Low back pain is one of the most frequent complaints that leads patients to seek medical attention. According to WHO, about 90% of people at least once in their lives had back pain. What should a practitioner do when managing patients with back pain? What is the real practice of treating such patients? The problem of acute low back pain is discussed by leading experts:

Head of the Department of Nervous Diseases and Neurosurgery of FSBEI of HE “Sechenov First Moscow State Medical University” of the Ministry of Health of the Russian Federation (Sechenov University) Dr. of Sci. (Med.), Professor Vladimir A. Parfenov

Head of the Laboratory of Pathophysiology of Pain and Clinical Polymorphism of Skeletal and Muscular Diseases of the FSBSI “SRIR named after V.A. Nasonova” Dr. of Sci. (Med.) Andrey E. Karateyev

During life, neck pain occurs in 20-70% of people, its prevalence in the total population is 4.9%, and the annual morbidity varies from 30 to 70%. Neck pain significantly reduces the quality of life and can lead to disability. It was found that the economic burden of neck pain is high and is associated with the amount of money spent on treatment, with «lost profits» due to employee illness, compensation for examinations and sick leave. Over the past decade, there has been an increase in the prevalence of neck pain, which increases the importance of improving the diagnostics, prevention and treatment of neck pain. Depending on the duration, neck pain is classified as acute, subacute and chronic. Neck pain may be non-specific (skeletal-muscular), secondary (specific, symptomatic) or associated with discogenic radiculopathy or cervical myelopathy. Nonspecific neck pain is the most common. Effective treatment of nonspecific neck pain includes therapeutic gymnastics, manual therapy, recommendations on lifestyle, activity and ergonomics in the organization of the workplace. Identification and correction of risk factors of neck pain occurrence, persistence and chronization are of great importance in the prevention and treatment of patients. Neck pain pharmacotherapy includes drugs from the group of non-steroidal anti-inflammatory drugs (NSAIDs): lor-noxicam, which has shown its effectiveness and good tolerance in the treatment of neck pain, cervicocranialgia, postoperative and skeletal-muscular pain. It is recommended to prescribe a short course of NSAIDs therapy in minimal therapeutic doses. In the chronic course of neck pain, antidepressants may be prescribed, especially when combined with depression.

The management of patients with Alzheimer’s disease (AD) is one of the urgent problems of modern medicine, however, not only general practitioners, but also neurologists in our country are not sufficiently aware of modern methods of AD therapy, which largely determines the errors in patient management. The disease is rarely diagnosed, patients are often observed with an erroneous diagnosis of chronic cerebrovascular disease (chronic cerebral ischemia, discirculatory encephalopathy) and do not receive the necessary treatment. It is relatively rare for AD patients to receive advice on non-drug therapies that include cognitive stimulation, cognitive training, regular physical activity, and antioxidant-rich nutrition. Anti dementic agents are rarely prescribed to patients: acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine) and memantine, an NMDA receptor blocker. Only a relatively small percentage of people who developed Alzheimer’s disease receive effective antidement therapy. This may be due to the fact that AD is not diagnosed or is diagnosed at more advanced stages of the disease when antidement therapy is not so effective, or that doctors do not have sufficient knowledge about antidement drugs and, finally, that the price of drugs is relatively high and the prescribing process for preferential provision of drugs is rather complicated. Unfortunately, antipsychotics and benzodiazepines are often unreasonably prescribed to patients with AD, the use of which impairs cognitive functions. The article presents a clinical observation of a relatively young patient with AD, who was followed up for a long time with an erroneous diagnosis of discirculatory encephalopathy. The issues of optimizing the management of AD patients in our country are discussed, and the data of the Cochrane review on the use of donepezil at different stages of the disease are analyzed.

