I85PREP
⌘ K
ABEM Pain Medicine study materials
ABEM Pain Medicine study resources

ABEM Pain Medicine practice questions

One question at a time. Build your ABEM Pain Medicine understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Basic Science of Pain: Anatomy, Physiology, and Pharmacology

A nociceptive primary afferent that is thinly myelinated and conducts impulses at approximately 5 to 30 meters per second is classified as which fiber type?

  1. C fiber
  2. A-beta fiber
  3. A-delta fiber Correct answer.
  4. A-alpha fiber

Explanation

A-delta fibers are thinly myelinated group III afferents that conduct at roughly 5 to 30 m/s and mediate the rapid, sharp first pain felt after injury. C fibers are unmyelinated and far slower, while A-beta and A-alpha fibers are large myelinated afferents serving low-threshold touch and proprioception.

Question 2Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Which neurotransmitter is the principal fast excitatory transmitter released by nociceptive primary afferents onto dorsal horn neurons?

  1. Glycine
  2. Acetylcholine
  3. GABA
  4. Glutamate Correct answer.

Explanation

Primary afferent terminals release glutamate, which acts on AMPA receptors for fast excitation and on NMDA receptors for prolonged depolarization of dorsal horn neurons. Peptides such as substance P are co-released and slow the transmission rather than serving as the fast transmitter.

Question 3Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Pain and temperature sensation from the trunk and limbs reaches the thalamus mainly through which pathway?

  1. Corticospinal tract
  2. Spinothalamic tract Correct answer.
  3. Dorsal column-medial lemniscus
  4. Spinocerebellar tract

Explanation

Nociceptive and thermoreceptive afferents synapse in the dorsal horn, cross in the anterior white commissure, and ascend in the contralateral spinothalamic tract to the ventroposterior thalamus. This crossed organization explains why cord lesions produce contralateral loss of pain and temperature.

Question 4Basic Science of Pain: Anatomy, Physiology, and Pharmacology

According to the gate control theory, activity in which afferent population reduces transmission of nociceptive signals in the dorsal horn?

  1. Large myelinated A-beta fibers Correct answer.
  2. Vagal afferent fibers
  3. Sympathetic postganglionic fibers
  4. Unmyelinated C fibers

Explanation

Large-diameter A-beta mechanoreceptive input excites inhibitory interneurons in the dorsal horn that suppress nociceptive transmission both presynaptically and postsynaptically, effectively closing the gate. Small C-fiber input conversely inhibits these interneurons and opens the gate.

Question 5Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Nonsteroidal anti-inflammatory drugs reduce peripheral pain sensitization primarily by inhibiting which enzyme?

  1. Lipoxygenase
  2. Phosphodiesterase
  3. Acetylcholinesterase
  4. Cyclooxygenase Correct answer.

Explanation

NSAIDs inhibit cyclooxygenase isoforms, lowering prostaglandin synthesis at sites of inflammation. Because prostaglandins sensitize nociceptor terminals, their reduction raises the activation threshold and lessens hyperalgesia.

Question 6Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Which group of peptides acts at endogenous opioid receptors to modulate pain?

  1. Somatostatins
  2. Tachykinins
  3. Endorphins and enkephalins Correct answer.
  4. Neuropeptide Y

Explanation

Beta-endorphin, the enkephalins, and the dynorphins are endogenous opioid peptides that activate mu, delta, and kappa receptors in the periphery, spinal cord, and brain. They produce analgesia by inhibiting transmitter release presynaptically and hyperpolarizing postsynaptic neurons.

Question 7Basic Science of Pain: Anatomy, Physiology, and Pharmacology

The substantia gelatinosa, a region important for modulating nociceptive input, corresponds to which Rexed lamina of the spinal cord?

  1. Lamina II Correct answer.
  2. Lamina I
  3. Lamina IX
  4. Lamina V

Explanation

The substantia gelatinosa is lamina II, a densely packed layer of small interneurons at the dorsal horn apex that gates nociceptive transmission. Lamina I is the marginal zone, and lamina V contains wide-dynamic-range neurons that project rostrally.

