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ABR Pain Medicine study materials
ABR Pain Medicine study resources

ABR Pain Medicine practice questions

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Question 1Anatomy, physiology, and neurobiology of pain

Which ion channel is the principal transducer of noxious heat in peripheral nociceptors?

  1. TRPV1 Correct answer.
  2. Piezo2
  3. TRPM8
  4. ASIC3

Explanation

TRPV1 is a nonselective cation channel expressed on small-diameter nociceptors and activated by capsaicin, extracellular protons, and temperatures above roughly 43°C. Its activation depolarizes the afferent terminal and initiates nociceptive signaling.

Question 2Anatomy, physiology, and neurobiology of pain

Which primary afferent fiber class carries sharp, well-localized first pain?

  1. C fibers
  2. Aδ fibers Correct answer.
  3. Aα fibers
  4. Aβ fibers

Explanation

Aδ fibers are thinly myelinated and conduct at roughly 5–30 m/s, producing the rapid, sharp first pain that is well localized. Unmyelinated C fibers conduct more slowly and give rise to delayed, burning second pain.

Question 3Anatomy, physiology, and neurobiology of pain

Where are the cell bodies of primary nociceptive afferents located?

  1. Sympathetic chain
  2. Dorsal root ganglion Correct answer.
  3. Ventral horn
  4. Dorsal horn

Explanation

Primary sensory neurons are pseudounipolar, with their cell bodies in the dorsal root ganglion and a peripheral process that innervates tissue plus a central process that enters the dorsal horn. The ventral horn contains motor neurons, and the sympathetic chain contains autonomic ganglion cells.

Question 4Anatomy, physiology, and neurobiology of pain

At what level do second-order fibers of the lateral spinothalamic tract decussate?

  1. Medulla
  2. Midbrain
  3. Thalamus
  4. Spinal cord segment of origin Correct answer.

Explanation

Nociceptive second-order neurons cross the midline in the anterior white commissure within one or two spinal segments of their entry level before ascending in the contralateral lateral spinothalamic tract. This crossing pattern explains why cord lesions produce contralateral sensory loss beginning a segment or two below the lesion.

Question 5Anatomy, physiology, and neurobiology of pain

Nociceptive C fibers terminate predominantly in which Rexed lamina?

  1. Lamina VII
  2. Lamina IX
  3. Lamina II Correct answer.
  4. Lamina IV

Explanation

Nociceptive C and Aδ afferents terminate most densely in lamina I and the substantia gelatinosa (lamina II), where they synapse on projection neurons and interneurons. Lamina II is rich in inhibitory interneurons that shape nociceptive output.

Question 6Anatomy, physiology, and neurobiology of pain

According to gate control theory, activation of large Aβ fibers in the dorsal horn does what?

  1. Inhibits nociceptive transmission via inhibitory interneurons Correct answer.
  2. Activates sympathetic outflow
  3. Has no effect on nociceptive transmission
  4. Increases nociceptive transmission

Explanation

In gate control theory, Aβ afferents excite inhibitory interneurons in the dorsal horn that presynaptically and postsynaptically suppress nociceptive transmission. C-fiber input inhibits those same interneurons, opening the gate and enhancing pain.

Question 7Anatomy, physiology, and neurobiology of pain

Which pathway carries discriminative touch and proprioception but not nociception?

  1. Spinoreticular tract
  2. Spinomesencephalic tract
  3. Spinothalamic tract
  4. Dorsal column–medial lemniscus pathway Correct answer.

Explanation

The dorsal column–medial lemniscus pathway carries discriminative touch, vibration, and conscious proprioception and decussates in the medulla. Nociceptive and thermal information travels in the anterolateral system.

Question 8Anatomy, physiology, and neurobiology of pain

Which neurotransmitter is released by virtually all primary nociceptive afferents at their central terminals?

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

Explanation

Glutamate is the principal fast excitatory transmitter at central terminals of nociceptors, acting on AMPA and NMDA receptors. Peptides such as substance P and CGRP are released alongside it and modulate transmission.

Question 9Anatomy, physiology, and neurobiology of pain

A dorsal horn neuron that responds to both innocuous brushing and noxious pinching of the same receptive field is best described as what?

