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VAX-D
Guidelines
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Treatment guidelines are designed to promote injury
specific treatment by identifying clinically acceptable
courses of care for disc injuries in order to achieve a
more rapid recovery and avoid the merry-go round of
drugs, palliative care and ineffective therapies.
Effective medical cost control is
achieved by establishing parameters for eligibility and
termination of treatment, by setting documentation
standards which support the appropriateness of the
treatment; by requiring additional documentation for
treatment falling outside the VAX-D guidelines.
Acute disc injury is one of the
primary processes leading to low back pain and lumbar
radiculopathy, although the pathophysiologic mechanisms
are still not well understood.
 It
is believed that increases in disc pressures resulting
from heavy lifting, rotation, vibrational and postural
forces etc. are important factors in the pathogenesis of
low back pain. Occupational groups with the highest
estimated prevalence of low back pain are those that
involve routine repetitive lifting such as heavy
industry, nursing, mechanics and repairers of vehicles,
operators of equipment for material moving and mining,
and people in the construction trades and related
occupations. The effects of disc hydraulics in
herniations or protrusions may cause a deformation of
the nerve roots and a compression-induced impairment of
the vasculature.
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In
addition, it has been found that the biochemical
properties of the nucleus pulposus may induce a
toxic or inflammatory reaction in the nerve root.
Therefore, the goal of developing and applying
specific target therapy for the treatment of disc
pathology is now essential.
Decompression by surgical means has become
established in the management of low back pain
associated with lumbar disc herniation. However,
for patients who are not candidates for surgery,
there is a need to establish a conservative
approach that offers an effective means of
returning the patient to a functional level of
activity.
Ramos and Martin (1994) have
reported that Vertebral Axial Decompression
enables a healthcare practitioner to lower
intradiscal pressure and decompress the
intervertebral lumbar discs and nerve roots under
precisely controlled, monitored conditions,
without surgical intervention and without
destruction of the bio-mechanical function of the
spinal segments 29. |
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 First
contact physicians should complete a detailed
history and physical examination and evaluate for
the presence of ‘red flags’ that would raise
suspicion of serious underlying conditions and
indicate a set of Critical Exclusionary Diagnoses
that would demand special treatment beyond that
ordinarily administered to patients with routine
lower back complaints.
These Critical Exclusionary Diagnoses include such
conditions as cauda equina syndrome, progressive
neurological deficit, fractures, neoplasm, spinal
instability, infection, persistent pain resulting
from previous spinal surgery (especially those
with surgical hardware), and extra-spinal
conditions. |
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Treatment -
General Approach and Basic Principles
For patients presenting with
acute symptoms for the first time, the physician
can initially proceed with up to four weeks of
treatment to include some combination of the
recommended therapies including, education,
activity modification, drug therapy and epidural
injections if indicated. The specific choice of
treatments will depend both on the medical
experience of the practitioner and the severity of
the patient's complaints.
Since a large percentage of low back pain is a
self-limiting problem of relatively short
duration, the majority of patients can be expected
to improve significantly after approximately four
weeks of treatment. For this reason, imaging
techniques beyond routine lumbar spinal x-rays are
not indicated in the initial phase of treatment.
If the specific symptoms resolve in four weeks
then the patient is encouraged to return to
regular activities.
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The principle
recommendations for assessing and treating
patients with low back pain include the following:
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Initial assessment of
patient with acute low back problems with a
focus on detecting serious systemic or local
disease (red flags) |
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Early initiation of
specific therapy targeting disc pathology.
Include the incorporation of VAX-D treatment
in the Intermediate (Sub-Acute) Phase of
therapy. |
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Only patients with
progressive neurological deficits, cauda
equina syndrome or spinal instability are
considered early surgical candidates. Research
indicates that in the absence of these
conditions, surgical patients have the same
long-term outcomes as those who receive
effective non-operative care. |
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Initial
Care- (Acute Phase) One to four weeks
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Intermediate Care –(Subacute Phase) Five to Twelve
weeks
If the exclusionary diagnoses are not suspected,
and the patient’s symptoms have not resolved in
the first four weeks, VAX-D Therapy should be
offered to those patients with a definitive
diagnosis of discogenic pain syndrome with or
without peripheral neuropathy.
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Neurological Testing /
Screening |
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Imaging studies (X-ray)
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Vertebral Axial
Decompression Therapy
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Activity modification
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Oral Medications |
Tertiary Care –Twelve weeks +
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Special Studies
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Other management
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Surgical Consultation |
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::Continued::
in
VAX-D Intermediate Care
section of Physicians Forum
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