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Pain Medicine
Board Review
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 Pain Medicine
Board Review

Anna Woodbury, MD
Department ofAnesthesiology
Emory University School ofMedicine
Veterans Afiairs Medical Center
Atlanta, Georgia

Boris Spektor, MD
Department ofAnesthesiology
Emory University School ofMedicine
Atlanta, Georgia
Vinita Singh, MD
Department ofAnesthesiology
Emory University School ofMedicine
Atlanta, Georgia
Brian Bobzien, MD
Department ofAnesthesiology
Emory University School ofMedicine
Grady Memorial Hospital
Atlanta, Georgia
Trusharth Patel, MD
Department ofAnesthesiology
Emory University School ofMedicine
Atlanta, Georgia
Jerry Kalangara, MD
Department ofAnesthesiology
Emory University School ofMedicine
Veterans Aflairs Medical Center
Atlanta, Georgia

ELSEVIER
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PAIN MEDICINE BOARD REVIEW ISBN: 978—0—823—4481 1—6

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Names: Woodbury, Anna, author.

Title: Pain medicine board review / Anna Woodbury, Boris Spektor, Vinita Singh, Brian Bobzien,
Trusharth Patel, Jerry Kalangara.
Description: First edition. | Philadelphia, PA : Elsevier, [2018] | Includes index.
Identifiers: LCCN 2017007004 | ISBN 9780323448116 (pbk. : alk. paper)
Subjects: | MESH: Pain Management—methods | Examination Questions
Classification: LCC RB127 | NLM WL 18.2 | DDC 616/.0472076—dc23 LC record
available at https://1ccn.loc.gov/2017007004

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Jose Avila-Calles, MD, PhD
Assistant Professor, Department of Anesthesiology (Pain
Medicine),Jackson Stephens Spine Center, University
of Arkansas for Medical Sciences
Brian Bobzien, MD
Assistant Professor, Department of Anesthesiology (Pain
Medicine), Emory University School of Medicine,
Director of Pain Services, Grady Memorial Hospital,
Atlanta, Georgia
Eashwar Balu Chandrasekaran, MD, MSc
Clinical Assistant Professor, Department of Emergency
Medicine, IUH Methodist Palliative Care Services,
Indiana University School of Medicine, Indianapolis,
Indiana
Shivang Vinod Desai, MD
Associate, Departments of Interventional Pain and
Anesthesiology, Geisinger Clinic
Danville, Pennsylvania
Lisa Guo Foster, MD
Associate Professor, Department of Orthopedics, Emory
Orthopaedics 8c Spine Center, Atlanta, Georgia
Lynn Marie Fraser, MD
Pain Medicine Fellow, Department of Anesthesiology,
University of North Carolina School of Medicine,
Chapel Hill, North Carolina
Jerry Kalangara, MD
Assistant Professor, Department of Anesthesiology (Pain
Medicine), Emory University School of Medicine,
Veterans Affairs Medical Center, Atlanta, Georgia
Brian H. Keogh, Jr., MD
Banner Health Interventional Pain and Spine
Management Clinic, Greeley, Colorado
Zachary Leuschner, MD
Pain Management Physician, Baylor Scott 8c White Health,
Marble Falls, Texas
Contributors
Daniel P. Loren, MD
Interventional Pain Management Specialist and
Anesthesiologist, Orlando, Florida
Joshua Meyer, MD
Interventional Pain Medicine, Dothan, Alabama
Preeti Narayan, MBBS
Regional Anesthesia and Acute Pain Fellow, Department
of Anesthesiology, Emory University, Atlanta, Georgia
Trusharth Patel, MD
Assistant Professor, Department of Anesthesiology (Pain
Medicine), Emory University School of Medicine,
Atlanta, Georgia
Joshua Scott Powers, MD
Bain Complete Wellness, Tampa, Florida
Moises Adrian Sidransky, MD
Interventional Pain Management, East Texas Medical
Center, Tyler, Texas
Vinita Singh, MD
Assistant Professor, Director of Cancer Pain Services,
Department of Anesthesiology (Pain Medicine), Emory
University School of Medicine, Atlanta, Georgia
Boris Spektor, MD
Program Director, Emory Pain Fellowship, Assistant
Professor, Department of Anesthesiology (Pain Medicine),
Emory University School of Medicine, Atlanta, Georgia
Liliana Viera—Ortiz, MD
Palliative Medicine, Trauma Hospital, University of
Puerto Rico, Medical Center, San Juan, Puerto Rico
Anna Woodbury, MD, C.Ac
Assistant Program Director, Emory Pain Fellowship,
Assistant Professor, Department of Anesthesiology (Pain
Medicine), Emory University School of Medicine,
Division Chief, Veteran’s Affairs Medical Center, Atlanta,
Georgia
Preface
The field of pain medicine is an ever-developing and expand-
ing field with an inherently multidisciplinary nature. The
field continues to advance with research into newer, safer,
and more comprehensive techniques for the management of
pain. In the face of a widespread opioid epidemic, physicians
from a variety of fields have become intensely interested in
nonnarcotic management of acute and chronic pain condi-
tions and learning how to appropriately assess opioid risk. As
those who study pain know, there are many varieties of pain
and many ways to target these individual pain sources and
interrupt their mechanisms of development.
This question book highlights some key concepts in the
pathophysiology and treatment of pain. It was compiled by
physicians from specialties and subspecialties including An—
esthesiology, Emergency Medicine, Pain Medicine, Pallia-
tive Care, Physical Medicine and Rehabilitation, and Re-
gional Anesthesia/Acute Pain, and it also includes editors
with expertise and special interests in Cancer Pain, Integra-
tive Medicine, and Pediatric Pain. Questions were written
primarily by fellows during their subspecialty training at
Emory University School of Medicine and reviewed/ edited
by their attendings. Editors represent four separate institu-
tions associated with Emory University School of Medicine,
bringing with them a wide range of backgrounds and exper-
tise with diverse patient populations.
vi
This question book is not intended as a stand-alone re-
source, but as an aid to guide studying and highlight key
points in pain management. It is a companion book to Prac—
tical Management of Pain, edited by Honorio Benzon et al.
Practical Management of Pain stands out as a comprehensive
resource for those interested in the study of pain; it is ap—
propriate both for those seeking board certification as well
as for those who simply wish to gain a deeper understanding
of pain and its various treatments. Healthcare practitioners
from a variety of fields would benefit from information
found in these books. In assessing currently available books
regarding pain medicine for our fellows to use for self-study
and board review, we found that most books on the market
were inadequate and inherently flawed. We therefore en—
couraged them to read Practical Management of Pain and, as
a group interested in furthering education and understand-
ing regarding pain medicine, came together (fellows and
faculty) to develop a question book based off of this com-
prehensive text. As such, this question book should be used
as an adjunct to specifically target areas in need of further
study, whether for board preparation or simply as a “test
your knowledge” guide to accompany Practical Management
ofPain.

The editors would like to acknowledge helpful discussions
and input from their colleagues in multiple departments at
Emory University School of Medicine. The multidisciplinary
pain fellowship at Emory and the development of this book
could not exist without the willingness and enthusiasm to
teach that has come from the cohesive groups of individuals
within these departments. These departments include Anes-
thesiology, Emergency Medicine, Hematology 8c Oncology,
Interventional Radiology, Neurology, Palliative Care, Physical
Medicine and Rehabilitation, Primary Care, Psychiatry, Psy-
chology, Radiology, and many others. Specific individuals de—
serving of thanks for their support and their commitment to
medical education include Laureen Hill (Chair, Department
of Anesthesiology), Anne Marie McKenzie—Brown (Director,
Center for Pain), Colette Curtis (Acute Pain), Tammie Quest
(Emergency Medicine & Palliative Care), Paul Desandre
Acknowledgments
(Emergency Medicine 8: Palliative Care), Lynn O’Neill
(Geriatrics, Internal Medicine & Palliative Care), Michael
Silver (Neurology), Taylor Harrison (Neurology 8c Electrodi—
agnostics), Natalie Strickland (Pediatric Pain), Jennifer
Steiner (Pain Psychology), Nadine Kaslow (Pain Psychology),
Howard Levy (Physical Medicine 8c Rehabilitation), William
Beckworth (Physical Medicine & Rehabilitation),]ose Garcia
(Physical Medicine 8c Rehabilitation), Randy Katz (Occupa—
tional Medicine & Physical Medicine 8c Rehabilitation), Scott
Firestone (Psychiatry), Walter Carpenter (Radiology). And of
course, the field would not advance without the aid of those
who have dedicated themselves to advancing research in
pain and neural networks, including Paul Garcia, Wei Huang,
Vitaly Napadow, Bruce Crosson, Ling Wei, and Shan Ping Yu.
Anna Woodbury, MD
vii
 GENERAL CONSIDERATIONS
The History of Pain Medicine
QUESTIONS
1. Which of the following anesthetics was administered for
labor pain to Queen Victoria in 1874 and subsequently
cited as legitimizing analgesia during labor?
A. Chloroform
B. Nitrous oxide
C. Cocaine
D. Morphine
E. Procaine
2. Which of the following theories combines both physical
and psychological aspects of pain perception and is
credited with revolutionizing pain research?
A. Pattern Theory
B. Sensory Interaction Theory
C. Gate Control Theory
D. The Fourth Theory of Pain
E. Specificity Theory
ANSWERS
I. A. Queen Victoria was given chloroform byjames Simp-
son in 1847 for the delivery of her eighth child, at
which point it became widely accepted that labor pain
should be medically managed. Prior to this, it was con—
sidered against Christian beliefs to provide or accept
analgesia during labor.
2. C. The Gate Control Theory, developed by Melzack
and Wall in 1965, states that nonnociceptive signals
can override nociceptive signals, and, as a result, the
perception of pain is reduced or eliminated. Interven-
tions such as peripheral nerve stimulators, TENS units,
and spinal cord stimulators, as well as biofeedback
3. Which of the following organizations is multidisci-
plinary, with members including but not limited to
physicians, dentists, psychologists, nurses, and physical
therapists?
A. The American Academy of Pain Medicine (AAPM)
B. The International Association for the Study of Pain
(IASP)
C. The International Spine Intervention Society
(SIS, formally ISIS)
D. The American Society of Interventional Pain
Physicians (ASIPP)
E. The American Society of Regional Anesthesia
(ASRA)
techniques, are based on the Gate Control Theory.
This theory is cited as ending the debate regarding
whether or not the cerebral cortex plays a role in pain.
Development of imaging such as PET, fMRI, and
SPECT later added credibility to this theory by demon—
strating the activation of the cerebral cortex in
response to pain.
3. B. The International Association for the Study of Pain
(IASP) is the largest multidisciplinary international as-
sociation, with a goal of furthering pain research by in-
tegrating professionals with different backgrounds and
disciplines.
 2 Taxonomy and Classification
of Chronic Pain Syndromes

QUESTIONS
1. The International Association for the Study of Pain D. Serves to exclude new syndromes such as those
(LASP) classification focuses on chronic pain; however, involving painful legs and moving toes
it includes syndromes that are not acute in nature, E. Is entirely psychogenic in nature
including which of the following?
A. Acute herpes zoster . Migraines fall under which of the following diagnostic
B. Burns with spasm categories?
C. Pancreatitis Pain Disorder, Somatoform Persistent

£115.09”?
D. Prolapsed intervertebral disk Pain Disorder, Psychological Origin
E. All of the above Pain Disorder, Malingering
Pain Disorder, Neuropathic
. The classification of chronic pain specifies five axes for Psychological or Behavioral Factor Associated with
describing pain. The second axis is the system most re- Disorders or Disease Classified Elsewhere
lated to the cause of the pain. Which of the following
are systems identified? 7. While defining pain, it is important to recognize that
A. The central, peripheral, and autonomic nervous pain is always a subjective state related to which of the
systems and special senses following?
B. Psychological and social function of the nervous Emotional state
PLUGS”?

system Physical state

C . Respiratory and vascular systems Psychiatric state
D. The musculoskeletal system and connective tissue Psychological state
E. All of the above Social state

3. Which of the following is NOT part of the diagnosis of 8. According to the IASP Taxonomy Committee, chronic
complex somatic symptom disorder? pain is defined as pain that has been present for what
A. Emotional disturbances length of time?
B. Health anxiety 3 months
HUGE”?