Question 8Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Local anesthetics produce analgesia and anesthesia by blocking which target?

  1. Voltage-gated potassium channels
  2. Voltage-gated sodium channels Correct answer.
  3. GABA-A receptors
  4. NMDA receptors

Explanation

Local anesthetics bind the inner pore of voltage-gated sodium channels in their open and inactivated states, preventing action potential generation and propagation in nociceptors. Because small unmyelinated fibers are blocked first, pain sensation is lost before touch or motor function.

Question 9Basic Science of Pain: Anatomy, Physiology, and Pharmacology

A patient receiving neuraxial opioid therapy develops good analgesia together with dose-limiting respiratory depression and constipation. Which receptor mediates these effects?

  1. Mu-opioid receptor Correct answer.
  2. Kappa-opioid receptor
  3. Nociceptin receptor
  4. Delta-opioid receptor

Explanation

Mu receptor activation produces analgesia at spinal and supraspinal sites but also respiratory depression, constipation, miosis, and dependence. Kappa agonists provide spinal analgesia with dysphoria and minimal respiratory depression, while delta receptors mainly modulate mu-mediated effects.

Question 10Basic Science of Pain: Anatomy, Physiology, and Pharmacology

A topically applied agent produces burning pain and, with repeated use, desensitization of nociceptors. Its receptor is a nonselective cation channel gated by capsaicin and by temperatures above about 43 degrees Celsius. Which channel is this?

  1. ASIC3
  2. TRPV1 Correct answer.
  3. TRPM8
  4. P2X3

Explanation

TRPV1 is expressed on small-diameter peptidergic nociceptors and opens in response to capsaicin, noxious heat, and protons. Prolonged activation drives calcium influx and desensitization, which is the basis for topical capsaicin analgesia.

Question 11Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Repetitive low-frequency stimulation of C fibers produces progressively larger dorsal horn responses. This wind-up depends most directly on which mechanism?

  1. Increased serotonin release from raphe neurons
  2. Presynaptic GABA-B receptor activation
  3. Summation of NMDA receptor-mediated calcium entry Correct answer.
  4. Upregulation of peripheral cyclooxygenase-2

Explanation

Repeated C-fiber release of glutamate and substance P progressively depolarizes dorsal horn neurons, relieving the magnesium block of NMDA receptors. The resulting calcium influx and kinase activation generate wind-up and initiate central sensitization.

Question 12Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Which neuropeptide, released from peptidergic nociceptor terminals, is a potent vasodilator and the target of monoclonal antibodies used to prevent migraine?

  1. Substance P
  2. Galanin
  3. Calcitonin gene-related peptide Correct answer.
  4. Somatostatin

Explanation

Calcitonin gene-related peptide is released from trigeminal and dorsal root ganglion nociceptors, dilates cranial vessels, and facilitates nociceptive transmission. Antibodies directed against the peptide or its receptor reduce migraine frequency.

Question 13Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Gabapentin and pregabalin reduce neuronal excitability by binding to which target?

  1. Sodium channels in the dorsal root ganglion
  2. The mu-opioid receptor
  3. Cyclooxygenase-2
  4. Alpha-2-delta subunit of calcium channels Correct answer.

Explanation

These drugs bind the alpha-2-delta auxiliary subunit of presynaptic voltage-gated calcium channels, reducing calcium influx and the release of glutamate and substance P from primary afferents. This accounts for their benefit in neuropathic pain.

Question 14Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Electrical stimulation of the periaqueductal gray produces analgesia primarily by activating which descending pathway?

  1. Nigrostriatal dopaminergic projections
  2. Thalamocortical glutamatergic projections
  3. Rostral ventromedial medullary neurons Correct answer.
  4. Spinocerebellar climbing fibers

Explanation

Periaqueductal gray output excites neurons of the rostral ventromedial medulla, which project through the dorsolateral funiculus to the dorsal horn and release serotonin and norepinephrine. This descending inhibitory system suppresses nociceptive transmission.

Question 15Basic Science of Pain: Anatomy, Physiology, and Pharmacology

A patient has lost pain and temperature sensation over the left leg but retains fine touch and vibration sense there. A lesion at which site best explains this pattern?