Any common disease (including Parkinson’s disease) is inevitably overgrown with myths. As a result, not scientifically grounded approaches based on the principles of evidence-based medicine, but irrational ideas, especially often of a pharmacophobic nature, begin to dominate in primary clinical practice among doctors and patients. In clinical practice, we can often face to a situation when doctors, dogmatically accepting the principle of delayed initiation of levodopa therapy, for a long time try to guide the patient on other antiparkinsonian drugs, despite the obvious ineffectiveness of such therapy and the increasingly growing immobility of the patient. This phenomenon, based on the irrational beliefs of not only doctors, but also patients in the toxicity of levodopa, is commonly referred to as levodopa phobia. Levodopa phobia, along with the emergence of a new generation of dopamine agonists (DAs), whose ability to delay the development of fluctuations and dyskinesias has been proven in a series of placebo-controlled studies, as well as the erroneous interpretation of the withdrawal syndrome of DAs as evidence of their high effectiveness, have led to the widespread use of this class. drugs. However, the use of DA turned out to be associated with an increased risk of such adverse events as daytime sleepiness, leg edema, impulsive-compulsive disorders, and withdrawal syndrome. All this served as the basis for the appearance of “dopamine agonists phobia”, which can lead to unjustifiably early prescription of levodopa and the development of dyskinesias. What is the optimal way for managementof PD patients today? In our opinion, the patient management formula that doctors should adhere to should be as follows: early prescription of dopaminergic drugs (more often DAs or levodopa) is necessary, which provides a quick possible, albeit incomplete, correction of a motor defect, which would be sufficient to preserve the patient’s motor activity, including his professional activity; as the symptoms increase, an escalation of antiparkinsonian therapy with the sequential addition of levodopa (or DAs), MAO B inhibitors, amantadines is necessary.

Frontotemporal degeneration (FTD) is a heterogeneous group of diseases causing neurodegeneration on the frontal and/or anterior temporal lobes. FTD is the second most common dementia in presenile age (up to 65 years) after Alzheimer’s disease. Usually, FTD is diagnosed at the age of 45-65 years, but an earlier and later onset is possible. Up to 40% of FTD cases have a positive family history. According to the current classification, the following clinical variants of FTD are distinguished: behavioral variant of FTD, agrammatic variant of primary progressive aphasia (PPA) and semantic variant of PPA. As they develop, these clinical syndromes overlap widely with each other and with atypical parkinsonism syndromes (progressive supranuclear paralysis, cortico-basal syndrome) and less often with motor neuron disease. Variations in the clinical features are determined by the localization of the degenerative-atrophic process. The behavioral variant of FTD accounts for more than half of the cases of FTD and is characterized by a combination of cognitive, behavioral, and emotional-affective disorders. In PPA, speech disorders appear for no apparent reason and progress continuously in the absence or with minimal severity of other cognitive and behavioral disorders for two or more years. The clinical features of PPA depend on the localization of the pathological process. The article reviews a clinical case of an agrammatic variant of PPA. Modern approaches to the diagnosis and management of this group of patients are shown. It seems appropriate to use memantin in patients with agrammatic variant of PPA.

Upper and lower extremity tunnel neuropathies are classified as the peripheral nervous system disorders and are quite common in clinical practice. The development of tunnel syndrome is associated with compression, entrapment of the nerve in the narrow anatomical spaces (anatomical tunnel). Sensory, motor, and trophic disorders are the main clinical manifestations of the nerve compression syndromes. The article describes the main upper extremity tunnel neuropathies, their names and affected nerves. The main common upper extremity tunnel neuropathies such as carpal tunnel syndrome and cubital tunnel syndrome are considered in depth. The carpal tunnel syndrome is currently recognized as the most common peripheral neuropathy. Risk factors, gender and age characteristics, prevalence, incidence of carpal tunnel syndrome and cubital canal syndrome are presented. A scope of specialized skills comprising certain motions that can contribute to the development of carpal tunnel syndrome is presented. The clinical manifestations of these tunnel syndromes are described. Sensory, motor, and trophic disorders are the main clinical manifestations of nerve compression syndromes. The course and signs of carpal tunnel syndrome that can be divided into three stages are provided. The main diagnostic methods for the syndrome examination are shown. The article provides the main conservative and surgical methods for the treatment of these tunnel syndromes. It was noted that the cubital canal syndrome requires surgical treatment more often. The issue of using thiamine, pyridoxine, cyanocobalamin and their combination for the treatment of tunnel neuropathies is considered in more depth. A clinical case of effective conservative treatment for the carpal tunnel syndrome is discussed.