C. Excessive amount of time devoted to health concerns 12 months

D. Symptoms and concerns must have lasted 12 months 6 months
E. None of the above 24 months
None of the above
. Based on the ICD—lO classification, a predominant
complaint that is persistent, severe, and distressing that . Consensus generally exists on the meaning or
cannot be explained fully by a physiologic process or definition of which of the following terms?
physical disorder is categorized as: A. Condition
A. Pain Disorder, Somatoform Persistent B. Disease
B. Pain Disorder, Psychological Origin C. Disorder
C. Pain Disorder, Malingering D. Symptom
D. Pain Disorder, Neuropathic E. Syndrome
E. Psychological or Behavioral Factor Associated with
Disorders or Disease Classified Elsewhere 10. All of the following are listed by the IASP as relatively
generalized pain syndromes except:
. The definition of complex regional pain syndrome A. Fibromyalgia
(type 1): B. Phantom Pain
A. Is related to the sympathetic nervous system C. Complex Regional Pain Syndrome
B. Is defined by its clinical phenomena D. Pain of Psychological Origin
C. Is defined solely for research purposes E. Radicular Pain
 CHAPTER 2 — Taxonomy and Classification of Chronic Pain Syndromes
ANSWERS
l. E. The LASP (International Association for the Study of
Pain) focuses on the classification of chronic pain syn-
drome, but includes some acute syndromes for compar-
ison (and because these acute conditions can often be-
come chronic). Acute herpes zoster, burns with spasm,
pancreatitis, and prolapsed intervertebral disk are all
examples of acute pain syndromes that are included.
. E. The classifications are divided into five axes: (l) ana-
tomic, (2) system, (3) temporal characteristics and pat-
tern, (4) intensity, (5) etiology. The second axis systems
include (a) central, peripheral, and autonomic nervous
and special senses; (b) psychological and social function;
(c) respiratory and vascular; (d) musculoskeletal and
connective tissue; (e) cutaneous and subcutaneous tissue
and glands, gastrointestinal, genitourinary, and other
organs/viscera; and (g) unknown systems.
. D. To be diagnosed with complex somatic symptom
disorder by DSM-IV criteria, patients must report at
least one distressing somatic symptom as well as at least
one of “emotional/ cognitive/behavioral disturbances:
high levels of health anxiety, disproportionate and
persistent concerns about the medical seriousness of
the ‘symptoms’ and an excessive amount of time and
energy devoted to the symptoms and health concerns,”
for at least 6 months’ duration.
4. A. Persistent Somatoform Pain Disorder is persistent,
severe, distressing pain that cannot be explained fully
by physiologic mechanisms. Pain during schizophrenia
or depression is not included.
. B. The name of CRPS was changed from RSD based on
the advice of a special subcommittee. Steps taken have
(1) defined CRPS type 1 by its clinical phenomena and
(2) developed identifying diagnostic criteria for clinical
agreement as well as for more stringent research pur-
poses. The classification has also helped in understand-
ing relatively new syndromes. The old name, RSD, was
3
based on a theoretical relationship to the sympathetic
nervous system.
E. Pain that is due to known or inferred psychophysio-
logic mechanisms, such as muscle tension pain or mi—
graines, but is believed to have a psychogenic cause
falls under the ICD-lO classification of Psychological or
Behavioral Factor Associated with Disorders or Disease
Classified Elsewhere.
D. The definition of pain by the IASP is “an unpleasant
sensory and emotional experience associated with ac-
tual or potential tissue damage or described in terms of
such damage.” This addresses the situation of patients
who appear to have pain but do not have obvious tissue
damage and acknowledges that pain is always subjective
and psychological, regardless of tissue damage.
. C. Chronic pain is pain that persists beyond the normal
healing process. Although the timeframe for this may
differ in practice and many types of pain become
chronic or persistent at 3 months, the 6—month division
was chosen for scientific purposes by the IASP as a
good entry to the patient population treated by pain
physicians.
. D. The words “disorder,” “syndrome,” and “disease”
are all in dispute regarding whether they reflect the
true phenomena that physicians treat. However, the
word “symptom” is not in dispute.
10. E. Relatively generalized syndromes include diffuse or
widespread pain that is poorly localized, such as rheu-
matoid arthritis, fibromyalgia, polymyalgia rheumatica,
pain of psychological origin, syringomyelia, central
pain, CRPS, phantom pain, stump pain, and periph-
eral neuropathy. Localized syndromes are divided by
the area affected (head, neck, limbs, thorax, abdomen,
spinal/ radicular) .
 Organizing an Inpatient Acute
Pain Service
QUESTIONS
1. Which of the following factors is likely to influence
postoperative opioid requirements?
A. Preoperative pain sensitivity
B. Presurgical opioid tolerance or a history of drug
abuse
C. Psychological factors, including catastrophizing and
anxiety
D. Age
E. All of the above
2. Which is the best intervention for inhibition of surgical
stress responses?
A. Neuraxial steroids
B. Neuraxial local anesthetics
C. Perineural local anesthetics
D. Systemic steroids
E. None of the above
. Postoperative pain is identified as one of the major
fears of patients undergoing surgery. What percentage
of patients consider it to be their primary fear?
A. 30%—40%
B. 40%—50%
ANSWERS
l. E. Achieving satisfactory acute pain management can be
challenging. It is often difficult to estimate a patient’s
postoperative analgesic requirements. The following
factors may influence postoperative opioid require—
ments: preoperative pain sensitivity, coexisting medical
conditions and associated multiple drug administration,
presurgical opioid tolerance or a history of drug abuse,
psychological factors (including catastrophizing and
anxiety), age, and type of surgery.
. B. Surgical stress responses are best inhibited by neur-
axial administration of local anesthetics; the adminis-
tration of other agents—systemically, neuraxially, or
perineurally—appears to contribute little additional
reduction of the endocrine (metabolic and catabolic)
stress response following operative procedures.
. C. Inadequacy of pain relief has been highlighted as a
quality-of—care measure and a focus of patients’ con-
cern. In a questionnaire survey, 57% of patients identi-
fied pain after surgery as their primary fear.
C. 50%—60%
D. 60%—70%
E. 80%—90%
. All of the following are examples of multimodal
analgesia EXCEPT:
A. Neuraxial block and music therapy
B. IV morphine and fentanyl patch
C. PCA morphine and thoracic epidural
D. Acupuncture and TENS
E. Femoral nerve block and stress reduction
. Which is an important first step in organizing an inpa-
tient acute pain service?
A. Enlisting the support of hospital administration and
defining resources
B. Assessment of need
C. Definition of service
D. Financing and business plan
E. Nursing education
4. B. A time-, energy—, and cost-effective acute pain pro-
gram should optimally provide multimodal and multidis-
ciplinary interventions, including systemic and regional
pharmacologic treatments, stress reduction, transcuta—
neous electrical nerve stimulation, music therapy, and
acupuncture. Extracting and integrating the relevant
expertise from multiple health care disciplines often
allows individualized and optimized pain management.
Disciplines commonly involved include psychology,
pharmacy, physical therapy, and nutrition.
5. A. Enlisting the support of hospital administration and
defining resources are a Vital first step in organizing an
inpatient acute pain service. Once the challenge of or—
ganizing an acute pain service is accepted, assessment
of need is mandatory. Once the mission statement has
been formulated in response to the perceived institu-
tional and community needs, it is necessary to define
the resources that will be required. The next step in the
process of organizing an inpatient acute pain service is
to construct the business plan.
 Measurement-Based
Stepped Care Approach to
Interdisciplinary Chronic
Pain Management

