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The Logistics: A Shift in Current
Practice Paradigms and Algorithms
Low-back pain [LBP] in active patients is common and often recurrent. The cause
of LBP and other symptoms is multi-factorial and diverse, and the precise identification
of the pain generators is often elusive. Family practice physicians frequently
diagnose mechanical LBP in patients without a clear path of optimal care.
Medical evidence, including the US government sponsored AHCPR meta-analysis,
has indicated that 85-90% of LBP will resolve within 6-12 weeks with |
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only palliative (symptomatic) care; therefore many
physicians question whether more specific intervention is really necessary
during this period.
However, recent longitudinal studies suggest that back pain is typically recurrent
in nature, even if the original symptoms resolve, and many patients suffer
chronic, unremitting symptoms at intervals. Studies indicate that over 60%
of patients with acute LBP, suffered at least one recurrence in the following
year. The high incidence of recurrence and chronicity point to the inadequacy
of current management protocols, and warrants analysis and revision of our
current treatment algorithms (standards).
The medical community, despite its appearance of being at the cutting edge
of health advancements, can often be quite conservative when it comes to adopting
new methods. If a patient does not experience a spontaneous resolution of their
back problem within the first two months, an initial benign problem may become
a chronic situation. This is why it is so important to institute early management
that is effective.
Lumbar disc degeneration is a common cause of low back pain and leg pain. Patients
with degenerative disc disease frequently have LBP as the earliest symptom.
Often patients recall that their back pain appears after periods of physical |
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activity or prolonged periods of sitting or standing.
Initially the pain may last a few hours or a few days and usually subsides
with a limitation of the patient’s activity and medication. The
pain pattern at this time is mechanical in nature, in the sense that
it is usually made worse by standing, lifting, twisting, and prolonged
sitting, and is often relieved by rest.
Since over 90% of clinically significant lumbar disc herniations occur at the
L4-L5 or L5-S1 levels, the most common neurologic impairments are those of
the L5 and the S1 nerve roots. Symptoms of disc protrusion are leg pain in
a root distribution aggravated by lifting, coughing, laughing, sneezing and
movements that increase intradiscal pressure. Important neurological signs
are sensory deficits (tingling, numbness) in the legs and feet [L5-S1], reduced
ankle reflexes [S1] and lower extremity weakness.
As the patient ages, painful episodes become more frequent or intense in nature,
and may lead to more disability. The majority of these patients are not ideal
surgical candidates. Specific therapy that targets disc pathology should be
initiated early for these patients.
If low back pain symptoms have not resolved within four weeks, VAX-D should
be considered (in the absence of contraindications) for those patients with
a diagnosis of discogenic pain; including those with radiculopathy. |
