Lower Back Pain: Causes, Home Treatment, Exercises and Red Flags

Lower back pain affects up to 8 out of 10 people at some point in their lives, and it is a leading cause of missed work worldwide. In the great majority of cases it is "non-specific", meaning it comes from strained muscles, ligaments or joints without a dangerous underlying disease. Despite the pain, it usually gets better by itself, and staying active is the key to recovery.

Common causes

• Muscle or ligament strain from lifting, twisting, sudden movement, or prolonged sitting
• Poor posture and weak core muscles, especially in desk workers and drivers
• Disc problems: bulging or herniated disc pressing on a nerve, causing sciatica
• Arthritis and degeneration of the spine and facet joints, more common with age
• Spinal stenosis: narrowing of the spinal canal, causing leg pain on walking
• Osteoporosis fractures of the vertebrae, especially in older women
• Excess weight and inactivity
• Pregnancy and childbirth
• Smoking, stress and poor sleep, which increase pain
• Less common: infection, inflammatory arthritis (ankylosing spondylitis), tumours, kidney stones (see kidney stones), and referred pain from the abdomen or pelvis

Symptoms

• Dull ache, stiffness or sharp pain in the lower back, often worse with movement or after prolonged sitting
• Muscle spasm
• Pain that spreads to the buttock or thigh
• With sciatica: shooting pain, tingling or numbness down the leg, sometimes to the foot

First steps at home

1. Stay active. Gentle walking and normal activities, as pain allows, speed recovery. Avoid bed rest longer than a day or two.
2. Use heat or cold: a hot water bottle or heat pack for 15-20 minutes helps muscle spasm. Ice may help in the first 48 hours for some.
3. Painkillers for short periods:

• Paracetamol is generally safe but has limited effect on back pain.
• NSAIDs such as ibuprofen, naproxen or diclofenac are often more effective. Take them with food, for the shortest time, and avoid them if you have kidney disease, stomach ulcers, heart disease, or if you might have dengue. See dengue warning signs.
• Muscle relaxants may help for a few days, but can cause drowsiness.
• Opioids are not recommended for routine back pain.

1. Change position often, and avoid sitting for more than 30-45 minutes without a short walk.
2. Sleep comfortably: on your side with a pillow between your knees, or on your back with a pillow under your knees. A medium-firm mattress is usually fine.
3. Lift correctly: bend your knees, keep the load close to your body and avoid twisting.
4. Reduce stress and keep a positive attitude. Fear of movement and worry can prolong pain.

Exercises

Start gently once the worst pain eases, and stop if the pain gets significantly worse or spreads down the leg.

• Knee-to-chest stretch: lie on your back and pull one knee toward your chest for 15-30 seconds, then switch.
• Pelvic tilt: lie on your back with knees bent, tighten your stomach and flatten your lower back against the floor for 5 seconds.
• Cat-camel: on hands and knees, slowly arch and round your back.
• Bridge: lie on your back with knees bent and lift your hips for 5 seconds, 10 repetitions.
• Bird-dog: on hands and knees, extend the opposite arm and leg.
• Walking, swimming, cycling and yoga or Pilates, built up gradually.

A physiotherapist can tailor a programme. Strengthening the core and glute muscles reduces recurrences.

Prevention

• Keep active: at least 150 minutes of moderate activity a week
• Maintain a healthy weight. See how to lose weight safely
• Stop smoking
• Set up your workstation: chair with lumbar support, screen at eye level, feet flat on the floor, and take breaks to stand and stretch
• Avoid prolonged sitting, including long drives and motorbike journeys, without stopping
• Wear supportive footwear and avoid high heels for long periods
• Build bone health: calcium, vitamin D and weight-bearing exercise, especially after menopause. See menopause symptoms
• Manage stress and sleep well

Red flags: seek urgent medical help

Go to hospital or see a doctor urgently if back pain comes with:

• Numbness around the genitals, buttocks or inner thighs (saddle numbness)
• Loss of bladder or bowel control, or difficulty passing urine
• Weakness or numbness in one or both legs that is getting worse
• Fever, chills or feeling very unwell, or recent infection or injection near the spine
• Pain after a fall or accident, or in someone with osteoporosis
• Unexplained weight loss, or a history of cancer
• Severe, constant pain that is worse at night or does not ease with rest
• Pain starting in a person under 20 or over 55 for the first time
• Abdominal pain, pulsating abdominal swelling or blood in urine (possible aortic, kidney or other problems)
• Long-term steroid use or immune suppression

Cauda equina syndrome, a compression of the nerves at the base of the spine, is a surgical emergency.

Medical treatment and tests

• Physiotherapy, exercise therapy, manual therapy and education
• Short courses of medication as above, and neuropathic pain medicines for persistent nerve pain
• X-ray, MRI or CT only if red flags or persistent severe symptoms
• Spinal injections or surgery for selected cases of severe nerve compression or spinal stenosis
• Psychological support and multidisciplinary pain programmes for chronic pain

When to see a doctor

See a doctor if your back pain does not improve after 2-4 weeks, is severe, keeps coming back, or follows an injury, or if you have leg symptoms. Seek urgent care for any red flag.

References

• NICE guideline NG59: low back pain and sciatica in over 16s
• The Lancet Series: low back pain (Hartvigsen J et al., 2018)
• American College of Physicians: noninvasive treatments for acute, subacute and chronic low back pain
• World Health Organization: low back pain fact sheet