Low back pain and the gym: which exercises help and how to train with a sore lower back
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Exercise is one of the best-supported treatments for chronic low back pain: a Cochrane review of 249 trials confirms it. And lifting with a slightly rounded back was not linked to more pain. Which exercises help, when to return to deadlifts and which signs mean you should see a doctor.
This article covers non-specific low back pain, the kind with no identifiable specific cause, which is by far the most common. If the pain runs down your leg with tingling or weakness, you have problems passing urine or stools, fever, unexplained weight loss, or it started after a blow or a fall, see a healthcare professional first.
For everything else, the evidence is clear and perhaps the opposite of what you were told: your lower back is not protected by rest, but by movement. In 2021, the Cochrane review by Hayden and colleagues pooled 249 trials on exercise for chronic low back pain. Exercise reduced pain by about 15 points out of 100 compared with no treatment, usual care or placebo, a difference the authors consider clinically important.
Rest or exercise: what guidelines recommend for low back pain
The Lancet series on low back pain (Foster and colleagues, 2018) sums up what clinical guidelines say: education that supports self-management, a return to normal activities and exercise, and prudent use of medication, imaging and surgery. It also points out the problem: in practice, rest, imaging, opioids, spinal injections and surgery are still overused.
Hayden's review also compared exercise with other treatments: it was probably better than education alone or physical therapy without exercise, and similar to manual therapy. Side effects were mostly minor, such as muscle soreness.
| Intervention | Result | Certainty of evidence |
|---|---|---|
| Exercise (chronic pain) | About 15 points less pain out of 100 compared with no treatment (Hayden, 2021) | Moderate |
| Exercise with education (prevention) | 45% lower risk of a new episode (Steffens, 2016) | Moderate |
| Exercise alone (prevention) | 35% lower risk of a new episode (Steffens, 2016) | Low to very low |
| Education alone | No preventive effect (Steffens, 2016) | Moderate to very low |
| Back belts | No preventive effect (Steffens, 2016) | Low to very low |
| Shoe insoles | No preventive effect (Steffens, 2016) | Low |
Should you lift with a straight back? What the evidence says
It is the most repeated advice in gyms and in workplace safety. The review by Saraceni and colleagues (2020) looked at whether bending the lower back more when lifting was linked to having or developing low back pain, and found no such relationship: 9 of the 11 studies found no difference between people with and without pain. In some, people with pain actually lifted with less flexion. The studies were of low quality, but they cast doubt on the idea that a slightly rounded back is an injury waiting to happen.
This does not mean technique is irrelevant: in the gym, a neutral, controlled position lets you move more weight and spread the effort. It means you do not need to fear every degree of flexion, or pick a bag up off the floor with your back stiff as a board.
Deadlifts with low back pain?
They can be part of the solution for the right person. In the trial by Aasa and colleagues (2015), 70 people with recurrent low back pain did 8 weeks of progressive deadlifts or low-load motor control exercises, both with pain education. Both groups improved pain, strength and endurance, with no difference in pain between them; motor control improved daily activity slightly more.
Who benefits most from deadlifts? In the analysis by Berglund and colleagues (2015), with 35 patients coached by a physical therapist with powerlifting experience, those who benefited most started with less pain, less disability and greater endurance of the hip and back extensors, measured with the Biering-Sørensen test. Build that base first; the barbell comes later. Technique is covered in our deadlift guide.
How to train with low back pain: a phased plan
An indicative progression, best adjusted with your physiotherapist if the pain is persistent:
| Phase | What to do | When to move on |
|---|---|---|
| 1. Recent or high pain | Move every day: walking, gentle mobility, glute bridges, bird-dogs and short side planks | When daily pain drops and you can walk for 30 minutes straight |
| 2. Low, stable pain | Strength work with moderate loads: goblet squats, dumbbell Romanian deadlifts, hip thrusts, chest-supported rows and 45° back extensions | When you complete sessions without the pain getting worse the next day |
| 3. Little or no pain | Gradual return to barbell deadlifts and squats: light loads, a comfortable range and small increases each week | Depending on how you progress |
The acceptable pain rule
Discomfort of up to 5 out of 10 during exercise is acceptable if it returns to your usual level by the next day. If it gets worse from one session to the next, reduce the load or range; do not stop altogether. It is the same rule we use in training with a shoulder or knee injury.