  1. Low-threshold mechanoreceptor
  2. Nociceptive-specific neuron
  3. Proprioceptive neuron
  4. Wide-dynamic-range neuron Correct answer.

Explanation

Wide-dynamic-range neurons receive convergent input from Aβ, Aδ, and C afferents, so they respond across the innocuous-to-noxious range and encode intensity. Nociceptive-specific neurons respond only to noxious stimuli, and low-threshold mechanoreceptors do not encode pain intensity.

Question 10Anatomy, physiology, and neurobiology of pain

Which receptor's activation in dorsal horn neurons mediates wind-up and long-term potentiation of nociceptive transmission?

  1. Glycine receptors
  2. NMDA receptors Correct answer.
  3. GABA-A receptors
  4. Mu-opioid receptors

Explanation

Repeated C-fiber input relieves the voltage-dependent magnesium block of NMDA receptors, permitting calcium influx that triggers wind-up and long-lasting synaptic potentiation. GABA-A and glycine receptors are inhibitory, and mu-opioid receptors reduce rather than amplify transmission.

Question 11Anatomy, physiology, and neurobiology of pain

Electrical stimulation of the periaqueductal gray produces analgesia primarily by doing what?

  1. Blocking primary afferent conduction
  2. Inhibiting thalamic relay directly
  3. Increasing sympathetic tone
  4. Activating descending pathways to the rostral ventromedial medulla Correct answer.

Explanation

The periaqueductal gray is a key midbrain component of descending pain control; its output engages the rostral ventromedial medulla, which projects to the dorsal horn. This circuit modulates nociceptive transmission rather than blocking primary afferent conduction.

Question 12Anatomy, physiology, and neurobiology of pain

Which opioid receptor subtype is primarily responsible for spinal and supraspinal analgesia and respiratory depression?

  1. Mu Correct answer.
  2. Delta
  3. Kappa
  4. Sigma

Explanation

The mu-opioid receptor is the principal target for analgesic opioids and mediates analgesia, respiratory depression, constipation, and dependence. Kappa receptors produce dysphoria and diuresis, while delta receptors modulate affective and inflammatory responses.

Question 13Anatomy, physiology, and neurobiology of pain

Substance P and CGRP are released from which afferent population and contribute to neurogenic inflammation?

  1. Aβ low-threshold afferents
  2. Peptidergic C fibers Correct answer.
  3. Preganglionic sympathetic fibers
  4. Aα motor axons

Explanation

Peptidergic C fibers release substance P and calcitonin gene-related peptide from peripheral terminals, producing vasodilation, plasma extravasation, and mast cell activation-neurogenic inflammation. These peptides also enhance central transmission.

Question 14Anatomy, physiology, and neurobiology of pain

Nociceptive input from the face relays in which thalamic nucleus before reaching cortex?

  1. Mediodorsal
  2. VPM Correct answer.
  3. Lateral geniculate
  4. VPL

Explanation

The trigeminal lemniscus relays facial nociception to the ventral posteromedial (VPM) nucleus of the thalamus, while body input relays to the ventral posterolateral (VPL) nucleus. From there, fibers project to the somatosensory cortex.

Question 15Anatomy, physiology, and neurobiology of pain

Which cortical region is most consistently associated with the affective-motivational dimension of pain?

  1. Primary visual cortex
  2. Primary motor cortex
  3. Cerebellar vermis
  4. Anterior cingulate cortex Correct answer.

Explanation

The anterior cingulate cortex, together with the insula, is consistently activated by pain and encodes its affective-motivational and interoceptive dimensions. Primary motor, visual, and cerebellar regions are not the main affective pain network.

Question 16Anatomy, physiology, and neurobiology of pain

Visceral pain is frequently referred to somatic structures because of what?

  1. Visceral pain is transmitted via the dorsal columns
  2. Visceral afferents synapse in the motor cortex
  3. Visceral and somatic afferents converge on the same second-order dorsal horn neurons Correct answer.
  4. Visceral organs lack nociceptors

Explanation

Visceral and somatic afferents converge on shared second-order neurons in the spinal cord, so the brain misattributes visceral nociceptive input to the more familiar somatic dermatome. This convergence underlies classic referred pain patterns such as cardiac pain in the left arm.

