Back pain is the first in the structure of pain syndromes. According to experts of the World Health Organization (WHO), its prevalence in developed countries reaches 40-80%, and the annual incidence – 5%. This pathology is leading among the reasons for seeking medical help, temporary disability, disability, which has serious economic consequences for the patient as well as for society as a whole.
We present the section devoted to the treatment of back pain, clinical recommendations “Pain Syndrome: Pathogenesis, Clinic, Treatment” of the Russian Interregional Society for the Study of Pain (ML Kukushkin, GR Tabeeva, EV Podchufarova, edited by N. N. Yakhno, 2011).
Back pain can be classified by duration, localization, leading pathophysiological mechanism, taking part in its formation, its causes for causing it.
Pain lasting less than 6 weeks is considered acute, from 6 to 12 weeks – subacute and more than 12 weeks – chronic. Patients with acute, subacute and chronic back pain are differentiated by the prognosis for recovery and recovery of work capacity, as well as approaches to diagnosis and treatment.
Localization of pain, local, reflected and irradiating pain. Local pain can be associated with any pathological process that affects the pain receptors of the skin, muscles, tendons, ligaments, joints, bones and other tissues. It is usually constant, but it can change its intensity depending on the change in body position or movement. The pain is acute, blunt or aching, can have a diffuse character, but always is felt in the area of tissue damage. The cause of local back pain may be, for example, facet pain syndrome, in which patients describe pain in the lumbar region of the aching nature, localized in the projection of the affected joint. It should be noted that facet joint dysfunction can simultaneously be the cause of reflected pain. The cause of local pain may be a potentially dangerous disease of the spine, for example, a compression fracture of the vertebral body with osteoporosis or a tumor lesion.
Reflected pain extends in areas lying within dermatomes associated with innervation of damaged structures. Usually, it is projected into these zones from the internal organs, for example, with diseases of the pancreas, pathology of the gastrointestinal tract, retroperitoneal space, gynecological diseases (Heda-Zakharyin phenomenon).
In some cases, the cause of reflected pain in the spine may be vascular disease. For example, with an aneurysm of the abdominal aorta, there may be pain in the lumbar spine, which is not related to physical activity. Obliterating lesion of the upper gluteal artery can lead to pain in the gluteal region, which is intermittent and depends on the distance traveled by the patient, resembling a neurogenic intermittent claudication in the lumbar stenosis. The pain is not provoked by physical activity, which increases the load on the spine: slopes, lifting of gravity, etc.
Irradiating pain, more often radicular or neural, is characterized by high intensity, distal distribution to the corresponding dermatome and associated disorders of sensitivity, reflex and motor disorders. The mechanism of this pain consists in stretching, irritation, compression of the rootlet or somatic nerve. With radicular pain, its spread almost always occurs in the direction from the spine to any part of the limb. Coughing, sneezing, or exercising are characteristic factors that increase this pain.
Chronic back pain can be formed with the participation of three pathophysiological components: nociceptive, neuropathic and psychogenic. For example, pain syndrome with compression radiculopathy often has a mixed character. Neuropathic pain is associated with damage to the spine due to its compression, edema, ischemia, and the formation of intranural inflammation. Nociceptive component takes part in the formation of pain due to the activation of nociceptors in the damaged disc and surrounding tissues containing free nerve endings (primarily in the roots and dura mater), with the initiation of immune inflammation in response to disc damage, as well as inflammatory reaction associated with the direct action of enzymes contained in the disk on the surrounding tissue. In addition, patients with compression radiculopathy often develop reflex musculoskeletal disorders, for example, muscular-tonal syndromes (in response to a change in the motor stereotype or to immobilize the affected motor segment), which, if preserved for a long time, can themselves become additional sources of nociceptive pain impulses. Thus, pain syndrome with radiculopathy is mixed. At the same time, it is shown that in patients with chronic back pain in the absence of clear clinical signs of lesion of the roots, pain formally corresponding to the characteristics of the neuropathic pain syndrome can form. Using a special questionnaire for the diagnosis of neuropathic Paindetect pain and an evaluation scale of neuropathic symptoms and signs of the University of Leeds (LANSS), it was possible to identify signs of neuropathic pain in 37-54.7% of patients with chronic back pain. According to the Russian epidemiological study of the prevalence of neuropathic pain, the development of neuropathic pain syndrome as the main cause of pain in the lumbar spine was found in 34.74% of the respondents, neck pain in 11.90%, chest pain in 3.94% of cases.
