Pain in the back and joints

One of the most common health problems among middle-aged and elderly people is back and joint pain. According to statistics, for medical help for these pains no less people are drawn than with angina and colds. The constant increase in the incidence rate is due to many reasons: the back and joints can get sick due to physical overload, because of inflammatory and autoimmune processes in the body. What you need to know about this problem, how to prevent or get rid of it? We hope that we will be able to answer most of your questions.

[1], [2], [3], [4]

Causes of the pain in the back and joints

Physicians have long traced the impact of urbanization on the increase in the number of people complaining of pain in the joints and back. This trend is largely due to both excessive physical overload and hypodynamia - the two "extremes" that are the "scourge" of the modern world.

A considerable part of the blame falls on both the wrong diet and the way of life with a lot of bad habits. For example, a surge in the frequency of seeking medical help often results from a so-called "whiplash injury": most people are less likely to walk, preferring to travel by transport. For the busy urban regime, the discontinuous movement of vehicles is typical, with frequent jerks and sudden braking. This is what causes injuries, which almost always remain invisible, but are accompanied by microdamages of the musculoskeletal system. Such damage gradually accumulates and eventually "poured out" into a serious problem with the back and joints.

At the present time, there are many reasons that can cause problems, which are manifested by pain. Most often, diseases of the back and joints are born in childhood and adolescence, and only a few decades later appear.

[5]

Risk factors

If we consider all the known atrophic-degenerative disorders in the musculoskeletal system, we can see that the overwhelming part of them is associated with overloading. Overloading entails not only a slow or rapid mechanical failure, which in time begins to worsen due to the slowing down of regeneration. There is also a deterioration in nutrition in the anatomical sector, which includes intervertebral discs, articular cartilage, etc.

What are the risk factors in question:

• excessive body weight;
• heavy physical work;
• systematic sports practice with dominating axial overload (observed in weightlifters, runners, athletes in high jump or length);
• prolonged static overloads ("sedentary" processes in production, work in the office, permanent and long stay behind the wheel);
• absence of conditions for a comfortable sleep (sleep on an unsuitable bed size, etc.).

Any of these factors can gradually disrupt the operation of the musculoskeletal system.

Overload is exacerbated by:

• altered spring functionality of the feet (for example, with transverse or longitudinal flat feet);
• disturbed damping properties of the spinal column;
• pathological deviations of the spinal column (in scoliosis, kyphosis);
• weakness of the cervical musculature.

Specialists consider and hereditary factor, when the patient in the family has patients with chronic diseases of the musculoskeletal system. A significant role is also given to malnutrition and ecology.

[6], [7], [8], [9]

Pathogenesis

Back and joint pain associated with the musculoskeletal apparatus is most often provoked by myofascial and muscular spasm. As a consequence of this spasm, the metabolism in the affected area is disturbed, blood circulation and nutrition of tissues worsens, muscle-ligamentous structures become inflamed, large joints suffer. This is often the case in patients with impaired posture or inflammatory processes in the muscles, as well as those who are forced to stay in the same position for a long time. Often, pain in the back and joints occurs after lifting heavy objects, with high-amplitude or severe motor activity, after hypothermia, as well as against such diseases as spondyloarthritis, interscapular syndrome, rheumatoid arthritis, etc.

A special role in the appearance of pain in the back is played by imbalance in the structure of the spinal column, its curvature, osteochondrosis, spondylosis, spondylolisthesis, etc. A similar mechanism of pain is seen in patients with brucellosis, in women during childbearing, in overweight patients, and also in persons suffering from hernias and protrusions of intervertebral discs.

Dystrophic metabolic disorders in the musculoskeletal apparatus in most cases are due to changes in metabolic processes in tissues, the formation of osteophytes. This phenomenon is not uncommon in patients with endocrine pathologies, gout. In this case, pain in the back and joints in patients is often combined with an increasing limitation of motor abilities, with hypermeteorological sensitivity.

Pathologies of the spine, associated with infectious inflammatory or tumor processes, also differ in strong and constant soreness. For example, back pain is found in patients with tuberculous spondylitis, and pain in the joints - with neoplasms affecting bone tissue.

