coping with lower back pain through exercise

If you're currently experiencing back pain and wondering whether exercise might help—or worrying that movement could make things worse—this guide explains what the clinical evidence actually shows, which types of exercise work best, and when it makes sense to seek professional guidance.

NICE Guidelines Put Exercise at the Heart of Treatment

The NICE guideline for low back pain and sciatica (NG59) was published in November 2016, with pharmacological recommendations updated in December 2020. The exercise recommendations remain unchanged and current. The guideline explicitly states: "Consider a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches) within the NHS for people with a specific episode or flare-up of low back pain with or without sciatica."

NICE classifies beneficial exercises into three categories:

• Biomechanical: strength training, stretching, and core stability work
• Aerobic: walking, swimming, cycling
• Mind-body: yoga, tai chi, Pilates

The guideline deliberately avoids recommending one type over another, instead emphasising that clinicians should "take people's specific needs, preferences and capabilities into account when choosing the type of exercise."

Crucially, NICE positions exercise as mandatory alongside other treatments. Manual therapy—including spinal manipulation, mobilisation, and massage—should only be offered as part of a treatment package including exercise. The same applies to psychological therapies using cognitive behavioural approaches. This represents a fundamental repositioning of exercise from supplementary to central.

NHS guidance aligns with NICE, stating that activities like "walking, swimming, yoga and pilates may also help ease back pain" and emphasising that patients "do not stay in bed for long periods of time."

Which Exercise Types Have the Strongest Evidence?

A 2021 Cochrane review—one of the largest ever conducted—analysed 249 randomised controlled trials involving 24,486 participants with chronic low back pain. The headline finding: exercise improves pain by approximately 15 points on a 0-100 scale at three months, with disability improving by 7 points. These represent clinically meaningful changes for most patients.

However, the evidence also shows that no specific exercise type demonstrates clear superiority when different approaches are compared head-to-head. The Cochrane review concluded that "exercise design and delivery characteristics were more associated with improved effectiveness than specific exercise types." This finding has been replicated across multiple systematic reviews.

The evidence for acute low back pain differs substantially. A 2023 Cochrane review of 23 trials found exercise therapy showed no clinically relevant effect compared to sham treatment or no treatment for acute episodes. This aligns with the natural history of acute back pain—most episodes resolve within weeks regardless of intervention. For acute pain, the evidence supports reassurance, advice to stay active, and self-management rather than formal exercise programmes.

Exercise Frequency, Intensity, and Realistic Timelines

The optimal exercise dose has been investigated in several studies. A 2021 study found that performing fewer than 1.45 treatment sessions per week increased the one-year risk of recurrence by 82%, leading researchers to recommend at least two sessions weekly as a minimum threshold.

Regarding programme duration, structured physiotherapy programmes typically run for 8-12 weeks in the supervised phase, with most patients experiencing initial improvements within 2-4 weeks and significant improvements by 6-8 weeks. However, the Chartered Society of Physiotherapy notes that the majority of musculoskeletal conditions improve within 6-8 weeks with appropriate management.

Managing Pain During Exercise

For exercise intensity, guidance centres on keeping pain within 0-5 out of 10 during exercise. Some muscle soreness the following day is normal and acceptable, particularly when starting a new programme. Pain should return to baseline within 30 minutes of completing exercise. If exercises consistently provoke pain above 5/10 or cause lasting increases in symptoms, the programme requires modification.

Progressive loading—the systematic increase in exercise demands—follows the principle of starting conservatively and increasing by 5-10% weekly. In practice, this means beginning a strengthening programme at 50-60% of previous activity levels, with gradual increases as tolerance improves.

Self-Management and Home Exercise Guidance

NICE Quality Standard QS155 emphasises that self-management education should occur "at all steps of the treatment pathway." The guidance states: "Low back pain and sciatica are common and recurrent conditions that can be long term. It is therefore important that the person learns how to manage their symptoms."

The key self-management messages include encouragement to continue normal activities, information about the benign nature of most back pain, the high probability of rapid improvement, and the importance of early return to work and normal life. Patients should understand that they do not need to be pain-free before returning to normal activities.

