EDPM

a. The ESRA EDPM Examination. How to prepare:

What do you need to study?

ESRA EDPM is an exam aiming to assess clinical skills in pain medicine practice. The questions are, in the majority, based on clinical and procedural knowledge. However, since clinical knowledge is underpinned by a good understanding of basic sciences both parts of the exam will probe the candidate’s knowledge of anatomy, physiology and pharmacology and, on occasion, pain ethics and research trials.

Where can you find the information?

While textbooks are an invaluable source of knowledge, they often contain outdated information, particularly in areas where science and clinical practice advance at a rapid pace.
The best way to prepare for both parts of the examination is to read and digest recent review articles on specific pain conditions and pain mechanisms in general. Some examples of these are below:

• Goh EL, Chidambaram S, Ma D. Complex regional pain syndrome: a recent update. Burns Trauma. 2017;5:2.
• Lavand'homme P. Transition from acute to chronic pain after surgery. Pain. Apr 2017;158 Suppl 1:S50-S54.
• Farooq K, Williams P. Headache and chronic facial pain. Continuing Education in Anaesthesia Critical Care & Pain. 2008;8(4):138-142.

Other high-quality source of revision material is the IASP Clinical Updates publications or the British Journal of Anaesthesia CPD resources. See examples below

• Schug SA, Bruce J. Risk stratification for the development of chronic postsurgical pain. Pain Rep. Nov 2017;2(6):e627.
• Pain after Amputation. MJE Neil, FRCA FFPMRCA .BJA Education, Volume 16, Issue 3, March 2016, Pages 107–112, https://doi.org/10.1093/bjaed/mkv028.

b. The Multiple Choice or Part I EDPM Examination:

The MCQ exam will consist of 60 True false MCQ questions.

Below two examples of clinical and basic sciences questions.

Q1. A 32-year-old lady complains of a recent onset of severe neck and right shoulder pain her MR scan shows a right sided C6/7 disc protrusion with no nerve compression:

A. A right C6 nerve root block is clinically and ethically justified
B. A cervical interlaminar epidural is justified
C. A cervical X Ray is required
D. A cervical nerve root block should avoid the use of particulate steroids
E. Radiofrequency denervation of the right C5 dorsal root ganglion is an appropriate intervention

Answers:

A. False the symptoms are more consistent with a C5 root distribution and there is no evidence of nerve compression
B. False in the absence of nerve compression the risks are unjustified
C. False unlikely to provide further information
D. True
E. False

Q2. A-δ fibers:

A. Are myelinated
B. Are low-threshold mechanoreceptors
C. Increase their firing as the intensity of the stimulus increases
D. Do not respond to noxious stimuli
E. Are thick nerves

Answers:

A. True
B. False
C. True
D. False
E. False

c. The Viva or Part II EDPM Examination:

The Viva Exam consist of two five-part questions with the top question based on a clinical scenario and following questions on pathophysiology, pharmacology, pain procedures and a pain syndrome. Question heading cover different topics in order to give candidates whose practice may not expose them to particular area of practice a fair chance. Candidates are however expected to possess sufficient theoretical knowledge to enable them to attempt all five parts.

An example of a viva question is below for guidance.

Q1. A 67-year-old man is referred with bilateral foot and calf burning pains worse in bed at night. Pains are improved on sitting but worsened on walking. The pain stops him from walking more than 15 meters on the flat. You will be asked about the differential diagnosis.

What is your differential diagnosis?

A. Peripheral vascular disease or critical limb ischaemia
B. Night cramps
C. Neurogenic claudication (spinal stenosis)
D. Diabetic neuropathy
E. Arthritis of foot joints

On examination he has mottled feet with purple discolouration of the tips of several toes. He has a small ulcer on the side of the fifth toe foot pulses are absent bilaterally.

What is your diagnosis? What questions would you wish to ask the patient?

A. Critical Limb ischaemia.
B. Risk factors: hypertension, ischaemic heart disease, smoking, diabetes
C. Has he seen a vascular team?
D. Past treatment

The patient shows you a letter from vascular surgery explaining that he has a femoropopliteal graft 10 years ago and further surgery is not recommended. He is due to start oral warfarin. What treatment would you recommend?

A. Analgesia: (candidate needs to be able to classify and discuss analgesics with some guidance into) simple analgesics, moderate strength opioids, and adjuvants and strong opioids?

Of relevance is the interaction of analgesics with anticoagulants such as warfarin which are used commonly in this group (warfarin effects decrease with carbamazepine and increased by celecoxib, diclofenac, duloxetine, etodolac, meloxicam, naproxen, paracetamol, venlafaxine)

B. Address and correct risk factors, if possible.
C. Chemical Lumbar sympathectomy (role not well established and not evidence-based but practiced as palliation), risks include long term genitofemoral neuralgia
D. Spinal Cord Stimulation (some evidence-based data suggest improved pain control and limb salvage but RCT contradictory), Cochrane review suggests that Spinal Stimulation produces best results when guided by Transcutaneous PO2
E. Amputation with pre-emptive analgesia such as epidural infusion, sciatic perineural infusion and continuous spinal infusion.

• Discuss the pathophysiology of chronic post-surgery pain
• Discuss the indication, dosage and adverse effects of carbamazepine
• Describe a technique and indications for pudendal nerve block
• Compare and contrast addiction vs physiological dependence

Good Luck to all and see you in Thessaloniki!

On behalf of The EDPM Faculty