Chronic Pain Syndromes — MCQs

10 questions

In a patient with a history of burning pain localized to the plantar aspect of the foot, the differential diagnosis must include -

Based on 1990 ACR criteria, the diagnosis of fibromyalgia is made in patients with a history of diffuse musculoskeletal pain and which of the following physical findings:

Primary afferent fibers secrete which nociceptive substance at the dorsal horn?

Sensations of pain from teeth and temperature are carried by

A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?

A 35-year-old woman presents with a history of recurrent migraines, unresponsive to prophylactic medications. What is the most appropriate next step in management?

Following are the features of persistent postoperative pain EXCEPT:

A patient complains to a physician of chronic pain and tingling of the buttocks. The pain is exacerbated when the buttocks are compressed by sitting on a toilet seat or chair for long periods. No lumbar pain is noted. Pain is elicited when the physician performs Freiberg&;s maneuver. Most likely diagnosis

ABPI increases artificially in

Q10

Which of the following conditions characteristically causes bilateral hypertranslucency of lung fields on chest X-ray?

Chronic Pain Syndromes Indian Medical PG Practice Questions and MCQs

Question 1: In a patient with a history of burning pain localized to the plantar aspect of the foot, the differential diagnosis must include -

A. Peripheral vascular disease
B. Plantar fibromatosis
C. Tarsal tunnel syndrome (Correct Answer)
D. Tarsal coalition

Explanation: ***Tarsal tunnel syndrome*** - This condition involves **compression of the posterior tibial nerve** or its branches as they pass through the tarsal tunnel, leading to **burning pain, numbness, and tingling** on the plantar aspect of the foot [2]. - Symptoms are often exacerbated by activity or prolonged standing and can be reproduced by tapping on the nerve (Tinel's sign). *Peripheral vascular disease* - While it can cause foot pain, it typically presents as **intermittent claudication** (pain with exertion that resolves with rest) or **ischemic rest pain**, often in the toes or forefoot [1]. - The pain is usually described as cramping or aching rather than burning and is associated with signs of **poor circulation** like diminished pulses and cool skin [1]. *Plantar fibromatosis* - This condition, also known as **Ledderhose disease**, involves the formation of benign fibrous nodules within the **plantar fascia**. - It usually presents as **palpable lumps** on the sole of the foot, which may or may not be painful, but burning pain is not a primary or characteristic symptom. *Tarsal coalition* - This is a congenital condition where two or more bones in the midfoot or hindfoot are **abnormally fused**, most commonly the calcaneus and navicular or talus and calcaneus. - It typically causes **pain, stiffness, and flatfoot deformity** that worsens with activity, but burning neuropathic pain is not its primary symptom.

Question 2: Based on 1990 ACR criteria, the diagnosis of fibromyalgia is made in patients with a history of diffuse musculoskeletal pain and which of the following physical findings:

A. Symmetrical joint tenderness
B. Muscle weakness
C. Multiple areas of tendonitis
D. 11 of 18 tender points (Correct Answer)

Explanation: ***11 of 18 tender points*** - The 1990 American College of Rheumatology (ACR) criteria for fibromyalgia require a history of **widespread pain** for at least 3 months and pain in **11 of 18 specific tender points** on digital palpation [1]. - These tender points are symmetrical and located in areas such as the **occiput**, low cervical, trapezius, supraspinatus, second rib, lateral epicondyle, gluteal, greater trochanter, and knee [1]. *Symmetrical joint tenderness* - While patients with fibromyalgia experience widespread pain, the diagnostic criteria focus on **tender points** in soft tissues, not typically tenderness within the joint capsules themselves [1], [2]. - **Joint tenderness** can be a feature of inflammatory arthritis, which is a different condition. *Muscle weakness* - **Muscle weakness** is not a primary diagnostic criterion for fibromyalgia; patients report pain and fatigue, but objective weakness is generally not present [2]. - Muscular pain and fatigue in fibromyalgia are due to altered pain processing, not primary muscle pathology leading to weakness [1]. *Multiple areas of tendonitis* - Although patients with fibromyalgia may experience localized pain that can sometimes be mistaken for **tendonitis**, it is not a specific diagnostic criterion [1]. - True **tendonitis** involves inflammation of a tendon and is usually localized to specific areas, unlike the diffuse tender points of fibromyalgia.