Multiple sclerosis (MS) is a chronic demyelinating disease of young employable people. Demyelination develops as a result of the autoimmune mechanisms of the damage to nerve fibers, while the neurodegenerative changes in the brain matter begin from the first days of the disease. MS in most cases has a wavy course (periods of exacerbations and remissions), over time the progression of disease worses the quality of life of patients. Usually, there are remitting, secondary progressive, and primary progressive MS. The «gold standard» of treatment after the diagnosis of MS is first-line drugs disease-modifying therapies (DMT) of the first line -glatiramer acetate and в—interferons. These drugs have been used for more than 20 years and have proven their effectiveness, safety and good tolerability in long-term continuous observational clinical studies. It is important to note that therapy should be started as early as possible, from the moment of diagnosis, since in most patients, even with a stable clinical picture and no symptoms, the disease progresses. Over time, this can lead to persistent, irreversible neurological deficits and disability. The use of active immune -modulating drugs requires constant monitoring of the patient’s condition by qualified neurologists. This article presents the results of clinical trials of Timexon® (glatiramer acetate) and Teberif ® (interferon beta- 1а) in patients with remitting multiple sclerosis and discusses the issues of prescribing first-line drugs, switching from one therapy to another within the first-line, monitoring the effectiveness and safety of treatment.

Due to the divergence of the acute insomnia conceptualization and difficulties in diagnostics, this phenomenon attracts comparatively little attention in the medical literature. Patients don’t seek medical attention and prefer self-treatment or wait for selfrecovery. This paper aims to review the literature concerning understanding the position of chronic insomnia in existing human models, systematization of aspects, related to insomnia development, and evidence of this relation. Apparently, acute insomnia is a non-specific hyperreaction to distress which tends to self-recovery. Ineffective coping strategies, dysfunctional thinking, and violation of sleep hygiene rules predispose transition from acute to chronic form. This is evidenced by epidemiological data: 1-year prevalence of acute insomnia in adults is about 30% among which 16-19% of cases are diagnosed for the first time and 7,4% become chronic.

Understanding of acute insomnia heterogeneity, as well as pathogenesis and predictors of chronization, reveals the perspectives for personalized treatment and prophylaxis. Acute insomnia is routinely managed with short-term prescription of GABAA receptor agonists, antihistamines, phytotherapy, while cognitive-behavioral therapy is commonly used for the chronic form of insomnia. Identification of behavioral and cognitive predictors of insomnia chronization enables management of insomnia with cognitive-behavioral therapy even in the early stages.

The article presents the actuality of the problem of hyperuricemia (HU) and gout in modern medicine, caused by the high prevalence and socio-economic consequences associated with the development in patients with these pathologies of earlier and more severe course of atherosclerosis, coronary heart disease, chronic kidney disease (CKD) and increased mortality. Illustrated pathogenetic mechanisms of HU influence on the cardiovascular system, which are characterized by the formation of endothelial dysfunction, increased adhesion and aggregation of thrombocytes, blood rheology disorders, increased levels of inflammatory markers, renal function disorders. It is highlighted that in arterial hypertension (AH) a possible mechanism for increasing the concentration of uric acid (UA) is a violation of renal excretion due to reduced tubal secretion. The data of the studies are presented, showing that in patients with type 2 diabetes mellitus and higher UA concentration is associated with increased risk of fatal and non-fatal stroke. Modern recommendations of HU correction, approved in the Russian Federation, are highlighted, where the expediency ofcomorbid condition therapy, correction of diet and lifestyle are noted. The consensus of the European Society of Cardiology and the Russian Society of Cardiology (RSC) on the management of patients with HU with high cardiovascular risk (CVR) and the RSC Clinical Practice Guidelines for AH are presented. Based on these documents, all patients with AH are recommended to evaluate the level of UA in serum and consider it high - more than 360 pmol/l, it is recommended to perform urate-lowering therapy for patients with high CVR, with the target level below 300 pmol/l. Modern possibilities of pathogenetic therapy of gout are presented. It is noted that the use of febuxostat demonstrates not only higher efficiency in reducing and maintaining the level of UA, but also better tolerance, in comparison with allopurinol. It is emphasized that elderly people do not need to correct the dose of febuxostat, it can be used by patients with CKD.

