A 59-year- old woman has been told by her orthopedist that the preferred treatment for her debilitating pain in both knees is knee replacement surgery. She agrees to have the surgery in one month when she will have time for rehabilitation. In the interim, the physician prescribes a medication for pain relief and to reduce inflammation. The woman is otherwise healthy, takes no medication, and has no known drug allergies. The physician decides on a nonsteroidal anti- inflammatory drug that has a high affinity for cyclooxygenase-2 (COX-2) and no affinity for COX-1. Compared to other NSAIDs, this drug is less likely to cause:

A 59-year- old woman has been told by her orthopedist that the preferred treatment for her debilitating pain in both knees is knee replacement surgery. She agrees to have the surgery in one month when she will have time for rehabilitation. In the interim, the physician prescribes a medication for pain relief and to reduce inflammation. The woman is otherwise healthy, takes no medication, and has no known drug allergies. The physician decides on a nonsteroidal anti- inflammatory drug that has a high affinity for cyclooxygenase-2 (COX-2) and no affinity for COX-1. Compared to other NSAIDs, this drug is less likely to cause:

A. Allergy
B. Blood clots
C. Elevated blood pressure
D. Gastric ulcer
E. Peripheral vasoconstriction


Answer: D

A 69-year-old male presents to your office complaining of pain in his neck that extends bilaterally over his shoulders. He also complains of an aching sensation in both of his arms and loss of fine motor control of his hands. This has been progressing over the past six months. He worked in construction and had multiple small neck injuries during college wrestling and football. His overall health is quite good. On X-rays studies of his cervical spine you would expect to find?

A 69-year-old male presents to your office complaining of pain in his neck that extends bilaterally over his shoulders. He also complains of an aching sensation in both of his arms and loss of fine motor control of his hands. This has been progressing over the past six months. He worked in construction and had multiple small neck injuries during college wrestling and football. His overall health is quite good. On X-rays studies of his cervical spine you would expect to find?

A. Normal findings
B. Nothing abnormal except for the loss of the cervical lordotic curve
C. Narrowing of multiple disc spaces, with osteophytes and loss of cervical lordosis
D. An anterior wedge deformity is present at C5
E. A large lytic lesion in the body of C4


Answer: C

In the most classical presentation of a herniated L4-L5 lateral disk herniation, the most common reflex change present is:

In the most classical presentation of a herniated L4-L5 lateral disk herniation, the most common reflex change present is:

A. No reflex change at all
B. Loss of cremasteric reflex
C. Loss of knee jerk reflex
D. Loss of ankle jerk reflex
E. Loss of plantar response (Babinski)


Answer: A

A 54-year-old male construction worker has had low back pain for about two months. He has had previous episodes of low back pain. Now, the pain is more intense than it was on prior episodes and seems to be getting worse rather than improving over time. He does remember lifting very heavy steel beams and the pain is now unbearable. He complains of numbness in both legs and across his buttocks. He is embarrassed to report that he was incontinent of urine and stool this morning. You should plan on:

A 54-year-old male construction worker has had low back pain for about two months. He has had previous episodes of low back pain. Now, the pain is more intense than it was on prior episodes and seems to be getting worse rather than improving over time. He does remember lifting very heavy steel beams and the pain is now unbearable. He complains of numbness in both legs and across his buttocks. He is embarrassed to report that he was incontinent of urine and stool this morning. You should plan on:

A. Admitting him to the hospital immediately
B. Arranging for outpatient physical therapy
C. Giving him a prescription for acetaminophen
D. Recommending him for an outpatient lumbar spine MRI
E. Recommending for him bed rest and a return visit in a week


Answer: A

A 25-year-old female medical student comes to your office asking for an MRI of her neck to confirm her suspicion that she has a herniated cervical disc. On exam, her triceps reflex is absent, and she has weakness of elbow extension and numbness on her long finger. You both expect the MRI to reveal a disc herniation at:

A 25-year-old female medical student comes to your office asking for an MRI of her neck to confirm her suspicion that she has a herniated cervical disc. On exam, her triceps reflex is absent, and she has weakness of elbow extension and numbness on her long finger. You both expect the MRI to reveal a disc herniation at:

A. C3
B. C4
C. C5
D. C6
E. C7


Answer: E

A 57-year-old physician presents to his doctor complaining of neck pain that radiates down the lateral aspect of his right arm. He also complains of numbness in his right thumb with weakness on resisted thumb extension. You suspect a herniated disc compression which nerve root?

