Low Back Pain
Low back pain is pain between the bottom of the ribs and the buttocks. Most episodes are called non-specific because a particular disease or injured structure cannot be confidently identified as the cause. Pain often changes with movement or position, and stiffness can make everyday tasks uncomfortable.
Key points
- What usually helps
- Staying active and exercise that suits you. No single type has been shown to be best.
- What you can do now
- Stay as active as your back allows. Walk and change position often.
- How long it takes
- A recent episode often improves within 2 to 6 weeks; long-standing pain usually needs 3 to 6 months.
- When to see a doctor first
- Some signs need emergency care. Check the list before you start treatment.
Symptoms
Does this sound like you?
- Deep, aching pain in the lower back
- Pain that changes with movement and position
- Morning stiffness that eases with movement
- Trouble changing position, such as getting up from a chair or out of bed
- Tight back muscles and holding yourself stiffly to protect the back (muscle guarding)
Often alongside it
- Pain that spreads into the buttock or thigh
- A feeling that the back might give way
- The muscles that hold you upright tire easily
- Broken sleep because some lying positions hurt
- Tension in other areas from moving differently to protect the back
Pain typically builds when you stay in one position for a long time and eases when you change position. Morning stiffness eases once you start moving. Many people find the same movements help or aggravate it each time.
Before using this comparison, check when these symptoms need a doctor first.
When to see a doctor first
Go to emergency
New trouble starting to pass urine or feeling it pass, new loss of bladder or bowel control, new numbness between the legs or around the back passage, new loss of genital sensation or sexual function, or severe or rapidly worsening weakness in both legs
Go to emergency now. These can be signs of cauda equina syndrome
Sudden unexplained weakness or numbness in an arm or leg, even if it improves
Call 911 now. This can be a stroke. Do not wait for a physiotherapy appointment
Get seen today
Pain that suddenly starts down both legs, or spreads from one leg to both, even without the signs above
Contact a medical clinician today for a same-day assessment
A new foot drop (the foot catches or slaps when you walk), or weakness in one leg that is getting worse
Same-day medical assessment
Fever, feeling generally unwell, or recent infection with severe back pain
Same-day medical assessment
Back pain after a fall or other trauma, or after a minor strain if you have osteoporosis or take long-term steroids
Same-day medical assessment to rule out a fracture
Check with your doctor
Back pain with a history of cancer, or unexplained weight loss
See your family doctor before starting physiotherapy
Constant pain that does not ease with rest or changing position, especially at night
See your family doctor before starting physiotherapy
Treatment
How it is treated
Main approach. Exercise can help reduce pain and improve function in persistent low back pain. No single type of exercise has been shown to be best, so I choose the one you will keep doing.
Alongside it. Hands-on treatment such as joint mobilization may give short-term relief when it is combined with exercise. I use it to make moving easier, not on its own.
Managing it over time. Staying active and keeping up regular exercise after the pain settles has the best evidence for reducing the chance of another episode.
A typical rehabilitation progression
Three phases, from settling symptoms to returning to full activity.
Recovery from low back pain is usually staged: calm the symptoms first, then rebuild the strength and capacity of the area, then return to your full activities. The phases below show how that can progress.
Phase 1Foundation: Calm the Tissue, Restore Comfortable Movement
The goal of the first few weeks is to calm flare-ups, rebuild your confidence moving, and find positions under load that you can manage. Staying active early, understanding what is going on, and gentle exercise built up step by step are consistently recommended by the NICE guideline (NG59), the American College of Physicians 2017 guideline and the 2021 physiotherapy clinical guideline for low back pain (George and colleagues).
Example exercises
- Short, frequent walks (5 to 10 minutes) rather than one long walk, built up over the first 1 to 2 weeks
- Cat-camel (slowly rounding and then arching your back) and pelvis tilts on hands and knees, 10 slow repetitions, to get each level of the lower back moving
- Lying on your back with knees bent and feet flat, slow breathing while you gently tighten your stomach muscles, 5 to 10 breaths, several times a day
- Dead bug (on your back, lowering the opposite arm and leg) and modified bird dog (an easier version of reaching out the opposite arm and leg on hands and knees), 2 sets of 6 to 8 per side, to practise keeping your back steady in its natural middle position (neutral spine)
- Breaks from long spells of sitting every 30 to 45 minutes, with a short stand or walk
Possible progression milestones
Pain at rest low and settling, sitting and standing for about 30 minutes without a meaningful flare-up, and confidence with basic daily tasks (dressing, driving short distances, getting in and out of bed) without holding your back stiffly to protect it.
