What is the recommended treatment for a patient with lower back and left lower limb radicular pain?

Physiotherapy for Lower Back and Left Lower Limb Radicular Pain

Physiotherapy is a crucial component in the management of lower back and left lower limb radicular pain, working in conjunction with other treatments to improve outcomes and quality of life. 1

Initial Assessment and Stratification

• Use the STarT Back tool within 2 weeks of pain onset to stratify patients according to risk of developing persistent disabling pain:

  • Low-risk: Self-management strategies
  • Medium-risk: Standard physiotherapy with patient-centered management plan
  • High-risk: Specialized physiotherapy with comprehensive biopsychosocial assessment 1, 2

• For severe radicular pain (disabling, intrusive, preventing normal activities) or patients with neurological deficits, consider earlier referral within 2 weeks of presentation 1

• For less severe radicular pain, referral to specialist services should occur no later than 3 months (earlier if pain is severe) 1

Physiotherapy Approach for Radicular Pain

First-line Interventions

1. Active Rehabilitation:

   • Core strengthening exercises focusing on stabilization
   • Aerobic fitness activities (not just stretching alone)
   • Individualized exercise program tailored to specific deficits 2

2. Manual Therapy Techniques:

   • Neural mobilization techniques - shown to be effective for short-term improvements in pain, function, and disability associated with lower back and radicular pain 3
   • Spinal manipulation when appropriate - can be beneficial for radicular pain when judiciously applied 4

3. Education and Self-Management:

   • Advise reactivation and avoiding bed rest
   • Proper body mechanics and ergonomic training
   • Pain neuroscience education 1, 2

Adjunctive Modalities

• Heat therapy for muscle relaxation
• TENS (Transcutaneous Electrical Nerve Stimulation) for pain modulation
• Massage therapy for muscle tension relief 2

Comprehensive Management Approach

Pain Management Integration

• Coordinate physiotherapy with appropriate pain relief strategies:
  • NSAIDs if not contraindicated
  • Topical analgesics for localized pain 2
  • Timing physiotherapy sessions after pain medication for optimal participation

Work-Related Considerations

• Use "fit notes" to manage return to modified work
• Implement workplace accommodations:
  • Anti-fatigue mats
  • Adjustable height work surfaces
  • Proper lifting techniques training
  • Regular position changes and breaks 2

Progression of Treatment

• For persistent radicular pain not responding to initial physiotherapy:
  1. Consider referral for image-guided steroid injections 1, 5
  2. Intensify rehabilitation during period of pain relief after injections 1
  3. Progress to more intensive interdisciplinary rehabilitation if needed 1

Special Considerations

• Exercise programs that incorporate individual tailoring, supervision, stretching, and strengthening are associated with the best outcomes 1

• Patient expectations should be addressed:

  • Avoid overreliance on imaging findings
  • Set realistic expectations (complete pain resolution may not be achievable)
  • Emphasize active self-management over passive treatments 2

• For chronic radicular pain, consider:

  • Cognitive behavioral therapy for pain coping strategies
  • Progressive relaxation techniques
  • Intensive interdisciplinary rehabilitation 1, 2

Monitoring and Follow-up

• Regular reassessment of pain, function, and quality of life
• Adjust treatment plan based on response
• Consider specialist referral if inadequate improvement after 12 weeks of treatment 1

Caution

• Avoid relying solely on passive treatments
• Do not recommend bed rest as it may worsen the condition
• Be aware that transcutaneous electrical nerve stimulation and traction have not been proven effective for chronic low back pain with radicular symptoms 1