medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/2079-701X-2020-21-70-77medsovet-5967Research ArticleНЕВРОЛОГИЯNEUROLOGYБоль в спинеBack painПизоваН. В.PizovaN. V.

д.м.н., профессор, кафедра нервных болезней с медицинской генетикой и нейрохирургией, 

150000, Ярославль, ул. Революционная, д. 5

Dr. of Sci. (Med.), Professor, Department of Nervous Diseases with Medical Genetics and Neurosurgery, 

5, Revolutsionnaya St., Yaroslavl, 150000

pizova@yandex.ruЯрославский государственный медицинский университетРоссияYaroslavl State Medical UniversityRussian Federation2020130120210217077Copyright © Пизова Н.В., 20212021Пизова Н.В.Pizova N.V.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-sovet.pro/jour/article/view/5967

Боль в нижней части спины является одной из основных причин нетрудоспособности во всем мире. Представлены данные о распространенности боли в нижней части спины. Даны сведения о патогенезе боли. Представлены временные характеристики боли. Рассмотрены факторы риска и триггеры для эпизодов боли в нижней части спины. Описаны наиболее частые причины специфической и неспецифической боли в нижней части спины. Чаще встречается неспецифическая боль в нижней части спины, поскольку конкретная патолого-анатомическая причина не может быть идентифицирована. Специфическая боль включает ноцицептивную и невропатическую боль. Для постановки правильного диагноза у пациента с болью в нижней части спины необходим тщательно собранный анамнез, который обычно дает важную информацию по выявлению причины болевого синдрома. Отдельно рассмотрены предупреждающие знаки («красные флажки») для конкретных причин боли в пояснице, требующих срочного лечения, и специфические психосоциальные факторы, способствующие хронификации боли («желтые флаги»). К «красным флажкам» относятся такие состояния, как подозрение на травматическое поражение, на опухоль, на инфекцию или на радикулопатию, синдром конского хвоста. «Желтые флажки» включают индивидуальные когнитивные, эмоциональные и поведенческие факторы, которые способствуют развитию хронических болей. Основная цель фармакотерапии боли в нижней части спины – дать пациентам возможность продолжить или возобновить свою обычную повседневную деятельность. Представлены основные рекомендуемые подходы в лечении острой и хронической боли в нижней части спины. Описаны основные нестероидные противовоспалительные препараты для перорального лекарственного лечения неспецифической боли в пояснице с дозами, основанными на фактических данных. Отдельное внимание отведено месту препарата диклофенак в терапии болевого синдрома. Представлены результаты систематизированных обзоров, посвященных анализу имеющихся сведений об эффективности и безопасности лекарственных форм для локального трансдермального введения, которые содержат НПВП.

Low back pain is a major cause of disability worldwide. Data on the prevalence of low back pain are presented. Information on the pathogenesis of pain is given. The temporal characteristics of pain are presented. Risk factors and triggers for episodes of low back pain are reviewed. The most common causes of specific and non-specific low back pain are described. Non-specific low back pain is more common, as no specific pathological-anatomical cause can be identified. Specific pain includes nociceptive and neuropathic pain. In order to make a correct diagnosis in a patient with low back pain, a thorough medical history must be taken, which usually provides important information in identifying the cause of the pain syndrome. The warning signs (‘red flags’) for specific causes of low back pain requiring urgent treatment and specific psychosocial factors contributing to chronic pain (‘yellow flags’) are considered separately. ‘Red flags’ include conditions such as suspected traumatic injury, tumour, infection or radiculopathy and cauda equina syndrome. «Yellow flags» include individual cognitive, emotional and behavioural factors that contribute to the development of chronic pain. The main aim of pharmacotherapy for low back pain is to enable patients to continue or resume their normal daily activities. The main recommended approaches in the treatment of acute and chronic low back pain are presented. The main non-steroidal anti-inflammatory drugs for the oral drug treatment of non-specific low back pain are described, with evidence-based doses. Special attention is given to the role of diclofenac in the treatment of pain. The authors present the results of systematic reviews that analyse the available data on the efficacy and safety of topical transdermal dosage forms that contain NSAIDs.

