The beneficial effects of cognitivebehavioral therapy in chronic pain are mediated by

A. Augmenting descending inhibitory pathways

B. Blocking transmission of pain in the spinothalamic tract

C. By releasing acetylcholine from parasympathetic nerve endings

D. None of the above

750 • ESSENTIALS OF PAIN MANAGEMENT Answers

1. The answer is A. Cornea is devoid of C fibers. Visceral pain is poorly localized and brain is insensitive to pain.

2. The answer is C. Both central and peripheral mechanisms are implicated in pain hypersensitivity. Allodynia is when pain is produced by stimuli which are not normally painful (e.g., touch) and hyperpathia is when repetitive stimuli produces the sensation of pain.

3. The answer is B. A-delta fibers are myelinated and fast conducting at 20 m/sec. They do respond to mechanical stimulus which is above a specific threshold.

4. The answer is C. The spinal gray matter is divided into 10 laminae depending on the histological appearance.

5. The answer is A. Outflow of descending inhibitory impulses from frontal cortex, cingulate gyrus and hypothalamus are influenced by the patient's psychological and emotional state. Psychological support, including imagery, biofeedback, and music therapy can reduce pain intensity by either facilitating descending pathways or inhibiting cortical perception.

Chapter 4: Acute and Chronic Mechanisms of Pain

1. Evan is a 45-year-old man who had undergone lumbar discectomy for back pain and leg pain about 3 weeks ago. He is now complaining of constant dull ache in his lower back along with sharp shooting pain down his right leg. He is also complaining of occasional burning sensation in the anterior aspect of his right thigh. Evan is likely suffering from

A. Neuropathic pain

B. Nociceptive pain

C. Mixed pain

D. Physiologic pain

2. Ionic basis of activation of nociceptors involves all EXCEPT

A. An inward sodium current

B. A depolarizing calcium current

C. Activation of nerve endings by potassium and hydrogen ions

D. Hyperpolarization of cell membrane

3. Action potentials through the sensitized nociceptors release the following peptides in and around the site of injury EXCEPT

A. Prostaglandin a

B. Calcitonin gene-related peptide

C. Cholecystokinin

D. Substance P

4. The correct sequence of the noxious stimulus from the periphery to the sensory cortex is

A. AS/C fibers^ dorsal ganglia^ spinothalamic tractshypothalamus^thalamus^ sensory cortex

B. AS/C fibers ^ dorsal ganglia^ spinothalamic tracts medullar thalamus^ sensory cortex

C. AS/C fibers ^ spinothalamic tracts dorsal ganglia^ medullar thalamus^ sensory cortex

D. AS/C fibers ^ spinothalamic tracts dorsal ganglia^medulla^hypothalamus^sensory cortex

5. The correct statement regarding NMDA receptor is

A. It is a 4-subunit, voltage-gated ligand-specific ion channel

B. Glutamate binding to NMDA receptors sustains an outward Ca2+ flux

C. Are responsible for producing analgesia

D. Ketamine acts as an NMDA agonist

Answers

1. The answer is C. This pain has feature of both neuropathic and nociceptive pain. It has radiation that is indicative of nerve damage either pre-existing or secondary to surgery. Assessing qualitative aspect of pain is important in diagnosis and management.

2. The answer is D. Transduction is the process by which the noxious stimulus at the nerve ending converted to electrical activity. Activation of nociceptor triggers a generator potential mediated by calcium ion which in turn activates an inward sodium current resulting in propagation of action potential along the axon. Potassium and hydrogen ions are involved in activation of the nerve endings. Hyperpolarization makes the cell membrane less excitable.

3. The answer is A. Prostaglandin a is not a peptide but an eicosanoid.

5. The answer is A. The effect of glutamate on NMDA receptor is sustained Ca2+ influx and it amplifies pain. Ketamine is NMDA receptor antagonist.

Chapter 5: Assessment of Pain: Complete Patient Evaluation

1. Somatic and visceral pain could be distinguished by the following:

A. Somatic pain is likely to be sharp, burning, and poorly localized

B. Visceral pain is likely to be dull, diffuse, and well localized

C. Referred pain is suggestive of its visceral origin

D. Autonomic disturbances are characteristic of somatic pain

2. A 48-year-old bus driver is complaining of acute left buttock pain moving down the back of thigh and leg to the heel. On examination, he has grade 4 flexion of the knee and 1+ ankle reflex on the left. He has reduced sensation to light touch over the same area. He is likely to have

A. S2 radiculopathy

B. Left sacro-iliac joint pain

C. Fracture of the left femur

D. Lumbar facet joint arthropathy

3. Which of the following statement is FALSE regarding cranial nerve testing?

A. Conjugate gaze testing assesses the functions of cranial nerves II, III, and VI

B. Trigeminal nerve has both sensory and motor functions

C. Gag reflex assesses the function of vagus nerve

D. Facial nerve has only motor function

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