over the medial epicondyle

Question 309

lateral epicondylitis

Answer 309

tennis elbow involves the extensor-supinator muscle mass, including the extensor caripi radioalis brevis -graspin or extending the wrist against resistance or supinating the forearm will cause pain

Question 310

de quervain disease

Answer 310

tenosynovitis of the tendon sheath of extensor pollicis brevis and adductor pollicis longus

Question 311

brachioradialis tendonitis

Answer 311

pain in the lateral forearm

Question 312

Approximately in what percentage of patients with malignancies does pain unrelated to cancer occur?

Answer 312

3%

Question 313

What NCV/EMG finding is the most helpful to differentiate between the direct tumor infiltration and the radiation fibrosis etiologies of brachial plexopathy?

Answer 313

myokymia

Question 314

If bony metastases are present, which primary cancer location has the best 5-year survival prognosis?

Answer 314

Thyroid

Question 315

The most frequent spinal cord symptom or sign in patients with carcinomatous meningitis is

Answer 315

reflex asymmetry

Question 316

The majority of patients with epidural metastasis have which pattern of pain?

Answer 316

Local

Question 317

Methadone

Answer 317

- highly variable oral bioavailabllity - low cost - no known active metabolites - high lipid solubility

Question 318

the most common lesions that produce thalamic pain

Answer 318

infarctions

Question 319

most peripheral neuropathies are classified as

Answer 319

demylinating, axonal or mixed

Question 320

Development of neuropathic pain

Answer 320

wide dynamic range neurons in the dorsal horn respond with increased frequency as the intensity of the repeated afferent stimulus increases

Question 321

which is most likely to be associated with neuropathic pain - traumatic nerve injury - stroke - syringomyelia - multiple sclerosis - large myelinated fiber neuropathy

Answer 321

syringomyelia

Question 322

If a patient with CRPS responds well to sympathetic ganglion block, this will tell you

Answer 322

the pain condition is sympathetically maintained

Question 323

neuropathic pan can result in

Answer 323

central sensitization allodynia hyperalgesia

Question 324

potentials neurophysiologic mechanisms underlying the development of neuropathic pain include

Answer 324

microglial activation in the spinal cord | cytokine production in the spinal cord

Question 325

when the stimulus of light touch exerts pain

Answer 325

allodynia

Question 326

phantom pain refers to

Answer 326

painful sensations referred to the missing limb

Question 327

when is phantom pain likely to start following an amputation

Answer 327

within the first week

Question 328

a patient with early and severe phantom pain

Answer 328

is more likely to suffer from long-standing pain

Question 329

the number of amputees who have severe phantom limb pain

Answer 329

5-10%

Question 330

preamputation pain

Answer 330

may sensitize the nervous system, explaining why some individuals may be more susceptible to development of chronic phantom pain

Question 331

what are the differences between stump pain and phantom pain?

Answer 331

- unlike phantom pain, stump pain occurs in the body part that actually exists - stump pain typically is described as a sharp, burning, electric-like, or skin-sensitive pain - stump pain is usually caused by a neuroma - surgical revision of the stump or removal of the neuroma is sometimes considered

Question 332

A neuroma is an inflammation of of a nerve that is seen universally after a nerve has been cut (amputation). They show spontaneous and abnormal evoked activity following mechanical or chemical stimulation from the periphery. This results from

Answer 332

- an increased and novel expression of sodium channels | - increased activity in afferent C fibers

Question 333

Some amputees show an abnormal sensitivity to pressure and repetitive stimulation of the stump. This can be reduced by

Answer 333

giving ketamine

Question 334

what plays a role in the mechanism for generating phantom pain

Answer 334

peripheral sensitization central sensitization cortical reorganization increased thalamus response to stimulation

Question 335

which medications have been proven in a well-controlled trial to treat phantom pain

Answer 335

tramadol gabapentin amitryptiline

Question 336

The gate control theory of pain has been used to explain phantom limb pain. It states

Answer 336

- following significant destruction of sensory axons by amputation, wide dynamic range neurons are freed by inhibitory control - self-sustaining neuronal activity may occur in spinal cord neurons

Question 337

primary dysmenorrhea

Answer 337

- pain is transmitted via the thoracolumbar spinal segments and pelvic afferents - the etiology of pain includes myometrial contractions leading to intense intrauterine pressure and uterine hypoxia - prostaglandins and leukotrienes production that sensitizes afferent pelvic nerves is part of its pathogenesis - altered central receptivity of the afferent input from the pelvis is thought to be relevant in its development

Question 338

chronic endometriosis

Answer 338

- ovaries, cul de sac, uterine tubes, surface of the bowel are among the common sites of pathologic implanation of the functioning endometrial tissue - retrograde menstruation, lymphatic spread and hematogenous spread of the endometrial tissue are all thought to play a role - definitive dx by visualization of the characteristic lesions without a mandatory histo confirmation - leuprolide acetate may be an effective treatment

Question 339

pudendal nerve originates from

Answer 339

S2,3, 4

Question 340

blocking sensory input to uterus and cervix

Answer 340

bilateral denervation of the inferior hypogastic nerves is as effective as a lumbar epidural block

Question 341

hymenal neuropathy

Answer 341

difficult pelvic exam due to complaints and emotions

Question 342

sympathetic pelvis syndrome

Answer 342

deep pain in the pelvis not associated with physically detectable abdominal wall or muscle tenderness

Question 343

common reasons for inadequate management of acute pain

Answer 343

- the common idea that pain is merely a symptom and not harmful itself - lack of understanding of the pharmacokinetics of various agents - lack of appreciation of variability in analgesic response to opioids - prescription of inappropriately low doses of opioids and thinking that opioids musst not be given more often than every 4 hours

Question 344

Pathological pain

Answer 344

- occurs in the context of central sensitization - occurs in the context of peripheral sensitization - outlasts the stimulus - spreads to non-damaged areas

Question 345

peri-operative administration of NSAIDs

Answer 345

has a synergistic effect with opioids

Question 346

NMDA receptors

Answer 346

- involved in development of windup facilitation - involved in development of central sensitization - involved in changes of peripheral receptive fields - involved in induction of oncogenes and long term potentiation

Question 347

visceral pain

Answer 347

dull and vague often periodic and builds to peaks often associated with nausea and vomiting poorly localized

Question 348

pre-emptive analgesia

Answer 348

- helpful in reducing postoperative pain in part by reducing the phenomenon of central sensitization - local anesthetics, opioids, and NSAIDs can be used for pre-emptive analgesia - may have potential to prevent the development of chronic pain states - thought to reduce neuroplastic changes in the spinal cord

Question 349

multimodal analgesia

Answer 349

- may include NSAIDS, acetaminophen, local anesthetics, and opioids in the same patient - it is beneficial because of the synergistic action of the individual medications with different sites of action along the pathway - facilitates early mobilization of the post-surgical patient - expedites return to normal parenteral nutrition

Question 350

PHN

Answer 350

- pain caused by herpes zoster for more than 1 month - mid-thoracic dermatomes is one of the most common sites - opthalmic division of the trigeminal nerve is one of the most common sites - may occur in any dermatome - incidence of 9-14% - approx 40% of patients have incomplete or no relief

Question 351

antidepressents with PHN

Answer 351

SSRIs have been found to be equally or more effective than TCAs or SNRI

Question 352

opioids and PHN

Answer 352

opioids tend to be less effective for the treatment of neuropathic pain than non-neuropathic pain

Question 353

most common cause of autonomic neuropathy in the developed world

Answer 353

DM

Question 354

diabetic amyotrophy

Answer 354

usually resolves within 1-2 years spontaneously

Question 355

prevalence of diabetic neuropathy

Answer 355

about 10% at diagnosis, rising to more than 50% in patients diagnosed for longer than 5 years

Question 356

most widely accepted cause of trigeminal neuralgia

Answer 356

arterial cross-compression of the trigeminal nerve in the posterior fossa

Question 357

gasserian ganglion

Answer 357

the 2 medial branches are sensory while the lateral branch is partially motor

Question 358

diagnosis of trigeminal neuralgia

Answer 358

diagnosis is clinical and test are only necessary to rule out associated conditions

Question 359

giant cell arteritis

Answer 359

more common in older patients with a peak incidence between 60-75 yo

Question 360

analgesic rebound headache

Answer 360

headache greater than 15 days per month that has developed or markedly worsened during medication overuse

Question 361

cluster headaches are characterized by

Answer 361

pain is strictly unilateral and autonomic symptoms occur ipsilateral t the pain

Question 362

pathophysiologic changes seen in migraine

Answer 362

activation and threshold reduction of the trigeminocervical complex by its most caudal cells

Question 363

co-morbid conditions with head aches

Answer 363

depression, anxiety , panic disorders

Question 364

hundred percent oxygen inhalation is a safe and effective method for acute treatment of

Answer 364

cluster headaches

Question 365

ramsay hunt syndrome is caused by the infection of the varicella-zoster virus of the

Answer 365

geniculate ganglion

Question 366

orthostatic headache is pathognomonic for

Answer 366

spontaneous intracranial hypertension

Question 367

which theory explains the presence of aura

Answer 367

cortical spreading depression

Question 368

chronic low back pain and neck pain persists 1 year or longer in what percentage

Answer 368

25-60%

Question 369

the prevalence of zygapophysial (facet) joint involvement in low back pain is

Answer 369

15-45%

Question 370

symptoms of early spinal cord compression include

Answer 370

rapid onset symmetric and profound weakness spasticity increased deep tendon reflexes

Question 371

specific indications for discography include

Answer 371

- further evaluation of abnormal discs to assess the extent of abnormality - assessment of patients who ahve failed to respond to surgical procedures to determine if there is possible recurrent herniation - assessment of discs before fusion to determine if the discs within the proposed fusion segment are symtomatic - assessment of minimally invasive surgical candidates to confirm a contained disc herniation

Question 372

signs and symptoms consistent with cervical radiculopathy

Answer 372

- normal muscle tone - negative babinski - weak tendon reflexes - positive axial compression test (spurling maneuver)

Question 373

Reasons associated with smoking as a risk factor for low back pain

Answer 373

- mineral content of the lumbar vertebrae is decreased - fibrinolytic disc activity is altered - blood flow and nutrition to the disc are diminished - increased degenerative changes of the lumbar spine

Question 374

age-related changes in the discs include

Answer 374

- collagen lamellae of the annulus fibrosus increases thickness - distinction between the nucleus pulposus and annulus fibrosis becomes less apparent - the nucleus pulposus is less able to transmit weight directly - 80% of nucleus pulposus cells in the elderly exhibit necrosis

Question 375

radiculopathy is a neurologic condition associated with

Answer 375

numbness weakness compression of axons ischemia of axons

Question 376

adverse effects of epidurally administered steroids include

Answer 376

cushing syndrome osteoporosis avascular bone necrosis suppression of the hypothalamus-pituitary axis

Question 377

relative contraindications to epidural steroid injections

Answer 377

pre-existing neurologic disorder

Question 378

L4-5 disk herniation with L5 nerve root involvement

Answer 378

weakness with dorsiflexion of great toe and foot

Question 379

In patients with chronic low back pain, the prevalence of SI joint pain is

Answer 379

15%

Question 380

spondylolysis

Answer 380

an acquired defect caused by fatigue fracture of the pars interarticularis

Question 381

spondylolisthesis

Answer 381

displacement of a vertebrae or the vertebral column in relationship to the vertebrae below it

Question 382

kissing spines

Answer 382

periostitis of spinous processes or inflammation of the affected ligament

Question 383

radiculopathy

Answer 383

neurologic condition in which conduction is blocked to the axons of a spinal nerve or its roots. It results in numbness and weakness

Question 384

radicular pain

Answer 384

pain that arises as a result of irritation of a spinal nerve or its roots

Question 385

evidence regarding the value of epidural injections for the management of chronic spinal pain demonstrates

Answer 385

strong for caudal epidural steroid injections for short-term relief of lumbar radiculopathy and post-lumbar laminectomy syndrome

Question 386

Intervertebral disks

Answer 386

- in normal intervertebral discs, nerve fibers are only found in the outer third of the annulus fibrosis - discs painful on discography and removed with operation have nerve growth deep into the annulus and into the nucleus pulposis - disc fissuring is a trigger for neoinnervation of a disk - the anterior and posterior nerve plexuses accompany the anterior and posterior longitudinal ligaments