Question 17Anatomy, physiology, and neurobiology of pain

Which primary afferent fiber class has the largest diameter and lowest mechanical threshold?

  1. Aδ fibers
  2. Aβ fibers Correct answer.
  3. C fibers
  4. B fibers

Explanation

Aβ fibers are the largest myelinated primary afferents, with the lowest mechanical threshold, and they mediate innocuous touch and vibration. Aδ and C fibers are smaller and higher threshold, and B fibers are autonomic.

Question 18Anatomy, physiology, and neurobiology of pain

Silent nociceptors are best characterized by which property?

  1. They are myelinated fast-conducting fibers
  2. They are unresponsive to mechanical stimuli until sensitized by inflammation Correct answer.
  3. They exclusively innervate viscera
  4. They are tonically active in uninjured tissue

Explanation

Silent nociceptors are unmyelinated afferents that are mechanically insensitive in normal tissue but become responsive after inflammation or tissue injury, contributing to hyperalgesia. They are not tonically active and are found in skin, muscle, and viscera.

Question 19Anatomy, physiology, and neurobiology of pain

Which mechanism best explains sympathetically maintained pain in complex regional pain syndrome?

  1. Catecholamine sensitivity of sensitized nociceptors Correct answer.
  2. Loss of proprioception
  3. Motor neuron degeneration
  4. Dorsal column demyelination

Explanation

After injury, nociceptors can upregulate α-adrenergic receptors and become sensitive to catecholamines, so sympathetic outflow evokes or worsens pain. This sensitization, not loss of proprioception or motor degeneration, characterizes sympathetically maintained pain.

Question 20Anatomy, physiology, and neurobiology of pain

Descending inhibitory control of nociception from the locus coeruleus is mediated mainly by which neurotransmitter?

  1. Norepinephrine Correct answer.
  2. Acetylcholine
  3. Serotonin
  4. Dopamine

Explanation

The locus coeruleus is the principal noradrenergic nucleus projecting to the spinal dorsal horn, where norepinephrine acts on α2 receptors to inhibit nociceptive transmission. Serotonergic descending control arises largely from the rostral ventromedial medulla.

Question 21Anatomy, physiology, and neurobiology of pain

Wind-up of dorsal horn neurons is best defined as what?

  1. A progressive increase in response to repeated constant-intensity C-fiber stimulation Correct answer.
  2. Persistent pain that continues after tissue healing
  3. Spontaneous ectopic firing in the dorsal root ganglion
  4. Allodynia evoked by Aβ input

Explanation

Wind-up is a frequency-dependent increase in dorsal horn neuron firing during repeated C-fiber stimulation of constant intensity, reflecting short-term synaptic plasticity. It is distinct from central sensitization, which is a longer-lasting increase in excitability.

Question 22Anatomy, physiology, and neurobiology of pain

Ectopic discharges in injured peripheral nerves are most closely linked to accumulation of which channels at the injury site?

  1. Chloride channels
  2. Voltage-gated sodium channels Correct answer.
  3. TRPM8 channels
  4. Voltage-gated potassium channels

Explanation

After nerve injury, voltage-gated sodium channels, including Nav1.7 and Nav1.8, accumulate at neuromas and injured axon membranes, lowering threshold and producing spontaneous ectopic firing. Potassium channel opening would generally reduce excitability.

Question 23Anatomy, physiology, and neurobiology of pain

In neuropathic pain models, spinal microglial activation contributes to pain hypersensitivity mainly through what?

  1. Enhanced descending inhibition
  2. Release of GABA and glycine
  3. Increased opioid peptide synthesis
  4. Release of BDNF and proinflammatory cytokines that disinhibit dorsal horn neurons Correct answer.

Explanation

Activated spinal microglia release BDNF, cytokines, and other mediators that shift dorsal horn neurons toward hyperexcitability, partly by downregulating inhibitory transmission. They do not enhance GABA/glycine release or opioid synthesis in this context.