QUESTIONS
1. Which of the following is FALSE regarding the World 5. All of the following are aberrant drug behaviors
Health Organization cancer pain analgesic ladder? EXCEPT:
A. It is focused on the relief of intensity of cancer pain. A. Self-induced oversedation
B. It incorporates relief of suffering of the cancer pain B. Continuing medication despite report of feeling
patient. intoxicated
C. It emphasizes treating the intensity of pain even at C. Early refill requests
the expense of function. D. Calling the office to report worsening pain
D. It includes three steps in its analgesic strategy. E. Self-directed dose increase
E. The goal of the ladder is complete freedom from
pain. . The 2006 Trends and Risks of Opioid Use for Pain
(TROUP) study found opioid use to be higher in pa-
. Which the following pain treatment domains should tients with mental health disorders and what other
ideally be included in a measurements-based stepped health problem?
care pain treatment algorithm? A. Chronic pelvic pain
A. Physical and emotional function B. Substance use disorders
B. Quality of sleep C. Chronic back pain
C. Risk for chemical dependency D. Postsurgical patients
D. Self-reported quality of life E. Patients with whiplash history
E. All of the above
. All of the following are validated opioid risk scales
. The Patient Health Questionnaire 4 (PHQ—4) is a EXCEPT:
screening tool for depression and anxiety. Which of the A. ORT
following is NOT assessed on this questionnaire? B. COMM
A. Feeling nervous, anxious, or on edge C. SOAPP—R
B. Not being able to stop or control worrying D. DIRE
C. Feeling down, depressed, or hopeless E. DOLOPLUS
D. Having little interest or pleasure in doing things
E. Feeling better off dead 8. Which of the following is true about patient access to
pain specialists?
4. Which of the following is true about daily morphine A. There is an overabundance of pain care providers in
equivalent dose (MED) and relative risk of mortality in the United States today.
patients on chronic opioid therapy? B. There is currently a significant shortage in pain
A. As daily morphine equivalent dose increases, providers relative to the number of people with
mortality risk also increases in tandem. chronic pain.
B. As daily morphine equivalent dose increases, C. The number of patients with chronic pain is cur-
mortality risk tends to plateau. rently well matched to the number of board-certified
C. As daily morphine equivalent dose increases, providers in pain care.
mortality risk decreases. D. In the United States, fewer than 1000 physicians
D. The 50—100 mg morphine equivalent dose has the were board-certified in pain care between 2000 and
highest risk for mortality. 2009.
E. Using between 20 and 50 mg morphine equivalents E. The current shortage in pain care expertise leaves
per day does not increase mortality risk relative to more than 100,000 people with chronic pain for
less than 20 mg daily. every pain specialist in the United States.
6 PART 1 — GENERAL CONSIDERATIONS
. Obstructive sleep apnea risk is thought to increase
with the dose of opioid used. Which of the following
is NOT an additional risk factor for obstructive sleep
apnea based on STOP-BANG criteria?
. Hypertension
mvow>
. Snoring
. BMI greater than 35
. Age less than 50
. Male gender
10. According to the model of measurement—based
stepped care, referral to a behavioral health specialist
is indicated when all of the following are present
EXCEPT:
PHQ—Q 2 15
FCC???
PHQ—4 2 5
Suicidal ideation
PTSD
Anxiety
11. A 28-year-old male with chronic pain presents to your
clinic. Opioid risk screening reveals a personal and
family history of cocaine use as well as a psychological
history of anxiety. According to the stepped care
model, he should be referred to see:
A. Pain physician
B. Physiatrist
C. Behavioral health specialist
D. Addiction medicine specialist
E. Sleep medicine specialist
12. A primary care physician is treating a 26-year-old
female with chronic diffuse pain of unclear etiology,
unresponsive to 3 months of conservative management
including opioid escalation. According to the stepped
care model, she should be referred to see:
A. Pain physician
B. Physiatrist
ANSWERS
1. B. The WHO cancer pain analgesic ladder is focused
strictly on alleviating the intensity of pain and does not
incorporate suffering of the cancer pain patient in its
analgesic strategy. Other answer choices listed are true
statements regarding the ladder.
2. E. All of the listed pain treatment domains should
ideally be included in a stepped care pain treatment
algorithm.
3. E. The question regarding suicidality comes from the
PHQ—Q screening tool rather than the simpler PHQ—4
questionnaire.
4. A. Relative risk of mortality with chronic opioid therapy
increases in parallel with escalating morphine equiva-
lent dose.
5. D. Contacting the office to report worsening pain is
considered appropriate behavior meriting reevaluation.
C. Behavioral health specialist
D. Addiction medicine specialist
E. Sleep medicine specialist
13. The concept of “adverse selection” in relation to
substance use disorders and chronic pain opioid
prescribing argues which of the following:
A. The patients at highest opioid risk are being
prescribed the highest opioid doses.
B. The patients with highest socioeconomic status are
being prescribed the highest opioid doses.
C. The patients with lowest opioid needs are being
prescribed the lowest opioid doses.
D. The patients at highest opioid risk are being
prescribed the lowest opioid doses.
E. The patients at lowest opioid risk are being
prescribed the highest opioid doses.
14. What is the morphine equivalent dose (MED) that
prompts a referral to a pain specialist according to
the stepped care model?
A. 0—19 mg MED
B. 20—49 mg MED
C. 50—79 mg MED
D. 80—119 mg MED
E. Greater than 120 mg MED
15. Physical medicine and rehabilitation referral is
prompted by all of the following EXCEPT:
A. Disability greater than 4 weeks
B. On-the—job pain interference
C. Ineffective return—to—work plan
D. Roland Morris > 12/ 24
E. Obesity
6. B. Presence of substance use disorder in addition to
mental health disorders predisposed patients to higher
opioid use in the TROUP study.
7. E. The first four options are validated opioid risk
screening tools: Opioid Risk Tool (ORT), the Screener
and Opioid Assessment for Patients with Pain—Revised
(SOAPP—R) ; the Current Opioid Misuse Measure
(COMM); and the Diagnosis, Intractability, Risk, and
Efficacy (DIRE). The DOLOPLUS scale, though vali-
dated, is used for behavioral pain assessment in elderly
with verbal communication problems, not for opioid
risk screening.
. B. There is currently a significant shortage of
board-certified pain physicians in the United States
relative to the number of patients with chronic pain.
. D. Age greater than 50 is a risk factor for OSA per the
STOP-BANG criteria.
 CHAPTER 4 — Measurement-Based Stepped Care Approach to Interdisciplinary Chronic Pain Management

10. E. While anxiety is often associated with chronic pain,
its presence alone is not considered sufficient for psy-
chiatrist referral according to the stepped care model
unless deemed poorly controlled despite conservative
measures.
11. D. This patient has an opioid risk tool score 28 and
thus merits referral to an addiction medicine specialist.
13. A. The patients at highest opioid risk are being
prescribed the highest opioid doses.
14. E. Greater than 120 mg MED.
15. E. All are true except obesity, which is one of the risk
factors for sleep medicine referral.

12. A. This patient merits referral to a pain medicine

specialist for further evaluation.
 5 The Health Care Policy
of Pain Management
QUESTIONS
1. Which of these statements is part of the International
Association for the Study of Pain (IASP) Declaration of
Montreal?
A. Only pain that has been objectively verified must be
treated.
B. Pain must be treated by a medical doctor specialty-
trained in pain management.
C. Patients should receive analgesia based on their
ability to pay.
D. Access to effective pain management is a basic
human right.
E. Patients must have a history negative for substance
abuse to qualify for opioids.
2. Which of the following phases of the Food and Drug
Administration Center for Drug Evaluation and Re—
search (FDA CDER) approval process focuses on the
ANSWERS
I. D. The Declaration of Montreal, published in 2010, states
that effective pain management is a basic human right.
It underscores the importance of government to enact
legislature that promotes access to pain management
for all. It consists of three articles, including:
0 Article I: The right of all people to have access to
pain management without discrimination.
0 Article 2: The right of people in pain to have their
pain acknowledged and to be informed about how
it can be assessed and managed.
0 Article 3: The right of all people with pain to have
access to appropriate assessment and treatment
of the pain by adequately trained health care
professionals.
2. B. The phases of the FDA CDER approval process are
tiered as follows:
0 Preclinical IND application: Animal data used to
justify testing of the drug in humans.
0 Phase I: Basic safety profile and pharmacokinetics of
the drug in 50—100 human subjects.
0 Phase II: Drug dosage, efficacy, and safety in 100—500
human subjects.
basic safety profile and pharmacokinetics of the drug
in human subjects?
A. Preclinical Investigational New Drug (IND) application
B. Phase I
C. Phase II
D. Phase III
E. Phase IV
3. Which of the following is NOT identified as a barrier to
access to pain treatment around the world?
A. Education of patient population
B. High cost of treatment
C. Lack of government policy on pain treatment and
drug supply
D. Poor training of health care workers
E. Fear among health care workers of legal action
0 Phase III: Confirmation of the safety and effective-
ness of the drug, its dosages, and drug interactions
in 1000—4000 human subjects.
0 Phase IV: New or expanded use for patient population
and long—term risks vs. benefits.
. A. Access to appropriate pain management worldwide
remains largely inadequate. Seventy-eight percent of
morphine consumed in 2010 went to only six countries.
Inexpensive oral medications are unobtainable in many
countries. Reasons cited include:
0 Failure of governments to put functioning drug supply
systems in place.
0 Failure to enact policies on pain treatment and
palliative care.
0 Poor training of health care workers.
0 Existence of unnecessarily restrictive drug control
regulations and practices.
0 Fear among health care workers of legal sanctions
for legitimate medical practice.
0 Unnecessarily high cost of pain treatment.
 Quality Assessment and 6
Improvement and Patient
Safety in the Pain Clinic

QUESTIONS
1. The majority of errors that take place in health care are C. Lack of evidence-based benchmarks or national “best
due to which of the following? practices”
A. Patient factors D. Lack of cooperation from patients
B. System defects E. Lack of government regulation to support such
C. Provider carelessness programs
D. Equipment malfunction
E. Resource misallocation 3. Which of the following tools has been shown to signifi-
cantly lower the death rate, reduce patient complica-
2. Which of the following is identified as the biggest hurdle tions, and is especially helpful in emergencies?
to establishing Continuous Quality Improvement (CQI) A. E-conferencing/ telecommuting
in pain medicine? B. Speech recognition software
A. Lack of additional reimbursement to justify higher C. Electronic prescriptions
quality care D. Safety checklist
B. Lack of support from hospital administration E. Patient portals

ANSWERS
1. B. According to the Institute of Medicine (IOM), a ma-
jority of errors in health care are more likely attributable
to system defects (as opposed to individual errors).
2. C. Because evidence available in peer-reviewed litera-
ture is insufficient for chronic pain interventions, estab-
lishing a CQI in the field of pain medicine largely relies
on consensus expert opinion instead.
3. D. Using a checklist has been shown to reduce patient
complications, which is thought to be due to decreases
in human error. Data shows that simply implementing a
safety checklist can substantially reduce patient mortality
rates. Checklists are critical in emergency situations,
such as local anesthetic toxicity, where a checklist/
protocol should be readily available.
 Education, Training, and
Certification in Pain Medicine
QUESTIONS
1. Which of the following describes the design of current
pain medicine training programs?
Comprehensive and multidisciplinary
cow?
. Emphasis on pharmacologic-only treatment
Centered around principles from anesthesiology
. Incorporating multidisciplinary principles from three
specialties including anesthesiology, psychiatry, and
neurology
E. Focus on objective physical exam findings
2. Which of the following is a consequence of the Food
and Drug Administration’s (FDA) 510(k) “substantially
similar device” process?
A. There must be data from >1000 patients demonstrat-
ing device efficacy.
B. There must be data from >1000 patients demon—
strating device safety.
C. Guideline stringency hinders device innovation.
ANSWERS
1. A. The original fellowship training programs in pain
medicine were extensions of the department of anesthe-
siology. Since that time, there has been a broadening
of specialties seeking training in pain medicine. In an
effort to standardize and ensure quality of pain medi-
cine training programs, four specialties have agreed to
ACGME requirements for fellowship programs, includ-
ing anesthesiology, neurology, physical medicine and
rehabilitation, and psychiatry, since 2007. This collabo-
ration between specialties echoes the views of the
American Academy of Pain Medicine and the American
Board of Pain Medicine, emphasizing a multidisciplinary
and multimodal approach to pain medicine.
. D. In order to expedite innovation and the introduc-
tion of new technology, devices can be cleared for
10
D. Introduction of devices to the market often outpaces
practitioner familiarity.
E. Creation of new devices becomes cost prohibitive for
manufacturers.
3. Which of the following is a problem in using interven-
tional techniques in pain medicine?
A. The procedures are only suitable for a small subset
of patients.
B. Randomized, controlled clinical trials are still lacking
for many interventional treatments.
C. There is a lack of patient cooperation with adhering
to the schedule of frequency required.
D. The complications from most of the procedures are
such that the risk outweighs the benefit.
E. Patients are unwilling to try novel procedures.
market if the FDA deems the risks and benefits are
comparable to a device that has been previously ap-
proved. The FDA’s 510(k) “substantially similar device”
process can require little additional efficacy data. In
some cases, practitioners are overwhelmed with new
technology available and are not able to keep pace with
the skills and knowledge required to use the device.
3. B. The trend in medicine favoring evidence—based therapy
has highlighted a relative lack of randomized controlled
trials in the pain medicine subspecialty to validate treat-
ments. At the same time, patients with chronic pain re-
quire treatment and are often willing to try novel proce—
dures. Practitioners must monitor their own outcomes to
aid in making decisions in patient care as well as use best
judgment of risk vs. benefit for each individual patient.
 BASIC CONSIDERATIONS

