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Back Pain.

Vertebrogenic neurologic and others skeletal-muscular


disorders.

Back pain is one of the most frequent complaints of patients in general medical practice and
one of leading (according to some data the second in the frequency after respiratory
diseases) rotation after the medical aid. In our country, patients with back pain more
frequently turn themselves to neurologists or specialists of manual medicine; however, with
the development of family medicine, the number of patients with back pain and inspected
and are treated by doctors of general practice increases.

Basic reasons for back pain. Back pain is an example but to 90% of cases is caused by
the degenerative-dystrophic changes of vertebrae (osteochondrosis, spondylosis,
spondyloarthrosis), congenital or acquired by deformation of spine, myofacial syndromes or
fibromyalgia.

Degenerative-dystrophic of vertebra is manifested by osteochondrosis - the degenerative


destruction of cartilage of intervertebral disc and by reactive changes of corpus (body) of
vertebrae. The destruction of intervertebral disc appears as a result of its repeated injuries
(heavy lifting, excess static and dynamic load, drop and other) and degenerative changes
dependent on age. Nucleus pulposus (center section of disc) dries and partially loses the
shock-absorbing function. The fibrous ring (annulus), located along the periphery of disc,
becomes thinner, formed cracks in it, causes nucleus pulposus to displace, and form
buckling (prolapse), and with the break of fibrous ring hernias (protrusion). The hernias of
intervertebral discs most frequently appear at lower lumbar segments, less frequently in
lower-cervical and the lower-lumbar, and in extremely rare case in thoracic segments.
Hernias of the vertebra disc (Schmorl’s hernia) are not clinically unknown. The hernias of
disc in the posterior and postero-lateral direction can cause the compression of
cerebrospinal radix (radiculopathy), spinal cord (myelopathy), it is more frequent at the
cervical level, or its vessels. In lesion of vertebral segment, relative instability of spine
appears, bone growths of bodies of vertebrae - osteophytes are developed, and ligaments
(spondylosis) and intervertebral joints (spondyloarthrosis) are damaged. The formation of
posterior osteophytes can lead to the contraction of vertebral canal, the formation of lateral
osteophytes lead to the compression of cerebrospinal radix in the intervertebral canal.

Besides compression, the syndromes are possible reflexes (muscular-tonic), which are
caused by pathologic pulsation from the painful receptors of the changed discs, ligaments
and joints of spine. The reflex muscle tension at first has protecting nature, since it leads to
the immobilization of the lesion segment; however, subsequently it becomes the factor,
which supports pain. The reflex syndromes of osteochondrosis of spine appear into the
period of life almost in each second person, compression - considerably less frequent.
Osteochondrosis of lumbar division frequently is combined with the pathology of sacral-iliac
articulations.

The frequent reason for back pain can be congenital or acquired deformations of spine
(scoliosis - curve of spine in the lateral plane, kyphosis - curve of spine posteriorly),
displacement of the bodies of vertebrae - spondylolisthesis (usually Lv it displaces forward
relatively S, or LIV relatively Lv), contraction of opening of vertebral canal (vertebral stenosis)
and caused by the decrease of calcium content in bones reduces in thickness of bone tissue
- osteoporosis, which complicates the compression of break of spine. These change usually
are combined with degenerative-dystrophic changes of vertebra.

Myofascial pain is caused by the formation of the aphis of the called trigger points (zones) in
the muscles and/or its connection with fascias. Trigger points appear under the influence of
chronic muscular stress with hard physical work, prolonged stay in inconvenient pose, acute
motion and other states. These points can be found in active or passive state, active trigger
point presents as the zone of the increased excitability of muscle or its fascia, it causes the
pain when rest and during motion, with accompanying muscle tension . Passive trigger point
is revealed only during the palpation of muscle that also makes it possible to determine.
Fibromyalgia is characterized by diffuse and usually symmetrical pain in the muscles of
body and extremities it more frequently in average and elderly age women, it is combined
with depression, sleep disorder, asthenia and other mental disorders, which indicates its
probable psychogenic origin.