Question 387

x-ray imaging is recommended for which cause of low back pain

Answer 387

spondylolisthesis

Question 388

L5

Answer 388

first toe dorsiflexion

Question 389

most frequent complication of a laminotomy with discectomy

Answer 389

dural tear

Question 390

favorable prognostic indicators for patients undergoing repeated lumbosacral surgery

Answer 390

female satisfactory outcome from prior surgeries operative findings of disk herniation radicular pain

Question 391

Waddell signs were developed to help identify nonorganic causes of low back pain. They include

Answer 391

tenderness stimulation distraction testing regional disturbance

Question 392

major criteria for cervicogenic headache

Answer 392

restricted neck range of motion

Question 393

neurogenic claudication can be distinguished from vascular claudication by

Answer 393

no change in pain with exercise

Question 394

characteristics associated with a poor prognosis for neck pain

Answer 394

prior neck pain passive coping techniques middle age compensation

Question 395

most common complication of fluoroscopically guided interlaminar cervical epidural injections

Answer 395

increased neck pain

Question 396

HIV related neuropathy

Answer 396

- HIV is found within endoneurial macrophages - antisulfatide antibodies are one of the humoral factors responsible for demylinating disease in AIDS patients - secretion of cytokines by the HIV infected glial cells may generate tissue specific autoimmune attack - the pathologic mechanisms in HIV related neuropathies are not well understood

Question 397

the most common painful neuropathy encountered in patients with HIV and AIDS is

Answer 397

predominantly sensory neuropathy of AIDS

Question 398

the pathophysiological processes that lead to vascular occlusion in patients with sickle cell

Answer 398

erythrocyte dehydration distortion of the shape of erythrocytes polymerization of the sickle cell hemoglobin on deoxygenation -decreased deformability of erythrocytes

Question 399

what makes the pain of SCD unique

Answer 399

SCD pain pathophys involves a combination of ischemic tissue damage and secondary inflammatory response

Question 400

at initial presentation, objective signs of a painful SCD crisis, such as fever, leukocytosis, joint effusions and tenderness occur in

Answer 400

50% of patients

Question 401

what percentage of hospital admissions in adult SCD patients result from acute sickle cell pain

Answer 401

more than 90%

Question 402

tramadol

Answer 402

- inhibits neuronal reuptake of serotonin and norepinephrine - acts as a weak u-receptor agonisst - does not have a "ceiling" effect - centrally acting - IS associated with addiction potential

Question 403

in SCI patients, chronic pain secondary to overuse is common in

Answer 403

shoulders and arms

Question 404

autonomic dysreflexia usually occurs after an SCI at

Answer 404

above T6

Question 405

Visceral pain with SCI

Answer 405

-unlikely that visceral pain may occur in the absence of any abdominal organ dysfunction -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 -autonomic dysreflexia cannot be triggered by visceral pain visceral pain is always present in an SCI patient as part of the central pain syndrome

Question 406

"at level" neuropathic pain

Answer 406

both peripheral and central components may be seen

Question 407

temporal summation of pain

Answer 407

abnormal increase in pain with each repetitive stimulus

Question 408

hyperpathia

Answer 408

exaggerated delayed painful perception after a noxious stimulus

Question 409

a common finding of patients with CRPS 1

Answer 409

nearly all patients with CRPS 1 have sweating abnormalities

Question 410

late changes observed in patients with CRPS1

Answer 410

trophic changes

Question 411

The diagnostic crieteria that differentiates CRPS2 from CRPS 1

Answer 411

lesion of a peripheral nerve structure is mandatory

Question 412

psychological findings in patients with CRPS

Answer 412

anxiety and depression

Question 413

The Lewis triple response

Answer 413

reddening of the skin at the site of the stimulus - spreading flare - local peripheral vasoconstriction mediated by the release of substance P

Question 414

The diagnosis of myofascial pain syndrom is confirmed when

Answer 414

the myofascial trigger point is identified by palpation

Question 415

the minimum criteria that must be satisfied in order to distinguish a myofascial trigger point from any other tender area in muscle are

Answer 415

a taut band and a tender point in that taut band

Question 416

why is the stretch and spray technique therapeutic for trigger points

Answer 416

the vapocoolant spray stimulates thermal and tactile A-b skin receptors, thereby inhibiting C fiber and A-d fiber afferent nociceptive pathways and muscle spasms, myofascial trigger points and pain when stretching

Question 417

therapeutic u/s and trigger points

Answer 417

not effective

Question 418

most common indication for dry needling of a trigger point

Answer 418

inactivation of a myofascial trigger pointes to facilitate physical therapy

Question 419

complication of trigger point injections

Answer 419

local hemorrhage infection transient nerve block syncope

Question 420

Reasons for failure after a trigger point injections.

Answer 420

- missed trigger point - injecting a secondary or satellite trigger point - insufficient muscle stretching in the clinic after injection - not enough stretching by the patient at home

Question 421

Most common anatomic variation causing unrelenting MS pain

Answer 421

leg length discrepancy and small hemipelvis

Question 422

what nutritional or hormonal factors have repeatedly been found to be low in persons with persistent myofascial pain?

Answer 422

iron folic acid vit b12 thyroid hormone

Question 423

biologic aberrations seen in most patients with fibromyalgia include

Answer 423

lowered pain thresholds to pressure induced pain - disordered sleep as evidenced by polysomnography - increased spinal fluid levels of substance p - no physiological or biochemical evidence for central sensitization

Question 424

what criteria is absolutely necessary for the classification of fibromyalgia syndrome

Answer 424

widespread pain for at least 3 months | pain sensitivity to 4kg of digital pressure at a minimum of 11 of 18 anatomically defined tender points

Question 425

what other clinical signs may occur with fibromyalgia

Answer 425

irritable bowel syndrom | urinary urgency

Question 426

fibromyalgia and sleep

Answer 426

- in am, patients can be stiff, cognitively sluggish and unrefreshed - commonly awaken feeling distressingly alert after only a few hours and then are unable to sleep soundly again - don't have any trouble napping

Question 427

secondary fibromyalgia refers to

Answer 427

fibromyalgia that occurs in the setting of another painful condition or inflammatory disorder

Question 428

substance p

Answer 428

a pronociceptive neurochemical mediator of pain because it carries or amplifies afferent signals

Question 429

management objectives for fibromyalgia

Answer 429

- not specific because there is still no cure - reestablish emotional balance - improve sleep - restore physical function

Question 430

dopamine and serotonin in fibromyalgia

Answer 430

- tryptophan, serotonin, 5ht and 5-hydroxyindole acetic acetic acid have been found to be decreased infibromyalgia patients - dopamine agonists have been found to decrease pain in fibromyalgia patients

Question 431

opioids and fibromyalgia in women

Answer 431

women with fibromyaligia have reduced u-opioid receptor availability within regions of the brain that normally process and dampen pain signals

Question 432

pahtophysiologic components of cancer pain

Answer 432

- somatic (nociceptive) pain - sympathetic pain - neuropathic - central

Question 433

The skeletal sites most commonly involved in osteolytic metastatic processes are

Answer 433

ribs and femur

Question 434

The primary compression of the spinal cord from metastatic deposits occurs in

Answer 434

- thoracic spine in 70% of patients - lumbar spine in 20% of patients - cervical spine in 10%

Question 435

In a patient with skeletal metastases, biphosphanates

Answer 435

- inhibit recruitment and function of osteoclasts - stimulate osteoblasts - have greatest effect in breast cancer and multiple myeloma - have an acute pain-relieving effect

Question 436

A possible compilation of a neurolytic celiac black

Answer 436

- persistent diarrhea - aortic pseudoaneurysm - intradiscal injection - damage to the artery of Adamkiewics

Question 437

what agents can be used effectively via implantable intrathecal delivery in cancer patients

Answer 437

- opioids - a2-adrenergic agonists - local anesthetics - ziconotide

Question 438

possible complications of chemotherapy

Answer 438

toxic peripheral neuropathy phn avascular necrosis pseudorheumatism

Question 439

peripheral neuropathies are characterized by

Answer 439

- sensory loss | - dysesthesias

Question 440

Areas of acute pain processing in cortical subcortical regions of the brain as determined by functional MRI include

Answer 440

anterior cingulate cortex | prefrontal cortex

Question 441

examples of painful small-diameter peripheral neuropathies

Answer 441

- ross syndrome (segmental anhidrosis) | - charcot-marie-tooth disease type 1

Question 442

chronic renal failure neuropathy is commonly manifested with

Answer 442

restless leg syndrome painful neuropathy distal weakness

Question 443

animal studies in neuropathic pain conditions have shown

Answer 443

- intraplantar injections of interleukin 1 reduces mechanical nociceptive threshold - il-1 hyperalgesia is mediated by bradykinin B-1 receptors - effects of Il-1 on mechanical hyperalgesia seems to be mediated by prostaglandins - Il-1 effects on nociceptions may be mediated by vagal afferents

Question 444

potential complications of stellate ganglion block include

Answer 444

pneumothorax lesion of recurrent laryngeal nerve neuritis

Question 445

Important factors invovled in the development of neuropathic pain include

Answer 445

- behavioral studies have shown that NMDA is involved in the induction and maintenance of pain-related behaviors - the spinal N-type voltage-dependent calcium channels are the predominant isoform involved in the pre and postsynaptic processing of sensory nociceptive information - tactile allodynia in the spinal nerve ligation model may be blocked by intrathecal N-type ca blockers like ziconotide - after nerve injury there is upregulation of the NMDA receptors

Question 446

what is an effect of u-opioid agonists in neuropathic pain conditions?

Answer 446

- decrease dynamic allodynia - decrease termperature threshold for cold pain - decrease static allodynia

Question 447

Effects of GABA in the modulation of afferent nociceptive input include

Answer 447

- GABA a produces postsynaptic inhibition via metabotropic receptors, which are ligand-gated Cl- channels - the dominant type of inhibition of glutaminergic excitatory postsynaptic action potential is produce by GABA and/or glycine - GABA b and adenosine produce postsynaptic hyperpolarization by activation K channels

Question 448

During the windup process

Answer 448

- cumuluative recruitment of NMDA receptor current leads to progressive relief of the Mg2+ blockade of the NMDA-receptor zone - intracellular calcium levels play a major role in the development of windup

Question 449

In patients with PHN

Answer 449

- histopathlogical studies in patients with PHN commonly show ganglion cell loss and fibrosis - antiviral drugs used in chronic PHN usually are ineffective in alleviating pain

Question 450

common phantom limb sensation in upper limb

Answer 450

clenched fist

Question 451

How does the peripheral nervous system play a role in phantom pain modulation

Answer 451

- DRG cells display an altered expression pattern of different sodium channels - long after limb amputation, injection of noradrenaline around a stump neuroma is reported to be intensely painful.