Phase 2Building Up Load: Strength and Tolerance
Once symptoms settle, the spine needs load to become more durable. This phase rebuilds strength in the hips, the trunk and the muscles along the back of the body (posterior chain), brings back bending from the hips (hinging) and squatting, and builds the work up to the level of your real-world demands. The 2021 Cochrane review by Hayden and colleagues found that exercise probably reduces pain and improves function compared with no treatment, usual care or placebo.
Example exercises
- Hip hinge progressions (bending forward from the hips with a flat back): broomstick hinge, kettlebell deadlift, single-leg Romanian deadlift, 3 sets of 6 to 10
- Goblet squat to a box (holding a weight at your chest), progressed in depth and load, 3 sets of 8 to 10
- Glute bridge and single-leg bridge variations, 2 to 3 sets of 8 to 12
- Side plank and modified Pallof press (holding a band or cable out in front of your chest without letting it twist you) to train the trunk to resist bending sideways and twisting
- Farmer carries (walking while holding a weight in each hand), 20 to 40 metres, 3 to 4 rounds, to keep the trunk firm under load
Possible progression milestones
Managing a moderate load in the hip hinge and squat with only mild discomfort that settles, walking 30 minutes comfortably, and a full workday without symptoms building up.
Phase 3Return to Function: Training for Your Own Demands
The last phase is about matching your strength and tolerance to the job, sport or hobby you are going back to. For a construction worker that looks different than it does for a runner or a lifter. Another episode in the first year is common (the Lancet series on low back pain), and a maintenance plan of regular exercise that you can keep doing may lower the chance of it.
Example exercises
- Trap bar or conventional deadlift (lifting a weight from the floor), with the weight built up gradually, 3 to 4 sets of 3 to 5
- Front squats or split squats at your training weights, matched to your goals
- Loaded carries and suitcase carries (a weight in one hand) at moderate to heavy loads
- Return to running or sport built up step by step through walk-run intervals or low-impact jumping and landing drills ()
- A maintenance program of two or three sessions a week that you can keep up on your own
Possible progression milestones
Managing full work, home and leisure demands with minimal pain, handling minor flare-ups on your own, and a written maintenance plan with realistic targets for load.
What you can do now
- Stay as active as your back allows. Keep up your normal day as much as you can, changing how you do things rather than stopping. Bed rest beyond a day or two can slow recovery and leave you less fit (deconditioned).Leg weakness that is new or getting worse, a foot that catches or slaps when you walk, or pain that spreads to both legs needs a same-day medical assessment. Signs such as new trouble passing urine, loss of bladder or bowel control, or numbness between the legs or around the back passage mean go to emergency now, as the warning signs on this page explain.
- Walk and change position often. Pain often builds when you stay in one position and eases when you change position, so stand or walk briefly every 30 to 45 minutes when you sit. Take short, frequent walks of 5 to 10 minutes rather than one long walk, and build them up over the first 1 to 2 weeks.
- Go easy on bending first thing. Discs take up water overnight, so the lower back is stiffer and more sensitive to bending in the first hour. Avoiding deep forward bending, such as tying shoes bent over, loaded rowing or sit-ups, for 30 to 60 minutes after waking often takes the edge off.Stiffness that lasts more than an hour each morning and improves through the day, especially in a younger person, is a pattern I flag for screening for inflammatory back pain.
- Find a sleeping position that lets you sleep. There is no single correct sleeping posture. Lying on your side with a pillow between your knees, or on your back with a pillow under your knees, suits many people in the first few days; if one position wakes you up sore, try the other.
- Keep training with short-term changes. If you lift or train, stopping completely can make things harder rather than easier. Cut back first on how much deadlifting you do, heavy loaded bending and deep bending first thing in the morning, and keep most of your program going.
What I use in clinic
- Spinal mobilization. Gentle hands-on movement of the spinal joints. Moderate-quality evidence supports short-term pain relief and better function when it is combined with exercise.
- Motor control exercise. Exercises that retrain control of the trunk muscles. They can help function in long-lasting (chronic) low back pain, with results similar to other types of exercise.
- Cognitive functional therapy. Relearning how to move, combined with work on beliefs about the back. In a large trial it reduced disability more than usual care.
Recovery
How long it takes
Most recent episodes improve meaningfully within 2 to 6 weeks. Long-standing (chronic) back pain usually needs 3 to 6 months for a meaningful change.
It is common for back pain to come back, and a new episode does not mean the damage is getting worse.
