Best Physical Therapy Exercises for Lower Back Pain: As Told by a Physical Therapist

Exercise offers several benefits that help reduce pain and day-to-day function. Some of these benefits include:

• Maintaining mobility in the joints and myofascial tissue (muscles, tendons, ligaments, and fascia) of the spine
• Improving blood flow to injured tissue, which promotes healing
• Improving and maintaining muscle mass for spinal stabilization
• Improving and/or maintaining cardiovascular health and endurance
• Reducing fear of movement

Additionally, exercise does not have the same side effects such as pharmacotherapy (drug treatment, another common conservative care approach for lower back pain), and has even been found to be more effective for reducing disability and improving quality of life (3).

• NSAIDs: While these have been found to be effective in reducing lower back pain, people who take NSAIDs on a long term basis increase their risk of developing heart disease or gastrointestinal complications (5).
• Opioids: While the use of these drugs may be effective in helping to manage moderate to severe lower back pain, they are habit-forming and carry significant risk of abuse (6).

Early physical therapy and exercise implementation has been found to decrease the need for long term opioid use in the management of musculoskeletal pain, thereby reducing the risk of addiction and abuse (7).

There are hundreds of different exercises that physical therapists will recommend to their clients to treat lower back pain. In general, the exercises fall into one or more of the following categories:

Flexibility and Stretching Exercises

Flexibility and stretching exercises are important because they help maintain mobility of the lower back muscles, joints, and connective tissue. If joints and tissues aren't moving well, then the whole body’s movement will be impaired and painful. Research shows that stretching exercises help alleviate chronic lower back pain and disability (8, 9).

Examples of stretching exercises for the lower back include:

• Hamstring stretches 
• Piriformis (a deep muscle in the buttock region) stretches 
• Sideways bending stretches 

Core Strengthening and Stabilization Exercises

Core muscles are muscles that support and provide stability to your trunk and spine, essentially forming a built-in back brace (10). The muscles included in this group are:

• Abdominal muscles (rectus abdominis, transversus abdominis, internal and external obliques)
• Back muscles (erector spinae muscles, multifidus muscles, quadratus lumborum muscles)
• Gluteal muscles (gluteus maximus, gluteus medius, and gluteus minimus)
• Pelvic floor muscles
• Diaphragm muscle
  

Strengthening the core muscles is important because without a strong core, the trunk and lower back lack the support they need for routine movements, increasing the risk of back injury (10). Core strengthening and stabilization exercises in particular have been shown to augment the size and strength of deep core muscles such as the transversus abdominis and multifidus muscles, which helps to relieve lower back pain (11). 

Examples of core strengthening/stabilization exercises include:

• Bridges
• Bird dogs
• Planks
  

Neuromuscular Re-Education and Training Exercises

The brain and other nervous system organs need properly perceive how the body is moving in space, so that they activate the appropriate muscles at the right time (10).

People with chronic lower back pain demonstrate delayed communications between the nervous system and muscles (in particular the transversus abdominis, multifidus, and glute muscles), indicating decreased neuromuscular control (10). This decreases the stability of the trunk and spine in everyday maneuvers, causing significant back pain from movement. 

Research has found that neuromuscular re-education exercises increase the activity of these muscles and have positive impacts on chronic back pain (12).

Examples of neuromuscular re-education exercises are:

• Pelvic tilts 
• Balance exercises on hands and knees
• Balance exercises in standing (such as single leg balance)
• Balance exercises on unsteady surfaces

Now that you know the types of exercises that can be included in a back exercise program, you’re probably wondering which ones are best for your case and how to perform them. 

It’s important to recognize that there are multiple potential causes of lower back pain. You might find that certain types of exercise are more helpful than others, depending on the root cause of your pain. It’s important for you to monitor your symptoms carefully as you ramp up on a new exercise routine, and also to be in close contact with your PT to make sure you’re progressing on the right track.

With that said, here are some routines of simple but effective physical therapy exercise routines that have been effective in my own clinical practice treating lower back pain. They’re by no means exhaustive, but they each include one or two instances of each type of exercise previously discussed, in order to maximize your performance and progress at each level.

Beginner

Pelvic Tilts

Lie on your back with your knees bent and your feet flat on the mat. If possible, place one hand underneath the small of your back, so you can feel the movement. Gently contract your abdominal muscles to push your back down into your hand. If it helps, imagine your belly button slowly being sucked in. You should not hold your breath to accomplish this exercise! Gently hold the contraction for 3 seconds before slowly releasing. Repeat 10 times.‍‍

Isometric Hip Flexion

Lie on your back with your knees bent and your feet flat on the mat. Lift your right knee up so it’s positioned straight up towards the ceiling. Press one hand into the knee, without letting your knee move. Hold the contraction for 3 seconds, then slowly lower the leg back down. Then perform on left leg. Repeat 10 times.

Bridges

Lie on your back with your knees bent and your feet flat on the mat. Gently contract your abdominals (as in the pelvic tilt described above), then squeeze your glutes together and lift your hips up off the mat. Only lift your hips up as high as you can without causing any back pain. Slowly lower your hips back down. Repeat 10 times.

Simplified Piriformis Stretch

Lie on your back with your knees bent and feet flat on the mat. Cross the right leg over the left leg, so your right foot is resting on your left knee. Using your right hand, gently push the right knee down towards the mat, until you feel a gentle stretch deep in the right hip. Hold this stretch for up to 10 seconds. Repeat 5-10 times, as tolerated. Then switch to your left leg. 