Back pain can be only symptom with the tumor of spinal cord, syringomyelia and others
disease of spinal cord. It appears with destruction of vertebrae and destuction of nervous
radixes as a result of the infectious processes (tubercular spondylitis, spinal epidural
abscess), new formation (primary and metastatic tumors of spine, myeloma disease),
dysmetabolic disturbances (hyperparathyroidism, Paget’s disease). Back pain can also be
caused by break of spine, stenosis of vertebral canal and ankylosis spondyloartrita
(Bekhterev disease). Back pain also appears in different somatic diseases (heart, stomach,
pancreas, kidney, organs of pelvic minor and others) by the mechanism of the pain reflex,
therefore it is necessary to have it in differential diagnostics.

The prevalence of different reasons for back pain substantially changes with the age.
Changes in the carriage (scoliosis, kyphosis), myofascial syndromes, congenital deformation
of spine and osteochondropathy (Scheuermann’s disease) are the most frequent reasons for
pain and to back at the children's and teenage period. Myofascial syndromes and injuries
serve as the leading reasons for pain and back in the young and middle age. Besides these
reasons, in elder age, back pain is frequently caused by spondylosis, spondyloarthrosis,
osteoporosis, metastases of tumors. In women, the frequent reason for pain is fibromyalgia.

Inspection of patient with the back pain. With collecting of complaints and anamnesis,
ask about localization and irradiation of pain, its duration and the circumstance of
appearance, dependence of pain on the position of body and motion of spine, transferred
injuries and disease. The appearance of a pain after awkward motion, prolonged stay in the
inconvenient pose, hard physical work, and also increased pain during changes in the
position of body and motions are characteristic for the neurologic manifestations of
degenerative-dystrophic of vertebra and myofascial syndromes. The estimation of the
emotional state of patient (development of depression and increased anxiety) has great
significance in chronic painful syndrome, which in many cases is caused and is supported by
psychogenic factors.

In patient with the back pain, visual inspection should be carried out, and determine
mobility of different divisions of spine, presence of local pain of spine and extremities,
muscle tension and pain during their palpation (neuroorthopedic inspection). During visual
inspection, it is possible to reveal the bend of spine to the lateral side (scoliosis), increased
the physiological bends of spine (lordosis or kyphosis), limitation of mobility in some
divisions of spine during the turnings in bed, getting up, walking or motion, which causes
stress of the affected muscle. During neurologic inspection, determine the presence of
paresis, sensory disorders, precipitation of reflexes, symptoms of tension of nervous radixes
and others neurologic disturbance, somatic inspection is directed toward the development
the malignant new formations, infectious process and somatic diseases, which can be
manifested by back pain.

In patients with back pain, the diagnosis frequently is put based on neurologic and
neuroorthopedic inspection, if it reveals the typical clinical pictures of degenerative-
dystrophic of vertebra, myofascial syndrome or fibromyalgia and in this case there are also
no signs of oncologic or inflammatory disease, and spinal trauma.

In some cases of back pain, further studies is necessary, to reveal other illnesses, which
sometimes hide themselves as pain syndromes. Indications of these cases include: (1)
untypical picture of painful syndrome (absence of connection of pain with motions of spine;
unusual localization of pain); (2) injury of back in anamnesis; (3) fever, symptoms of
intoxication, oncological disease; (4) disturbance of pelvic organs function, with the signs of
destruction of spinal cord.

In such cases, additional investigations are necessary, the most frequently used one are: (1)
X-ray of spine in several projections, (2) general and biochemical analysis of blood, (3) CT or
MRI of spine, (4) densitometry (estimation of bone density) and scintinography of spine and
bones of basin and extremities.

The X-ray of spine makes it possible to exclude the congenital anomalies and deformations,
break of vertebrae, displacement of bodies of vertebrae (spondylolisthesis), inflammatory
diseases (spondylitis), primary and metastatic tumors. The X-ray of spine cannot accurately
determine the hernia of intervertebral disc, but indirectly its presence is indicated by the
decrease of the height of intervertebral disc. Signs of degenerative-dystrophic changes
(osteochondrosis, spondylosis or spondyloarthrosis) are seen almost in 50% middle age and
in majority of elder patients, there is no direct dependence between the presence and their
manifestation and back pain. Therefore, the development of degenerative-dystrophic
changes in X-ray does not exclude the presence of other reasons for back pain and it cannot
be the basis of clinical diagnosis.