острая и хроническая больболь в нижней части спиныдиагностикалечениедиклофенакacute and chronic painlow back paindiagnosistreatmentdiclofenacReferencesGlobal, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Lancet. 2016;388(10053):1545–1602. doi: 10.1016/S0140-6736(16)31678-6.Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Lancet. 2016;388(10053):1545–1602. doi: 10.1016/S0140-6736(16)31678-6.Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. GBD 2016 DALYs and HALE Collaborators. Lancet. 2017;390(10100):1260–1344. doi: 10.1016/S0140-6736(17)32130-X.Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. GBD 2016 DALYs and HALE Collaborators. Lancet. 2017;390(10100):1260–1344. doi: 10.1016/S0140-6736(17)32130-X.Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Lancet. 2017;390(10100):1211–1259. doi: 10.1016/S0140-6736(17)32154-2.Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Lancet. 2017;390(10100):1211–1259. doi: 10.1016/S0140-6736(17)32154-2.Hoy D., Bain C., Williams G., March L., Brooks P., Blyth F. et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012;64:2028–2037. doi: 10.1002/art.34347.Hoy D., Bain C., Williams G., March L., Brooks P., Blyth F. et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012;64:2028–2037. doi: 10.1002/art.34347.Jordan K.P., Kadam U.T., Hayward R., Porcheret M., Young C., Croft P. Annual consultation prevalence of regional musculoskeletal problems in primary care: an observational study. BMC Musculoskelet Disord. 2010;11:144. doi: 10.1186/1471-2474-11-144.Jordan K.P., Kadam U.T., Hayward R., Porcheret M., Young C., Croft P. Annual consultation prevalence of regional musculoskeletal problems in primary care: an observational study. BMC Musculoskelet Disord. 2010;11:144. doi: 10.1186/1471-2474-11-144.Dieleman J.L., Baral R., Birger M., Bui A.L., Bulchis A., Chapin A. et al. US spending on personal health care and public health, 1996–2013. JAMA. 2016;316(24):2627–2646. doi: 10.1001/jama.2016.16885.Dieleman J.L., Baral R., Birger M., Bui A.L., Bulchis A., Chapin A. et al. US spending on personal health care and public health, 1996–2013. JAMA. 2016;316(24):2627–2646. doi: 10.1001/jama.2016.16885.Lambeek L.C., van Tulder M.W., Swinkels I.C., Koppes L.L., Anema J.R., van Mechelen W. The trend in total cost of back pain in The Netherlands in the period 2002 to 2007. Spine (Phila Pa 1976). 2011;36:1050–1058. doi: 10.1097/BRS.0b013e3181e70488.Lambeek L.C., van Tulder M.W., Swinkels I.C., Koppes L.L., Anema J.R., van Mechelen W. The trend in total cost of back pain in The Netherlands in the period 2002 to 2007. Spine (Phila Pa 1976). 2011;36:1050–1058. doi: 10.1097/BRS.0b013e3181e70488.Dieleman J.L., Cao J., Chapin A., Chen C., Li Z., Liu A. et al. US Health care spending by payer and health condition, 1996–2016. JAMA. 2020;323(9):863–884. doi: 10.1001/jama.2020.0734.Dieleman J.L., Cao J., Chapin A., Chen C., Li Z., Liu A. et al. US Health care spending by payer and health condition, 1996–2016. JAMA. 2020;323(9):863–884. doi: 10.1001/jama.2020.0734.Кукушкин М.Л. Боль в спине: мишени для патогенетической терапии. РМЖ. 2011;(30):1862. Режим доступа: https://www.rmj.ru/articles/nevrologiya/Boly_v_spine_misheni_dlya_patogeneticheskoy_terapii.Kukushkin M.L. Back pain: targets for pathogenetic therapy. RMZh = RMJ. 2011;(30):1862. (In Russ.) Available at: https://www.rmj.ru/articles/nevrologiya/Boly_v_spine_misheni_dlya_patogeneticheskoy_terapii.Курушина О.В., Барулин А.Е. Современные аспекты лечения болей в спине. РМЖ. 2012;(10):528. Режим доступа: https://www.rmj.ru/articles/nevrologiya/Sovremennye_aspekty_lecheniya_boley_v_spine.Kurushina M.L., Barulin A.E. Current aspects of back pain treatment. RMZh = RMJ. 2012;(10):528. (In Russ.) Available at: https://www.rmj.ru/articles/nevrologiya/Sovremennye_aspekty_lecheniya_boley_v_spine.Баринов А.Н. Сегментарные механизмы формирования мышечного спазма, спастичности и хронизации боли. Врач. 2012;(5). Режим доступа: https://medi.ru/info/695.Barinov A.N. Segmental mechanisms of muscle spasm, spasticity, and pain chronification. Vrach = The Doctor. 