[10], [11], [12], [13], [14], [15], [16]

Epidemiology

Doctors say that patients' complaints about pain in the back and joints in 90% of cases are associated with pathologies of the spinal column, and more often - with osteochondrosis. According to statistics, the spread of this disease affects almost all age groups: doctors explain this by launching a physiological reaction of dehydration of intervertebral discs already in childhood - from about six years. Such a process can proceed in different ways - in some people it is slow, for others it is rapid. Therefore, back pain can occur, as in 40-year-old men, and in adolescents.

And a few more statistical facts:

• Every second patient in our country becomes temporarily unable to work every year due to pain in the back and joints.
• More than 90% of cases of such pains are associated with pathologies of the spine (displacement, overstrain, disc herniation, etc.). Other cases are inflammation, arthritis, trauma, etc.
• Pain in the back and joints is a symptom that ranks second in the frequency of seeking medical help (in the first place, ARI and ARVI).
• In the world, eight people out of ten have regular pain in the joints or back.

[17], [18], [19], [20], [21], [22], [23], [24]

Symptoms

At the initial stages of the pathological process, pain in the back, joints and muscles can appear only periodically: first - after motor or other physical activity, then - in a calm state. Over time, the pain syndrome becomes more prolonged or permanent.

The first signs of pain in different patients differ, which allows them to be classified into several groups:

• Acute pains appear unexpectedly and do not last long, while the victim can clearly indicate their location.
• Aching pain, as a rule, differ in the extent of the lesion. They only make themselves felt periodically, and it is difficult to pinpoint the pathological focus in many cases.
• Chronic pain in the hip joints and back usually have a protracted character and can bother from six months or more. Such patients should necessarily undergo a detailed diagnostic examination: often the causes of chronic pain are diseases requiring surgical intervention.

If the inflammatory process affects the joint, the pain can spread to other sites, which significantly "confuses" the clinical picture. So, often a pain in the hip joint, giving back, ankles, gluteal zones, groin, and also on the inner, back or outer surface of the extremities is often noted.

Symptoms that occur against the background of pain, depend on their primary cause of appearance. Such a cause can be a violation of the spine, neuralgia, sciatica, muscular disease. For example, one of the most common causes is osteochondrosis - it is a pathology associated with dystrophic changes in articular cartilage. When osteochondrosis a person has a backache, gives to the hip joint or limb, numbness, numbness in the body, muscle cramps and spasms may occur. One of the manifestations of such a disease is radiculitis - an inflammatory process affecting the spine of the spinal nerve.

Many specialists associate the appearance of pain in the back with age-related changes. Deterioration of nourishment of tissues, violation of innervation lead to the fact that fibro-cartilaginous intervertebral discs lose moisture and flexibility. In the end, even a non-intensive movement causes uncomfortable sensations and pain. Many elderly patients note that over the years they crack joints and hurts their back. As tissues become dehydrated, the cartilage is compressed and displaced. In the clinical picture, this is manifested by a sharp pain in the joints and lower back.

Pain in the back and joints of a child

In childhood, referral to the doctor for back pain and joints is much less common than in adults. It would seem, where the child can take a dystrophic process, because the kid does not experience any excessive loads, does not get stresses and hypothermia. However, the reasons for the appearance of pain still exist:

• incorrect posture, incorrect position of the body during sleep or sitting;
• injuries, falls;
• chondropathy, intervertebral hernia;
• spondyloarthritis, spondylopathies;
• infectious diseases (including tuberculosis, osteomyelitis);
• tumors of bones, cartilage, ligamentous apparatus, spinal cord;
• blood diseases (hereditary hematological pathologies);
• diseases of the digestive tract or the genitourinary system, which give an irradiation of pain to the area of the back or joints.

It is worth noting that the spectrum of childhood pathologies, for which such a clinical symptom as back and joint pain is typical, is quite extensive and varied. The doctor should be very careful, after all, competent and timely diagnosis is very important for the further health and quality of life of the child.