  1. Left dorsal columns of the spinal cord
  2. Right medullary medial lemniscus
  3. Right spinothalamic tract in the spinal cord Correct answer.
  4. Left peripheral nerve with only large fibers affected

Explanation

Pain and temperature fibers cross within the spinal cord and ascend in the contralateral spinothalamic tract, so a right-sided cord lesion causes left-sided loss of these modalities. Dorsal column function for touch and vibration travels ipsilaterally in the cord and remains intact.

Question 16Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Prostaglandin E2 contributes to peripheral hyperalgesia chiefly by which action at nociceptor terminals?

  1. Blocking voltage-gated sodium channels
  2. Lowering the nociceptor activation threshold Correct answer.
  3. Increasing potassium conductance
  4. Opening chloride channels on the terminal

Explanation

Prostaglandin E2 acts at EP receptors coupled to Gs, raising cyclic AMP and protein kinase A activity. Kinase-mediated phosphorylation sensitizes TRPV1 and sodium channels, so stimuli that were previously innocuous now activate nociceptors.

Question 17Basic Science of Pain: Anatomy, Physiology, and Pharmacology

In inflammatory pain, nerve growth factor sensitizes nociceptors by binding which receptor on small peptidergic afferents?

  1. TrkA Correct answer.
  2. TrkB
  3. TrkC
  4. The p75 receptor alone

Explanation

Nerve growth factor binds the TrkA receptor tyrosine kinase on peptidergic nociceptors, enhancing TRPV1 function and increasing substance P and calcitonin gene-related peptide expression. TrkB and TrkC are the receptors for brain-derived neurotrophic factor and neurotrophin-3 respectively.

Question 18Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Substance P released from nociceptive terminals acts preferentially at which receptor?

  1. Bradykinin B2 receptor
  2. NK3 receptor
  3. NK1 receptor Correct answer.
  4. CGRP receptor

Explanation

Substance P is a tachykinin with highest affinity for the NK1 receptor, a Gq-coupled receptor on dorsal horn projection neurons that contributes to slow excitatory potentials and neurogenic inflammation. NK2 and NK3 receptors prefer other tachykinins.

Question 19Basic Science of Pain: Anatomy, Physiology, and Pharmacology

A gain-of-function mutation in SCN9A producing a hyperexcitable dorsal root ganglion sodium channel causes which inherited pain disorder?

  1. Familial hemiplegic migraine
  2. Inherited erythromelalgia Correct answer.
  3. Fabry disease
  4. Congenital insensitivity to pain

Explanation

SCN9A encodes the Nav1.7 channel, which is concentrated in small nociceptors and amplifies subthreshold depolarizations. Gain-of-function variants lower the activation threshold and produce inherited erythromelalgia with burning pain, whereas loss-of-function variants cause congenital insensitivity to pain.

Question 20Basic Science of Pain: Anatomy, Physiology, and Pharmacology

The endogenous peptide nociceptin, also called orphanin FQ, activates which receptor?

  1. NOP/ORL1 receptor Correct answer.
  2. Kappa-opioid receptor
  3. Mu-opioid receptor
  4. Delta-opioid receptor

Explanation

Nociceptin preferentially activates the NOP (ORL1) receptor, a Gi-coupled receptor homologous to opioid receptors but insensitive to classical opioid alkaloids. Its net action in pain circuits is often pronociceptive or anti-opioid, and it also modulates stress and reward.

Question 21Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Endocannabinoids such as anandamide and 2-arachidonoylglycerol suppress transmitter release in pain circuits through which mechanism?

  1. Activation of postsynaptic NMDA receptors
  2. Inhibition of GABA synthesis
  3. Activation of presynaptic CB1 receptors Correct answer.
  4. Blockade of glycine receptors

Explanation

Endocannabinoids are synthesized postsynaptically on demand, diffuse retrogradely, and activate presynaptic CB1 receptors coupled to Gi proteins. This reduces calcium entry and transmitter release, producing a modulatory brake on nociceptive transmission in the dorsal horn and amygdala.

