Home Program for Low Back Pain: Flexion-Based

Is this the right program for you?

Back pain has a direction. Some backs feel better bending forward and worse arching back; some are the opposite. This program is for the first group. It is usually the right one if:

• Standing or walking for a while brings on back, buttock, or leg pain, and sitting down or leaning on a shopping cart relieves it. That pattern is typical of spinal stenosis.
• Arching back, lying flat on your stomach, or reaching overhead hurts, and curling up or sitting eases it.
• The pain is from the small joints at the back of the spine (facet joints), which are loaded by arching.
• You are over 50 and the problem is narrowing rather than a herniated disc.

If bending forward, sitting, and lifting are what make your back and leg worse, and standing or walking helps, you need the opposite plan: my extension-based program. If you are not sure, your therapist can test the direction in one visit by moving you each way and seeing which one makes the leg pain retreat toward the back. That is the test that decides.

The idea

Bending forward opens the canal and the openings where the nerves leave the spine, and it unloads the facet joints. Stretching into that direction gives relief, and strengthening the muscles that hold the pelvis tucked and the spine neutral keeps the relief through the day. The program is three parts: flexion stretches for relief, core work that holds a neutral spine, and walking that builds back endurance.

Part 1: flexion stretches (daily, several times a day)

Do these on waking, after standing or walking, and before bed.

• Single knee to chest. Lying on your back, pull one knee toward your chest with both hands, the other leg flat or bent. Hold 20 seconds, then switch. 3 rounds each.
• Double knee to chest. Both knees pulled in, low back pressed to the floor. Hold 20 seconds, 3 rounds.
• Posterior pelvic tilt. Lying on your back with knees bent, flatten the low back into the floor by tightening the lower belly and tucking the tailbone under. Hold 5 seconds, 10 times. This small motion is the heart of the program; learn it lying down, then sitting, then standing.
• Cat stretch. On hands and knees, round the back up toward the ceiling, tuck the chin and the tailbone, hold 5 seconds, return to flat. 10 times. Skip the arching half of the usual cat-camel.
• Child's pose. From hands and knees, sit back onto the heels with the arms stretched forward, forehead toward the floor. Hold 30 seconds, 3 rounds.
• Seated forward bend. Sit in a chair with feet apart, bend forward and let the hands reach toward the floor. Hold 20 seconds, 3 rounds. This is the one to use during a flare while out of the house.
• Hamstring stretch. Lying on your back, a strap around one foot, raise the straight leg until you feel the back of the thigh. 20 seconds, 3 rounds each side. Tight hamstrings pull the pelvis into an arch.
• Hip flexor stretch. Half-kneeling, tuck the pelvis under and shift forward until you feel the front of the kneeling hip. 20 seconds, 3 rounds each side. A tight hip flexor pulls the low back into an arch when you stand.

Part 2: core in a neutral spine (four days a week)

The goal is a trunk that keeps the pelvis tucked and the spine still while the arms and legs move.

• Abdominal bracing. Lying on your back with knees bent, tighten the lower belly as if preparing for a poke, without holding your breath. Hold 10 seconds, 10 times. Then do it sitting and standing.
• Dead bug. On your back with hips and knees at 90 degrees, low back pressed down, slowly lower one arm overhead and the opposite heel toward the floor, then return. 10 each side.
• Bridge. Knees bent, tuck the pelvis, squeeze the buttocks and lift the hips until the body is straight from shoulders to knees. Do not arch. Hold 3 seconds, 2 sets of 10.
• Bird-dog with a tucked pelvis: on hands and knees, reach one arm forward and the opposite leg back only as far as the back stays flat. 10 each side.
• Side plank from the knees, 20 to 30 seconds each side, 3 rounds. Progress to the feet.
• Curl-up. On your back, one knee bent, hands under the low back, lift the head and shoulders an inch. Hold 5 seconds, 10 times.
• Wall sit with the low back flat against the wall, 20 to 30 seconds, 3 rounds.
• Seated marching with the pelvis tucked, 20 lifts.

Part 3: build endurance

• A stationary bike is the best cardio for this pattern: you are flexed, the canal is open, and the legs work. 15 to 30 minutes most days.
• Walking: start with the distance you can manage before the leg symptoms begin, and stop before they do. Add a few minutes each week. Walking slightly uphill, or with trekking poles, keeps the spine a little flexed and often extends the distance. My walking plan for spinal stenosis has the details.
• Swimming and water walking are good. Avoid the butterfly and breaststroke kick, which arch the back.

Why the hamstrings matter

The hamstring stretch in Part 1 is doing more than loosening a muscle. 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.

Day-to-day habits

• Sit with the low back supported and the knees level with or slightly above the hips.
• Stand with one foot up on a low step or a rail when you must stand in one place; switch feet. It tucks the pelvis.
• Sleep on your side with the knees drawn up and a pillow between them, or on your back with pillows under the knees.
• Avoid prolonged overhead work and lying on the stomach.

Notes for the physical therapist

• Flexion-biased program for extension-intolerant low back pain: lumbar stenosis, facet-mediated pain, and extension-provoked spondylolisthesis.
• Confirm directional preference at the first visit (repeated movement testing); if flexion peripheralizes and extension centralizes, switch to the extension-based program.
• Emphasize posterior pelvic tilt control, hip flexor and hamstring length, and trunk endurance (McGill big three, flexion-biased), with hip abductor strengthening.
• Manual therapy as indicated (lumbar flexion mobilization, hip mobilization).
• Progress walking tolerance with a flexion bias (inclined treadmill, poles, bike), and track walking distance as the main outcome.
• Refer back to me if leg symptoms progress, if there is weakness, or if walking tolerance is not improving at 6 to 8 weeks; an epidural injection or, for severe stenosis, a decompression 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, Lumbar Spinal Stenosis: orthoinfo.aaos.org (opens in a new tab)

My guides to lumbar spinal stenosis, the walking plan for spinal stenosis, the core program for low back pain, and the extension-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 down a leg, or if you notice the warning signs at the end.