What changes the timeline
- Staying active early tends to help recovery
- Taking an active part in managing it tends to help recovery
- Previous episodes may mean a longer recovery
- How well you sleep affects how sensitive you are to pain
How I track it. I track how much the pain gets in the way of the tasks that matter to you, how well you move when I test those tasks in clinic, and how confident you feel in daily activities
Similar conditions
Conditions that can feel similar
- Lumbar Radiculopathy / Disc Herniation
- The leg hurts more than the back, and the pain often runs below the knee along the path of one nerve (a dermatomal pattern). Lifting the straight leg, or sitting slumped and straightening the knee, brings on the leg pain (straight leg raise or slump test). Sometimes particular muscles are weak or a reflex is changed. Worse with sitting, bending forward, coughing or sneezing.
- Lumbar Spinal Stenosis
- Heaviness or cramping in both legs that builds with standing and walking and eases quickly when you sit or lean forward (neurogenic claudication). Typically in people over 60. Leg symptoms, more than back pain, limit how far you can walk.
- Sacroiliac Joint Dysfunction
- Pain on one side, just below the belt line over the bony bump at the back of the pelvis (the PSIS). People often point to it with one finger. A group of tests that press on or stretch the joint brings on the familiar pain (distraction, thigh thrust, compression, Gaenslen and sacral thrust tests). The pain rarely spreads below the knee.
- Facet-Mediated Pain
- Pain in one area of the lower back that is worse leaning back and twisting, and eased by bending forward. Any spread into the buttock or back of the thigh typically stops at the knee. Checks of the nerves (strength, feeling and reflexes) are normal.
- Hip Osteoarthritis (referring into low back)
- Pain in the groin or front of the thigh. Turning the hip inward is limited and painful when it is tested (hip internal rotation). Pain is worse standing and walking on the leg rather than with back positions. Low back symptoms often come from walking and moving differently because of the hip.
- Vertebral Compression Fracture
- Sudden pain in one spot of the spine, often after a minor fall or strain in someone older or on long-term steroid medicine (corticosteroids). Pain is worse when the spine takes weight and better lying down. Pressing on one bony point of the spine is commonly sore. A scan is needed when this is suspected.
- Inflammatory / Serious Pathology (red flags)
- Night pain that never lets up, feeling generally unwell, unexplained weight loss, fever, a history of cancer, or numbness or weakness that keeps getting worse. These move the picture away from ordinary back pain and need an urgent medical review rather than physiotherapy alone.
Questions
What patients ask me most
Do I need an MRI for low back pain?
Usually not in the first 6 weeks. NICE NG59 and the American College of Physicians guidance both advise against early imaging for non-specific low back pain because scans frequently show disc bulges, degenerative changes, and protrusions in people with no pain at all. Imaging becomes useful when there are warning signs, numbness or weakness that keeps getting worse, or when symptoms have not responded to a fair trial of non-surgical care and a scan would actually change the plan.
Should I rest or stay active?
Stay as active as your back allows. Bed rest beyond a day or two can slow recovery and leave you less fit (deconditioned).
How long does low back pain usually take to settle?
Most recent episodes improve meaningfully in 2 to 6 weeks. The Lancet Low Back Pain Series describes a pattern of rapid early improvement followed by a slower tail, with many people experiencing some residual or recurring symptoms. Recurrence does not mean your back is getting worse. It usually reflects load, sleep, stress, and training history more than structural change.
What position should I sleep in?
The position that lets you sleep. There is no single correct posture. Side-lying with a pillow between the knees and back-lying with a pillow under the knees are the two setups that work for most people in the first few days. If a position wakes you up sore, try the other.
Is it safe to keep exercising or lifting weights?
Often yes, with short-term changes. Stopping training completely can make things harder rather than easier. What I usually adjust first is deadlift volume, heavy loaded bending, and deep bending first thing in the morning, while keeping most of your program going. Some discomfort during exercise can be acceptable, depending on your assessment. I watch how symptoms behave during the session and the next day, whether you are functioning better, and whether any leg symptoms are stable. New weakness, spreading numbness or steadily worsening leg pain needs reassessment.
Why does my back feel worse in the morning?
Discs take up water overnight, which makes the lower back slightly taller and stiffer first thing, and more sensitive to bending in the first hour. Avoiding deep forward bending (tying shoes bent over, loaded rowing, sit-ups) for 30 to 60 minutes after waking often takes the edge off. Prolonged, dramatic morning stiffness that lasts more than an hour and improves through the day, especially in a younger person, is a pattern I flag for inflammatory back pain screening.
