What Should You Do First for Lower Back Pain?
Start by staying active within your pain tolerance, applying ice or heat, and taking over-the-counter anti-inflammatory medications like ibuprofen or naproxen. Avoid prolonged bed rest. Most acute lower back pain resolves within 4 to 6 weeks with these conservative approaches recommended by the American College of Physicians.
The American College of Physicians (ACP) updated its clinical practice guidelines in 2017, recommending that patients with acute or subacute lower back pain first try nonpharmacologic treatments. These include superficial heat application, massage, acupuncture, or spinal manipulation. If medications are needed, the ACP recommends nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) or naproxen (Aleve) as first-line options. Skeletal muscle relaxants such as cyclobenzaprine may be considered as a second-line option for short-term use only.
Early movement is critical for recovery. A landmark study published in The Lancet found that advice to stay active was consistently more effective than bed rest for acute lower back pain. Walking is one of the simplest and most effective activities you can do. Start with short walks of 10 to 15 minutes and gradually increase duration as your pain allows. The goal is to maintain normal daily activities as much as possible while avoiding movements that significantly worsen your symptoms.
If your pain does not improve within 4 to 6 weeks, or if it worsens, consult a healthcare provider. They may recommend physical therapy, which has strong evidence supporting its effectiveness for both acute and chronic lower back pain. A physical therapist can design a personalized exercise program targeting your specific deficits in core stability, hip mobility, and lumbar flexibility.
The American College of Physicians updated its clinical practice guidelines recommending nonpharmacologic treatments first
A landmark study published in The Lancet found that advice to stay active was consistently more effective than bed rest
What Are the Most Common Causes of Lower Back Pain?
The most common causes include muscle or ligament strains, degenerative disc disease, facet joint dysfunction, and herniated discs. Approximately 85% of lower back pain is classified as nonspecific, meaning no precise anatomical source can be identified through imaging. Mechanical factors account for the vast majority of cases.
Muscle and ligament strains are the most frequent cause of acute lower back pain, often resulting from sudden movements, heavy lifting with poor form, or prolonged static postures. The paraspinal muscles, including the erector spinae and multifidus, can become strained when they are overloaded beyond their capacity. These injuries typically heal within 2 to 6 weeks with appropriate activity modification and progressive loading. The lumbar multifidus muscle in particular has been shown to atrophy rapidly after injury, contributing to recurrence if not specifically rehabilitated.
Degenerative disc disease involves the gradual breakdown of intervertebral discs in the lumbar spine, most commonly at the L4-L5 and L5-S1 levels. As discs lose hydration and height with age, they provide less cushioning between vertebrae, potentially causing pain during weight-bearing activities. It is important to note that disc degeneration visible on MRI is extremely common in pain-free individuals. A systematic review in the American Journal of Neuroradiology found disc degeneration in 37% of 20-year-olds and 96% of 80-year-olds without any symptoms.
Herniated discs occur when the soft inner nucleus pulposus pushes through a tear in the outer annulus fibrosus, potentially compressing nearby spinal nerve roots. This accounts for approximately 5% of lower back pain cases and can cause radicular symptoms including pain, numbness, or weakness radiating down the leg (sciatica). The L4-L5 and L5-S1 levels are most commonly affected. Most disc herniations resolve with conservative treatment, and surgery is typically reserved for cases with progressive neurological deficits.
Facet joint dysfunction, spinal stenosis, sacroiliac joint dysfunction, and spondylolisthesis are additional structural causes that a healthcare provider may identify through physical examination and, when indicated, diagnostic imaging. Psychosocial factors including workplace dissatisfaction, depression, and catastrophizing have also been strongly associated with the development of chronic lower back pain according to research published in Spine.
A systematic review found disc degeneration in 37% of 20-year-olds and 96% of 80-year-olds without symptoms
How Does Physical Therapy Help Lower Back Pain?
Physical therapy reduces lower back pain through targeted exercises that strengthen core stabilizers, improve spinal mobility, and correct movement patterns. The American Physical Therapy Association recommends it as a first-line treatment, and research shows it reduces pain intensity by 30% to 50% and significantly lowers the risk of recurrence.
A comprehensive physical therapy program for lower back pain typically includes three components: therapeutic exercises, manual therapy, and patient education. Therapeutic exercises focus on strengthening the deep core stabilizers, particularly the transversus abdominis and lumbar multifidus muscles, which act as a natural muscular corset for the lumbar spine. Research published in the Journal of Orthopaedic and Sports Physical Therapy (JOSPT) has consistently demonstrated that motor control exercises targeting these muscles reduce pain and disability more effectively than general exercise alone.