Question 452

Studies done on preemptive analgesia for amputation

Answer 452

- most have been very poor methodological quality - 2 included blinding and randominization showed no signfiicant differences versus control - aim is to thwart spinal sensitization by blocking the cascade of intraneuronal responses that take place after peripheral nerve injury

Question 453

What dietary modifications should be made to alleviate symptoms of interstitial cystitis

Answer 453

restrict spicy food eliminate alcohol intake cease smoking

Question 454

sodium pentosan polysulfate (elmiron)

Answer 454

- an oral analoge of heparin | - increases anti-adherent surface of the bladder lining

Question 455

x-ray imaging is recommended for which cause of low back pain

Answer 455

spondylolisthesis

Question 456

L5

Answer 456

first toe dorsiflexion

Question 457

most frequent complication of a laminotomy with discectomy

Answer 457

dural tear

Question 458

favorable prognostic indicators for patients undergoing repeated lumbosacral surgery

Answer 458

female satisfactory outcome from prior surgeries operative findings of disk herniation radicular pain

Question 459

Waddell signs were developed to help identify nonorganic causes of low back pain. They include

Answer 459

tenderness stimulation distraction testing regional disturbance

Question 460

major criteria for cervicogenic headache

Answer 460

restricted neck range of motion

Question 461

neurogenic claudication can be distinguished from vascular claudication by

Answer 461

no change in pain with exercise

Question 462

characteristics associated with a poor prognosis for neck pain

Answer 462

prior neck pain passive coping techniques middle age compensation

Question 463

most common complication of fluoroscopically guided interlaminar cervical epidural injections

Answer 463

increased neck pain

Question 464

HIV related neuropathy

Answer 464

- HIV is found within endoneurial macrophages - antisulfatide antibodies are one of the humoral factors responsible for demylinating disease in AIDS patients - secretion of cytokines by the HIV infected glial cells may generate tissue specific autoimmune attack - the pathologic mechanisms in HIV related neuropathies are not well understood

Question 465

the most common painful neuropathy encountered in patients with HIV and AIDS is

Answer 465

predominantly sensory neuropathy of AIDS

Question 466

the pathophysiological processes that lead to vascular occlusion in patients with sickle cell

Answer 466

erythrocyte dehydration distortion of the shape of erythrocytes polymerization of the sickle cell hemoglobin on deoxygenation -decreased deformability of erythrocytes

Question 467

what makes the pain of SCD unique

Answer 467

SCD pain pathophys involves a combination of ischemic tissue damage and secondary inflammatory response

Question 468

at initial presentation, objective signs of a painful SCD crisis, such as fever, leukocytosis, joint effusions and tenderness occur in

Answer 468

50% of patients

Question 469

what percentage of hospital admissions in adult SCD patients result from acute sickle cell pain

Answer 469

more than 90%

Question 470

tramadol

Answer 470

- inhibits neuronal reuptake of serotonin and norepinephrine - acts as a weak u-receptor agonisst - does not have a "ceiling" effect - centrally acting - IS associated with addiction potential

Question 471

in SCI patients, chronic pain secondary to overuse is common in

Answer 471

shoulders and arms

Question 472

autonomic dysreflexia usually occurs after an SCI at

Answer 472

above T6

Question 473

Visceral pain with SCI

Answer 473

-unlikely that visceral pain may occur in the absence of any abdominal organ dysfunction -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 -autonomic dysreflexia cannot be triggered by visceral pain visceral pain is always present in an SCI patient as part of the central pain syndrome

Question 474

"at level" neuropathic pain

Answer 474

both peripheral and central components may be seen

Question 475

temporal summation of pain

Answer 475

abnormal increase in pain with each repetitive stimulus

Question 476

hyperpathia

Answer 476

exaggerated delayed painful perception after a noxious stimulus

Question 477

a common finding of patients with CRPS 1

Answer 477

nearly all patients with CRPS 1 have sweating abnormalities

Question 478

late changes observed in patients with CRPS1

Answer 478

trophic changes

Question 479

The diagnostic crieteria that differentiates CRPS2 from CRPS 1

Answer 479

lesion of a peripheral nerve structure is mandatory

Question 480

psychological findings in patients with CRPS

Answer 480

anxiety and depression

Question 481

The Lewis triple response

Answer 481

reddening of the skin at the site of the stimulus - spreading flare - local peripheral vasoconstriction mediated by the release of substance P

Question 482

The diagnosis of myofascial pain syndrom is confirmed when

Answer 482

the myofascial trigger point is identified by palpation

Question 483

the minimum criteria that must be satisfied in order to distinguish a myofascial trigger point from any other tender area in muscle are

Answer 483

a taut band and a tender point in that taut band

Question 484

why is the stretch and spray technique therapeutic for trigger points

Answer 484

the vapocoolant spray stimulates thermal and tactile A-b skin receptors, thereby inhibiting C fiber and A-d fiber afferent nociceptive pathways and muscle spasms, myofascial trigger points and pain when stretching

Question 485

therapeutic u/s and trigger points

Answer 485

not effective

Question 486

most common indication for dry needling of a trigger point

Answer 486

inactivation of a myofascial trigger pointes to facilitate physical therapy

Question 487

complication of trigger point injections

Answer 487

local hemorrhage infection transient nerve block syncope

Question 488

Reasons for failure after a trigger point injections.

Answer 488

- missed trigger point - injecting a secondary or satellite trigger point - insufficient muscle stretching in the clinic after injection - not enough stretching by the patient at home

Question 489

Most common anatomic variation causing unrelenting MS pain

Answer 489

leg length discrepancy and small hemipelvis

Question 490

what nutritional or hormonal factors have repeatedly been found to be low in persons with persistent myofascial pain?

Answer 490

iron folic acid vit b12 thyroid hormone

Question 491

biologic aberrations seen in most patients with fibromyalgia include

Answer 491

lowered pain thresholds to pressure induced pain - disordered sleep as evidenced by polysomnography - increased spinal fluid levels of substance p - no physiological or biochemical evidence for central sensitization

Question 492

what criteria is absolutely necessary for the classification of fibromyalgia syndrome

Answer 492

widespread pain for at least 3 months | pain sensitivity to 4kg of digital pressure at a minimum of 11 of 18 anatomically defined tender points

Question 493

what other clinical signs may occur with fibromyalgia

Answer 493

irritable bowel syndrom | urinary urgency

Question 494

fibromyalgia and sleep

Answer 494

- in am, patients can be stiff, cognitively sluggish and unrefreshed - commonly awaken feeling distressingly alert after only a few hours and then are unable to sleep soundly again - don't have any trouble napping

Question 495

secondary fibromyalgia refers to

Answer 495

fibromyalgia that occurs in the setting of another painful condition or inflammatory disorder

Question 496

substance p

Answer 496

a pronociceptive neurochemical mediator of pain because it carries or amplifies afferent signals

Question 497

management objectives for fibromyalgia

Answer 497

- not specific because there is still no cure - reestablish emotional balance - improve sleep - restore physical function

Question 498

dopamine and serotonin in fibromyalgia

Answer 498

- tryptophan, serotonin, 5ht and 5-hydroxyindole acetic acetic acid have been found to be decreased infibromyalgia patients - dopamine agonists have been found to decrease pain in fibromyalgia patients

Question 499

opioids and fibromyalgia in women

Answer 499

women with fibromyaligia have reduced u-opioid receptor availability within regions of the brain that normally process and dampen pain signals

Question 500

pahtophysiologic components of cancer pain

Answer 500

- somatic (nociceptive) pain - sympathetic pain - neuropathic - central

Question 501

The skeletal sites most commonly involved in osteolytic metastatic processes are

Answer 501

ribs and femur

Question 502

The primary compression of the spinal cord from metastatic deposits occurs in

Answer 502

- thoracic spine in 70% of patients - lumbar spine in 20% of patients - cervical spine in 10%

Question 503

In a patient with skeletal metastases, biphosphanates

Answer 503

- inhibit recruitment and function of osteoclasts - stimulate osteoblasts - have greatest effect in breast cancer and multiple myeloma - have an acute pain-relieving effect

Question 504

A possible compilation of a neurolytic celiac black

Answer 504

- persistent diarrhea - aortic pseudoaneurysm - intradiscal injection - damage to the artery of Adamkiewics

Question 505

what agents can be used effectively via implantable intrathecal delivery in cancer patients

Answer 505

- opioids - a2-adrenergic agonists - local anesthetics - ziconotide

Question 506

possible complications of chemotherapy

Answer 506

toxic peripheral neuropathy phn avascular necrosis pseudorheumatism

Question 507

peripheral neuropathies are characterized by

Answer 507

- sensory loss | - dysesthesias

Question 508

Areas of acute pain processing in cortical subcortical regions of the brain as determined by functional MRI include

Answer 508

anterior cingulate cortex | prefrontal cortex

Question 509

examples of painful small-diameter peripheral neuropathies

Answer 509

- ross syndrome (segmental anhidrosis) | - charcot-marie-tooth disease type 1

Question 510

chronic renal failure neuropathy is commonly manifested with

Answer 510

restless leg syndrome painful neuropathy distal weakness

Question 511

animal studies in neuropathic pain conditions have shown

Answer 511

- intraplantar injections of interleukin 1 reduces mechanical nociceptive threshold - il-1 hyperalgesia is mediated by bradykinin B-1 receptors - effects of Il-1 on mechanical hyperalgesia seems to be mediated by prostaglandins - Il-1 effects on nociceptions may be mediated by vagal afferents

Question 512

potential complications of stellate ganglion block include

Answer 512

pneumothorax lesion of recurrent laryngeal nerve neuritis

Question 513

Important factors invovled in the development of neuropathic pain include

Answer 513

- behavioral studies have shown that NMDA is involved in the induction and maintenance of pain-related behaviors - the spinal N-type voltage-dependent calcium channels are the predominant isoform involved in the pre and postsynaptic processing of sensory nociceptive information - tactile allodynia in the spinal nerve ligation model may be blocked by intrathecal N-type ca blockers like ziconotide - after nerve injury there is upregulation of the NMDA receptors

Question 514

what is an effect of u-opioid agonists in neuropathic pain conditions?

Answer 514

- decrease dynamic allodynia - decrease termperature threshold for cold pain - decrease static allodynia

Question 515

Effects of GABA in the modulation of afferent nociceptive input include

Answer 515

- GABA a produces postsynaptic inhibition via metabotropic receptors, which are ligand-gated Cl- channels - the dominant type of inhibition of glutaminergic excitatory postsynaptic action potential is produce by GABA and/or glycine - GABA b and adenosine produce postsynaptic hyperpolarization by activation K channels

Question 516

During the windup process

Answer 516

- cumuluative recruitment of NMDA receptor current leads to progressive relief of the Mg2+ blockade of the NMDA-receptor zone - intracellular calcium levels play a major role in the development of windup

Question 517

In patients with PHN

Answer 517

- histopathlogical studies in patients with PHN commonly show ganglion cell loss and fibrosis - antiviral drugs used in chronic PHN usually are ineffective in alleviating pain

Question 518

common phantom limb sensation in upper limb

Answer 518

clenched fist

Question 519

How does the peripheral nervous system play a role in phantom pain modulation

Answer 519

- DRG cells display an altered expression pattern of different sodium channels - long after limb amputation, injection of noradrenaline around a stump neuroma is reported to be intensely painful.

Question 520

Studies done on preemptive analgesia for amputation

Answer 520

- most have been very poor methodological quality - 2 included blinding and randominization showed no signfiicant differences versus control - aim is to thwart spinal sensitization by blocking the cascade of intraneuronal responses that take place after peripheral nerve injury

Question 521

What dietary modifications should be made to alleviate symptoms of interstitial cystitis

Answer 521

restrict spicy food eliminate alcohol intake cease smoking

Question 522

sodium pentosan polysulfate (elmiron)

Answer 522

- an oral analoge of heparin | - increases anti-adherent surface of the bladder lining

Question 523

what substances are involved in descending inhibition

Answer 523

GABA Serotonin Endogenous opioid peptides norepinephrine

Question 524

What are the psychological factors affecting pain responses

Answer 524

fear and helplessness sleep deprivation anxiety cultural differences

Question 525

what are psychological methods for reducing pain

Answer 525

- placebo and expectation - psychological support - procedural and instructional information - cognitive coping strategies

Question 526

Gastrointestinal impairment in a postsurgical patient can be

Answer 526

- worsened by increased sympathetic activity because of severe pain - contributed to by administration of opioids - mitigated by early mobilization of the patient

Question 527

optimal epidural placement for lower abdominal surgery

Answer 527

T10-12

Question 528

optimal epidural placement for upper abdominal surgery

Answer 528

T8-10

Question 529

optimal epidural placement for lower extremity surgery

Answer 529

L2-4

Question 530

optimal epidural placement for upper extremity surgery

Answer 530

C7-T2

Question 531

The most common characteristics of pain in PHN include

Answer 531

steady burning or aching | paroxysmal and lancinating

Question 532

Interventional therapy for PHN

Answer 532

- no proven surgical cure fro PHN has been found - cryotherapy is likely to bring only short-term reliev - topical lidocaine may provide effective analgesia - TENS has been shown to give an effective symptomatic relief in some patients

Question 533

antiviral agents in the acute phase of herpes zoster

Answer 533

-competitively inhibit DNA polymerase terminating DNA synthesis and viral replication -are generally well tolerated -hasten healing of the rash may reduce the duration of PHN

Question 534

steroids and acute herpes zoster

Answer 534

- are not currently recommended - may provide pain relief in the acute phase - have no benefit in prevention of PHN

Question 535

charcot joints

Answer 535

- affects primarily weight-bearing joints - can be caused by multiple causes other than DM - is related to the destruction of afferent proprioceptive fibers

Question 536

most commonly utilized medication in peripheral neuropathic pain

Answer 536

NSAIDs

Question 537

treatment of painful diabetic neuropathy and glycemic control

Answer 537

- tight glycemic control can halt or slow the progression of distal sensorimotor neuropathy - hemoglobin A1 target should be <6% - euglycemia is the ideal goal - wt loss and exercise program is an important part of glycemic control in a diabetic patient

Question 538

The current treatment for painful diabetic neuropathy

Answer 538

antiepileptics antidepressants opioids

Question 539

the convulsive tic

Answer 539

- more severe in males | - because of presence of bilateral facial spasms

Question 540

trigeminal neuralgia

Answer 540

- periods of weeks/months without pain - increase pain by commonly benign stimuli, like talking, eating , or washing - pain often alleviated by sleep - bilateral trigeminal neuralgia is seen more often than expected in patients with MS - more common in females - highest incidence in elderly

Question 541

The retrogasserian glycerol injection

Answer 541

recurrence rates are the highest of all ablative techniques | sensory loss is less common than with radiofrequency thermocoagulation

Question 542

most common cranial neuralgia

Answer 542

trigeminal neuralgia

Question 543

potential factors involved in the development of trigeminal neuroalgia

Answer 543

- ion channel upregulation in the area of the rigeminal injury - focal demyelination - up to 30% of patients with trigeminal neuralgia have arterial cross compression at the level root entry zone

Question 544

spontaneous intracranial hypertension

Answer 544

- congenital subarachoid or Tarlov cysts are a potential site for dural weakness and rupture - are no characteristic findings on MRI

Question 545

A common treatment for patients with PDPH is epidural blood patch (EBP). What is important to know about this therapy?