Roegent CT or MRI makes it possible to reveal disc hernia, to determine its sizes and
localization, and also to reveal stenosis of vertebral canal, tumor of spinal cord or other
neurologic illnesses. It is important to note that with CT and MRI of spine, the dystrophic
changes are revealed frequently, especially in the elder age. These changes are revealed
almost in 90% of elder patients with back pain. The presence of hernia of intervertebral
discs according to data of CT or MRI, especially small sizes, does not exclude other reason
for back pain and cannot be the basis of clinical diagnosis. The densitometry of the bones is
used for diagnostics of reduction in the bone density (osteoporosis), scintigraphy of the
bones to determine their metastatic destruction.
Degenerative-dystrophic changes in the spine (osteochondrosis, spondylosis,
spondyloarthrosis) are more frequently manifested as form the lumbar reflex syndromes:
Lumbago, lumbalgia, lumboishialgia.

Lumbago (lower back pain) is acute, shooting pain, which is usually developed during the
physical load (heavy lifting) or in awkward motion. Patient frequently stay in the
inconvenient position, any movements leads to increase of pain. Examination reveals
tension of muscles of back, usually scoliosis, flattening of lumbar lordosis or kyphosis,
significant limitation of mobility in the lumbar division because of increased pain. The
symptoms of the destruction of peripheral nervous system are not determined.

Lumbalgia (back pain) and lumboishialgia (pain of spine and at posterior surface of leg)
are developed more frequently after physical load, awkward motion or supercooling, less
frequently - without any reasons. Pain is dull, increased during motions of spine, specific
poses, walking. For lumboishialgia, pain is characteristic in gluteal and on posterolateral
surface of leg, but different from the destruction of nervous radix (radiculopathy) with reflex
syndromes, the pain does not reach the toes. Inspection reveal pain, tension in muscle of
back and posterior muscles group of leg, movement limitation of spine, frequently scoliosis,
and symptoms of tensions (Lasegue, Wasserman and others).

Radiculopathy of lumbar and first sacral radixes are manifested by the acute shooting
pain of lumbar and leg. During inspection of patient, besides muscle-tonic syndrome
(tension of muscles of back and foot), sensory, reflex and/or motor disturbance in the zone
of radix lesion also observed in reflex lumboishialgia. Radicular pain is more intensive than
pain in muscle-tonic syndrome, and it is characterized by irradiation in proximal-distal
direction along the path of radix. Radicular pain is acute, sometimes “dagger” type, usually
happens during motion, and cough. Other characteristics are increased pain after sneezing,
moving chin to sternum, symptoms of tension of nervous radix. More frequently lesions are
in the fifth lumbar (L5) and first sacral (S1) radixes, less frequently in fourth lumbar radix (L4)
and the very rarely in upper lumbar radixes

In radiculopathy of S1, pain and paresthesia stretch out from the back and gluteal to over
the posterior surface thigh, posterolateral surface of leg to the lateral edge of foot and last
toe. The zone of pain and tactile hypesthesia is revealed on the external surface of thight
and last toe, less frequently - on the posterior surface of thigh; Achilles tendon reflex loss,
the involvement of motor part of radix is determined by the weakness of gastrocnemius
muscle, sometimes - pronators of foot.
In radiculopathy of L5, pain and paresthesia stretch out from the back and gluteal along the
external surface of thigh and thigh to the internal edge of foot and big toe. The zone of
hypesthesia is revealed on the external surface of thigh and big toe, reflexes are preserved;
the involvement of the motor part of the radix is determined with weakness of m. extensor
hallucis longus, it is less frequent - back flexors and pronators of foot.

In radiculopathy L4, pain and paresthesias is on anteromedial surface of thigh, sometimes


and over the medial surface of thigh. The zone of hypesthesia is revealed in the same
region, loss of patellar reflex, the weakness of quadriceps muscle of thigh can be
determined. Important diagnostics methods are neurovisualization (CT or MRI), which reveal
the damage of radix by disc hernia or by osteophyte.

Cervicalgia and cervicobrahialgia are reflex syndromes at the neck level, which frequently
develop after physical load or awkward motion of neck. Cervicalgia is pain in the neck
region, which is frequently extended to back of the head (cervicocranialgia).

Cervicobrahialgia is pain in the neck region with the propagation into the hand. Pain is
characteristically increased during motions of neck or, on the contrary, with the prolonged
monotonous position (in cinema, after sleep on the dense high pillow and others).
Examinations reveal tension of neck muscles, limitation of motions in the neck division, pain
during the palpation of spinous processes and intervertebral joints on the side of pain.