Back pain is a symptom, not a nosological form. Therefore, when its classification is often used anatomotopographic terms that do not reflect the essence of the pathological process, and denote the area in which pain is localized. So, local pain in the neck is designated as “cervicalgia”, in the thoracic spine – “thoracalgia”, in the lumbosacral region – “lumbalgia”. For pain radiating from the cervical spine to the arm, the term “cervicobrahialgia” is used, in the occipital or other area of the head – “cervicocranium”, and pain that spreads from the lumbosacral region to the leg is called “lumbo-schiaalgia”. In the literature, these terms are understood, first of all, skeletal-muscular pain syndromes, i.e. states in which the sources of pain can be muscles, joints and ligaments. Pain associated with lesions of the cervical, thoracic, lumbar or sacral roots, described in the radiculopathy.
Analysis of complaints and anamnesis.
Despite the considerable variety of descriptions of pain by different patients, it is important to actively identify characteristics that allow us to assume the pathophysiological mechanism underlying the formation of the sensation of pain. Thus, the development of acute, clearly localized pain, rapidly regressing spontaneously or against the background of taking analgesics, not accompanied by a change in surface sensitivity, is characteristic of nociceptive pain syndromes associated with damage to the joints of the spine, ligamentous apparatus and muscles. The emergence of shooting, burning pain, irradiating in the limb and accompanied by a change in sensitivity, is typical for neuropathic pain syndrome associated with compression radiculopathy. In this case, even when the patient is questioned, it is often possible to identify the symptoms of sensitive disorders: allodynia, hyperpathy, paresthesia and dysesthesia.
The nociceptive component can play a leading role in the formation of a chronic pain syndrome, associated, for example, with joint damage (articular joints or sacroiliac articulations). Such pain is usually aching in nature, occurs or worsens with the load on the altered joints and short-term (for the duration of the drug) decreases after the introduction of the local anesthetic into the affected joint. In all cases, it is necessary to analyze the situation in which pain has arisen, the factors that enhance and weaken it, the features of the preceding exacerbations. Pain in the defeat of the internal organs (visceral pain) is often poorly localized, may be accompanied by nausea, changes in the color of the skin, excessive sweating, is of a spasmodic type, often radiating to the opposite half of the body.
The bizarre descriptions of pain, senestopathy allow one to suspect the presence of psychogenic pain syndrome, but its diagnosis is possible only on the basis of the complete exclusion of other causes of pain. It should be noted that pain in the lumbar spine without irradiation in the limb in a patient under the age of 50 years, in the absence of a malignant neoplasm in the anamnesis, clinical signs of systemic disease and neurological deficiency, with a probability of more than 99% is due to benign musculoskeletal disorders, for example, myofascial pain syndrome MFBS) or joint dysfunction. Nevertheless, even at the first examination of the patient it is important to identify symptoms indicating that back pain can be a symptom of a more serious, usually somatic, pathology. So, one should pay attention to the presence of fever, local soreness and an increase in the local temperature in the paravertebral area, which are characteristic for infectious lesions of the spine. His risk is also increased in patients receiving immunosuppressive therapy, intravenous (IV) infusions, who are HIV-infected and addicted. The presence of a tumor (primary or metastatic) can be indicated by an unreasonable decrease in body weight, a malignant neoplasm of any localization in the anamnesis, the preservation of pain at rest and at night, and the age of the patient over 50 years old. Compression fracture of the spine is more often observed in cases of injuries, with the use of corticosteroids and in patients older than 50 years. Spondyloarthritis can be suspected if there is concomitant uveitis and arthralgia (including anamnesis).
includes neurological, neuro-orthopedic and somatic examination. With pain in the back and extremities, a properly conducted clinical examination allows in most cases to identify the source or sources of pain, the pathogenesis of the pain syndrome, to presume or accurately determine the nature of the underlying pathological process.
