home Audience 12 Chronic pain. Types of chronic pain. Common pain syndromes in neurological practice: causes, diagnosis and treatment of back and neck pain

Chronic pain. Types of chronic pain. Common pain syndromes in neurological practice: causes, diagnosis and treatment of back and neck pain

Pain is initially a vital biologically expedient phenomenon, which under normal conditions plays the role of the most important physiological defense mechanism. It mobilizes everything necessary for the survival of the body functional systems, allowing you to overcome or avoid harmful influences that provoked pain. About 90% of all diseases are associated with pain.
The classification of the temporal aspect of pain distinguishes between transient, acute and chronic pain.
Transient pain is provoked by activation of nociceptive transducers of receptors in the skin or other body tissues in the absence of significant tissue damage. The function of such pain is determined by the speed of its occurrence after stimulation and the speed of elimination, which indicates that there is no danger of damaging effects on the body. IN clinical practice, for example, transient pain is observed during intramuscular or intravenous injection. It is assumed that transient pain exists to protect a person from the threat of physical damage from external environmental factors in the form of a kind of learning or pain experience.
Acute pain- a necessary biological adaptive signal about possible (in the case of pain experience), beginning or already occurring damage. The development of acute pain is associated, as a rule, with well-defined painful irritations of superficial or deep tissues and internal organs or dysfunction of the smooth muscles of internal organs without tissue damage. The duration of acute pain is limited by the time it takes to repair damaged tissue or the duration of smooth muscle dysfunction. Neurological causes of acute pain can be traumatic, infectious, dysmetabolic, inflammatory and other damage to the peripheral and central nervous system (CNS), meninges, short-term neural or muscular syndromes.
Acute pain is divided into superficial, deep, visceral and referred. These types of acute pain differ in subjective sensations, localization, pathogenesis and causes.
Chronic pain V neurological practice the situation is much more current. The International Association for the Study of Pain defines chronic pain as "...pain that continues beyond normal period healing." In practice, this can take several weeks or more than six months. Chronic pain can also include recurring pain conditions (neuralgia, headaches of various origins and etc.). The point, however, is not so much in temporal differences, but in qualitatively different neurophysiological, psychological and clinical features. The main thing is that acute pain is always a symptom, and chronic pain can essentially become an independent disease. It is clear that therapeutic tactics in eliminating acute and chronic pain has significant features. Chronic pain in its pathophysiological basis may have a pathological process in the somatic sphere and/or primary or secondary dysfunction of the peripheral or central nervous system, it can also be caused by psychological factors. From a medical point of view, it is acute and chronic pain that becomes the reason for visiting a doctor because of its destabilizing and maladaptive role.
According to various researchers, from 7 to 64% of the population periodically experience pain, and from 7.6 to 45% suffer from recurrent or chronic pain. According to WHO, pain syndromes constitute one of the leading causes (up to 40%) of visits to a doctor in the primary care system. medical care. The structure of chronic neurogenic pain syndromes is dominated by pain of musculoskeletal origin (radiculopathy, lumbar ischialgia, cervicobrachialgia, etc.) and headaches. In the structure of neurological appointments, patients with chronic pain syndromes account for up to 52.5%. According to some reports, up to 75% of patients suffering from chronic pain syndromes prefer not to see a doctor.

