Low Back Pain: The Complete Guide to Causes, Relief and Getting Moving Again

Low back pain is the single biggest cause of disability in the world. Around 619 million people were living with it in 2020, and almost everyone will experience it at some point. The good news is that most back pain is not caused by serious damage, most episodes improve within weeks, and the things that help most are simple: staying active, understanding your pain, and building strength.

This guide explains what causes back pain, which warning signs need urgent attention, why scans are usually unhelpful, which treatments work, and how to reduce the chance of it coming back.

How common is low back pain?

The Global Burden of Disease study published in The Lancet Rheumatology estimated that 619 million people had low back pain in 2020, a figure expected to rise to around 843 million by 2050 as populations grow and age. It affects people in every country, every income group and every age, including children and teenagers. It is the leading reason people stop working or reduce their hours, and a major cause of early retirement.

Understanding your back

Your lower back (lumbar spine) is made up of five large vertebrae stacked on top of each other, separated by discs that act as shock absorbers. The spine is supported by strong ligaments and powerful muscles. It is designed to bend, twist, lift and carry. Despite how it can feel during an episode of pain, your spine is one of the strongest structures in your body and is not easily damaged.

Types of low back pain

Non-specific low back pain

About 90 percent of people with back pain have what is called non-specific low back pain. This means no single structure can be identified as the cause. It may involve muscles, ligaments, joints and discs, along with how the nervous system processes pain. “Non-specific” does not mean the pain is imagined or not serious to you; it means it is not caused by a dangerous condition and does not need specific medical treatment such as surgery.

Sciatica (radicular pain)

Sciatica happens when a nerve root in the lower back is irritated, usually by a bulging disc. It causes pain that travels down the leg, often below the knee, and is sometimes worse than the back pain itself. It may come with pins and needles, numbness or weakness. Most sciatica improves within six to twelve weeks without surgery.

Serious causes

Fewer than 1 percent of people with back pain have a serious underlying cause, such as a fracture, infection, cancer, inflammatory disease or cauda equina syndrome. These are rare, but it is important to know the warning signs.

Red flags: get urgent help

Go to an emergency department straight away if you have back pain with any of the following signs of cauda equina syndrome, a rare but serious compression of the nerves at the base of the spine:

• Numbness or tingling around your genitals, buttocks or inner thighs (saddle area)
• New difficulty passing urine, or not being able to feel when your bladder is full
• New loss of control of your bladder or bowels
• Sexual problems such as loss of sensation
• Weakness or numbness in both legs, or worsening weakness

See a healthcare provider promptly (the same day or within a few days) if you have:

• Back pain with fever, chills or feeling generally unwell
• A history of cancer, or unexplained weight loss
• Back pain after a significant fall or accident, or a minor fall if you have osteoporosis
• Severe pain that is constant, worse at night and not eased by any position
• Back pain starting before age 20 or after 55 with no obvious cause
• Long-term steroid use, a weakened immune system or injecting drug use
• Morning stiffness lasting more than 30 minutes that improves with exercise, in a person under 40 (possible inflammatory back pain)

What causes back pain?

Back pain usually has several contributing factors rather than one cause:

• Lifting, twisting or an unusual activity, often something you have done many times before
• Lack of physical activity and reduced fitness
• Long periods of sitting or standing in one position
• Poor sleep, stress, anxiety and low mood
• Smoking and excess weight
• Physically demanding or monotonous work
• Fear of movement and beliefs that the back is damaged
• Pregnancy, due to hormonal changes and posture

Interestingly, research has not found that any particular “correct” posture prevents back pain. Bodies are designed to move and vary positions; the best posture is the next one.

Why scans usually do not help

Many people with back pain expect an X-ray or MRI, but guidelines from NICE, the World Health Organization and others advise against routine imaging for non-specific back pain. Scans often show changes such as disc bulges, disc degeneration and arthritis that are extremely common in people without any pain. In studies of people with no back pain, around a third of 20-year-olds and over 80 percent of 50-year-olds have disc degeneration on MRI.

Finding these “abnormalities” can make people more worried, more cautious about moving, and more likely to have unnecessary procedures, which can make outcomes worse. Imaging is useful when red flags are present, when surgery is being considered for persistent sciatica, or when symptoms do not follow the expected course.

What helps acute back pain (the first six weeks)

Keep moving

Bed rest used to be recommended, but it slows recovery. Stay as active as you can within your pain, continue normal daily activities as much as possible, and gradually increase what you do. Short, frequent walks are excellent. It is fine to rest in a comfortable position for short periods, but avoid staying in bed for days.

Understand that hurt does not mean harm

Back pain can be very intense even when nothing is damaged. The nervous system can become sensitive and amplify pain signals. Knowing this reduces fear, which in turn reduces muscle tension and pain.

Heat

A hot water bottle or heat pack wrapped in a towel can relax muscles and ease pain in the first few days.