Answer 545

- maintenance of supine position for 2 hours after the patch provides higher chances for success - the effectiveness of EBP is reduced when the dural tear was caused by a large size needle

Question 546

The incidence of PDPH is between 1 and 75%. Factor(s) that prevent its development at the time of dural puncture include

Answer 546

- use of intrathecal catheter | - use of small-gauge spinal needle

Question 547

Diagnostic criteria for cervicogenic headache by the international headache society and the international association for the study of pain include

Answer 547

- unilateral headache - relief of acute attacks by blocking the greater occipital nerve with local anesthetic - aggravation of the headache with neck movements - decrease range of neck motion

Question 548

cervicogenic headache

Answer 548

- 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 - is more common in females; a female to male ration of 4 to 1 - mean age is the beginning of the fourth decade - is aggravated by neck movement and alleviated by occipital nerve block

Question 549

cortical spreading depression

Answer 549

- may produce the aura symptoms - produces activation of the trigeminal nerve endings - consisst of decreased cerebral blood flow spreading forward from the occipital cortex

Question 550

migraines and auras

Answer 550

- with an aura is associated with an increase of cerebral blood flow that happens after the headache begins - without aura there is no change in cerebral blood flow

Question 551

migraine is a risk factor for

Answer 551

- major depression - manic episodes - anxiety disorders - panic disorders

Question 552

migraines

Answer 552

- begin in the first three decades of life - is of higher prevalence in the fifth decade - decrease symptoms in the last trimester of their pregnancy in most females

Question 553

tension-type headache

Answer 553

- has more common onset during adolescence and young adulthood - reduces CNS levels of serotonin that may be responsible for abnormal pain modulation

Question 554

For any structure to be deemed a cause of low back pain, it must have...

Answer 554

- a nerve supply - be capable of causing low back pain in healthy volunteers - be susceptible to disease or injuries known to be painful - be shown to be a source of pain in a patient using diagnostic techniques of known reliability and validity

Question 555

Defined region of low back pain

Answer 555

- superiorly by an imaginary line through the T12 spinous process - inferiorly by a transverse line through the posterior sacrococcygeal joints - laterally by the lateral borders of the erector spine - within the region overlying the sacrum

Question 556

complications of cervical transforaminal injections

Answer 556

- cerebellar infarction - cerebral infarction - spinal cord infarction - anterior spinal artery syndrome

Question 557

discographic stimulation is considered positive if

Answer 557

- thermal stimulation with a wire electrode causes pain | - pain is reporoduced at pressures less than 50 psi and preferably less than 15 psi

Question 558

the use of chemonucleolysis for lumbar disc hernations is indicated for

Answer 558

- contained disc protrusions | - herniations unresponsive to nonsurgical management

Question 559

causes of FBSS include

Answer 559

- inappropriate selection of patients - irreversible neural injury - inadequate surgery - new injury to nerves and spine

Question 560

selection criteria for elective lumbosacral spine surgery include

Answer 560

- radicular pain with corresponding dermatomal segmental sensory loss - abnormal imaging study showing nerve root compression - signs of segmental instability consistent with symptoms

Question 561

the main types of cervical involvement in rheumatoid arthritis include

Answer 561

- aa subluxation - cranial settling - subaxial subluxation

Question 562

whiplash and whiplash-associated disorders comprise a range of injuries to the neck caused by or related to a sudden distortion of the neck. Characteristics include

Answer 562

- spinal cord injury - referred shoulder pain - sensory defiicits - headaches

Question 563

distraction testing allows an examiner to identify neurologic and mechanical abnormalities in the cervical spine. It is characterized by

Answer 563

- relief of neck pain - lifting head from the chin and occipit - relief of pressure on zygapophyseal joints

Question 564

Tests for neck pain

Answer 564

- distraction testing - valsalva test - spurling maneuver

Question 565

HIV infection related neuropathies

Answer 565

- inflammatory demylinating polyneuropathies occur early in the course of HIV infection - vasculitis-related neuropathies occur midcourse in HIV infection - distal sensory neuropathies occur late in HIV infection - HIV related neuropathies tend to be nonspecific to the stage of HIV infections

Question 566

Sensory neuropathies of AIDs

Answer 566

- predominant symptom is pain in the soles of the feet - ankle jerks are often absent or reduced - as symptoms of the neuropathy progress, they usually remain confined to the feet

Question 567

facilitators of pain transmission

Answer 567

supstance P and bradykinin

Question 568

leg ulcers and SCD

Answer 568

- leg ulcers occur in 5-10% of the adult SCD patients | - many leg ulcers heal within a few months of treatment

Question 569

SCD and supplemental oxygen

Answer 569

- supplemental low-flow oxygen is often given to patients with SCD painful crisis in efforts to diminish the number of reversibly sickled cells - there is little supportive data for the use of supplemental oxygen in SCD - routine oxygen administration in the absence of hypoxemia may impair reticulocytosis in SCD patients - routine oxygen administration in the absence of hypoxemia has no proven benefit in SCD patients

Question 570

treatment of vasoocclusive crises of SCD during pregnancy

Answer 570

- aggressive hydration - supplemental oxygen in patients with hypoxemia - partial exchange transfusions - prophylactic transfusions

Question 571

opioids and SCD

Answer 571

fast opioid dose increases may lead to hypoxemia and/or hypercarbia, which may exacerbate sickling of erythrocytes

Question 572

autonomic dysreflexia manifests itself with

Answer 572

increased blood pressure - flushing and sweating in areas above the SCI - marked reduction in peripheral blood flow - decline in heart rate

Question 573

anterior cord syndrome

Answer 573

- prognosis for motor function recovery is very poor | - it is characterized by complete motor function loss

Question 574

posterior cord syndrome

Answer 574

- preservation of temperature sensation | - uncommon

Question 575

brown-sequard syndrome

Answer 575

- ipsilateral motor deficit - contralateral pain sensation deficit - contralateral temperature sensation deficit - uncommon

Question 576

pharmacologic actions of anticonvulsants

Answer 576

- modulation of sodium and calcium channels | - increased gaba inhibition

Question 577

Heterotopic ossification is commonly seen in patients with traumatic brain injury, CVS, burns, trauma, total joint arthroplasty and SCI. HO and SCI

Answer 577

- hip is most commonly affected | - osteoclast inhibitors are used for both treatment and prophylaxis

Question 578

CRPS in the initial stages may be associated with

Answer 578

- neurogenic inflammation - higher local levels of tumor necrosis factor alpha - high systemic CGRP levels - increase in protein concentration in fluid of affected joints

Question 579

motor abnormalities and CRPS

Answer 579

- decrease active range of motion and increase amplitude of physiological tremor is seen in about 50% of the patients - they may be explained by abnormalities in the cerebral motor processing

Question 580

CRPS and extremities

Answer 580

- affected extremities after brain injury are at higher risk of developing CRPS than unaffected - upper extremities are more commonly affected than lower extremities

Question 581

bone scintigraphy

Answer 581

- three stages of the 3 phase bone scan include the perfusion, blood-pool, and mineralization phases - homogenous unilateral hyperperfusion in the perfusion phase is consistent with CRPS - homogenous unilateral hyperperfusion in the blood-pool phase is consistent with CRPS - patients with CRPS show increase unilateral periarticular trace uptake in the mineralization phase

Question 582

C-fiber impulses

Answer 582

- after sensitization, antidromic impulses to peripheral C fiber terminals release vasoactive substance - neurally released substances trigger neurogenic inflammation - neurogenic inflammation includes axonal reflex, vasodilation and plasma extravasation - C-fiber activation peripherally releases CGRP and substance P

Question 583

major peripheral pathologic findings in patients with CRPS are

Answer 583

- patch atrophy of some muscle cells - capillary microangiopathy - wallerian degeneration

Question 584

second most common cause of CRPS

Answer 584

medical procedures

Question 585

hallmark of central sensitization

Answer 585

cutaneous dynamic mechanical allodynia

Question 586

characteristics of CRPS1 in pediatrics include

Answer 586

- CRPS 1 is more common in girls - the lower extremity is more often affected - CRPS may have genetic predisposition

Question 587

characteristics of CRPS 2 in peds includes

Answer 587

- incidence is similar in boys and girls | - erb palsy do not generally develop CRPS

Question 588

To confirm the diagnosis of CRPS

Answer 588

- there are no lab tests to confirm | - bone scan is nonspecific

Question 589

movement disorders in CRPS

Answer 589

deep tendon reflexes are normal to brisk | akinesia is a prominent finding

Question 590

In terms of CRPS and dystonia, which is characterized by involuntary contractions of one or more muscles, it can be said that

Answer 590

- dystonia is a prominent feature of CRPS - dystonia in patients with CRPS typically presents with flexure postures - tonic dystonia often spares the first two digits

Question 591

supraspinal regulatory mechanisms that may explain some of the features of CRPS include

Answer 591

- spread of cortical representation of the affected limb - patients with generalized dystonia have increased intracortical excitability to sensory stimuli - motor cortical disinhibition - early increase activity of the thalamus contralateral to the affected limb

Question 592

myofascial trigger point characteristics

Answer 592

- referral of pain to a distant site upon activation of the trigger point - autonomic phenomenon, suc as piloerection or changes in local circulation (regional blood flow and limb temperature) in response to trigger point activation

Question 593

the definitive goal of treatment of persons with myofascial pain syndrome are

Answer 593

- restoration of function through inactivation of the trigger point - restoration of normal tissue mobility - relief of pain

Question 594

inactivation of the myofascial trigger point can be accomplished

Answer 594

- manually - by direct injection of local anesthetic into the muscle - by dry needle intramuscular stimulation of the myofascial trigger point - by correcting structural mechanical stressors

Question 595

trigger point injections with botulinum toxin

Answer 595

- can cause flu-like myalgia | - is long-lasting trigger point injection capable of about a 3 month inactivation of the trigger point

Question 596

chronic myofascial neck pain and acupuncture

Answer 596

- -shallow needling reduce the pain of chronic myofascial neck pain - -found to be superior to dry needling - found to be better than placebo

Question 597

what symptoms supports fibromyalgia as opposed to myofascial pain syndrome

Answer 597

- widespread pain - irritable bowel syndrome - distal paresthesias - occipital headaches

Question 598

risk factors for the development of fibromyalgia syndrome

Answer 598

- physical trauma - febrile illness - family history

Question 599

sleep and fibromyalgia

Answer 599

- problems initiating sleep - awakening in the middle of the night - light, unrefreshing sleep - difficulty napping throughout the day