The mechanism of pain formation

Therapy of pain syndromes involves identifying and eliminating the source or cause that caused the pain, determining the degree of involvement of various parts of the nervous system in the formation of pain, and relieving or suppressing the pain itself.
The first central link that perceives multimodal afferent information is the neuronal system of the dorsal horn of the spinal cord. It is a cytoarchitectonically very complex structure, which in functional terms can be considered as a kind of primary integrative center of sensory information.
After quite complex processing pain afferentation in the segmental apparatus of the spinal cord, where it is affected by excitatory and inhibitory influences emanating from the peripheral and central parts of the nervous system, nociceptive impulses are transmitted through interneurons to the cells of the anterior and lateral horns, causing reflex motor and autonomic reactions. Another part of the impulses excites neurons, the axons of which form ascending pathways.
Nociceptive afferentation is sent to the brain along the spinothalamic, spinoreticular, and spinomesencephalic pathways. The somatosensory cortex receives afferent information from the ipsilateral parts of the thalamus. Corticofugal fibers go from the postcentral parts of the parietal cortex to the same nuclei of the thalamus opticus and are partly part of the corticobulbar and corticospinal descending tracts. At the level of the somatosensory cortex, spatiotemporal analysis of pain information is carried out. Corticofugal fibers from the frontal cortex are directed both to the same thalamic structures and to neurons of the reticular formation of the brainstem, formations of the limbic system (cingulate gyrus, hippocampus, fornix, septum, entorhinal cortex) and the hypothalamus. Thus, the frontal cortex, along with providing the cognitive and behavioral components of the integrative response to pain, is involved in the formation of a motivational-affective assessment of pain. The temporal cortex plays important role in the formation of sensory memory, which allows the brain to evaluate the current pain sensation, comparing it with previous ones. Thus, the state of the suprasegmental structures of the central nervous system - the cortex, limbic system, brainstem-diencephalic formations, which form the motivational-affective and cognitive components of pain behavior, actively influences the conduct of pain afferentation.
Descending inhibitory cerebrospinal control over the conduction of pain impulses is a function of the antinociceptive system, carried out by the structures of the cerebral cortex, the diencephalic level, the periventricular and periaqueductal gray matter, rich in enkephalin and opiate neurons, and some nuclei of the reticular formation brain stem(the main one is the raphe major nucleus), in which the main neurotransmitter is serotonin. The axons of the neurons of this nucleus are directed down the dorsolateral funiculus of the spinal cord, ending in the superficial layers of the dorsal horn. Some of them, like most of the axons from the reticular formation, are noradrenergic. The participation of serotonin and norepinephrine in the functioning of the antinociceptive system explains the reduction in pain caused by tricyclic antidepressants, the main property of which is the suppression of reuptake at serotonergic and norepinephrine synapses and, thereby, increasing the descending inhibitory effect on neurons of the dorsal horn of the spinal cord.
Essential Opiates play a role in the functioning of the antinociceptive system. Opiate receptors are located on the endings of C-fibers in the dorsal horn of the spinal cord, in the descending inhibitory pathways from the brain to the spinal cord, and in areas of the brain that transmit pain signals. There are three main types of opiate receptors: m- (mu), k- (kappa) and d- (delta) receptors. These major types of opiate receptors are also subdivided, and each subtype is affected by different endo- and exogenous opiates.
The distribution of opiate peptides and opiate receptors is observed at different levels of the central nervous system. Dense distribution of receptors is found in the dorsal horns of the spinal cord, midbrain and thalamus. A high density of opiate receptors was also found in the medial part of the thalamus and in the limbic structures of the forebrain; these structures may play an additional important role in the analgesic response to administered drugs and in the mechanism of drug addiction. The highest concentration of spinal opiate receptors is observed in the superficial layers posterior horns spinal cord. Endogenous opiate peptides (enkephalin, endorphin, dynorphin) interact with opioid receptors whenever painful stimuli occur as a result of overcoming the pain threshold. b-Endorphin has equal affinity for m- and d-receptors, while dynorphins A and B have high affinity for k-receptors. Enkephalins have a high affinity for d-receptors and a relatively low affinity for k-receptors.
C-type fibers can contact inhibitory enkephalinergic interneurons, which inhibit the conduction of pain impulses in the dorsal horns and the nucleus of the spinal tract of the trigeminal nerve. Inhibition of the release of excitatory transmitters is also provided by other pain inhibitors - these are GABA and glycine, found in interneurons of the spinal cord. These endogenous substances modulate the activity of the central nervous system and inhibit the transmission of pain signals. The pain response is also inhibited by serotonin and norepinephrine as part of the descending pathway from the brain to the spinal cord that controls the pain mechanism.
Thus, under normal conditions, there is a harmonious relationship between the intensity of the stimulus and the response to it at all levels of organization of the pain system.
However, long-term repeated damaging effects often lead to changes functional state(increased reactivity) of the pain system, which gives rise to its pathophysiological changes. From this point of view, nociceptive, neuropathic and psychogenic pain are distinguished.
Nociceptive pain occurs when any tissue damage causes excitation of peripheral pain receptors and specific somatic or visceral afferent fibers. Nociceptive pain is usually transient or acute, the painful stimulus is obvious, the pain is usually clearly localized and is well described by patients. The exceptions are visceral pain and referred pain. Nociceptive pain is characterized by rapid regression after the prescription of a short course of painkillers, including narcotic analgesics.
Neuropathic pain caused by damage or changes in the state of the somatosensory (peripheral and/or central parts) system. Neuropathic pain can develop and persist in the absence of an obvious primary painful stimulus, manifests itself in the form of a number of characteristic signs, is often poorly localized and is accompanied by various disorders of surface sensitivity: hyperalgesia ( intense pain with mild nociceptive irritation of the primary damage zone, or neighboring and even distant zones); allodynia (the occurrence of pain when exposed to non-painful stimuli of different modalities); hyperpathy (pronounced reaction to repeated painful stimuli with the persistence of a feeling of severe pain after the cessation of painful stimulation); pain anesthesia (sensation of pain in areas devoid of pain sensitivity). Neuropathic pain is poorly responsive to morphine and other opiates in usual analgesic doses, which indicates that its mechanisms differ from nociceptive pain.
Neuropathic pain can be spontaneous or induced. Spontaneous pain is characterized by a burning sensation, usually on the skin surface, which reflects the activation of peripheral C-nociceptors. Such pain can also be acute when it is caused by excitation of poorly myelinated A-delta nociceptive afferents of the skin. Shooting pains, similar to an electrical discharge, radiating to a limb segment or face, usually the result of ectopic generation of impulses along the paths of poorly myelinated C-fiber muscle afferents responding to noxious mechanical and chemical stimuli. The activity of this type of afferent fiber is perceived as “cramp-like pain.”
Psychogenic pain occur in the absence of any organic damage, which would explain the severity of pain and associated functional disorders. The question of the existence of pain of exclusively psychogenic origin is debatable, however, certain personality traits of the patient can influence the formation of pain. Psychogenic pain is one of many disorders characteristic of somatoform disorders. Any chronic illness or illness accompanied by pain affects the emotions and behavior of the individual. Pain often leads to anxiety and tension, which themselves increase the perception of pain. Psychophysiological (psychosomatic) mechanisms, acting through the corticofugal systems, change the state of internal organs, striated and smooth muscles, stimulate the release of algogenic substances and the activation of nociceptors. The resulting pain, in turn, increases emotional disturbances, thus closing a vicious circle.
Among other forms of mental disorders, the most closely associated with chronic pain is depression. Various options for the temporal relationship of these disorders are possible - they can occur simultaneously or one may precede the manifestations of the other. In these cases, depression is often not endogenous, but psychogenic in nature. The relationship between pain and depression is complex. In patients with clinical severe depression the pain threshold decreases, and pain is a common complaint in patients with primary depression, which can occur in a “masked” form. Patients with pain caused by a chronic somatic disease often also develop depression. The rarest form of pain in mental illness- this is its hallucinatory form, which occurs in patients with endogenous psychoses. Psychological mechanisms of pain also include cognitive mechanisms that link pain with conditional social benefits, receiving emotional support, attention, and love.

Principles of pain treatment

General principles of pain treatment include a clinical assessment of the state of the neurophysiological and psychological components of the nociceptive and antinociceptive systems and impact on all levels of organization of this system.
1. Elimination of the source of pain and restoration of damaged tissue.
2. Impact on the peripheral components of pain - somatic (elimination of inflammation, swelling, etc.) and neurochemical (stimulation of pain receptors). The most pronounced effect is exerted by drugs that affect the synthesis of prostaglandins: non-narcotic analgesics (paracetamol), non-steroidal anti-inflammatory drugs (diclofenac potassium and sodium, ibuprofen, etc.) and providing a decrease in the concentration of substance P in the terminals of fibers conducting pain impulses (drugs capsicum for external use - capsaicin, capsin, etc.).
3. Inhibition of pain impulses along the peripheral nerves and in the ultrasound system (introduction of local anesthetics, alcohol and phenol denervation, transection of peripheral nerves, ganglionectomy).
4. Impact on the processes occurring in the dorsal horns. In addition to applications of capsicum preparations, which reduce the concentration of CP in the dorsal horns, a number of other methods of therapy are used:
a) administration of opiates systemically or locally (epidurally or subdurally), which provides increased enkephalinergic inhibition of pain impulses;
b) electrical stimulation and other methods of physical stimulation (physiotherapy, acupuncture, transcutaneous electrical neurostimulation, massage, etc.), causing inhibition of nociceptive neurons of the dorsal horn by activating enkephalinergic neurons;
c) the use of drugs that affect GABAergic structures (baclofen, tizanidine, gabapentin);
d) the use of anticonvulsants (carbamazepine, diphenin, lamotrigine, valproate and benzodiazepines), which inhibit the conduction of nerve impulses along sensory nerves and have an agonistic effect on GABAergic receptors of neurons of the dorsal horns and cells of the nucleus of the spinal tract of the trigeminal nerve. These drugs are especially effective for neuralgia;
e) use of agonist drugs a 2 - adrenergic receptors - clonidine, etc.;
f) the use of serotonin reuptake blockers, which increase the concentration of this neurotransmitter in the nuclei of the reticular formation of the brain stem, from which descending inhibitory pathways emanate, affecting the interneurons of the dorsal horn (fluoxetine, amitriptyline).
5. Impact on the psychological (and at the same time on the neurochemical) components of pain with the use of psychotropic pharmacological drugs (antidepressants, tranquilizers, antipsychotics); use of psychotherapeutic methods.
6. Elimination of sympathetic activation in corresponding chronic pain syndromes (sympatholytic agents, sympathectomy).
Treatment of acute pain involves the use of four main classes of drugs: opiates, nonsteroidal anti-inflammatory drugs (NSAIDs), simple and combination analgesics.
To relieve acute pain syndrome, opiate analgesics are used: buprenorphine, butorphanol, meperidine, nalbuphine, etc. The most widely used of this group of drugs is tramadol, which, according to WHO recommendations, belongs to the second stage of pain therapy, occupying an intermediate place between therapy with non-steroidal anti-inflammatory drugs and narcotic analgesics. The unique dual mechanism of action of tramadol is realized through binding to m-opioid receptors and simultaneous inhibition of the reuptake of serotonin and norepinephrine, which contributes to additional activation of the antinociceptive system and an increase in the threshold of pain sensitivity. The synergy of both mechanisms determines the high analgesic effectiveness of tramadol in the treatment of various pain syndromes in neurology. Clinically important is the fact that there is no synergy side effects, which explains the greater safety of the drug compared to classical opioid analgesics. For example, unlike morphine, tramadol does not lead to disturbances in breathing and circulation, gastrointestinal motility and urinary tract, and with long-term use in recommended doses (maximum daily dose 400 mg) does not lead to the development of drug dependence. It is used in injection form (for adults intravenously or intramuscularly in a single dose of 50-100 mg), for oral administration (single dose 50 mg) and in the form of rectal suppositories (100 mg). In the acute period of pain, its combined use with NSAIDs is most effective, which not only allows for the inclusion of various analgesic mechanisms and enhances the effectiveness of analgesic therapy, but also reduces the number of side effects from the gastrointestinal tract associated with the use of NSAIDs.
In the treatment of chronic pain syndromes, the first-line drugs are tricyclic antidepressants, among which the non-selective reuptake inhibitor amitriptyline is most widely used. The following drugs are anticonvulsants GABA agonists: valproic acid derivatives, gabapentin, lamotrigine, topiramate, vigabatrin. The use of anxiolytics, phenathiazine derivatives (chlorpromazine, fluanxol, etc.), potentiates the effect of opiates, benzodiazepines - promotes muscle relaxation.
Depending on the specific clinical situation, these drugs and methods can be used separately or, as is more common with neurogenic pain, in combination. A separate aspect of the problem of pain is the tactics of patient management. Current experience has proven the need for examination and treatment of patients with acute and especially chronic pain in specialized inpatient or outpatient centers. Due to the wide variety of types and mechanisms of pain, even with a similar underlying disease, there is a real need for the participation of various specialists in their diagnosis and treatment - neurologists, anesthesiologists, psychologists, clinical electrophysiologists, physiotherapists, etc. Only a comprehensive interdisciplinary approach to the study of theoretical and clinical problems of pain can solve the urgent problem of our time - saving people from suffering associated with pain.

