Understanding Chronic Leg and Foot Pain: Causes, Symptoms, and Treatment Options

May 11, 2024

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Chronic leg and foot pain, also known as chronic pain in legs and feet, is a common and often debilitating condition that can significantly impact a person’s quality of life. As a medical professional, it is crucial to provide patients with accurate and accessible information about this condition, empowering them to make informed decisions about their health and well-being. In this comprehensive guide, we will explore the causes, symptoms, and treatment options for chronic leg and foot pain, helping patients better understand and manage this challenging condition.

Leg and foot pain can range from mild discomfort to severe, disabling pain that interferes with daily activities. When this pain persists for more than three months, it is considered chronic[1]. Chronic leg and foot pain can have various causes, including musculoskeletal disorders, neurological conditions, and vascular issues, making accurate diagnosis and targeted treatment essential for effective management.

Anatomy of the Leg and Foot

To better understand chronic leg and foot pain, it is helpful to have a basic understanding of the anatomy of these regions. The leg and foot are complex structures, consisting of bones, muscles, tendons, ligaments, nerves, and blood vessels, all working together to enable movement and support the body’s weight.

StructureFunction
BonesProvide structure and support for the leg and foot, including the femur, tibia, fibula, tarsal bones, metatarsals, and phalanges
MusclesEnable movement and stability, including the quadriceps, hamstrings, calf muscles, and intrinsic foot muscles
TendonsConnect muscles to bones, allowing for force transmission and movement
LigamentsConnect bones to other bones, providing stability and support to the joints
NervesTransmit sensory and motor signals between the brain, spinal cord, and the leg and foot
Blood VesselsSupply oxygen and nutrients to the tissues of the leg and foot, including arteries, veins, and capillaries

Understanding the intricate relationships between these structures can help patients and healthcare providers better identify the source of chronic leg and foot pain and develop targeted treatment plans.

Common Causes of Chronic Leg and Foot Pain

Chronic leg and foot pain can have various causes, ranging from musculoskeletal disorders to neurological conditions. Some of the most common causes include:

  1. Arthritis: Osteoarthritis, rheumatoid arthritis, and other forms of arthritis can cause inflammation, pain, and stiffness in the joints of the leg and foot[2].
  2. Peripheral neuropathy: Damage to the nerves in the leg and foot, often due to diabetes, can cause burning, tingling, or numbness.
  3. Plantar fasciitis: Inflammation of the thick band of tissue that runs along the bottom of the foot can cause heel pain and arch pain.
  4. Tendinitis: Inflammation of the tendons, such as the Achilles tendon or posterior tibial tendon, can cause pain and stiffness in the leg and foot.
  5. Stress fractures: Tiny cracks in the bones of the leg or foot, often due to overuse or repetitive stress, can cause pain and discomfort.
  6. Varicose veins: Enlarged, twisted veins in the leg can cause aching, heaviness, and cramping.
  7. Spinal conditions: Herniated discs, spinal stenosis, and other spinal disorders can cause radiating pain, numbness, or weakness in the leg and foot.

Identifying the underlying cause of chronic leg and foot pain is essential for developing an effective treatment plan and managing symptoms.

Symptoms of Chronic Leg and Foot Pain

The symptoms of chronic leg and foot pain can vary depending on the underlying cause and the individual patient. Some common symptoms include:

  • Aching, throbbing, or burning pain in the leg or foot
  • Stiffness or limited range of motion in the affected joints
  • Swelling or tenderness in the leg or foot
  • Numbness, tingling, or weakness in the leg or foot
  • Difficulty walking or bearing weight on the affected leg or foot
  • Pain that worsens with activity or improves with rest
  • Visible changes in the appearance of the leg or foot, such as redness or deformity

Patients experiencing these symptoms for more than three months should consult with a healthcare provider for proper evaluation and diagnosis.

Diagnosing Chronic Leg and Foot Pain

Diagnosing chronic leg and foot pain typically involves a combination of a thorough medical history, physical examination, and, in some cases, additional tests. Your healthcare provider will ask about your symptoms, the location and duration of your pain, and any other relevant medical information.

During the physical examination, your doctor will assess your leg and foot, checking for tenderness, swelling, deformity, or limited range of motion. They may also evaluate your gait, reflexes, and sensory function to identify any neurological issues.