Manual therapy techniques including spinal mobilization, soft tissue manipulation, and myofascial release can provide short-term pain relief and improved range of motion. These hands-on techniques work by reducing muscle guarding, improving segmental spinal mobility, and modulating pain perception through neurophysiological mechanisms. The ACP guidelines include spinal manipulation as a recommended nonpharmacologic treatment for acute lower back pain, supported by multiple systematic reviews showing small but clinically meaningful benefits.
Patient education is a critical and often underappreciated component of physical therapy for lower back pain. Understanding that most back pain is not caused by serious structural damage, learning proper body mechanics for daily activities, and developing self-management strategies for flare-ups all contribute to long-term outcomes. A 2019 meta-analysis in the British Journal of Sports Medicine found that exercise combined with education reduced the risk of lower back pain recurrence by 45% over the following year.
Motor control exercises targeting these muscles reduce pain and disability more effectively than general exercise alone
Exercise combined with education reduced the risk of lower back pain recurrence by 45% over the following year
What Are the Best Exercises for Lower Back Pain?
The best exercises for lower back pain include core stabilization exercises like bird-dogs, dead bugs, planks, and pelvic tilts, along with hip mobility exercises such as hip flexor stretches and glute bridges. Walking, swimming, and yoga have also shown significant benefits in clinical trials for both acute and chronic lower back pain.
Core stabilization exercises recommended by the ACSM and NSCA form the foundation of exercise-based treatment for lower back pain. The bird-dog exercise involves extending the opposite arm and leg from a hands-and-knees position, challenging the multifidus and transversus abdominis without excessive spinal loading. Dead bugs are performed lying on your back with arms extended toward the ceiling and knees bent at 90 degrees, then slowly lowering opposite arm and leg toward the floor. Start with 2 sets of 8 to 10 repetitions on each side and progress gradually.
Planks build endurance in the entire core musculature including the rectus abdominis, obliques, transversus abdominis, and erector spinae. Begin with modified planks on your knees if needed, holding for 10 to 15 seconds and building toward 30 to 60 second holds. Dr. Stuart McGill, a leading spine biomechanics researcher, recommends the side plank as particularly beneficial for lower back pain because it strengthens the quadratus lumborum and obliques while placing minimal compressive load on the lumbar spine.
Hip mobility exercises are equally important because tight hip flexors and weak gluteal muscles alter lumbar spine mechanics and increase stress on the lower back. The hip flexor stretch (half-kneeling position, pushing hips forward gently) held for 30 seconds addresses the iliopsoas, while glute bridges strengthen the gluteus maximus. Perform glute bridges by lying on your back with knees bent, feet flat on the floor, and lifting your hips toward the ceiling. Aim for 3 sets of 12 to 15 repetitions.
Walking is the simplest and most consistently recommended exercise for lower back pain. The CDC Physical Activity Guidelines recommend 150 minutes per week of moderate-intensity aerobic activity, and walking satisfies this requirement while being gentle on the spine. A randomized controlled trial published in the European Spine Journal found that a walking program was as effective as clinic-based group exercise for improving pain and disability in people with chronic lower back pain.
A walking program was as effective as clinic-based group exercise for chronic lower back pain
- Bird-dogs: 2 to 3 sets of 8 to 10 reps per side, focusing on slow controlled movement
- Dead bugs: 2 to 3 sets of 8 to 10 reps per side, keeping lower back pressed into the floor
- Planks: 3 sets of 15 to 60 second holds, maintaining neutral spine alignment
- Glute bridges: 3 sets of 12 to 15 reps, squeezing glutes at the top
- Hip flexor stretch: 2 to 3 sets of 30 second holds per side
- Walking: 20 to 30 minutes daily at a comfortable pace
What Medications Are Used for Lower Back Pain?
First-line medications include over-the-counter NSAIDs such as ibuprofen (400 to 600 mg every 6 to 8 hours) and naproxen (220 to 440 mg every 8 to 12 hours). The American College of Physicians recommends NSAIDs as first-line pharmacologic therapy, with muscle relaxants as second-line options for short-term use only.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most widely recommended medications for lower back pain, supported by strong evidence from multiple systematic reviews. Ibuprofen (brand names Advil, Motrin) and naproxen (Aleve) are available over the counter and provide both pain relief and anti-inflammatory effects. The typical dosing for ibuprofen is 400 to 600 mg every 6 to 8 hours with food, not exceeding 1200 mg daily without physician supervision. Naproxen is dosed at 220 to 440 mg every 8 to 12 hours. Both medications carry risks of gastrointestinal bleeding and should be used at the lowest effective dose for the shortest duration.
Acetaminophen (Tylenol) was previously recommended as a first-line option for lower back pain, but a landmark 2014 randomized controlled trial published in The Lancet found that acetaminophen was no more effective than placebo for acute lower back pain. As a result, the ACP no longer recommends acetaminophen as a first-line treatment, though it remains an option for patients who cannot take NSAIDs due to gastrointestinal or cardiovascular risk factors.