V.V. Alekseev

MMA im. I.M.Sechenova

Article from the Clinician's Directory
Publishing house MediaMedica

Chronic pain syndrome (CPS)- this is independent neurological disease characterized by prolonged pain. Typically, CHD occurs due to illness or injury.

It is necessary to distinguish between pain caused directly by the disease and chronic pain syndrome, which is a complex disorder of the functioning of a number of organs and systems. “Normal”, physiological pain is protective in nature. It subsides at the same time as pathological process, which causes pain, while the symptoms of chronic heart disease appear regardless of the underlying disease. That is why modern neurology considers chronic pain syndrome as a separate problem, the successful solution of which is possible only with the participation of specialists in the treatment of chronic pain using A complex approach to illness.

Reasons for development

Most often, chronic pain syndrome develops as a complication of diseases of the musculoskeletal system. The most common causes of CHD - joint diseases (osteoarthrosis, rheumatoid arthritis) and fibromyalgia. Patients with spinal tuberculosis and various tumors often suffer from chronic pain.

It is believed that for the development of chronic pain syndrome, the presence of one diagnosis is not enough - a special type of organization of the nervous system is also required. As a rule, CHD develops in people prone to depression, hypochondria, and severe stress overeating.

It is important to understand that in such patients, chronic pain syndrome is a manifestation of depression, its “mask,” and not vice versa, although the patients themselves and their loved ones usually consider depressed mood and apathy to be a consequence of painful sensations.

However, chronic pain syndrome should not be considered a problem of an exclusively psychological nature. Psychogenic pain, discussed above, really plays a huge role in the development of CHD, but inflammatory, neurogenic (caused by disruptions in the functioning of the nerves responsible for transmitting pain impulses) and vascular mechanisms formation of chronic pain. Even problems that seem to be far from medicine, such as social isolation of patients, can worsen the course of CHD. A vicious circle is formed: the patient cannot meet with friends because pain in the knee or back prevents him from leaving the house, and the lack of informal communication leads to even greater pain.

A separate problem is chronic pain syndrome in cancer patients. As a rule, it develops on late stages oncological diseases, however, the timing of the onset of pain and its intensity depend not only on the localization of the tumor and the extent of the tumor process, but also on the patient’s individual sensitivity to pain, the characteristics of his psyche and constitution.

Diagnosis of chronic pain syndrome

The starting point in diagnosing CHD is a conversation between the doctor and the patient and a thorough history taking. It is important that the conversation does not boil down to a formal listing of past and existing illnesses: events such as the death of loved ones, loss of a job, or even moving to another city deserve mention no less than arthrosis or a sprain suffered a year ago.

To assess the intensity of pain, the patient may be asked verbal rating scale (ShVO) or visual analogue scale (YOUR). Using these scales allows the doctor to understand how serious problem pain for a particular patient, and choose the most appropriate treatment option.

An important stage in the diagnosis of chronic pain syndrome is the determination of the mechanism that plays a key role in the formation of chronic pain syndrome. It depends on whether it turns out to be psychogenic, neurogenic or some other treatment strategy.

Pain in cancer patients

In cancer patients, pain can be associated not only with the disease itself, but also with the process of its treatment. Thus, surgical interventions often lead to the development of phantom pain and adhesions, chemotherapy damages the nervous system and provokes the development of joint pain. In addition, the serious condition itself and the need for bed rest are risk factors for the development of CHD: bedridden patients often develop bedsores. Determining the cause of increased pain in a severe cancer patient is the first step towards alleviating his condition and improving the quality of life.

Treatment of chronic pain syndrome

CHD is a complex disease, which is based on several mechanisms.

The effectiveness of traditional painkillers (primarily non-steroidal anti-inflammatory drugs, NSAIDs) in the treatment of chronic pain syndrome is low: they only slightly reduce the intensity of pain or do not help at all. The fact is that NSAIDs can affect only some mechanisms of the development of chronic pain syndrome, for example, inflammation.

To influence the processes occurring directly in the central nervous system, patients are prescribed drugs from other groups, primarily antidepressants .

Drug therapy is only one of the areas of complex treatment of CHD. Actively used to combat chronic pain physio- And psychotherapy , auto-training techniques And relaxation. The fight against the underlying disease, for example, osteoarthritis, plays an important, but not decisive role in the treatment of CHD.

The treatment strategy for chronic pain syndrome in cancer patients is somewhat different. In addition to medication and psychotherapeutic methods of combating pain, they are also shown palliative care : a set of measures aimed at improving the quality of life and minimizing the damage that tumor process causes to the body. For example, clearing the blood of tumor toxins or surgically removing part of the tumor mass can improve well-being and, as a result, stabilize the emotional state, which will naturally lead to a decrease in the severity of pain.

In addition, for cancer patients, special drug pain relief regimens , allowing you to effectively relieve pain and increase, as far as possible, the quality of life.