A 57-year-old physician presents to his doctor complaining of neck pain that radiates down the lateral aspect of his right arm. He also complains of numbness in his right thumb with weakness on resisted thumb extension. You suspect a herniated disc compression which nerve root?

A. C3
B. C4
C. C5
D. C6
E. C7



Answer: D

A 54-year-old male construction worker has had low back pain for about two months. He has had previous episodes of low back pain. Now, the pain is more intense than it was on prior episodes and seems to be getting worse rather than improving over time. He does remember lifting very heavy steel beams and the pain is now unbearable. He complains of numbness in both legs and across his buttocks. He is embarrassed to report that he was incontinent of urine and stool this morning. You should plan on:

A 54-year-old male construction worker has had low back pain for about two months. He has had previous episodes of low back pain. Now, the pain is more intense than it was on prior episodes and seems to be getting worse rather than improving over time. He does remember lifting very heavy steel beams and the pain is now unbearable. He complains of numbness in both legs and across his buttocks. He is embarrassed to report that he was incontinent of urine and stool this morning. You should plan on:

A. Admitting him to the hospital immediately
B. Arranging for outpatient physical therapy
C. Giving him a prescription for acetaminophen
D. Recommending him for an outpatient lumbar spine MRI
E. Recommending for him bed rest and a return visit in a week


Answer: A

A 35-year-old male presents to your office with complaints of back pain and some weakness in his left leg. It has been present for a few weeks and the back and leg pains have been increasing in intensity. You are concerned about a herniated lumbar disc. His left ankle jerk reflex (achilles tendon reflex) is absent and you find numbness on the lateral aspect of the lower leg and sole of his left foot. This is most commonly caused by a:

A 35-year-old male presents to your office with complaints of back pain and some weakness in his left leg. It has been present for a few weeks and the back and leg pains have been increasing in intensity. You are concerned about a herniated lumbar disc. His left ankle jerk reflex (achilles tendon reflex) is absent and you find numbness on the lateral aspect of the lower leg and sole of his left foot. This is most commonly caused by a:

A. Herniated nucleus pulposus at the L1-L2 level
B. Herniated nucleus pulposus at L2-L3 level
C. Herniated nucleus pulposus at L3-L4 level
D. Herniated nucleus pulposus at L4-L5 level
E. Herniated nucleus pulposus at L5-S1


Answer: E

A 35-year-old male presents to your office with complaints of back pain and some weakness in his left leg. It has been present for a few weeks and the back and leg pains have been increasing in intensity. You are concerned about a herniated lumbar disc. His left ankle jerk reflex (achilles tendon reflex) is absent and you find numbness on the lateral aspect of the lower leg and sole of his left foot. These findings are typical of compression of:

A 35-year-old male presents to your office with complaints of back pain and some weakness in his left leg. It has been present for a few weeks and the back and leg pains have been increasing in intensity. You are concerned about a herniated lumbar disc. His left ankle jerk reflex (achilles tendon reflex) is absent and you find numbness on the lateral aspect of the lower leg and sole of his left foot. These findings are typical of compression of:

A. L2 nerve root
B. L3 nerve root
C. L4 nerve root
D. L5 nerve root
E. S1 nerve root

Answer: E

A 25-year-old medical student comes to your office asking for an MRI of her neck to confirm her suspicion that she has a cervical disc herniation. On exam, her triceps reflex is absent. She has weakness of elbow extension and numbness on her long finger. You expect the MRI to reveal a disc herniation at at which of the following levels?