When examining a patient, it is important to pay attention to changes in posture, posture, gait, the presence of contractures, deformities and asymmetry of the limbs. It is necessary to evaluate the configuration of the spinal column, the safety or changes in physiological kyphosis in the thoracic and lordosis in the cervical and lumbar spine, their change (strengthening or flattening), the presence of scoliosis in standing, sitting and lying. As guidelines, the position of the shoulder-blades, the angles of the shoulder blades, the awns, the crests of the iliac bones, the distortion of the Michaelis rhombus, the asymmetry of the gluteal folds, and the deformation of the joints are assessed.
When analyzing the gait, attention should be paid to its features, such as avoiding the transfer of body weight to the diseased leg, which shortens the time to rest on it (antalgic gait). To reduce the burden on the patient’s leg, a number of patients resort to the use of additional means of support – surrounding objects, walking stick, crutches.
With a neurological examination, it is necessary to clarify the presence and nature of motor disorders, sensitive and trophic disorders, and changes in tendon reflexes. When lesions of the lumbar and sacral roots, along with positive sensory disorders in the form of pain, paresthesia and dysesthesia, it is necessary to identify negative sensory symptoms (hypesthesia, anesthesia or dysesthesia of certain types of sensitivity: tactile, painful, temperature, vibrational or joint-muscular). Both sensitive, motor and vegetative disorders are localized in the innervation zone of the affected root. Signs of the neuropathic nature of the pain syndrome is a combination of positive (paresthesia, dysesthesia, hyperalgesia, allodynia) and negative symptoms (hypoesthesia, anesthesia). To identify hyperalgesia, which, depending on the type of stimulus that caused it, can be thermal, cold, mechanical and chemical, stimuli of the appropriate modality are used: gradual warming or cooling of the affected area, mechanical and chemical effects. Mechanical hyperalgesia is divided into hyperalgesia associated with brush irritation (“brush hyperalgesia”), needle hyperalgesia (both are combined with the term “dynamic hyperalgesia”) and static hyperalgesia caused by a slight blunt pressure.
The most frequent clinical sign of a neuropathic pain syndrome is sensory disorders in the form of hypesthesia and anesthesia of certain types of sensitivity: tactile, painful, temperature, vibrational or joint-muscular. The temperature sensitivity in the area of the corresponding dermatome is conveniently studied using a special cylinder with plastic and metal ends or tubes with warm and cold water. Pain sensitivity is examined by applying a light prick. The joint-muscular sensitivity is studied in the joints of terminal phalanges of fingers and toes. Assessment of the degree of disturbance of vibration sensitivity is performed using a graduated 128 Hz tuning fork on an 8-point scale on the protruding parts of the bone in the innervation zone of the affected root.
A number of scales can be used to assess the “neuropathic” component of back pain: a questionnaire for diagnosing neuropathic pain DN4, a Neuropathic Pain Scale (NPS) scale, a PainDETECT questionnaire, an evaluation scale of neuropathic symptoms and signs of the University of Leeds (Leeds Assessment of Neuropathic Symptoms and Signs – LANSS).
Motor disorders are more often represented by weakness and hypotrophy of muscles in the innervation zone of the affected roots. Muscle strength is estimated according to the following conventional scale: 0 – normal; 1 – reduced by 25% compared with the intact side; 2 – reduced to 50% (for example, the patient can not walk on the heels – for extensors of the feet, on the toes – for flexors); 3 – decrease by 75% (movements are possible only without resistance); 4 – a reduction of more than 75% (muscle strength does not overcome gravity – only downward and downward movements are possible); 5 points – plegy (impossibility of contraction of muscles innervated by the affected nerve).
Evaluation of tendon reflexes is performed separately for each limb. On the feet – Achilles and knees, on the hands – carporadial, as well as reflexes from the biceps and triceps muscles. When assessing vegetative and trophic disorders, it is necessary to pay attention to changes in color and turgor of the skin, the presence of hyperkeratosis, peeling, hypo and hypertrichosis, a change in the growth rate of the nails.
For the convenience of the examination it is necessary to know the so-called “indicator” muscles innervated by the corresponding roots, and the typical zones of the sensory disorders in the corresponding affected spine of the dermatomes.