Pain Pathways: Peripheral,

Spinal, Ascending, and
Descending Pathways

QUESTIONS
1. What is the primary termination site for sensory integra- 5. Prolonged membrane hyperpolarization has what effect
tion in the pain pathway? on the role of GABA—B receptors?
A. Thalamus A. Change from inhibition to more inhibition
B. Medulla B. Change from inhibition to excitation
C. Basal ganglia C. Change from excitation to inhibition
D. Dorsal columns D. Increased threshold for depolarization
E. Frontal cortex E. No effect

. What are the small unmyelinated axonal fibers with slow 6. Which of the following is the primary afferent excitatory
conduction velocities that relay noxious input from the neurotransmitter?
skin and other tissues to the central nervous system? A. Substance P
A. A-delta fibers B. CGRP
B. A—beta fibers C. IL—I
C. C fibers D. Glutamate
D. Free nerve endings E. Norepinephrine
E. Dorsal root ganglia
. Noxious cutaneous input is relayed by which of the
The dorsal horn is anatomically organized in laminae. following lamina projection neurons as the crossed
Small unmyelinated fibers terminate in laminae , spinothalamic tract pathway traveling in the lateral
while large myelinated fibers terminate in laminae and ventrolateral white matter en route to the VPL?
A. II—III, IV—V
B. I—II, III—V
C. III—V, I—II
D. II—IV, I—III
E. V, I—II

. The substantia gelatinosa is associated with which of the . The gray matter of the dorsal horn includes the following
following lamina? Rexed laminae:
A. Lamina I A. I—IV
B. Lamina II B. I—VI
C. Lamina III C. II—IV
D. Lamina IV D. II—VI
E. Lamina V E. I—X

ll
12 PART 2 — BASIC CONSIDERATIONS
9. All of the following are considered ascending medial
pain pathways EXCEPT:
A. Spinoamygdalar
B. Spinohypothalamic
C. Spinoreticular
D. Spinothalamic
E. Medial spinothalamic
ANSWERS
I. A. The primary termination site for sensory integration
is the thalamus. Peripheral nociceptors transmit nox—
ious information to second-order neurons at the spinal
cord and brainstem levels, which are then sent by pro-
jection neurons of the pain system to integration sites
in the brainstem. Though the primary site for integrat-
ing sensory information is the thalamus, many other
brain structures are also involved.
. C. C fibers (group IV) are small unmyelinated nocicep-
tors with conduction velocities less than 2.5 m/ sec.
A—delta fibers (group III) are small fibers with a conduc-
tion velocity of 4—30 m/ sec and conduct faster because
of a thin myelin sheath produced by Schwann cells.
Both of these axonal fibers carry noxious input from
tissue to the CNS.
. B. Small unmyelinated C—fiber nociceptor endings for
somatic sensation are distributed mainly in focused
areas of laminae I and II, though visceral afferents can
extend multiple segments and are widely dispersed in
ipsilateral laminae I, II, V, and X, or contralateral V and
X. Large myelinated A—beta fibers carrying nonnocicep-
tive input terminate in laminae III—V.
B. Interneurons of lamina II (substantia gelatinosa) syn-
thesize inhibitory (GABA) and excitatory (glutamate)
neurotransmitters. Opioid receptors are also found on
these nerve cells.
. B. GABA (y-aminobutyric acid) primarily reduces neu-
ronal excitability and provides presynaptic inhibition,
though with prolonged hyperpolarization/nociceptive
input, GABA—B receptors can change their role from
inhibition to excitation, leading to a positive feedback
loop that can establish chronic pain.
10. Which of the following structures most likely contrib-
ute to memory and learning related to painful stimuli
as indicated by fMRI imaging studies?
A. The VPL thalamus, SI, and S11 cortices
B. The ACC, cerebellum, and lentiform nucleus
C. The insula, cerebellum, and frontal cortex
D. The ACC, PCC, SI, and S11 cortices
E. The insula, lentiform nucleus, and periaqueductal
gray
D. Glutamate is an excitatory amino acid and plays
key roles in neural activation throughout the nervous
system. It is the primary neurotransmitter in afferent
nociception.
C. Noxious cutaneous input from lamina I, IV, and V
is relayed by projection neurons along the crossed STT
(spinothalamic tract) in the lateral and ventrolateral
white matter to the VPL (ventral posterolateral) and
posterior thalamus.
. B. Laminae I—X are all considered gray matter, but the
dorsal horn includes only laminae I—VI. Some deeper
laminae are also involved in nociceptive processing.
. D. The spinoamygdalar, spinohypothalamic, medial spi-
nothalamic and spinoreticular pathways, and connec-
tions to the anterior cingulate and prefrontal and insu-
lar limbic cortices are all medial pain pathways. The
spinothalamic tract is a nonoverlapping but parallel
lateral pathway.
10. C. Centers for higher processing can modulate aware—
ness of and responses to pain as well as regulate emo-
tional, autonomic, and motor responses. The insula,
cerebellum, and frontal cortex contribute to avoidance
behaviors and other types of memory and learning re-
lated to the painful stimulus. The VPL thalamus and
SI and 811 cortices are somatosensory—proeessing regions.
The ACC (anterior cingulate cortex) may be involved
in interpreting emotional significance of pain via the
limbic system.
 A Review of Pain-Processing
Pharmacology

QUESTIONS
1. What are the two key inhibitory neurotransmitters? Which of the following receptors are activated by cold
A. NMDA, glycine or menthol?
B. Somatostatin, substance P A. TRPM8
C. AMPA, glutamate B. TRPVl
D. GABA, glycine C. ASIC
E. Somatostatin, NMDA D. TRPV2
E. TRPVS
. Following a peripheral nerve injury, ongoing pain from
ectopic activity is due to the up—regulation of what type . Which of the following protein kinases phosphory—
of channels? lates the NMDA receptor to lower its threshold for
A. Calcium activation?
B. Sodium A. PKA
C. Potassium B. PKC
D. Chloride C. MAPK
E. Fluoride D. AMPA
E. All of the above
. All of the following are effects of substance P binding
EXCEPT: . Blockage of the facilitated state called “wind-up” has
A. Mast cell degranulation been reported with the use of:
B. Swelling of skin A. Opioids
C. Local erythema B. Prostaglandins
D. Vomiting C. Nitric oxide
E. Vasoconstriction D. NMDA antagonists
E. 5-HT3 inhibitors
. After nerve injury there is an increase in axonal excit—
ability that is associated with which of the following? . Chemical injury to a nerve is MOST LIKELY to be
A. Up—regulation of potassium channels and down- characterized by:
regulation of sodium channels A. Reddening at the site of the stimulus
B. Up—regulation of sodium channels and down-regulation B. An initial burst of afferent firing
of potassium channels C. Increased capillary permeability
C. Down-regulation of sodium and potassium channels D. Local arterial dilation
D. Up—regulation of sodium and potassium channels E. Regional hyperalgesia
E. Up—regulation of calcium channels and down-
regulation of sodium channels 10. Which of the following occurs after nerve injury?
A. Increased local catecholamine release
. All of the following mediators are released with tissue B. Alpha-adrenergic antagonists increase excitation of
injury and depolarize and sensitize primary afferent the injured axon
terminals EXCEPT: C. Down-regulation of alpha-l-adrenergic receptor
A. TNF—alpha expression
B. Substance P D. Decreased local catecholamine release
C. Bradykinin E. Decreased activity at the DRG or injured neuroma
D. Histamine
E. Glycine

l3
IA PART 2 — BASIC CONSIDERATIONS
ANSWERS
1. D. GABA and glycine act on GABA—A/GABA—B and gly—
cine receptors, reducing excitation. Glycine is an inhibi-
tory amino acid. Somatostatin is classified as an inhibi-
tory hormone with a range of functions throughout the
body including modulating peripheral inflammation,
the gastrointestinal tract, and the brain. The NMDA
(N—methyl—D—aspartate) receptor requires glutamate or
aspartate binding for activation. Substance P contributes
to enhanced nociception. AMPA (d-amino-S-hydroxy-
5-methyl—4—isoxazolepropionate) receptors, like NMDA
receptors, are activated by glutamate. Glutamate is a main
excitatory neurotransmitter. GABA (”y-aminobutyric acid)
primarily reduces neuronal excitability and provides presyn—
aptic inhibition, though with prolonged hyperpolarization/
nociceptive input, GABA—B receptors can change their
role from inhibition to excitation, leading to a positive
feedback loop that can establish chronic pain.
B. Sodium channel expression is increased in neuromas
and dorsal root ganglia following nerve injury. Lidocaine
can block ectopic activity and attenuate hyperpathic
states after nerve injury. There are a variety of sodium
channels in primary afferent neurons (Navl.6—Navl.9).
Navl.8 and Navl.9 are resistant to a sodium channel
blocker (TTX) and found primarily in G fibers. Variants
such as Navl.8 are important because, for example,
Navl.8 reverses nerve-injury—evoked pain states in animal
models. Mutations in Navl.7 in humans can cause
extremely painful conditions, while loss-of—function
mutations can lead to prominent insensitivity. Gain of
function mutations (i.e., to the sodium ion channel
alpha subunit gene SCN9A) can result in syndromes
like erythromelalgia, characterized by severe periodic
pain from blocked blood vessels.
. E. Substance P acts on the neurokinin—l (NK—l) recep-
tor and is involved in inflammation, pain perception
(along with glutamate), and the vomiting centers.
Substance P is also a potent vasodilator in conjunction
with nitric oxide.
B. Following nerve injury, sodium channel expression
has been found to be significantly increased, while po-
tassium (K+) currents have been shown to be reduced,
suggesting down-regulation of K+ channels.
5. E. Following tissue injury, a variety of cytokines and
inflammatory neurotransmitters are released, leading
to sensitization. Glycine, however, is an inhibitory neu-
rotransmitter and has not been shown to result in
increased afferent sensitization.
6. A. Transducer channels on afferent terminals have dif—
ferent sensitivities to specific stimuli. Some channels
transducing a physical sensation are also activated by
chemicals and can reproduce the physical sensation
when exposed to the chemical. For example, the
TRPVl (>43OC) vanilloid receptor is activated by
capsaicin (heat sensation), while the TRPM8 (QB—28°C)
receptor is activated by menthol (cold sensation), and
the TRPA (<17 oC) receptor is activated by mustard oil.
B. It has been shown that PKG (protein kinase C)
phosphorylates sites on NMDA and AMPA receptors,
which can lower threshold for activation and increase
membrane permeability.
E. Through the bulbospinal pathway, C fibers make
contact with neurons that project into the brainstem
contacting serotonergic neurons, which then project
to the spinal dorsal horn contacting lamina V neurons.
Cells of lamina V in the deep dorsal horn are noted
for their ability to display a state known as “wind-up.”
Blockage of this pathway using 5-HT?) inhibitors has
been reported to reduce “wind-up” facilitation.
B. Following nerve injury, afferent axons display an
initial burst of afferent firing followed by electrical
silence for hours—days and finally the appearance of
spontaneous bursting activity for hours-days. This is
correlated to an initial degeneration of the injured
nerve followed by new sprouting. Answer choices A, C,
D, and E are associated with tissue injury.
10. A. Stimulation of these postganglionic axons and
increased catecholamine release can excite the injured
axon and DRG, but this activation can be blocked by
alpha—adrenergic antagonism.
 Pain and Brain Changes

