What is the initial physical therapy (PT) and management for a patient with low back pain suspected to be due to lumbar disc herniation?

From the Guidelines

Initial physical therapy for lumbar disc herniation should focus on pain management and gentle exercises, with the goal of reducing inflammation, strengthening supporting muscles, and improving spinal stability. The treatment typically begins with relative rest for 24-48 hours, avoiding activities that worsen symptoms while maintaining some movement. Pain management includes NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks, and possibly muscle relaxants such as cyclobenzaprine (5-10mg three times daily) for short-term use, as recommended by the American College of Physicians and the American Pain Society 1.

Key Components of Physical Therapy

• Gentle stretching exercises for the lower back and hamstrings
• Core strengthening exercises like pelvic tilts and bridges
• McKenzie extension exercises to centralize pain and reduce disc pressure on nerve roots
• Heat or ice therapy for 15-20 minutes several times daily based on patient preference
• Education on proper body mechanics, including bending at the knees rather than the waist when lifting and maintaining neutral spine positioning during daily activities

Progression of Therapy

As pain decreases, therapy should advance to include more dynamic exercises and functional movements. This approach works by reducing inflammation around the herniated disc, strengthening supporting muscles to improve spinal stability, and teaching movement patterns that minimize disc pressure. Clinicians should provide patients with evidence-based information on low back pain, advise patients to remain active, and provide information about effective self-care options, as stated in the guidelines 1.

Importance of Patient Education

Patients should be informed of the generally favorable prognosis of acute low back pain with or without sciatica, including a high likelihood for substantial improvement in the first month, and should be encouraged to remain active, which is more effective than resting in bed for patients with acute or subacute low back pain 1.

From the Research

Initial Physical Therapy (PT) and Management

For a patient with low back pain suspected to be due to lumbar disc herniation, the initial physical therapy (PT) and management may involve:

• Nonsurgical measures, as most patients can experience relief with these approaches 2
• A multifaceted approach, including patient education, acute inflammation control, closed disc reduction, remedial therapeutic care, and individualized rehabilitation training 3
• Conservative combination therapy, such as mechanical physiotherapy (McKenzie), gabapentin, and transforaminal epidural injections, which has been shown to be effective in reducing pain and improving function 4
• Non-surgical approaches, including physical therapy modalities and alternative therapies, which are considered the preferred initial management methods 5

Specific Interventions

Some specific interventions that have been identified as effective for the conservative treatment of lumbar disc herniation associated with radiculopathy include:

• Patient education and self-management
• McKenzie method
• Mobilization and manipulation
• Exercise therapy
• Traction (short-term outcomes)
• Neural mobilization
• Epidural injections, all of which have moderate evidence (Level B) of effectiveness 5
• Other interventions, such as dry needling, may have weak evidence of effectiveness (Level C), while some may have conflicting or no evidence (Level D) of effectiveness 5

Comparison of Surgical and Conservative Management

Studies have compared the results of surgery with conservative management for lumbar disc herniations, finding that:

• Conservative management can give satisfactory results in a high proportion of patients, particularly those with mild or moderate nerve root compression 6
• Surgical treatment can yield faster resolution of symptoms, but the chances of a successful outcome are higher in patients with marked nerve root compression, no or mild back pain, and a short duration of symptoms 6
• Surgery may be considered if the patient does not respond after at least 2 months of conservative treatment 6