Diagnostics of the pain in the back and joints

As soon as the first signs of pain in the back and joints are discovered, you should immediately visit a doctor for advice. Depending on the nature of the pain and on the presence of other symptoms, the medical specialist will be able to suspect a particular disease. And to confirm the assumptions, the doctor will prescribe additional diagnostic measures, consisting of a number of laboratory and instrumental procedures. Such procedures include:

• Analyzes in the laboratory:
  • a general blood test that indicates the presence of inflammatory changes in the body, will help detect anemia and assess the quality of blood clotting;
  • urinalysis - a study that allows you to assess the level of protein, glucose and bilirubin;
  • biochemistry of blood and the determination of specific markers of rheumatoid diseases.
• Instrumental diagnostics:
  • X-ray and ultrasound examination helps to identify breaches of bone integrity, dislocations, arthritis or arthrosis, and also to find out the cause of such disorders;
  • computer tomography - provides an opportunity to examine the affected area from different sides and at different depths of tissues;
  • magnetic resonance imaging - allows you to layer-by-layer to examine the state of cartilage, vascular network, musculature, periosteum and vertebrae discs;
  • osteoscintigraphy - helps to assess the quality of blood circulation in the bone system and the intensity of metabolic processes, to detect violations of the integrity of bones, arthritis, tumors and osteomyelitis.

[25], [26], [27], [28], [29]

Differential diagnosis

Differential diagnosis with the appearance of pain in the back and joints is quite complicated, as it requires a careful analysis of all possible causes and clinical picture of the disease. So, the doctor should analyze the possibility of development and exclude or confirm the presence of the following diseases:

• diseases of the joints, as well as muscles and ligaments that are located near the focus of pain (including trauma, inflammation and degeneration of tissues);
• anatomical disorders in the joints and vertebral column, congenital and acquired dislocations, contractures, chronic pathologies;
• systemic processes in the body (autoimmune, infectious and inflammatory processes, neurological disorders);
• so-called stressful or psychological pains (appear as a result of stress loads and eventually pass independently).

The signs of these diseases are similar in many respects, as all of them can manifest as pains in the back and joints.

[30], [31], [32], [33], [34], [35]

Treatment of the pain in the back and joints

What if my back and joints hurt? Of course, refer to a doctor - vertebrologist (for problems with the spine), a rheumatologist (with inflammatory articular diseases), an orthopedist (with degenerative joint lesions), a traumatologist (if the pain in the back and joints are associated with trauma). You can also consult a doctor of a broader direction - for example, a surgeon or a family doctor, and he will already give a referral to a specialist closer to your problem.

After determining the disease, which has caused the appearance of pain in the back and joints, begin treatment - not specifically pain, namely its root causes. The main line of concomitant treatment should be the elimination of pain syndrome.

With pains in the back and joints, medicines are most often used to eliminate the process of inflammation, to normalize the temperature, to stop pain. Of the analgesics, the choice mostly falls on non-steroid drugs such as Diclofenac, Ibuprofen, Indomethacin, Orthofen, etc. These medications, depending on the situation, are prescribed in injections, tablets, and also as external ointment preparations.

For very severe pains, narcotic analgesics, including Morphine, Fentanyl, Promedol, etc., can be used according to the doctor's prescription. However, such medicines are prescribed only in extreme cases - for example, if the strongest pain is caused by a malignant disease.

The standard course of treatment with analgesics and NSAIDs can last no longer than 10 days. Longer reception of the listed medications can negatively affect the patient's health (so, the digestive system is often affected, there are problems with the stomach and duodenum).

If the pain is caused by a muscle spasm, then to remove it you need muscle relaxants - medications that relax the muscles. Especially often these drugs are used for back pain: it can be medications on the basis of tolperisone (Midokalm), tizanidine (Sirdalud), etc.

In addition to drug treatment, special attention should be paid to the use of a special belt-retainer, bandage. These adaptations are relevant if the pain in the back and joints is caused by trauma or surgical intervention, as well as with back pain in pregnant women.

To completely get rid of the pain you will need a comprehensive approach: medication, exercise therapy, massage, reflexes and physiotherapy.

Preparations for pain in the back and joints

If severe pain in the back is concerned, then in most cases the doctor will prescribe injections - it can be analgesics, or blockades with the use of glucocorticoids. The mechanism of action of such blockade injections is to suppress the transmission of a pain impulse from the affected area to the brain.

At the trigger points, a novocaine or lidocaine injection is administered, which causes muscle relaxation and normalizes the tone.

Paravertebral blockade is carried out in pathologies of the spinal column - in particular, with neurological disorders. To conduct such a procedure can only be decided by a qualified experienced doctor, and do it only in a stationary environment.

Next, we present to your attention the groups of drugs most often used for pain in the back and joints.