Question 22Basic Science of Pain: Anatomy, Physiology, and Pharmacology

In the rostral ventromedial medulla, increased activity of which neuronal class promotes pain facilitation?

  1. Spinothalamic projection cells
  2. OFF cells
  3. Dorsal column nuclear cells
  4. ON cells Correct answer.

Explanation

Rostral ventromedial medullary ON cells fire just before nociceptive reflexes and enhance dorsal horn responses, producing descending facilitation. OFF cells show the opposite pattern and suppress nociception, so the balance between the two populations sets net descending tone.

Question 23Basic Science of Pain: Anatomy, Physiology, and Pharmacology

In some patients with complex regional pain syndrome, pain is worsened by sympathetic activation. Which mechanism best explains this coupling?

  1. Sprouting of large afferents into lamina II
  2. Ectopic discharge from motor axons
  3. Alpha-adrenergic sensitization of injured nociceptors Correct answer.
  4. Loss of dorsal root ganglion neurons

Explanation

After nerve injury, nociceptors can express alpha-adrenergic receptors, so norepinephrine released by sympathetic terminals evokes ectopic firing and pain. This adrenergic coupling is the rationale for sympathetic blockade in selected patients.

Question 24Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Lamina I of the dorsal horn contains which neuronal population that projects to the thalamus and parabrachial area?

  1. Nociceptive-specific projection neurons Correct answer.
  2. Serotonergic raphe neurons
  3. Parasympathetic preganglionic neurons
  4. Cholinergic motor neurons

Explanation

Marginal-zone neurons in lamina I receive monosynaptic input from A-delta and C nociceptors, express NK1 receptors, and project through spinothalamic and spinoparabrachial pathways. They drive the sensory-discriminative and affective components of pain.

Question 25Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Chronic mu-opioid administration leads to tolerance largely through which cellular adaptation?

  1. Receptor desensitization and downregulation Correct answer.
  2. Increased receptor gene transcription
  3. Reduced synthesis of endogenous opioid peptides
  4. Inhibition of adenylyl cyclase by Gs proteins

Explanation

Prolonged mu agonist exposure drives G-protein receptor kinase-mediated phosphorylation, beta-arrestin recruitment, and receptor internalization or downregulation, so a given dose produces less signaling. Compensatory cyclic AMP superactivation after withdrawal also contributes to dependence.

Question 26Basic Science of Pain: Anatomy, Physiology, and Pharmacology

A patient reports a sharp, well-localized pain immediately after a needle stick, followed by a slower burning ache. Which primary afferent fiber class mediates the immediate sharp component?

  1. A-beta fibers
  2. A-delta fibers Correct answer.
  3. C fibers
  4. A-alpha fibers

Explanation

A-delta fibers are thinly myelinated and conduct quickly, so they carry the first sharp, discriminative pain. C fibers are unmyelinated and slower, producing the delayed burning pain. A-alpha and A-beta fibers are large myelinated fibers serving proprioception and low-threshold touch.

Question 27Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Where are the cell bodies of primary afferent neurons that carry pain from the lower limb located?

  1. In the ventral horn of the spinal cord
  2. In the thalamic ventroposterior nucleus
  3. In the sympathetic chain ganglia
  4. In the dorsal root ganglion Correct answer.

Explanation

Primary afferent neurons are pseudounipolar, with their cell bodies in the dorsal root ganglion and axons projecting centrally to the dorsal horn. The ventral horn contains motor neurons, and sympathetic chain ganglia contain postganglionic sympathetic neurons. The thalamus contains second- or third-order relay neurons, not primary afferent cell bodies.

Question 28Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Nociceptive input from the face and oral cavity is relayed through which thalamic nucleus before reaching the cortex?

  1. Mediodorsal nucleus
  2. Lateral geniculate nucleus
  3. Ventroposterolateral nucleus
  4. Ventroposteromedial nucleus Correct answer.

Explanation

The ventroposteromedial nucleus receives trigeminothalamic fibers carrying facial pain and temperature information. The ventroposterolateral nucleus relays spinothalamic input from the body. The lateral geniculate and mediodorsal nuclei serve visual and limbic-association functions, respectively.