2012;(5). (In Russ.) Available at: https://medi.ru/info/695.van Tulder M., Becker A., Bekkering T., Breen A., del Real M.T.G., Hutchinson A. et al. Chapter 3 European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15(2S):169–191. doi: 10.1007/s00586-006-1071-2.van Tulder M., Becker A., Bekkering T., Breen A., del Real M.T.G., Hutchinson A. et al. Chapter 3 European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15(2S):169–191. doi: 10.1007/s00586-006-1071-2.Fischbein R., McCormick K., Selius B.A., Labuda Schrop S., Hewit M., Baughman K., Meeker J. The assessment and treatment of back and neck pain: an initial investigation in a primary care practice-based research network. Prim Heal Care Res Dev. 2015;16(5):461–469. doi: 10.1017/S1463423614000504.Fischbein R., McCormick K., Selius B.A., Labuda Schrop S., Hewit M., Baughman K., Meeker J. The assessment and treatment of back and neck pain: an initial investigation in a primary care practice-based research network. Prim Heal Care Res Dev. 2015;16(5):461–469. doi: 10.1017/S1463423614000504.Gatchel R.J., Peng Y.B., Peters M.L., Fuchs P.N., Turk D.C. The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychol Bull. 2007;133(4):581–624. doi: 10.1037/0033-2909.133.4.581.Gatchel R.J., Peng Y.B., Peters M.L., Fuchs P.N., Turk D.C. The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychol Bull. 2007;133(4):581–624. doi: 10.1037/0033-2909.133.4.581.Casser H.R., Seddigh S., Rauschmann M. Acute Lumbar Back Pain. Dtsch Arztebl Int. 2016;113(13):223–234. doi: 10.3238/arztebl.2016.0223.Casser H.R., Seddigh S., Rauschmann M. Acute Lumbar Back Pain. Dtsch Arztebl Int. 2016;113(13):223–234. doi: 10.3238/arztebl.2016.0223.Maher C., Underwood M., Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070):736–747. doi: 10.1016/S0140-6736(16)30970-9.Maher C., Underwood M., Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070):736–747. doi: 10.1016/S0140-6736(16)30970-9.Hoy D., Brooks P., Blyth F., Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010;24(6):769–781. doi: 10.1016/j.berh.2010.10.002.Hoy D., Brooks P., Blyth F., Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010;24(6):769–781. doi: 10.1016/j.berh.2010.10.002.Fejer R., Leboeuf-Yde C. Does back and neck pain become more common as you get older? A systematic literature review. Chiropr Man Therap. 2012;20(1):24. doi: 10.1186/2045-709x-20-24.Fejer R., Leboeuf-Yde C. Does back and neck pain become more common as you get older? A systematic literature review. Chiropr Man Therap. 2012;20(1):24. doi: 10.1186/2045-709x-20-24.Deyo R.A., Weinstein J.N. Low back pain. N Engl J Med. 2001;344(5):363–370. doi: 10.1056/NEJM200102013440508.Deyo R.A., Weinstein J.N. Low back pain. N Engl J Med. 2001;344(5):363– 370. doi: 10.1056/NEJM200102013440508.Koes B.W., van Tulder M.W., Thomcaas S. Diagnosis and treatment of low back pain. BMJ. 2006;332(7555):1430–1434. doi: 10.1136/bmj.332.7555.1430.Koes B.W., van Tulder M.W., Thomcaas S. Diagnosis and treatment of low back pain. BMJ. 2006;332(7555):1430–1434. doi: 10.1136/bmj.332.7555.1430.Nijs J., Apeldoorn A., Hallegraeff H., Clark J., Smeets R., Malfliet A. et al. Low back pain: guidelines for the clinical classification of predominant neuropathic, nociceptive, or central sensitization pain. Pain Physician. 2015;18(3):E333–346. Available at: https://pubmed.ncbi.nlm.nih.gov/26000680.Nijs J., Apeldoorn A., Hallegraeff H., Clark J., Smeets R., Malfliet A. et al. Low back pain: guidelines for the clinical classification of predominant neuropathic, nociceptive, or central sensitization pain. Pain Physician. 2015;18(3):E333–346. Available at: https://pubmed.ncbi.nlm.nih.gov/26000680.Zehra U., Bow C., Lotz J.C., Williams F.M.K. Structural vertebral endplate nomenclature and etiology: a study by the ISSLS Spinal Phenotype Focus Group. Eur Spine J. 2018;27(1):2–12. doi: 10.1007/s00586-017-5292-3.Zehra U., Bow C., Lotz J.C., Williams F.M.K. Structural vertebral endplate nomenclature and etiology: a study by the ISSLS Spinal Phenotype Focus Group. Eur Spine J. 2018;27(1):2–12. doi: 10.1007/s00586-017-5292-3.Яхно Н.Н. (ред.) Боль: руководство для врачей и студентов. М.: МЕДпрессинформ; 2009. 304 с. Режим доступа: http://kazangmu.ru/files/hospther/ Bol.PDF.Iakhno N.N. (ed.). Pain: guide for doctors and students. Moscow: MEDpressinform; 2009. 304 p. (In Russ.) Available at: http://kazangmu.ru/files/hospther/Bol.PDF.Waddell G., Burton A.K. Occupational health guidelines for the management of low back pain at work: evidence review. Occup Med (Lond). 2001;51(2):124–135. doi: 10.1093/occmed/51.2.124.Waddell G., Burton A.K. Occupational health guidelines for the management of low back pain at work: evidence review. Occup Med (Lond). 