Self-treatment techniques for lower back pain
One of the most common questions that I get goes something like this, “Hey, I tweaked my lower back the other day. It’s really hurting me. What stretches should I do?”
This can be a tricky question to answer, because so many things in injury rehabilitation depend. Back pain (and injury rehab in general) can depend on:
Your unique history: Have you had lower back pain previously? Hip pain? Any traumas or surgeries?
The severity of your injury: Does hurt a little? A lot? Are there any red flags, such as muscle weakness, that need to be promptly investigated further?
Your activities/hobbies: Are you a cyclist? Runner? Yogi? Not very active?
Your specific anatomy and biomechanical factors: How is your muscle strength, flexibility and joint range of motion?
Your lifestyle: Nutrition, sleep, stress, overall health.
And so much more.
However, there are usually a few safe ways to attempt to relieve lower back pain on your own, and I often send out the general recommendations below as a response when I get asked about back pain.
Before we dive into those recommendations, I want to reframe how you think about back pain. Often, back pain can be scary, and to some extent for good reason: Everyone has a friend or family member who’s struggled with back pain for years, possibly needing surgery, or attempting every treatment out there. Back pain can be painful, seemingly random or mysterious, and it strikes the central pillar of our body, which can make almost every position painful. Some people feel fragile after they’ve had an episode or two of back pain, or like that area that was injured can never heal.
But, there is hope! Anatomically, the structures of the back are little different than the rest of the body. Just like the rest of the body, there are muscles, ligaments, bones, joints, and nerves. And just like the rest of the body, the back can heal. The back can recover. The back does not have to hurt. Even if you’ve had pain for years. To get there, we follow the principles that work throughout the rest of the body. When something is injured, we typically:
Offload the injured area for a short time, to avoid doing further damage and allow it to calm down.
Progressively expose the injured area to non-painful movement.
Give the injured area support from the muscles surrounding it and nearby.
Temporarily avoid activities and movements that will exacerbate the injury.
Gradually work back into activities that were once painful.
Address any factors that contributed to the injury or your risk of injury.
Here’s an example that most people have experienced or can visualize: Spraining your ankle. When you roll your ankle, you often irritate or injure a ligament (the anterior talofibular ligament), a joint (the talocrural joint), and possibly some muscles or even nerves (such as the peroneal muscle and nerve groups). What do most people do, often intuitively on their own?
Limp around for a few days, or use a crutch (this offloads the injured ankle)
Begin gradually moving the ankle to help work out some swelling and reduce stiffness (progressively expose the ankle to non-painful movement).
Work on balance, calf strength, and strengthening of the lower leg muscles to help protect the ankle and give it support (give the ankle muscle support / motor control).
Avoid rolling the ankle again or aggressively stretching in the direction that the ankle was rolled (avoid exacerbating activities).
Slowly begin to ease back into walking, hiking, or running as the pain subsides (gradually work back into painful activities).
Address any factors that contributed to the ankle sprain, which could include hip strength, overall lower extremity motor control, ankle mobility, or something else.
As you’ll see, we can follow this same process for back pain. A physical therapist can help you tailor that treatment to your unique history, anatomy, and injury, and identify factors that may have contributed to the injury in the first place, but the theory behind the process is remarkably similar.
Our huge caveat is: If any of these make your back pain worse, if you have any changes in your ability to go to the bathroom (a sign of spinal cord involvement), if you have any muscle weakness, numbness, tingling, dizziness, nausea, falls, difficulty walking or swallowing, fevers, pain at night, or if your back pain does not improve, see a qualified medical professional like a Doctor of Physical Therapy for an evaluation.
With that caveat aside, here are a few things to try:
1. Offload the back
Laying down in a 90/90 position with diaphragmatic breathing and self-traction. This is our go-to for the majority of types of back pain to decrease pain. Depending on the severity of your symptoms, we generally recommend 5-10 minutes, 2-4 times per day. Using a band if you have access to one is ideal.
2. Provide the back with non-painful movement
Movement and exercise are essential. The evidence is clear - physical activity helps back pain. Movement and exercise help to keep the back healthy, reduce inflammation, and decrease pain. Being inactive tends to make back pain worse. So, even when your back hurts, try to find some type of activity that is either non-painful, or at least neutral (doesn’t make your pain worse).
Low intensity aerobic exercise with nasal breathing is a great place to start. Breathing continuously in and out of your nose is an automatic check on intensity. If need to resort to mouth breathing, you are working too hard. Together, low intensity exercise and nasal breathing stimulate both the diaphragm and parasympathetic nervous system, which can help to downregulate your system and improve symptoms. Aim for a minimum of 30 minutes, five times per week.
If your back gets painful in the evenings, doing a short walk before bed can also be very helpful.
Side-lying windmill - This is a simple drill that often feels great in individuals with back pain, as it opens up the joints of the back, hips, and shoulders. Don’t view this as an aggressive stretch, but rather as a gentle mobilization. If it does cause pain, skip it for now. (That’s a general rule for any of these recommendations as well.)
3. Give the back muscle support
Activating and working muscles around the torso can help to reduce force on the joints and ligaments of the back, and there is some evidence that resistance training reduces the body’s pain response.
Give the exercises below a shot. If you combine them all for a 2-3 sets, it actually turns into a great whole-body exercise routine.
Hollow hold - The transverse abdominis activation at the start of this activation is key. Hold for 10-15 breaths, reinforcing the muscle contraction with each exhale.
Side plank - Start with 10-15 second holds, working up to 30-45 seconds, and then progressing to more advanced variations from there.
Front plank and variations - Be sure to watch this video, as most people do not have proper muscle activation in their plank. Like the side plank, start of 10-15 second holds and focus on the full engagement, then progress to 30-45 seconds.