QUESTIONS

1. The TRPVl receptor differentiates which type(s) of D. Magnetoencephalography (MEG)

pain? E. None of the above
A. Noxious heat
B. Acidity . A 32-year-old female underwent cesarean section 1 year
G. Gapsaicin prior to presenting to your office. She has a well-healed,
D. All of the above low, transverse scar. She now presents to the pain clinic
E. None of the above with severe pain at the far right end of the scar. She de-
scribes the pain as intermittent sharp, burning, shoot-
. The dominant excitatory neurotransmitter in all ing pain, exacerbated by touch. On exam, you detect a
nociceptors is: knot at the right distal portion of the incision, and
A. Substance P upon light touch she jumps off the table and curses at
B. Serotonin you. What is the MOST LIKELY way you would describe
G. Acetylcholine her pain:
D. Glutamate A. Abnormal/Hyperalgesia
E. Norepinephrine B. Abnormal/Allodynia
C. Neuropathic pain
Intracranial recordings show that the earliest pain- D. Inflammatory pain
induced brain activity occurs where? E. Visceral pain
A. SI cortex
B. SII cortex . It’s determined that the above patient has a neuroma.
G. Thalamus What INCORRECTLY describes the pain that she’s
D. Hypothalamus experiencing?
E. Dorsal horn A. Neuromas generate spontaneous ectopic activity that
directly contributes to the perception of spontaneous
. Enhanced sensation and neural transmission at sites pain.
remote from the site of injury is referred to as: B. Neuromas are sensitive to temperature, mechanical,
A. Hyperalgesia and chemical stimuli.
B. Primary sensitization C. C—type nerve fibers are involved in spontaneous
G. Secondary sensitization ectopic activity.
D. Desensitization D. A—type nerve fibers are involved in spontaneous
E. Allodynia ectopic activity.
E. Noradrenergic sensitization results in separation of
. Which of the following is considered a nonnociceptive sympathetic and sensory neuronal activity.
touch afferent receptor that, following central sensitiza-
tion, may carry peripheral pain signals to the CNS? 9. Which of the following best describes the mechanisms
A. A—delta involved in sensitization?
B. A-beta A. There is decreased release of excitatory neurotrans-
G. G fibers mitters such as glutamate and substance P.
D. A—gamma B. Opioid receptors are down-regulated with neuro—
E. Schwann cells pathic pain.
C. Opioid receptors are down-regulated with inflamma-
. What electrical study or imaging tool can be used to tory pain.
verify the presence of ongoing spontaneous pain in a D. Potassium chloride (KGl) transporter down-regulation
patient? increases the effects of GABA release.
A. Electroencephalogram (EEG) E. Release of substance P and other peptides closes
B. Positron emission tomography (PET) the N—methyl—D-aspartate (NMDA) glutamate-gated
G. Functional MRI (fMRI) channel.

15
16 PART 2 — BASIC CONSIDERATIONS
10. The dimension of pain thought to include interaction
with previous experience and involve the prefrontal
cortex is termed:
A. Sensory-discriminative
B. Cognitive-evaluative
C. Affective-motivational
D. Behavioral-cortical
E. Emotional—receptive
11. Which of the following is true of placebo analgesia?
A. It cannot be blocked by naloxone.
B. The endogenous opioid system is involved.
C. The somatosensory cortex is involved.
D. There is no correspondence between placebo
analgesia and reward.
E. All of the above
12. Which of the following is TRUE regarding bone
cancer pain?
A. Substance P and other neuropeptides, such as
CGRP, are unregulated.
B. Up—regulation of galanin and neuropeptide Y
occurs.
C. Neuropathic pain and bone cancer pain have
similar changes with substance P and CGRP.
D. The greatest change observed in the spinal cord in
response to metastatic bone cancer pain is activa—
tion of astrocytes.
E. All of the above
ANSWERS
l. D. The TRPVl receptor responds to stimuli including
heat, acidity, and hot pepper capsaicin. These stimuli
can enhance each other.
2. D. Glutamate is the dominant excitatory nociceptor
neurotransmitter.
3. B. Intracranial recordings show that the earliest pain—
induced signals originate near the SH cortex, implicat—
ing SH and adjacent insula regions as the primary brain
areas for receiving nociceptive input.
4. C. Secondary sensitization leads to enhanced neural
transmission distant from the site of injury, thought to
result from reorganized spinal cord nociceptive circuitry.
Primary sensitization, in contrast, leads to increased
transmission near the site of injury.
5. B. A—delta and C fibers are the primary nociceptors in
healthy organisms. A—beta afferents are large nonnoci—
ceptive, heavily myelinated touch receptors. However,
following central sensitization, input from these touch
receptors can result in the sensation of pain.
6. E. Currently, there is no objective measure of brain activ—
ity that can conclusively determine whether an individual
is in pain. However, fMRI and PET are able to provide
valuable information regarding the pathologic process—
ing of nociception and pain perception.
13. You are performing a neurologic sensory exam. The
patient shows normal sensation to light touch in the
distributions of the radial and median nerves and in-
creased sensitivity to pinprick. What most accurately
describes this phenomenon?
A. Allodynia
B. Hypesthesia
C. Paresthesia
D. Hyperalgesia
E. Secondary sensitization
14. Chronic pain conditions are consistently associated
with decreased activity in which brain structure(s)?
A. Prefrontal cortex
B. Thalamus
C. Reticular activating system
D. Pons
E. All of the above
15. Based on brain-imaging studies, which of the following
is implicated as a cause for the autonomic symptoms
experienced in cluster headaches?
A. Activation of the first (ophthalmic) division of the
trigeminal nerve
B. Activation of cranial parasympathetic outflow from
the seventh cranial nerve
C. Cortical spreading depression
D. Activation of the trigeminovascular system
E. Hyperemia in the occipital cortex
7. B. While the pain may be described as inflammatory
and/ or neuropathic as well, the patient is clearly expe—
riencing an abnormal response to mechanical light
touch. This would be described as tactile allodynia, an
experience where a typically innocuous sensation such
as light touch becomes painful.
8. E. Neuromas are sensitive to multiple sensations and
generate spontaneous ectopic activity from both A and
C fibers. Noradrenergic sensitization can result in cou-
pling of sympathetic and sensory inputs.
9. B. In sensitization, opioid receptors are down—regulated
with neuropathic pain, though C) up—regulated with
inflammatory pain; A) there is an increased release of
excitatory neurotransmitters; D) KCl receptor down-
regulation decreases the effects of GABA release; E)
these peptides open the NMDA channel, leading to
increased sensitization.
10. B. Traditionally, pain perception consists of the following
dimensions: sensory-discriminative, cognitive-evaluative,
and affective-motivational. The cognitive-evaluative di—
mension includes previous experiences and cognitive
influences on perception of pain intensity and, tradi-
tionally, the prefrontal cortex is thought to be involved
in this dimension. Note: Neuroimaging studies have
assessed paradigms that do not easily fit into these
three traditional dimensions and tend to discuss

cortical areas and brain regions involved in specific
functions instead.
ll. B. The placebo response involves the endogenous opi-
oid system and can be blocked by naloxone. Studies
have shown a correspondence between placebo anal-
gesia and reward pathways. The PAG and amygdala are
involved, as well as the prefrontal/rostral ACC.
12. D. A unique set of neurochemical changes occur at the
level of the spinal cord and dorsal root ganglion for
each type of pain: inflammatory, neuropathic, or cancer
pain. The greatest change in metastatic bone cancer
pain is activation of astrocytes at the spinal cord.
13. D. Hyperalgesia describes the abnormally increased
response to pain for a stimulus that would typically cause
pain, but not to the extent observed. A) Allodynia de-
scribes a painful response to a normally nonnoxious
stimulus such as light touch. B) Hypesthesia describes
diminished sensation. C) Paresthesia describes abnormal
CHAPTER 10 — Pain and Brain Changes 17
sensation. E) Secondary sensitization is enhanced sensa-
tion at sites distant from the site of injury.
14. B. Clinical brain imaging studies show reduced activ-
ity in and transmission through the thalamus for
chronic clinical pain (as opposed to experimentally
induced acute pain). There is, however, increased ac-
tivity in the prefrontal cortex in chronic pain. These
changes support the idea that chronic pain condi—
tions are associated with increased involvement of
brain regions for cognition and emotion. Meanwhile,
the sensory and nociceptive regions of the brain (thala-
mus) show decreased activity. There is also a reduc-
tion in neocortical gray matter.
15. B. Activation of cranial parasympathetic outflow from
cranial nerve VII is thought to result in the autonomic
symptoms in cluster headaches. A) Activation of V1 is
thought to mediate the excruciating unilateral pain
in cluster headaches. Answer choices C—E apply to
migraine headaches.
 An Introduction to
Pharmacogenetics In Pain
Management: Knowledge of
How Pharmacogenomics May
Affect Clinical Care

QUESTIONS
1. Polymorphism of an enzyme involved in tetrahydrobiop- C. Codeine
terin (BH4) synthesis in primary sensory neurons of the D. Oxycodone
dorsal root ganglion following nerve injury results in E. Hydrocodone
which of the following?
A. Increased sensitivity to painful stimuli . Analgesics that require breakdown in the liver through
B. Reduced sensitivity to painful stimuli CYP45O to achieve analgesic effects are metabolized by
C. Increased sensitivity to analgesic medications which of the following?
D. Reduced sensitivity to analgesic medications A. CYP1A2
E. Reduced ability to heal following injury B. CYP2D6
C. CYP2C9
2. Which of the following phenotypes is consistent with D. CYP2C19
either multiple copies of a functional allele or an allele E. CYP3A4
with increased gene transcription?
A. Nonmetabolizer . Which of the following is the name for a field of medi-
B. Poor metabolizer cine that includes a patient’s genetic background and
C. Intermediate metabolizer uses the information to predict how a patient will
D. Extensive metabolizer respond in terms of efficacy and side effects when
E. Ultra-rapid metabolizer given a medication?
A. Pharmacognosy
3. A patient with known mutation in the CYP450 enzyme B. Pharmacokinetics
requires analgesic medication. Which of the following C. Pharmacogenomics
are NOT metabolized through this system at standard D. Genesiology
prescribed doses? E. Pharmacodynamics
A. Hydromorphone
B. Tramadol

ANSWERS
1. B. Patients with increased pain tolerance are thought
to have a polymorphism (a genetic variant) in GTP cy-
clohydrolase, which is the rate-limiting enzyme involved
in tetrahydrobiopterin (BH4) synthesis. BH4 has been
shown to be involved in regulation of inflammatory and
neuropathic pain. It is estimated that this polymor-
phism is associated with increased pain tolerance and is
present in 15% of the population. Similarly, reduced
pain tolerance has been linked to polymorphisms in
other genes. Different responses to analgesics among
patients can be attributed to genetic variance as well.
2. E. Classification of phenotypes for enzymes includes the
following:
0 Poor metabolizers: Two nonfunctional enzyme alleles.
0 Intermediate metabolizers: At least one reduced
functional allele.
0 Extensive metabolizers: At least one functional allele.
0 Ultra-rapid metabolizers: Multiple copies of a func-
tional allele or an allele with a promoter mutation
that confers increased transcription of that gene.
Phenotype variations can be responsible for the vast
difference in clinical effect as well as side effects

