Timing of Physiotherapy After Prolapsed Disc with Radiculopathy
Patients with prolapsed disc and radicular symptoms can begin physiotherapy immediately—there is no need to wait, and early intervention within 2 weeks of symptom onset is recommended for optimal outcomes. 1, 2, 3
Immediate Initiation of Conservative Management
Physiotherapy should start immediately as part of first-line conservative management, which is the standard of care for lumbar disc herniation with radiculopathy 1, 2.
The natural history of lumbar disc herniation with radiculopathy shows improvement within the first 4 weeks with noninvasive management in most patients 1.
The majority of disc herniations demonstrate reabsorption or regression by 8 weeks after symptom onset, supporting early conservative treatment 1, 2.
Evidence Supporting Early Physiotherapy Intervention
For severe or disabling radicular pain, referral to physiotherapy should occur within 2 weeks of presentation to prevent prolonged disability 1.
A pilot randomized controlled trial (POLAR study) demonstrated that early intervention physiotherapy (within 2 weeks) is feasible and showed comparable or slightly better outcomes compared to delayed treatment at 6 weeks 3.
Clinical case series have documented successful resolution of radicular symptoms within 3-4 weeks using mechanical physiotherapy techniques, even with large disc prolapses (8-14mm) 4, 5.
Stratified Approach Based on Severity
For patients with mild to moderate symptoms:
- Begin physiotherapy immediately with patient-centered, goal-oriented programs 1, 3.
- Advise remaining active rather than bed rest, which is more effective for acute low back pain 1.
- Provide education about the favorable prognosis and expected improvement within the first month 1, 2.
For patients with severe, disabling radicular pain:
- Initiate physiotherapy within 2 weeks of presentation 1.
- Consider concurrent evaluation for image-guided steroid injections if symptoms are intrusive and prevent normal daily activities 1.
For patients with progressive neurological deficits (motor weakness, foot drop):
- Begin physiotherapy immediately while arranging urgent imaging and specialist evaluation 2.
- Do not delay conservative management while awaiting imaging or surgical consultation 2.
Critical Red Flags Requiring Immediate Specialist Referral
While physiotherapy can begin immediately, the following conditions require urgent imaging and specialist evaluation in addition to (not instead of) physiotherapy 1, 2:
- Cauda equina syndrome (urinary retention/incontinence, bilateral weakness, saddle anesthesia) 2.
- Progressive motor deficits (e.g., worsening foot drop) 2.
- Suspected malignancy, infection, or fracture 1, 2.
Components of Effective Early Physiotherapy
Mechanical therapy using repeated end-range spinal movements (McKenzie method) has demonstrated clinical efficacy within 2-5 treatment sessions 5.
Mobilization of adjacent spinal segments (e.g., upper thoracic spine for cervical radiculopathy) combined with specific extension exercises 4.
Activity modification without complete restriction, avoiding bed rest 1, 2.
Patient education emphasizing self-management and the favorable natural history 1.
Common Pitfalls to Avoid
Do not delay physiotherapy while waiting for imaging—imaging is not indicated in the first 6 weeks unless red flags are present 1, 2.
Do not prescribe bed rest; patients should remain active as tolerated 1.
Do not rely solely on passive modalities (heat, massage, ultrasound); active rehabilitation should be the primary focus 6.
Do not wait for complete pain resolution before starting physiotherapy—early mobilization is therapeutic 1, 3.
Timeline for Escalation if Conservative Management Fails
Review progress within 2 weeks of symptom onset 1.
If no improvement after 6 weeks of conservative therapy including physiotherapy, consider MRI and specialist referral for potential epidural steroid injection or surgical evaluation 1, 2, 7.
For less severe radicular pain, specialist referral should occur no later than 3 months if symptoms persist 1.