Question 29Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Extracellular ATP released from damaged tissue excites nociceptor terminals primarily through which receptor?

  1. MrgprD
  2. P2X3 Correct answer.
  3. ASIC3
  4. TRPM8

Explanation

P2X3 is an ATP-gated ion channel expressed on small nociceptive afferents, and it contributes to purinergic pain signaling after tissue injury. TRPM8 detects cooling and menthol, while ASIC3 responds to extracellular protons. MrgprD is a mas-related G protein-coupled receptor for certain pruritogens and irritants, not the main ATP sensor.

Question 30Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Two amide local anesthetics have pKa values of 7.9 and 8.5. At a tissue pH of 7.4, which property explains the faster onset of the agent with the lower pKa?

  1. It is eliminated more slowly by hepatic metabolism
  2. It blocks potassium channels more selectively
  3. More uncharged base crosses the membrane Correct answer.
  4. A larger fraction is bound to plasma proteins

Explanation

Local anesthetics cross the axon membrane in their uncharged base form and then become protonated to block sodium channels from inside. A pKa closer to tissue pH increases the fraction of uncharged base, speeding diffusion and onset. Protein binding, hepatic clearance, and potassium-channel selectivity do not determine onset in this way.

Question 31Basic Science of Pain: Anatomy, Physiology, and Pharmacology

A patient with ultrarapid CYP2D6 metabolism receives codeine and develops excessive sedation and respiratory depression. Which active metabolite is responsible?

  1. Hydromorphone
  2. Morphine Correct answer.
  3. Norcodeine
  4. Codeine-6-glucuronide

Explanation

Codeine is a prodrug that CYP2D6 converts to morphine, which provides most of its analgesic and toxic effects. Ultrarapid metabolizers form morphine more rapidly and can develop opioid toxicity. Codeine-6-glucuronide and norcodeine are minor metabolites with much less mu-opioid activity.

Question 32Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Which dorsal horn neurons respond to both innocuous and noxious stimulation and are thought to contribute to secondary hyperalgesia and referred pain?

  1. Inhibitory interneurons in lamina II
  2. Nociceptive-specific neurons in lamina I
  3. Wide-dynamic-range neurons in lamina V Correct answer.
  4. Motor neurons in lamina IX

Explanation

Wide-dynamic-range neurons in lamina V receive convergent input from A-beta, A-delta, and C fibers, so they encode stimulus intensity across touch and pain ranges. Their sensitization contributes to hyperalgesia and to the spread of pain. Lamina I nociceptive-specific cells respond mainly to noxious input, lamina II interneurons modulate input, and lamina IX contains motor neurons.

Question 33Basic Science of Pain: Anatomy, Physiology, and Pharmacology

After peripheral nerve injury, spinal microglia release a factor that causes a shift in neuronal chloride gradient and weakens GABA-mediated inhibition. Which factor is most directly responsible?

  1. CGRP
  2. Substance P
  3. BDNF Correct answer.
  4. NGF

Explanation

Activated microglia release BDNF, which downregulates the potassium-chloride cotransporter KCC2 in dorsal horn neurons. The resulting rise in intracellular chloride makes GABA-A and glycine receptor activation less inhibitory or even excitatory. NGF, CGRP, and substance P are nociceptive mediators but are not the microglial factor that produces this anion-gradient shift.

Question 34Basic Science of Pain: Anatomy, Physiology, and Pharmacology

Intrathecal ziconotide produces analgesia by selectively blocking which voltage-gated calcium channel?

  1. P/Q-type (Cav2.1)
  2. T-type (Cav3.2)
  3. L-type (Cav1.2)
  4. N-type (Cav2.2) Correct answer.

Explanation

Ziconotide is a synthetic conotoxin that blocks N-type Cav2.2 calcium channels on primary afferent terminals in the dorsal horn. This reduces calcium influx and release of excitatory neurotransmitters such as glutamate and substance P. L-, T-, and P/Q-type channels are not the selective target of ziconotide.