Chronic pain is pain that lasts a long time. In medicine, the distinction between acute and chronic pain is sometimes determined by an arbitrary interval of time from the onset of the disease. The two most commonly used markers are 3 months and 6 months from onset. Although some theorists and researchers have set the transition period from acute to chronic pain at 12 months. Others consider acute pain to be pain that lasts less than 30 days, chronic pain to be pain that lasts more than six months, and subacute pain to last from one to six months.
A popular alternative definition of chronic pain that does not assume an arbitrarily fixed duration is “pain that extends beyond the expected healing period.” Epidemiological studies have shown that 10 to 55% of people in different countries have chronic pain.
Chronic pain can occur in any human organ, including the brain or spinal cord. It is difficult to treat and is often treated by a team of doctors. Some people with this condition even receive opioid therapy, and some of them are even harmed by the treatment. Various non-opioid medications are widely used depending on whether the pain is organ tissue or neuropathic. Psychological treatments, including cognitive behavioral therapy, hypnotherapy, and acceptance and treatment therapy, have been proven by decades of research to effectively improve the quality of life of patients with chronic pain. Severe forms of the disease lasting 10 years or more provoke an increase in the mortality rate of such patients several times, especially from heart and respiratory diseases. People with long-lasting pain symptoms tend to have higher rates of anxiety, sleep disturbances, etc. These symptoms correlate with each other, and it is often unclear which factor is the initial factor for the disease. Generalized signs of chronic pain syndromes are as follows:

Pain syndromes	Generalized signs of syndromes
A. Reasonably generalized head and neck syndromes	1. Relatively localized head and neck syndromes
A. Reasonably generalized head and neck syndromes	2. Neuralgia of the head and face
B. Relatively localized head and neck syndromes	3. Craniofacial pain of musculoskeletal origin
	4. Ear, nose and oral cavity syndromes
	5. Primary headache syndromes, vascular disorders and cerebrospinal fluid syndromes
	6. Pain of psychological origin in the head, face and neck
	7. Concordant and cervical musculoskeletal disorders
	8. Temporal neck pain
C. Back pain	9. Cardiovascular or radicular pain syndromes
C. Back pain	10. Thoracic spine syndrome or radicular pain
E. Local limb syndromes	11. Shoulder, arm and hand pain
	12. Vascular disease of the extremities
	13. Collagen disease of the extremities
	14. Advanced functional disease limbs
	15. Chronic failure in the limbs
	16. Pain of psychological origin in the lower extremities
F. Visceral and other main canal syndromes except spinal and radicular pain	17. Visceral and other pain in chest
	18. Pain of psychological origin
	19. Pain caused by abdominal or gastrointestinal tract
	20. Direct abdominal pain
	21. Abdominal pain of visceral origin
	22. Abdominal pain syndromes of generalized diseases
	23. Chronic pelvic pain syndromes
	24. Diseases Bladder, uterus, ovaries, testicles and prostate and their appendages
	25. Pain perceived in the rectum, perineum and external genitalia of nociceptive or neuropathic cause
G. Back pain	26. Lumbar spinal or radicular pain syndromes
	27. Spastic or radicular pain syndrome
	28. Syndromic pain in the coccyx
	29. Diffuse or generalized pain in the spine
	30. Dull pain of psychological origin radiating to the spine
H. Local syndromes of the lower extremities	31. Local syndromes in the leg or foot: pain of neurological origin
	32. Pain syndromes of the hip and thigh of musculoskeletal origin
	33. Musculoskeletal syndromes of the legs

Chronic pain can lead to decreased physical activity due to fear of worsening pain, which often leads to weight gain for the patient. The intensity of the pain syndrome, stability, and immunity to pain are influenced by the different levels and types of social support that a patient with this disease receives.

Classification of chronic pain

The International Association for the Study of Pain defines chronic pain as pain without a biological cause that persists after normal tissue healing. The International Classification of Diseases (DSM-5) classifies this disease as one chronic pain disorder, somatic symptoms, remaining from three previously recognized pain disorders. The duration of such disorders must be at least 6 months. The proposed ICD-11 classification of chronic pain offers 7 categories for chronic pain.
1. Chronic primary pain: defined by 3 months of constant pain in one or more anatomical areas that is unexplained by other diseases.
2. Chronic cancer pain: defined as cancer or treatment-related visceral, musculoskeletal or bone pain.
3. Chronic post-traumatic pain: pain lasting 3 months or more after injury or surgery, excluding infectious or pre-existing conditions.
4. Chronic neuropathic pain: pain caused by somatosensory damage to the nervous system.
5. Chronic headache and orofacial pain: pain occurring in the head or facial muscles on 50% or more of days over a 3-month period.
6. Chronic visceral pain: pain that occurs in any internal organ.
7. Chronic musculoskeletal pain: pain that occurs in bones, muscles, joints or connective tissue.
The following systematization of long-term pain is accepted everywhere in medical practice:

Chronic pain disorders
Neuropathic pain	Mixed pain	Systematized pain
Peripheral neuropathies (diabetes, HIV)	Migraine and daily chronic headache	Lower back pain
Postoperative neuralgia	Fibrolgia, arrhythmia	Rheumatoid arthritis
Trigeminal neuralgia	Phantom limb pain	Osteoarthritis
Pain syndrome after a stroke	Complex regional pain syndrome	Chronic inflammatory process
Spinal cord injury	Multiple sclerosis	Somatophoric pain disorder
Neuropathic low back pain	Lower back pain	Postoperative pain
	Myofascial pain syndrome	Sports injuries
	Musculoskeletal pain

Chronic pain can be divided into "nociceptive" (caused by inflamed or damaged tissues activating specialized pain sensors called nociceptors) and "neuropathic" (caused by damage or degeneration of the nervous system).
Nociceptive pain can be divided into “superficial” and “deep”, and deep pain into “deep somatic” and “visceral”.

Superficial pain is initiated by activation of receptors in the skin or superficial tissues. Deep somatic pain is initiated by stimulation of receptors in ligaments, tendons, bones, blood vessels, fascia and muscles, and is a dull, aching, poorly localized pain. Visceral pain occurs during internal organs. Visceral pain can be well localized, but is often extremely difficult to detect, and multiple visceral areas produce "mentioned" pain when damaged or inflamed, where the sensation is located in an area distant from the site of pathology or injury.
Neuropathic pain is divided into “peripheral” (originating in the peripheral nervous system) and “central” (originating in the brain or spinal cord).
Peripheral neuropathic pain is often described by patients as “burning,” “tingling,” “electrifying,” or “stabbing,” or “pins and needles.”

Pathophysiology

With persistent activation of pain sensors in the spinal cord, exacerbation of pain may occur. This causes pathological changes that reduce the threshold of pain signals that must be transmitted to the . That is, pain sensations are sharply reduced, which can lead to pathogenic changes in the body, because there is no proper response of the body to the symptoms of serious diseases.

Treatment. Alternative medicine

, including self-hypnosis, are effective in treating diseases of this kind. Research has shown that these treatments are not effective for spinal cord or brain injuries.

Preliminary studies have shown that psychotropic medications are useful and in some cases very effective in treating chronic pain, but further research is needed.

Some types of Chinese Wushu gymnastics have been shown to reduce pain, stiffness and the quality of life of patients, with chronic conditions, such as osteoarthritis, low back pain and osteoporosis. Acupuncture has also been found to be an effective and safe treatment for reducing pain and improving quality of life in chronic pelvic pain syndrome.
The effect of transcranial magnetic stimulation treatment is currently not supported by evidence, and the results demonstrated are small and short-lived.