2001;51(2):124–135. doi: 10.1093/occmed/51.2.124.Airaksinen O., Brox J.I., Cedraschi C., Hildebrandt J., Klaber-Moffett J., Kovacs F. et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15(2S):192–300. doi: 10.1007/s00586-006-1072-1.Airaksinen O., Brox J.I., Cedraschi C., Hildebrandt J., Klaber-Moffett J., Kovacs F. et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15(2S):192–300. doi: 10.1007/s00586-006-1072-1.Hartvigsen J., Hancock M.J., Kongsted A., Louw Q., Ferreira M.L., Genevay S. et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356–2367. doi: 10.1016/S0140-6736(18)30480-X.Hartvigsen J., Hancock M.J., Kongsted A., Louw Q., Ferreira M.L., Genevay S. et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356–2367. doi: 10.1016/S0140-6736(18)30480-X.Shiri R., Falah-Hassani K. Does leisure time physical activity protect against low back pain? Systematic review and meta-analysis of 36 prospective cohort studies. Br J Sports Med. 2017;51(19):1410–1418. doi: 10.1136/bjsports-2016-097352.Shiri R., Falah-Hassani K. Does leisure time physical activity protect against low back pain? Systematic review and meta-analysis of 36 prospective cohort studies. Br J Sports Med. 2017;51(19):1410–1418. doi: 10.1136/bjsports-2016-097352.Shiri R., Karppinen J., Leino-Arjas P., Solovieva S., Viikari-Juntura E. The association between obesity and low back pain: a meta-analysis. Am J Epidemiol. 2010;171(2):135–154. doi: 10.1093/aje/kwp356.Shiri R., Karppinen J., Leino-Arjas P., Solovieva S., Viikari-Juntura E. The association between obesity and low back pain: a meta-analysis. Am J Epidemiol. 2010;171(2):135–154. doi: 10.1093/aje/kwp356.Shiri R., Karppinen J., Leino-Arjas P., Solovieva S., Viikari-Juntura E. The association between smoking and low back pain: a meta-analysis. Am J Med. 2010;123(1):87.e7-35. doi: 10.1016/j.amjmed.2009.05.028.Shiri R., Karppinen J., Leino-Arjas P., Solovieva S., Viikari-Juntura E. The association between smoking and low back pain: a meta-analysis. Am J Med. 2010;123(1):87.e7-35. doi: 10.1016/j.amjmed.2009.05.028.Shmagel A., Foley R., Ibrahim H. Epidemiology of chronic low back pain in US adults: data from the 2009–2010 National Health and Nutrition Examination Survey. Arthritis Care Res (Hoboken). 2016;68(11):1688–1694. doi: 10.1002/acr.22890.Shmagel A., Foley R., Ibrahim H. Epidemiology of chronic low back pain in US adults: data from the 2009–2010 National Health and Nutrition Examination Survey. Arthritis Care Res (Hoboken). 2016;68(11):1688–1694. doi: 10.1002/acr.22890.Suleiman Z., Kolawole I., Okeyemi A. Fluoroscopic-guided sacroiliac, joint injections for treatment of chronic axial low back pain in a tertiary Hospital in Nigeria: a preliminary study. Ghana Med J. 2018;52(3):153–157. doi: 10.4314/gmj.v52i3.8.Suleiman Z., Kolawole I., Okeyemi A. Fluoroscopic-guided sacroiliac, joint injections for treatment of chronic axial low back pain in a tertiary Hospital in Nigeria: a preliminary study. Ghana Med J. 2018;52(3):153–157. doi: 10.4314/gmj.v52i3.8.Traeger A.C., Buchbinder R., Elshaug A.G., Croft P.R., Maher C.G. Care for low back pain: can health systems deliver? Bull World Health Organ. 2019;97(6):423–433. doi: 10.2471/BLT.18.226050.Traeger A.C., Buchbinder R., Elshaug A.G., Croft P.R., Maher C.G. Care for low back pain: can health systems deliver? Bull World Health Organ. 2019;97(6):423–433. doi: 10.2471/BLT.18.226050.Traeger A.C., Buchbinder R., Harris I.A., Clavisi O.M., Maher C.G. Avoid routinely prescribing medicines for non-specific low back pain. Br J Sports Med. 2019;53(3):196–199. doi: 10.1136/bjsports-2017-098614.Traeger A.C., Buchbinder R., Harris I.A., Clavisi O.M., Maher C.G. Avoid routinely prescribing medicines for non-specific low back pain. Br J Sports Med. 2019;53(3):196–199. doi: 10.1136/bjsports-2017-098614.Traeger A.C., Lee H., Hubscher M., Skinner I.W., Moseley G.L., Nicholas M.K. et al. Effect of intensive patient education vs placebo patient education on outcomes in patients with acute low back pain: a randomized clinical trial. JAMA Neurol. 2019;76(2):161–169. doi: 10.1001/jamaneurol.2018.3376.Traeger A.C., Lee H., Hubscher M., Skinner I.W., Moseley G.L., Nicholas M.K. et al. Effect of intensive patient education vs placebo patient education on outcomes in patients with acute low back pain: a randomized clinical trial. JAMA Neurol. 