28. The formal presentation of Myofascial Pain syndrome diagnostic criteria includes each of the following, EXCEPT
(A) Resolution of the symptoms after Trigger Point Injection with local anesthetic
(B) Referral pain is evident
(C) Twitch response and Trigger Points are the common features
(D) Limited ROM of the affected muscle or muscles
(E) Widespread body pain

24. Which of the following is the acceptable statement about pathogenesis of FMS? (A) There is evidence to suggest that FMS is a disorder of abnormal processing of sensory information within the central nervous system. (B) Several neurochemical mediators of pain, substance P, nerve growth factor, dynorphin A, glutamate, nitric oxide, serotonin and noradrenaline are viewed as pronociceptive because they carry or amplify afferent signals, leading to the brain perception of increased pain. (C) The elevation of cerebrospinal fluid substance P in FMS is due to lowered activity of cerebrospinal fluid substance P esterase because the rate of cleavage of libeled substance P by FMS cerebrospinal fluid was lower than normal. (D) In different subtypes of FMS, it is believed that nerve growth factor may be responsible for the elevated cerebrospinal fluid substance P through its effects on central sensitization and neuroplasticity. (E) A specific Gi-protein-coupled receptor in peripheral blood leukocytes was found to be dysfunctional in patients with FMS. This resulted in lower baseline, also depressed intracellular levels of cyclic AMP and proposed as a diagnostic test for FMS.

25. When the administration of opioids failed to manage pain or the dose of opioids are noted to escalate, the following differential diagnosis should be considered, except: (A) Limited absorption of oral preparations-vomiting or gastric stasis. (B) Pain poorly responsive to opioids alone- such as Neuropathic pain (C) Pharmacological factors: Opioid-induced hyperalgesia and allodynia (D) Psychological factors: Distress, Anxiety or Depression (E) All of the above should be considered

26. Nociceptive pain: (A) Occurs only in laboratory animals. (B) Occurs under conditions of normal peripheral and central nervous system function. (C) Typically responds poorly to opioid analgesics. (D) Typically responds poorly to NSAIDs. (E) Typically responds favorably to adjuvant analgesics.

27. A patient had chronic pain over the neck, medial scapula, anterior chest, medial aspect of arm and forearm. Horner's syndrome was also noted. Which root compression is the most likely? (A) C5 root compression (B) C6 root compression (C) C7 root compression (D) C8 root compression (E) T1 root compression

29. A parturition of heroin abuse history ask for painless labor, which one is improper? (A) Meperidine (B) Continuous epidural analgesia (C) Nitrous oxide (D) Butorphanol (E) Intrathecal morphine

30. Correct comparisons between osteoarthritis (OA) and rheumatoid arthritis (RA) dose not include: (A) Steroids and the newer drugs that focus on controlling cytokines, such as tumor necrosis factor (TNF), may reduce pain in OA and RA (B) OA mainly involve the joints and RA may present extra-articular features (C) OA appears to be a mechanically driven, and RA presents an immunologically driven disorder (D) Pain management is similar in RA and OA, but the main focus is on controlling the disease process through the use of disease-modifying antirheumatic drugs (DMARDs) (E) Female sex is a common factor in either OA or RA j

31. A 27-year-old woman with a history of malignant melanoma and multiple subcutaneous metastases has been successfully managed with slowly increasing doses of MS-Contin (Morphine SR), in conjunction with doxepin and ibuprofen. She calls the pain center to complain of a new onset of increasing nausea, vomiting, and headaches, as well as poor pain control. The most appropriate immediate action would be to (A) speak with the patient by telephone and tell her to increase the MS-Contin (B) see the patient as soon as possible to determine if there is a new, treatable source of pain (C) schedule the patient for an evaluation in your office within the week (D) switch to a fentanyl patch since the patient is nauseated and may be unable to take oral analgesics (E) add ondansetron for nausea and vomiting so she is able to continue to take oral analgesics

32. Regarding the actions of spinal and supraspinal analgesia for opioids, which of the following statement is most likely: (A) Opioid receptors are mostly located at a predominantly (70%) postsynaptic location on the central terminals of only small diameter nociceptive primary afferents. (B) The contribution of kappa, delta and mu receptors to the total opiate binding throughout the spinal cord is estimated to be delta ＞ mu ＞kappa. (C) Opioids inhibit OFF cells via GABA neurons and activate ON cells in the rostromedial medulla (RVM) leading to changes in spinal descending controls. (D) Nitric oxide (NO) is required for the 5-HT-mediated inhibition of PAG output and reversal of antinociception. (E) Fibers descending from the PAG to the dorsal horn of the spinal cord are mostly enkephalinergic, lycinergic and GABAergic.

33. Regarding NSAIDs or Coxibs, which of the following statement is least likely: (A) Ketorolac is one of the acidic anti-inflammatory analgesics with high potency and fast elimination. (B) Paracetamol is an non-acidic antipyretic analgesic with weak inhibition on cyclooxygenase. (C) The analgesic effect, as demonstrated by number-needed-to-treat (NNT), of oral Tramadol (100 mg) is better than oral Celecoxib (400 mg). (D) Topical NSAIDs are effective in strains and sprains and in arthritic conditions. (E) Paracetamol is an alternative for analgesic in patients with exacerbation of asthma.

34. Regarding antidepressant analgesics, which of the following statement is least likely: (A) According to NNT data in treating postherpetic neuralgia, imipramine has slightly better analgesic effect than oxycodone. (B) Desipramine (25-300 mg/day, oral) has low potency of anticholinergic effect and sedation. (C) Fluoxetine (5-40 mg/day, oral) has no anticholinergic and sedative effects. (D) Venlafaxine is relatively free of muscarinic cholinergic, histaminic and alpha-adrenergic receptor effects. (E) The analgesic effect of antidepressants in treating neuropathic pain is dependent of its antidepressant action.