Anesthetic for pain in back and joints
	Dosing and Administration	Side effects	special instructions
Dolaren	Tablets are taken after a meal, one piece 2-3 times a day.	Constipation, diarrhea, abdominal pain, stomach ulcer (with long-term use).	Dolaren is a combination of paracetamol and diclofenac. Allowed to admission from 6 years of age.
Ketoprofen	At the initial stage of therapy, the drug is taken in the "shock" volume of 300 mg / day, with food, 2-3 times. Further, maintenance therapy is administered at 50 mg three times a day.	Nausea, diarrhea, abdominal pain, dizziness, drowsiness.	Ketoprofen can be taken from 14 years. Contraindications: gastric ulcer, lactation period, second half of pregnancy.
Meloxicam	Take one tablet once a day, at breakfast.	Anemia, pain in the head, stomach pain, indigestion.	Meloksikam not used in pregnancy and breastfeeding, as well as up to 15 years of age.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ointments and gels for pain in the joints and back
	Dosing and Administration	Side effects	special instructions
Gel Diclofenac	Easily rub into the affected area 3-4 times a day. The course of therapy should not exceed 2 weeks.	Rarely is an allergy, redness of the skin.	There is no evidence that the gel can be used to treat children younger than 14 years of age.
Arthrosilen	Rub in a sore spot twice a day, for 10 days.	Rarely - local irritation reactions, allergies.	The gel contains ketoprofen. It is not used for preschool children.
Viprosal	Apply a small layer on the clean skin twice a day. The course of therapy is from 7 to 30 days.	Rarely - allergies.	Viprosal is well tolerated by patients of any age. The possibility of using ointment during pregnancy is discussed with the doctor.

Injections with pain in back and joints
	Dosing and Administration	Side effects	special instructions
Voltaren	Usually 75 mg (one ampoule) of the drug is administered once a day, intramuscularly.	Disturbances of the stool, defeat of the digestive tract.	Do not use Voltaren for more than two days in a row.
Diclofenac sodium	Enter intramuscularly 75 mg of the drug up to 2 times a day, for 4-5 days.	Dyspepsia, erosive-ulcerative processes in the stomach.	The drug is not used to eliminate pain in the back and joints in children under 6 years.
Revmoxics	The drug is administered intramuscularly at 7.5-15 mg once a day, no more than five consecutive days.	Dyspepsia, edema, colitis, gastritis.	The drug is not used to treat pregnant and lactating women, as well as children under 15 years of age.

Suppositories for pain in the back and joints
	Dosing and Administration	Side effects	special instructions
Revmalgin	Use rectally one suppository at night.	Dizziness, dyspeptic symptoms, tachycardia.	The drug is not used in pediatrics.
Dikloobl	Apply in the form of rectal suppositories of 100-150 mg per day.		For children's practice there are special children's suppositories - for example, Nurofen.
Indometacin	For adults, use 1 suppository (50 mg) up to 3 times a day, or 1 suppository (100 mg) 1-2 times a day.	Noise in the ears, tachyarrhythmia, allergic reactions, indigestion.	Treatment with the drug should not last more than one week.

Tablets from back pain and joint pain
	Dosing and Administration	Side effects	special instructions
Orthophenia	Take 25-50 mg orally up to 3 times a day.	Epigastric pain, nausea, pain in the head.	Orthofen is not used to relieve pain in children under six years old.
Ketorolac	Take one tablet of 10 mg every 4-6 hours. The total duration of the reception is not more than one week.	Pain in the stomach, loss of appetite, diarrhea, nausea.	Ketorolac is not used for the treatment of back pain and joint pain in children under 16 years old.
Nimesulide	Take 100 mg of the drug twice a day, after meals.	Drowsiness, heartburn, indigestion, allergic reactions.	Absolute contraindication to drug treatment is pregnancy.

In order to prevent pain in the back and joints, it is necessary that the body in the required quantity received natural bioactive substances, which include vitamins and minerals. The bony system needs calcium, but its assimilation is impossible without vitamin D ₃. For the well-coordinated work of the ligaments, collagen is needed, which again is absorbed in combination with vitamins A and E.

In addition, the musculoskeletal system needs such vitamins:

• vitamin A - improves the absorption of phosphorus;
• ascorbic acid - strengthens the formation of collagen;
• vitamin B ₆  improves the absorption of magnesium, balances the mineral-salt metabolism.