2019;76(2):161–169. doi: 10.1001/jamaneurol.2018.3376.Tuakli-Wosornu Y.A., Terry A., Boachie-Adjei K., Harrison J.R., Gribbin C.K., LaSalle E.E. et al. Lumbar intradiskal Platelet-Rich Plasma (PRP) injections: a prospective, double-blind randomized controlled study. PMR. 2016;8(1):1–10. doi: 10.1016/j.pmrj.2015.08.010.Tuakli-Wosornu Y.A., Terry A., Boachie-Adjei K., Harrison J.R., Gribbin C.K., LaSalle E.E. et al. Lumbar intradiskal Platelet-Rich Plasma (PRP) injections: a prospective, double-blind randomized controlled study. PMR. 2016;8(1):1–10. doi: 10.1016/j.pmrj.2015.08.010.Valimahomed A.K., Haffey P.R., Urman R.D., Kaye A.D., Yong R.J. Regenerative techniques for neuraxial back pain: a systematic review. Curr Pain Headache Rep. 2019;23(3):20. doi: 10.1007/s11916-019-0758-0.Valimahomed A.K., Haffey P.R., Urman R.D., Kaye A.D., Yong R.J. Regenerative techniques for neuraxial back pain: a systematic review. Curr Pain Headache Rep. 2019;23(3):20. doi: 10.1007/s11916-019-0758-0.Weeks W., Pike J., Donath J., Fiacco P., Justice B. Conservative spine care pathway implementation is asociated with reduced health care expenditures in a controlled, before-after observational study. J Gen Intern Med. 2019;34(8):1381–1388. doi: 10.1007/s11606-019-04942-7.Weeks W., Pike J., Donath J., Fiacco P., Justice B. Conservative spine care pathway implementation is asociated with reduced health care expenditures in a controlled, before-after observational study. J Gen Intern Med. 2019;34(8):1381–1388. doi: 10.1007/s11606-019-04942-7.Weir S., Samnaliev M., Kuo T.C., Ni Choitir C., Tierney T.S., Cumming D. et al. The incidence and healthcare costs of persistent postoperative pain following lumbar spine surgery in the UK: a cohort study using the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES). BMJ Open. 2017;7(9):e017585. doi: 10.1136/bmjopen-2017-017585.Weir S., Samnaliev M., Kuo T.C., Ni Choitir C., Tierney T.S., Cumming D. et al. The incidence and healthcare costs of persistent postoperative pain following lumbar spine surgery in the UK: a cohort study using the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES). BMJ Open. 2017;7(9):e017585. doi: 10.1136/bmjopen-2017-017585.Zhang T., Liu Z., Liu Y., Zhao J., Liu D., Tian Q. Obesity as a risk factor for low back pain: a meta-analysis. Clin Spine Surg. 2018;31(1):22–27. doi: 10.1097/BSD.0000000000000468.Zhang T., Liu Z., Liu Y., Zhao J., Liu D., Tian Q. Obesity as a risk factor for low back pain: a meta-analysis. Clin Spine Surg. 2018;31(1):22–27. doi: 10.1097/BSD.0000000000000468.Heneweer H., Vanhees L., Picavet H. Physical activity and low back pain: a U-shaped relation? Pain. 2009;143(1–2):21–25. doi: 10.1016/j.pain.2008.12.033.Heneweer H., Vanhees L., Picavet H. Physical activity and low back pain: a U-shaped relation? Pain. 2009;143(1–2):21–25. doi: 10.1016/j.pain.2008.12.033.van Hecke O., Torrance N., Smith B.H. Chronic pain epidemiology and its clinical relevance. Br J Anaesth. 2013;111(1):13–18. doi: 10.1093/bja/aet123.van Hecke O., Torrance N., Smith B.H. Chronic pain epidemiology and its clinical relevance. Br J Anaesth. 2013;111(1):13–18. doi: 10.1093/bja/aet123.Dorner T.E., Muckenhuber J., Stronegger W.J., Rsky É., Gustorff B., Freidl W. The impact of socio-economic status on pain and the perception of disability due to pain. Eur J Pain. 2011;15(1):103–109. doi: 10.1016/j.ejpain.2010.05.013.Dorner T.E., Muckenhuber J., Stronegger W.J., Rsky É., Gustorff B., Freidl W. The impact of socio-economic status on pain and the perception of disability due to pain. Eur J Pain. 2011;15(1):103–109. doi: 10.1016/j.ejpain.2010.05.013.Johannes C.B., Le T.K., Zhou X., Johnston J.A., Dworkin R.H. The prevalence of chronic pain in United States adults: results of an internet-based survey. J Pain. 2010;11(11):1230–1239. doi: 10.1016/j.jpain.2010.07.002.Johannes C.B., Le T.K., Zhou X., Johnston J.A., Dworkin R.H. The prevalence of chronic pain in United States adults: results of an internet-based survey. J Pain. 2010;11(11):1230–1239. doi: 10.1016/j.jpain.2010.07.002.Leclerc A., Gourmelen J., Chastang J.F., Plouvier S., Schmidt C.O., Raspe H. et al. Back pain in the German adult population: prevalence, severity, and sociodemographic correlates in a multiregional survey. Spine (Phila Pa 1976). 2007;32(18):2005–2011. doi: 10.1097/BRS.0b013e318133fad8.Leclerc A., Gourmelen J., Chastang J.F., Plouvier S., Schmidt C.O., Raspe H. et al. Back pain in the German adult population: prevalence, severity, and sociodemographic correlates in a multiregional survey. Spine (Phila Pa 1976). 