Question 35Pain Assessment, Diagnosis, and Evaluation

Which pain intensity instrument asks the patient to verbally rate pain from 0 to 10, where 0 is no pain and 10 is worst pain imaginable?

  1. Numeric Rating Scale Correct answer.
  2. Wong-Baker FACES scale
  3. McGill Pain Questionnaire
  4. Visual Analog Scale

Explanation

The Numeric Rating Scale is an 11-point verbal or written scale from 0 to 10. It is simple, validated, and widely used for pain intensity in adults.

Question 36Pain Assessment, Diagnosis, and Evaluation

The McGill Pain Questionnaire primarily measures which aspect of the pain experience?

  1. Sensory, affective, evaluative qualities Correct answer.
  2. Functional interference with daily activities
  3. Neuropathic symptom screening
  4. Pain intensity on a 0-10 scale

Explanation

The McGill Pain Questionnaire uses word descriptors grouped into sensory, affective, evaluative, and miscellaneous categories. It yields pain rating indices that characterize the multidimensional quality of pain.

Question 37Pain Assessment, Diagnosis, and Evaluation

The Pain Catastrophizing Scale assesses which cognitive-affective construct?

  1. Depressive symptom severity over the past two weeks
  2. Pain acceptance and engagement in valued activities
  3. Rumination, magnification, and helplessness Correct answer.
  4. Fear of movement and reinjury during activity

Explanation

The Pain Catastrophizing Scale contains 13 items scored on rumination, magnification, and helplessness. Higher scores indicate greater catastrophic thinking about pain.

Question 38Pain Assessment, Diagnosis, and Evaluation

PainDETECT is a screening questionnaire designed to identify which type of pain?

  1. Nociceptive pain from osteoarthritis
  2. Cancer-related breakthrough pain
  3. Neuropathic pain components Correct answer.
  4. Visceral pain from irritable bowel syndrome

Explanation

PainDETECT includes seven sensory symptom items, a temporal pattern item, and a radiating pain item. Scores suggest whether a neuropathic pain component is likely.

Question 39Pain Assessment, Diagnosis, and Evaluation

The PAINAD scale is used to assess pain in which population?

  1. Patients with acute postoperative delirium
  2. Children younger than three years of age
  3. Adults with advanced dementia Correct answer.
  4. Adolescents with chronic migraine

Explanation

PAINAD is a five-item observational tool for pain in people with advanced dementia. It scores breathing, negative vocalization, facial expression, body language, and consolability.

Question 40Pain Assessment, Diagnosis, and Evaluation

The FLACC scale assesses pain in children by scoring which behaviors?

  1. Heart rate, blood pressure, oxygen saturation, and respiratory rate
  2. Sleep quality, appetite, mood, and play behavior
  3. Verbal rating, visual analog score, and numeric rating
  4. Face, legs, activity, cry, consolability Correct answer.

Explanation

FLACC stands for Face, Legs, Activity, Cry, and Consolability. Each category is scored 0 to 2, giving a total of 0 to 10 for children who cannot reliably self-report.

Question 41Pain Assessment, Diagnosis, and Evaluation

The PHQ-9 is primarily used to assess which condition in patients with chronic pain?

  1. Neuropathic pain quality
  2. Pain-related fear of movement
  3. Depressive symptom severity Correct answer.
  4. Opioid misuse risk

Explanation

The PHQ-9 scores the nine DSM depression criteria over the past two weeks. It is commonly used in pain settings to screen for and monitor depression.

Question 42Pain Assessment, Diagnosis, and Evaluation

Which clinical finding is most characteristic of a myofascial trigger point?

  1. Allodynia in a stocking-glove distribution
  2. Taut band with a hypersensitive spot Correct answer.
  3. Weakness confined to a single nerve root
  4. Dermatomal loss of pinprick sensation

Explanation

A myofascial trigger point is a hyperirritable spot within a taut band of skeletal muscle. Palpation often reproduces the patient's referred pain and a local twitch response.

Question 43Pain Assessment, Diagnosis, and Evaluation

A patient with diabetes reports burning feet and has reduced pinprick sensation. Which screening tool is most appropriate to quantify a neuropathic pain component?