18
CHAPTER 1 l — An Introduction to Pharmacogenetics in Pain Management: Knowledge of How Pharmacogenomics May AtfectCIinical Care
between two patients taking the same weight-based
dosage of medication.
3. A. Although 40%—50% of medications are metabolized
in the liver through the CYP450 family of enzymes,
three opioids are not, including hydromorphone,
morphine, and oxymorphone.
. B. Analgesics that are metabolized by CYP450 include
codeine, dextromethorphan, oxycodone, and tramadol.
Prodrugs require CYP2D6 for conversion to the active
19
form, for example conversion of codeine to the active
metabolite morphine.
. C. By preemptively identifying patients at risk for ad-
verse side effects or poor efficacy from medication, the
field of pharmacogenomics may improve health care
outcomes and efficiency, including higher success rate
after medication administration, lower incidence of side
effects, and reduction of cost. As a relatively new field, it
shows promise in terms of tailoring medication regi-
mens to each patient.
 2 Psychosocial Aspects
of Chronic Pain

QUESTIONS
1. Chronic pain is best understood using which of the C. Positive reinforcement
following models? D. Both A and B
A. Biomedical E. All of the above
B. Biopsychosocial
C. Psychogenic . What is an exaggerated negative orientation toward
D. Secondary-gain actual or anticipated pain experiences?
E. Both A and C A. Self-efficacy
B. Fear avoidance
. In regards to psychological factors that play an important C. Pain catastrophizing
role in the experience of pain, which of the following is D. Anxiety
an affective factor rather than a cognitive factor? E. Negative reinforcement
A. Anger
B. Catastrophic thinking 6. Your patient had significant pain following his physical
C. Beliefs about pain therapy sessions, and now every time he drives by the
D. Self-efficacy facility he becomes tense and his back pain increases in
E. Coping severity. This is considered:
A. Classical conditioning
3. All of the following are examples of passive coping strat- B. Operant conditioning
egies EXCEPT: C. Negative reinforcement
A. Inactivity D. Punishment
B. Distraction E. Fear avoidance
C. Medications
D. Alcohol . According to one study, the target of a patient’s anger
E. Avoidance was most commonly acknowledged to be the:
A. Health care worker
4. According to the operant conditioning principles of re- B. Attorney
inforcement, the following response to a specific behav- C. Insurance company
ior will likely decrease the probability of the behavior D. Patient themselves
recurring: E. Significant other
A. Neglect
B. Negative reinforcement

A NSWE RS

1. B. In chronic pain, there may or may not be an identifi—
able pathologic process or organic cause. Pain can also
take a significant emotional toll on the patient leading
to feelings of demoralization, helplessness, hopeless-
ness, depression, and anxiety, to name a few. Since peo-
ple rarely live in complete isolation, there is a larger
social context that impacts and influences a person’s
chronic pain. Given the multidimensional nature of
chronic pain, a biopsychosocial approach is best used
to understand this condition. This model focuses on the
illness as a whole, which is the result of a complex inter-
action of biologic, psychological, and social variables.
Both the patient’s perception of his/her pain, as well as
the response to the illness and treatments, can be
understood more completely by using this model.
2. A. Affective factors are emotions, and in chronic pain,
they are mainly negative emotions such as depression,
anxiety, and even anger. The other factors listed are
cognitive factors, which are involved in how someone
thinks, perceives, and reasons. Catastrophic thinking is
defined as an exaggerated negative orientation toward
actual or anticipated pain experiences. It can also be
described as a set of maladaptive beliefs. Beliefs about
the meaning of pain influence a person’s expectations
about pain and can be either positive or negative.

2O
Another random document with
no related content on Scribd:
Worora, known vernacularly as “wirrauwa,” is beyond doubt an
indigenous evolution. It is much like a bushman’s billycan in shape—
a cylindrical vessel closed at one end and with a handle at the other,
measuring from four to twelve inches in height, and from six to nine
inches in width. A circular piece of woolly-butt bark is cut for the
base, and this is surrounded by another sheet which forms the
cylinder. The joints are carefully stitched together with threads of split
cane, using a bone-awl to prick the holes; then melted resin from the
eucalyptus tree is applied over the seam to render it water-tight. The
edge of the open mouth may be strengthened by cross-stitching and
applying resin. The handle is made of human hair-string, several
pieces of which are threaded diametrically across the open end of
the bucket, through holes previously made with a bone-awl, and tied.
The outer surfaces of the vessel are often painted. The usual device
consists of alternate bars of red and white or red and black, joined at
the top and bottom by horizontal lines of red; occasionally the whole
surface may be splashed or daubed with white, or the above designs
may be embellished with regularly spaced dots and “emu tracks.”
Lastly we shall briefly refer to the skin water-bag which is used (or
has been used) by the desert tribes of central Australia, from central
Western Australia to Western Queensland. A kangaroo, wallaby,
euro, or dingo is killed and the animal’s skin removed almost in toto
by making a circular cut around its neck, and, whilst one or two men
hold on to the head, others detach the skin from the carcase and pull
it off inside-out. The neck-hole forms the mouth of the bag, but all the
other openings are tied, stitched, or pinned together. The limbs are
cut off near the paws, the tail near its root, and the resulting holes
securely tied with string. The limb-pieces are tied together and act as
straps to assist the native carrying the bag when filled with water.
To fill these vessels with water, bailers are available either in the
form of specially constructed or of naturally occurring objects; no
matter which they are, they usually also answer the purpose of
drinking cups. Along the north coast of Australia the large melon
shell is perhaps the handiest; it is either used as it is found or its
inner whorls and columella are broken away, leaving just the
spacious outer shell to hold the water like a bowl. The same remarks
apply to the large Fusus pricei, and other molluscs.
The Narrinyerri and other tribes south of Adelaide used human
calvaria as drinking vessels. The facial skeleton of a complete skull
was broken away so as only to leave the brain-box; and this held the
water.
The broken shells of the large boabab nuts are similarly used in
the Northern Kimberleys of Western Australia, and now and then the
broken shell of the emu egg also makes a very serviceable cup.
A miniature bark-cooleman is constructed by the Wongapitcha,
Aluridja, and Arunndta tribes, like that described on page 92, about
eight inches long and half as wide, which serves the purpose of a
bailer, drinking-vessel, fire-shovel, and special food-carrier. It is
strongly convex lengthwise, and therefore comparatively deep.
The Bathurst Islanders tear or cut a piece of bark from a tree,
usually the ti-tree or “paper-bark,” out of which they fashion a cup.
The piece of bark measures about twelve inches in length, and eight
in width. It is first folded longitudinally at about its middle, and then
both ends of the doubled piece are folded transversely at about one-
quarter the whole length. The overturned parts of the inner sheet of
the first fold are clasped between the fingers on the inside and the
thumb on the outside, when the cup is ready for use.
The natural water supplies available over so vast an expanse of
territory as is embraced by the continent of Australia and its
subjacent islands, occur, as one might have expected, in great
variety. There is no need for us to consider such familiar supplies as
rivers, creeks, lakes, billabongs, waterholes, and springs; we shall
just briefly consider a few of the more uncommon cases, which are
of special interest. The native has a wonderful instinct for locating
hidden supplies of water; and many a European wanderer has
perished in the Australian bush, within a stone’s throw of the life-
saving fluid, all for the want of that gift, which to the primitive
inhabitant of the desert central regions means his very existence.
 Along the superficially dry, sandy beds of “rivers” in arid Australia,
he is able to pick sites, at which, by shallow digging with his hands
and yam-stick, he can in quick time produce a “native well,” sufficient
to supply the needs of all the camp. The water is often exposed
within a foot or two of the surface, but at times he has to dig to a
depth of from five to six feet, which so far as my experience goes
seems to be the limit. When not in use, or when the camp moves on,
the natives always take care to cover the mouth of the well in order
that wild animals cannot reach the water and pollute it. When the
well is deep, its sides are made secure with pieces of timber and
brushwood, and cross-pieces are left to serve as a ladder whereby
the native can attain the water. Similar wells are constructed in the
catchment basins adjacent to the hills.

PLATE XII

Juvenile Types.

1. Full-face, female, Wongkanguru tribe.

 2. Profile, female, Aluridja tribe.

Rock-holes in granite (Musgrave Ranges), quartzite (Krichauff

Ranges), or limestone (Nullarbor Plains) are favoured on account of
the cool, clear water which they generally contain. Where such are of
a cavernous nature, and opening from a bare inclined surface, the
natives often build a small bank of clay across the slope to direct the
flow of water, resulting from a downpour, towards the hole. A unique
variety of this type was discovered by us at Ullbönnalenna, east of
the Musgrave Ranges. Through a hole in the barren slope of gneiss,
a communication has been established by atmospheric denudation
with a small reservoir below. To obtain the water contained in it, the
natives keep a broom-shaped piston handy, with which they pump
the fluid to the surface, as required. The piston is merely a rod, about
five feet long, round one end of which a bundle of brushwood is
securely tied with string. The size of the brushwood bundle is such
that it exactly fits the hole in the rock (about six inches). The
implement is inserted, brushwood foremost, and slowly pushed down
into the water, and, after a short interval, quickly withdrawn again.
The water, which had collected behind this “piston-head,” is thereby
forcibly ejected, and is collected inside a small enclosure of clay built
around the hole.
The aborigines are most particular about preserving their water
supplies against pollution, especially where such is brought about by
excremental and decaying animal matter. In the Musgrave Ranges,
the natives did not in the slightest object to our camels being
watered at the supplies they were dependent upon, but when the
animals dirtied the rocks above the hole and there was a chance of
the discharge running into the water, they immediately set to and
built a barrier of earth to intercept the flow before it reached the hole.
In the Northern Kimberleys of Western Australia valuable pools of
water collect upon the boabab trees. The branches of this species
surround the “gouty” stem in a circle at the top, like the heads of a
hydra, and by this means form a concavity between them, which is
capable of storing a considerable volume of cool, clear rain-water. To
reach this water, the natives construct ladders by simply driving a
series of pointed pegs into the soft bark of the tree one above the
other.
Certain desert trees like the Currajong have the property of
retaining considerable quantities of water in their tissues, even under
the worst conditions of drought, for periods of many weeks or
months. This water the native obtains by felling the tree and setting
fire to the crown; the water oozes out from the cut trunk and is
collected in bark carriers. The “Bloodwood” (Eucalyptus corymbosa)
has similar properties.
In the Denial Bay district a remarkable mallee (Eucalyptus
dumosa) grows, whose roots supply the natives with water. This
mallee is a rather big tree, which lives in association with other
smaller species of the same genus. It appears, also, that not every
specimen of the particular species referred to contains water; it
requires the experience of an aboriginal to predict which of the trees
is likely to carry such. Having selected his tree, the native proceeds
to expose one of the lateral roots, which grow in the sand at no great
depth from the surface. The root is then cut in two places, three or
four feet apart, and lifted from the ground in a horizontal position;
finally it is turned on end over a bark cooleman, when water, clear as
crystal, begins to drip from the lower end into the vessel. Sufficient
water can thus be collected to sustain the camp, if need be, for even
a longish period.
Other trees in central Australia are known to possess similar
properties though to a lesser extent, as for instance the Needle-Bush
(Hakea lorea, var. suberea).
When, after a good day’s march, the natives have the luck to strike
a big waterhole, each of the party immediately quenches his thirst by
literally “filling up” on the spot. Different methods are adopted to
accomplish this. Some prefer to remain prone at the water’s edge,
whilst others wade into the deeper parts of the hole, and, placing
their hands upon their knees, stoop and drink off the surface.
The Cambridge Gulf tribes pull a long-stalked leaf of the water-lily,
which, after they have cut it at top and bottom, acts like a tube and
permits them to suck the cooler fluid from a depth.
 After quenching his thirst, a native will on a hot day often cool his
system by pouring water on to his head. The women-folk and
children are very fond of splashing the head with cold water, which
they might do repeatedly during the day, provided the opportunity is
afforded. Bathing during the heat of the day is also commonly
enjoyed by all the northern tribes, especially those resident in the
tropics where water is abundant.
 CHAPTER XIII
CAMP LIFE