Medicines

• Anti-inflammatory painkillers such as ibuprofen or naproxen may help in the short term if they are safe for you. Check with a pharmacist if you have stomach, kidney or heart problems, asthma, or take other medicines.
• Paracetamol alone has been shown in large trials to be no better than placebo for acute low back pain, so it is not recommended on its own.
• Opioids such as codeine or tramadol are not recommended for most back pain because of side effects and limited benefit.
• Muscle relaxants such as diazepam are generally not recommended because of drowsiness and dependence risk and lack of benefit.

Sleep positions

Try lying on your side with a pillow between your knees, or on your back with a pillow under your knees. Getting out of bed by rolling onto your side, dropping your legs over the edge and pushing up with your arms can reduce pain.

Exercise: the cornerstone of treatment

For back pain lasting longer than a few weeks, exercise is one of the most effective treatments. No single type is clearly best; the best exercise is the one you enjoy and will keep doing. Options with good evidence include:

• Walking programmes
• Strengthening exercises for the back, hips and abdomen
• Pilates
• Yoga and tai chi
• Swimming and water exercise
• Group exercise classes

Simple exercises to start with

• Knee rolls: lying on your back with knees bent, gently roll your knees from side to side.
• Knee to chest: lying on your back, bring one knee towards your chest and hold for 10 seconds, then switch.
• Pelvic tilt: lying on your back, flatten your lower back into the floor by tightening your stomach, then relax.
• Cat-camel: on hands and knees, gently arch and then round your back.
• Bridge: lying on your back with knees bent, lift your buttocks off the floor.
• Bird dog: on hands and knees, extend one arm and the opposite leg, keeping your back level.

Start gently and gradually increase. Some discomfort is normal. If an exercise sharply increases leg pain or causes numbness, stop and seek advice.

Other treatments

• Manual therapy (spinal manipulation, mobilisation or massage) may help some people in the short term when combined with exercise.
• Psychological approaches such as cognitive behavioural therapy (CBT) and pain reprocessing therapy can significantly reduce pain and disability in persistent back pain, by changing how the brain interprets pain signals and reducing fear of movement.
• Combined physical and psychological programmes are recommended for people whose back pain is affecting work or daily life.
• Acupuncture is not recommended by NICE for back pain but is recommended in some other countries’ guidelines; evidence is mixed.
• Back belts, corsets, foot orthotics and TENS are not recommended for back pain.

Sciatica: what you need to know

Sciatica is usually caused by a disc bulge pressing on or irritating a nerve root. The body often reabsorbs disc material over time, which is why most people improve within weeks to a few months.

Treatment includes staying active, exercises guided by a physiotherapist, and pain relief. Medicines specifically for nerve pain, such as gabapentin and pregabalin, have not been shown to help sciatica and are not recommended for it. An epidural steroid injection may be considered for severe sciatica to provide short-term relief while the body heals.

Surgery (such as microdiscectomy) may be considered if severe leg pain persists for more than six to twelve weeks despite treatment, or urgently if there is progressive weakness or cauda equina syndrome. Surgery often relieves leg pain faster, but long-term results at one to two years are often similar to non-surgical care.

Persistent (chronic) back pain

About one in five people with an episode of back pain still have pain a year later. Chronic pain is complex: it involves changes in how the nervous system processes signals, along with sleep, mood, stress, work and beliefs about pain. This does not mean the pain is “in your head”; it is very real, but it often responds best to a combination of approaches rather than a single fix.

• Graded activity: increasing activity step by step regardless of day-to-day pain fluctuations
• Exercise you enjoy, done regularly
• Psychological therapies for pain
• Improving sleep
• Staying at work or returning gradually, with adjustments
• Reducing reliance on medicines that do not help

Spinal surgery for chronic back pain

Spinal fusion and disc replacement for non-specific chronic back pain have limited evidence and significant risks, and NICE does not recommend spinal fusion or disc replacement for low back pain except within research. Radiofrequency denervation may be considered for some people with persistent pain from the facet joints after a positive diagnostic block.

Back pain at work

Staying at work, or returning early with modified duties, leads to faster recovery than long periods off. Being off work for long periods is linked with poorer outcomes. Talk to your employer or occupational health service about temporary adjustments, such as lighter duties, more frequent breaks, a different chair or desk, or flexible hours.

Healthcare workers and back pain

Nurses, care assistants and porters have high rates of back pain because of patient handling. Safe patient handling programmes, using hoists, slide sheets and other equipment, and working in teams reduce injuries. Training in “correct lifting technique” alone has not been shown to prevent back pain, so equipment and safe staffing matter.

Back pain in pregnancy

Back and pelvic girdle pain affect most pregnant women. Staying active, water exercise, pelvic floor and core exercises, supportive footwear, a pregnancy support belt for pelvic pain, and physiotherapy can help. Avoid lifting heavy objects and take breaks from standing. Back pain with regular tightenings, bleeding or fever needs urgent assessment.