Other important active substances for joints are:

• chondroitin - strengthens cartilage, ligaments, tendinous fibers;
• collagen - provides flexibility and strength of tissues;
• Glucosamine - strengthens tendons and ligamentous apparatus;
• methylsulfonylmethane - promotes restoration of bones and cartilage;
• silicon - increases the quality of collagen, keeps calcium in the tissues of bones;
• manganese - helps to deliver oxygen to cartilage and bones;
• sulfur - provides metabolic processes in the cartilaginous tissue;
• selenium - improves the cartilaginous structure.

Indispensable for pain in the back and joints are also a pair of fatty acids - namely, linoleic and γ-linoleic acids.

Physiotherapeutic treatment

Physiotherapy for pain in the back and joints is one of the basic methods included in the treatment regimen. Procedures are necessary, both to prevent the development of complications, and to repair damaged tissue, relieve pain, and to enhance the therapeutic effect.

• Electrophoresis involves the use of a direct current that penetrates deep into the skin. Thanks to this, it is possible to deliver painkillers, anti-inflammatory and regenerating agents directly to inflamed tissues.
• UV irradiation (SUF-irradiation) - is an irritation of the skin by electromagnetic waves up to 400 nm in length. This allows you to eliminate pain in the back and joints with arthrosis, arthritis, bursitis, tendinitis, etc.
• Infrared laser treatment is used for osteochondrosis, arthrosis, polyarthritis, synovitis. The procedures help to reduce the sensitivity of nerve roots, stabilize blood circulation, stop the inflammatory process.
• UHF-therapy involves exposure to joints of high-frequency ultrasound. As a result of this treatment, the pain becomes less intense, the swelling subsides, the inflammation is suppressed.
• Magnetotherapy is based on the effect of an alternating or constant, low and high-frequency magnetic field. Especially often this treatment is used for pain in the hip, knee or elbow joints.
• Therapeutic baths are prescribed for patients with arthrosis, arthritis, etc. The most useful baths for pain in the back and joints are:
  • hydrogen sulphide;
  • nitrogen;
  • radon.

The treatment of baths can be repeated twice a year, approximately 10-12 daily procedures.

Physiotherapy treatment for pain in the back and joints is prescribed only by a specialist: it is important to make sure there are no contraindications.

Alternative treatment

Many good reviews have been received from patients practicing medical treatment of the spinal column and joints with bay leaf. To prepare the broth, take 3-4 medium leaves, grind them, pour 300 ml of hot water and place on a small fire. Boil for about three minutes, poured together with the cake into a thermos bottle and kept for the night. In the morning, the medicine is filtered and proceeds to reception: 2 sips a quarter of an hour before a meal. Drinking a large amount of decoction at a time is not recommended, as this can lead to gastric bleeding. Since such treatment is complex and dangerous, it is necessary to consult a doctor before conducting it.

If the house has sea buckthorn oil, then it can be rubbed into sore spots several times a day. Simultaneously, it is necessary to brew tea on the basis of sea-buckthorn berries and drink it during the day.

Well relieve pain in the back and joints of the application of clay, as well as applying compresses from aloe with honey. To prepare a simple compress, take 150 ml of vodka, 100 ml of honey and 50 ml of aloe juice. All ingredients are mixed and placed in a refrigerator for 7 days. The received medicine rubs sore spots, and then wraps them with a warm scarf. This procedure is best done before bedtime. To obtain a lasting effect, you need to do 8-10 procedures.

[36],

Herbal Treatment

With pain in the back and joints it is very good to use infusions and tinctures of certain medicinal plants. The choice of such plants is very extensive:

• birch leaves;
• cherry leaves;
• Lucky bagulnik;
• the color of elderberry;
• leaves of nettle;
• thyme creeping;
• Needles (spruce, juniper);
• pijma;
• sweet clover;
• purslane.

Most infusions should be prepared as follows: Take 2 tsp. Leaves, brewed 200 ml of boiling water, insisted for a quarter of an hour, filtered and drunk throughout the day in small sips.

A good effect has a medicinal ointment. For its preparation take 2 tbsp. L. Herbs of St. John's wort, as much hops and medicinal clover. The listed plants are ground into a powder, mixed with 50 g of vaseline oil and well ground. The obtained ointment is used for compresses, which are put on the night of the diseased joint.

