Exercises for back pain: what helps, the warning signs and a gentle routine

First, the warning signs

Most back pain is not serious. The NHS and the HAS both insist on reassurance. But some signs call for medical help before any exercise programme.

In the UK, call 999 or go to A&E (elsewhere, call your local emergency number) if back pain comes with numbness, tingling or weakness in both legs, loss of feeling around the genitals or anus, new difficulty controlling the bladder or bowels, chest pain, or follows a serious accident. See a doctor urgently if you feel feverish or unwell, or if severe pain starts suddenly or worsens quickly. See your GP if the pain has not improved after a few weeks, stops your daily activities, is worse at night or at rest, or comes with unexplained weight loss.

This list follows the NHS page on back pain. The HAS uses the same idea under the name of red flags, and stresses that it is their combination that should raise concern. Without such signs, the HAS does not recommend imaging for an acute episode, because what a scan shows often does not match the pain.

What the guidelines actually advise

The three main public sources agree on the essentials.

• NHS: stay active and continue your daily activities, do not stay in bed for long periods, try exercises and stretches, and stop if the pain gets worse. Walking, swimming, yoga and pilates may help.
• HAS: physical exercise is the main treatment allowing a favourable course. Activity should be progressive and split into manageable amounts, according to your preferences. A doctor should reassess you two to four weeks after an acute episode.
• NICE: consider a group exercise programme, of whatever kind suits the person, and do not offer belts or corsets.

The research behind them is consistent. Hayden's Cochrane review found that exercise reduced chronic low back pain by about 15 points out of 100 compared with no treatment, with moderate certainty. A Cochrane review by Saragiotto and colleagues found that motor control, or core stability, exercise helped compared with minimal intervention but was not better than other exercise. The lesson is freeing: choose the exercise you will actually do.

A gentle routine to start

For the first days of a flare, the aim is to keep moving without provoking the pain. A sequence of five gentle movements, once or twice a day:

1. Walking. Several short walks a day, 5 to 10 minutes each, at a comfortable pace. Walking is often the easiest place to start.
2. Knee rocking. On your back, knees bent, feet flat. Let both knees fall slowly to one side then the other, within a comfortable range, ten times.
3. Cat and camel. On hands and knees, slowly round the back, then let it sag gently, ten times, staying in the comfortable range.
4. Pelvic tilt. On your back, knees bent, gently flatten the lower back against the floor by tightening the abdomen, hold two seconds, release, ten times.
5. Glute bridge. Same position, lift the hips a few centimetres, hold two seconds, lower, eight to ten times.

Mild discomfort during exercise is common and is not a sign of damage. A pain that sharpens, spreads down the leg or lasts much longer after the session is a signal to stop that movement and talk to a professional.

Progressing to strength work

Once daily movement is comfortable, the next step is to make the back and hips stronger. A meta-analysis by Tataryn and colleagues, eight trials and 408 people with chronic low back pain, found that training the posterior chain (hips, glutes and back extensors) reduced pain and disability more than general exercise, with no difference in adverse events. A trial by Aasa and colleagues found that a progressive deadlift programme and low-load motor control exercises gave similar pain relief.

In practice, over several weeks:

• Bird dog and dead bug, for trunk control. Our core workout gives the technique and a progression.
• Hip hinge, first with a broom along the back, then with a light weight. The hip hinge guide explains it step by step.
• Squat to a chair, then without the chair, and a plank held for short, clean sets.

Should you avoid bending forward? A meta-analysis by Saraceni and colleagues found low-quality evidence that bending the lower back while lifting is not a risk factor for low back pain. Lift in a way that feels comfortable and controlled, and build the load gradually.

Posture and desk breaks

There is no perfect posture to find. A review of 41 reviews by Swain and colleagues found no consensus that particular spinal postures cause low back pain. What seems to help is changing position often rather than holding any position for hours, which is the message of our guide on posture in long meetings.

The calculator on this page counts the movement breaks in your working day. The rhythm of a break every 20 to 30 minutes comes from trials on sitting and metabolism, such as one by Dunstan and colleagues in which two minutes of walking every 20 minutes lowered blood sugar after meals. It is not a back pain treatment in itself, but it is an easy way to stay active, which every guideline asks for.

This guide does not replace a medical opinion. If you have had back surgery, have osteoporosis, are pregnant, or if your pain follows a fall or comes with fever, numbness or weakness, ask your doctor or a physiotherapist before starting. Stop any exercise that makes the pain clearly worse.

Keep your back moving with Never Skip Club

Back pain responds best to activity that lasts, and lasting is the hard part. Never Skip Club helps with that. Once your doctor or physiotherapist has cleared you for exercise, choose the body area, the Easy level, 20, 30 or 45 minutes and where you are, and the app builds a guided session of five or six animated exercises in about a minute, with your sets logged. Join a crew of three to seven friends with a gentle rhythm, such as three sessions a week: the ranking rewards regularity, not extra effort, which suits a back that needs steady progress. Create your free account, and if you would like a professional to adapt the session to your back, find a coach from our network. Already a member? Sign in.