The essentials: with non-specific low back pain, movement is treatment. There is no magic exercise; what works is a regular, progressive programme you can tolerate.
Prevention: the exercise that protects your back
To avoid a new episode, the meta-analysis by Steffens and colleagues (2016), with 21 trials and more than 30,000 people, is conclusive: exercise, especially combined with education, reduced the risk of low back pain coming back. Belts, insoles and education alone did not. No specific exercise is needed: any regular strength programme that includes hips, back and core will do. Core exercises are in the plank and back exercises in best back exercises.
Common mistakes with low back pain
- Bed rest: guidelines recommend returning to normal activities as soon as possible (Foster, 2018).
- Asking for an MRI with no red flags: guidelines call for prudent use of imaging (Foster, 2018); ask your doctor whether you really need one.
- Buying a belt to train “protected”: it does not prevent low back pain (Steffens, 2016).
- Going straight back to heavy deadlifts: hip and back endurance first, load later (Berglund, 2015).
- Fearing every degree of flexion: the evidence does not support the idea that bending your back when lifting causes low back pain (Saraceni, 2020).
In the Progrevia generator you can mark your lower back as injured: the engine leaves out the exercises that load it most, such as deadlifts, good mornings, squats and barbell rows, and builds your routine with alternatives. When your healthcare professional gives you the green light, you can untick it and reintroduce them gradually.
- Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews. 2021;9:CD009790.
- Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 2018;391(10137):2368-2383.
- Steffens D, Maher CG, Pereira LS, Stevens ML, Oliveira VC, Chapple M, et al. Prevention of low back pain: a systematic review and meta-analysis. JAMA Internal Medicine. 2016;176(2):199-208.
- Saraceni N, Kent P, Ng L, Campbell A, Straker L, O'Sullivan P. To flex or not to flex? Is there a relationship between lumbar spine flexion during lifting and low back pain? A systematic review with meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2020;50(3):121-130.
- Aasa B, Berglund L, Michaelson P, Aasa U. Individualized low-load motor control exercises and education versus a high-load lifting exercise and education to improve activity, pain intensity, and physical performance in patients with low back pain: a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy. 2015;45(2):77-85.
- Berglund L, Aasa B, Hellqvist J, Michaelson P, Aasa U. Which patients with low back pain benefit from deadlift training? Journal of Strength and Conditioning Research. 2015;29(7):1803-1811.
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Frequently asked questions
Can I go to the gym with low back pain?
With non-specific low back pain, usually yes, and it tends to help. The Cochrane review by Hayden (2021) found that exercise reduces pain by about 15 points out of 100. If the pain runs down your leg with tingling or weakness, you have a fever or it started after a blow, see a professional first.
What exercises are good for low back pain?
No single one is better than the rest: a regular, progressive programme is what works. To start, walking, glute bridges, bird-dogs and side planks; then strength work with moderate loads such as dumbbell Romanian deadlifts or hip thrusts.
Are deadlifts bad for your lower back?
Not necessarily. In the trial by Aasa (2015), progressive deadlifts improved pain as much as motor control exercises. Those who benefit most have little pain and good endurance of the hip and back extensors (Berglund, 2015).
Do back belts help prevent pain?
No. In the meta-analysis by Steffens (2016), back belts did not reduce the risk of low back pain. What did reduce it was exercise, especially combined with education.
When should I see a doctor about low back pain?
If the pain runs down your leg with tingling or weakness, you have problems passing urine or stools, fever, unexplained weight loss, or it started after a blow or a fall. Also if it does not improve after several weeks.
Informational content based on the available scientific evidence: it does not replace advice from a healthcare professional. If you have an injury or a medical condition, or are pregnant, check with one before changing your training or diet.
