Figure 1. Sagittal MRI of lumbar spine.
A 34-year-old man presents with a 1-week history of lower back pain and sharp pain radiating down the right leg. He notes doing a lot of yard work and started to notice increasing back pain the next day. A few days after the back pain started the patient experienced radiating leg pain. Oral ibuprofen has helped with the pain but he reports still having symptoms throughout the day at his construction job. The patient also denies bowel and bladder changes.
On physical examination the patient has no weakness or loss of sensation to light touch in the lower extremities. The patient had radiographs taken at an urgent care center prior to his visit, which are negative for arthritis or acute changes. A sagittal magnetic resonance imaging (MRI) of the lumbar spine is performed (Figure 1).
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The patient is diagnosed with a moderate disc herniation at L5-S1 and a mild herniation at L4-L5. Lower back disc herniation is one of the most common disorders leading to acute lower back pain. Over 90% of disc herniations will improve with conservative care, with most patients not requiring invasive injections or surgery.1-3
The goal of physical therapy for an acute disc herniation is to relieve pain and improve function back to a baseline level over a 4- to 6-week period. During the first few weeks, flexion exercises should be avoided as disc herniations generally occur from repetitive flexion or fixed flexion positions. Lumbar flexion increases the pressure on the disc and can potentially increase the size of the disc herniation.1,2
Back extension exercises are recommended initially after injury, which offer the best clinical response. The most common technique involves back extension performed while the patient is prone and resting on the elbows.1,2
Lumbar spine segmental traction therapy has been shown to reduce pain and decrease the size of the herniated disc.2 If the patient has little to no pain for a duration of 1 to 2 weeks, core stabilizing exercises and lower extremity stretching can begin.3
Bracing and bed rest should be avoided as these will decondition the lumbar spine muscles, which is counterproductive.1-3
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopaedics for Physician Assistants.
1. Vangelder LH, Hoogenboom BJ, Vaughn DW. A phased rehabilitation protocol for athletes with lumbar intervertebral disc herniation. Int J Sports Phys Ther. 2013;8(4):482-516.
2. Karimi N, Akbarov P, Rahnama L. Effects of segmental traction therapy on lumbar disc herniation in patients with acute low back pain measured by magnetic resonance imaging: a single arm clinical trial. J Back Musculoskelet Rehabil. 2017;30(2):247-253. doi:10.3233/BMR-160741
3. Bakhtiary AH, Safavi-Farokhi Z, Rezasoltani A. Lumbar stabilizing exercises improve activities of daily living in patients with lumbar disc herniation. J Back Musculoskelet Rehabil. 2005;18(3-4):55-60. doi:10.3233/BMR-2005-183-401