  1. Oswestry Disability Index
  2. DN4 questionnaire Correct answer.
  3. CAGE questionnaire
  4. Pain Catastrophizing Scale

Explanation

The DN4 combines sensory descriptors with bedside examination findings such as hypoesthesia and allodynia. It is validated for screening neuropathic pain.

Question 44Pain Assessment, Diagnosis, and Evaluation

Conditioned pain modulation is best described as which phenomenon?

  1. Pain is reduced by distracting the patient with a cognitive task
  2. Repeated stimulation increases pain intensity over time
  3. Pain thresholds are lower in unaffected body regions
  4. One painful stimulus inhibits another Correct answer.

Explanation

Conditioned pain modulation tests descending inhibitory function. A conditioning stimulus reduces the pain rating of a test stimulus, reflecting endogenous analgesia.

Question 45Pain Assessment, Diagnosis, and Evaluation

Which finding on bedside testing suggests enhanced temporal summation?

  1. Rising pain ratings with repeated pinprick Correct answer.
  2. Pain evoked by a normally nonpainful brush stroke
  3. Loss of vibration sense in the distal toes
  4. Reduced pain rating after a cold pressor conditioning stimulus

Explanation

Temporal summation is the progressive increase in pain evoked by repeated identical nociceptive stimuli. Enhanced summation suggests central sensitization.

Question 46Pain Assessment, Diagnosis, and Evaluation

According to the 2016 revised fibromyalgia criteria, which combination is required for diagnosis?

  1. At least 11 tender points and a positive control point
  2. WPI and SSS thresholds with 3 months of symptoms Correct answer.
  3. Elevated erythrocyte sedimentation rate and morning stiffness
  4. Positive anti-nuclear antibody and symmetric small-joint arthritis

Explanation

The 2016 criteria use the Widespread Pain Index and Symptom Severity scale. Diagnosis requires appropriate score combinations and symptoms present for at least three months, without another explanation.

Question 47Pain Assessment, Diagnosis, and Evaluation

Which statement best distinguishes radicular pain from radiculopathy?

  1. Radicular pain requires imaging evidence; radiculopathy is a clinical diagnosis
  2. Radicular pain is confined to the back; radiculopathy radiates to the limb
  3. Radicular pain always includes motor weakness; radiculopathy is pain alone
  4. Radicular pain is pain in a root distribution; radiculopathy adds deficit Correct answer.

Explanation

Radicular pain follows a dermatomal distribution due to nerve root irritation. Radiculopathy additionally includes objective sensory, motor, or reflex deficits.

Question 48Pain Assessment, Diagnosis, and Evaluation

Which finding supports a diagnosis of lumbar facet joint-mediated pain?

  1. Pain relief only after epidural steroid injection
  2. Sensory loss in a dermatomal distribution
  3. Concordant relief after medial branch blocks Correct answer.
  4. Reproduction of pain with straight leg raise

Explanation

Facet joint pain is diagnosed by controlled medial branch blocks that produce concordant relief. A positive response to two comparative blocks increases diagnostic confidence.

Question 49Pain Assessment, Diagnosis, and Evaluation

Which cluster of physical examination tests is used to provoke sacroiliac joint pain?

  1. Distraction, compression, thigh thrust Correct answer.
  2. Spurling, Jackson, and distraction tests
  3. Phalen, Tinel, and Durkan tests
  4. Lachman, McMurray, and pivot shift tests

Explanation

Sacroiliac provocation tests include distraction, compression, thigh thrust, sacral thrust, and Gaenslen maneuvers. Multiple positive tests increase the likelihood of SI joint pain.

Question 50Pain Assessment, Diagnosis, and Evaluation

Provocative lumbar discography is most useful for which purpose?

  1. Diagnosing facet joint arthropathy
  2. Disc reproduction of concordant pain Correct answer.
  3. Detecting epidural fibrosis after surgery
  4. Measuring nerve root conduction velocity

Explanation

Discography injects contrast into a disc and assesses pain provocation and morphology. It is used to evaluate whether a specific disc is a pain generator, typically before surgery.