Question 24Anatomy, physiology, and neurobiology of pain

Neurons in the rostral ventromedial medulla that facilitate nociception are termed what?

  1. Wide-dynamic-range projection neurons
  2. Off-cells
  3. Neutral cells
  4. On-cells Correct answer.

Explanation

RVM on-cells show a burst of activity immediately before a nociceptive withdrawal and facilitate spinal nociception. Off-cells pause before the reflex and exert inhibition, while neutral cells show no consistent relationship.

Question 25Anatomy, physiology, and neurobiology of pain

Which change best explains allodynia after central sensitization?

  1. Reduced threshold and expanded receptive fields of dorsal horn neurons Correct answer.
  2. Decreased glutamate release
  3. Loss of Aβ afferents
  4. Increased opioid receptor density

Explanation

Central sensitization lowers the threshold and expands the receptive fields of dorsal horn neurons, so normally innocuous Aβ input can activate nociceptive pathways and produce allodynia. It does not result from loss of Aβ afferents or reduced glutamate release.

Question 26Anatomy, physiology, and neurobiology of pain

At what level do most axons of the spinothalamic tract cross the midline?

  1. Within the dorsal horn of the segment where they entered the cord
  2. In the anterior white commissure, one to two segments above the segment where they entered the cord Correct answer.
  3. In the medulla, at the level of the pyramidal decussation
  4. In the midbrain, just caudal to the thalamus

Explanation

Nociceptive primary afferents synapse in the dorsal horn, and the second-order axons then cross in the anterior white commissure approximately one to two segments above their entry level. They ascend in the contralateral anterolateral column, which is why a cord lesion produces contralateral sensory loss beginning a segment or two below the lesion.

Question 27Anatomy, physiology, and neurobiology of pain

The cell body of a primary nociceptive afferent sits in the dorsal root ganglion. Which morphology does this neuron have?

  1. Bipolar, with separate dendrite and axon arising from opposite poles
  2. Multipolar, with several dendrites contacting peripheral tissue
  3. Pseudounipolar, with a single axon that bifurcates into peripheral and central branches Correct answer.
  4. Anaxonic, lacking a distinguishable axon

Explanation

Dorsal root ganglion neurons are pseudounipolar: one process leaves the soma and divides into a peripheral branch that innervates tissue and a central branch that enters the spinal cord. This arrangement allows the cell body to serve as a metabolic hub without lying in the conduction path.

Question 28Anatomy, physiology, and neurobiology of pain

Unmyelinated C fibers terminate most densely in which laminae of the dorsal horn?

  1. Laminae III and IV
  2. Laminae I and II Correct answer.
  3. Laminae V and VI
  4. Laminae VII and VIII

Explanation

C fibers end predominantly in the superficial dorsal horn, laminae I and II, with some terminations in lamina V. Aδ fibers also terminate in lamina I and deeper laminae, but the densest C-fiber input is superficial.

Question 29Anatomy, physiology, and neurobiology of pain

Which primary afferent class is thinly myelinated and conducts in the range of roughly 5 to 30 m/s?

  1. C fibers
  2. Aβ fibers
  3. Aα/Ia afferents
  4. Aδ fibers Correct answer.

Explanation

Aδ fibers are thinly myelinated and conduct at about 5 to 30 m/s, carrying rapid sharp pain and some temperature information. C fibers are unmyelinated and much slower, while Aβ and Aα fibers are large, heavily myelinated, and faster.

Question 30Anatomy, physiology, and neurobiology of pain

A small-diameter dorsal root ganglion neuron is activated both by capsaicin and by temperatures above about 43°C. Which channel most directly accounts for both responses?

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

Explanation

TRPV1 is a nonselective cation channel expressed by many small nociceptors and is opened by capsaicin, noxious heat, and extracellular protons. Its activation depolarizes the terminal and generates the receptor potential that initiates nociceptive signaling.

Question 31Anatomy, physiology, and neurobiology of pain

During inflammation, prostaglandin E2 lowers the threshold of nociceptors at the injury site. Which intracellular mechanism best explains this effect?

