In 2018, published works that focus on European and American recommendations for the treatment of chronic back pain, where using opioid analgesics, it is recommended to take into account their complexity in multimorbid pathology in patients, since there is no effectiveness of pain reduction due to polypharmacotherapy. The peculiarity of the treatment is that the prevalence of musculoskeletal pain more often reaches its peak in elderly patients and is about 60%, which allows to establish an important direction in therapy - taking into account multimorbid pathology. It is necessary to take into account the accompanying chronic pathology because in patients with back pain hypertension occurs in 58.7%, chronic kidney disease occurs in 29.1% of patients, diabetes mellitus occurs in 23.1% of patients, depressive disorders occur in 15 , 3% of patients. Today it is proved that the common use of NSAIDs is critical for adverse events on the part of their use in patients with multimorbid pathology. In a number of clinical studies, the significant effect of tolperisone has been proven to relieve muscular spasm in acute and chronic back pain compared to tizanidine, where tolperisone is more often used in multimorbid pathology as a relaxant of skeletal muscles. The combination therapy strategy potentially represents a paradigm shift in rehabilitation therapy and can be very important for early intervention in spasticity management processes. In order to expand the scope of potential therapeutic use, the basic requirement for safe treatment is the quantitative basis of evidence of safety and efficacy, which, for example, is now presented in full on tolperisone hydrochloride. The new therapeutic options include a progressive addition of convergent therapy, where it is assumed that the potential for therapeutic purposes will be strengthened in view of the multimorbid pathology in the patient with back pain.

While neurological manifestations of osteochondrosis account for 60 to 70% of all diseases of the peripheral nervous system, vertebral radiculopathy make up 8 to 10% of other osteochondrosis complications. This often result in temporary and even permanent disability. There are three basic types of pain syndromes: somatogenic (nociceptive pain); neurogenic (neuropathic pain); psychogenic (psychogenic pain). The article provides clinical classification of vertebrogenic diseases of the peripheral nervous system and factors of vertebrogenic pain caused by degenerative changes of the spine. We have presented a quantitative and qualitative assessment of pain, special neurological and general neuroorthopedical methods of examination of patients with vertebral pain. Analyzed the clinical characteristics of muscle-tonic and dystrophic lesions of muscles and given differential diagnosis. For acute pain, treatment algorithms are suggested for vertebrogenic disease and radiculopathy, indicated possible side effects and complications.

The paper shows ways to optimize the training of doctors in the field of Reflexotherapy. Used problem methodology of training, provided experience in organizing practical classes, clinical examinations of patients. Іmportance in the process of training specialists at the Department of Neurology and Reflexology is given to practical classes, where students must realize in a real clinical situation, at the bed of the patient, they mastered theoretical ideas about the mechanisms of therapeutic action of reflexotherapy in certain diseases and conditions, indications and contraindications to the conduct of procedures Reflexotherapy, the method of selecting patients for reflexology and recreating the acquired skills of acupuncture diagnosis and procedures. Reflexology A significant role in the preparation of future reflexology doctors is also given to seminars, which have the role of a kind of chain between theoretical knowledge and their practical implementation in clinical work: it requires a logical doctor’s actions and skills in making specific decisions. Practical’s are carried out for various types of seminars, but the most popular are the colloquium workshop and clinical-workshop. Situation tasks are made on the basis of the «Bank» of clinical treatments according to different nosology’s. The presented clinical cases based on data analysis of patients who were under the supervision of teachers of the Department of Neurology and Reflexology and were used in the preparation of seminars-clinical treatments, dealing with the treatment of patients with pain syndromes using reflexotherapy. Presented clinical cases of effective use of acupuncture treatment in patients with pain syndromes due to reduction of «pain threshold».

