Strength training for lower back pain: what the best evidence actually says

National guidelines prioritise exercise-based care, and high-quality reviews show meaningful reductions in pain and improved function when you combine progressive loading with education and the wider factors that drive persistent pain. [1]

Why exercise works for lower back pain (and why “rest” alone doesn’t)

Most ongoing lower-back pain isn’t caused by a single damaged structure. It’s multifactorial, physical, psychological, and social. On the physical side, de-conditioning (reduced strength/endurance of the lumbar extensors and hip musculature) is common in NSLBP. Meta-analysis shows people with LBP often present with weaker hip abductors/extensors and knee extensors reduced trunk extensor endurance is frequently reported, both are trainable with progressive loading. [2]

At the same time, pain science shows persistent LBP can involve changes in pain processing, fear of movement, stress, poor sleep, and reduced confidence in your back’s capacity. Effective treatment addresses both the capacity (strength/endurance) and the psychosocial factors via graded loading, confidence-building, and clear education.

What the guidelines say (UK & international)

• NICE (UK): Offer exercise programmes as first-line care. Consider manual therapy only as part of a package that includes exercise. Do not offer passive electrotherapies (e.g., ultrasound, TENS) or traction as standalone treatments. [1]
• American College of Physicians: Non-drug care with exercise ahead of medication for chronic LBP. [3]
  Guidelines also emphasise individualisation: what works varies by presentation, beliefs, movement fears, and lifestyle.

What do the best reviews about Exercise for lower back pain show

• Cochrane 2021 (249 trials): Exercise is probably more effective than no treatment/usual care, reducing pain by ~15/100 (clinically meaningful). Functional gains are smaller but present. [4]
• Network meta-analysis 2023: Across types, structured exercise beats minimal care. Pilates, McKenzie, and functional restoration often rank well; the common thread is consistent, progressive exercise with guidance. [5]
• Pain education: Teaching that “hurt ≠ harm” and that graded loading is safe reduces fear-avoidance and supports better exercise outcomes.

Does strength training help lower back pain specifically?

Yes if applied with intelligent dosing. Randomised work shows an 8-week progressive strength programme (squats, deadlifts, planks, etc.) reduced recurrence (8.3% vs 33.3%) and improved strength and disability scores. Resistance training also supports psychological well-being, crucial when fear of movement is in the mix. [6]

Good practice: keep pain manageable, progress gradually, combine with education, and modify during flares or high fear-avoidance.

What about other treatments for lower back pain?

Manual techniques (manipulation/mobilisation) can offer small, short-term relief, best used as a bridge into active rehab but not not a replacement for exercise. Long-term change comes from progressive loading and movement confidence, supported by sleep, stress, and activity upgrades.

Key takeaways

• Exercise works. Progressive, coached loading is first-line for most NSLBP.
• Passive care is adjunct. Use manual therapy to help you move, not instead of moving.
• Progress > perfection. Build capacity, build confidence, and personalise the plan.

Next steps: book a free consultation

Want to find our more about how I can help your lower back pain? Book a free 30 mminute consultation at the Sowton gym (or online).

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References (selected)

1. https://www.nice.org.uk/guidance/ng59/chapter/Recommendations
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC6454257
3. https://www.acpjournals.org/doi/10.7326/M16-2367
4. https://pubmed.ncbi.nlm.nih.gov/34580864/
5. https://pmc.ncbi.nlm.nih.gov/articles/PMC10250000/
6. https://pubmed.ncbi.nlm.nih.gov/33187076/

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