A 25-year-old medical student comes to your office asking for an MRI of her neck to confirm her suspicion that she has a cervical disc herniation. On exam, her triceps reflex is absent. She has weakness of elbow extension and numbness on her long finger. You expect the MRI to reveal a disc herniation at at which of the following levels?

A. C3-C4 level
B. C4-C5 level
C. C5-C6 level
D. C6-C7 level
E. C7-T1 level

Answer: D

A patient sustained a cervical sprain/strain (somatic dysfunction) secondary to trauma. She complains of non radiating neck pain in absence of shoulder pain. Given this scenerio, which of the following signs/symptoms would more likely be present than any other?

A patient sustained a cervical sprain/strain (somatic dysfunction) secondary to trauma. She complains of non radiating neck pain in absence of shoulder pain. Given this scenerio, which of the following signs/symptoms would more likely be present than any other?

A. Hyper-reflexia in the lower extremities
B. Loss of bowel control
C. Loss of urinary bladder control
D. Numbness in the hands in a dermatomal pattern
E. Occipital headaches

Answer: E

What is the treatment for pseudoaddiction?

What is the treatment for pseudoaddiction?

A. Discharge your patient from the practice secondary to drug seeking behavior
B. The patient has demonstrated a genetic tendency for addition and should be monitored carefully
C. To redesign the analgesic regimen so that analgesics are provided at an appropriate dose and dosing interval
D. To call a family intervention and address the problem from a psychosocial protocol
E. Taper the patient off of their current pain medication and change to a different analgesic


Answer: C

Which is the most specific of the urine drug tests?

Which is the most specific of the urine drug tests?

A. Immunoassay drug panels
B. Gas chromatography-mass spectrometry
C. Hair test
D. Breath test
E. Saliva screen


Answer: B

What are the 4 A's for pain management?

What are the 4 A's for pain management?

A. Analgesia, Activities of daily living, Adverse events and Aberrant drug-taking behaviors
B. Alcoholism, Addiction, Anatomical changes, Adversity
C. Abnormal character, Avoidance, Apoplectic, Association with past trauma
D. Abdominal pain, Alcoholics Anonymous, Assistance seeking, Associated behaviors
E. Addiction Medicine, Anorexia, Abdominal pain, Anhidrosis


Answer: A

Which of the following are side effects from chronic opioid use?

Which of the following are side effects from chronic opioid use?

A. Fatigue and decreased libido from low levels of testosterone and DHEA
B. Diarrhea and dilated pupils
C. Hyperactivity from increased adrenal secretions
D. Insomnia and nocturia
E. Increase 5HT secretions in the central nervous system


Answer: A

A 42-year-old nurse presents to the office to see if OMM can be helpful for her long-standing foot pain. The patient had sustained her foot injury five years prior when a car ran over her foot while trying to cross the street. She sustained multiple fractures at that time and the injury healed subsequent to multiple surgeries. There is no back pain and no pain in the legs. She is currently on morphine 60mg every twelve hours. Physical examination reveals relatively normal lumbar range of motion, normal straight leg raise, and reveals normal muscle tone, strength and sensation throughout both lower extremities. The foot and ankle are painful to touch on the surface. There is decreased range of motion of the ankle with erythema and skin dystrophic/atrophic changes. Which of the following pain management approaches is indicated:

A 42-year-old nurse presents to the office to see if OMM can be helpful for her long-standing foot pain. The patient had sustained her foot injury five years prior when a car ran over her foot while trying to cross the street. She sustained multiple fractures at that time and the injury healed subsequent to multiple surgeries. There is no back pain and no pain in the legs. She is currently on morphine 60mg every twelve hours. Physical examination reveals relatively normal lumbar range of motion, normal straight leg raise, and reveals normal muscle tone, strength and sensation throughout both lower extremities. The foot and ankle are painful to touch on the surface. There is decreased range of motion of the ankle with erythema and skin dystrophic/atrophic changes. Which of the following pain management approaches is indicated:

A. Addition of another opioid medication
B. Celiac block
C. Lumbar epidural steroid injection at L5 and S1 levels
D. Lumbar sympathetic block
E. High velocity/low amplitude OMM to the subtalar join


Answer: D

A 40-year-old male presents with a one-week history of low back pain without radiation. The symptoms started after he was carrying some luggage. There is no tingling, numbness in the legs, nor any reported weakness. There is minimal spasm in the paravertebral muscles in the lumbo-sacral spine, straight leg raising test is negative and the neurological examination is normal. There are somatic dysfunctions in form of neutral dysfunctions L1-L5 NSleftRright. Which of the following statements is most appropriate?