Question 600

pathophysiologically, fibromyalgia

Answer 600

- is a disorder of abnormal processing of sensory information within the CNS - exhibits a narrow array of recognized objective physiological and biologic abnormalities - 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 - demonstrates abnormal spinal cord windup

Question 601

cytokines and fibromyalgia

Answer 601

- IL-8 has been found to be significantly higher in the serum of fibromyalgia patients, especially in depressed patients - the production of IL-8 in vitro is stimulated by substance P

Question 602

FDA approved treatment for fibromyalgia

Answer 602

pregabalin

Question 603

the test that is the most objective determination of disabilty

Answer 603

sickness illness profile

Question 604

what is the symptom checklist 90 and its revised version

Answer 604

-a screen for psychologic symmptoms and overall levels of distress

Question 605

what test addresses limitations in activities of daily living

Answer 605

oswestry low back pain disability questionnaire

Question 606

beck depression inventory

Answer 606

is a 21 item self-report measure of depression for the last 30 years

Question 607

in pain assessment

Answer 607

patients self report of pain is the most valid measure of the pain experience

Question 608

A conscious exaggeration of physical or psychologic symptoms for some easily recognized goal or secondary gain is

Answer 608

malingering

Question 609

McGill pain questionnaire

Answer 609

consists of three major measures - location and pattern of the pain over time - sensory, effective component of pain - intensity of the pain

Question 610

advantages of MMPI-2 include

Answer 610

- it provides 10 clinical scales, 3 validity scales - considdered the gold standard - is well-normed and extensively researched

Question 611

in evaluating patients for SCS using MMP1 Richard North's group noted that

Answer 611

- patients with high scores on scale 1 (hypochondriasis) ended to proceed from SCS trial to implant - patients with higher scores on scale 3 (hysteria) had positive short-term but not long-term outcome

Question 612

In regard to MMPI as a predictor of treatment outcome

Answer 612

- it is based on common diagnoses of 1930s | - items overlapping a great degree across the 10 clinical scale

Question 613

multidimensional pain assessment inventories include

Answer 613

- pain disability index - illness behavior questionnaire - sickness impact profile, west haven-yale multidimensional pain inventory - dallas pain questionnaire

Question 614

regarding pain scores on the numeric rating scale

Answer 614

- decreased pain scores suggest positive outcome from the treatment of pain - should be used only occasionally - correlates highly with pain measured on in verbal scale and VAS - correlates highly with anxiety and depression

Question 615

SF-36

Answer 615

yields scores on 10 health scales relating to physical, social, and emotional factors -does not have gender or age norms

Question 616

physiologic correlations of pain (heart rate and bp)

Answer 616

- may habituate with time despite presence of pain | - is a great way of measuring the intensity of pain

Question 617

according to melzack and Casey (1968) the 3 major psychologic dimensions of pain are

Answer 617

- sensory discriminative - cognitive evaluative - motivational affective

Question 618

the most frequently used self-rating instruments for measurement of pain in a clinical setting are

Answer 618

- VAS | - McGill Pain Questionnaire

Question 619

cognitively impaired elderly patients

Answer 619

- do not respond to pain assessment questionnaire - do respond appropriately if given VAS or numerical rating scale (NRS) - malingering by an elderly patient may be an attempt to divert attention away from possible need for instituitionalization

Question 620

most common microbe that grows in cultures of infected intrathecal pump wounds

Answer 620

staph epidermis

Question 621

signs and symptoms supporting an intrathecal catheter-tip inflammatory mass

Answer 621

diminishing analgesic effects pain that mimic nerve root compression pain that mimic cholecystitis

Question 622

advantages of intrathecal drug-delivery are

Answer 622

- first-pass effect can be avoided - intrathecal morphine is 300times as effective as oral morphine for equipotent pain treatment - the number of CNS derived side effects can be reduced

Question 623

Things to contemplate prior to placing an intrathecal pump

Answer 623

- does the patient have an acceptable physiologic explanation for the pain syndrome - does the patient have alife expectancey of 3 months or longer - psychologic clearance is not needed in the patient with cancer pain

Question 624

Ziconotide was approved for infusion into the CSF using an intrathecal drug-delivery system by the food and drug administration in 2004. Its proposed MOA

Answer 624

blocks N-type calcium channels

Question 625

granulomas have been found to occur with all medications used intrathecally except

Answer 625

sufentanil

Question 626

side effect given intrathecally: urinary retention

Answer 626

opioids, bupivicaine

Question 627

side effect given intrathecally: extrapyramidal

Answer 627

droperidol

Question 628

side effect given intrathecally: hypotension

Answer 628

bupivicaine, clinidine

Question 629

side effect given intrathecally: auditory disturbances

Answer 629

baclofen

Question 630

side effect given intrathecally: sedation

Answer 630

opioids, clonidine, midazolam

Question 631

side effect given intrathecally: nausea

Answer 631

opioids

Question 632

side effect given intrathecally: worsening of depression

Answer 632

clonidine

Question 633

facilitators of pain transmission

Answer 633

supstance P and bradykinin

Question 634

leg ulcers and SCD

Answer 634

- leg ulcers occur in 5-10% of the adult SCD patients | - many leg ulcers heal within a few months of treatment

Question 635

SCD and supplemental oxygen

Answer 635

- supplemental low-flow oxygen is often given to patients with SCD painful crisis in efforts to diminish the number of reversibly sickled cells - there is little supportive data for the use of supplemental oxygen in SCD - routine oxygen administration in the absence of hypoxemia may impair reticulocytosis in SCD patients - routine oxygen administration in the absence of hypoxemia has no proven benefit in SCD patients

Question 636

treatment of vasoocclusive crises of SCD during pregnancy

Answer 636

- aggressive hydration - supplemental oxygen in patients with hypoxemia - partial exchange transfusions - prophylactic transfusions

Question 637

opioids and SCD

Answer 637

fast opioid dose increases may lead to hypoxemia and/or hypercarbia, which may exacerbate sickling of erythrocytes

Question 638

autonomic dysreflexia manifests itself with

Answer 638

increased blood pressure - flushing and sweating in areas above the SCI - marked reduction in peripheral blood flow - decline in heart rate

Question 639

anterior cord syndrome

Answer 639

- prognosis for motor function recovery is very poor | - it is characterized by complete motor function loss

Question 640

posterior cord syndrome

Answer 640

- preservation of temperature sensation | - uncommon

Question 641

brown-sequard syndrome

Answer 641

- ipsilateral motor deficit - contralateral pain sensation deficit - contralateral temperature sensation deficit - uncommon

Question 642

pharmacologic actions of anticonvulsants

Answer 642

- modulation of sodium and calcium channels | - increased gaba inhibition

Question 643

Heterotopic ossification is commonly seen in patients with traumatic brain injury, CVS, burns, trauma, total joint arthroplasty and SCI. HO and SCI

Answer 643

- hip is most commonly affected | - osteoclast inhibitors are used for both treatment and prophylaxis

Question 644

CRPS in the initial stages may be associated with

Answer 644

- neurogenic inflammation - higher local levels of tumor necrosis factor alpha - high systemic CGRP levels - increase in protein concentration in fluid of affected joints

Question 645

motor abnormalities and CRPS

Answer 645

- decrease active range of motion and increase amplitude of physiological tremor is seen in about 50% of the patients - they may be explained by abnormalities in the cerebral motor processing

Question 646

CRPS and extremities

Answer 646

- affected extremities after brain injury are at higher risk of developing CRPS than unaffected - upper extremities are more commonly affected than lower extremities

Question 647

bone scintigraphy

Answer 647

- three stages of the 3 phase bone scan include the perfusion, blood-pool, and mineralization phases - homogenous unilateral hyperperfusion in the perfusion phase is consistent with CRPS - homogenous unilateral hyperperfusion in the blood-pool phase is consistent with CRPS - patients with CRPS show increase unilateral periarticular trace uptake in the mineralization phase

Question 648

C-fiber impulses

Answer 648

- after sensitization, antidromic impulses to peripheral C fiber terminals release vasoactive substance - neurally released substances trigger neurogenic inflammation - neurogenic inflammation includes axonal reflex, vasodilation and plasma extravasation - C-fiber activation peripherally releases CGRP and substance P

Question 649

major peripheral pathologic findings in patients with CRPS are

Answer 649

- patch atrophy of some muscle cells - capillary microangiopathy - wallerian degeneration

Question 650

second most common cause of CRPS

Answer 650

medical procedures

Question 651

hallmark of central sensitization

Answer 651

cutaneous dynamic mechanical allodynia

Question 652

characteristics of CRPS1 in pediatrics include

Answer 652

- CRPS 1 is more common in girls - the lower extremity is more often affected - CRPS may have genetic predisposition

Question 653

characteristics of CRPS 2 in peds includes

Answer 653

- incidence is similar in boys and girls | - erb palsy do not generally develop CRPS

Question 654

To confirm the diagnosis of CRPS

Answer 654

- there are no lab tests to confirm | - bone scan is nonspecific

Question 655

movement disorders in CRPS

Answer 655

deep tendon reflexes are normal to brisk | akinesia is a prominent finding

Question 656

In terms of CRPS and dystonia, which is characterized by involuntary contractions of one or more muscles, it can be said that

Answer 656

- dystonia is a prominent feature of CRPS - dystonia in patients with CRPS typically presents with flexure postures - tonic dystonia often spares the first two digits

Question 657

supraspinal regulatory mechanisms that may explain some of the features of CRPS include

Answer 657

- spread of cortical representation of the affected limb - patients with generalized dystonia have increased intracortical excitability to sensory stimuli - motor cortical disinhibition - early increase activity of the thalamus contralateral to the affected limb

Question 658

myofascial trigger point characteristics

Answer 658

- referral of pain to a distant site upon activation of the trigger point - autonomic phenomenon, suc as piloerection or changes in local circulation (regional blood flow and limb temperature) in response to trigger point activation

Question 659

the definitive goal of treatment of persons with myofascial pain syndrome are

Answer 659

- restoration of function through inactivation of the trigger point - restoration of normal tissue mobility - relief of pain

Question 660

inactivation of the myofascial trigger point can be accomplished

Answer 660

- manually - by direct injection of local anesthetic into the muscle - by dry needle intramuscular stimulation of the myofascial trigger point - by correcting structural mechanical stressors

Question 661

trigger point injections with botulinum toxin

Answer 661

- can cause flu-like myalgia | - is long-lasting trigger point injection capable of about a 3 month inactivation of the trigger point

Question 662

chronic myofascial neck pain and acupuncture

Answer 662

- -shallow needling reduce the pain of chronic myofascial neck pain - -found to be superior to dry needling - found to be better than placebo

Question 663

what symptoms supports fibromyalgia as opposed to myofascial pain syndrome

Answer 663

- widespread pain - irritable bowel syndrome - distal paresthesias - occipital headaches

Question 664

risk factors for the development of fibromyalgia syndrome

Answer 664

- physical trauma - febrile illness - family history

Question 665

sleep and fibromyalgia

Answer 665

- problems initiating sleep - awakening in the middle of the night - light, unrefreshing sleep - difficulty napping throughout the day

Question 666

pathophysiologically, fibromyalgia

Answer 666

- is a disorder of abnormal processing of sensory information within the CNS - exhibits a narrow array of recognized objective physiological and biologic abnormalities - 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 - demonstrates abnormal spinal cord windup

Question 667

cytokines and fibromyalgia

Answer 667

- IL-8 has been found to be significantly higher in the serum of fibromyalgia patients, especially in depressed patients - the production of IL-8 in vitro is stimulated by substance P

Question 668

FDA approved treatment for fibromyalgia

Answer 668

pregabalin

Question 669

what is the symptom checklist 90 and its revised version

Answer 669

-a screen for psychologic symmptoms and overall levels of distress

Question 670

what test addresses limitations in activities of daily living

Answer 670

oswestry low back pain disability questionnaire

Question 671

beck depression inventory

Answer 671

is a 21 item self-report measure of depression for the last 30 years

Question 672

in pain assessment

Answer 672

patients self report of pain is the most valid measure of the pain experience

Question 673

A conscious exaggeration of physical or psychologic symptoms for some easily recognized goal or secondary gain is

Answer 673

malingering

Question 674

McGill pain questionnaire

Answer 674

consists of three major measures - location and pattern of the pain over time - sensory, effective component of pain - intensity of the pain