It is extremely important to identify symptoms of damage to the caudal peduncle in patients with pain in the lumbar spine, which include sensitivity disorders (anesthesia) in the anogenital region and distal sections of the legs, peripheral paresis of the leg muscles, prolapse of achilles reflexes and pelvic disorders in the form of a lack of urge to urinate / defecation, retention or incontinence of urine and feces. For skeletal-muscular pain syndromes, there are no changes in the neurological status of the patient, but in some cases, the MSFE, when the strained muscle compresses the vascular bundle or nerve, there are paresthesias, less often – gipalgesia or hyperalgesia in the innervation zone of the corresponding nerve. Transient vegetative disorders can be noted in the form of puffiness and a non-rough change in the color of the skin in the distal parts of the limb. The non-anatomical distribution of sensory and motor disturbances reflects their psychogenic origin.
With nevorortopedic examination, palpation is determined by the soreness of the muscles, joints and ligament apparatus. With light palpation with a pressure of about 4 kg, you can identify multiple painful areas that are localized in different parts of the body – gender points characteristic of fibromyalgia. Trigger zones (TZ) – areas of local soreness in the form of a tight strand, located along the muscle fibers, revealed by palpation of the muscles, are characteristic of the MFBS. The common soreness of soft tissues, even with mild, superficial palpation, reflects the presence of psychological ill-being (inadequate pain behavior). It is also necessary to evaluate active and passive movements in the cervical, thoracic and lumbosacral spine. Normally, in the cervical spine, rotation is 80 °, lateral inclinations – 45 °, extension – 75 °, bending – 60 °. In the shoulder joint, the amplitude of movements in the sagittal plane is 180 ° (total flexion and extension).
With lumboschialgic syndromes, the determination of the angle of the straight leg lift (Laceg’s symptom) is of clinical importance. Compression radiculopathy is characterized by its limitation from 30 ° to 50 °, irradiation of pain from the lumbosacral region along the posterolateral surface of the foot to the toes of the foot and its strengthening with the rear folding of the foot and the inclination of the head forward. It should be noted that the positive symptom of Lasega should not be interpreted solely as a result of the tension of the rootlet or nerve trunks. The most common causes of its appearance is the stretching of the posterior group of hamstrings and gluteus muscles, especially if they have T3. In cases of pain in the buttocks and sacrum, which occurs when testing the Lasega symptom, the mechanism of its formation can be the stretching of the capsule of the blocked sacroiliac joint and the subsequent reflex tension of the muscles of the lumbosacral region.
A somatic examination is aimed at excluding visceral pathology as a cause of pain in the back and extremities. It includes the identification of causeless weight loss, fever, skin discoloration, palpation of the abdominal cavity and pelvis, auscultation of the heart and lungs. Patients with pain in the pelvic and sacral region should carry out a rectal examination to exclude gynecological or urological pathology. In all cases of suspicion of a visceral source of pain, it is necessary to refer the patient to a consultation with the appropriate specialist (urologist, proctologist, gynecologist, cardiologist).
Instrumental methods of examination.
After the clinical neurological and neurological examination to clarify the sources of pain impulses in a number of cases, it is necessary to conduct instrumental survey methods. With pain in the lumbar spine and extremities, visualization methods are of particular importance, the usefulness of which is determined by the duration of the pain syndrome, anamnestic features and the presence of changes in the neurological and somatic status of patients. In the overwhelming majority of cases, acute and chronic back pain is a benign condition, and most patients do not need additional instrumental examinations. However, the presence of severe neurological and somatic disorders may require an urgent paraclinical examination. For example, weakness in the leg muscles, decreased sensitivity in the anogenital area (saddle anesthesia), pelvic disorders indicate the presence of compression of the cauda equina roots and require immediate MRT or CT scan, followed by a neurosurgeon’s examination of the need for urgent surgical intervention. The absence of a link between pain and movement, its preservation at night, the presence of a malignant neoplasm in the anamnesis, HIV infection, the use of immunosuppressants, intravenous infusions, unconscionable weight loss, fever and nocturnal hyperhidrosis, and the age of a patient under 20 and over 50 require additional methods of research already at the first reference of the patient with the purpose of excluding, first of all, infectious and neoplastic lesions of the spine. In all these cases, a spine X-ray is necessary in the direct and lateral projection, a general analysis of blood and urine, and if there is a suspicion of osteomyelitis, an epidural abscess or a lesion of the cauda equina roots, a MRI of the lumbosacral spine. If it is necessary to clarify the state of bone structures after carrying out X-rays, scintigraphy is shown in a number of cases. If you suspect a malignant neoplasm of the prostate, you need to investigate the level of specific antigen of the prostate (PSA). In the presence of a trauma in a recent history (a fall from height, traffic accidents, etc.), as well as long-term use of corticosteroids and the age of patients older than 55 years, it is necessary to conduct a radiograph of the spine, and if its informativeness and duration of pain over 10 days are insufficient – scintigraphy or CT of the spine. All patients with acute pain syndrome lasting more than 1 month, as well as all patients with chronic back pain, are shown to perform a spine X-ray in the direct and lateral projections in order to exclude tumor lesion of the spine. In the presence of clinical symptoms of compression of rootlets or spinal cord and in other diagnostic doubtful cases, the MRI of the corresponding spine department is shown to clarify the state of the structures of the spinal canal and determine the further tactics of patient management. Table 3 shows the main markers of a potentially dangerous pathology in acute back pain and associated with their presence of the disease.