If your healthcare provider suspects an underlying condition is causing your chronic leg and foot pain, they may recommend additional tests, such as:

  • X-rays to visualize the bones and joints of the leg and foot
  • MRI or CT scans to assess soft tissues, such as muscles, tendons, and ligaments
  • Nerve conduction studies or electromyography (EMG) to evaluate nerve function
  • Blood tests to check for signs of inflammation, infection, or autoimmune disorders
  • Ultrasound to assess blood flow and identify vascular issues

Accurate diagnosis is crucial for developing a targeted treatment plan that addresses the root cause of your chronic leg and foot pain.

Non-Surgical Treatment Options

For many patients with chronic leg and foot pain, non-surgical treatments can effectively manage symptoms and improve function. Some common non-surgical options include:

  1. Pain medication: Over-the-counter or prescription pain relievers, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or opioids, can help reduce pain and inflammation.
  2. Physical therapy: A physical therapist can teach you specific exercises and stretches to help strengthen the muscles of the leg and foot, improve flexibility, and reduce pain[3].
  3. Orthotics: Custom-made shoe inserts or braces can help redistribute pressure, provide support, and alleviate pain in the leg and foot.
  4. Lifestyle modifications: Losing weight, avoiding high-impact activities, and wearing supportive footwear can help reduce stress on the leg and foot and manage pain.
  5. Cognitive-behavioral therapy: This type of therapy can help patients develop coping strategies and manage the emotional impact of chronic pain.

Working closely with your healthcare provider to develop a personalized non-surgical treatment plan can help you effectively manage your chronic leg and foot pain and improve your quality of life.

Surgical Treatment Options

In some cases, when non-surgical treatments are not sufficient to manage chronic leg and foot pain, surgical intervention may be necessary. The specific surgical procedure will depend on the underlying cause of your pain and the severity of your condition.

Some common surgical options for chronic leg and foot pain include:

  1. Joint replacement: For patients with advanced arthritis or severe joint damage, joint replacement surgery, such as ankle or knee replacement, can help alleviate pain and restore function.
  2. Tendon or ligament repair: Surgical repair of damaged tendons or ligaments, such as the Achilles tendon or the plantar fascia, can help reduce pain and improve stability in the leg and foot.
  3. Nerve decompression: Surgery to relieve pressure on compressed nerves, such as the tarsal tunnel or the peroneal nerve, can help reduce pain and improve sensory function.
  4. Vascular surgery: Procedures to address vascular issues, such as varicose vein removal or bypass surgery for peripheral artery disease, can help improve blood flow and reduce pain in the leg and foot.
  5. Spinal surgery: In cases where spinal disorders are contributing to chronic leg and foot pain, surgical procedures such as discectomy, laminectomy, or spinal fusion may be necessary.

It is essential for patients to discuss the potential risks and benefits of surgical treatment with their healthcare provider to determine the most appropriate course of action.

Preventing Chronic Leg and Foot Pain

While not all cases of chronic leg and foot pain can be prevented, there are several steps patients can take to reduce their risk and maintain good musculoskeletal health:

  1. Maintain a healthy weight: Excess weight puts additional stress on the legs and feet, increasing the risk of pain and joint damage.
  2. Exercise regularly: Low-impact exercises, such as swimming, cycling, or elliptical training, can help strengthen the muscles of the leg and foot, improve flexibility, and reduce the risk of injury.
  3. Wear supportive footwear: Choosing shoes that provide adequate arch support, cushioning, and stability can help reduce stress on the legs and feet and prevent pain.
  4. Practice good posture: Maintaining proper posture while sitting, standing, and walking can help distribute weight evenly and reduce strain on the legs and feet.
  5. Stretch regularly: Incorporating stretching exercises into your daily routine can help improve flexibility, reduce muscle tension, and prevent pain in the legs and feet.
  6. Manage underlying health conditions: Effectively managing conditions such as diabetes, obesity, and peripheral artery disease can help reduce the risk of developing chronic leg and foot pain.

By adopting these preventive measures, patients can help minimize their risk of developing chronic leg and foot pain and maintain good musculoskeletal health.

