22. October 2018

physiotherapists share the best lower back stretches for pain relief

Introduction - What is Manipulative Therapy and What Conditions Can It Be Used For?

Modern physiotherapy offers a comprehensive, evidence-based approach to managing lower back pain, in which hands-on techniques like manipulative therapy play a specific and supportive role. Manipulative therapy, also referred to as manual therapy, is a specialised area of physiotherapy that involves the skilled, manual application of forces to the body's joints and soft tissues.¹ It is a physical form of therapy performed by Chartered Physiotherapists in the UK to treat musculoskeletal pain and restore normal function.¹

The Chartered Society of Physiotherapy (CSP), the professional body for UK physiotherapists, defines manipulative therapy as the treatment of a patient by passive movement. Crucially, this treatment must always be preceded by a thorough examination and assessment by the therapist. This diagnostic process allows the physiotherapist to determine the specific indications for mobilisation or other manual techniques, ensuring the treatment is both safe and appropriate for the individual's condition.³ This emphasis on clinical reasoning distinguishes professional physiotherapy from more generalised forms of bodywork.

This hands-on approach encompasses a wide spectrum of techniques, each with a distinct purpose and application. A skilled physiotherapist will select from this toolkit based on a comprehensive assessment of the patient's condition, the tissues involved, and the desired therapeutic outcome.²

Key Manipulative Physiotherapy Techniques

Soft Tissue Techniques: These methods involve the direct application of pressure, stretching, and kneading to the muscles and connective tissues surrounding the spine and other joints. The goal is to reduce muscular tension, improve local circulation, release painful "trigger points," and prepare the area for further treatment.¹
Mobilisation and Articulation: This involves the physiotherapist applying gentle, passive, and often rhythmic movements to a joint within its natural range of motion. This technique is used to relieve stiffness, reduce pain, and gradually improve the joint's mobility in a controlled manner.⁴
Manipulation: Often referred to as a high-velocity, low-amplitude (HVLA) thrust, this technique involves a quick, precise, and controlled movement applied to a joint at the very end of its physiological range.⁵ This action can relieve pressure at the joint, improve nerve function, and reduce inflammation.¹ It is frequently accompanied by an audible 'pop' or cavitation, which is simply the release of gas from the joint fluid.
Muscle Energy Technique (MET): MET is an active technique where the patient is asked to contract a specific muscle or move in a particular direction against a precisely applied counter-force from the physiotherapist. This method is highly effective for increasing a joint's range of motion and relaxing overactive muscles.¹

Conditions Effectively Treated with Manipulative Therapy

Manipulative therapy is a versatile tool used primarily for musculoskeletal problems. A comprehensive UK evidence report concluded that spinal manipulation and mobilisation are effective for treating acute, sub-acute, and chronic non-specific low back pain.⁶ Its application, however, extends far beyond the lumbar spine.

Evidence and clinical practice support its use for a range of other conditions, including:

Neck pain and stiffness ¹
Shoulder disorders, such as rotator cuff issues and frozen shoulder (adhesive capsulitis) ⁶
Sciatica and radiating leg pain ⁶
Headaches, particularly those originating from the neck (cervicogenic headaches) and migraines ¹
Sports injuries, such as sprains and strains ⁷
Whiplash-associated disorders ⁸

While these hands-on techniques can provide significant and often immediate relief from pain and stiffness, their role in modern, evidence-based practice is nuanced. The immediate neurophysiological effects of manipulation—such as pain relief through gate control mechanisms and the relaxation of hyperactive muscles—create a valuable, temporary "window of opportunity".⁵ During this period of reduced pain and improved mobility, a patient is better able to engage in the most critical component of their recovery: active rehabilitation and exercise. Therefore, the primary goal of manipulative therapy within a comprehensive physiotherapy treatment plan is not to passively "fix" the issue, but to facilitate the patient's active participation in building long-term strength, resilience, and confidence in their movement.

What Are the Most Typical Symptoms of Lower Back Pain?

Lower back pain is an extremely common condition, defined clinically as pain and discomfort located in the region below the costal margin (the bottom of the ribs) and above the inferior gluteal folds (the crease of the buttocks), with or without associated leg pain.⁹ The experience of lower back pain can vary dramatically from person to person, affecting individuals of all ages and activity levels.