Preparation of camping ground—The bed and its coverings—Sleeping order—

Brushwood shelters—Various habitations—Vermin-proof platforms—Common
position during sleep—Friendly meetings and salutations—Sitting postures—
Sense of Modesty—Bird-like attitude—Gins procure firewood—The campfire
—Methods of cooking—Fire-shovels—Fire-stick—Fire-whisk—Fire-saw—
Women the recognized transport agents—Care of weapons—Sundry
occupations while in camp—Absence of wearing apparel—Pubic coverings—
Cosmetics—Hair-belts—Pristine philosophy—Removing thorns—The
aboriginal loves his dog—The dingo.

Having arrived at the chosen camp-site, each family group at once

busies itself clearing a patch of ground of any obstacles, like stones
and lumps of earth, the biggest of which are picked up by hand or
crushed by foot, the smaller brushed aside with the sides of the feet.
In addition, the women may be told to sweep the ground with
branches to clear it of grass-seeds and burrs. Should it be that the
spot is only reached after dusk, the natives set fire to one or two dry
bushes, the glare of which supplies them with the necessary light.
Each adult scoops a “bed” for himself on the sand, and lights a
small fire on one or both sides of it.
The northern coastal tribes very often spread sheets of paper-bark
over the sand, and they might also cover their bodies with similar
material. Should the mosquitoes become a great nuisance, one often
sees them completely covered with sand.
The south-eastern tribes of Australia, including those of the River
Murray and Adelaide Plains, used skins and rugs made of kangaroo
and opossum skins, neatly sewn together, to lie upon and under.
 PLATE XIII

1. The game of “gorri,” Humbert River, Northern Territory.

2. A “Kutturu” duel, Aluridja tribe.

 The children sleep with or close to their parents. When an
aboriginal has more wives than one, his camp is subdivided
according to their number, and he sleeps with his favourite.
The strangest conditions reign on Groote Island in the Gulf of
Carpentaria, where the women practically live apart from the men
during the whole of the day, and only come into camp after sundown
to deliver the food supplies they have collected over day. When on
the march, every adult female carries two big sheets of paper-bark
with her, which she holds with her hands, one in front and another
behind her person. Whenever a stranger approaches, they duck
behind these sheets of bark, as into a box, for cover.
No matter when or where an aboriginal camps, he constructs a
brushwood shelter or windbreak at the head-end of his resting place.
This consists of a few branches or tussocks stuck in the ground or
piled against any bush, which might be growing upon the patch of
ground selected. Under ordinary circumstances, this is the only
shelter erected.
Even under the best of conditions, the night’s rest of an aboriginal
is hard, and at times very cold and wet. It is not an uncommon
experience for a person to sit up part of the night, hugging a fire, and
when the sun is up to lie in its warmth to make good the sleep lost.
During a run of wet weather or when the camp is to be of a more
permanent nature, different kinds of structures are erected, or
already existing habitations selected, which will afford a better
shelter than the crude structures referred to.
Natural caves or shelters beneath a sloping wall of rock, although
frequently chosen as a mid-day camp, are not favoured on account
of the superstitious dread of the evil spirit, whose haunts are
supposed to be in the rocks. Caves are in any case only occupied
during the heat of summer, the rocks being considered too cold to sit
and lie upon in winter. If possible, a tribe will always make for the
sandhill country in the winter, the sand making a very much softer
and warmer bed. Such caves as are regularly occupied almost
invariably have the walls and ceiling decorated with ochre drawings.
 The opportunity of camping under large hollow tree-trunks, when
available, is never neglected in wet weather. In the southern districts,
as for instance the Adelaide Plains and along the River Murray, the
large red-gums, especially such as have been partly destroyed by a
passing bush-fire, supply the best covers of this description, whilst
on the north coast of Australia the boabab occasionally becomes
hollow in a like way, and makes a very snug and roomy camp.
Huts are constructed after different patterns according to the
materials available. In the Musgrave Ranges, as in most parts of
central Australia, the usual plan is to ram an uprooted dry trunk of
mulga into the sand in an inverted position, so that the horizontal
root system rests at the top, generally about five feet from the
ground. Making this the central supporting column, branches of
mulga and other bushes are placed in a slanting position against it,
so that they rest between the roots at the top and form a more or
less complete circle at the base, measuring some eight or nine feet
in diameter. An opening is left, away from the weather-side, large
enough to permit of free access. The spaces and gaps between the
branches are filled with small bushes, tussocks, and grass, and on
top of it all sand is thrown.
Very often the branches are placed around a standing tree for a
central support, and now and again they are simply made to rest
against one another in the required conical fashion.
Roof-like shelters are made by piling branches and brushwood
either upon the overhanging branches of a tree or across two bushes
which happen to be standing close together.
On Cooper’s Creek, in the extreme south-western districts of
Queensland, these huts are more carefully constructed. A solid,
almost hemispherical framework is erected consisting of stout curved
posts, with a prong at one end, so placed that the prongs interlock
on top and the opposite ends stand embedded in the sand in a
circle. Vide Plate XV, 1. The structure is covered with the long reeds
that abound along the banks of the large waterholes of the Cooper.
Some of the huts are indeed so neatly thatched that they have quite
a presentable appearance.
 The eastern Arunndta groups, in the Arltunga district, cover a light
framework of mulga stakes, erected after the general central
Australian pattern, entirely with porcupine grass (Plate XV, 2).
At Crown Point, on the Finke River, other groups of the same tribe
cover their huts with branches and leaves of the Red Gum.
When camped on the great stony plains or “gibbers” of central
Australia, it is often very difficult to find a suitable covering for the
huts, the vegetation being either unsuitable or too scanty. On that
account the Yauroworka in the extreme north-east of South Australia
utilize the flat slabs and stones which abound in that locality to deck
their more permanent domiciles with. The supporting structure must,
of course, be made particularly strong to carry the weight of the
stones. The crevices between the stones are filled with clay to
render them water-tight, and earth is banked up against the base of
the walls both inside and outside.
Along the north coast of Australia, from the Victoria River to Cape
York, the prevalent type of hut is a half-dome structure, whose frame
consists of a series of parallel hoops, stuck into the ground and held
in position by a number of flexible sticks tied at right angles to the
former with shreds of Hybiscus bark. The ends of the cross-pieces
are poked into the ground on that side of the framework which will be
opposite the entrance of the hut when completed. The hoops are
made of slightly decreasing size from the entrance towards the back,
and so correspond in height with the upward curve of the cross-
pieces. This skeleton-frame is covered with sheets of “paper-bark”
(Melaleuca) and grass; and the floor of the interior is carpeted with
similar material; a small space is however left uncovered to hold the
fire. Such a hut measures about five feet by five feet at the base, and
is four feet high. In Queensland palm leaves may take the place of
the paper-bark sheets.
In districts where the mosquitoes are very troublesome, the dome
is completed by erecting hoops on the open side as well, and making
the cross-switches long enough to be lashed to them all and to be
stuck into the sand at both ends. The whole structure is covered with
bark, but three or four small holes are left along the base for the
people to slip in by; and a ventilation-hole is left at the top of the
dome to allow the smoke to escape from the fire, which is burned
inside to keep out the insects.
Provisional rain-shelters are made by cutting a big sheet of bark
from one of the eucalypts, usually the “stringy bark.” To do this the
bark is chopped through circumferentially on the butt in two places,
about seven or eight feet apart, slit vertically between the two
incisions, and removed by levering it off with two chisel-pointed rods.
The sheet is folded transversely at its centre and stood upon the
sand like a tent.
At times the sheet of bark is simply laid length-wise against two or
three sticks previously stuck into the ground. In the more durable
structures of this type, two forked poles are rammed into the ground
so that they can carry a horizontal piece after the fashion of a ridge-
pole of a tent. Against the latter then are stood several sheets of
bark at an angle of about forty-five degrees.
Occasionally a scaffold is erected with four poles and cross-pieces
at the corners of an oblong space, and sheets of bark are then laid
across the top. The sheets are of sufficient length to hang over the
sides of the frame so that their weight bends them into an arch along
the centre.
Commander Lort Stokes found similar structures near Roebuck
Bay in the north of Western Australia, but in place of the bark they
there had a slight, rudely-thatched covering.
In districts where thieving dogs, ants, or other vermin become
troublesome, the men construct platform-larders, upon which any
reserve supplies of meat are laid. Hawks are the greatest nuisance
in camp. It is astonishing with what fearlessness such birds fly right
into camp and swoop the meat from the natives. As a protection
against theft of this description, the campers cover their stores with
branches.
The position favoured during sleep is to lie upon one side, with the
legs drawn up towards the stomach and bent in the knees. The head
rests upon one or both hands; should one hand not be so occupied,
it is usually placed between the closed thighs. At Delamere in the
Victoria River country, the natives were observed to have convex
pieces of bark in their possession which were used as head-rests
during the night.
It goes without saying, of course, that the aboriginal might at any
time change his position during sleep to one of the many commonly
adopted by European or other people.
During the warm summer months, the campers are up with the
first glimpse of dawn, but when the nights become cold, they often
remain huddled by the fires until the sun is high up in the sky.
When a messenger or visitor approaches a camp at night, he will
not do so without announcing his arrival in advance by loudly calling
from afar to the groups at the fireside. Should a person be
discovered prowling the surroundings of a camp, without having
heralded his coming, he runs grave risk of being speared, on the
chance that he be on no good business.
In the way of salutations, hand-shaking and kissing are unknown,
but when two friends meet it is quite the usual thing for them to walk
together for a while, hand-in-hand. When a person, who has been
long absent, returns to camp, everybody is so overcome with joy that
he starts crying aloud as if his joy were grief.
On the occasion of friendly Arunndta groups visiting, all members
of both parties, male and female, approach each other with their
spears, boomerangs, shields, and fighting sticks. The visitors first sit
down in a body while the others walk around them, in a widening
course, flourishing their weapons high in the air and shrieking with
joy; later they return the civilities by acting similarly.
When seating himself, an aboriginal always prefers the natural
surface of the ground to any artificial or natural object, which might
serve him in a manner suggestive of a chair. Rocks and fallen tree-
trunks might occasionally be used, and children are sometimes seen
sitting upon the lowest big branches of trees, especially if they slope
downwards to the ground. But even in these cases they rarely allow
the legs to dangle, preferring to draw them, bent in the knee, close
against the body, and usually with the arms thrown around the legs
or resting upon the knees.
The men use the same method, when squatting at ease upon the
ground, keeping their thighs apart, heels touching and close against
the buttocks, with their elbows resting upon their knees and their
hands usually joined in front. When the hands are to be used, the
sitter acquires greater stability by placing the feet further apart and
swinging the arms over the knees.
Another common posture is to double the shins under the thighs
and rest them half-laterally upon the ground. This method is
frequently combined with the previously mentioned by holding one
leg one way and the other the other.
From either of these positions, the sitter may change by tucking
the shins well under the thighs and rolling on to the side of one of his
thighs.
Again, he may change by simply stretching his legs forward full
length.
These methods are made use of by men, women, and children
alike. Unless it be that the person prefers his legs to remain in close
apposition, whilst squatting in any of the positions indicated, he will
endeavour to hide his shame behind one of his feet. This is
particularly characteristic of the women, and their natural sense of
decency is prettily described in the narration of the voyage in search
of La Perouse as follows: “Though for the most part they are entirely
naked, it appears to be a point of decorum with these ladies, as they
sit with their knees asunder, to cover with one foot what modesty
bids them conceal in that situation.”
By their method of standing at ease on one leg, the natives of
Australia have evolved a remarkable posture which reminds one of
birds. In this position, a man rests the sole of his unoccupied foot
against the knee of the standing leg, and usually props his body with
a spear-thrower (Plate XVI, 2).
Strictly speaking, it is the duty of the women to gather firewood,
although very often, when there is a supply close at hand, the men
will also drag a few logs to the family camp. The women, on the
other hand, are required to collect sufficient to keep the fire going,
during the day for cooking purposes and during the night for warming
and lighting purposes. At times this entails weary searching and
long-distance marching. We have already referred to the way they lift
the pieces of wood from the ground, between the toes of one foot, to
the hand on the opposite side, by passing the piece behind the body;
the same hand next stacks the wood upon the head, where the other
holds and steadies it. By this method, the gin has no need to stoop,
and can in consequence build up astonishingly high piles of wood
upon her head (Plate XVII). A small pad is usually first laid upon the
head to prevent the scalp from chafing and the wood from slipping.
Arrived at the camp, a gin throws her load to the ground and breaks
the longer pieces across her head with her hands.
A native’s idea of a good fire is to keep it as small as possible, but,
at the same time, to derive a cheerful glow from it. His opinion of the
European traveller’s camp-fire is that it is so ridiculously big that one
cannot lie near to it, without being scorched. In the winter the native
often selects a large dry log if available and keeps this aglow at one
end throughout the night; in the absence of such a log, he will at
frequent intervals find it necessary to attend to his fire during the cold
hours of the night. So diligently, indeed, does he nurse his fire that
his eyes often become inflamed in consequence of the continued
irritation by smoke when he fans a smouldering flame with his
breath.
A small fire like this, especially when it has burned for some time,
is quite sufficient to cook all the smaller articles, which constitute the
daily bill of fare, as for instance roots, tree-grubs, and lizards.
When, however, big game like a kangaroo is to be prepared, larger
fires are essential and special culinary rules observed. A method,
which has been in use practically everywhere in Australia, and is still
found in use among the uncontaminated tribes, is to burn a big fire
for a while upon a sandy patch, and then to lay a number of flat
stones upon the red-hot coals and cover everything with sand. After
a while the sand is scraped aside and the oven is ready for use. In
the Northern Territory the stones are substituted by brick-like lumps
broken off one of the tall termite-hills, which abound in that country.
In south-eastern Australia and along the River Murray the stones
selected are usually composed of travertine or limestone.
In the Musgrave Ranges oven-stones are not in use, the game
being simply laid upon, and covered with, hot ashes and sand.
“Big” cooking is done by the men, whilst the women are required
to attend to the preparation of all smaller articles like yams, grubs,
and seeds.