Back pain in children and teenagers

Back pain is common in teenagers, often related to sport, heavy school bags or long hours using screens, and is usually not serious. Seek advice if a young child has back pain, if pain is persistent, severe, present at night, or accompanied by fever, weight loss or neurological symptoms.

Preventing back pain from coming back

Recurrence is common: around a third of people have another episode within a year. The strongest evidence for prevention is for exercise, especially when combined with education. Other helpful steps include:

• Regular physical activity, at least 150 minutes a week
• Strengthening exercises two or more times a week
• Breaking up long periods of sitting every 30 to 60 minutes
• Maintaining a healthy weight
• Stopping smoking
• Getting enough sleep and managing stress
• Lifting loads close to your body and using equipment for heavy or awkward loads

Common myths about back pain

• Myth: Rest is best. Fact: Staying active speeds recovery.
• Myth: Back pain means damage. Fact: Most back pain is not due to damage, and pain levels do not reflect the condition of the spine.
• Myth: I need a scan. Fact: Scans rarely change treatment and can increase worry.
• Myth: My disc has slipped out of place. Fact: Discs do not slip; they can bulge, and bulges often shrink over time.
• Myth: I must keep my back straight when lifting. Fact: Bending the back is safe for most people; what matters is building strength and lifting loads you are used to.
• Myth: Back pain will get worse as I age. Fact: Back pain is actually most common in middle age, not old age.

The nurse’s role

Practice nurses, occupational health nurses and pain specialist nurses help people understand back pain, screen for red flags, review medicines, support return to work and signpost to exercise and physiotherapy services. Nurses also play a key role in safe patient handling and in looking after their own backs.

Building a back-friendly routine

Small daily habits make a big difference over months and years. Think of your back like any other part of your body: it gets stronger when it is used regularly and gradually challenged, and it becomes more sensitive when it is protected and kept still.

• Morning: a few gentle movements such as knee rolls and cat-camel before getting dressed can ease stiffness.
• During the day: change position often. If you sit for work, stand or walk for a couple of minutes every 30 to 60 minutes. A phone call is a good reason to stand.
• Lifting: hold loads close to your body, avoid twisting while lifting heavy objects, and ask for help or use equipment with heavy or awkward loads. Gradually building up the weight you lift in the gym or garden makes your back more resilient.
• Evening: a walk after dinner, some stretching, and a calm wind-down routine support both your back and your sleep.

Back pain, emotions and stress

Pain is produced by the brain, based on signals from the body and on how threatening the brain judges those signals to be. Stress, anxiety, low mood, poor sleep and past experiences can all turn the volume of pain up. This is why two people with identical scans can have very different pain. It also means that calming the nervous system, through reassurance, movement, relaxation, good sleep and talking therapies, can genuinely reduce pain.

People who believe their back is fragile, or that pain always means harm, are more likely to develop long-term pain. Learning about pain is itself a treatment. Many people find that understanding why they hurt makes them less afraid to move, which starts a positive cycle of more activity, more strength and less pain.

Choosing the right professional

Most back pain can be managed with self-care and support from a nurse, pharmacist or physiotherapist. Physiotherapists are experts in exercise and movement and can tailor a programme to you. If you see a chiropractor or osteopath, look for someone who encourages activity and exercise rather than relying on repeated manipulation, scans or long courses of treatment. Be cautious about anyone who tells you your spine is “out of alignment” and needs regular adjustments indefinitely, or who sells expensive packages up front.

Frequently asked questions

How long does back pain last?

Most acute back pain improves significantly within two to six weeks, although some people have lingering symptoms for longer.

Should I use heat or ice?

Heat tends to help more for back pain. Use whichever feels better for you.

Is a firm mattress better for back pain?

Research suggests a medium-firm mattress may be better than a very firm one, but comfort matters most.

Can I go to the gym with back pain?

Yes. Keep exercising, adjusting the load and type of exercise to your symptoms, and build up gradually.

Will I need surgery?

Very few people with back pain need surgery. It is mainly considered for persistent, severe sciatica or serious conditions.

Is my back pain caused by my kidneys?

Kidney pain is usually felt higher, in the side or flank, and often comes with fever, urinary symptoms or blood in the urine. Muscle-related back pain usually changes with movement.

But it hurts so much. How can moving be right?

It feels wrong because pain is designed to protect you. But in most back pain, the alarm system is turned up too loud. Gentle movement sends safety signals to the nervous system, eases muscle spasm and keeps you strong, while rest makes the back stiffer and more sensitive. You do not have to push through severe pain; start small, and move a little more each day.

Related: Sciatica: symptoms and relief · Back pain in nurses · Osteoarthritis guide

Sources: World Health Organization guideline for non-surgical management of chronic primary low back pain in adults (2023), National Institute for Health and Care Excellence (NG59), GBD 2021 Low Back Pain Collaborators (The Lancet Rheumatology, 2023), The Lancet Low Back Pain Series (2018).