Question 3: Primary afferent fibers secrete which nociceptive substance at the dorsal horn?

A. Substance P (Correct Answer)
B. Acetylcholine
C. Norepinephrine
D. Epinephrine

Explanation: ***Substance P*** - **Substance P** is a neuropeptide released by **C fibers** and **A-delta fibers** (primary afferent nociceptors) in the dorsal horn of the spinal cord. - It acts as a **neurotransmitter** and **neuromodulator**, contributing to the transmission and amplification of pain signals. *Acetylcholine* - **Acetylcholine** is a primary neurotransmitter in the **neuromuscular junction** and the autonomic nervous system. - While it has some roles in the CNS, it is not the primary nociceptive substance secreted by afferent fibers in the dorsal horn. *Norepinephrine* - **Norepinephrine** (noradrenaline) is a neurotransmitter involved in the **fight-or-flight response** and mood regulation. - It can modulate pain, but it is not directly released by primary afferent fibers as a nociceptive substance in the dorsal horn. *Epinephrine* - **Epinephrine** (adrenaline) is a hormone and neurotransmitter primarily associated with the **sympathetic nervous system** and stress response. - It does not serve as a direct nociceptive transmitter released by primary afferent fibers in the spinal cord.

Question 4: Sensations of pain from teeth and temperature are carried by

A. Lateral spinothalamic tract (Correct Answer)
B. Trigeminal nerve pathway
C. Ventral spinothalamic tract
D. Corticospinal tract

Explanation: ***Lateral spinothalamic tract*** - The **lateral spinothalamic tract** primarily carries sensations of **pain and temperature** from the body to the brain. - This pathway is crucial for transmitting these somatosensory modalities from the periphery, including dental structures, up the spinal cord to the **thalamus** and then to the cerebral cortex. *Trigeminal nerve pathway* - The **trigeminal nerve (CN V)** is responsible for sensory innervation of the face, including teeth, and jaw motor function. - While it transmits sensory information from the teeth, its central pathway eventually synapses with the **trigeminal lemniscus** which then projects to the thalamus, rather than directly being the spinothalamic tract itself. *Ventral spinothalamic tract* - The **ventral (anterior) spinothalamic tract** primarily carries sensations of **crude touch and pressure**. - It does not significantly contribute to the transmission of pain and temperature, which are the main sensations from teeth and temperature described. *Corticospinal tract* - The **corticospinal tract** is a major **motor pathway** that originates in the cerebral cortex and descends to the spinal cord. - It is responsible for **voluntary fine motor control** of the limbs and body, having no role in carrying sensory information like pain or temperature.

Question 5: A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?

A. Grade I (Mild claudication)
B. Grade II (Moderate claudication) (Correct Answer)
C. Grade III (Severe claudication)
D. Grade IV (Ischemic rest pain)

Explanation: ***Grade II (Moderate claudication)*** - **Grade II claudication** is characterized by **intermittent claudication** where the patient experiences pain while walking but can **continue walking with effort**. - This level of claudication reflects a moderate degree of peripheral arterial disease, where blood flow is sufficiently compromised to cause pain with exertion but not severe enough to force immediate cessation of activity. - The patient in this scenario can continue ambulation despite discomfort, which is the defining feature of this grade. *Grade I (Mild claudication)* - **Grade I claudication** involves discomfort or pain that the patient can **tolerate without significantly altering their gait or pace**. - In this stage, the pain is minimal, and the patient may perceive it as a dull ache or mild fatigue rather than true pain. - Walking can continue without significant effort or limitation. *Grade III (Severe claudication)* - **Grade III claudication** is marked by pain that is **severe enough to stop the patient from walking within a short distance** (typically less than 200 meters). - The pain forces the patient to rest and recover before they can resume walking. - This represents significant functional limitation in daily activities. *Grade IV (Ischemic rest pain)* - **Grade IV**, also known as **critical limb ischemia**, involves **pain even at rest**, especially in the feet or toes, often worsening at night when the limb is elevated. - This stage indicates severe arterial obstruction and is frequently associated with **ulcers, non-healing wounds, or gangrene**. - This represents advanced peripheral arterial disease requiring urgent intervention. **Note:** This grading system is a simplified clinical classification. The standard medical classifications for peripheral arterial disease are the **Fontaine classification** (Stages I-IV) and **Rutherford classification** (Categories 0-6).