A 40-year-old male presents with a one-week history of low back pain without radiation. The symptoms started after he was carrying some luggage. There is no tingling, numbness in the legs, nor any reported weakness. There is minimal spasm in the paravertebral muscles in the lumbo-sacral spine, straight leg raising test is negative and the neurological examination is normal. There are somatic dysfunctions in form of neutral dysfunctions L1-L5 NSleftRright. Which of the following statements is most appropriate?

A. Bed rest for one to two weeks is indicated
B. Imaging studies including X-rays, MRI and bone scan should be ordered immediately
C. Neurodiagnostic studies including an EMG are indicated as the studies of choice
D. NSAIDS and muscle relaxants together with OMM would be appropriate
E. Opioid medications are indicated to be started within one week


Answer: D

Which of the following is correct about the various pain types?

Which of the following is correct about the various pain types?

A. A viscero-somatic reflex is an example of nociceptive pain
B. Neuropathic pain is an example of nociceptive pain
C. Somatic pain is an example of non-nociceptive pain
D. Sympathetic pain is an example of nociceptive pain
E. Visceral pain is an example of non-nociceptive pain

Answer: A

A 64-year-old school superintendent with known rheumatoid arthritis presents to the office with a recurrent episode of significant hand and wrist pain after having been virtually pain-free for about eight months on DMARD therapy as closely monitored by her rheumatologist. She questions the doctor as to how it could be that she has these painful chronic-recurrent flare-ups alternating with pain-free periods, all the while it seems that the "arthritis is getting better" with the medications. What would be the best explanation, based on the article by D. Marcus: "Treatment of Nonmalignant Chronic Pain?"

A 64-year-old school superintendent with known rheumatoid arthritis presents to the office with a recurrent episode of significant hand and wrist pain after having been virtually pain-free for about eight months on DMARD therapy as closely monitored by her rheumatologist. She questions the doctor as to how it could be that she has these painful chronic-recurrent flare-ups alternating with pain-free periods, all the while it seems that the "arthritis is getting better" with the medications. What would be the best explanation, based on the article by D. Marcus: "Treatment of Nonmalignant Chronic Pain?"

A. Central block of pain transmission along the spino-thalamic tract to the limbic system
B. Central neural plasticity
C. Near complete loss of nociception at the joints in the hands
D. Patient is emotionally more stable as she has accepted the disease
E. Significant atrophy of interneurons in the spinal cord


Answer: B

A 56-year-old female with a known history of seropositive rheumatoid arthritis maintained on etanercept injections presents complaining of right knee pain and swelling for two days. She has been in good health otherwise and denies fevers and chills. She reports stiffness in the right knee that lasts for longer than 1 hour. Her other joints are doing well. You perform an arthrocentesis and remove 30cc of clear fluid. You send the sample to the lab, and 24 hours later no organisms are seen. The patient follows up later that day. The best course of management for this patient is:

A 56-year-old female with a known history of seropositive rheumatoid arthritis maintained on etanercept injections presents complaining of right knee pain and swelling for two days. She has been in good health otherwise and denies fevers and chills. She reports stiffness in the right knee that lasts for longer than 1 hour. Her other joints are doing well. You perform an arthrocentesis and remove 30cc of clear fluid. You send the sample to the lab, and 24 hours later no organisms are seen. The patient follows up later that day. The best course of management for this patient is:

A. Biofeedback
B. Fentanyl patch
C. Intra-articular steroid injection to the right knee
D. Opiod "lollipop"
E. Referral to orthopedist for consideration of knee replacement

Answer: C