Radiculopathy of lower neck radixes is encountered far less frequent than reflex syndromes,
and it is manifested, other than muscular- tonic syndrome, by sensory, reflex and/or motor
disturbances of innervations zone of radix lesion. In radiculopathy; pain is noted on the edge
of trapezoideus muscle, in their upper divisions of arm with the irradiation over its front
surface, radial surfaces of forearm and frequently to thumbs and indicating finger, and
possible sensory disturbances in these regions, reduction of reflex of biceps muscle and
carpalradial reflex, light paresis of the muscles, which ensure the flexor of forearm and the
external rotation arm.
With radiculopathy C7, pain is noted in the scapula and irradiates to region of thoracic
muscles, armpit, posterior lateral surface of arm, posterior surface of forearm, indicating
and middle fingers; possible sensory disturbances in these regions, reduction ofreflex of
triceps, weakness of muscles, which extend the forearm. CT or a MRI-study of the neck
division of spine is informative.

In thoracic segments, reflex and compression syndrome of degenerative-dystrophic of


vertebra are encountered considerably less frequent than in the lumbar and neck divisions.
They are manifested by reflex muscle-tonic syndromes, in radiculopathy by sensory
disturbance of zone of radixes lesion.

Period of reflex and compression complications of degenerative-dystrophic changes of


vertebra is different. In majority of cases at 20-60 year old, the periodic exacerbation of
disease are observed, it is more frequent after physical loads, awkward motion or
supercooling. Reflex syndromes usually pass in the period of several days or 2-4 weeks,
while radiculopathy in the course of months, but in some cases they may assume chronic
course of years. After 60 years old, exacerbation of diseases frequently become rare or
stops entirely.

Spondylolisthesis (most frequent displacement of Lv forward relative to SI or LIV, relatively


LIV) usually appears at child or teenage period, but it is manifested clinically in middle and
elderly age. Characteristically, pain is in the lower divisions of back, limitation of mobility in
but gluteal division, palpated “step” from one spinal process to lower one (from L v to S1, or
from L!v to Lv), expressed lumbar lordosis. Pain is increased when standing and, also, when
walking. In some cases, as a result of the compression of cerebrospinal radixes, peripheral
paresis of extremities, segmental-radicular type sensory disorder or disturbance of pelvic
organs function appear.

Lumbar stenosis (contraction of vertebral canal in lumbar division) is manifested by pain


in the lower divisions of back usually with the irradiation to the thigh and leg. As rule, pain
increases when standing and walking. It can resemble the intermittent limping, connected
with the destruction of vessels. In some cases, peripheral paresis of feet and its sensory
disturbances appear. While sitting, the inclination forward and flexion of body, the
symptoms decrease or disappear.

Vertebrogenic cervical myelopathy relates to the rare complications of the


degenerative-dystrophic changes of vertebra, which are manifested by the contraction of
vertebral canal at neck level and by compression of spinal cord. It appears predominantly at
middle and elderly age and usually develops gradually. Pain and limitation of motions in the
neck division of spine are at first noted. Subsequently, weakness in the extremities follows,
peripheral paresis in hands of patients is revealed, in feet - spastic paresis and deep
sensory disturbance. In rare cases, function of pelvic organs is disrupted.

Compression of the radixes of the coccyx is another rare complication of


osteochondrosis, caused by large middle hernias of the discs of L5-S1 and L4-L5. It is
manifested by acute pain in both feet, numbness in them and anogenital region and the
disturbance of pelvic organs function. Compression of radicular-spinal artery of L 5 and S1 is
manifested by of back pain and the foot and also weakness of foot (paralyzing sciatica) with
the subsequent weakening of pain. In extreme rare cases, artery supplying the spinal cord
squeezes (spinal stroke), which is manifested by paralysis of feet, conductor type of sensory
disorders of and pelvic disturbances.

Diagnosis of reflex and compression complications of degenerative-dystrophic


changes in the spine is based on clinical data and requires the elimination of other
possible reasons for back pain. X-ray of spine is used, to eliminate possible congenital
anomalies and deformations, spondylosis, inflammatory diseases (spondylitis), primary and
metastatic tumors. X-ray CT or MRI can reveal disc hernia, to determine its size and
localization, and also stenosis of vertebral canal, spondylolisthesis, tumor and other
illnesses of spinal cord.