Osteoarthritis is a common disease and occupies the leading place in the number of cases of disability in the world. The pathogenesis of this topical nosology is actively condemned, and researchers have offered a lot of evidence for the leading role of inflammation in the pathogenesis of osteoarthritis, which, by stimulating internal catabolic reactions of chondrocytes, leads to inflammation of the synovial membrane and, as a result, the occurrence of joint pain. Osteoarthritis is the disease with the highest incidence of comorbidities, which complicates the choice of medications for its treatment. And, despite the variety of recommendations, the issue of treating patients with OA remains complex. Based on the recommendations of ESCEO, which were updated in 2019, it is necessary to follow a step-by-step tactic, according to which the introduction of hyaluronic acid preparations intra-articularly is recommended at the 2nd stage of therapy as part of advanced pharmacological correction. Intra-articular hyaluronic acid injection is an alternative local treatment option that provides symptomatic benefit without systemic adverse events. The clinical example demonstrates the experience of joint decision-making on the tactics of managing a patient with persistent OA and the ineffectiveness of therapy at the previous stages. Preference was given to the preparation with high-molecular hyaluronic acid, in the production of which no cross-linking agents were used, due to its effectiveness and safety. A good analgesic and symptom modifying effect of the drug was demonstrated with the result remaining for 6 months. The authors believe that in patients with high comorbidity, drugs for intra-articular administration of hyaluronic acid can take a worthy place in the treatment of osteoarthritis.

Infection caused by hepatitis B virus (HBV) remains an important global public health problem with high morbidity and mortality. In modern rheumatology the problem of HBV as a comorbid infection deserves undoubted attention, especially in immune inflammatory rheumatic diseases (IIRD). This fact makes it necessary to modify the treatment tactics of patients receiving modern antirheumatic therapy, including basic anti-inflammatory (BAID) and genetically engineered biological drugs (GEBD). Given the expected further increase in the use of GEBD and new oral targeted BAID (Janus kinase inhibitors) in the treatment of rheumatic diseases, rheumatologists should be aware of the potential risk, recommendations for screening and opportunities for prevention and monitoring of HBV-reactivation (HBV-r). Most of the literature on HBV-r has been obtained from haematology and oncology, which uses combinations of drugs with higher immunosuppressive potential, usually for a short period of time (months). This data should be interpreted with caution in regard to rheumatic diseases, where immunosuppression intensity is lower and therapy duration is longer (several years). In recent years, an attempt has been made to stratify the HBV-r risk according to the patient’s serological status and the type and duration of immunosuppressive treatment used. Based on the above factors, the American Gastroenterological Association has classified the risk of HBV-r as low (<1%), moderate (1-10%) and high (>10%). However, appearance of new drugs and longer duration of their use in rheumatic diseases, wherethere are usually no established timeframes for discontinuation of treatment, require additional explanation of the recommendations on the curation and monitoring of HBV-r. This article presents modern data on HBV-r risk in patients with HBV during treatment with various BAID and GEBD, emphasizes the importance of screening examination for HBV-infection before the planned immunosuppressive therapy and highlights issues related to the tactics of prescribing antiviral prophylaxis and monitoring of these patients condition.

