Low Back Pain: What to Do and Which Exercises Help

Low back pain is the leading cause of activity limitation worldwide. In roughly 90 % of cases it is non-specific: no single culprit structure can be identified, and the prognosis is good — most episodes improve substantially within four to six weeks. The trouble is that the popular approach of resting, getting an MRI and "protecting the back" contradicts the evidence and often turns an acute episode into a chronic one.

What actually hurts#

In the large majority of cases the source is a combination of muscles, ligaments, fascia and joints, not a "slipped disc". Degenerative changes appear on scans in most people without pain: Brinjikji's review found disc degeneration in about 37 % of asymptomatic 20-year-olds and nearly 96 % of 80-year-olds. Bulges, herniations and "degenerative disc disease" on MRI are far more often age-related normality than a diagnosis.

That is why guidelines (NICE, the Lancet Low Back Pain Series) advise against routine imaging in the absence of warning signs. Incidental findings do not change management, but they frighten people and push them towards unnecessary procedures.

What to do in the acute phase#

The first few days are the only period when reducing load makes sense. But reducing is not the same as stopping.

1. Move within tolerance. Walking, light everyday activity, changing position every 20–30 minutes. Complete rest beyond a day or two slows recovery.
2. Find comfortable positions. On your back with a bolster under the knees, or on your side with a pillow between the knees. That is unloading, not a regimen.
3. Heat rather than ice. Reviews show a small benefit from superficial heat in acute pain; ice has no convincing evidence in non-specific back pain.
4. Pain relief if needed. A short NSAID course, contraindications permitting; paracetamol performs poorly in acute back pain. Muscle relaxants briefly and only as prescribed.
5. Restrict only what genuinely hurts. You do not need to avoid bending and lifting forever — that is the road to fear of movement.

Exercise: what the evidence shows#

The Cochrane review by Hayden and colleagues (2021) on chronic low back pain found that exercise beats no treatment for pain and function, but no specific type outperforms the others. Pilates, strength work, stabilisation exercises, walking and yoga produce comparable effects. The practical conclusion: choose what you will actually do regularly.

A base programme#

Exercise	How to do it	Volume
Glute bridge	On your back, lift the hips, squeeze the glutes, don't arch the lower back	3 sets of 10–15
Bird-dog	On all fours, extend opposite arm and leg, keep the torso still	3 × 8 per side
Forearm plank	Straight line head to heels, abdomen braced	3 × 20–40 seconds
Side plank	From knees or feet, hips don't sag	3 × 15–30 seconds per side
Dead bug	On your back, lower opposite arm and leg, lower back pressed down	3 × 8 per side
Side-lying hip abduction	Straight leg, movement at the hip joint	3 × 12 per side
Cat-cow	Gentle spinal flexion and extension	10 cycles, as a warm-up

A useful pain rule: an increase to 3–4 out of 10 during the exercise is acceptable if it settles within an hour afterwards and isn't worse the next day. This lets you train without setbacks.

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What to add after 2–4 weeks#

Once the base exercises feel easy, strength training becomes the key element. It is the only way to genuinely increase your back's tolerance to everyday loading. Squats and deadlifts with gradually increasing weight, learning to lift objects properly, and work for the glutes and hamstrings. Separately, aerobic activity: 30 minutes of walking a day reduces recurrence on its own.

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What works poorly or not at all#

Approach	Assessment
Bed rest	Harmful, slows recovery
Routine MRI without red flags	No benefit to outcomes, raises risk of unnecessary intervention
Back braces worn continuously	Not recommended; weaken muscles with prolonged use
Traction	No demonstrated effectiveness
Ultrasound, TENS	Weak or negative evidence
Injections for non-specific pain	Not recommended outside radicular syndromes
Manual therapy	Small short-term benefit as an adjunct to active treatment
Massage	Temporary relief, no substitute for exercise

Preventing recurrence#

A back that has hurt once tends to hurt again: roughly half of people have a recurrence within a year. What genuinely reduces the odds:

• Regular exercise — the best-evidenced preventive factor, effective in both strength and combined programmes.
• Adequate sleep. Sleep loss lowers pain thresholds and increases pain intensity.
• Stress management. Psychosocial factors predict chronicity more strongly than imaging findings.
• Weight loss if you carry excess, reducing both load and systemic inflammation.
• Less uninterrupted sitting — standing up every 30–45 minutes matters more than the "right" chair.

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The bottom line#

Non-specific low back pain is common and, in most cases, benign with a good prognosis. The core principles: don't lie down, move within tolerance; skip the MRI in the absence of red flags; exercise regularly, choosing something you will keep doing for months; and return gradually to full loading, including strength work. With bladder or bowel dysfunction, progressive weakness, fever, trauma or a cancer history, see a doctor immediately.