Intermediate‍

Piriformis Stretch

Lie on your back with your knees bent and your feet flat on the mat. Cross your right leg over your left leg, so your right foot is resting on your left knee. Place both hands behind your left knee, then pull your left knee up towards your chest (left foot should come off the mat). You should feel a deep stretch in your right hip. Hold the stretch for 10 seconds, then slowly lower your legs back onto the mat. Repeat 5 - 10 times, as tolerated, then repeat on your other leg.‍

Dead Bugs

Lie on your back with your knees bent and your feet flat on the mat. Lift both arms up so the hands are pointed straight towards the ceiling. Gently contract your abdominals, then lift your right knee up towards your chest while simultaneously lifting your left arm up over your head. Slowly lower back to starting position, then switch to lifting your left knee up with your right arm. Alternate for 10 repetitions.‍

Bird Dogs

Start on your hands and knees, maintaining a neutral spine position (back not arched or rounded). Gently contract your abdominal muscles, then slowly lift your right leg back and up off the mat, while simultaneously lifting your left arm up off the mat. Do not lift your arm and leg so high that you feel your back start to arch. Hold for 3 seconds, then slowly lower back to starting position and repeat with your opposite arm and leg. Do this 10 times.

If possible, do this exercise next to a mirror so you can periodically check your spine and make sure you are keeping a neutral spine position throughout the movement

Fire Hydrants

Position yourself on your hands and knees, maintaining a neutral spine position (i.e. your back should not be arched or rounded). Gently contract your abdominal muscles to maintain a neutral spine position. While keeping your right knee bent, slowly lift your right leg sideways up off the mat. This movement looks similar to a dog who is lifting his leg up to urinate on a fire hydrant (hence the name!) Your back should remain in neutral spine position, without the hip lifting and rolling upwards. Slowly lower your leg back down onto the mat, then repeat on your left leg. Perform 10 times.

Advanced

Single Leg Bridges

Lie on your back with your knees bent and your feet flat on the mat. Lift one leg up so your foot is off the mat. Contract your abdominals, then squeeze your glutes and lift your hips off the mat. Keep your hips level with each other throughout the exercise (i.e. don’t let one hip drop down towards the mat). Slowly lower back to starting position, then repeat on your other leg. Repeat 10 times.

Side Planks

Lie on your right side with your right elbow on the mat directly beneath your shoulder. Keep your left hand on your left hip. Contract your abdominals, then lift your hips up off the mat until your trunk is in a straight line with your legs. Hold the position for 10 seconds, or as long as you can tolerate, then lower back to the starting position. Repeat 10 times, and then repeat on your left side. 

Single Leg Balance on Unsteady Surface

Find a pillow, cushion, a soft patch of grass, or some other soft, pliable surface. Place your hands on your hips, then stand on one foot on the unsteady surface. Hold for up to 10 seconds. Repeat 5 times. If this is too difficult, you can try standing on one foot on a level surface instead. 

Monster Walks

Place a circular resistance band around your ankles. Stand with your feet shoulder-width apart. Bend your knees and place your hands on your hips. While maintaining tension on the band, step your right foot forward and slightly outward towards the right, so that your right leg moves in an arc before your right foot hits the floor. Then repeat the same arc motion on your left side. Walk forward like this for 10-15 steps, then turn around and monster walk back to the starting position. Repeat for 3-5 laps. You should feel the muscles in your outer hip region working throughout this exercise.

There have been several studies which also support the use of aerobic exercise in the prevention and treatment of lower back pain, especially when combined with strengthening exercises (2, 3). 

Examples of aerobic exercise include walking, running, cycling, dancing, and swimming. Sports that combine these activities, such as soccer, tennis, and baseball also count. Research has even shown that sports like climbing improve lower back pain (13)!

Taking up an aerobic sport will not only improve your pain outcome, but will also help prevent the recurrence of your lower back pain.

While there is strong evidence for the benefits of exercise for your lower back pain, it’s still important to understand that in certain circumstances, some exercises may potentially do harm.

Exercises That Increase Pain

No matter what, you should not feel a sharp increase in your pain symptoms while doing any specific exercise. If you experiment with a new exercise a few times and it consistently worsens your pain symptoms, that’s an indication to stop!

Repeated Flexion Exercises

While there’s some evidence indicating that lumbar flexion (forward bending) exercises may be helpful in reducing lower back pain (when combined with other treatment interventions) (2), other studies have indicated that forward bending increases strain on your spinal discs (14). The increased stress can damage and deform your discs, which will worsen your pain in the long run. 

With this in mind, exercises that involve repeated forward flexion should therefore be considered with caution. These exercises include:

• Toe touches (in sitting or standing). It's better to instead perform hamstring stretches while lying on your back, so that the whole stretch goes through your hamstring and does not pressure your spine.
• Traditional sit-ups. It’s better to instead try core strengthening exercise that maintain a neutral position for the spine, so as to decrease pressure on the spinal discs and avoid compression of the hip flexors.
  

As a final note, you should know that no one type of exercise is strictly better than the others (4, 15).

Core strengthening, while shown to be effective, has not definitively been proven to be more effective than neuromuscular re-training exercises, or vice versa. Likewise, these types of exercise have not definitively been proven to be more or less effective than aerobic conditioning or stretching activities in reducing lower back pain.

What does this mean for you?

It means that the best thing you can do if you are suffering from lower back pain is to find an exercise routine that works for you, and just do it!

Find a physical activity that you can consistently perform (which you may even enjoy!) and stick with it. 

You may be surprised at just how quickly you find pain relief when you resolve to follow a regular exercise plan.