Epidemiology

A systematic review of the literature on chronic pain found that the prevalence of chronic pain varies between countries, ranging from 10% to 55% of the population. There are more women affected by the problem than men, and this disease consumes a large number of medical resources of the globe.
A large-scale telephone survey of 15 European countries and Israel found that 19% of respondents over 18 years of age had experienced symptoms for more than 6 months, including the last month, and more than twice during the previous month. last week, with a pain intensity of 5 or greater, on a scale of 1 (no pain) to 10 (worst intensity), 4839 of these respondents with chronic pain were interviewed in detail.
Sixty-six percent of them had pain intensity at moderate (5-7) and 34% at severe (8-10); 46% had constant pain, 56% intermittent; 49% were ill for 2-15 years; And 21% were diagnosed with depression due to pain. Sixty-one percent of respondents were unable or unable to work outside the home, 19% lost their jobs, and 13% changed jobs because of their pain. Forty percent had inadequate treatment for other conditions, and less than 2% were seen by a pain management specialist.
In Russia, the prevalence of chronic pain is estimated at approximately 30%, leaving approximately 44 million Russians with partial or total disability. According to the Ministry of Health, about 50 million Russians live with chronic pain, which indicates that approximately a third of the adult population suffers from chronic pain syndrome.

Consequences

Chronic pain is associated with higher rates of depression and anxiety. Sleep disturbances due to both medications and disease symptoms are more likely to occur in patients with chronic pain.
Chronic pain can lead to a decrease in physical activity due to fear of worsening pain, which often leads to a sedentary lifestyle and. Such comorbid disorders can be very difficult to treat due to the high risk of interactions between various medicines, especially when pathologies are treated by different doctors. Severe chronic pain reduces a patient's life expectancy by 6-10 years, especially from heart disease and respiratory diseases.
Modern medicine suggests several mechanisms for the influence of pain syndromes on the life expectancy of such patients, for example:
Abnormal endocrine stress response. In addition, chronic stress appears to influence the risk of cardiovascular disease and accelerate the atherosclerotic process. However, further research is needed to clarify the relationship between severe chronic pain, stress and cardiovascular health.

Psychology. Impact on personality.

Let's look at the most common personality profiles found in people with chronic pain. Neurotic Personality - Expresses an exaggerated preoccupation with the body's feelings, develops bodily symptoms in response to stress, and often fails to recognize one's emotional state, including depression. A neurotic personality also expresses an exaggerated preoccupation with bodily symptoms and develops them in response to pain, but in addition also demands and complains. Some researchers argue that this is what causes acute pain to prevent chronic disease, but clinical evidence points to a different pathway, chronic pain causing neuroticism. When long-term pain is relieved by therapeutic intervention, the neurotic triad and anxiety scores decrease, often to normal levels.
Self-esteem, often low in people with chronic pain, also shows striking improvement once the pain resolves. Researchers have suggested that "catastrophe" may play a significant role in the course and symptoms of the disease. Pain catastrophizing is the tendency to describe an illness in more exaggerated terms than the average person, to think much more about the pain when it occurs, or to feel more helpless and hopelessly ill. People who highly assess the risks of a catastrophic development of the disease are likely to rate the intensity of their pain higher than those who are not inclined to dramatize events.

It is often believed that the tendency to catastrophic consequences causes a person to experience pain as more intense. One proposal is that catastrophizing influences pain perception by altering attention and expectancy and increasing emotional responses to pain. However, according to at least, some aspects of "catastrophizing" may
be the result of intense pain sensation, not its real reasons. That is, the more severe pain a person experiences, the more likely it is that he will have thoughts about it that correspond to a fatal development of events.

Ppsychology. Social support

Social support has important consequences for people with chronic pain. Specifically, pain intensity, pain control, and pain tolerance have been observed as outcomes influenced by different levels and types of social support. Most of These studies focused on emotional, instrumental, material and informational social support. People with permanent painful conditions, tend to rely on their social support as a coping mechanism and therefore have better outcomes when they are part of more supportive social environments. In most of the studies reviewed, there was a direct relationship between social activities or social support and pain. More high levels pain intensity was associated with a decrease in social activity, more low level social support in the family and society and a decrease in the patient’s social functioning.

Psychology. Impact on mental processes

The impact of chronic pain on the mind is an understudied area, but several preliminary findings have recently been published. Most people with chronic pain complain of cognitive impairment, such as forgetfulness, difficulty paying attention, and difficulty completing normal daily tasks. Objective testing has shown that people with chronic pain tend to experience impairments in attention, memory, mental flexibility, language ability, cognitive responsiveness, and speed in completing structured tasks.

Chronic pain can be caused by many various reasons, including psychogenic factors. Quite often, patients experience severe pain, but no physical illnesses cannot be detected. For example, a person complains of a sore throat, but a thorough medical examination shows that there is nothing wrong with the throat.

What do such pains indicate? They are a sign of a serious psychological problem that you are not even aware of. Perhaps, with the help of pain, the body is trying to protect you from something. So, a situation is possible when a person begins to have a headache before sexual contact. The pain may be subconscious defensive reaction from being involved with an unwanted partner. Or pain regularly occurs in the throat when communicating with certain people. In this way, the subconscious is trying to protect you from contacts that pose a danger.

Find out exactly psychological reason Chronic pain can be difficult to manage because in most patients it is related to an event that occurred in childhood—before 6 years of age. One of the diagnostic methods in such cases is hypnosis. The foundations of a person’s personality are laid in the first years of life. Everything that happened to us before the age of six has enormous emotional significance. Perhaps it was then that some situation arose that your subconscious perceived as danger. And you have developed a psychological defense mechanism.

At that time and in that situation, it was the best way to protect you. You were saved thanks to the pain caused by your subconscious. Pain could protect you from many things - from the severity of your father, from communicating with classmates who did not like you, and even from loneliness (for a child, loneliness is a cause of particular fear, since he feels abandoned). And since the main function of the subconscious is to save a person’s life, it will do everything to ensure safety.

When a person grows up, he learns to objectively assess life situations and begins to defend himself in conscious ways. But the old response program does not disappear. Some people psychological problem associated with feelings of resentment; in others, with guilt or aggression. In such situations, it is naturally not worth directing the hypnotic effect simply for pain relief. The pain, of course, will subside, but its cause will not go away. That is, hypnosis should be aimed at eliminating the psychological problem itself. When the internal conflict is resolved, the pain will go away. As a result, you will feel liberated, calm and confident.

To correct a serious psychological problem that originates in early childhood, a person must remember the event that was followed by the first attack of pain. Being in an unchanged consciousness, a person is unlikely to be able to remember such situations. Memory is designed in such a way that traumatic moments go deep into its depths and do not disturb us with unpleasant thoughts. Only a trance state makes it possible to recall from memory any event and any decision you make.

So, we remembered the event underlying chronic pain. Now there is an opportunity to resolve the situation differently and come to new conclusions. After this, the pain will stop bothering you. You will become whole and experience inner freedom.

Important to remember! It is better not to use medications to treat such pain. The pill will temporarily muffle the physical discomfort, but the psychological conflict will not be resolved. The body signals that it needs help, but we simply turn away from it. This is pretty stupid, we need to solve the problem.

Pain and psychosomatics

Hypnotherapy has some benefits for treating chronic pain. After all, with its help, a psychological problem is eliminated, and we get the opportunity to change children's decisions that interfere with a normal life. As a result, mental tension goes away, the body relaxes, which leads to the disappearance psychosomatic diseases. When there is no tension in the body, a person's overall health becomes much better.