2007;32(18):2005–2011. doi: 10.1097/BRS.0b013e318133fad8.Hoy D., March L., Brooks P., Blyth F., Woolf A., Bain C. et al. The global burden of low back pain: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73(6):968–974. doi: 10.1136/annrheumdis-2013-204428.Hoy D., March L., Brooks P., Blyth F., Woolf A., Bain C. et al. The global burden of low back pain: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73(6):968–974. doi: 10.1136/annrheumdis-2013-204428.Van Wambeke P., Desomer A., Ailliet L., Berquin A., Demoulin C., Depreitere B. et al. Low back pain and radicular pain: assessment and management. Good Clinical Practice (GCP). Brussels: Belgian Health Care Knowledge Centre (KCE); 2017. KCE Reports 287. D/2017/10.273/36. Available at: https://www.researchgate.net/publication/317012887_LOW_BACK_PAIN_AND_RADICULAR_PAIN_ASSESSMENT_AND_MANAGEMENT.Van Wambeke P., Desomer A., Ailliet L., Berquin A., Demoulin C., Depreitere B. et al. Low back pain and radicular pain: assessment and management. Good Clinical Practice (GCP). Brussels: Belgian Health Care Knowledge Centre (KCE); 2017. KCE Reports 287. D/2017/10.273/36. Available at: https://www.researchgate.net/publication/317012887_LOW_BACK_PAIN_AND_RADICULAR_PAIN_ASSESSMENT_AND_MANAGEMENT.Chenot J.F., Greitemann B., Kladny B., Petzke F., Pfingsten M., Schorr S.G. Non-specific low back pain. Dtsch Arztebl Int. 2017;114(51–52):883–890. doi: 10.3238/arztebl.2017.0883.Chenot J.F., Greitemann B., Kladny B., Petzke F., Pfingsten M., Schorr S.G. Non-specific low back pain. Dtsch Arztebl Int. 2017;114(51–52):883–890. doi: 10.3238/arztebl.2017.0883.Qaseem A., Wilt T.J., McLean R.M., Forciea M.A. Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514–530. doi: 10.7326/M16-2367.Qaseem A., Wilt T.J., McLean R.M., Forciea M.A. Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514–530. doi: 10.7326/M16-2367.Stochkendahl M.J., Kjaer P., Hartvigsen J., Kongsted A., Aaboe J., Andersen M. et al. National clinical guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27(1):60–75. doi: 10.1007/s00586-017-5099-2.Stochkendahl M.J., Kjaer P., Hartvigsen J., Kongsted A., Aaboe J., Andersen M. et al. National clinical guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27(1):60–75. doi: 10.1007/s00586-017-5099-2.Bruyère O., Cooper C., Pelletier J.P., Maheu E., Rannou F., Branco J. et al. A consensus statement on the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) algorithm for the management of knee osteoarthritis – From evidence-based medicine to the real‐life setting. Semin Arthritis Rheum. 2016;45(4S):3–11. doi: 10.1016/j.semarthrit.2015.11.010.Bruyère O., Cooper C., Pelletier J.P., Maheu E., Rannou F., Branco J. et al. A consensus statement on the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) algorithm for the management of knee osteoarthritis – From evidence-based medicine to the real‐life setting. Semin Arthritis Rheum. 2016;45(4S):3–11. doi: 10.1016/j.semarthrit.2015.11.010.Smith S.R., Deshpande B.R., Collins J.E., Katz J.N., Losina E. Comparative pain reduction of oral non-steroidal anti-inflammatory drugs and opioids for knee osteoarthritis: systematic analytic review. Osteoarthritis Cartilage. 2016;24(6):962–972. doi: 10.1016/j.joca.2016.01.135.Smith S.R., Deshpande B.R., Collins J.E., Katz J.N., Losina E. Comparative pain reduction of oral non-steroidal anti-inflammatory drugs and opioids for knee osteoarthritis: systematic analytic review. Osteoarthritis Cartilage. 2016;24(6):962–972. doi: 10.1016/j.joca.2016.01.135.Gan T.J. Diclofenac: an update on its mechanism of action and safety profile. Curr Med Res Opin. 2010;26(7):1715–1731. doi: 10.1185/03007995.2010.486301.Gan T.J. Diclofenac: an update on its mechanism of action and safety profile. Curr Med Res Opin. 2010;26(7):1715–1731. doi: 10.1185/03007995.2010.486301.McGettigan P., Henry D. Use of nonsteroidal antiinflammatory drugs that elevate cardiovascular risk: an examination of sales and essential medicines lists in low, middle, and high income countries. PLoS Med. 2013;10(2):e1001388. doi: 10.1371/journal.pmed.1001388.McGettigan P., Henry D. Use of nonsteroidal antiinflammatory drugs that elevate cardiovascular risk: an examination of sales and essential medicines lists in low, middle, and high income countries. PLoS Med. 2013;10(2):e1001388. doi: 10.1371/journal.pmed.1001388.Altman R., Bosch B., Brune K., Patrignani P., Young C. Advances in NSAID development: evolution of diclofenac products using pharmaceutical technology. Drugs. 2015;75(8):859–877. doi: 10.1007/s40265-015-0392-z.Altman R., Bosch B., Brune K., Patrignani P., Young C. Advances in NSAID development: evolution of diclofenac products using pharmaceutical technology. Drugs. 2015;75(8):859–877. doi: 10.1007/s40265-015-0392-z.Чичасова Н.В., Имаметдинова Г.Р. Место Вольтарена в клинической практике: акцент на переносимость препарата. Современная ревматология. 2009:(1):78–85. Режим доступа: https://mrj.ima-press.net/mrj/article/view/214/209.Chichasova N.V., Imametdinova G.R. Place of Voltaren in clinical practice: emphasis on its tolerability. Sovremennaya Revmatologiya = Modern Rheumatology. 