Living with Chronic Leg and Foot Pain

Living with chronic leg and foot pain can be challenging, but there are several strategies patients can employ to manage their symptoms and maintain a good quality of life:

  1. Develop a pain management plan: Work with your healthcare provider to create a comprehensive pain management plan that includes medication, therapy, and lifestyle modifications.
  2. Stay active: While it may be tempting to avoid physical activity due to pain, regular low-impact exercise can help improve muscle strength, flexibility, and overall musculoskeletal health.
  3. Manage stress: Incorporating stress-reduction techniques, such as deep breathing, meditation, or yoga, into your daily routine can help reduce muscle tension and manage pain.
  4. Modify your environment: Making adjustments to your home or workplace, such as using ergonomic furniture or installing grab bars, can help reduce stress on the legs and feet and make daily activities more manageable.
  5. Seek support: Joining a support group or talking with a therapist can help patients cope with the emotional impact of chronic pain and develop effective coping strategies.

Remember, while chronic leg and foot pain can be challenging, with the right combination of treatment, lifestyle modifications, and support, it is possible to effectively manage your symptoms and maintain a good quality of life.

The Role of Physical Therapy in Managing Chronic Leg and Foot Pain

Physical therapy plays a crucial role in the management of chronic leg and foot pain, helping patients improve strength, flexibility, and function. A physical therapist can develop a personalized treatment plan based on your specific needs and goals, which may include:

  1. Stretching exercises: Gentle stretching exercises can help improve flexibility, reduce muscle tension, and alleviate pain in the legs and feet.
  2. Strengthening exercises: Targeted strengthening exercises can help improve the strength and stability of the muscles in the legs and feet, reducing the risk of injury and managing pain.
  3. Gait training: A physical therapist can analyze your gait and provide guidance on proper walking techniques to reduce stress on the legs and feet and improve overall function.
  4. Manual therapy: Techniques such as massage, joint mobilization, and soft tissue manipulation can help reduce pain, improve range of motion, and promote healing in the legs and feet.
  5. Modalities: Physical therapists may use modalities such as ultrasound, electrical stimulation, or heat/cold therapy to help reduce pain and inflammation in the legs and feet.

Engaging in regular physical therapy sessions and following a home exercise program can help patients with chronic leg and foot pain effectively manage their symptoms and improve their quality of life.

Alternative and Complementary Therapies for Chronic Leg and Foot Pain

In addition to traditional medical treatments, some patients with chronic leg and foot pain may find relief through alternative and complementary therapies. While the effectiveness of these therapies may vary, they can be used in conjunction with conventional treatments to help manage symptoms and improve overall well-being.

Some common alternative and complementary therapies for chronic leg and foot pain include:

  1. Acupuncture: This ancient Chinese practice involves the insertion of thin needles into specific points on the body to help reduce pain and promote healing.
  2. Massage therapy: Therapeutic massage can help reduce muscle tension, improve circulation, and alleviate pain in the legs and feet.
  3. Chiropractic care: Chiropractors use manual adjustments and manipulations to help alleviate pain, improve joint function, and promote overall musculoskeletal health.
  4. Herbal remedies: Some herbs, such as turmeric, ginger, and boswellia, have anti-inflammatory properties that may help reduce pain and inflammation in the legs and feet[4].
  5. Mind-body techniques: Practices such as meditation, deep breathing, and progressive muscle relaxation can help reduce stress, manage pain, and improve overall well-being.

It is essential for patients to discuss the use of alternative and complementary therapies with their healthcare provider to ensure safety and avoid potential interactions with conventional treatments.

The Importance of Proper Footwear in Managing Chronic Leg and Foot Pain

Wearing appropriate footwear is a simple yet effective way to manage chronic leg and foot pain and prevent further discomfort. Proper footwear can help distribute weight evenly, provide support and cushioning, and reduce stress on the legs and feet.

When choosing footwear, consider the following factors:

  1. Arch support: Look for shoes with adequate arch support to help distribute weight evenly and reduce strain on the feet and legs.
  2. Cushioning: Shoes with ample cushioning, particularly in the heel and forefoot areas, can help absorb shock and reduce the impact on the legs and feet.
  3. Stability: Opt for shoes with a stable base and supportive midsole to help prevent excessive pronation or supination, which can contribute to leg and foot pain.
  4. Fit: Ensure that your shoes fit properly, with enough room in the toe box and a snug fit around the heel and midfoot to prevent slipping and reduce friction.
  5. Activity-specific: Choose footwear that is appropriate for your specific activities, such as running shoes for jogging or supportive sandals for walking.

In some cases, custom-made orthotics or shoe inserts may be necessary to provide additional support and alleviate pain in the legs and feet. Consult with your healthcare provider or a podiatrist to determine if orthotics are appropriate for your specific condition.