Acute skeletal-muscular pain.
The degree of evidence of the treatment method is a level 4 system where high-level evidence is consistent with the reproducible data of qualitatively conducted numerous randomized controlled trials, moderate – reproducible data from less qualitative multiple randomized controlled trials (mainly due to small patient samples), low – data from one randomized controlled research or conflicting data from numerous studies with the use of control groups, lack of evidence – studies conducted without comparison groups, theoretical assumptions, expert opinions. The optimal tactics of managing a patient with acute pain in the lumbosacral region, based on the principles of evidence-based medicine, boils down to several provisions: informing the patient; exclusion from bed rest; the appointment proved effective treatment; correction of treatment tactics with its inefficiency in the period of 4-12 weeks.
Rational information about the nature of the disease, its prognosis and treatment methods allows to correct misconceptions of the patient about back pain and to strengthen his active participation in rehabilitation programs. This aspect has been given more attention only in the last few years. It is shown that the “educational booklet” reduces the number of repeated calls to the general practitioner for back pain, and a 15-minute clarification by trained average medical personnel, accompanied by a demonstration of a booklet about pain and a subsequent phone call, leads to greater patient satisfaction with treatment. At the same time, the diagnosis of any specific pathology of the spine (“disc hernia”, “radiculopathy”) in the absence of clinical symptoms of compression of the lumbosacral roots or signs of serious pathology, conflicting opinions and advice of doctors increase psychological distress and misconceptions about the prognosis of the disease, leading to an increase painful behavior, the degree of disability and the deterioration of the prognosis for recovery. Informing the patient is based on a moderate level of evidence. The volume of information is usually limited to 3-5 key positions (good prognosis, absence of the need for radiography in the absence of serious pathology, connection of pain with muscles, ligaments, disc and joints, the need to maintain activity). It is desirable to provide a patient with a brief memo containing these statements.
To maintain the level of daily activity is the most frequent position of clinical recommendations from around the world in managing patients with acute back pain. With acute musculoskeletal pain, there is no need to comply with bed rest, even in the first days of the disease, wearing fixation belts, as well as using a pedestal when moving (walking stick or crutch). Currently, 6 systematic reviews and 10 randomized controlled trials are available on the effects of bed rest on acute pain in the lumbosacral region. With a high degree of evidence, bed rest should be excluded from the management of this group of patients. However, given that in a number of cases, high pain intensity can significantly limit the amount of daily activity, individual clinical recommendations (for example, from the UK) indicate that the patient can comply with bed rest, but he should be informed that the restriction of activity in this case is his own response to pain, not a method of treatment.