2009:(1):78–85. (In Russ.) Available at: https://mrj.imapress.net/mrj/article/view/214/209.Brunner M., Dehghanyar P., Seigfried B., Martin W., Menke G., Müller M. Favourable dermal penetration of diclofenac after administration to the skin using a novel spray gel formulation. Br J Clin Pharmacol. 2005;60(5):573–577. doi: 10.1111/j.1365-2125.2005.02484.x.Brunner M., Dehghanyar P., Seigfried B., Martin W., Menke G., Müller M. Favourable dermal penetration of diclofenac after administration to the skin using a novel spray gel formulation. Br J Clin Pharmacol. 2005;60(5):573–577. doi: 10.1111/j.1365-2125.2005.02484.x.Miyatake S., Ichiyama H., Kondo E., Yasuda K. Randomized clinical comparisons of diclofenac concentration in the soft tissues and blood plasma between topical and oral applications. Br J Clin Pharmacol. 2009;67(1):125–129. doi: 10.1111/j.1365-2125.2008.03333.x.Miyatake S., Ichiyama H., Kondo E., Yasuda K. Randomized clinical comparisons of diclofenac concentration in the soft tissues and blood plasma between topical and oral applications. Br J Clin Pharmacol. 2009;67(1):125–129. doi: 10.1111/j.1365-2125.2008.03333.x.Brunner M., Davies D., Martin W., Leuratti C., Lackner E., Müller M. A new topical formulation enhances relative diclofenac bioavailability in healthy male subjects. Br J Clin Pharmacol. 2011;71(6):852–859. doi: 10.1111/j.1365-2125.2011.03914.x.Brunner M., Davies D., Martin W., Leuratti C., Lackner E., Müller M. A new topical formulation enhances relative diclofenac bioavailability in healthy male subjects. Br J Clin Pharmacol. 2011;71(6):852–859. doi: 10.1111/j.1365-2125.2011.03914.x.Escribano E., Calpena A.C., Queralt J., Obach R., Domenech J. Assessment of diclofenac permeation with different formulations: anti-inflammatory study of a selected formula. Eur Pharm Sci. 2003;19(4):203–210. doi: 10.1016/S0928-0987(03)00103-9.Escribano E., Calpena A.C., Queralt J., Obach R., Domenech J. Assessment of diclofenac permeation with different formulations: anti-inflammatory study of a selected formula. Eur Pharm Sci. 2003;19(4):203–210. doi: 10.1016/S0928-0987(03)00103-9.Folzer E., Gonzalez D., Singh R., Derendorf H. Comparison of skin permeability for three diclofenac topical formulations: an in vitro study. Pharmazie. 2014;69(1):27–31. Available at: https://pubmed.ncbi.nlm.nih.gov/24601219/.Folzer E., Gonzalez D., Singh R., Derendorf H. Comparison of skin permeability for three diclofenac topical formulations: an in vitro study. Pharmazie. 2014;69(1):27–31. Available at: https://pubmed.ncbi.nlm.nih.gov/24601219/.Lane M.E. Skin penetration enhancers. Int J Pharm. 2013;447(1–2):12–21. doi: 10.1016/j.ijpharm.2013.02.040.Lane M.E. Skin penetration enhancers. Int J Pharm. 2013;447(1–2):12–21. doi: 10.1016/j.ijpharm.2013.02.040.Marwah H., Garg T., Goyal A.K., Rath G. Permeation enhancer strategies in transdermal drug delivery. Drug Deliv. 2016;23(2):564–578. doi: 10.3109/10717544.2014.935532.Marwah H., Garg T., Goyal A.K., Rath G. Permeation enhancer strategies in transdermal drug delivery. Drug Deliv. 2016;23(2):564–578. doi: 10.3109/10717544.2014.935532.Nivsarkar M., Maroo S.H., Patel K.R., Patel D.D. Evaluation of skin penetration of diclofenac from a novel topical non aqueous solution: a comparative bioavailability study. J Clin Diagn Res. 2015;9(12):FC11–13. doi: 10.7860/JCDR/2015/15690.6956.Nivsarkar M., Maroo S.H., Patel K.R., Patel D.D. Evaluation of skin penetration of diclofenac from a novel topical non aqueous solution: a comparative bioavailability study. J Clin Diagn Res. 2015;9(12):FC11–13. doi: 10.7860/JCDR/2015/15690.6956.Vitorino C., Sousa J., Pais A. Overcoming the skin permeation barrier: challenges and opportunities. Curr Pharm Des. 2015;21(20):2698–2712. doi: 10.2 174/1381612821666150428124053.Vitorino C., Sousa J., Pais A. Overcoming the skin permeation barrier: challenges and opportunities. Curr Pharm Des. 2015;21(20):2698–2712. doi: 10.2174/1381612821666150428124053.Derry S., Conaghan P., Da Silva J.A.R., Wiffen P.J., Moore R.A. Cochrane Pain, Palliative and Supportive Care Group. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2016;2016(4):CD007400. doi: 10.1002/14651858.CD007400.pub3.Derry S., Conaghan P., Da Silva J.A.R., Wiffen P.J., Moore R.A. Cochrane Pain, Palliative and Supportive Care Group. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2016;2016(4):CD007400. doi: 10.1002/14651858.CD007400.pub3.McCarthy D. Nonsteroidal anti-inflammatory drug-related gastrointestinal toxicity: definitions and epidemiology. Am J Med. 1998;105(5A):3S–9S. doi: 10.1016/s0002-9343(98)00274-5.McCarthy D. Nonsteroidal anti-inflammatory drug-related gastrointestinal toxicity: definitions and epidemiology. Am J Med. 1998;105(5A):3S–9S. doi: 10.1016/s0002-9343(98)00274-5.Kienzler J.L., Gold M., Nollevaux F. Systemic bioavailability of topical diclofenac sodium gel 1% versus oral diclofenac sodium in healthy volunteers. J Clin Pharmacol. 