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Резюме. Боль -одна Распространенность острой и хронической боли в спине у взрослых удвоилась за последнее десятиле-тие и продолжает резко возрастать у стареющего на-селения, затрагивая как мужчин, так и женщин во всех этнических группах [6]. Боль оказывает существенное влияние на функциональную способность, поскольку ограничивает возможность заниматься некоторыми видами профессиональной деятельности и является одной из основных причин временной нетрудоспо-собности [1].Экономическое бремя, связанное с болью, пред-ставляется непосредственно высокими расходами на здравоохранение и снижением производитель-ности [2].Эти расходы, как ожидается, возрастут еще больше в ближайшие несколько лет. Боль в спине представ-ляет собой серьезную социальную и экономическую проблему, которая чаще всего встречается у взрослого населения, с преобладанием до 84 % [3]. Распростра-ненность хронической боли в спине в США среди взрослых в возрасте 20-69 лет составила 13,1 % [4]. Боль в спине имеет различные потенциальные ана-томические источники, такие как нервные корешки, мышцы, фасции, кости, межпозвоночные диски, органы брюшной полости и др. [5].Хроническая боль в спине является синдромом, который сохраняется не менее 12 недель [6]. Многие авторы предлагают определять хроническую боль как боль, которая длится дольше ожидаемого периода заживления, избегая точных показателей времени. Это определение очень важно, так как оно подчер-кивает концепцию, согласно которой хроническая боль в спине имеет четко определенные основные патологические причины и является болезнью, а не симптомом. Хроническая боль в спине является основной причиной инвалидности во всем мире [2]. Диагностическая оценка пациентов с болевым син-дромом является сложным процессом и требует точ-ных клинических решений. Тем не менее определение источника боли имеет фундаментальное значение при выборе терапевтического подхода.Согласно концепции ВОЗ (Scoping Document for WHO Guidelines for the pharmacological treatment of persisting pain in adults with medical illnesses, 2012), ÏÐÀÊÒÈÊÓÞ×ÎÌÓ ÍÅÂÐÎËÎÃÓ /TO PRACTICING NEUROLOGIST/ © «Международный неврологический журнал», 2016

Pain - one of the most common reasons for handling to a neurologist. Approximately 80% of the population is plagued at one time or another by back pain, especially lower back pain. Nervous system detects and interprets a wide range of endogenous and environmental irritants. Pain mediated by nociceptors, through the peripheral sensory neurons that signal potential damage to the skin via stimulus conversion into electrical signals that are relayed to higher brain centers.

The theory of the five elements is widely used in traditional Chinese medicine, and the division of natural phenomena according to the properties of the five elements and the nature of the relationship between them, is practical in clinical acupuncture: to characterize the structural, physiological and pathological features of the patient, diagnosis and treatment. With the development of diseases there is a pathological relationship between Zhang-Fu organs and tissues that they are subordinated to. The human body is an organic whole, in which there are numerous interconnections in the development of the pathological process due to the existing modified interconnections. It is established that the theory of five elements is a simple theory with certain limitations. The laws of the relationship between the elements of the U-Syin cycle are not a reflection of all possible interconnections between the Zhang-Fu organs and the related tissues. In clinical practice, these laws show objective physiological and pathological communications between the internal organs and can be used in the process of acupuncture diagnosis and treatment. The theory of the five elements lies at the heart of the methodology of traditional acupuncture diagnostics, used during its implementation and data analysis, it determines the pathological states in accordance with the characteristics and laws of the relationship of the five elements and formulates the syndromic diagnosis of traditional Chinese Medicine (TCM).

Pain is a condition that is one of the most common diseases in the world. Many patients with vertebrogenic pain syndromes are multimorbidic, so they always receive field pharmacotherapy. Studies on multimorbidity have shown that chronic pain syndromes in the diagnosis and treatment are always interpreted as secondary, associated with somatic and mental disorders. Back pain can be divided into two large groups: vertebrogenic (degenerative, traumatic, inflammatory, neoplastic and other lesions of the vertebrae) and nonvertebrogenic genesis (stretching of ligaments and muscles, myofascial syndromes, fibromyalgia, somatic diseases, psychogenic factors, etc.). further). In the context of discussing vertebrogen pain syndromes, it is necessary to mention degenerative-dystrophic changes (osteochondrosis) of the spine primarily as in the vast majority of cases vertebroneurological pathology is associated with them. The following stages are distinguished: therapeutic, medical-rehabilitation, rehabilitation.