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Neurology, Neuropsychiatry, Psychosomatics

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Vol 11, No 2S (2019): Спецвыпуск: боль в спине и конечностях
https://doi.org/10.14412/2074-2711-2019-2S

CLINICAL GUIDELINES

7-16 115
Abstract

Examination of a patient with chronic low back pain (LBP) is aimed at eliminating its specific cause and assessing the social and psychological factors of chronic pain. The diagnosis of chronic nonspecific (musculoskeletal) LBP is based on the exclusion of a specific cause of pain, discogenic radiculopathy, and lumbar stenosis. It is advisable to identify possible pain sources: pathology of intervertebral disc pathology, facet joints, and sacroiliac joint and myofascial syndrome.

An integrated multidisciplinary approach (a high level of evidence), including therapeutic exercises, physical activity optimization, psychological treatments (cognitive behavioral therapy), an educational program (back pain school for patients), and manual therapy, is effective in treating chronic musculoskeletal LBP. For pain relief, one may use nonsteroidal anti-inflammatory drugs in minimally effective doses and in a short cycle, muscle relaxants, and a capsaicin patch, and, if there is depressive disorder, antidepressants (a medium level of evidence). Radiofrequency denervation or therapeutic blockages with anesthetics and glucocorticoids (damage to the facet joints, sacroiliac joint), back massage, and acupuncture (a low level of evidence) may be used in some patients.

Therapeutic exercises and an educational program (the prevention of excessive loads and prolonged static and uncomfortable postures and the use of correct methods for lifting weights, etc.) are recommended for preventive purposes. 

LECTURES

17-24 71
Abstract
Chronic back pain is a significant biomedical problem due to its high prevalence and negative impact on quality of life and socioeconomic indicators. Mental disorders play a substantial role in the genesis of chronic pain. This review discusses the issues of back pain comorbid with depressive, anxiety disorders, post-traumatic stress disorder, and somatoform disorder. It also considers the features of the clinical manifestations of pain associated with mental disorders. There are data on the neurobiological relationship between pain and mental disorders and on the personality traits of patients with chronic back pain.
25-32 67
Abstract
Among the adult population, every two persons have experienced at least an episode of back pain during their lifetime. Nonspecific (musculoskeletal) low back pain (LBP) becomes chronic in 3–10% of people. These cases require combined interdisciplinary treatment, including optimal pharmacotherapy, rational physical activity, therapeutic exercises, psychological methods, an educational program (back pain school for patients); some cases need manual therapy, massage. Psychological methods assist patients to cope with pain catastrophizing, to increase daily activity, and to reduce the likelihood of disease recurrence. The results of clinical trials and systematic reviews demonstrate that cognitive behavioral therapy and mindfulness therapy (mindfulness-based stress reduction) are effective in treating chronic LBP. The paper describes a clinical case: an example of effective treatment of a female patient with chronic nonspecific LBP, by applying an integral interdisciplinary approach.
33-39 74
Abstract
Back pain treatment is one of the most common problems in medical practice. The paper presents the theoretical and practical bases of physical therapy for people experiencing pain in the back and neck, considers in detail the main kinesiotherapy techniques used in modern rehabilitation, analyzes the principles of their selection for the most effective recovery of locomotor activity and for reduction of the severity of pain syndrome, and discusses the modes of motor activity. Hardware techniques that facilitate the implementation of complex therapeutic movements are considered separately. A rationale is provided for the importance of increasing motor activity and muscular strength and normalizing muscle tone, by restoring blood circulation and by reducing inflammation and pathological impulses from the affected spine. The possibilities of kinesiotherapy for acute and chronic nonspecific back pain, discogenic radiculopathy, and lumbar stenosis are discussed.

ORIGINAL INVESTIGATIONS

40-45 35
Abstract

Objective: to compare the efficiency of medical and surgical treatments for discogenic low back radiculopathy.