  1. Increased expression of CGRP in the dorsal root ganglion
  2. EP receptor-mediated increase in cAMP and PKA-dependent enhancement of Nav1.8 current Correct answer.
  3. Loss of GABAergic inhibition in lamina II
  4. Activation of microglial p38 MAP kinase in the spinal cord

Explanation

PGE2 binds EP receptors on nociceptor terminals, raising cAMP and activating PKA, which phosphorylates and enhances tetrodotoxin-resistant sodium current carried largely by Nav1.8. This makes the terminal fire at lower stimulus intensities, producing peripheral sensitization.

Question 32Anatomy, physiology, and neurobiology of pain

Nociceptive projection neurons in lamina I that terminate in the parabrachial nucleus are most important for which aspect of pain?

  1. Gating of innocuous mechanoreceptive input
  2. Affective and autonomic responses to pain Correct answer.
  3. Reflex withdrawal of the limb
  4. Discriminative localization of the stimulus

Explanation

The spino-parabrachial pathway carries lamina I nociceptive signals to the parabrachial nucleus, which projects to the amygdala, hypothalamus, and other limbic structures. This pathway is therefore positioned to generate the emotional, motivational, and autonomic components of pain.

Question 33Anatomy, physiology, and neurobiology of pain

After entering the spinal cord through the dorsal root, fine nociceptive afferents travel rostrally and caudally for one or two segments within which structure before synapsing?

  1. Lissauer's tract (dorsolateral fasciculus) Correct answer.
  2. The medial lemniscus
  3. The anterior white commissure
  4. The lateral corticospinal tract

Explanation

Small afferents enter the dorsolateral fasciculus, or Lissauer's tract, at the apex of the dorsal horn and branch up and down for a segment or two before terminating in the superficial laminae. This longitudinal spread helps explain the rostrocaudal overlap of segmental sensory effects.

Question 34Anatomy, physiology, and neurobiology of pain

A gain-of-function mutation in SCN9A, the gene encoding Nav1.7, produces which clinical pain phenotype?

  1. Episodic ataxia
  2. Inherited erythromelalgia with burning pain and redness of the extremities Correct answer.
  3. Congenital insensitivity to pain
  4. Familial hemiplegic migraine

Explanation

Nav1.7 is a voltage-gated sodium channel concentrated in small dorsal root ganglion neurons, where it helps set the threshold for action potential initiation. Gain-of-function variants lower that threshold and cause inherited erythromelalgia, whereas loss-of-function variants cause congenital insensitivity to pain.

Question 35Anatomy, physiology, and neurobiology of pain

A patient develops burning contralateral hemibody pain weeks after an infarct involving the thalamus. Which thalamic structure is most typically involved?

  1. Pulvinar
  2. Anterior nucleus
  3. Ventroposterolateral nucleus Correct answer.
  4. Medial geniculate body

Explanation

The ventroposterolateral nucleus relays spinothalamic and dorsal column information from the body, and its damage can produce Dejerine-Roussy central post-stroke pain. The ventroposteromedial nucleus plays the analogous role for the face.

Question 36Anatomy, physiology, and neurobiology of pain

Which structure receives nociceptive input from the parabrachial nucleus and is most closely linked to the emotional salience and fear learning associated with pain?

  1. Central nucleus of the amygdala Correct answer.
  2. Primary somatosensory cortex
  3. Cerebellar vermis
  4. Ventroposterolateral thalamus

Explanation

The parabrachial nucleus sends strong nociceptive projections to the central nucleus of the amygdala, a key node for threat detection, fear learning, and autonomic activation. This connection supports the emotional and defensive dimensions of pain rather than its precise sensory localization.

Question 37Anatomy, physiology, and neurobiology of pain

Extracellular ATP released from damaged tissue excites a subset of small-diameter sensory neurons. Which ion channel directly mediates this effect?

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

Explanation

P2X3 is an ATP-gated cation channel expressed on a subset of small dorsal root ganglion neurons, and it depolarizes the terminal when extracellular ATP rises after tissue damage. It contributes to nociception in inflammatory, neuropathic, and visceral pain models.

Question 38Anatomy, physiology, and neurobiology of pain

A patient with a lateral medullary infarction has loss of pain and temperature sensation on the ipsilateral face and the contralateral body. Which structure explains the ipsilateral facial finding?