But! If the problem of pain does not lie in psychological trauma, and not in the past, and such cases are more than 70%, then psychotechniques will be useless, including hypnosis. This means we need to work with the current state of things. Sometimes it is beneficial for the body to be sick, watch the video where this is explained in detail:

Be healthy, and know that the solution to your pain is not as difficult as it seems to you at first glance, although you may have been looking for an answer for many years. The solution is simple and obvious, and when you find it you will be amazed. For example, you can start with this:

Neuropathic pain, unlike ordinary pain, which is a signaling function of the body, is not associated with dysfunction of any organ. This pathology has recently become an increasingly common illness: according to statistics, 7 out of 100 people suffer from neuropathic pain of varying degrees of severity. This type of pain can make doing the simplest activities excruciating.

Kinds

Neuropathic pain, like “ordinary” pain, can be acute or chronic.

There are also other forms of pain:

Moderate neuropathic pain in the form of burning and tingling. Most often felt in the extremities. It does not cause any particular concern, but it creates psychological discomfort in a person.
Pressing neuropathic pain in the legs. It is felt mainly in the feet and legs, and can be quite pronounced. Such pain makes walking difficult and brings serious inconvenience to a person’s life.
Short-term pain. It may last only a couple of seconds and then disappears or moves to another part of the body. Most likely caused by spasmodic phenomena in the nerves.
Excessive sensitivity when the skin is exposed to temperature and mechanical factors. The patient experiences discomfort from any contact. Patients with this disorder wear the same familiar things and try not to change positions during sleep, since changing positions interrupts their sleep.

Causes of neuropathic pain

Neuropathic pain can occur due to damage to any part of the nervous system (central, peripheral and sympathetic).

We list the main influencing factors for this pathology:

Clinical picture and diagnosis of neuropathic pain

Neuropathic pain is characterized by a combination of specific sensory disturbances. The most characteristic clinical manifestation of neuropathy is a phenomenon called “allodynia” in medical practice.

Allodynia is a manifestation of a pain reaction in response to a stimulus that healthy person does not cause pain.

A neuropathic patient can experience severe pain from the slightest touch and literally from a breath of air.

Allodynia can be:

mechanical, when pain occurs when pressure is applied to certain areas of the skin or irritation with fingertips;
thermal, when pain manifests itself in response to a temperature stimulus.

There are no specific methods for diagnosing pain (which is a subjective phenomenon). However, there are standard diagnostic tests that allow you to evaluate symptoms and, based on them, develop a therapeutic strategy.

Serious assistance in diagnosing this pathology will be provided by the use of questionnaires to verify pain and its quantitative assessment. It will be very useful to accurately diagnose the cause of neuropathic pain and identify the disease that led to it.

To diagnose neuropathic pain in medical practice, the so-called method of three“S” - look, listen, correlate.

look - i.e. identify and evaluate local disorders of pain sensitivity;
listen carefully to what the patient says and note characteristic signs in his description of pain symptoms;
correlate the patient’s complaints with the results of an objective examination;

It is these methods that make it possible to identify symptoms of neuropathic pain in adults.

Neuropathic pain - treatment

Treatment of neuropathic pain is often a lengthy process and requires a comprehensive approach. The therapy uses psychotherapeutic, physiotherapeutic and medicinal methods.

Medication

This is the main technique in the treatment of neuropathic pain. Often, such pain cannot be relieved with conventional painkillers.

This is due to the specific nature of neuropathic pain.

Treatment with opiates, although quite effective, leads to tolerance to the drugs and can contribute to the development of drug addiction in the patient.

IN modern medicine most often used lidocaine(in the form of ointment or patch). The drug is also used gabapentin And pregabalin- effective medicines foreign production. Together with these drugs they use sedatives for the nervous system, reducing its hypersensitivity.

In addition, the patient may be prescribed drugs that eliminate the consequences of the diseases that led to neuropathy.

Non-drug

Plays an important role in the treatment of neuropathic pain physiotherapy. IN acute phase diseases use physical methods to relieve or reduce pain syndromes. Such methods improve blood circulation and reduce spasmodic phenomena in the muscles.

At the first stage of treatment, diadynamic currents, magnetic therapy, and acupuncture are used. In the future, physiotherapy is used that improves cellular and tissue nutrition - laser, massage, light and kinesitherapy (therapeutic movement).

During the recovery period physical therapy is given great importance. Various relaxation techniques are also used to help eliminate pain.

Treatment of neuropathic pain folk remedies not particularly popular. Patients are strictly prohibited from using traditional methods of self-medication (especially heating procedures), since neuropathic pain is most often caused by inflammation of the nerve, and its heating is fraught with serious damage, including complete death.

Acceptable phytotherapy(treatment with herbal decoctions), however, before using any herbal remedy You should consult your doctor.

Neuropathic pain, like any other, requires careful attention. Timely treatment will help avoid severe attacks of the disease and prevent its unpleasant consequences.

The video will help you understand the problem of neuropathic pain in more detail:

For quotation: Kotova O.V. Common pain syndromes in neurological practice: causes, diagnosis and treatment of back and neck pain // RMJ. Medical Review. 2013. No. 17. P. 902

Almost every neurologist in his work encounters patients suffering from back and neck pain. Back pain causes long-term disability in 4% of the world's population, is the second most common cause of temporary disability, the fifth most common cause of hospitalization, and at the same time requires huge material costs to eliminate it.