Myofascial pain is manifested by tension of muscle and by the presence of trigger points in
them, which is revealed by manual study of muscles. Active trigger point is a steady source
of the pain, which amplifies during the palpation in point of the muscle; the latent trigger of
point causes pain only during its palpation. In each muscle, myofascial syndrome appears
independently, with its characteristic localization of pain when trigger zone is irritated,
which extended beyond the limits of projection of muscle on skin surface. In myofascial
syndrome, symptoms of peripheral nervous system destruction is not present, with
exception of those cases, when tensioned muscles squeeze nerve trunk.

Myofascial pain is frequently encountered in scalene muscle and quadratus lumborum. In


destruction of scalene muscle is turning of head is almost doubly limited because the pain
can extend around humeral joint and along hand. In myofascial syndrome of quadrates
lumborum muscle, pain in the back and pain during the palpation of muscle occurs and the
pain frequently is extended to gluteal region, iliac crest and trochanter major of thigh.

Diagnosis of myofascial syndromes is based on clinical data and elimination of others


possible causes of pain; differential diagnosis of reflex syndromes (muscular-tonic
syndromes) as a result of degenerative-dystrophic of vertebra is usually complex, and the
combination of these diseases is possible.

Pain can pass spontaneously if causing factors of myofascial pain are absent, if muscle is
rested for several days. On the contrary, physical load, stress situation and other negative
influences can contribute to the chronic course myofascial syndrome, which is accompanied
by the development of dystrophic processes in the muscles involved.

Fibromyalgia is encountered predominantly in women. Diffuse and symmetrical pain in the


body and the extremities is characteristic. The painful points are noted, which by light touch
of palpation increases pain. In fibromyalgia, in contrast to the myofascial pain, the pressure
on painful points does not cause muscular tension and propagation of pain to other regions.
Painful zones usually are located in the occipital region, neck, inter-scapular region, back,
gluteal, and medial surface of knee joint. The destructions of peripheral nervous system is
not noted. In patients with fibromyalgia, frequently depression, asthenia, sleep disturbance,
tension headache and pain syndromes of other localization are seen. Diagnosis is based on
clinical data. Chronic course of disease predominates with the frequent exacerbation,
frequently caused by psychogenic factors.

Other illnesses, which are manifested by back pain. Tumor of spinal cord,
syringomyelia and other illnesses of spinal cord manifested by back pain usually is
combined with other neurologic disorders, and without presence muscular-tonic syndrome.
Diagnosis is established with the aid of CT or MRI of spine.

With the destructive destruction of spine (tubercular spondylitis, primary tumor or


metastasis of spine, osteoporosis, hyper-parathyroidism), local pain frequently is observed,
diagnosis is established on the basis the results of X-ray photograph and/or CT or MRI of
spine.

Break of spine, congenital or acquired deformations of spine (scoliosis), deformed


spondyloarthritis, rheumatoid arthritis, Paget’s disease are also manifested by back pain.
Roentgenological methods of study are more significant in their diagnosis.

In somatic diseases, pain reflected in MRI usually is not combined with other manifestations
disease and it is not accompanied by muscle tension of spine and usually pain does not
increase during motions of spine. Reflection pain usually is diffuse and dull, but with times,
pain becomes more acute and superficial.

Treatment of back pain is based on the therapy of main disease. Subsequently,


treatment for more frequent reasons for back pain is started - neurologic complications of
degenerative-dystrophic changes of vertebra, myofascial pain and fibromyalgia.

The treatment of reflex syndrome and radiculopathy as a result of degenerative-dystrophic


changes of vertebra is based in the acute period on the rest, A the running of acute
inclinations and unhealthy pos. Bed rest is recommended for the course of several days
until decrease of acute pain, rigid bed (panel under the mattress), analgesics, NSAIDs
(diclofenac, indomethacin, movalis, Celebrex and others) and myorelaxants (Mydocalm,
Sirdalud). After this, it is recommended to gradually increases physical load, patient should
avoid excessive muscular tension (prolonged more sedentary position, heavy lifting, etc).
During declining of pain, gradual increase of motor activity exercise on involved muscles is
recommended. Earlier and more active patients gradually return to the labor can decrease
the probability of chronic course of pain syndrome.