Nutrition and Chronic Leg and Foot Pain

Proper nutrition can play a role in managing chronic leg and foot pain by promoting overall health, reducing inflammation, and supporting musculoskeletal function. Some dietary considerations for patients with chronic leg and foot pain include:

  1. Anti-inflammatory foods: Consuming a diet rich in anti-inflammatory foods, such as fruits, vegetables, whole grains, lean proteins, and healthy fats, can help reduce inflammation in the body and manage pain[5].
  2. Omega-3 fatty acids: Foods high in omega-3 fatty acids, such as fatty fish, flaxseeds, and walnuts, have been shown to have anti-inflammatory properties and may help reduce pain and stiffness in the legs and feet.
  3. Vitamin D and calcium: Adequate intake of vitamin D and calcium is essential for maintaining strong bones and preventing conditions such as osteoporosis, which can contribute to leg and foot pain.
  4. Hydration: Staying well-hydrated can help reduce inflammation, improve joint lubrication, and promote overall musculoskeletal health.
  5. Avoiding trigger foods: Some patients may find that certain foods, such as processed foods, refined sugars, or nightshade vegetables, exacerbate their leg and foot pain. Keeping a food diary can help identify potential trigger foods.

Incorporating a balanced, nutrient-rich diet into your overall treatment plan can help support your body’s natural healing processes and manage chronic leg and foot pain.

The Emotional Impact of Chronic Leg and Foot Pain

Chronic leg and foot pain can have a significant emotional impact on patients, affecting their mental health and overall quality of life. Living with persistent pain can lead to feelings of frustration, anger, sadness, and even depression or anxiety.

It is essential for patients with chronic leg and foot pain to address the emotional aspects of their condition and seek support when needed. Some strategies for managing the emotional impact of chronic pain include:

  1. Counseling or therapy: Talking with a mental health professional can help patients develop coping strategies, manage stress, and address any underlying emotional issues related to their chronic pain.
  2. Support groups: Joining a support group for individuals with chronic pain can provide a sense of community, validation, and encouragement from others who understand the challenges of living with persistent pain.
  3. Mindfulness and relaxation techniques: Practicing mindfulness, meditation, or deep breathing exercises can help reduce stress, manage pain, and promote emotional well-being.
  4. Engaging in enjoyable activities: Finding ways to participate in hobbies, social activities, or other enjoyable pursuits, despite pain limitations, can help improve mood and maintain a sense of purpose.
  5. Communicating with loved ones: Openly discussing the emotional impact of chronic pain with family and friends can help foster understanding, support, and stronger relationships.

Addressing the emotional aspects of chronic leg and foot pain is just as important as managing the physical symptoms. By incorporating emotional support and self-care strategies into your overall treatment plan, you can improve your mental health and quality of life while living with chronic pain.

The Role of Pain Management Specialists in Treating Chronic Leg and Foot Pain

For patients with complex or refractory chronic leg and foot pain, working with a pain management specialist can be beneficial. Pain management specialists are healthcare providers who have advanced training in evaluating, diagnosing, and treating various pain conditions.

A pain management specialist can help patients with chronic leg and foot pain by:

  1. Conducting a comprehensive evaluation: Pain management specialists will thoroughly assess your medical history, physical condition, and specific pain symptoms to develop an accurate diagnosis and treatment plan.
  2. Developing a multimodal treatment approach: Pain management specialists often use a combination of treatments, such as medication, interventional procedures, physical therapy, and psychological support, to address chronic pain from multiple angles.
  3. Offering interventional procedures: Pain management specialists can perform interventional procedures, such as nerve blocks, injections, or spinal cord stimulation, to help alleviate chronic leg and foot pain.
  4. Coordinating care with other providers: Pain management specialists often work closely with other healthcare providers, such as primary care physicians, orthopedists, or physical therapists, to ensure a coordinated and comprehensive approach to pain management.
  5. Providing ongoing support and monitoring: Pain management specialists will regularly follow up with patients to assess the effectiveness of treatments, make necessary adjustments, and provide ongoing support and guidance.

If you are experiencing chronic leg and foot pain that is not adequately controlled with standard treatments, consider discussing a referral to a pain management specialist with your primary healthcare provider.