My MRI showed disc degeneration. Is my back damaged?
Probably not in the way that report sounds. Brinjikji and colleagues (AJNR 2015) pooled imaging findings in pain-free adults and showed disc degeneration in around 37% of 20 year olds and 96% of 80 year olds, with disc bulges present in roughly 30% and 84% respectively. Those changes are part of a normal aging spine, not a structural diagnosis. I treat the clinical picture, not the scan.
When should I be worried about back pain?
Go to emergency now for new trouble starting to pass urine or feeling it pass, new loss of bladder or bowel control, new numbness between the legs or around the back passage, or severe or rapidly worsening weakness in both legs. New loss of genital sensation or sexual function with back or leg pain also needs emergency assessment. These can be signs of cauda equina syndrome. Contact a medical clinician today if pain suddenly starts down both legs or spreads from one leg to both, even without those signs. A new foot drop (the foot catches or slaps when you walk) or worsening weakness in one leg needs a same-day medical assessment. Sudden unexplained weakness or numbness in an arm or leg, even if it improves, can be a stroke: call 911 now. See your family doctor before starting physiotherapy for unexplained weight loss, severe unrelenting night pain, or a history of cancer, and get assessed the same day for fever with back pain.
The science
The Science of Low Back Pain
Most low back pain is called non-specific or mechanical. It comes from the joints, discs, muscles and ligaments of the lower back, and a scan rarely pins it to one structure. Discs and joints change with age in people with and without pain, so those changes on their own do not explain the pain.
When pain lasts beyond about 3 months, the nervous system can become more sensitive, so movements that were once comfortable start to hurt. That is a change in sensitivity, not a sign of new damage. A smaller group develop irritation with leg pain (sciatica), and some have pain that behaves more like the facet or . Each of those has its own page.
Contributing factors
Back pain usually builds when the load on the back runs ahead of what it is used to: a weekend of yard work, a jump in training, a long drive, or weeks of poor sleep and stress. No single posture or lifting style has been shown to cause back pain on its own (Swain and colleagues, Journal of , 2020), so I do not ask people to fear bending or sitting.
What does matter is variety and capacity. Long stretches in any one position tend to stiffen and sensitise the back, and a back that is rarely loaded has less in reserve. Fitness, sleep, stress and confidence to move all change how sensitive the back is, which is why the plan covers more than exercises.
Research
What the studies show
Exercise for long-lasting low back pain
A Cochrane review of 249 studies (24,486 people) with long-lasting (chronic) low back pain found that exercise probably reduces pain and improves function compared with no treatment, usual care or a placebo. The evidence is moderately certain. The trials were too varied to name one best type or amount of exercise.
Supports exercise as one of the first treatments to use, chosen to suit the person rather than one fixed program.
Hayden JA, Ellis J, Ogilvie R, et al. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021;9(9):CD009790. PMID: 34580864.
Which physiotherapy treatments a review panel recommended for recent low back pain
After looking at 21 systematic reviews and 21 randomised trials, the panel recommended high-velocity hands-on spinal techniques (thrust techniques) and low-level laser therapy for acute low back pain (pain that started recently). For sub-acute low back pain (pain that has lasted a little longer), it recommended trunk control exercises (core stability or motor control exercise), the same spinal thrust techniques and massage.
Hands-on care is one of the recommended options for recent-onset back pain. I use joint mobilization rather than high-velocity techniques, and pair it with exercise.
Wang XQ, Wang YL, Witchalls J, et al. Physical therapy for acute and sub-acute low back pain: A systematic review and expert consensus. Clin Rehabil. 2024;38(6):715-731. PMID: 38317586.
- Exercise. A Cochrane review of 249 studies found that exercise probably helps long-lasting low back pain compared with no treatment, usual care or a placebo, and the evidence is moderately certain. The studies were too varied to recommend one best type or amount of exercise (Hayden and colleagues, 2021).
- Working on beliefs as well as movement. Cognitive functional therapy, which addresses beliefs about pain and fears about moving, reduced disability more than usual care (Kent and colleagues, RESTORE trial, Lancet 2023).
- Matching treatment to the person. Sorting people by how their back pain presents (Fritz and colleagues, 2007) is a way of choosing where to start. It does not promise a better result than a well-chosen general program.
Related Conditions
Conditions I commonly see alongside, or confused with, this one.
Getting back to it
Physiotherapy for low back pain, built around the activity you want back.