The symptoms can manifest in a variety of ways:

Ache and Stiffness: Many people describe a dull, persistent ache or a feeling of stiffness in the lower back, which may be worse in the morning or after periods of inactivity, such as prolonged sitting.¹⁰
Sharp or Stabbing Pain: The pain can also be sharp, shooting, or stabbing, often triggered by specific movements like bending, lifting, or twisting.¹⁰
Burning Sensations: Some individuals report a hot or burning pain in the back, which can sometimes radiate into the legs.¹⁰
Muscle Spasms: The muscles in the back can go into a sudden, involuntary, and often severe contraction or spasm. This can be intensely painful and may temporarily limit movement significantly.¹⁰
Mechanical Pain: A key characteristic of most common lower back pain is its mechanical nature. This means the intensity of the pain changes with position and activity. It may be worse when standing or walking for long periods and relieved when sitting or lying down, or vice versa.¹¹

Differentiating Localised Back Pain from Sciatica

It is important to distinguish between pain that is confined to the lower back and pain that radiates into the leg, a condition commonly known as sciatica. Sciatica is not a diagnosis in itself, but a symptom that indicates irritation or compression of the sciatic nerve or its nerve roots in the lumbar spine.¹⁴

When a nerve is irritated, symptoms can include:

Pain that travels from the lower back, through the buttock, and down the back or side of the leg, sometimes reaching the foot or toes.¹³
Sensory changes such as pins and needles (paraesthesia), numbness, or a tingling sensation along the path of the nerve.¹⁰
Weakness in the muscles of the leg or foot, which might manifest as difficulty lifting the foot (foot drop) or weakness when pushing off the toes.¹⁰

It is reassuring to know that the vast majority of lower back pain is classified as "non-specific," meaning it is not attributable to a recognisable, known specific pathology like a fracture, infection, or tumour.⁹ Most episodes are triggered by simple mechanical strains, such as staying in one position for too long, lifting an object awkwardly, or a flare-up of a pre-existing issue.¹⁰ The spine is a strong and resilient structure, and pain does not usually signify serious damage.¹⁰

However, while most back pain can be safely self-managed, certain symptoms warrant professional medical advice. The following table provides guidance on the appropriate course of action based on the nature of the symptoms.

Self-Manage with Gentle Exercise & Activity	Contact Your GP for Assessment	Seek Urgent Medical Attention (A&E or Call 111)
Dull aches, stiffness, or mechanical pain that changes with position and activity.¹¹	Pain that is persistent, severe, and does not improve after several weeks of self-care.¹⁰	New and significant loss of bladder or bowel control (e.g., inability to urinate or stop urinating, or leaking from the bowel).¹⁰
Muscle spasms that are gradually improving.¹⁰	Pain that is constant and does not change with movement or rest.¹⁰	Numbness or pins and needles around your genitals or buttocks (often called "saddle anaesthesia").¹⁰
Symptoms that begin to settle within 6 weeks.¹⁰	Pain that is significantly worse at night and disturbs sleep.¹⁰	New and significant weakness in both legs, or feeling unsteady on your feet.¹⁴
Pain that is localised to the back or radiates into the buttock or thigh but is not worsening.¹³	Pain accompanied by unexplained weight loss, fever, or feeling generally unwell.¹²	Back pain that follows a recent significant trauma, such as a fall from a height or a major accident.¹⁰

The experience of pain is not purely a physical sensation. Factors such as stress, anxiety, depression, and fear of movement can significantly influence and even perpetuate back pain.¹¹ Stress can lead to increased muscle tension, while fear of movement can result in guarding and stiffness, creating a vicious cycle where inactivity worsens the very pain it is intended to protect against. This is why the National Institute for Health and Care Excellence (NICE) guidelines for lower back pain are built upon a "biopsychosocial" model, which acknowledges the interplay between physical factors (bio-), psychological factors (psycho-), and social factors (such as work environment).¹⁶ An effective physiotherapy treatment plan, therefore, addresses the whole person, not just the anatomical structures of the spine.

3 Foundational Stretching Techniques for Pain Relief

knee to chest exercise For many people with low back pain, the natural instinct is to rest and avoid movement for fear of causing more damage. However, physiotherapy guidance strongly encourages the opposite approach. Keeping as active as possible is one of the most effective strategies for recovery.¹⁷ A crucial concept to embrace is that 'hurt does not equal harm'. It is normal to feel some discomfort when you begin to move a stiff and sore back, but this gentle movement is essential for healing and preventing long-term problems.¹⁷

The following three exercises are foundational techniques often recommended by physiotherapists. They are designed to be safe, gentle, and effective for restoring movement and reducing pain. It is important to perform them slowly and with control, and to stop immediately if any exercise causes a sharp, severe, or worsening of pain.¹⁸

Technique 1: The Knee-to-Chest Stretch

This is a classic stretch for gently elongating the muscles of the lower back and buttocks, helping to relieve tension and stiffness.

