It can be sudden or subtle, and is sometimes devastating. That's the nature of a back injury, something Gerard Byrne and Sarah Haskell know intimately. Byrne, who is the commissioner of parks and recreation in Greenburgh, NY, felt a sharp pain when he bent over to pick up a ventilation fan during a kitchen renovation in his home. It turned out to be a herniated disc.

Haskell, a textile artist in York, ME, first experienced numbness in her feet that progressed to pain so intense she couldn't stand up on her own. Her injury, a ruptured disc, had been caused by repetitive motion as she worked a manually powered loom.

Byrne and Haskell are just two of the millions of Americans with a condition that causes back pain. According to a 2020 study by the US Centers for Disease Control and Prevention (CDC), one in four people had experienced lower back pain in the past three months.

Often the pain is severe enough to prompt a visit to a specialist. At New York's Hospital for Special Surgery, 27,500 patient visits in 2019 were related to lower back pain or injuries, compared with 23,000 for knee pain or injuries and 10,000 for shoulder problems.

Haskell's neurologist recommended surgery to remove the protruding disc material that was creating painful pressure. That was in 1990; in 2018, when Byrne injured himself, his doctor prescribed physical therapy. The difference in recommendations over those 28 years reflects the changing views toward back care. “When I started out, there were a lot more spine surgeries,” says Daniel L. Menkes, MD, FAAN, chair of neurology at Oakland University's William Beaumont School of Medicine in Rochester Hills, MI. “Surgeries designed to restore former anatomy were the norm. Unfortunately, not all had their intended outcome.”

Today, Dr. Menkes says, conservative treatment including physical therapy is the first course of action for uncomplicated lower back pain.

The perspective of physical therapists has changed too. Thirty or so years ago, their emphasis was on rest, anti-inflammatory medication, and possibly opioids, says Neil McKenna, a doctor of physical therapy (DPT) based in Solana Beach, CA.

While opioids are still prescribed—“despite an overall lack of evidence to support their efficacy,” notes the CDC—exercise is now the preferred treatment, says Amanda Scheer, a DPT at the Hospital for Special Surgery. Research supports this updated approach: A 2016 British study in the journal Healthcare found that a program emphasizing muscular strength, flexibility, and aerobic fitness can increase range of motion, assist with day-to-day movements, and promote healing by reducing stiffness that can cause pain.

In 2017, the American College of Physicians (ACP) updated its guidelines on back pain and recommended that doctors “exhaust all other treatment options” before prescribing opioids. Preferred treatments cited by the ACP include heat, massage, acupuncture, spinal manipulation, and physical therapy. The new guidelines also recommended, for the first time, mindfulness-based stress reduction. Recent evidence suggests that a multidisciplinary approach involving meditation, cognitive behavioral therapy, and other mindfulness strategies that teach patients how to cope with the pain is more effective than pharmaceutical options. For persistent pain, the ACP recommends nonsteroidal anti-inflammatory drugs.

After her surgery, Haskell worked with a physical therapist to strengthen her core and back muscles. Byrne did the same. His physical therapist, John McKillop, PT, focused on Byrne's lower back, buttocks muscles, and hamstrings.

Because Byrne, a former pole vaulter and a part-time high school sports official, was in good shape, he was soon able to do more challenging strengthening exercises, including crunches with a stability ball propped under his knees. “This allowed him to strengthen his abdominal muscles while his spine was in a neutral position,” says McKillop, who practices in Ardsley, NY.

Movements like those are like WD-40 for your muscles, says Dr. Menkes. “These exercises improve the elasticity of the soft tissue in the lower back. It's like an old car—you can't keep it in the garage and expect it to run smoothly. You need to drive it around.” Moreover, he says, “If you're consistent in your exercise regimen, you'll probably lose weight, and that is going to be good for your back as well.”

In addition to stretching and strengthening specific muscles with a therapist, doctors recommend aerobic exercises such as walking, swimming, yoga, and bicycling. As for which is best for back pain, Scheer endorses them all. “There are definitely folks whose back pain is so acute they can't move; they need some manipulation just to find a position of comfort. But as soon as possible, we want to get them moving.”

And aging is no excuse to slow down, says McKillop. “Some of my older patients have this mentality that it's time to do less,” he says. “I tell them they actually need to do more just to maintain their strength and stability.”

Consistency is key, says Byrne. “The one thing I would say is that it's really important that you stick with the program after you're done with formal physical therapy.” It has paid off for the 65-year-old, who has been able to resume his physically demanding work as a basketball and volleyball referee.

“You have to keep doing it,” agrees Haskell, who is now 70. Besides her daily yoga practice, in which she incorporates some exercises her PT showed her 30 years ago, she walks, swims, or cross-country skis regularly. “That injury was so painful and debilitating that it imprinted a huge lesson,” Haskell says. “I know that I have to stay active.”

Four Exercises for a Healthy Back

Most experts agree that exercise—starting with gentle stretching movements—has become the go-to treatment for lower back pain. Physical therapists determine which particular exercises are most appropriate for their individual patients.

But for general back health, consider these four exercises recommended by Neil McKenna, a doctor of physical therapy in Solana Beach, CA.

Supine leg rocking. Lie on your back with your knees bent and your feet on the floor. Gently rock your legs back and forth from left to right. “This loosens the hips and lower body,” McKenna says. Do two sets of 10 reps. (From one side to the other would be one rep.)

Cow/cat. This pose, commonly used in yoga, is great for stretching the lower back, says McKenna. Start on your hands and knees with your fingers pointed straight ahead. Inhale and slowly arch your back (cow). Hold for three seconds, then exhale and round your back (cat), dropping your head and raising your shoulders. Repeat at least seven times.

Supine heel slides. Lie on your back with your knees bent. Slowly slide out one leg to a straight position, then slide it back up. Do the same with the other leg. Don't hold your breath on these. To facilitate the slide, wear socks or put a towel under your feet. Do two sets of 10 reps for each leg.

Bird dog. Get on your hands and knees and keep your back flat. Lift one arm so it forms a straight line with your back, return to starting position, then lift the other arm. With both hands on the ground, extend the legs, one at a time. Then try to combine the moves—raising left arm and right leg together, then right arm and left leg together. Do one set of eight reps, each rep being arm and opposite leg together or one arm or leg at a time (depending on ability). Hold each lift for three seconds. Stop if you have pain or trouble holding a position.