Pain guide · Back pain
Sudden low back pain, often after lifting, bending or twisting, sometimes after nothing at all. The back feels stiff, guarded and sore to move, and the muscles may tighten into a spasm.
"Pulled muscle" and "spasm" are descriptions, not diagnoses: for nearly all back pain no specific damaged tissue can be found. The label matters less than the plan, because the advice is the same: keep moving, use heat if it helps, and build back up.
Exercise is for pain that has been checked or is clearly mild and settling.
In cohorts of people seeking care for new back pain, average pain fell from 52 out of 100 to 23 by six weeks and 12 by six months. The NHS says back pain usually improves within a few weeks but can last longer or come back.
The NHS lists strains (pulled muscles) as a common cause, but for nearly all back pain no specific damaged tissue can be identified, so there is no need to work out exactly what you pulled.
In one cohort of 250 people, 69% had another episode within a year of recovering. That is why the last stage of the plan matters.
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Imaging did not improve outcomes in trials, and NICE advises against routine scans for low back pain outside specialist settings. Scans are for warning signs.
NICE suggests considering an anti-inflammatory (NSAID) at the lowest effective dose for the shortest time, not paracetamol on its own, and not routinely opioids for acute low back pain. Ask a pharmacist: anti-inflammatories such as ibuprofen may help but don't suit everyone.
In a Cochrane review, advice to stay active gave small improvements in pain and function over advice to rest in bed (2 trials, 401 people, moderate quality). NICE encourages carrying on with normal activities and getting back to work as soon as you can, and the NHS says don't stay in bed for long periods.
Heat wraps reduced pain and disability slightly in the short term in acute and subacute back pain (2 trials, 258 people), and adding exercise to heat reduced pain further at 7 days in one trial of 100 people. The American College of Physicians recommends superficial heat. Evidence on cold is too thin to judge; the NHS suggests ice for pain and swelling and heat for stiffness or spasm.
An overview of reviews (21 trials, 2,685 people) found exercise therapy made little or no important difference to pain or disability in acute low back pain compared with advice to stay active, usual care, manipulation or a booklet, on very low to moderate certainty evidence. A US physiotherapy guideline words it weakly: clinicians "can use" exercise for acute low back pain.
So in the first weeks, staying active matters more than any particular exercise. The gentle moves below are for comfort and confidence.
In a trial of 312 people with back pain, 74% had a directional preference: repeated bending one way eased their pain. Exercises matching it did better than opposite or non-directional exercises, and a third of the unmatched groups dropped out within 2 weeks. Pain that moves back towards the spine (centralises) predicted a good outcome in 21 of 23 studies.
Test it gently: if bending forward eases your pain, use the knees-to-chest moves; if arching back eases it, use sphinx and the press-up.
Adding the McKenzie method to first-line care for acute back pain reduced pain only slightly (about 0.4 to 0.7 points out of 10), with no difference in disability or in the chance of the pain persisting, though people sought less extra care.
Across prevention trials, exercise plus education lowered the risk of a new episode (risk ratio 0.55, about half the risk). In people who had recovered, a progressive walking and education programme nearly doubled the time to the next episode (a median of 208 days against 112).
NICE advises against belts or corsets, traction, TENS, ultrasound and acupuncture for low back pain, and recommends manual therapy only as part of a package that includes exercise.
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Some discomfort during exercise is fine, and it does not mean you are doing damage: the WHO counts "hurt does not necessarily mean harm" among the messages people with back pain need. Aim for pain you would call mild to moderate, no more than about 5 out of 10. It should settle within an hour or so, and your back should be no worse the next morning. If it is worse, do less next time (fewer reps, a smaller range, a lighter load), not nothing.
Leg symptoms are the exception: stop or shrink any movement that sends pain, pins and needles or numbness further down your leg. If leg symptoms move back towards your spine, that is a good sign, even if your back aches a little more for a while.
If pain climbs day after day, or you notice any warning sign, stop and get it checked. The 5 out of 10 figure matches this site's other pain guides and has not been tested in a back pain trial; in trials of long-lasting muscle and joint pain, exercise that allowed some pain did no harm.
Start at the first stage. Each move opens a full guide with a 3D demo.
Days 0 to 7, daily. Heat for 20 minutes at a time, wrapped in a towel, if it helps. To rest, lie on your back with your knees bent and supported, or on your side with a pillow between your knees. Keep the knees-to-chest moves or sphinx and the press-up, whichever eases your pain. Doses are editorial starting points.