  1. The medial lemniscus
  2. The principal sensory trigeminal nucleus
  3. The nucleus solitarius
  4. The spinal trigeminal nucleus and tract Correct answer.

Explanation

Pain and temperature fibers from the face descend ipsilaterally in the spinal trigeminal tract and synapse in the spinal trigeminal nucleus, which extends into the medulla. A lateral medullary lesion therefore interrupts these ipsilateral fibers and produces facial pain and temperature loss on the same side as the lesion, while body fibers have already crossed and are affected contralaterally.

Question 39Anatomy, physiology, and neurobiology of pain

In a syrinx of the cervical spinal cord, pain and temperature sensation is lost first in the upper limbs with relative sacral sparing. Which arrangement of the spinothalamic tract explains this pattern?

  1. Sacral fibers cross at a higher level than cervical fibers
  2. Sacral fibers ascend in the dorsal columns
  3. Sacral fibers synapse in lamina II before cervical fibers do
  4. Sacral fibers lie laterally in the anterolateral column and are spared by a lesion that begins centrally Correct answer.

Explanation

The spinothalamic tract is laminated with sacral fibers positioned laterally and cervical fibers medially. An expanding central cord lesion therefore damages the medially placed cervical fibers first, producing arm and upper trunk sensory loss with relative preservation of sacral sensation.

Question 40Anatomy, physiology, and neurobiology of pain

Fast excitatory synaptic transmission from primary nociceptive afferents to dorsal horn neurons is mediated mainly by which receptor?

  1. Neurokinin 1 receptors
  2. Metabotropic glutamate receptor 5
  3. AMPA/kainate receptors Correct answer.
  4. NMDA receptors

Explanation

Primary afferents release glutamate, which opens AMPA and kainate receptors to generate the rapid excitatory postsynaptic potential in dorsal horn neurons. NMDA receptors contribute after sufficient depolarization, and neurokinin 1 receptors mediate slower substance P responses.

Question 41Pain assessment, diagnosis, and patient evaluation

A clinician asks a patient to choose a whole number from 0 to 10 that best represents current pain, with 0 indicating no pain and 10 indicating the worst pain imaginable. Which assessment tool is being used?

  1. Numeric Rating Scale Correct answer.
  2. Wong-Baker Faces Scale
  3. Verbal Descriptor Scale
  4. Visual Analog Scale

Explanation

The Numeric Rating Scale uses whole numbers from 0 to 10, where 0 is no pain and 10 is the worst pain imaginable. It is simple, validated for many pain conditions, and can be administered verbally or in writing. A Visual Analog Scale uses a continuous line without discrete numbers, and face scales use pictures rather than numbers.

Question 42Pain assessment, diagnosis, and patient evaluation

The DN4 questionnaire is designed primarily to do which of the following?

  1. Quantify depressive symptom severity over the past two weeks
  2. Screen for neuropathic pain using symptoms and bedside tests Correct answer.
  3. Measure functional disability from low back pain in daily activities
  4. Estimate opioid misuse risk before starting long-term therapy

Explanation

The DN4 (Douleur Neuropathique 4) is a 10-item screening tool with seven symptom questions and three bedside examination items. A score of 4 or more out of 10 suggests neuropathic pain. It does not measure disability, depression, or opioid risk.

Question 43Pain assessment, diagnosis, and patient evaluation

A patient describes numbness along the palmar surface of the thumb and index finger. This sensory distribution most closely matches which nerve root?

  1. C6 Correct answer.
  2. C7
  3. C8
  4. C5

Explanation

The C6 nerve root supplies the palmar thumb and index finger and contributes to the biceps and brachioradialis reflexes. C7 typically involves the middle finger, C8 the ring and little fingers, and C5 the lateral arm and deltoid. Numbness in the thumb and index finger therefore points to C6.

Question 44Pain assessment, diagnosis, and patient evaluation

The patellar reflex is most commonly used to assess which nerve root level?