How to Perform:

Lie on your back on a comfortable, firm surface like a mat on the floor or your bed. Bend both knees and place your feet flat on the surface.²⁰
Gently bring one knee up towards your chest. Clasp your hands either behind your thigh or over your shin, whichever is more comfortable.¹⁸
Carefully pull the knee closer to your chest until you feel a comfortable stretch in your lower back and buttock area. As you do this, try to keep your lower back pressed gently into the floor.²¹
Hold this position for 15 to 30 seconds, breathing deeply and relaxing into the stretch.¹⁸
Slowly release the leg and return to the starting position.
Repeat the stretch with the other leg.
Finally, perform the stretch by bringing both knees to your chest at the same time, hugging them gently.²⁰ Repeat the entire sequence 2 to 3 times.

Specific Benefits & Case Example: This stretch is particularly effective for relieving the lumbar and gluteal tightness that contributes to lower back pain.²²
Case Example: For an individual who experiences significant stiffness and pain upon waking, performing the knee-to-chest stretch gently while still in bed can be a highly effective way to ease that morning discomfort. It helps to mobilise the hips and lower back, making the transition from lying to standing much more comfortable.¹⁸
Precautions: The pull should always be gentle and controlled, never forced to the point of sharp pain. If the stretch causes or significantly increases your existing back or leg pain, you should not continue with it.²¹

Technique 2: The Cat-Cow Stretch

This dynamic movement is excellent for improving the mobility and flexibility of the entire spine, from the neck down to the tailbone.

How to Perform:

Start on your hands and knees in a "tabletop" position. Ensure your hands are directly under your shoulders and your knees are directly under your hips.²³
Cow Pose: As you inhale, gently drop your belly towards the floor. Lift your chest and tailbone towards the ceiling, creating an arch in your back. Look slightly forward, being careful not to strain your neck.¹⁹
Cat Pose: As you exhale, press your hands into the floor and round your spine up towards the ceiling. Tuck your chin towards your chest and let your head hang heavy.¹⁹
Continue to flow smoothly and rhythmically between these two positions, coordinating the movement with your breath.
Repeat the sequence for 5 to 10 repetitions, once or twice a day.²⁴

Specific Benefits & Case Example: The primary benefit of the Cat-Cow stretch is its ability to improve segmental spinal mobility. It encourages each vertebra to move independently in both flexion (rounding) and extension (arching), which can alleviate the feeling of being "stuck" or rigid.¹⁹
Case Example: For an office worker who spends long hours sitting at a desk, the spine can become stiff and locked in a slightly flexed position. Performing the Cat-Cow stretch as a regular break during the workday is an ideal way to counteract this postural strain, reintroducing gentle movement and relieving the tension that builds up in the spinal muscles and joints.
Precautions: The movement should always be slow, controlled, and within a pain-free range. If either the arching or rounding motion increases your pain, stop the exercise immediately.¹⁹

Technique 3: The Pelvic Tilt

This is a subtle but powerful exercise that focuses on neuromuscular re-education and pain modulation rather than a deep stretch. It is often one of the first and safest exercises prescribed in the early stages of back pain.

How to Perform:

Lie on your back with your knees bent and your feet flat on the floor, about hip-width apart. Rest your arms by your sides.²⁶
Allow your back to rest in its natural position. There will likely be a small space between your lower back and the floor.²⁶
As you exhale, gently engage your lower abdominal muscles to flatten your lower back against the floor. You should feel your pelvis rock or tilt backwards slightly.²⁶
Hold this flattened position for 3 to 5 seconds.
As you inhale, relax your muscles and allow your pelvis to tilt forward, returning to the starting position and recreating the small curve in your lower back.²⁷
Repeat this small, controlled rocking motion for 5 to 10 repetitions.²⁶

Specific Benefits & Case Example: The pelvic tilt is exceptional for activating the deep core stabilising muscles, particularly the transverse abdominis, which acts like a natural corset for the spine.²⁶ It also provides gentle, pain-relieving movement to the lumbar joints.²⁸
Case Example: For someone experiencing an acute flare-up of back pain where larger movements are too provocative, the pelvic tilt is an ideal starting point. The gentle oscillations can help to reduce pain and inflammation, while the muscle activation begins the process of re-establishing the brain-muscle connection for core control, all without placing significant strain on the sensitive tissues.²⁸
Precautions: This is a very subtle movement. The focus must be on control and using the lower abdominal muscles, not on achieving a large range of motion. Avoid pushing with your feet or using your gluteal muscles to lift your hips off the floor, as this changes the exercise into a bridge.²⁸

These three exercises are not just a random collection; they represent a logical therapeutic progression for early-stage recovery. The process begins with re-establishing fine motor control and modulating acute pain with minimal movement (Pelvic Tilt). It then progresses to restoring a larger, yet still gentle, range of motion in flexion and extension (Knee-to-Chest and Cat-Cow). This structured approach to movement helps individuals to think more like a physiotherapist about their own rehabilitation, choosing the right type of exercise for their current stage of pain and recovery.