Skeletal muscle relaxants such as cyclobenzaprine (Flexeril) and tizanidine (Zanaflex) may be considered for short-term use (up to 2 weeks) when NSAIDs alone are insufficient. These medications primarily work through sedation and should not be used long-term. The ACP explicitly recommends against opioid medications for lower back pain except in patients who have failed all other treatments, citing the significant risks of dependence, overdose, and limited long-term efficacy demonstrated in clinical trials.
Acetaminophen was no more effective than placebo for acute lower back pain
Can Poor Posture Cause Lower Back Pain?
Poor posture contributes to lower back pain by placing uneven stress on spinal structures, but the relationship is more nuanced than commonly believed. Prolonged static postures, whether sitting or standing, are a stronger risk factor than any single posture. Regular movement breaks and posture variation are more important than maintaining a perfect sitting position.
The relationship between posture and lower back pain has been extensively studied but remains debated among researchers. A systematic review published in the European Spine Journal found limited evidence that specific spinal curvatures predict lower back pain development. What the evidence more consistently supports is that prolonged static postures of any kind, including sitting for more than 2 hours continuously, increase lumbar disc pressure and muscular fatigue in the erector spinae and multifidus muscles, contributing to pain symptoms.
Workplace ergonomics does play a role in lower back pain prevention. The Occupational Safety and Health Administration (OSHA) recommends adjusting your workstation so your feet are flat on the floor, knees at approximately 90 degrees, and monitor at eye level. Using a lumbar support cushion that maintains the natural lordotic curve of the lumbar spine can reduce disc pressure. However, the most important recommendation is to take movement breaks every 30 to 45 minutes, even if only for 1 to 2 minutes of walking or standing.
Research from McGill University has shown that the concept of an ideal static posture is misleading. Instead, spine health is better served by posture variability, meaning regularly changing positions throughout the day. Alternating between sitting, standing, and walking distributes mechanical loads across different spinal structures. Sit-to-stand desks have shown moderate evidence for reducing lower back pain in office workers when used in combination with regular movement breaks and stretching throughout the workday.
What Role Does Body Weight Play in Lower Back Pain?
Excess body weight, particularly abdominal obesity, significantly increases the risk of lower back pain by placing additional mechanical load on the lumbar spine and promoting systemic inflammation. A meta-analysis found that individuals with a BMI over 30 have a 33% higher risk of developing lower back pain compared to those with a normal weight.
The biomechanical effects of excess weight on the lumbar spine are well documented. Every additional pound of body weight adds approximately 4 pounds of compressive force to the lumbar spine during walking due to leverage effects. Abdominal obesity is particularly problematic because it shifts the body's center of gravity forward, increasing lumbar lordosis (the inward curve of the lower back) and placing greater stress on the facet joints and posterior spinal structures. This altered spinal loading pattern accelerates disc degeneration and increases the risk of herniation.
Beyond mechanical loading, obesity promotes chronic low-grade systemic inflammation through adipokines released by visceral fat tissue. These inflammatory mediators, including tumor necrosis factor-alpha (TNF-alpha) and interleukin-6, sensitize pain receptors and contribute to disc degeneration at the cellular level. Research published in Arthritis & Rheumatology has demonstrated that inflammatory markers are significantly elevated in obese individuals with lower back pain compared to lean individuals with similar structural findings on MRI.
Weight management through a combination of dietary modification and physical activity can meaningfully reduce lower back pain. A randomized controlled trial published in Spine found that a structured weight loss program resulting in 5% to 10% body weight reduction led to clinically significant improvements in pain and disability scores. The ACSM recommends combining aerobic exercise with resistance training for sustainable weight management, with low-impact options such as walking, swimming, and cycling being particularly suitable for individuals with active lower back pain.
Individuals with a BMI over 30 have a 33% higher risk of developing lower back pain
When Should You Consider Surgery for Lower Back Pain?
Surgery for lower back pain is only considered after 6 to 12 months of failed conservative treatment, or immediately when red flag symptoms like progressive neurological deficits are present. The American Academy of Orthopaedic Surgeons (AAOS) estimates that fewer than 5% of people with lower back pain ultimately require surgical intervention.
The most common surgical procedures for lower back pain include microdiscectomy for herniated discs causing persistent radiculopathy, laminectomy for spinal stenosis, and spinal fusion for instability or spondylolisthesis. Microdiscectomy has the strongest evidence base, with randomized trials showing that surgical patients experience faster pain relief than those treated conservatively, though outcomes tend to converge at 1 to 2 years. The Spine Patient Outcomes Research Trial (SPORT) published in JAMA found that surgical and nonsurgical treatments produced similar long-term functional improvements for disc herniation.