  1. L4 Correct answer.
  2. L3
  3. S1
  4. L5

Explanation

The L4 nerve root mediates the patellar reflex and knee extension. The S1 root mediates the ankle reflex and plantar flexion, while C5-C6 and C7 are associated with the biceps and triceps reflexes, respectively. A diminished patellar reflex suggests L4 root or femoral nerve dysfunction.

Question 45Pain assessment, diagnosis, and patient evaluation

Which finding in a patient with acute low back pain should prompt immediate evaluation for cauda equina syndrome?

  1. Unilateral paraspinal muscle spasm on palpation
  2. Pain reproduced by facet joint loading maneuvers
  3. Pain that improves when the patient lies supine
  4. Urinary retention with saddle anesthesia Correct answer.

Explanation

Cauda equina syndrome is a surgical emergency, and new urinary retention or incontinence with saddle anesthesia are classic red flags. Bilateral leg weakness and decreased rectal tone also raise concern. Muscular spasm and positional pain relief are nonspecific and do not require emergent imaging by themselves.

Question 46Pain assessment, diagnosis, and patient evaluation

The PHQ-9 is most useful in the evaluation of chronic pain for which purpose?

  1. Screening for opioid misuse risk before prescribing
  2. Assessing severity of depressive symptoms Correct answer.
  3. Documenting the quality of neuropathic pain symptoms
  4. Measuring pain-related catastrophizing and fear of movement

Explanation

The PHQ-9 maps directly onto the nine DSM criteria for major depression and grades severity from 0 to 27. It is widely used in chronic pain because depression commonly coexists and worsens pain-related outcomes. Opioid risk, catastrophizing, and neuropathic quality require different instruments.

Question 47Pain assessment, diagnosis, and patient evaluation

The Oswestry Disability Index is used to quantify which domain in patients with low back pain?

  1. Functional disability in daily activities Correct answer.
  2. Pain intensity at rest during the past 24 hours
  3. Opioid withdrawal severity and craving
  4. Neuropathic symptom quality and distribution

Explanation

The Oswestry Disability Index contains ten sections covering activities such as lifting, walking, sitting, and self-care, and it is reported as a percentage of disability. It measures function rather than pain intensity or neuropathic quality. It is not an opioid withdrawal scale.

Question 48Pain assessment, diagnosis, and patient evaluation

A straight leg raise test that reproduces leg pain at 30 to 70 degrees of hip flexion is most suggestive of which condition?

  1. L5 or S1 nerve root irritation Correct answer.
  2. Hip osteoarthritis with joint space narrowing
  3. Lumbar spinal stenosis with neurogenic claudication
  4. Sacroiliac joint dysfunction with positive provocation tests

Explanation

The straight leg raise tensions the lower lumbar nerve roots and is positive when it reproduces radicular pain between roughly 30 and 70 degrees of hip flexion. Pain below the knee is more specific for L5 or S1 root irritation. Hip, sacroiliac, and spinal stenosis presentations are evaluated with different maneuvers and histories.

Question 49Pain assessment, diagnosis, and patient evaluation

Which description best defines allodynia?

  1. Pain evoked by a stimulus that is normally not painful Correct answer.
  2. An exaggerated pain response to a normally painful stimulus
  3. Loss of pain sensation in a dermatomal distribution
  4. Spontaneous burning pain without any stimulus

Explanation

Allodynia is pain caused by a stimulus that does not normally provoke pain, such as light brushing of the skin. Hyperalgesia, by contrast, is an increased response to a stimulus that is already painful. Spontaneous pain and sensory loss are separate phenomena.

Question 50Pain assessment, diagnosis, and patient evaluation

The 2016 revision of the fibromyalgia diagnostic criteria combines which two measures?

  1. PainDETECT score and DN4 score
  2. Tender point count and erythrocyte sedimentation rate
  3. Widespread Pain Index and Symptom Severity scale Correct answer.
  4. Oswestry Disability Index and PHQ-9

Explanation

The 2016 fibromyalgia criteria use the Widespread Pain Index, which counts painful body regions, and the Symptom Severity scale, which rates fatigue, waking unrefreshed, and cognitive symptoms. Diagnosis also requires that symptoms be present for at least three months and not be better explained by another disorder. Tender point counts are no longer required.