Patients and methods. 32 patients (including 13 men; mean age, 39.1±11.8 years) received inpatient medical treatment with epidural glucocorticoids; 32 patients (including 19 men; mean age. 42.3±12.1 years) had surgical treatment (removal of a herniated disk). A questionnaire [numerical pain rating scale (NPRS), Oswestry disability index, and quality of life questionnaire (QOL), SF-12] survey was carried out on admission to the clinic, after 7–14 days during treatment (pain intensity and functional status), and after 3, 6, and 12 months.

Results and discussion. There were no clinical differences between the patient groups at baseline. Both groups showed a significant decrease in pain intensity and reduced disability after 7–14 days of treatment, with a persistent positive effect over 12 months (p < 0.01). During a year, both groups exhibited better quality of life (p < 0.01). In the surgical treatment group, leg pain intensity was noted to become lower in the early stages (NPRS scores were 0.97 vs 2.41 after 7–14 days and 0.84 vs 1.56 scores after 3 months; p < 0.05); however, this advantage did not persist in the long-term. No significant differences were found between the groups in back pain intensity, disability, and QOL indicators throughout the follow-up period.

Conclusion. There were no significant clinical differences between patients with discogenic low back radiculopathy who are referred to hospital for surgical or medical treatment. Surgery makes it possible to reduce more rapidly the intensity of leg pain; however, no benefits of surgical treatment in terms of back pain intensity, disability, and QOL are noted. It is advisable to inform patients about the favorable course of the disease and the possibility of natural regression of disc herniation. 

46-51 66
Abstract

Objective: to analyze the typical medical practice management of patients with carpal tunnel syndrome (CTS), to evaluate the efficiency of surgical treatment, and to identify factors influencing the successful outcomes of surgical treatment.

Patients and methods. The investigation enrolled 85 patients (14 men and 71 women; mean age, 62±10.8 years). Previous diagnosis and treatment of patients were assessed in other healthcare facilities. All patients underwent median nerve decompression. The efficiency of surgical treatment was assessed according to the Boston Carpal Tunnel Questionnaire (BCTQ) and a visual analogue scale for pain before and 1, 3, 6, and 12 months after surgery.

Results and discussion. Informative diagnostic tests are rarely performed in patients with CTS, but cervical spine neurovisualization is often unreasonably prescribed. Erroneous diagnoses (predominantly those of cervical spine osteochondrosis (46%), and diabetic neuropathy (6%)) are made frequently (60%) in patients with CTS; the latter receive ineffective treatment for a long time. Surgical treatment in reducing pain and improving hand functionality is noted to be highly effective. The mean BCTQ score decreased from 2.81±0.68 to 1.62±0.55 and 1.24±0.41 at 1 and 12 months, respectively (p<0.05), the mean functional state score dropped from 2.92±0.78 to 2.4±0.72 and 1.46±0.57, respectively (p<0.05). Permanent numbness, subjective weakness, thenar muscle atrophy, Stage III CTS, and diabetes mellitus are predictors for less pronounced improvement in BCTQ scores after surgery (p<0.05).

Conclusion. Physicians are noted to be unaware of the manifestations of CTS and effective methods for its diagnosis and treatment. Decompression surgery is shown to be a highly effective procedure in patients with CTS following 1 and 12 months. 