PLATE XIV

1. Arunndta boy practising with toy shield and boomerang.

2. Wordaman warrior, holding prevalent north-western type of spear-thrower and

wearing pubic fur tassel.
 Slight variations are noticed in the method of cooking a kangaroo
according to the locality. In the Musgrave Ranges, the animal is
prepared whole. The skin is not detached, whilst the bony paws may,
or may not, be removed beforehand in order to secure the sinews,
which are used all over Australia for tying purposes in the
manufacture of their implements and weapons. The carcase is laid
upon its back and completely covered with hot ashes and sand, and
thus permitted to cook. When sufficiently, and that according to our
ideas often means only partly, cooked, the skin can easily be
removed. The belly of the baked carcase is cut open and the gut laid
aside. What remains is then pulled to pieces by hand and the
portions distributed among all members having a right to such. The
meat is tender and juicy when cooked this way. Even the intestines,
after their contents have been squeezed out by the aid of two
fingers, are eaten by the less privileged members of the tribe. The
Arunndta call the last-named dish “uttna kalkal.” Most of the bones, if
not crushed between the jaws, are shattered between two stones
and the marrow eaten.
The Wogait and other tribes on the north coast break the legs of
the animal and tie them together in pairs with shreds of Hybiscus
bark. The carcase is opened at one side to remove the entrails, and
an incision is also made into the anus to clear it. In the case of a
kangaroo, the tail is cut off and cooked separately in ashes. The skin
is not removed. When thus prepared, the animal is transferred to an
oven as described above and first covered with a piece or two of
“paper-bark,” then with hot sand and ashes.
In order that they may readily scoop out a fireplace, scrape the
sand to and from the roast, and handle the meat, vegetable, seed-
cake, or whatever the article in the oven might happen to be, the
Northern Kimberley tribes have invented a long wooden shovel. This
is a slightly hollowed blade, about three feet in length, four inches
wide at the lower end, and decreasing in width at the hand end. The
implement is mostly cut out of a sheet of eucalyptus bark.
The central tribes generally make use of a discarded or defective
boomerang, which seems to answer the purpose very well.
 Perhaps the most important article a native possesses is the fire-
stick. No matter where he might be, on the march or in camp, it is his
constant companion. Important as it is, the fire-stick is only a short
length of dry branch or bark, smouldering at one end. It is carried in
the hand with a waving motion, from one side to another. When
walking in the dark, this motion is brisker in order to keep alive
sufficient flame for lighting the way. A body of natives walking in this
way at night, in the customary Indian file, is indeed an imposing
sight. Directly a halt is made, a fire is lit, to cook the meals at day
and to supply warmth during sleep at night. When camp is left, a
fresh stick is taken from the fire and carried on to the next stopping
place.
In consequence of carrying the fire-stick too close to the body
during cold weather, most of the natives have peculiar, irregular
scars upon abdomen and chest which have been caused by burns.
The Wongapitcha call these marks “pika wairu.”
If by accident the fire should become extinguished, a fresh flame is
kindled by one of the methods depending upon the friction and heat
which are produced by rubbing two pieces of wood together. Two
methods are in use, all over Australia and the associated islands to
the north; the one is by means of the “fire-whisk,” the other by the
“fire-saw.”
In the first-mentioned case, two pieces of wood are used, usually a
flat basal piece, with a small circular hollow in its centre, and a long
cylindrical stick, rounded at one end. The native assumes a sitting
position with his legs slightly bent in the knees. He places the flat
piece of wood upon the ground and holds it securely beneath his
heels. The rounded point is now inserted into the small hollow, and,
holding the stick vertically between the flat palms of his hands, the
native briskly twirls it like a whisk (Plate XXII). The twirling action is,
however, not backwards and forwards, but in one direction only. After
a while, the wood dust that accumulates by the abrasion begins to
smoke, then smoulder. Suddenly the native throws his stick aside,
and quickly stooping over the smoking powder, gently blows upon it
whilst he adds a few blades of dry straw or other easily inflammable
material. When the smouldering dust has been coaxed into flame,
more straw and twigs are added, then larger pieces of wood, until
eventually a blazing fire results.
Often a small notch is cut at the side of the central hollow in order
that the smouldering powder might find its way down to a piece of
bark placed beneath the basal stick, and there, by the aid of gentle
blowing, ignite the dry grass, which was previously laid upon the
bark for that purpose.
Usually, during the process of twirling, a little fine sand is placed
upon the hollow to increase the friction. A curious practice was
observed among the Larrekiya at Port Darwin, which seems to be
opposed to the friction principle. When the fire-maker has, by careful
twirling, adjusted the point of the upright stick, so that it fits nicely
into the hole in the basal piece, he squeezes a quantity of grease
from the sebaceous glands of his nose, which he scrapes together
with his finger-nails and transfers in a lump to the ankle of his left
foot. Then he resumes the twirling, and, so soon as the stick begins
to smoke, he applies its hot end to the grease, which spreads itself
over the point. The stick having been thus lubricated, the process is
continued as before.
The central tribes, like the Dieri, Wongapitcha, and Aluridja,
usually make the basal piece short and flat, and wider than the
twirling stick. The Dieri select needlebush for the twirling stick, and
Hack’s Pea (Crotalaria) for the basal piece. The other tribes
mentioned combine the needlebush wood with that of a mulga root.
The northern tribes almost invariably employ two long sticks, one
of which has a rounded point at one end, the other a series of
shallow circular pits, into which the point of the twirling piece just
described fits when the implement is in use.
The Mulluk-Mulluk, Ponga-Ponga, and other tribes of the Daly
River district carry a number of these sticks about with them,
especially in the rainy season, when there is always a chance of the
fire-stick being extinguished by an unexpected tropical deluge. The
fire-making apparatus is carried in a receptacle, which consists of a
single segment of a bamboo, with a septum at the bottom. The sticks
are stuck into this cylindrical holder, which keeps them perfectly dry
even during a prolonged season of rain, after the fashion of arrows in
a quiver.
Fire-making implements are carried by the men, whilst the fire-
stick is, as often as not, carried by the women also. As we have
already seen in connection with the carriage of water, it is the
concern of the women to undertake the transport of the camp-
belongings from one site to another. When moving they pack
themselves with the domestic implements, collecting-vessels,
personal paraphernalia, and their infants, whilst their husbands
burden themselves only to the extent of a few spears, a spear-
thrower, and the fire-producing sticks just mentioned. The men
declare that it would be most unwise to be burdened with any
impediment themselves, while on the march, because at any
moment, and when least expected, they might be pounced upon by
an enemy, who would make good use of their unpreparedness. So
also, should game of any kind suddenly come into view, the men,
who are the recognized hunters, must always be ready for quick
action, or in a position to take up the chase immediately. Hence it
comes about that in the best interests of the tribe the women are
required to undertake the transport.