The most common cause of back pain is dorsopathies. This is a group of diseases musculoskeletal system and connective tissue, the leading symptom complex of which is pain in the trunk and extremities of non-visceral etiology. The defining symptom of dorsalgia is the appearance of severe pain associated with irritation of the nerve endings located in the soft tissues of the spine.
The sources of pain impulses for back pain are:
. muscles, ligaments, fascia,
. facet joints,
. nerves, spinal nodes,
. intervertebral disc, vertebrae, dura mater.
It should be remembered that back pain is primary, associated with degenerative changes vertebral structures, and secondary, caused by other pathological conditions. Therefore, when examining a patient with acute back pain, it is necessary to differentiate musculoskeletal pain from pain syndromes associated with somatic or oncological pathology.
There are several methods for diagnosing dorsopathies: X-ray examination, spondylography, computed tomography (CT) and magnetic resonance imaging (MRI). However, detected degenerative-dystrophic changes in the spine cannot always be compared with clinical manifestations diseases and often occur in patients who do not suffer from back pain. This paradox cannot always be explained to the patient, which leads to his firm belief that there are “serious causes” of back pain that the doctor cannot detect. At the same time, the use of expensive diagnostic methods is also not always justified, because asymptomatic disc herniations, according to CT and MRI, occur in 30-40% of cases, and in 20-30% of cases there is no connection between the severity of the clinical picture and neuroimaging data. Depending on which structures of the spinal column are involved in the process in each specific case, either compression or reflex syndromes predominate in the clinical picture.
Compression syndromes develop if altered structures of the spine deform or compress roots, blood vessels or the spinal cord. Reflex vertebrogenic syndromes arise as a result of irritation of various structures of the spine, which has powerful sensory innervation. It is believed that only bone The vertebral bodies and epidural vessels do not contain pain receptors. Based on localization, vertebrogenic syndromes are distinguished at the cervical, lumbosacral and thoracic levels.
Cervical syndromes
Clinical syndromes of cervical localization are largely determined by the structural features of the cervical spine: there is no disc between C1 and C2, C2 has a tooth, which in pathological conditions can cause compression of spinal structures. Passes through the transverse processes of the cervical vertebrae vertebral artery. Below C3, the vertebrae are connected using uncovertebral joints, the structures of which can become deformed and serve as a source of compression.
Compression syndromes
cervical localization
At the cervical level, roots, vessels, and the spinal cord may be subject to compression. When individual roots are compressed, the following clinical picture can be observed:
. root C3 - pain in the corresponding half of the neck;
. root C4 - pain in the area of the shoulder girdle, collarbone. Atrophy of the trapezius, splenius and longissimus muscles of the head and neck; possible cardialgia;
. root C5 - pain in the neck, shoulder girdle, lateral surface of the shoulder, weakness and atrophy of the deltoid muscle;
. root C6 - pain in the neck, scapula, shoulder girdle, radiating along the radial edge of the hand to the thumb, weakness and hypotrophy of the biceps brachii muscle, decreased reflex from the tendon of this muscle;
. C7 root - pain in the neck and scapula, spreading along outer surface forearms to fingers II and III, weakness and atrophy of the triceps brachii muscle, decreased reflex from its tendon;
. root C8 - pain from the neck spreads along the inner edge of the forearm to the fifth finger of the hand, decreased carporadial reflex.
Cervical reflex syndromes
Clinically manifested by lumbago or chronic pain in the neck area with irradiation to the back of the head and shoulder girdle. On palpation, pain is detected in the area of the facet joints on the affected side. Sensitivity disorders, as a rule, do not occur.
The cause of pain in the neck, shoulder girdle, and scapula can be a combination of several factors, for example, reflex pain syndrome due to osteochondrosis of the spine in combination with microtraumas of the tissues of the joints and tendons. Thus, with glenohumeral periarthrosis, damage to the C5-C6 discs is often observed in combination with injury to the shoulder joint or other diseases that play a trigger role. Clinically, with glenohumeral periarthritis, pain in the periarticular tissues of the shoulder joint and limitation of movements in it are noted. The adductor muscles of the shoulder and periarticular tissues are painful on palpation, there are no sensory disorders, tendon reflexes saved.
Vertebrogenic neurological complications in the thoracic spine with osteochondrosis are rare, since the bone frame of the chest limits displacement and compression. Pain in the thoracic region often occurs with inflammatory (including specific) and inflammatory-degenerative diseases (ankylosing spondylitis, spondylitis, etc.).
Lumbar compression
syndromes
Upper lumbar compression syndromes are relatively rare.
Compression of the L2 root (L1-L2 disc) is manifested by pain and loss of sensitivity along the inner and anterior surfaces of the thigh, and decreased knee reflexes.
Compression of the L4 root (L2-L4 disc) is manifested by pain along the anterior inner surface of the thigh, decreased strength, followed by atrophy of the quadriceps femoris muscle, and loss of the knee reflex.
Compression of the L5 root (L4-L5 disc) is a very common location. It manifests itself as pain in the lower back with irradiation along the outer surface of the thigh, the anterior surface of the leg, the inner surface of the foot and big toe. Hypotonia and wasting of the tibialis muscle and decreased strength of the dorsal flexors of the thumb are noted.
Compression of the S1 root (L5-S1 disc) is the most common location. It manifests itself as pain in the buttock, radiating along the outer edge of the thigh, lower leg and foot. The strength of the triceps surae muscle decreases, sensitivity in the areas of pain irradiation is impaired, and the Achilles reflex fades.
Lumbar reflex syndromes
Lumbago - acute pain in the lower back (lumbago). Usually develops after physical activity. Manifests itself with sharp pain in the lumbar region. The antalgic posture and tension of the lumbar muscles are objectively determined. Symptoms of loss of function of the roots of the lumbosacral region, as a rule, are not detected.
Lumbodynia is chronic pain (dull, aching) in the lower back. When touched, tenderness of the spinous processes and interspinous ligaments and facet joints is determined (at a distance of 2-2.5 cm from midline) V lumbar region, in which movements are limited. There are no sensory disorders.
Piriformis syndrome. The piriformis muscle begins at the anterior edge of the upper sacrum and attaches to the inner surface of the greater trochanter of the femur. Its main function is hip abduction. Between the piriformis muscle and the sacrospinous ligament passes sciatic nerve. Therefore, when the piriformis muscle is tense, compression of the nerve is possible, which occurs in some cases with lumbar osteochondrosis. Clinical picture piriformis syndrome is characterized by sharp pain in the subgluteal region radiating down the back surface lower limb. Hip adduction causes pain and the Achilles reflex is reduced. The pain syndrome is accompanied by regional vasomotor disturbances, the severity of which depends on the position of the body - the pain decreases when lying down and intensifies when walking.
Differential diagnosis of compression and reflex vertebrogenic syndromes
Vertebrogenic compression syndromes are characterized by the following features :
. pain is localized in the spine, radiating to the limb, right up to the fingers or toes;
. pain increases with movement in the spine, coughing, sneezing, straining;
. Symptoms of loss of function of compressed roots are determined: impaired sensitivity, muscle wasting, decreased tendon reflexes.
With reflex vertebrogenic syndromes, the following is observed:
. pain is local, dull, deep, without irradiation;
. pain intensifies with load on the spasmed muscle, its deep palpation or stretching;
. There are no symptoms of loss.
Treatment of pain syndrome
In general, the treatment of pain syndrome is based on 2 main principles:
1. Therapy should be aimed at reducing pain, increasing general activity, improving sleep and the patient’s mood.
2. If it is impossible to completely eliminate the pain syndrome, it is necessary to minimize the intensity of the pain, its duration and the frequency of exacerbations - the pain should not significantly reduce the patient’s vital activity.
Treatment of acute back and neck pain