Indications for surgical referral include progressive neurological deficits (increasing weakness or numbness), cauda equina syndrome (loss of bowel or bladder control, saddle anesthesia), severe radicular pain unresponsive to 6 to 12 weeks of conservative treatment, and spinal instability confirmed by imaging. Importantly, the presence of structural findings on MRI alone is not sufficient justification for surgery, as disc herniations and degenerative changes are common in asymptomatic individuals.
Emerging surgical technologies include artificial disc replacement as an alternative to fusion, minimally invasive transforaminal lumbar interbody fusion (TLIF), and regenerative approaches such as intradiscal platelet-rich plasma (PRP) injections. While artificial disc replacement shows promising early results for maintaining spinal motion, long-term data beyond 10 years remain limited. Patients considering surgery should seek opinions from both an orthopedic spine surgeon and a neurosurgeon, and should exhaust comprehensive conservative treatment first.
Surgical and nonsurgical treatments produced similar long-term functional improvements for disc herniation
How Can You Prevent Lower Back Pain From Coming Back?
Prevention centers on maintaining a consistent exercise program emphasizing core strengthening, staying physically active with at least 150 minutes per week of moderate activity, maintaining a healthy body weight, and practicing good movement mechanics during daily activities. Research shows that exercise plus education reduces recurrence risk by 45%.
Regular exercise is the single most effective strategy for preventing lower back pain recurrence. A 2016 systematic review and meta-analysis published in JAMA Internal Medicine analyzed 23 randomized controlled trials with over 30,000 participants and found that exercise alone reduced the risk of a new lower back pain episode by 33%, while exercise combined with education reduced it by 45%. The most effective programs involved core strengthening exercises performed 2 to 3 times per week for at least 30 minutes, combined with regular aerobic activity such as walking, cycling, or swimming.
Maintaining a healthy weight and managing stress are additional important prevention strategies. The CDC Physical Activity Guidelines for Americans recommend at least 150 minutes per week of moderate-intensity aerobic activity and muscle-strengthening activities on 2 or more days per week for overall health. These same recommendations apply to lower back pain prevention. Stress management through techniques such as mindfulness meditation, progressive muscle relaxation, or cognitive behavioral therapy can reduce the psychological risk factors associated with chronic lower back pain.
Proper lifting mechanics reduce the risk of acute back injuries. The NIOSH (National Institute for Occupational Safety and Health) recommends keeping the load close to your body, bending at the hips and knees rather than the waist, avoiding twisting while lifting, and asking for help with loads exceeding 50 pounds. In the workplace, ergonomic modifications such as adjustable chairs, standing desks, and regular movement breaks have been shown to reduce the incidence of occupational lower back pain by 20% to 30%.
Exercise alone reduced the risk of a new lower back pain episode by 33%, while exercise combined with education reduced it by 45%
What Alternative Therapies Are Effective for Lower Back Pain?
Several alternative therapies have evidence supporting their use for lower back pain. The American College of Physicians recommends acupuncture, yoga, tai chi, mindfulness-based stress reduction, and spinal manipulation as nonpharmacologic treatment options. These are particularly appropriate for chronic lower back pain when combined with exercise.
Yoga has been studied extensively for lower back pain, with multiple randomized controlled trials demonstrating benefits. A 2017 Cochrane review found that yoga improved back-related function and reduced pain intensity compared to no exercise at 3 and 6 months. Specific yoga styles studied include Iyengar, Viniyoga, and Hatha yoga, with classes typically lasting 60 to 90 minutes performed 1 to 2 times per week. Key poses beneficial for the lower back include cat-cow, child's pose, sphinx, and supine spinal twist. Yoga also addresses psychological components of pain through breathwork and mindfulness.
Acupuncture has moderate evidence supporting its use for chronic lower back pain. A large meta-analysis published in the Archives of Internal Medicine found that acupuncture was superior to sham acupuncture and no-acupuncture controls for chronic pain conditions including lower back pain. The ACP includes acupuncture as a recommended treatment option. Typical treatment involves 6 to 12 sessions over 4 to 8 weeks, with needles placed at specific acupoints along the back, hips, and legs. The mechanisms of action are thought to involve modulation of endogenous opioid pathways and local anti-inflammatory effects.
Mindfulness-based stress reduction (MBSR), an 8-week structured program involving meditation, body scanning, and gentle yoga, has shown effectiveness for chronic lower back pain. A randomized trial published in JAMA found that MBSR produced clinically meaningful improvements in pain and functional limitations that were sustained at 26 weeks. Cognitive behavioral therapy (CBT) has similarly strong evidence and is recommended by the ACP. Tai chi, with its slow, controlled movements and emphasis on balance, has emerging evidence for lower back pain, particularly in older adults.
Yoga improved back-related function and reduced pain intensity at 3 and 6 months