If there is a need for anesthesia, the patient should be prescribed medication at regular intervals (not on demand), with paracetamol and NSAIDs being the drugs of choice. All NSAIDs can be conventionally divided into groups, based on the primary effect on cyclooxygenase (COX) isoforms: COX1 and COX2. Most standard NSAIDs (diclofenac, ketoprofen, indomethacin, etc.) are classified as nonselective inhibitors of COX. The predominantly selective inhibitors of COX2 include nimesulide and meloxicam, with highly selective coxibes. The selectivity of drugs for COX2 provides a higher degree of safety in relation to the gastrointestinal tract (GI tract). The incidence of gastrointestinal side effects with non-selective COX inhibitors is about 10%, and the risk of serious adverse events increases significantly in the elderly. The least frequent side effects from the gastrointestinal tract in the treatment of nonselective NSAIDs are noted with the use of diclofenac and ibuprofen, which may be due to the more frequent administration of low doses of these drugs. In general, the advantage of any one NSAID before others in the treatment of acute pain in the back is not shown. Therefore, when choosing NSAIDs it is necessary to take into account the presence and nature of risk factors for adverse events, the presence of co-morbidities, the nature of interaction with other drugs and the cost. The maximum recommended time for the use of oral NSAIDs is 10-14 days.
Regarding paracetamol, there are currently two systematic reviews showing that it has no advantages with respect to the analgesic effect before NSAIDs. At the same time, the spectrum of side effects of this drug is well studied, and the risk of their development is relatively low. Therefore, in most clinical recommendations, it is referred to as a drug for the relief of back pain along with NSAIDs. When paracetamol is ineffective, the use of NSAIDs is recommended.
The efficacy of muscle relaxants in acute back pain is shown. According to modern clinical recommendations, muscle relaxants should be prescribed as a short course in the form of monotherapy or in addition to paracetamol and NSAIDs with insufficient effectiveness of the latter.
Concerning non-medicinal methods of treatment of acute pain in the back, it can be noted that manual therapy is recommended for patients who have not returned to the normal level of daily activity. At the same time, the majority of clinical recommendations, including the latest European ones, do not indicate the optimal timing of manual therapy. It is noted that this method of treatment is more effective than placebo, however, it has no advantages over other types of treatment (physiotherapy exercises, “school pain in the back”, taking analgesics). In general, spinal manipulations in patients with back pain musculoskeletal performed by qualified specialists are a safe method of treatment (the risk of development of the horse tail compression syndrome is less than 1 per million).
Modern clinical recommendations point out the inexpediency of prescribing special exercises for acute pain in the lumbosacral region. Multidisciplinary treatment programs are useful in working patients with subacute pain in the back and restriction of activity for more than 4-8 weeks. They usually include an educational program (“back pain school”), physical therapy, studying and, if possible, changing working conditions, behavioral psychotherapy. However, the contribution of each of these methods of influence can not be studied.
With acute pain in the back, ineffective traction of the spine, percutaneous electrical neurostimulation is proved. Due to the lack of evidence base in the treatment program for a patient with acute pain in the lumbar region, it is not advisable to include physiotherapy, wearing a warming belt, the use of psychotherapy, visiting a “school of back pain”, the appointment of a massage. There is a weak evidence of the effectiveness of acupuncture in acute pain in the lumbosacral region.
Thus, in the overwhelming majority of cases, acute back pain is a benign self-limiting condition, and most patients do not need additional instrumental examinations. Optimal is considered an active approach to treatment. If necessary, drug therapy, the drugs of choice are NSAIDs and paracetamol.
Patients who do not show improvement within 4 weeks of treatment need to be screened again for markers of clinically significant pathology, as well as identification of signs of psychosocial distress and correction of therapy taking into account the revealed violations.
Chronic pain in the back. A major problem is the treatment of patients with chronic (persisting for more than 3 months) pain syndrome. Within their framework, both radicular (eg, neurogenic intermittent claudication) and skeletal-muscular and psychogenic pain syndromes are noted. In all cases of chronic pain syndromes, it is necessary to try to reveal as much as possible the source of painful impulse using data from both a neurological and a neurological examination using diagnostic blockades. Proceeding from the different specific weight of the role of psychological factors and objective violations in each individual case of chronic pain syndrome, treatment of patients should be aimed at correction of both peripheral sources of pain and accompanying psychological disorders.