Bird dog - 10-12 repetitions on each side, keeping your lower back as still as possible. If you need an external cue, try balancing a foam roller across your lower back to help keep it flat and still.
Clam shell - Work until you get a muscle fatigue or burn in your gluteus medius, which is approximately where the top outside edge of a back pocket normally sits on a pair of jeans or pants.
Suspension Row - 10-12 repetitions, with your feet in a position where this is difficult but you have full range of motion. Maintain a light contraction of your transverse abdominis (lower abdominal muscles) and avoid extending at your lower back.
Push Up - 10-12 repetitions, also with transverse abdominis engagement. As you start to fatigue, be sure not to extend at your lower back.
Goblet Squat - 10-12 repetitions, again engaging the transverse abdominis throughout the movement. Going to a box or bench can be helpful to limit your depth (going too low can be painful initially in individuals with back pain) and engage the posterior chain.
4. Temporarily avoid movements that will exacerbate the injury
Be cautious of stretching. Stretching can make some types of back pain worse. Lower back pain is often associated with a feeling of stiffness, and this leads people to attempt a lot of stretching as their self-treatment. However, that feeling of stiffness in the body may not be caused by short or tight muscles. The body can feel stiff in response to many different stimuli, not just short muscles. Stretching, particularly hamstring stretching or forward folds, can inadvertently tension the sciatic nerve or load the intervertebral discs, both of which can actually worsen back pain. Stretching may feel relieving in the the moment, but exacerbate the problem overall. Again, stretching can make some types of back pain worse. We occasionally include some stretches or mobilizations in low back pain plans of care, but only to help address specific examination findings. As such, without a physical therapy evaluation, we do not recommend stretching for lower back pain.
Instead of stretching, if you have a lot of stiffness try some gentle soft tissue work along with self-traction and diaphragmatic breathing. Here is a video that shows some common spots that can be sensitive or stiff.
Watch out for end-range movements, most commonly flexing forward, particularly in the morning. The structures of the back can be more sensitive in the morning, and taking them to end range can be painful.
Slumped positions - We want to avoid slump positions not because any single posture is bad, but because slumping increases load on many lower back structures. In general, constantly varied posture is more important than holding a single posture for an extended period of time. So, don’t try to sit upright and erect all day — even that can increase load to your back or overwork your muscles. Instead, try to move around frequently.
Work on hip hinging - Many people with back pain struggle to move their back and hips independently of one another, and subsequently move into lumbar flexion anytime they move their hips or bend forward. Working on hip hinging can be a powerful way to both avoid an exacerbating movement and work on a contributing factor to the injury. The video has several helpful tips and techniques.
We say “temporarily” avoid these positions as none of them are inherently bad. It’s just like that ankle sprain idea: it’s not bad or damaging to move your ankle into an inverted position (the most common direction of a sprain). But if this is how you sprained it, inversion will be painful for a time. The same goes for the lower back. We can work back towards previously painful motions as irritability decreases.
5. Progress back towards previously painful movements and full activities, monitoring load carefully
Find a level of activity that’s not painful and stay there for 2-3 weeks before progressing. We often see people who are doing all of the right things, get their back feeling great, but then reinjure it because they progress back too quickly. Even frequent injuries don’t necessarily mean that you have to stop your activity altogether. You probably just need help modifying your overall load and with a progression strategy.
This could mean a few things depending on your activities of choice.
If you lift weights, this often means limiting squat depth, elevating your deadlift, decreasing your load/weights, or some other modification to continue training without pain.
If you do endurance sports, this could be dialing back volume and/or intensity to a non-painful level
If you are a yogi, this might mean limited end-range positions (i.e forward folds and back bends), and focusing on muscle activation in each pose rather than stretching.
6. Address factors that may have led to the back injury
This is where our prescription for self-treatment has to end, as this part completely individual. These recommendations are a great starting point towards reducing your back pain. But, there can be a variety of factors that set someone up for back injury, from overuse to decreased hip and thoracic mobility to impaired movement patterns to simply stress and lack of sleep. In some injuries, extending backward is worse than flexing forward. There are more complex components of back pain such as high tension strategies or central sensitization. Sometimes you can just lift something awkward and strain the back with very few contributing factors. It just all depends. If you’ve had more than one bout of back pain, we recommend a physical therapy evaluation to identify and address the factors that are causing recurring pain.
To bring things together, here’s how you might implement these strategies throughout the day:
Morning: Take a short walk upon waking up. If you are sore or stiff, avoid flexing forward as much as you can while getting ready in the morning, as this can be a painful trigger.
At work: Vary your posture throughout the stay: stand for a while, walk around the office often, sit without slumping, and cycle through different positions. Practice hip hinging a few times throughout the day. At least once in the morning and once in the afternoon, lay down for 5-10 minutes to do some diaphragmatic breathing and self-traction.
Exercise session: Start your gym/workout/exercise session with banded traction or self-traction if a band isn’t available. Practice hip hinging as part of your warm up. Do 2-3 sets of all the exercises listed above. Then, do 20-30 minutes of low intensity cardiovascular work, such as a light jog or incline treadmill walking. If you try cycling, try to have an upright position to avoid bending forward. Finish with another bout of diaphragmatic breathing and self-traction.
Evening: Take another short walk after dinner. Before bed, do some gentle rolling with a tennis ball to the glutes, hamstrings and lower back muscles, along with a few side-lying windmill mobilizations.
If you’ve been struggling with lower back pain, give these techniques a shot, but also consider scheduling an appointment with a physical therapist to help diagnose your issue specifically and create an individualized treatment plan based on your unique circumstances. At EVOLVE, we offer free phone consults for patients who are not sure if our approach is right for them. Click below to schedule - we are happy to help!