Question 6: A 35-year-old woman presents with a history of recurrent migraines, unresponsive to prophylactic medications. What is the most appropriate next step in management?

A. Combination prophylactic therapy
B. Trial of alternative prophylactic medication from different class
C. Referral to headache specialist
D. Evaluation for medication overuse headaches (Correct Answer)

Explanation: ***Evaluation for medication overuse headaches*** - **Medication overuse headache (MOH)** is a common cause of chronic daily headache and can lead to unresponsiveness to prophylactic treatments in patients with pre-existing primary headache disorders. - Identifying and addressing MOH involves gradually withdrawing the overused acute medication, which can lead to significant improvement in headache frequency and severity. *Trial of alternative prophylactic medication from different class* - While switching prophylactic medications is a standard approach when a drug is ineffective, it's crucial to rule out MOH first, as continued use of acute medications can worsen the underlying migraine condition and perpetuate refractoriness [1]. - Introducing new prophylactic treatments without addressing MOH may not be effective and can delay appropriate management [1]. *Combination prophylactic therapy* - Combination therapy can be considered for refractory migraines, but it's generally reserved for cases where single-agent prophylactic regimens have failed and MOH has been excluded. - Adding more medications before assessing for MOH might further complicate treatment and obscure the root cause of treatment unresponsiveness. *Referral to headache specialist* - Referral to a headache specialist is often appropriate for refractory migraines, but the specialist will likely also prioritize ruling out secondary causes like MOH. - A structured evaluation for MOH can often be initiated by the primary care provider before or in conjunction with a specialist referral.

Question 7: Following are the features of persistent postoperative pain EXCEPT:

A. Pain from pre-surgical problem is excluded
B. Pain present for at least 3 months (Correct Answer)
C. Pain where other causes are excluded
D. Pain that develops after surgical procedure

Explanation: *Pain present for at least 3 months* - This statement is an **incorrect** feature of persistent postoperative pain. The diagnostic criteria for persistent postoperative pain typically define it as pain lasting for at least **2 months** after surgery. - The definition requires a minimum duration of 2 months, not 3 months, for the pain to be considered chronic or persistent. **Pain from pre-surgical problem is excluded** - Persistent postoperative pain refers to new or increased pain directly attributable to the surgical procedure itself, excluding the original pain condition. - This criterion ensures that the **chronic pain** being evaluated is a consequence of the surgery and not a continuation or recurrence of the initial problem. *Pain where other causes are excluded* - This is a key diagnostic criterion, as it ensures that the pain is not due to other independent medical conditions, infections, or surgical complications. - Excluding other causes helps to confirm that the persistent pain syndrome is directly related to the **surgical intervention**. *Pain that develops after surgical procedure* - The pain must have developed or significantly increased in intensity after the surgical procedure for it to be considered persistent postoperative pain. - This distinguishes it from pre-existing pain conditions that may be ongoing but are not directly linked to the **surgical trauma**.

Question 8: A patient complains to a physician of chronic pain and tingling of the buttocks. The pain is exacerbated when the buttocks are compressed by sitting on a toilet seat or chair for long periods. No lumbar pain is noted. Pain is elicited when the physician performs Freiberg&;s maneuver. Most likely diagnosis

