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.
7 620028, Екатеринбург, ул. Репина, 3 У пациента с острой поясничной болью (ПБ) проводят оценку жалоб и данных анамнеза, краткое соматическое и неврологическое обследование, определяют наличие симптомов опасности. Диагноз острой неспецифической (скелетно-мышечной) ПБ основывается на исключении специфической причины боли (потенциально опасного заболевания), дискогенной радикулопатии и поясничного стеноза. В случаях типичной скелетно-мышечной боли, отсутствия симптомов опасности не рекомендуются проведение рентгенографии, рентгеновской компьютерной томографии, магнитно-резонансной томографии в первые 4 нед заболевания. Целесообразность их выполнения рассматривается при сохранении ПБ сверх этого времени. Пациент с острой неспецифической (скелетно-мышечной) ПБ должен быть проинформирован о благоприятном исходе заболевания, необходимости сохранять физическую и социальную активность, избегать постельного режима, при возможности продолжать профессиональную деятельность. Для облегчения боли можно использовать нестероидные противовоспалительные препараты в минимально эффективных дозах и коротким курсом, а также миорелаксанты (средний уровень доказательности). Части пациентов целесообразно назначить мануальную терапию и массаж спины (низкий уровень доказательности). Для предупреждения рецидивов ПБ рекомендуются образовательная программа (профилактика чрезмерных нагрузок, длительного пребывания в статических и неудобных позах, правильные способы подъема тяжестей и др.) и вне периода обострения -лечебная гимнастика. Ключевые слова: острая неспецифическая (скелетно-мышечная) поясничная боль; рекомендации по диагностике, лечению и профилактике. Контакты: Вероника Александровна Головачева; xoxo.veronicka@gmail.com Для ссылки: Парфенов ВА, Яхно НН, Кукушкин МЛ и др. Острая неспецифическая (скелетно-мышечная) поясничная боль. Рекомендации Российского общества по изучению боли (РОИБ). Неврология, нейропсихиатрия, психосоматика. 2018;10(2):4-11. Acute nonspecific (musculoskeletal) low back pain Guidelines of the Russian Society for the Study of Pain (RSSP)
Migraine is one of the most common types of headache, which can lead to a significant decrease in quality of life. Researchers identify migraine with aura, migraine without aura, and chronic migraine that substantially reduces the ability of patients to work and is frequently concurrent with mental disorders and drug-induced headache. The complications of migraine include status migrainosus, persistent aura without infarction, migrainous infarction (stroke), and a migraine aura-induced seizure. The diagnosis of migraine is based on complaints, past medical history, objective examination data, and the diagnostic criteria as laid down in the International Classification of Headache Disorders, 3 rd edition. Add-on trials are recommended only in the presence of red flags, such as the symptoms warning about the secondary nature of headache. Migraine treatment is aimed at reducing the frequency and intensity of attacks and the amount of analgesics taken. It includes three main approaches: behavioral therapy, seizure relief therapy, and preventive therapy. Behavioral therapy focuses on lifestyle modification. Nonsteroidal anti-inflammatory drugs, simple and combined analgesics, triptans, and antiemetic drugs for severe nausea or vomiting are recommended for seizure relief. Preventive therapy which includes antidepressants, anticonvulsants, beta-blockers, angiotensin II receptor antagonists, botulinum toxin type A-hemagglutinin complex and monoclonal antibodies to calcitonin gene-related peptide or its receptors, is indicated for frequent or severe migraine attacks and for chronic migraine. Pharmacotherapy is recommended to be combined with non-drug methods that involves cognitive behavioral therapy; progressive muscle relaxation; mindfulness; biofeedback; post-isometric relaxation; acupuncture; therapeutic exercises; greater occipital nerve block; non-invasive high-frequency repetitive transcranial magnetic stimulation; external stimulation of first trigeminal branch; and electrical stimulation of the occipital nerves (neurostimulation).
Information about a favorable prognosis for a patient, recommendations for activities, and optimal pharmacotherapy are a mainstay in the effective treatment of acute nonspecific low back pain (NLBP). Standard pharmacotherapy for acute NLBP includes nonsteroidal anti-inflammatory drugs (NSAIDs). However, the longer their administration and larger doses, the higher the risk of side effects are. NSAIDs are contraindicated in some cases. In this connection, it has become necessary to search for new opportunities for the pharmacotherapy of acute NLBP. The results of experimental studies have demonstrated the analgesic and anti-inflammatory effects of high-dose B vitamins. Clinical trials have confirmed the efficacy of vitamin B complex (thiamine, pyridoxine, and cyanocobalamin) in the treatment of acute NLBP. The paper considers the practical significance of concomitant administration of B vitamins and NSAIDs in NLBP and notes the efficacy of milgamma used both alone and in combination with NSAIDs in the treatment of acute NLBP.
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