Finding Holistic and Evidence-Based Treatments for Lower Back Pain

holistic treatment for lower back pain Managing lower back pain effectively in the UK is guided by a patient-centred, evidence-based framework established by the National Institute for Health and Care Excellence (NICE). These guidelines are considered the gold standard and inform the practice of both NHS and private physiotherapists.¹⁶ The core principle of this modern approach is a shift away from passive treatments towards a holistic, biopsychosocial model that empowers individuals to take an active role in their recovery through self-management and targeted exercise.¹⁶

The Central Role of Exercise in Physiotherapy Treatment

According to the NICE guidelines (NG59), a structured exercise programme should be considered the main component of non-invasive physiotherapy treatment for a specific episode or flare-up of low back pain, with or without sciatica.²⁹ This is because exercise is not only effective for reducing pain and improving function in the short term, but its benefits can be sustained long after the course of treatment has ended.³⁰

The recommendation is for a tailored programme that may include:

Group exercise classes: These can focus on biomechanical principles, aerobic fitness, or mind-body approaches such as yoga or tai chi.³¹
A combination of approaches: A physiotherapist will design a programme that includes elements of muscle strengthening, postural control, stretching, and movement instruction, all tailored to the individual's specific needs, capabilities, and preferences.¹⁶

Adjunctive Therapies: Understanding Their Role in a Holistic Plan

While exercise is the cornerstone of treatment, other therapies can play a valuable supporting role. However, it is crucial to understand how and when they should be integrated into a treatment plan, according to the best available evidence.

Manual Therapy: A Tool to Enable Movement

Manual therapy, which includes the manipulative techniques discussed earlier such as spinal manipulation, mobilisation, and soft tissue massage, is recommended by NICE, but with a very important condition: it should only be considered as part of a treatment package that also includes exercise.¹⁶ It is not recommended as a standalone treatment. The hands-on techniques are used to reduce pain and improve mobility, thereby making it easier and more comfortable for the patient to perform their essential rehabilitation exercises.

Emerging Technology: Shockwave Therapy

Shockwave therapy, or Extracorporeal Shockwave Therapy (ESWT), is a non-invasive treatment that uses high-energy sound waves passed through the skin to target areas of chronic pain and stimulate healing in muscles and soft tissues.³⁴ The proposed mechanism involves increasing local blood flow, stimulating the body's natural repair processes, and breaking down scar tissue or calcifications.³⁴

While NICE has deemed shockwave therapy safe for a number of chronic tendon conditions, and some clinical studies have shown it can be effective in reducing chronic low back pain and improving function, its evidence base for this specific condition is still developing.³⁴ Therefore, it is not yet a routine recommendation within the NICE guidelines for low back pain but may be considered by some specialists as part of a broader physiotherapy programme for persistent cases.

Clarifying Misconceptions: The Role of Electro Therapy

Electro therapy encompasses treatments that use electrical currents to achieve a therapeutic effect. The most common form associated with pain relief is TENS (Transcutaneous Electrical Nerve Stimulation), which involves placing pads on the skin to deliver a mild electrical current intended to block pain signals from reaching the brain.³⁴

It is essential for patients to be aware of the current clinical guidance on this modality. While electro therapy was once a common part of physiotherapy, the NICE guidelines are now clear and explicit:

Do not offer TENS for managing low back pain.³¹
Do not offer therapeutic ultrasound or interferential therapy for managing low back pain.³¹

This recommendation is not based on safety concerns, but on a lack of high-quality evidence. Multiple systematic reviews and trials have concluded that these forms of electro therapy are no more effective than a placebo or sham treatment for reducing pain or improving function in people with low back pain.³⁸ This highlights a potential gap between some historical practices and current, evidence-based best practice. An expert-led physiotherapy treatment plan should always be grounded in the most up-to-date national guidelines, ensuring that patients receive care that is proven to be effective.

Ultimately, a thorough assessment by a qualified physiotherapist is the crucial first step. This allows for an accurate diagnosis and the creation of a personalised, holistic treatment plan that combines the right evidence-based elements—be it exercise, manual therapy, education, or other modalities—to address the individual's specific condition, goals, and lifestyle.