A. Popliteus tendinitis
B. Piriformis syndrome (Correct Answer)
C. Disk compression of the sciatic nerve
D. Fibromyalgia

Explanation: ***Piriformis syndrome*** - The presented symptoms, including **chronic pain and tingling of the buttocks exacerbated by sitting**, and particularly the positive **Freiberg's maneuver**, are classic indicators of **piriformis syndrome**. - **Freiburg's maneuver** involves forced internal rotation of the hip in flexion, which stretches the piriformis muscle and compresses the **sciatic nerve**, reproducing the patient's pain. *Popliteus tendinitis* - This condition affects the **popliteus muscle** and tendon, typically causing pain in the **posterolateral knee** during activities like running or downhill walking. - The symptoms described, such as **buttock pain and tingling**, are not characteristic of popliteus tendinitis. *Disk compression of the sciatic nerve* - While this can cause **sciatic nerve pain in the buttocks and leg**, it is usually associated with **lumbar pain** or a history of back trauma, which is explicitly stated as absent in this case. - The pain from **disc compression** often presents differently, with more prominent **radicular symptoms** extending down the leg, and may not be specifically exacerbated by sitting directly on the buttocks in the same manner as piriformis syndrome. *Fibromyalgia* - **Fibromyalgia** is a widespread chronic pain condition characterized by musculoskeletal pain, fatigue, and tenderness in multiple **tender points** throughout the body. - It does not typically present with localized pain and tingling specifically in the buttocks exacerbated by sitting, nor would it be specifically provoked by **Freiberg's maneuver**.

Question 9: ABPI increases artificially in

A. Ischemic limb ulcers
B. Intermittent claudication syndrome
C. Deep vein thrombosis (DVT)
D. Conditions causing arterial calcification (Correct Answer)

Explanation: ***Conditions causing arterial calcification*** - In cases of **arterial calcification**, particularly in conditions like **diabetes** and **chronic kidney disease**, the blood vessels become stiff and non-compressible. - This stiffness leads to falsely elevated ankle systolic pressures because the cuff cannot effectively compress the calcified arteries, resulting in an artificially high **Ankle-Brachial Pressure Index (ABPI)** reading [2]. *Ischemic limb ulcers* - **Ischemic limb ulcers** are a direct consequence of **peripheral artery disease (PAD)**, which is characterized by reduced blood flow to the extremities [2]. - In these conditions, the ABPI would be **decreased** (typically < 0.9), indicating impaired blood supply, not an increase [2]. *Intermittent claudication syndrome* - **Intermittent claudication** is a classic symptom of **peripheral artery disease (PAD)**, where pain occurs in the legs during exercise due to insufficient blood flow [1]. - This syndrome is associated with a **reduced ABPI**, as arterial narrowing limits oxygen delivery to the muscles during exertion [1]. *Deep vein thrombosis (DVT)* - **Deep vein thrombosis (DVT)** is a condition involving a blood clot in a deep vein, typically in the legs. - DVT does not directly cause an artificial increase in ABPI; it primarily affects venous return and can cause swelling and pain, but not elevated arterial pressure readings [2].

Question 10: Which of the following conditions characteristically causes bilateral hypertranslucency of lung fields on chest X-ray?

A. Mcleod syndrome
B. Poland syndrome
C. Emphysema (Correct Answer)
D. Pneumothorax

Explanation: ***Correct: Emphysema*** - **Emphysema** causes destruction of alveolar walls, leading to enlarged air spaces and **air trapping**, making both lungs appear hypertranslucent on X-ray - This **bilateral hypertranslucency** is due to reduced lung tissue density, decreased vascular markings, and increased air volume - Classic radiographic features include flattened diaphragms, increased retrosternal space, and hyperlucent lung fields *Incorrect: Mcleod syndrome* - Also known as **Swyer–James–MacLeod syndrome**, this condition causes **unilateral** lung or lobe hyperlucency due to post-infectious obliterative bronchiolitis - The key differentiating feature is that it's **unilateral**, whereas the question asks for bilateral hypertranslucency - Affected lung shows air trapping on expiratory films *Incorrect: Pneumothorax* - A **pneumothorax** presents as a **unilateral** or focal hypertranslucent area due to air in the pleural space - Characterized by **absence of lung markings** beyond the visceral pleural line and associated lung collapse - This is a pleural space abnormality, not a bilateral parenchymal lung disease *Incorrect: Poland syndrome* - **Poland syndrome** is a congenital condition with absence or underdevelopment of the pectoralis major muscle - Can lead to **unilateral** apparent hyperlucency on the affected side due to missing chest wall muscle - This is a **chest wall anomaly**, not a parenchymal lung disease causing bilateral hypertranslucency

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