Coping with Chronic Leg and Foot Pain at Work

Managing chronic leg and foot pain while working can be challenging, but there are several strategies that can help patients cope with their symptoms and maintain productivity:

  1. Ergonomic adjustments: Modifying your work environment, such as using an ergonomic chair, adjustable desk, or supportive footwear, can help reduce stress on the legs and feet and alleviate pain.
  2. Frequent breaks: Taking regular breaks to stand, stretch, or walk can help improve circulation, reduce muscle tension, and manage pain throughout the workday.
  3. Job modifications: Discussing your chronic pain condition with your employer and exploring potential job modifications, such as reduced standing time or flexible scheduling, can help accommodate your needs and maintain productivity.
  4. Pain management techniques: Incorporating pain management techniques, such as deep breathing, progressive muscle relaxation, or mindfulness exercises, into your workday can help manage pain and reduce stress.
  5. Communication with colleagues: Openly communicating with your colleagues about your chronic pain condition can help foster understanding, support, and a more accommodating work environment.

Remember, it is essential to prioritize your health and well-being while managing chronic leg and foot pain at work. Collaborating with your employer, healthcare provider, and colleagues can help you develop an effective plan for coping with your symptoms and maintaining job performance.

The Impact of Chronic Leg and Foot Pain on Sleep

Chronic leg and foot pain can significantly impact sleep quality and duration, leading to daytime fatigue, mood disturbances, and reduced overall quality of life. Pain can make it difficult to fall asleep, stay asleep, or achieve restful sleep stages.

Some strategies for improving sleep while living with chronic leg and foot pain include:

  1. Establishing a consistent sleep schedule: Going to bed and waking up at the same time each day can help regulate your body’s internal clock and improve sleep quality.
  2. Creating a comfortable sleep environment: Ensuring your bedroom is dark, quiet, and cool, and using supportive pillows and mattresses can help promote comfort and reduce pain-related sleep disturbances.
  3. Practicing good sleep hygiene: Avoiding caffeine, alcohol, and electronic devices before bedtime, and engaging in relaxation techniques such as deep breathing or meditation, can help prepare your body and mind for sleep.
  4. Timing pain medication: Working with your healthcare provider to optimize the timing of your pain medication can help ensure that your pain is adequately controlled during sleep hours.
  5. Using supportive devices: Utilizing supportive devices, such as leg pillows, knee braces, or compression stockings, can help alleviate pain and improve sleep quality.

If chronic leg and foot pain continues to significantly impact your sleep despite implementing these strategies, consult your healthcare provider for further evaluation and treatment options. Addressing sleep disturbances is a crucial component of managing chronic pain and improving overall quality of life.

Staying Active with Chronic Leg and Foot Pain

Engaging in regular physical activity is essential for patients with chronic leg and foot pain, as it can help improve muscle strength, flexibility, and overall musculoskeletal health. However, it is important to choose activities that are appropriate for your specific condition and fitness level.

Some low-impact activities that may be suitable for patients with chronic leg and foot pain include:

  1. Swimming or water aerobics: The buoyancy of water helps reduce stress on the joints and muscles, making these activities an excellent choice for patients with chronic pain.
  2. Cycling: Stationary or recumbent cycling can provide a cardiovascular workout while minimizing impact on the legs and feet.
  3. Elliptical training: Elliptical machines offer a low-impact alternative to running or walking, allowing for a cardiovascular workout with reduced stress on the lower extremities.
  4. Yoga or Pilates: These practices can help improve flexibility, strength, and balance while promoting relaxation and stress reduction.
  5. Tai Chi: This gentle, flowing form of exercise can help improve balance, reduce pain, and promote overall well-being.

When starting a new physical activity program, it is essential to begin slowly and gradually increase the intensity and duration of your workouts. Listen to your body and stop or modify activities if you experience increased pain or discomfort. Consult with your healthcare provider or a physical therapist to develop a personalized exercise plan that takes into account your specific condition and goals.

The Role of Assistive Devices in Managing Chronic Leg and Foot Pain

Assistive devices can play a crucial role in managing chronic leg and foot pain, helping to reduce stress on the affected areas, improve mobility, and enhance overall function. Some common assistive devices for patients with chronic leg and foot pain include:

  1. Orthotics: Custom-made shoe inserts or arch supports can help redistribute pressure, provide support, and alleviate pain in the feet and legs.
  2. Braces or splints: Ankle, knee, or foot braces can help stabilize joints, reduce pain, and improve alignment.
  3. Canes or walkers: These devices can help reduce weight-bearing on the affected leg or foot, improve balance, and enhance mobility.
  4. Compression stockings: Graduated compression stockings can help improve circulation, reduce swelling, and alleviate pain in the legs and feet.
  5. Wheelchairs or scooters: For patients with severe or debilitating chronic leg and foot pain, wheelchairs or scooters can help maintain independence and improve overall quality of life.