REVIEWS

52-61 49
Abstract
The development of effective and safe treatments for osteoarthritis (OA), the most common chronic joint disease, is one of the main challenges facing modern medicine. Despite the fact that there are many drugs and non-drug therapies, the treatment of OA is not always successful, especially in terms of long-term prognosis. This is determined by the heterogeneity of OA, different phenotypes of this disease, as well as by a significant variability in its course, which complicates individual therapy choice. In this situation, a well-informed patient can become an effective physician assistant. Thus, the patient can control his/her condition in accordance with the responsible self-treatment principles: to assess therapy results and disease exacerbations, to maintain muscle tone and the necessary level of motor activity, to carry out therapeutic exercises, as well as to independently stop short-term increased pain episodes with over-the-counter analgesics. One of the most popular over-the-counter painkillers used worldwide is naproxen administered in low doses. This drug has proven to be an effective analgesic with good tolerability, standing out among all nonsteroidal anti-inflammatory drugs having a minimal risk for cardiovascular events. Teraliv 275 mg, a new over-thecounter formulation of naproxen, has currently emerged in Russia now. It seems that this medication will become an essential element of therapy for OA within the concept of responsible self-medication.
62-68 184
Abstract
One of the most common anatomical sources of nonspecific back pain is sacroiliac joint (SIJ) injury. The paper gives data on the structure, features of diagnosis and treatment of pain caused by SIJ dysfunction. A multimodal approach, including psychotherapeutic techniques, kinesiotherapy, the use of nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants, is recommended for chronic pain. The authors give their own experience with drug treatment of 51 patients (36 women and 15 men; mean age, 56.4±2.1 years) with SIJ dysfunction, by using periarticular blockages with local anesthetics and glucocorticoids or radiofrequency SIJ denervation. They note the efficiency of using Airtal® as a NSAID and Mydocalm® as a muscle relaxant.
69-75 70
Abstract
Neck pain is one of the common causes of maladjustment. Acute neck pain in most cases regresses independently in the period of a few weeks to months; however, it recurs in half of cases. Although the potential specific causes of cervicalgia are rare; nevertheless, in some cases the patient should undergo a detailed examination that is based on the identification of red flags and can optimize a search for the cause of pain syndrome. A consideration of the important principles of classifying pain in acute and chronic, neuropathic and nociceptive pain can serve as an important landmark in choosing the optimal treatment strategy for a patient. Unlike low back pain, neck pain has been investigated in an insufficient number of randomized controlled studies, which makes this analysis extremely relevant. The paper discusses the use of nonsteroidal anti-inflammatory drugs for back pain and the efficacy and safety of celecoxib.
76-82 44
Abstract
Back pain is a significant sociomedical problem due to its high prevalence and negative impact on quality of life. According to the latest data, the pain persists in a considerable number of patients for a year or even several years after its onset, which necessitates the search for a cause of the pain syndrome. The facet syndrome induces pain in 15–66% of cases and is most often due to facet joint osteoarthritis. A comprehensive clinical and diagnostic examination helps one to identify facet joint injury; and targeted pathogenetic and multimodal therapy, including non-steroidal anti-inflammatory drugs, provides complete pain relief in most cases and slows the progression of the disease.
83-88 76
Abstract
The paper considers various variants of nervous system injury in alcoholic disease. It discusses the epidemiology, pathogenesis, diagnosis, and clinical manifestations of central and peripheral nervous system lesions in the presence of acute and chronic alcohol intoxication. Attention is paid to the issues of etiotropic, pathogenetic, and symptomatic treatment for neurological manifestations of alcoholic disease and to the role of neurotropic B vitamins in the treatment of alcohol-induced deficiency and non-deficiency states.
89-97 47
Abstract
Cubital tunnel syndrome (CTS) is manifested as hand sensory and motor impairments due to ulnar nerve compression in the cubital tunnel. The diagnosis is based on clinical data and is confirmed by electroneuromyography and ultrasonography. Conservative treatment methods (avoiding certain postures and movements; elbow splinting or orthosis use; and special exercises) is indicated for early-stage and mild CTS. Surgical treatment is indicated when conservative treatment is ineffective and when a patient has objective hand muscle weakness and atrophy. The paper considers the etiology, pathogenesis, and risk factors of CTS, and principles of its clinical and instrumental diagnosis and treatment in patients with this condition.
98-102 69
Abstract
Low back pain (lumbodynia) is a most common reason for seeking medical care and a most common of disability. The review presents current clinical guidelines for the management of patients with acute nonspecific lumbodynia. The diagnosis of acute nonspecific lumbodynia is based on clinical findings and, in most cases, requires no instrumental studies. Nonsteroidal anti-inflammatory drugs are most effective in reducing pain. Additional therapies, such as therapeutic exercises, manual therapy, massage, acupuncture, etc., are discussed. There are data on the use of B vitamins, Milgamma® in particular, in acute non-specific lumbalgia.


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ISSN 2074-2711 (Print)
ISSN 2310-1342 (Online)