In case of acute pain, the patient should be advised to remain in bed for 1-3 days. You should start right away drug therapy in the form of the use of non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, muscle relaxants. The list of drugs from the NSAID group is quite extensive: diclofenac, lornoxicam, ketoprofen, meloxicam, etc. The form of administration (tablets, suppositories, injections) is chosen based on the intensity of the pain syndrome. All NSAIDs have anti-inflammatory, analgesic and antipyretic effects, are able to inhibit the migration of neutrophils to the site of inflammation and platelet aggregation, and also actively bind to serum proteins. NSAIDs vary in the severity of their therapeutic effect, tolerability, and the presence of side effects. Thus, the high gastrotoxicity of NSAIDs is widely known, which is associated with indiscriminate inhibition of both isoforms of cyclooxygenase (COX). Data from numerous clinical studies indicate that the incidence of adverse events from the gastrointestinal tract (GIT) when taking the vast majority of non-selective NSAIDs reaches 30%.
In this regard, for the treatment of severe pain syndromes, drugs are needed that have a powerful and rapid anti-inflammatory and analgesic effect with minimal risk of adverse events. Such drugs undoubtedly include the drug Amelotex (international name - meloxicam) pharmaceutical company Sotex. Amelotex belongs to the class of oxicams, a derivative of enolic acid. The drug selectively inhibits the enzymatic activity of cyclooxygenase-2 (COX-2). Amelotex does not have a damaging effect on the gastrointestinal tract, cardiovascular system, or kidneys.
A feature of the pharmacokinetics of Amelotex is its binding to plasma proteins, which is 99%. The drug passes through histohematic barriers and penetrates into the synovial fluid. Concentration in synovial fluid reaches 50% of Cmax in plasma. It is excreted equally in feces and urine, mainly in the form of metabolites. Excreted unchanged through the intestines<5% от величины суточной дозы, в моче в неизмененном виде препарат обнаруживается только в следовых количествах. Т1/2 мелоксикама составляет 15-20 ч. Плазменный клиренс - в среднем 8 мл/мин.
In 2008, a study was conducted in which Amelotex was used in patients with diseases of the musculoskeletal system. The purpose of the study was to evaluate the effectiveness and tolerability of Amelotex in patients in therapeutic practice. The study was conducted at the St. Petersburg State Medical University named after. Academician I.P. Pavlova. The study involved 25 patients aged from 23 to 81 years with diagnoses of osteochondrosis, gonarthrosis, and polyosteoarthrosis. Patients were prescribed the drug Amelotex, 1 ampoule (1.5 ml) intramuscularly 1 time per day for 6 days. The high effectiveness of the drug was noted by both patients and doctors. After using Amelotex, 80% of patients showed improvement, 20% showed significant improvement. The selective NSAID Amelotex was very well tolerated, as stated by 61% of patients, 36% assessed tolerability as good, 3% as satisfactory. A clinical study has shown that the use of Amelotex reduces the severity of pain and increases the range of motion in the joints and spine.
Amelotex is widely used in rheumatological practice, in particular in patients with gout. One of the Russian open randomized studies presents the results of the effective and safe use of Amelotex, prescribed to prevent attacks of arthritis in patients with gout when initiating therapy with allopurinol. This study included 20 men with gout who were examined at the Scientific Research Institute of the Russian Academy of Medical Sciences from May 2010 to April 2011. Average age of patients was 55.9±12.5 years (37-72 years), the duration of the disease was 10.4±6.9 years. The results of the study demonstrated that a monthly course of therapy with Amelotex can minimize the risk of exacerbations of arthritis when prescribed allopurinol.
Another open randomized study assessed the effectiveness of a 4-week course of Amelotex therapy in patients with gonarthrosis. This study included 48 patients (22 men and 26 women) with only chronic pain syndrome (>3 months). The average age of the patients was 58.5±10.4 years, the median duration of the disease was 10.3±7.8 years. Amelotex was prescribed at a dose of 15 mg (1.5 ml intramuscularly) 1 time/day for 5 days, then orally at a dose of 7.5 mg 1 time/day. The authors conclude that the use of intramuscular injections of Amelotex followed by the administration of its oral form in a low dose in patients with osteoarthritis (OA) leads to a significant, persistent reduction in the severity of pain, improved functional activity with good tolerability of the drug.
The drug should be administered deeply intramuscularly at a dose of 7.5-15 mg once a day. The maximum dose is 15 mg/day. Tablet forms of the drug should be taken with meals. If a positive therapeutic effect is achieved, the dose can be reduced to 7.5 mg/day. The maximum daily dose should not exceed 15 mg, and the initial daily dose in patients with increased risk development of side effects - 7.5 mg/day.
Doctors of various specialties have long been using neurotropic B vitamins in their practice, which in high doses have an analgesic effect, which leads to a reduction in the need for NSAIDs, because their effect is enhanced.
Medicine CompligamB is a complex of neurovitamins of group B, intended for the treatment of diseases of the nervous system of various origins: neuropathies and polyneuropathies, various pain syndromes. CompligamV has a convenient release form that takes into account the duration of the course of treatment. The drug is available in injection form, each ampoules (2 ml) contains thiamine hydrochloride - 100 mg, pyridoxine hydrochloride - 100 mg, cyanocobalamin - 1 mg, lidocaine hydrochloride - 20 mg.
An important quality of the drug CompligamV is the ability to enhance and prolong the analgesic effect achieved by prescribing basic pain therapy - NSAIDs and painkillers, which is explained by the presence of its own multilateral analgesic effect.
This is confirmed by the results of a study conducted by T.A. Vygovskaya, in which the effectiveness of the combined use of CompligamV and Amelotex in complex treatment OA. We examined 30 patients (25 women and 5 men) aged from 49 to 83 years with a disease duration of 2 to 20 years (on average 6.8 years) with predominant damage to the knees, ankles and shoulder joints, II-IV radiographic stage of the disease (according to A. Larsen). In 48.3% of patients, OA was complicated by reactive synovitis of the knee and ankle joints. The minimum course of treatment for OA was 15 days: during the first 5 days, Amelotex (15 mg intramuscularly) and CompligamB were prescribed simultaneously, and from the 6th to the 15th day treatment with CompligamB was continued. The effectiveness of treatment was assessed by changes in clinical indicators, ranked from 0 to 5, according to the Oswestry questionnaire (pain at rest, pain with movement, limitation of the range of active and passive movements). A clinically significant effect was stated when the scores in each section decreased by 6 points or more. In addition, data on the health status scale, pain intensity scale, and the risk of developing gastrointestinal complications according to the G. Singh index were assessed. During complex therapy with Amelotex and Compligam B, a significant improvement in clinical indicators was noted (decreased arthritis, increased exercise tolerance, decreased severity of pain).
Another study examined the effectiveness of combination therapy with Amelotex and CompligamB in patients with dorsopathies. The standard approach to the treatment of the acute period of dorsopathy is to provide pain relief to the patient as quickly as possible. For this purpose, a combination treatment regimen with Amelotex No. 5 1.5 ml intramuscularly and CompligamV No. 10 2 ml intramuscularly was used. The study included 60 patients aged 31 to 57 years who, when visiting a doctor, complained of acute back pain lasting from 7 to 10 days. 24 patients had a history of degenerative-dystrophic disease of the spine. The patients were divided into 2 groups - 43 people with diabetes mellitus(SD) type 2 (compensated) and 17 people - with peptic ulcer, duodenal ulcer in remission. In all patients, pain syndrome was expressed as:
- reflex-muscular syndrome (12 people);
- myofascial syndrome (15);
- vertebrogenic radiculopathy (29);
- fibromyalgia (4).
The study used the Oswestry Questionnaire, the Clinical General Impression Scale, which was filled out by the doctor during treatment, and a 10-point pain intensity scale (patients noted the intensity of pain experienced at the time of the study). In 11 patients with type 2 diabetes and 9 patients with peptic ulcer disease, the maximum score was 50. Of the two groups of patients who received treatment with Amelotex No. 5 15 mg/1.5 ml intramuscularly and CompligamV No. 10 2 ml intramuscularly, no side effects. All patients completed the full course of treatment with 100% relief of acute back pain.
Muscle relaxants, without having a direct analgesic effect, have found widespread use in the treatment of dorsopathies. The main representatives of this group are tolperisone, baclofen, tizanidine. They are most effective when the muscular-tonic component of pain predominates.
The presence of compression syndrome is an indication for the prescription of anti-ischemic drugs: antioxidants, antihypoxants, vasoactive drugs. For back and neck pain, a wide range of physiotherapeutic procedures and local treatment are also used.

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