What is the recommended physiotherapy approach for back pain due to disk herniation?

Physiotherapy Approach for Back Pain Due to Disk Herniation

For patients with back pain due to disk herniation, a stratified physiotherapy approach based on risk assessment using the STarT Back tool is recommended, with medium-risk patients receiving targeted physiotherapy and high-risk patients requiring comprehensive biopsychosocial assessment and management. 1

Initial Assessment and Risk Stratification

• Use the STarT Back tool at 2 weeks from pain onset to categorize patients into low, medium, or high risk for developing persistent disabling pain 1
• Risk stratification determines appropriate physiotherapy intervention:
  • Low-risk: Self-management with education about favorable prognosis
  • Medium-risk: Referral to physiotherapy with patient-centered management plan
  • High-risk: Referral to physiotherapy with comprehensive biopsychosocial assessment 1

Conservative Management Approach

• Conservative management for 4-6 weeks is strongly recommended as the initial approach for most patients with lumbar disc herniation 2
• Remaining active is more effective than bed rest for uncomplicated disc herniation 2
• For acute disc herniation, evidence supports:
  • McKenzie-concept exercises
  • Mobilization therapies
  • Traction 3
  • Pain-reducing physical therapies (cold or electrotherapy) 3

Physiotherapy Interventions Based on Stage

Acute Phase (0-6 weeks)

• Prioritize pain management and maintaining mobility
• McKenzie-based directional preference exercises have demonstrated efficacy 3
• Cold therapy and electrotherapy can help reduce pain 3
• Avoid bed rest beyond a few days; encourage progressive ambulation 2

Subacute and Chronic Phase (>6 weeks)

• Focus on active rehabilitation with progressive exercises
• Training of local strength endurance of back and abdominal muscles has proven effectiveness 3
• Spinal manipulation may provide modest benefits for pain and function 1
• Massage therapy may be beneficial when combined with exercise and education 1

Special Considerations

• Patients with radicular symptoms (sciatica) often benefit from directional preference exercises and neural mobilization techniques
• Most disc herniations show some degree of reabsorption by 8 weeks after symptom onset 2
• Younger patients with shorter duration of symptoms tend to respond better to interventions 4

When to Consider Other Approaches

• If no improvement after 4-6 weeks of conservative management, imaging (MRI preferred) may be warranted 2
• Consider surgical referral for:
  • Persistent radicular symptoms despite conservative management
  • Progressive neurological deficit
  • Cauda equina syndrome
  • Significant functional impairment affecting daily activities 2

Common Pitfalls to Avoid

• Prescribing bed rest rather than encouraging activity
• Failing to stratify patients by risk, leading to under or over-treatment
• Relying on passive treatments alone without progression to active rehabilitation
• Neglecting the psychological and social aspects of pain, especially in high-risk patients
• Ordering imaging too early, which may lead to unnecessary interventions 2

The British Pain Society pathway emphasizes that "physical therapy for all" is not an effective approach for people with low back pain, highlighting the importance of stratified care based on risk assessment 1. This approach directs resources to those most in need while reducing unnecessary treatments for low-risk patients.