Conclusion

The journey to recovery from lower back pain is a proactive one, centred on empowerment, understanding, and consistent, gentle movement. The evidence is clear that for the vast majority of cases, the pain is not a sign of serious harm, and that staying active is the most effective strategy for healing and preventing recurrence. By incorporating foundational stretches such as the Knee-to-Chest, Cat-Cow, and Pelvic Tilt, individuals can take direct control of their symptoms, working to restore mobility and alleviate the stiffness that often perpetuates the pain cycle.

The modern, holistic approach to lower back pain management in the UK, championed by leading bodies like NICE and the Chartered Society of Physiotherapy, places the patient at the centre of their own care. This approach prioritises active rehabilitation through tailored exercise programmes as the cornerstone of effective treatment. Hands-on techniques like manual therapy serve as valuable tools to reduce pain and improve movement, thereby enabling a more effective engagement with exercise. While emerging technologies like shockwave therapy show promise, it is equally important to move away from passive modalities like electro therapy, which have been shown by robust evidence to lack clinical benefit.

Taking an active role in your rehabilitation, armed with the right information and a positive mindset, is the key to a successful outcome. The path to recovery is not about finding a single "cure," but about building a toolkit of self-management strategies and developing a partnership with a healthcare professional who can guide you with an evidence-based plan. For a personalised assessment and a treatment plan tailored to your specific needs, seeking the guidance of a qualified professional is the most effective step on your journey to recovery through physiotherapy.

Physiotherapy for Lower Back Pain: Frequently Asked Questions

How much does physiotherapy for back pain cost in the UK?

On the NHS, physiotherapy is free but may have waiting lists; private treatment typically costs £40-£80 per session depending on location and specialist expertise.

How do I find a qualified physiotherapist in the UK?

Look for practitioners registered with the Chartered Society of Physiotherapy (CSP) and the Health and Care Professions Council (HCPC), or ask your GP for a referral to NHS physiotherapy services.

How long and how often should I attend physiotherapy sessions for back pain?

Most treatment plans involve weekly sessions for 4-6 weeks, with each session lasting 30-60 minutes, though this varies based on individual needs and condition severity.

What preventative measures can I take to avoid lower back pain recurring?

Regular core-strengthening exercises, maintaining good posture, proper lifting techniques, and ergonomic workstations can significantly reduce recurrence risk.

Is it better to use heat or ice for lower back pain?

Heat is generally better for chronic, stiff back pain as it increases blood flow and relaxes muscles, while ice works better for acute injuries with inflammation and swelling.

Can I take pain medication alongside physiotherapy treatment?

Over-the-counter pain relievers like paracetamol or NSAIDs can complement physiotherapy by reducing pain and inflammation, making exercises more comfortable to perform.

Are there specific exercises for herniated discs or sciatica beyond the basics?

Neural gliding exercises, specific directional preference movements (McKenzie method), and targeted stabilization exercises may be recommended for herniated discs or sciatica.

How long does recovery from lower back pain typically take?

Most acute episodes improve significantly within 4-6 weeks with appropriate management; chronic cases may require 3-6 months of consistent treatment and exercise.

What ergonomic changes should I make to my workspace?

Ensure your chair provides proper lumbar support, position your monitor at eye level, keep feet flat on the floor, and take regular movement breaks every 30 minutes.

When might surgery be considered for lower back pain?

Surgery is typically only considered when there's persistent pain despite conservative treatment, progressive neurological symptoms, or structural issues causing severe functional limitations.

Are there special considerations for back pain during pregnancy?

Pregnancy-related back pain benefits from gentle prenatal exercises, support belts, pelvic floor training, and specific side-lying stretches that are safe for both mother and baby.

Can obesity contribute to lower back pain?

Yes, excess weight increases pressure on spinal structures and alters body mechanics; even modest weight loss of 5-10% can significantly reduce lower back pain symptoms.

What home equipment might help manage back pain?

Supportive mattresses, ergonomic pillows, lumbar rolls for chairs, foam rollers for self-massage, and stability balls for gentle exercise can all help manage back pain at home.

What's the difference between a physiotherapist and an osteopath for treating back pain?

Physiotherapists typically focus on exercise-based rehabilitation and functional improvement, while osteopaths often emphasize manual manipulation of the spine and surrounding tissues.

Can psychological approaches help with chronic back pain?

Cognitive behavioral therapy (CBT), mindfulness, and pain management programs can effectively address the psychological aspects of chronic pain and improve overall outcomes.