Question 675

advantages of MMPI-2 include

Answer 675

- it provides 10 clinical scales, 3 validity scales - considdered the gold standard - is well-normed and extensively researched

Question 676

in evaluating patients for SCS using MMP1 Richard North's group noted that

Answer 676

- patients with high scores on scale 1 (hypochondriasis) ended to proceed from SCS trial to implant - patients with higher scores on scale 3 (hysteria) had positive short-term but not long-term outcome

Question 677

In regard to MMPI as a predictor of treatment outcome

Answer 677

- it is based on common diagnoses of 1930s | - items overlapping a great degree across the 10 clinical scale

Question 678

multidimensional pain assessment inventories include

Answer 678

- pain disability index - illness behavior questionnaire - sickness impact profile, west haven-yale multidimensional pain inventory - dallas pain questionnaire

Question 679

regarding pain scores on the numeric rating scale

Answer 679

- decreased pain scores suggest positive outcome from the treatment of pain - should be used only occasionally - correlates highly with pain measured on in verbal scale and VAS - correlates highly with anxiety and depression

Question 680

SF-36

Answer 680

yields scores on 10 health scales relating to physical, social, and emotional factors -does not have gender or age norms

Question 681

physiologic correlations of pain (heart rate and bp)

Answer 681

- may habituate with time despite presence of pain | - is a great way of measuring the intensity of pain

Question 682

according to melzack and Casey (1968) the 3 major psychologic dimensions of pain are

Answer 682

- sensory discriminative - cognitive evaluative - motivational affective

Question 683

the most frequently used self-rating instruments for measurement of pain in a clinical setting are

Answer 683

- VAS | - McGill Pain Questionnaire

Question 684

cognitively impaired elderly patients

Answer 684

- do not respond to pain assessment questionnaire - do respond appropriately if given VAS or numerical rating scale (NRS) - malingering by an elderly patient may be an attempt to divert attention away from possible need for instituitionalization

Question 685

most common microbe that grows in cultures of infected intrathecal pump wounds

Answer 685

staph epidermis

Question 686

signs and symptoms supporting an intrathecal catheter-tip inflammatory mass

Answer 686

diminishing analgesic effects pain that mimic nerve root compression pain that mimic cholecystitis

Question 687

advantages of intrathecal drug-delivery are

Answer 687

- first-pass effect can be avoided - intrathecal morphine is 300times as effective as oral morphine for equipotent pain treatment - the number of CNS derived side effects can be reduced

Question 688

Things to contemplate prior to placing an intrathecal pump

Answer 688

- does the patient have an acceptable physiologic explanation for the pain syndrome - does the patient have alife expectancey of 3 months or longer - psychologic clearance is not needed in the patient with cancer pain

Question 689

Ziconotide was approved for infusion into the CSF using an intrathecal drug-delivery system by the food and drug administration in 2004. Its proposed MOA

Answer 689

blocks N-type calcium channels

Question 690

granulomas have been found to occur with all medications used intrathecally except

Answer 690

sufentanil

Question 691

side effect given intrathecally: urinary retention

Answer 691

opioids, bupivicaine

Question 692

side effect given intrathecally: extrapyramidal

Answer 692

droperidol

Question 693

side effect given intrathecally: hypotension

Answer 693

bupivicaine, clinidine

Question 694

side effect given intrathecally: auditory disturbances

Answer 694

baclofen

Question 695

side effect given intrathecally: sedation

Answer 695

opioids, clonidine, midazolam

Question 696

side effect given intrathecally: nausea

Answer 696

opioids

Question 697

side effect given intrathecally: worsening of depression

Answer 697

clonidine

Question 698

multilevel disk disease treatment

Answer 698

-transforminal ipidural steroid injection facet joint medial branch diagnostic block -spinal cord stimulator trial

Question 699

Causes of axial low back pain

Answer 699

- SI arthropathy - internal disc disruption - quadratus lumborum and psoas syndrome

Question 700

The false positive rate of diagnostic lumbar facet medial branch blocks are

Answer 700

25-41%

Question 701

percentage of cases where the pain relief is caused by placebo response following interventional procedures

Answer 701

35%

Question 702

complications of sphenopalatime ganglion radiofrequency thermocoagulation

Answer 702

infection epistaxis bradycardia

Question 703

complication of third occipital nerve radiofrequency thermocoagulation

Answer 703

ataxia

Question 704

Positive lumbar provacative discogram for mechanical disc sensitization includes reproduction of patient's pain with injection of the contrast in nucleus pulposus at what pressure above the "opening pressure"

Question 705

the technique of cervical discography includes needle entry through the skin from the

Answer 705

anterior right side of the neck

Question 706

when performing intralaminar cervical epidural steroid injections without fluoroscopic guidance, the chances of having false positive loss of resistance are close to

Answer 706

50%

Question 707

when performing intralaminar cervical epidural steroid injections, the unilateral contrast (and medication) spread is expected in what percentage of cases

Answer 707

50%

Question 708

complications of lumbar sympathetic block

Answer 708

genitofemoral neuralgia retrograde ejaculation intravascular injection

Question 709

Best method for evaluating the adequacy of lumbar sympathetic block

Answer 709

temperature change

Question 710

stellate ganglion is located between the

Answer 710

C7-T1

Question 711

In relation to the stellate ganglion the subclavian artery is located

Answer 711

anteriorly

Question 712

when performing lumbar discography, the opening pressure is the recorded pressure signifying

Answer 712

first appearance of the contrast in nucleus pulposus

Question 713

intradiscal electrothermal coagulation outcomes are adversely affected by

Answer 713

obesity

Question 714

when performing lumbar discography, in relation to the laterality of pain, which of the following should be the needle entry site

Answer 714

laterality does not make a difference

Question 715

published complications from cervical transforaminal epidural steroid injection

Answer 715

epidural abscess neuropathic pain quadriplegia and death

Question 716

in order to minimize the risk for complications when cervical transforaminal epidural steroid injection is performed how shoul dthe needle be positioned in relation to the neural foramina

Answer 716

posteriorly

Question 717

The single needle approach to medial branch block diagnosis in comparison to standard multiple needle approach

Answer 717

- causes less discomfort for the patient - decreases the volume of local anesthetics used for the skin and subcutaneous tissues - takes less time to perform

Question 718

The incidental intrathecal overdose of intrathecal morphine while performing a pump refill should be treated by

Answer 718

intrathecal and IV naloxone airway protection possible irrigation of the CSF with saline

Question 719

while analyzing a malfunctioning SCS implanted device, a sign of lead breakage or disconnect is a measured impedance of

Answer 719

>4000 ohms

Question 720

accurate placement of a stimulator lead for occipital nerve peripheral stimulation is

Answer 720

posterior to the C2 spinous process

Question 721

Adequate SCS introducer needle epidural space at entry level for the desired coverage of the foot pain is

Answer 721

L3-4 interspace

Question 722

the placement of SCS electrodes for coverage of intractable chest pain caused by angina should be at the epidural level of

Answer 722

T1-2

Question 723

most effective approach for performing lumbar epidural steroid injections is

Answer 723

transforaminal

Question 724

during interlaminar epidural steroid injections contrast should be

Answer 724

used in the anteroposterior view

Question 725

what is the most likely complication after successful SCS implant

Answer 725

lead breakage or migration

Question 726

intraspinal elements and conductivity

Answer 726

from highes to lowest: | CSF, longitudinal white matter, gray matter, transverse white matter, dura

Question 727

phenol

Answer 727

carries a higher risk for neuroma formation than alcohol - painless on delivery - most concerning for a side effect - arrhythmia

Question 728

pain relief and neuraxial neurolysis

Answer 728

pain relief is less than 6 months

Question 729

gray is used to measure

Answer 729

absorbed dose

Question 730

maximum total permissible dose equivalents

Answer 730

50 mSv/year

Question 731

most operator exposure during fluoroscopically guided blocks is when

Answer 731

the xray tube is above the patient

Question 732

the intensity of scattered beam is ____greater at the radiation entrance on the skin than the exit site

Answer 732

985

Question 733

average patient radiation exposure dose during pain procedures is

Answer 733

10 times more than during angiograpphy

Question 734

radiation dose to the patients and medical personnel can be reduced by

Answer 734

decreasing the distance between the image intensifier and the patient

Question 735

intrathecal pumps and infections

Answer 735

- device-related infection is the most common, potentially reducible, serious adverse event associated with intrathecal pumps - management of infections associated with drug-delivery systems usually involves the administration of antibiotics and explantation of the device

Question 736

good technique for placing intrathecal pumps

Answer 736

- antibiotics for 7-10 days after permanent implant - if the entry point is above L2, the patient should be conversant, and the angle of entry should be as shallow as possible - placing the patient in the lateral decubitus position with the hips flexed and the knees bent.

Question 737

Disease states that may benefit from intra-thecal drug delivery system

Answer 737

- intractable spasticity related to cerebral palsy and spinal cord injuries - interstitial cystitis - cancer related syndromes - rheumatoid arthritis

Question 738

benefits of intra-thecal pumps

Answer 738

- overall toxicity is better - pain relief is better - improve fatigue and level of consciousness in patients vs medical management - there is a trend to increased survival in patients who have IT pumps

Question 739

third occipital nerve

Answer 739

- innervates C2-3 facet joint | - curves around superior articular process of the C3 vertebrae

Question 740

for the peripheral stimulation of the occipital nerve

Answer 740

-the electrode should be place subcutaneously at the C1-2 level

Question 741

T2 and T3 sympathetic block

Answer 741

- used for treatment of upper extremity complex regional pain syndrome - will help by denervating the Kuntz nerves - can lead to pneumothorax

Question 742

vertebroplasty may be indicated for

Answer 742

- multiple myelopma - chronic compression fractures of the vertebral body - osteolytic metastatic tumors

Question 743

piriformis muscle injection

Answer 743

- should be done at medial part of a muscle - botox can be used - nerve stimulation may aid in muscle location - identification of the muscle can be done through rectal exam

Question 744

SI joint pain

Answer 744

-transmitted by L4 medial branch, L5 dorsal ramus, and S1-3 lateral branches

Question 745

ganglion impar block

Answer 745

- is indicated for sympathetically maintained pain in perineal area - can be complicated by perforation of the rectum

Question 746

complications of intrathecal pump

Answer 746

- granuloma formation - CSF leak - pump rotation - hormonal imbalance

Question 747

increased pain with intrathecal opioid delivery

Answer 747

- progression of disease - catheter kink should be considered - look for withdrawal symptoms

Question 748

What drugs are used in decompressive neuroplasty

Answer 748

- hyaluronidase - hypertonic saline - steroids - local anesthetics

Question 749

SCS used for

Answer 749

- interstitial cystitis - postlaminectomy syndrome - CRPS - sympathetically mediated pain - phantom limb pain - SCI - intractable abdominal or visceral pain - neurogenic thoracic outlet syndrome

Question 750

risks associated with SC

Answer 750

- epidural hematoma - spinal cord injury - implanted pulse generator failure - electromechanical failure of lead or extension cable

Question 751

SCS and visceral pain

Answer 751

- SCS suppresses visceral response to colon distention in animal models - case studies have indicated SCS may be helpful for visceral pain but at this time there is a lack of supporting randomized controlled trials

Question 752

What should be considered when selecting patients for SCS

Answer 752

- disease pathology - untreated drug addiction - patient comorbidities

Question 753

radiofrequency and SI joint

Answer 753

radiofrequency treatment of sacral lateral branches have been proposed for efficacious treatment of SI joint pain

Question 754

advantages of pulsed radiofrequency over continuous radiofrequency ablation

Answer 754

- virtually painless - compared to pulsed radiofrequency, continuous RF has a higher risk of inducing spinal instability secondary to multifidus muscle denervation

Question 755

most reported complication with acupuncture

Answer 755

bruising or bleeding

Question 756

what substances are involved in the analgesic effect of acupuncture

Answer 756

serotonin norepinephrine nitric oxide B-endorphin

Question 757

Ginkgo biloba

Answer 757

- used to treat multiple conditions such as asthma, bronchitis, fatigue and tinnitus - tried to improve alzheimer's and dementia - tried with intermittent claudication and ms - -side effects include headache, nausea, diarrhea, dizziness, and allergic skin reactions - may increase bleeding