When considering an assistive device, it is essential to consult with your healthcare provider or a physical therapist to ensure that the device is appropriate for your specific condition and properly fitted for your needs. Proper use and maintenance of assistive devices are also crucial for optimal benefit and safety.

Traveling with Chronic Leg and Foot Pain

Traveling with chronic leg and foot pain can present unique challenges, but with proper planning and preparation, patients can still enjoy the benefits of travel while managing their symptoms. Some tips for traveling with chronic leg and foot pain include:

  1. Plan ahead: Research your destination, accommodations, and transportation options to ensure that they are accessible and suitable for your needs.
  2. Pack appropriately: Bring comfortable, supportive footwear, any necessary assistive devices, and sufficient medication to last throughout your trip.
  3. Stay active: Incorporate regular stretching and low-impact exercises into your travel routine to help maintain flexibility and reduce pain.
  4. Manage stress: Utilize stress-reduction techniques, such as deep breathing or meditation, to help manage pain and maintain emotional well-being during travel.
  5. Communicate your needs: Inform travel companions, transportation staff, or accommodations providers about your chronic pain condition and any specific requirements you may have.
  6. Take frequent breaks: When traveling by car, plane, or train, take regular breaks to stand, stretch, or walk around to help reduce stiffness and pain.
  7. Listen to your body: Pay attention to your body’s signals and adjust your travel plans or activities as needed to manage your pain and avoid overexertion.

By planning ahead, staying active, and communicating your needs, you can successfully navigate the challenges of traveling with chronic leg and foot pain and enjoy the many benefits of exploring new destinations.

Conclusion

Chronic leg and foot pain can have a significant impact on a patient’s quality of life, affecting physical function, emotional well-being, and overall happiness. However, by understanding the causes, symptoms, and treatment options for chronic leg and foot pain, patients can work with their healthcare providers to develop an effective management plan and take steps to improve their daily lives.

Key strategies for managing chronic leg and foot pain include:

  1. Collaborating with healthcare providers to develop a comprehensive treatment plan that addresses both the physical and emotional aspects of chronic pain.
  2. Incorporating lifestyle modifications, such as maintaining a healthy weight, engaging in regular low-impact exercise, and wearing supportive footwear, to reduce stress on the legs and feet.
  3. Utilizing non-pharmacological therapies, such as physical therapy, cognitive-behavioral therapy, and complementary therapies, to help manage pain and improve function.
  4. Addressing the emotional impact of chronic pain through counseling, support groups, and stress-reduction techniques.
  5. Adapting daily routines and environments, such as using assistive devices or making ergonomic adjustments at work, to accommodate chronic pain and maintain independence.

Remember, while living with chronic leg and foot pain can be challenging, there is hope for improved quality of life. By staying proactive, informed, and engaged in your care, you can successfully navigate the journey of managing chronic pain and reclaim your daily life.

References

  1. Mills, S., Torrance, N., & Smith, B. H. (2016). Identification and Management of Chronic Pain in Primary Care: a Review. Current Psychiatry Reports, 18(2), 22. https://doi.org/10.1007/s11920-015-0659-9
  2. Hawker, G. A., Mian, S., Kendzerska, T., & French, M. (2011). Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care & Research, 63(S11), S240-S252. https://doi.org/10.1002/acr.20543
  3. van Middelkoop, M., Rubinstein, S. M., Kuijpers, T., Verhagen, A. P., Ostelo, R., Koes, B. W., & van Tulder, M. W. (2011). A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. European Spine Journal, 20(1), 19-39. https://doi.org/10.1007/s00586-010-1518-3
  4. Ghasemian, M., Owlia, S., & Owlia, M. B. (2016). Review of Anti-Inflammatory Herbal Medicines. Advances in Pharmacological Sciences, 2016, 1-11. https://doi.org/10.1155/2016/9130979
  5. Totsch, S. K., & Sorge, R. E. (2017). Immune System Involvement in Specific Pain Conditions. Molecular Pain, 13, 1744806917724559. https://doi.org/10.1177/1744806917724559
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