Safe Home Exercises

The Chartered Society of Physiotherapy provides specific home exercise guidance through their video programme. Safe exercises patients can perform independently include:

• Pelvic tilts: Lying on your back with knees bent, engage your lower abdominals to tilt the pelvis, flattening then arching the back
• Knee-to-chest stretches: Bringing one knee to chest using hands under thigh while keeping the other leg flat or bent
• Heel slides: Engaging your core while sliding one foot out until the leg is straight, maintaining a neutral spine
• Bridge exercises: For gluteal strengthening to support the lower back
• Cat-cow stretches: For gentle spinal mobility on hands and knees

When Exercise Is Not Appropriate: Red Flags and Urgent Referral

While exercise benefits the vast majority of back pain patients, certain presentations require immediate medical evaluation. The NHS advises calling 999 or attending A&E for:

These symptoms may indicate cauda equina syndrome, a medical emergency requiring urgent surgical evaluation. CES affects approximately 1-3 per 100,000 population and represents only 0.04% of primary care back pain presentations, but delayed treatment can result in permanent bladder and bowel dysfunction, loss of sexual function, and lower limb paralysis.

Additional red flags warranting urgent GP consultation include high temperature with back pain (possible spinal infection), unexplained weight loss (possible malignancy), lumps or swelling in the back, pain worse at night or at rest, and upper back pain between the shoulders.

However, only 1-4% of patients presenting with back pain have red flag conditions—for the vast majority, exercise remains appropriate and beneficial.

The Burden of Back Pain in the UK

Low back pain affects approximately one in six adults in England and represents the leading cause of disability in the UK. Lifetime prevalence is estimated at 59-80%, with 12-month period prevalence of 36-39%.

The economic burden is substantial. Direct NHS costs are estimated at £3.2-5 billion annually in primary care alone. When indirect costs including work absence are included, the total economic burden reaches £10-12 billion per year. Back pain accounts for approximately 28-31 million lost workdays annually.

Recovery timelines offer grounds for optimism:

• 50% of patients improve within 10 days
• 75% of patients improve within four weeks
• 90% of patients improve by six weeks

However, prognostic indicators suggest that those off work for one month have a 20% chance of still being off at one year, emphasising the importance of early, active management to prevent chronicity.

Common Myths That Need Debunking

When to See a Chartered Physiotherapist

The Chartered Society of Physiotherapy recommends seeking professional assessment when:

• Pain is getting worse rather than better despite self-management
• Symptoms have not significantly improved after 4-6 weeks
• There are changes in ability to walk or leg weakness
• Early morning stiffness lasts more than 30 minutes
• You're struggling to cope with symptoms

The evidence comparing supervised physiotherapy to self-directed exercise shows supervised programmes produce superior outcomes for patient satisfaction, trunk muscle endurance, and strength. While pain and disability improvements are similar, supervised programmes better address kinesiophobia and build the confidence needed for long-term self-management.

Physiotherapist-led programmes typically include:

• Assessment using risk stratification tools (such as STarT Back)
• Individualised exercise prescription combining core stability, flexibility, strengthening and aerobic components
• Education about pain and prognosis
• Manual therapy as an adjunct to exercise where appropriate
• Guidance on progressive return to normal activities

Conclusion

The evidence supporting exercise for low back pain is robust and consistent across major guidelines. For chronic pain, structured exercise programmes—whether Pilates, yoga, strength training, or aerobic exercise—produce clinically meaningful improvements in pain and function. For acute pain, the priority is reassurance and maintaining activity rather than formal exercise programmes, given most episodes resolve within weeks.

The most important clinical messages are:

• Exercise should form the foundation of any treatment approach
• No single exercise type is clearly superior
• Consistency and patient preference matter more than the specific modality
• The goal is building long-term self-management capacity
• At minimum, aim for twice-weekly exercise sessions to reduce recurrence risk

Red flags requiring urgent evaluation are rare, affecting only 1-4% of presentations. For the vast majority of patients, movement is medicine—and the outdated advice to rest and protect the spine has given way to evidence-based encouragement to stay active, exercise progressively, and return to normal activities as quickly as safely possible.

Frequently Asked Questions

References & Further Reading

The clinical evidence cited in this article comes from the following authoritative sources:

1. NICE Guideline NG59: Low back pain and sciatica in over 16s: assessment and management (2016, updated 2020). www.nice.org.uk/guidance/ng59
2. Cochrane Review (Hayden et al., 2021): Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews. www.cochranelibrary.com
3. NHS Back Pain Guidance: Comprehensive patient information on causes, treatment and self-management. www.nhs.uk/conditions/back-pain
4. Chartered Society of Physiotherapy: Back pain advice, video exercises and guidance on when to seek help. www.csp.org.uk/conditions/back-pain
5. Fernández-Rodríguez et al. (2022): Best Exercise Options for Reducing Pain and Disability in Adults With Chronic Low Back Pain. Journal of Orthopaedic & Sports Physical Therapy. www.jospt.org
6. NICE Quality Standard QS155: Low back pain and sciatica in over 16s – self-management and assessment. www.nice.org.uk/guidance/qs155