3D demoTreadmill walkingBeginner · Cardio machine3 to 10 min, several times a day · Around the house counts
Harder: Treadmill jogging
3D demoLegs up the wall (Viparita Karani)Beginner · A wallA few minutes, as needed · A supported rest position
Harder: Plow pose (Halasana)
3D demoOne Knee To ChestBeginner · Other / check instructions3 holds of 20 to 30 s · If bending forward eases it
Harder: Superman
3D demoHug Knees To ChestBeginner · Other / check instructions3 holds of 20 to 30 s · Once one knee at a time is comfortable
3D demoSphinx pose (Salamba Bhujangasana)Beginner · No equipment3 holds of 20 to 30 s · If arching back eases it
Harder: Cobra pose (Bhujangasana)
3D demoProne press-up (McKenzie press-up)Beginner · No equipment10 slow reps, a few times a day · If sphinx eases it; a McKenzie-style repeated movement
3D demoCat-cowBeginner · No equipment6 to 8 slow waves, small range
Move on when: Getting in and out of bed and walking for 10 minutes are manageable, and the pain is easing day by day.
About days 7 to 21. Back to normal activities and work as soon as you can, as NICE advises, plus two or three short exercise sessions a week.
3D demoGlute bridgeBeginner · No equipment2 to 3 sets of 8 to 10 · Once the pelvic tilt bridge is easy
Easier: Pelvic tilt into bridge · Harder: Glute kickback (quadruped hip extension)
Move on when: These feel steady, and your back is no worse the next morning.
From about week 3, then ongoing. This is where exercise earns its place: it lowers the chance of the next episode.
3D demoKettlebell deadliftBeginner · A kettlebell3 sets of 8 to 10, light
Harder: Dumbbell Romanian deadlift
3D demoBird dogBeginner · No equipment3 sets of 8 each side
Easier: Bird dog, one limb at a time · Harder: Bodyweight get-up
3D demoSide plankIntermediate · No equipment3 holds of 20 to 30 s each side
Easier: Knee side plank · Harder: Side plank with leg lift
3D demoSuitcase carryIntermediate · A dumbbell + A kettlebell3 walks of 20 m each side
Easier: Farmer's carry · Harder: Overhead carry (waiter's walk)
3D demoDumbbell goblet squatIntermediate · A dumbbell3 sets of 8 to 10
Easier: Bodyweight squat · Harder: Back squat with bands
3D demoTreadmill walkingBeginner · Cardio machineAt least 5 days a week, building to 30 min · The WalkBack trial's target
Harder: Treadmill jogging
Move on when: Add load gradually, one change at a time, then keep two strength days and regular walking going.
Bed rest does worse than staying active. Break up sitting with short walks: in one cohort, sitting for more than 5 hours a day predicted the pain coming back.
If bending forward hurts and arching eases it, do more of the easing direction for now, and the other way round. This is a temporary choice, not a lifelong rule.
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No trial shows that a particular movement harms acute back pain. Lifting and bending come back gradually as pain allows, and bending the back while lifting has not been shown to be risky. A brace or belt is not recommended.
Seven gentle stretches and mobility moves for a stiff lower back, done lying and kneeling.
12 minBeginner7 movesA wallA steady 30 to 45 minute cardio session at talk-but-not-sing pace: walk, cycle, row or cross-train, counting toward weekly activity guidelines.
40 minBeginner3 movesCardio machine, A wallHeat has the better evidence: in two trials heat wraps eased pain and disability slightly in the short term, and there is too little research on cold to judge. The NHS suggests ice for pain and swelling and heat for stiffness or spasm, so use whichever feels better, wrapped in a towel.
Most new back pain improves a lot within six weeks: in a large analysis, average pain fell from 52 out of 100 to 23 in that time. See a GP if it isn't getting better after a few weeks, stops your daily activities or worries you.
If you can, yes. NICE encourages getting back to work and normal activities, and staying active does slightly better than rest. Break up long spells of sitting with short walks.
Gentle movement, yes, if it eases the pain: knees to chest if bending forward helps, sphinx if arching back helps, plus knee rolls and small cat-cows. In the first weeks, staying active matters more than any particular exercise, so don't force a stretch that makes it worse.
Back pain with chest pain needs a 999 call. Pain with a fever or feeling generally unwell needs a same-day check with a GP or NHS 111. If neither applies and it doesn't settle, see a GP.
Usually not. Imaging did not improve outcomes in trials, and NICE advises against routine scans for low back pain. Scans are for warning signs.
Exercise education, not a diagnosis or treatment plan. It is written from the guidelines and studies listed above; review by a clinician is pending. If your pain follows an injury, is severe, is getting worse, or comes with any warning sign listed on this page, get it assessed. Health disclaimer.