Homeopathy

Treatment of pain in the back and joints with the help of homeopathy is an unconventional and difficult decision. It is impossible to practice such therapy on its own, as there are specific features of the appointment of homeopathic remedies, which only an experienced doctor-homeopath knows. In addition, there are contraindications - for example, malignant formations, the presence of individual intolerance to medicinal components. Preliminary it is necessary to pass a diagnostic examination, to pass the necessary tests to clarify the diagnosis.

The most common homeopathic remedies for back pain and joint pain are:

• Rhododendron - if joint pain is accompanied by headaches and general weakness;
• Calcarea Carbonica - if you are concerned about pain in the knees and hip joints;
• Dulcamara - if back pain intensifies in dampness and in cold weather;
• Ruta - is prescribed for osteochondrosis or polyarthritis;
• Bryonia - if the pain in the back and joints is worse during walking;
• Phytolyacca - if pain occurs against the background of excessive body weight;
• Rus toxicodendron - if pains affect the ligamentous apparatus and appear even at rest;
• Apis - if the pain is combined with swelling and redness of the joints.

The dosage of the above drugs and the frequency of their administration are determined by the doctor on an individual basis.

Surgery

The surgeon's help for pain in the back and joints may be necessary in cases when conservative and medicinal treatment did not lead to improvement of the patient's condition, and the presence of constant pain worsens the patient's quality of life. In particular, the operation is prescribed if incessant pain in the back is associated with intervertebral hernia, stenosis of the canal of the spinal cord, spondylolisthesis, as well as with traumatization of the spinal column. Also, indications for surgery may be degenerative processes in intervertebral discs associated with age-related spinal wear.

The basic types of surgical intervention for pain in joints are:

• puncture - play a diagnostic and therapeutic role (used to introduce medicinal solutions inside the joint);
• arthrotomy - is the opening of the synovial articular layer for its drug treatment;
• arthroplasty - implies the restoration of the functionality and motor ability of the joint;
• resection is the removal of bone articular surfaces (for example, with purulent bone destruction);
• arthroscopy - is performed with the help of an endoscope and has a therapeutic and diagnostic value;
• prosthetics - replacement of parts of the joint, or its full replacement with an implant (to restore motor ability).

Complications and consequences

Depending on the reason for the pain in the back and joints, there can be a variety of complications.

Common complications can be associated with the use of various medications to relieve pain. Unpleasant consequences often are allergic reactions, fever, hypersensitivity reactions, autoimmune response (with the use of corticosteroid drugs).

If back pain is associated with problems in the spine, then in the absence of treatment, there may be:

• paralysis of the limbs;
• paraplegia;
• neurological signs;
• breakdown of brain functions.

When squeezing nerves, there may be a pinch - for example, sciatica. This pathology is accompanied by strong shooting pains in the back, which are often given to the buttocks, hip, limb.

Problems with joints often cause disruption of motor abilities: the patient may lose his ability to work and become disabled.

Diseases of the spinal column can provoke failures in the work of internal organs. In particular, the pathology of the lumbar region sometimes causes problems with the urogenital system.

[37], [38], [39], [40], [41], [42], [43],

Prevention

What to do, so that the pain in the back and joints never bother? Doctors voiced the basic rules of prevention:

• body weight control, correct balanced nutrition;
• regular moderate moderate exercise;
• warm-up before exercise (be it sports or work);
• the correct position of the back and body when standing, walking, sitting;
• properly selected shoes - high-quality, with a small heel, at low speed;
• good conditions for sleep (adequate length of bed, quality mattress, comfortable pillow);
• absence of bad habits;
• regular examination of the doctor, preventive diagnostics.

[44], [45], [46], [47], [48]

Forecast

The prognosis depends on the cause of the pain, and on how correctly the patient will perform all the prescriptions and recommendations of the attending physician. Both the spine and the joints should be protected, not forgetting about gymnastics, healthy lifestyle and healthy nutrition. If you adhere to all the recommendations, then it will speed up recovery for a considerable period of time. Also, avoid any overloads - both physical and stressful.

If there are pains in the back and joints, then you need to urgently seek medical help. A timely trip to the doctor will help prevent the development of unpleasant consequences and provide motor comfort for many years.

[49], [50],