Home Program for Low Back Pain: Extension-Based (McKenzie Method)

Is this the right program for you?

Back pain has a direction. This program is for the back that dislikes bending forward and likes arching back. It is usually the right one if:

• Sitting, slouching, bending forward, lifting, coughing, or getting up from a chair make the back or the leg worse.
• Standing, walking, and lying on your stomach feel better.
• The pain comes from a disc: a bulge or a herniation, with or without pain down the leg.
• You are under about 50, or the MRI shows a disc rather than narrowing.

If arching back is what hurts and bending forward is what helps, you need the opposite plan: my flexion-based program. Your therapist can settle the question at the first visit by moving you repeatedly each way and watching what the pain does.

The idea, and the one rule that guides it

The disc is a cushion with a soft center. Bending forward squeezes that center backward, toward the nerves. Arching back squeezes it forward, away from them. Done repeatedly, arching can move a bulge off the nerve and let the back settle. That is the basis of the McKenzie method, which physical therapists call Mechanical Diagnosis and Therapy.

The rule that guides everything is centralization. Pain that moves from the leg up toward the back, or from the buttock into the center of the back, is improving, even if the back itself hurts more for a while. Pain that moves farther down the leg is worsening. Every exercise below is judged by that rule: if the leg pain retreats, keep going; if it advances, stop and tell your therapist. Let that rule, not the amount of pain alone, guide what you do.

The core exercise: extension in lying (press-ups)

Do this every two to three hours while awake during the first weeks, and always after sitting.

1. Lie on your stomach for two to three minutes, arms at your sides, and breathe. If this alone increases leg pain, put a pillow under the belly for a day or two and try again.
2. Prop on the elbows for two to three minutes, hips on the floor, back relaxed.
3. Press up. Hands under the shoulders, straighten the arms and lift the upper body while the hips and pelvis stay on the floor. Let the back sag. Go as far as is comfortable, hold one to two seconds, and lower. Do 10, going a little further each time as the back allows. Breathe out as you press.

The first few repetitions may increase back pain. That is acceptable as long as the leg pain is not spreading down. Over the first few days the press-ups usually become easier and the leg pain retreats.

The standing version: extension in standing

For the office, the car, and anywhere you cannot lie down.

• Stand with the feet apart, hands on the low back with the fingers pointing down, and lean back as far as is comfortable, keeping the knees straight. Hold one to two seconds, return. 10 times, every hour you are sitting, and after any bending or lifting.

The first two weeks: calm it down

• Press-ups every two to three hours, standing extensions hourly.
• Walk 5 to 10 minutes several times a day on level ground. Keep moving; bed rest makes this worse.
• Sit as little as you can, and when you must, use a lumbar roll (a rolled towel or a small cushion) in the small of the back and get up every 20 to 30 minutes. Your car seat needs the roll too.
• No bending at the waist, no lifting, no twisting, no sit-ups, no toe-touches, no hamstring stretches in a forward bend. Bend at the knees and hips with a straight back to pick things up.
• Sleep on your back with a small pillow under the low back or the knees, or on your stomach if that is comfortable. Get out of bed by rolling to the side and pushing up with the arms.
• Medicines as we discussed. Ice or heat for 15 minutes, whichever helps.

Weeks 2 to 6: keep the gains and add stability

Continue the press-ups three or four times a day as the leg settles. Add, in a neutral spine:

• Abdominal bracing, 10-second holds, 10 times.
• Bird-dog, 10 each side.
• Bridge, 2 sets of 10. Keep the back neutral, not arched.
• Side plank from the knees, 20 to 30 seconds each side, 3 rounds.
• Prone leg lifts: lying on the stomach, lift one straight leg a few inches, 10 each side.
• Hip hinge practice with a dowel along the spine: bend at the hips with the back flat, 10 times.
• Nerve glides once leg pain is easing: sit at the edge of a chair, straighten the painful leg and pull the toes up while looking down, then relax while looking up. 10 slow repeats, twice a day. Stop if it increases leg pain.
• Walking builds to 30 minutes a day.

Why the hamstrings matter

Even in an extension-based program the hamstrings matter, because a tucked pelvis works against the very curve you are trying to restore. The hamstrings run from the sitting bones at the back of the pelvis to just below the knee. When they are tight, they pull the back of the pelvis down and tuck it under (a posterior pelvic tilt), which flattens the natural inward curve of the low back (the lumbar lordosis). A flat low back then has to round forward every time you bend, sit, or reach, because the hips cannot. Freer hamstrings reverse that chain: the pelvis can tilt forward again, the low back keeps its curve, bending comes from the hips (the hip hinge) instead of the spine, and the pressure inside the discs and the strain on the structures behind them fall. Stretch each hamstring for 20 to 30 seconds, 3 to 5 times, once or twice a day, with the low back kept flat, and roll the back of the thigh on a foam roller first if that helps. The gain comes from the nervous system allowing more length, so it stays only with regular stretching. The full explanation is in my core program for low back pain.

Week 6 and beyond: build it back

• Hip and core strength three times a week: hip hinges, squats, bridges, bird-dogs, side planks, and later deadlifts with a light load and a neutral spine.
• Return to running, cycling, and sport in stages, with the standing extensions kept as a habit after any time spent sitting or bending.
• Gentle flexion returns to the program last, once the leg has been quiet for several weeks, so that the back regains its full motion. Your therapist guides this step.
• Keep the press-ups as a daily habit if your work involves sitting. Ten in the morning and ten after work prevent most recurrences.

Notes for the physical therapist

• Extension-biased, directional-preference program for flexion-intolerant, discogenic low back pain with or without radicular symptoms.
• Confirm directional preference with repeated-movement testing; a lateral shift should be corrected before sagittal extension. Treat centralization as the primary outcome.
• If extension peripheralizes, stop and reassess: try extension with hips offset, then consider a flexion bias or a non-directional program.
• Sitting posture correction with a lumbar roll, and a hip hinge for all bending, from the first visit.
• Add trunk endurance work (McGill big three) in neutral once symptoms have centralized; restore flexion range at the end, gradually.
• Refer back to me for progressive weakness, leg pain that is not centralizing or is disabling at 6 to 8 weeks despite a proper trial, or any cauda equina sign; an epidural injection or a microdiscectomy are the next steps.

Call 911 or go to an emergency room if you have

• New trouble controlling your bladder or bowels.
• Numbness in the groin, buttocks, or inner thighs.
• Weakness in both legs, or weakness that is getting worse quickly.

Learn more

OrthoInfo, Herniated Disk in the Lower Back: orthoinfo.aaos.org (opens in a new tab)

My guides to lumbar radiculopathy, the home program for sciatica, the core program for low back pain, and the flexion-based program.

This program is a starting place and a set of suggestions for your physical therapist, not a prescription. Your therapist will adjust it to your exam. Stop and call us if an exercise sends pain farther down a leg, or if you notice the warning signs at the end.