Question 758

ginseng

Answer 758

- supports overall health and boost immune system - can cause allergic reactions - increase both mental and physical performance - some studies have shown that ginseng lowers the bg level - side effects include headache, sleep disturbances, gi problems

Question 759

principles of naturopathy

Answer 759

- healing power of nature - identification and treatment of the cause of disease - treatment of the whole person - doctor as a teacher

Question 760

homeopathy

Answer 760

- stimulates the body's ability to heal by itself - remedy contains giving small doses of highly diluted substances that can cause similar symptoms - same substance if given in a larger dose would produce illness or symptoms

Question 761

glucosamine and chondroitin

Answer 761

- considered dietary supplements - may cause serious adverse events such as congestive heart failure and chest pain - may have more substantial treatment effects in a subgroup of patients with moderate to severe pain

Question 762

echinacea

Answer 762

- studies indicate that it does not prevent colds or other infections - studies have not proven that echinacea shortens the course of colds or flu - can cause allergic reactions including rash, asthma, and anaphylaxis - GI side effects are most common

Question 763

second most common cause of pain in the elderly

Answer 763

cancer

Question 764

pain assessment in the elderly is usually more difficult than in the young because it is often complicated by

Answer 764

poor memory

Question 765

American Geriatric Society and pain

Answer 765

acetominophen is the drug of choice for relieving mild to moderate pain

Question 766

A functional pain scale has been standardized for the older population

Answer 766

- rating pain as tolerable or intolerable - a functional component that adjusts the score depending on whether a person can respond verbally - a 0-5 scale that allows rapid comparison with previous pain levels

Question 767

what is a major concern regarding anti-epileptic agents when used to treat neuropathic pain in the elderly patient

Answer 767

- propensity to interfere with vit D metabolism | - may disrupt balance

Question 768

opioids and geriatrics

Answer 768

u-receptor antagonists are less desirable

Question 769

elderly and pain

Answer 769

prevalence of pain in patients older than 60 is twice the incidence of those younger than 60

Question 770

pharmacokinetics and elderly

Answer 770

volume of distribution clearance of drugs elimination half-life receptor binding affinity

Question 771

chronic use of NSAIDs in geriatrics

Answer 771

- monitor liver and renal function - concomitant use of meds such as misoprostol or H2 blockers - occasional testing for fecal occult blood

Question 772

definition of recurrent abdominal pain in childhood and adolescence

Answer 772

-abdominal pain with no organic cause occurring on at least three occasions over a 3 month period that is severe enough to alter the childs normal activity

Question 773

migraines and pediatrics

Answer 773

most children with common migraines present with abdominal pain

Question 774

chest pain and peds

Answer 774

cardiac involvement is rare. | an ECG is indicated but mainly for reassurance

Question 775

best choice for mgt of painful hemarthroses in children suffering from hemophilia

Answer 775

-acetominophen

Question 776

CRPS1 and children

Answer 776

- affected area is usually upper limbs as opposed to the lower limb in adults - multidisciplinary tx is recommended - typical children are intelligent, overachievers - sympathetic blocks are indicated to help with pt

Question 777

pediatrics and regional anesthesia

Answer 777

-spinal anesthesia has had limited indications in children because of the incidence of postspinal headaches

Question 778

differences between opioid abuse and opioid physical dependence include

Answer 778

physical dependence is a physiological state characterized by the presence of withdrawal symptoms during abstinence

Question 779

whiplash injury is from

Answer 779

hyperextension of the neck from an indirect force

Question 780

cervical structures involved in whiplash

Answer 780

- sternocleidomastoid muscle - longus colli muscle - scalene muscles

Question 781

prognostic indicator of chronic symptoms after sustaining a whiplash injury

Answer 781

- use if cervical collar for more than 12 weeks - physical therapy restarted more than once - numbness and pain in the upper extremity - requirement of home traction

Question 782

characteristics of below-level neuropathic pain in patients with SCI include

Answer 782

not related to position or activity

Question 783

during pregnancy, NSAIDs may

Answer 783

increase the risk of renal injury

Question 784

SSRI and pregnancy

Answer 784

SSRIs (fluoxetine and paroxetine) are rated category B...they are safe to administer while breast feeding.

Question 785

anticonvulsants during pregnancy

Answer 785

use of anticonvulsants during lactation does not seem to be harmful to infants

Question 786

opioids compatible with breast feeding

Answer 786

codeine methadone fentanyl propoxyphene

Question 787

substance abuse risk assessment

Answer 787

- is required as a minimum standard of care with chronic pain - is poorly conducted by most physicians - can reduce medico-legal risk when chronic opioid therapy is being considered - can be improved by use of brief, standardized screening questionnaires

Question 788

with a work related spine injury, pain and disability are most dependent upon

Answer 788

the employee's appraisal of his work setting

Question 789

In general, a successful return to work with back pain is more likely if

Answer 789

the return to work is rapid, ideally within 12 months of the injury

Question 790

commonly used quality of life measures include

Answer 790

short form 36 and the sickness impact profile

Question 791

the minnesota multiphasic personality inventory

Answer 791

is a 566 item true/fals self report used to assist with assessment of overall psychopathology

Question 792

hypnosis is used to

Answer 792

reduce acute pain and relax the patient

Question 793

mind-body and structured stress management programs often employ

Answer 793

short-term, time-limited treatment techniques - monitoring of stressors and precipitants of pain - cognitive therapy to reduce perception of pain and control over all symptoms - relaxation training

Question 794

a person's degree of belief that he/she can successfully manage aspects of their pain, including their pain level is termed

Answer 794

self-efficacy

Question 795

typical detection time in urine for methadone

Answer 795

2-4 days

Question 796

moa for cocaine in the CNS

Answer 796

mediating its effects through dopamine cells in the ventral tegmentum

Question 797

opioid induced constipation

Answer 797

treat constipation

Question 798

Diagnostic and statistical manual of mental disorder definition of substance abuse includes at least on of the following in 12 months

Answer 798

- maladaptive pattern leading to distress or impairment - recurrent failure to fill role - recurrent physically hazardous behavior recurrent legal problems

Question 799

amphetamines in UDT

Answer 799

- tests for emphetamines/methamphetamines are highly cross-reactive - UDT will detect other sympthomimetic amines such as ephedrine and pseudoephedrine

Question 800

UDT and cocaine

Answer 800

tests for cocaine react prinicpally with cocaine and its primary metabolite, benzoylecgonine -tests for cocaine have low cross-reactivity with other substances

Question 801

delirium tremens

Answer 801

nightmares, agitation, global confusion, disorientation, visual and auditory hallucinations, fever, hypertension, diaphoresis, and other signs of autonomic hyperactivity (tachycardia and hypertension).

Question 802

schedule 1 substances

Answer 802

high potency for abuse and the substance has no currently accepted medical use in treatment in the US

Question 803

schedule 2 substances

Answer 803

have high potential for abuse and may lead to severe psychlogic or physical dependence

Question 804

marijauna UDT

Answer 804

- reasonably reliable - marinol tests positive - protonix may test false positive

Question 805

DSM-IV definition of substance dependence includes

Answer 805

tolerance, withdrawal and continued use despite problems

Question 806

disability

Answer 806

a condition that relates to function relative to work or other obligations

Question 807

CAGE questionnaire

Answer 807

alcohol abuse

Question 808

CPT (current procedural technology)

Answer 808

a systematic listing and coding of procedures and services performed by physicians

Question 809

what determines the number of drug receptor complexes formed

Answer 809

receptor affinity for the drug

Question 810

professional courtesy

Answer 810

when a physician practice waives all or part of a fee for services for office staff, other physicians or family members

Question 811

impairment

Answer 811

- a loss, loss of use, or derangement of any body part, organ system or organ function - an anatomical, physiological, or psychologic abnormality that can be shown by medically acceptable clinical and laboratory diagnostic techniques

Question 812

functional restoration

Answer 812

- includes an interdisciplinary approach with physical therapy, occupational therapy, vocational rehabilitation, psychology, nursing and physician - phases of rehabilitation and functional restoration include initial reconditioning, comprehensive phase and follow up phase

Question 813

sedentary work

Answer 813

lifting a maximum of 10lb | requirement of occasional walking and standing, but mostly sitting

Question 814

determination of disability benefits include

Answer 814

age educational background previous work history residual functional capacity

Question 815

purposes of rehabilitation

Answer 815

- to resolve deconditioning syndrome that developed from prolonged bed rest with loss of muscle strength, decreased flexibility and increased stiffness - to optimize outcome by restoring function and returning to activity - to minimize potential or recurrence or reinjury

Question 816

The henneman size principle of therapeutic exercise says motor units are recruited in order of

Answer 816

increasing size, increasing contraction strength, and escalating fatigue

Question 817

example of an open kinetic chain exercise

Answer 817

knee extensions

Question 818

found to reduce risks of fall in elderly

Answer 818

tai chi

Question 819

central pain

Answer 819

- patients with central pain are usually affected by a change in temperature - central pain caused by a thalamic infarction is often a burning pain that may be described as agonizing and is on the side contralateral to the lesion - almost 90% of all central pain is caused by cerebral vascular accidents - no single pharmacologic, surgical or other treatment has been proven to be helpful in the long term

Question 820

fibromyalgia

Answer 820

- affects women more than men - suggestion that genetic factors contribute to the etiology - mood and anxiety disorders are signficant comorbidities in fibromyalgia - patients with fibromyalgia may experience a range of other symptoms including IBS or bladder issues

Question 821

Tissue structures are warmed via

Answer 821

conduction convection conversion

Question 822

the SAID principle (specific adaptation to imposed demand) of therapeutic exercise for pain management include

Answer 822

- stronger muscles develop with strength training | - pliability of connective tissue increases with flexibility exercises

Question 823

strength training consists of

Answer 823

isometric isotonic isokinetic

Question 824

LSO (lumbosacral) supports

Answer 824

- there was moderate evidence that LSO supports were ineffective for primary low back pain prevention - lumbar supports are more effective in reducing back pain than no treatment

Question 825

CARF

Answer 825

the rehabilitation accreditation commission

Question 826

physical effects of aquatic therapy include

Answer 826

- increase in cardiac output | - offloading of immersed joints

Question 827

what pain states have been found to respond to botox

Answer 827

chronic low back pain | tennis elbow

Question 828

therapeutic tx for fibromyalgia

Answer 828

- recreational therapy can be an important aspect of return to socialization - aerobic exercise is probably the most important therapeutic treatment for fibromyalgia

Question 829

patrick test (Faber)

Answer 829

The test is performed by having the tested leg flexed, abducted and externally rotated. If pain is elicited on the ipsilateral side anteriorly, it is suggestive of a hip joint disorder on the same side. If pain is elicited on the contralateral side posteriorly around the sacroiliac joint, it is suggestive of pain mediated by dysfunction in that joint.

Question 830

Gaenslen test

Answer 830

To perform Gaenslen's test, the hip joint is flexed maximally on one side and the opposite hip joint is extended, stressing both sacroiliac joints simultaneously. This is often done by having the patient lying on his or her back, lifting the knee to push towards the patient's chest while the other leg is allowed to fall over the side of an examination table, and is pushed toward the floor, flexing both sacroiliac joints.

Question 831

compression test

Answer 831

Apply compression to the joint with the patient lying on his or her side. Pressure is applied downward to the uppermost iliac crest

Question 832

open kinetic chain exercises

Answer 832

- typically performed whre the foot/leg or hand/arm is free to move, and non-weight bearing, with the movement occurring at the peripheral joint. - examples include knee extensions, straight leg raises and biceps curls

Question 833

closed kinetic chain exercise

Answer 833

-the distal part of the limb-upper or lower , is fixed to the ground or the the wall or plate. Examples include leg press, push up, and running exercises.