2010;50(1):50–61. doi: 10.1177/0091270009336234.Kienzler J.L., Gold M., Nollevaux F. Systemic bioavailability of topical diclofenac sodium gel 1% versus oral diclofenac sodium in healthy volunteers. J Clin Pharmacol. 2010;50(1):50–61. doi: 10.1177/0091270009336234.Barthel H.R., Haselwood D., Longley S. 3rd, Gold M.S., Altman R.D. Randomized controlled trial of diclofenac sodium gel in knee osteoarthritis. Semin Arthritis Rheum. 2009;39(3):203–212. doi: 10.1016/j.semarthrit.2009.09.002.Barthel H.R., Haselwood D., Longley S. 3rd, Gold M.S., Altman R.D. Randomized controlled trial of diclofenac sodium gel in knee osteoarthritis. Semin Arthritis Rheum. 2009;39(3):203–212. doi: 10.1016/j.semarthrit.2009.09.002.Galer B.S. A comparative subjective assessment study of PENNSAID(R) and Voltaren Gel(R), two topical formulations of diclofenac sodium. Pain Pract. 2011;11(3):252–260. doi: 10.1111/j.1533-2500.2010.00420.x.Galer B.S. A comparative subjective assessment study of PENNSAID(R) and Voltaren Gel(R), two topical formulations of diclofenac sodium. Pain Pract. 2011;11(3):252–260. doi: 10.1111/j.1533-2500.2010.00420.x.Sintov A.C., Botner S. Transdermal drug delivery using microemulsion and aqueous systems: influence of skin storage conditions on the in vitro permeability of diclofenac from aqueous vehicle systems. Int J Pharm. 2006;311(12):55–62. doi: 10.1016/j.ijpharm.2005.12.019.Sintov A.C., Botner S. Transdermal drug delivery using microemulsion and aqueous systems: influence of skin storage conditions on the in vitro permeability of diclofenac from aqueous vehicle systems. Int J Pharm. 2006;311(12):55–62. doi: 10.1016/j.ijpharm.2005.12.019.Riess W., Schmid K., Botta L., Kobayashi K., Moppert J., Schneider W. et al. The percutaneous absorption of diclofenac. Arzneimittelforschung. 1986;36(7):1092–1096. (In German) Available at: https://pubmed.ncbi.nlm.nih.gov/3768079.Riess W., Schmid K., Botta L., Kobayashi K., Moppert J., Schneider W. et al. The percutaneous absorption of diclofenac. Arzneimittelforschung. 1986;36(7):1092–1096. (In German). Available at: https://pubmed.ncbi.nlm.nih.gov/3768079.Имаметдинова Г.Р., Иголкина Е.В. Топические формы диклофенака в лечении заболеваний опорно-двигательного аппарата. Медицинский совет. 2018;(12):98–104. doi: 10.21518/2079-701X-2018-12-98-104.Imametdinova G.R., Igolkina E.V. Topical diclofenac for the treatment of the musculoskeletal diseases. Meditsinskiy sovet = Medical Council. 2018;(12):98–104. (In Russ.) doi: 10.21518/2079-701X-2018-12-98-104.Бадокин В.В. Значение локальной терапии НПВП в клинической практике. Врач. 2012;(4):81–85. Режим доступа: https://dlib.eastview.com/browse/doc/26881188?enc=eng.Badokin V.V. The importance of topical NSAID therapy in clinical practice. Vrach = The Doctor. 2012;(4):81–85. (In Russ.) Available at: https://dlib.eastview.com/browse/doc/26881188?enc=eng.Bussin E., Cairns B., Bovard J., Scott A. Randomised controlled trial evaluating the short-term analgesic effect of topical diclofenac onch onic Ach illes tendonpain: a pilot study. BMJ Open. 2017;7(4):e015126. doi: 10.1136/bmjopen-2016-015126.Bussin E., Cairns B., Bovard J., Scott A. Randomised controlled trial evaluating the short-term analgesic effect of topical diclofenac onch onic Ach illes tendonpain: a pilot study. BMJ Open. 2017;7(4):e015126. doi: 10.1136/bmjopen-2016-015126.Derry S., Wiffen P., Kalso E., Bell R., Aldington D., Phillips T. et al. Affiliations expand. Topical analgesics for acute and chronic pain in adults – an over view of Cochrane Reviews. Cochrane Database Syst Rev. 2017;5(5):CD008609. doi: 10.1002/14651858.CD008609.pub2.Derry S., Wiffen P., Kalso E., Bell R., Aldington D., Phillips T. et al. Affiliations expand. Topical analgesics for acute and chronic pain in adults – an over view of Cochrane Reviews. Cochrane Database Syst Rev. 2017;5(5):CD008609. doi: 10.1002/14651858.CD008609.pub2.McCarberg B., D’Arcy Y. Options in topical therapies in the management of patients with acute pain. Postgrad Med. 2013;125(4S):19–24. doi: 10.1080/00325481.2013.1110567011.McCarberg B., D’Arcy Y. Options in topical therapies in the management of patients with acute pain. Postgrad Med. 2013;125(4S):19–24. doi: 10.1080/00325481.2013.1110567011.

The authors declare that there are no conflicts of interest present.