Chronic pain is still one of the most pressing problems of modern medicine. The article presents the main pathogenetic mechanisms of pain syndrome in osteoarthritis (OA). The recommendations of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) 2019 are presented. OA therapies, which indicate that when starting OA therapy, chondroitin sulfate (CS) or glucosamine sulfate (GS) should be considered as the First Step, then nonsteroidal antiinflammatory drugs (NSAIDs) should be added locally, and only then, if ineffective, oral NSAIDs are prescribed, with the exception of hip OA. Intramuscular (i/m) administration of CS can increase the bioavailability of the medicinal preparation (MP). The article also presents a clinical case of the use of LP CS (Artogistan; Bioiberica S.A., Spain) in a 58-year-old patient with pain in the lower back pain, OA of the intervertebral joints. Artogistan was prescribed at a dose of 100 mg (1 ml) every other day according to the scheme: the first 3 days of 100 mg (1 ml), starting from 4 days -200 mg (2 ml) every other day, a course of 35 injections. A positive response to therapy was received. According to the recommendations of ESCEO (2019) experts: 1) the use of CS as a basic therapy for OA is proven-from the first step and at all subsequent stages; 2) It is recommended to use drugs made exclusively from pharmaceutical substances of CS and GS; 3) CS and GS are prescribed for a long time (6-12 months), but not in courses. In the Russian Federation, parenteral forms of pharmaceutical-quality CS are available, the effectiveness of which is proven in RCTs.

The article presents a clinical case of an elderly patient who had consulted a neurologist due to rapidly developed various complications of diabetes in the form of damage to the peripheral and central nervous systems. The debut of diabetic amyotrophy two years ago in our patient was mistakenly considered as a manifestation of osteochondrosis of the lumbosacral spine. The recommended drug therapy did not reduce symptoms and caused gastrointestinal disorders, which led to the independent withdrawal of all drugs. Polypharmacy reduced the patient’s adherence to therapy and reduced the frequency of regular visits to the doctor.

The article deals with the pathogenesis of the main neurological complications of diabetes (diabetic neuropathy and cognitive disorders) in elderly people with arterial hypertension. The possibility of their therapeutic correction to reduce the number of medications taken by patients is discussed. Tactics of polymorbid patients taking into account concomitant chronic diseases should include normalization of glucose levels, correction of vascular risk factors, non-pharmacological methods of treatment - lifestyle changes, diet therapy, regular moderate physical activity. The use of alpha-lipoic (thioctic) acid (Berlithion) as a lipophilic antioxidant will help to slow down the development of complications.

In accordance with modern concepts, pain is divided into neuropathic and nonspecific (nociceptive). Often the pain syndrome is of a mixed nature, combining the features of both options, each of which requires a separate approach to treatment. The main task of pain therapy is its effective and rapid relief with the relative safety of the prescribed treatment. The message is devoted to the analysis of a clinical case of treatment of pain of a mixed nature, acutely developed in a patient in the cervical spine as a result of inadequate physical activity, which led to damage to the intervertebral disc and complicated cervical radiculopathy. Selftreatment performed by the patient, which included, among other things, NSAIDs, did not lead to the desired result due to the inadequacy and lack of systemic therapy. In order to establish a clinical diagnosis, both physical and paraclinical research methods were used, which made it possible to verify the cause of neck pain and the nature of the complications that developed. In order to quickly relieve the pain syndrome, a stepwise scheme of therapy with dexketoprophen was used, which led to the desired effect within 5 days (a decrease in pain intensity by more than 50% from the initial level). To continue treatment, NSAIDs with a selective effect on COX-2 were used. Also, according to the indications, the complex therapy included drugs of the following groups: proton pump inhibitor, muscle relaxant, anticonvulsant, combined preparation of B vitamins, thioctic acid preparation, combined preparation from the group of slow-acting symptomatic agents and non-drug methods (cognitive-behavioral therapy, soft tissue manual therapy techniques, Exercise therapy). The adequacy of the therapy was confirmed by relief of pain syndrome and regression of neurological symptoms in the absence of adverse events. This clinical case illustrates the possibilities of successful conservative treatment of mixed pain in an outpatient setting.