Question 834

tai chi

Answer 834

- internal chinese martial art often practiced with the aim of promoting health and longevity - improves balance in persons of all ages

Question 835

pilates

Answer 835

- "contrology" - focuses on core postural muscle which helps keep the body balanced and which are essential for providing support for the spine

Question 836

yoga

Answer 836

- group of ancient spiritual practices originating in india - involves flexibiilty combined with strength training - relaxes the mind and body

Question 837

bedrest

Answer 837

- increased resting heart rate - oxygen consumption decreases in proportion to the intensity of the exercise - muscle breakdown, osteoporosis and joint contractures

Question 838

lumbar stabilization

Answer 838

a type of exercise that attempts to strengthen muscles in the abdomen and posterior spine (multifidus) by cocontracting the muscles in a position of "neutral spine"

Question 839

neutral spine

Answer 839

a position where the spine hurts the least so exercise can take place

Question 840

core

Answer 840

the muscles between the chest (nipple line) and the waist

Question 841

impairment

Answer 841

"a loss, loss of use, or derangement of any body part, organ system, or organ function" -the functional consequence of the disability

Question 842

disability

Answer 842

"an alteration of an individual's capacity to meet personal, social or occupational demands or statutory or regulatory requirements because of an impairment

Question 843

physical capacity

Answer 843

the capacity of the body to operate

Question 844

McKenzie exercises

Answer 844

most well known as a set of spinal extension exercises - goal is to off-load the disk compression the the spinal nerve and reduce the leg pain. Often the pain"centralizes" to the lower back where it can be improved by other therapy methods. - directionally based

Question 845

Williams exercises

Answer 845

- a set of flexion based exercises - persons with acute paracentral disc herniations might get worse leg pain with flexion-type exercises - can be beneficial in cases of stenosis or lateral disk herniations - stationary bik is a flexion exercise

Question 846

Ely test

Answer 846

evaluates rectus femoris

Question 847

posterior pelvic tilt

Answer 847

- decrease lumbar lordosis | - gluteus medius and hamstring instability

Question 848

anterior pelvic tilt

Answer 848

- increased lumbar lordosis | - rectus femoris and iliopsoas tightening

Question 849

Thomas test

Answer 849

evaluates iliopsoas for tightening

Question 850

achilles tendonosis

Answer 850

- eccentric loading has been shown to be helpful - controversy over inflammation - weak evidence for NSAIDs and other tx

Question 851

patellofemoral pain syndrome (PFPS)

Answer 851

- insidious in onset and bilateral - often associated with load bearing exercises and repetition of this exercise - closed kinetic chain exercises, patellar taping and activity modification with NSAIDS are tx - strengthening of the vastus medialis obliquus and other quadriceps muscles are important in the treatment and not strengthening of the hamstrings

Question 852

phantom limb sensation

Answer 852

- almost universal occurrence at some time during the first month of surgery - strongest sensations come from body parts with the highest brain cortical representation (fingers/toes) - normal in character or pleasant warmth and tingling - incidence increases with age - may be an attempt to preserve self image or a permanent neural memory - telescoping

Question 853

telescoping

Answer 853

- the patient loses sensations from the mid-portion of the limb, with subsequent shortening of the phantom. - most common in upper extremity - last body parts to disappear are those with the highest representation in the cortex - only painless phantoms undergo this

Question 854

CAGE questions

Answer 854

-useful in helping make the diagnosis of alcoholism

Question 855

sedentary work

Answer 855

lifting 10lb maximum, with occasional lifting or carrying of small, light objects

Question 856

light work

Answer 856

-employee must be able to lift up 20lb and carry up to 10

Question 857

medium work

Answer 857

-employee must be able to lift up to 100lb frequently and carry up to 50lb

Question 858

heavy work

Answer 858

-objects more than 100lb must be lifted and more than 50lb must be carried

Question 859

purposes of rehab

Answer 859

- to resolve deconditioning syndrome - to optimize outcome - to minimize need for surgical intervention

Question 860

consultation vs. referral

Answer 860

Consultation: suspected problem. only opinion or advice sought. written opinion returned to attending physician Referral: problem known. transfer of total patient care for mgt of specified condition. No further communication with referring physician is required.

Question 861

Avoiding developing tolerance with epidurals

Answer 861

- selecting the lowest effective narcotic dose - place the catheter as close as possible to the cord level of the painful areas - giving multiple, small, divided doseas rather than one or two large, daily boluses - suing low-dose continous infusions whenever possible.

Question 862

cocaine

Answer 862

-acts by blocking reuptake of neurotransmitters (norepinephrine, dopamine, and serotonin) at the synaptic junctions, resulting in increased neurotransmitter concentrations

Question 863

Consultation

Answer 863

-an opinion is requested -patient is not referred three Rs -request for opinion is received -render the service/opinin -report back to the physician requesting your opinin

Question 864

most frequent side effect of opioid therapy

Answer 864

constipation | -as the dose of opioid increases, so does the potential for constipation.

Question 865

UDT methods: amphetamines

Answer 865

low specificity - tests are highly cross-reactive - they will detect other sympathomimenticamines such as ephedrine and pseudoephedring

Question 866

UDT: cocaine

Answer 866

very specific | -react prinicpally with cocaine and its primary metabolite, benzoylecgonine

Question 867

schedule 1

Answer 867

- the drug or other substance has a high potential for abuse - the drug or other substances has no currently accepted medical use in treatment in the US - there is a lack of accepted safety for the use of the drug or other substance under medical supervision

Question 868

schedule 2

Answer 868

the drug or other substance has a high potential for abuse - the drug or other substances has no currently accepted medical use in treatment in the us or a currently accepted medical use with severe restrictions - abuse of the drug or other substances may lead to severe psychologic or physical dependence

Question 869

schedule 3

Answer 869

- the drug or other substance has a potential for abuse less than the drugs or other substances in schedules 1 and 2 - the drug or other substances has no currently accepted medical use in treatment in the us - abuse of the drug or other substance may lead to moderate or low physical dependence or high psychologic dependence

Question 870

schedule 4

Answer 870

- the drug or other substance has a low potential for abuse relative to the drugs or other substances in schedule 4 - the drug or other substance has a currently accepted medical use in treatment in the US - abuse of the drug or other substances may lead to limited physical dependence or psychologic dependence relative to the drugs or other substances in schedule 4

Question 871

UDT: marijuana

Answer 871

moderate specificity - reasonable reliability - marinol: positive - protonix: false-positive

Question 872

metabolites of morphine

Answer 872

M3g and M6g

Question 873

metabolites of meperidine

Answer 873

normeperidine

Question 874

metabolites of hydromorphone

Answer 874

hydromorphone 3 glucuronide

Question 875

metabolites of oxycodone

Answer 875

noroxycodone, oxymorphone, oxycodols

Question 876

metabolites of fentanyl

Answer 876

extensive metabolism via hepatic pathways

Question 877

metabolites of codeine

Answer 877

norcodeine | morphine

Question 878

metabolites of hydrocodone

Answer 878

dihydromorphone hydromorphone dihydrocodeine

Question 879

metabolites of pentazocine

Answer 879

metabolized almost exclusively in the liver

Question 880

predominant cause of pain in the elderly

Answer 880

musculoskeletal | -2nd is cancer

Question 881

most pain complaints in the elderly

Answer 881

organic, not psychiatric

Question 882

most common cause of adverse drug rxn in elderly

Answer 882

NSAIDs

Question 883

greatest concern with antiepileptics

Answer 883

-propensity to disrupt balance and to interfere with vitamin D metabolism

Question 884

meperidine and elderly

Answer 884

-should be avoided either alone or in combination with a product such as hydroxyzine

Question 885

agonist/antagonist and elderly

Answer 885

no role

Question 886

compliance

Answer 886

approx 50% - worse with increased number of meds race, drug, dosage form, cost insurance and coverage. communication

Question 887

when first starting opioid therapy

Answer 887

- use drugs with a short half-life - drugs such as hydro and oxycodone have minimal active metabolites and relatively short half-life - drugs such as methadone havea variable half-life (12-190) or meperidine accumulates of its metabolites are toxic to kidneys and CNS

Question 888

prior to chemical neurolysis

Answer 888

-patients must have had successful pain relief after a diagnostic local block and no intolerable side effects. Frequent side effects can include - persistent pain at the site of injection, paresthesias, hyperesthesia, sytemic hopytension, bowel and bladder dysfunction, motor weakness, deafferentation pain and neuritis.

Question 889

definition of recurrent abdominal pain in childhood

Answer 889

excludes abdominal pain resulting from known medical conditions

Question 890

common migraine

Answer 890

type seen in children before puberty - most recurrent migraine in children - no aura before and no unilateral focal localization of the pain - pain is usually bifrontal or bitemporal

Question 891

classic migraine

Answer 891

- former starts with a visual aura in 30% of children affected - a sensory, sensorimotor aura or speech impairment - followed by severe, throbbing, hemicranial, well-localized headache

Question 892

migraine in children

Answer 892

defined as a recurrent headache accompanied by three of the following symptoms - recurrent abdominal pain with or without nausea or vomiting - throbbing pain on one side of the cranium - relief of the pain by rest - a visual, sensory, or motor aura - a family history - about 70% of children with common migraine have abdominal pain

Question 893

ophthalmoplegic migraine

Answer 893

rare in children before 4-5 yrs | usually affects only one eye and is often accompanied by mydriasis.

Question 894

chest pain in children

Answer 894

relatively common, ranks third after headaches and abdominal pain

Question 895

costochondritis

Answer 895

most common cause of chest pain in children -often occurs after an upper respiratory infection, can radiate to the back adn can last from a few days to several months

Question 896

most common hemoglobinopathy in US

Answer 896

sickle cell anemia

Question 897

pain and SCD

Answer 897

- where there is occlusion of small vessels - usually small bones of the extremities in smaller children and abdomen, chest, long bones, and lower back in older children

Question 898

painful crisis in SCD

Answer 898

- triggered by hypoxemia, cold, infection and hypovolemia - prodromal phase - occurs up to 2 days before the actual sickle crisis with numbness, paresthesias, and an increase in circulating cells - initial phase - lasts 1-2 days and includes pain, anorexia, and fear and anxiety - established phase - pain that lasts 3-7 days, inflammation, swelling and leukocytosi are present

Question 899

the goals of the sympathetic blockade are to

Answer 899

1. ascertain the sympathetic origin of the disorder 2. break the vicious circle of sympathetically maintained pain 3. permit more vigorous physical activity

Question 900

growth is an important factor in sports injuries for 2 reasons

Answer 900

1. growth cartilage is less resistant to injury than the adult-type cartilage 2. growth spurts in children cause tendon and muscle tightness, leading to pain and sometimes stress fracture. These fractures are most often seen in the tibia or fibula

Question 901

the most common side effects found with narcotic administration

Answer 901

nauseau or vomiting and pruritis

Question 902

whiplash

Answer 902

the resultant injury caused by an abrupt hyperextension of the neck from an indirect force - symptoms may occur 12-24 hrs later because the muscular hemorrhag and edema may need to evolve prior to inciting a nociceptive response. - the cervical flexors, specifically the sternocleidomastoid, scalene and the longus colli undergo acute stretch reflex. Some fibers are torn

Question 903

5 category labeling system for all drugs in US

Answer 903

rates the potential risk for teratogenic or embryotoxic effects according to scientific and clinical evidence

Question 904

category A

Answer 904

controlled human studies indicate no apparent risk to fetus. (multivitamins)

Question 905

category B

Answer 905

animal studies do not indicate a fetal risk or do indicate a teratogenic risk, but well controlled human studies have failed to show a risk -acetominophen, butorphanol, nalbuphine, caffeine, fentanyl, hydrocodone, methadone, meperidine, morphine, oxycodone

Question 906

category C

Answer 906

studies indicate teratogenic or embryocidal risk in animals, but no controlled studies have been done in women or no controlled studies in animals or humans

Question 907

category D

Answer 907

positive evidence of human fetal risk, but in certain circumstances, the benefits of the drug may outweigh the risks involved

Question 908

category x

Answer 908

-includes drugs where there is positive evidence of significant fetal risk, and the risk clearly outweighs any possible benefit

Question 909

aspirin and pregnancy

Answer 909

-prostaglandins appear to trigger labor and the aspirin-induced inhibition of prostaglandin synthesis may result in prolonged gestation and protracted labor

Question 910

ibuprofen and pregnancy

Answer 910

may result in reversible oligohydramnios and mild constriction of the fetal ductus arteriosus

Question 911

benzodiazepines and pregnancy

Answer 911

- first trimester exposure may be associated with an increased risk of congenital malformations - cleft lip and cleft palate - may experience withdrawal symptoms after birth