In the treatment of MFBS, an integrated approach is used. It includes the impact on all levels involved in the formation of a vicious circle of pain. This includes the effect on the muscle concerned and TK: its stretching, massage, exposure to heat or cold, percutaneous neurostimulation, electrostimulation and injections of botulinum toxin type A, the appointment of analgesics, antidepressants, muscle relaxants. The most effective are injections of local anesthetics in TK. Usually inject 0.5-1 ml of a 0.5% solution of novocaine. After injection, passive stretching of the muscle is performed. To relax the remaining tension of muscle fibers above the muscle and the area of reflected pain, it is advisable to spray the refrigerant (chloroethyl). Irrigation is carried out at a speed of about 10 cm / s, the direction of the jet is 30 ° to the surface of the skin. Other local methods of treatment include ischemic compression (strong and prolonged compression of the trigger point with your fingertips for 1 minute with a gradual increase in the pressure force to 10-13 kg, leading to its inactivation), massage, ultrasound application (in continuous or pulsed mode with intensity 0 , 2-0.5 W / cm2 around the TK). An important place is occupied by applications on painful areas of the skin of gels, ointments – both anti-inflammatory and irritating. It is justified to use dimexide applications in combination with corticosteroids, lidocaine, procaine. In addition, the relaxation of spasmodic muscles is achieved by post-isometric relaxation (IRP). PIR is reduced to muscle relaxation after their volitional stress without changing the distance between the attachment points of the muscle (i.e., after isometric tension). If the effectiveness of treatment is inadequate, botulinum toxin injections are expedient, followed by IRP. At МФСС receptions of a soft-tissue manual therapy (techniques of a myofascial relaxation, muscular-energetic techniques, etc.) are effective. Correcting the asymmetry of the body, the motor stereotype, avoiding provoking loads and poses is beneficial.
In the cases of dysfunction of the arched, rib-transverse joints, rib-chest and sacroiliac joints, blockades with local anesthetics and corticosteroids are shown and manual therapy is performed. With prolonged maintenance of pain syndrome and short-term effect from drug blockades in cases of dysfunction of arched joints and sacroiliac joints, it is necessary to consider the use of their radiofrequency denervation (RFD), which leads to a reduction in the severity of pain by at least 60% in 80% of patients.
Drug therapy for exacerbations of chronic musculoskeletal pain syndromes includes the administration of NSAIDs in conventional doses of 5-7 days, muscle relaxants and antidepressants. Amitriptyline (50-100 mg per day) is effective in 50-60% of patients with chronic back pain. Selective serotonin reuptake inhibitors (fluoxetine, paroxetine, sertraline), devoid of the side effects of tricyclic antidepressants, are used to correct concomitant chronic pain of depression, anxiety and sleep disorders, but the antinociceptive effect is much less pronounced. A group of selective serotonin and noradrenaline reuptake inhibitors, including venlafaxine (75 mg per day) and duloxetine (60 mg per day), is promising for the treatment of patients with chronic pain. Selective serotonin and noradrenaline reuptake inhibitors are included in the latest (2006) European clinical guidelines as an effective treatment for chronic pain in the lumbosacral region.
If depression often accompanies chronic pain, then at the stage of subacute pain (with a duration of pain of 6 to 12 weeks), anxiety disorders are often brought to the fore, related to the patient’s presentation of uncertainty or a negative prognosis for a full quick recovery. Behavioral and cognitive behavioral psychotherapy helps to correct incorrect, impeding the patient’s convalescence about the nature of his illness, change the social reinforcement of painful behavior, reduce dependence on analgesic therapy and increase the level of daily activity.
Behavioral psychotherapy based on the principle of reinforcement, includes several aspects: gradual activation of patients, changing social reinforcement of pain behavior, reducing dependence on analgesic therapy, teaching patients self-control skills.
Gradual activation of patients should begin with the explanation that small physical activity is not harmful, but useful. For this purpose, it is advisable first to ask the patient to keep a diary of daily activity and then together to analyze how much time during the day he spends lying because of pain in his back. For example, if the daily normal activity of the patient is only 4 hours, the initial goal of treatment may be to recommend actively 20 minutes per hour. Gradually, the duration of motor activity increases, for example, up to 5-10 minutes rest after 1.5 hours of stay in an upright position, and achievements are recorded by the patient in a diary. It is advisable to combine the activation with exercise physiotherapy exercises with gradually increasing loads, while aerobic exercises (walking, swimming) are preferable.