In acute pain of lower part of back, it is possible to use the fixing belt, in pain in neck - neck
collar. However, prolonged fixation of neck or lumbar division is not recommended, with
exception of some cases, for example, traumatic break of vertebrae or their displacement
(spondylolisthesis). The lumbar fixing belt can also be used periodically with the need for
movement in the case of acute pain, and also heavy lifting after the calming of pain. It is
possible to use the physiotherapy anesthetic procedures, rubbing ointment, compression of
30-50% solution of dimexide and novocaine, novocaine and hydrocortisone blockades.

In radiculopathy, especially in paralyzing sciatica with radicular pain and paresis of foot,
drugs to improve blood circulation in vessels of cerebrospinal radix are used, for example
pentoxiphyllin (Trental, vaso-nit).
If reflex syndromes of degenerative-dystrophic changes in the spine usually are passed in 1-
4th week; then for radiculopathy, the periods of restoration is prolonged to 6-8 weeks. With
the chronic course the reflex syndromes and radiculopathy, physiotherapy treatment, non-
steroidal anti-inflammatory drugs, myorelaxants, manual therapy; reflexotherapy and
sanitation and health treatment can be effective. In many patients with prolonged period of
pain syndrome, depressive disorder is revealed and significant effect can be seen from the
use of antidepressants (Amitriptylene, Fluoxetin and other) with combination of other
methods of therapy, and by especially therapeutic gymnastics.
Surgical treatment (removal of disc hernia) is necessary in those rare cases, when the
compression of spinal cord or cerebrospinal radixes appears. Surgical treatment in optimal
periods is indicated in lumbar stenosis, spondylolisthesis and vertebrogenic cervical
myelopathy.

To prevent the aggravations of osteochondrosis, it is recommended to avoid the provoking


factors (lift of large loads, heavy lifting of bag in one hand, supercooling and other), with
regular therapeutic gymnastics care.

In myofascial pain, it is necessary to give muscle rest for several days. It is possible to use
exercises for tensioned muscles (postizometric relaxation), myorelaxants (Mydocalm,
Sirdalud), physiotherapy (ultrasound), reflexotherapy or local introduction of anesthetics to
the trigger zones, compresses with the dimexide and anesthetics.

In fibromyalgia, the most effective treatment is anti-depression (Amitriptylene, Fluoxetin


and others). To decrease pain, non-steroidal anti-inflammatory drugs, physiotherapy,
therapeutic gymnastics and reflex therapy is used. In many patients, only some declining of
pain is observed after the course of treatment, and frequently aggravations appear, which
requires the repeated courses of treatment.

Brief information about the neurologic manifestations of


degenerative-dystrophic changes of vertebra, myofascial syndrome and fibromyalgia
Basic Degenerative-dystrophic Myofascial pain Fibromyalgia
characteris changes of vertebra syndrome
tics
Reason of Reflex (muscular-tonic) Formation of active and With background
pain syndromes and passive trigger zones of depression and asthenia
radiculopathy muscle appears diffuse pain
(psychogenic pain)
Clinical Appearance of a pain Appearance of the pain Appearance of diffuse pain
picture afterward to physical load, after physical load, with background of
increased pain when increased pain during depression, pain during
change position of motion, which causes the palpation of muscles
vertebrae, movements, tension of muscle, in neck, sleep and
muscle-tonic syndrome and presence of painful zones extremities, motion of
in radiculopathy symptoms during palpation of muscle vertebrae frequently are
of lesion of radix unconfined
X-ray of Signs of osteochondrosis, Specific changes is Specific changes is
vertebrae spondilosis, absence absence
spondyloarthrosis
CT or МRI of Frequently by hernia of Specific changes is Specific changes is
vertebrae intervertebral discs absence absence
Diagnosis Characteristic changes with the neurologic and the neuroorthopedic inspection, the
absence of data on clinical signs and additional studies (X-ray of spine, CT or MRI) after
another reason for back pain
Treatment In the acute period - rest, Avoid tension of muscle, Antidepressants, NSAIDs,
analgesics, NSAIDs, postizometric relaxation, therapeutic gymnastics
myorelaxants, during introduction of anesthetics
weakening pain - into the trigger points,
therapeutic the gymnastics myorelaxants, during the
weakening pain -
therapeutic gymnastics