Lower back pain: what helps day to day, with Peter O'Sullivan

For most people, lower back pain has no single damaged part to find, so the useful questions are what turns it up and what keeps it coming back. What helps day to day is plain: check the warning signs once, keep moving in a smaller version of your day, build back up gradually, and have a plan ready for the next flare.

O'Sullivan is a John Curtin Distinguished Professor in the School of Allied Health Sciences at Curtin University, introduced on Feel Better, Live More by Dr Rangan Chatterjee as a clinician, researcher and educator in musculoskeletal pain. With his team he developed cognitive functional therapy, an approach for disabling back pain that he teaches to clinicians (O'Sullivan et al., 2018). This article uses his general advice from that conversation, not the therapy itself.

With a new bout, he first makes sure nothing serious has been missed. Then he takes the history: "has there been an injury? No injury. So what was going on for you at that time? That's so important" (47:05). Below, you'll learn to read a bad back day, keep your day going through it, and plan the next one.

What's going on in your back?

1. Rule out the rare serious causes, once

In 2020, lower back pain affected about 619 million people worldwide, and it is the single leading cause of disability (WHO, 2023). In about 90% of cases it is non-specific, meaning no specific disease or structural reason can be found to explain it. Australia's national care standard puts it the other way: "more than 95% of low back pain cases do not have serious underlying causes" (ACSQHC, 2022). NHS inform in Scotland adds that "the spine is strong and back problems are rarely due to any serious disease or damage" (NHS inform).

Rare isn't never, so the 1h Protocol to Manage Back Pain opens with a check. Serious causes of back pain are rare, but a few signs mean you should get checked.

Get medical help straight away if any of these start:

• Trouble peeing, or leaking pee or poo without meaning to
• Numbness around your genitals or bottom, or sex feeling different
• Both legs weak, numb or tingly, or you can't walk because of the pain
• Pain after a serious fall, accident or blow
• Chest pain or trouble breathing with it; or new pain far worse than before, or getting worse fast

See a doctor first if you have:

• A fever, or feeling hot, shivery or unwell
• Cancer in the past, or weight lost without trying
• Pain worse at night or unchanged by moving or resting; high between the shoulder blades; one leg weak or numb

If a new flare isn't getting better after a few weeks, keeps getting worse, or worries you, see a doctor. If you're pregnant, talk to your midwife or doctor about your back. If you've had back surgery recently, follow the advice of the team that treated you.

2. Read pain as an alarm, not a damage meter

Pain is real, but it isn't a damage meter, which is why a scan so often fails to explain it: scans of people with no back pain often show the same disc changes (see do you need an MRI?).

The program uses a simple model for this, the Alarm, the Guard and the Load. It is a useful way to see a back day, not the whole story:

• The Alarm. Pain's volume moves with how protected your body feels. Bad nights and heavy weeks can turn it up.
• The Guard. Bracing and holding still help early on. When they stay, they go with more pain and more limits.
• The Load. Backs cope with what they're used to. Sudden big days and long still days go with flare-ups; everyday movement goes with less pain.

Each is a link found in studies, not a proven cause, so no single thing (your posture, your mattress, the way you lifted the box) has to be the villain.

3. Ask what else was going on

O'Sullivan's history question is about the whole week, not the moment it caught. In his experience, back pain is "often at a time of stress, the person's not sleeping well, they're run down, they're tired, they're tense, they've got other stuff going on" (47:19). Treat that as a pattern to look for, not a cause. Our guide to back pain, sleep and stress covers what the sleep and work studies found.

Here's what that looks like in practice. After your next bad day, ask three questions, one per part:

• Alarm: what turned the volume up this week? A short night, a heavy week, a worry?
• Guard: what did I brace, hold my breath through, or stop doing?
• Load: what jumped (a big job, a new sport), and what stayed still too long (a long drive, a day at the desk)?

What helps day to day?

4. Keep a smaller version of your day

"Rest until it stops hurting" is the advice the trials least support. In a Cochrane review, two trials with 401 people with new back pain found that advice to stay active did slightly better than advice to rest in bed, for pain and for getting on with the day; the differences were small (Dahm et al., 2010). In a Finnish trial of 186 employees with new back pain, a week in, 41% of those told to rest in bed for two days were still off work, against 20% of those who carried on as usual (Malmivaara et al., 1995).

Guidance agrees. "Do not wait for all the pain to be gone before you start moving," says the Australian standard, and "avoid long periods of bed rest, which can slow down recovery" (ACSQHC).

Keep going doesn't mean push through. A smaller day still has its shape: get up and dressed, walk, even just to the corner, and do what matters most, slower. Our guides to rest or move with back pain and the first hours of a flare go further.

5. Build back up a step at a time

O'Sullivan's example is a sprained ankle: you wouldn't go running on it the next day (48:44). After a lifting or twisting incident, he says, you wouldn't tell someone to go back to lifting tomorrow either. You'd tell them to "get yourself moving, don't do heavy lifting for a couple of days, get your movement back, relax your body, build your confidence back," and then build up what they lift gradually (48:48 to 49:10).

The Australian standard words it as a rule of thumb: if your pain is worse after activity and stays that way, take things "a little easier at first and gradually build up over a few days or weeks" (ACSQHC). If you've ticked any of the warning signs above, see a doctor before you build up. Our guides to lifting with back pain and back pain after a busy day show how to build up without a big jump.

6. Choose movement you'll keep doing

No single movement fixes back pain. In a 2021 Cochrane review of 249 trials, exercise eased long-lasting low back pain compared with no treatment, usual care or placebo, with moderate certainty; compared with other treatments, its advantage was small (Hayden et al., 2021). So the best movement is the one you'll still be doing in a month.

Walking is easy to keep, and it has a large trial behind it. In the WalkBack trial, among 701 Australian adults who had just recovered from a bout of back pain, those given a walking plan, with six coaching sessions over six months, went a median of 208 days before their next bout that limited what they could do; those with no plan went 112 (Pocovi et al., 2024). Walking and coaching came together, so the trial can't separate them. See walking for back pain.

Everyday movement points the same way. A 2011 review of ten years of studies found that intense effort in sport or exercise went with more back pain, while everyday leisure activity, such as cleaning, went with less sick leave for back or neck pain in one study, and gardening with less back pain in another (Heneweer et al., 2011). These are links, not proof. If your day is mostly sitting, see back pain from sitting.

Why does it keep coming back?

7. Know the usual course, without a promise

"Most problems should have improved within 6 weeks," says NHS inform (NHS inform). A 2024 review pooled 47 groups of people (9,224 in all): in new back pain, average pain fell from 56 out of 100 to 26 within six weeks (moderate certainty). In pain that had lasted three months or more, it fell more slowly, from 56 to 40 over a year (very low certainty) (Wallwork et al., 2024). Those are averages, not a timetable.

And it often returns. The best available estimate, from a 2018 Lancet series, is that about 1 in 3 people have another bout within a year of getting better, and broader counts find more (Hartvigsen et al., 2018). Coming back doesn't mean something is wrong. It makes a plan for the next bout worth having.

8. Plan the next flare before it comes

O'Sullivan is wary of promising that back pain goes for good. For some of the people in his work, he says, the result is that they still get back pain from time to time but know how to handle it. "To me, that's the goal" (1:16:50 to 1:17:09).

Write one line for the moment your back goes, such as: "When my back goes, I'll breathe out, remind myself a flare passes, and keep a smaller version of my day going." Pick the two or three things you'd keep even on a bad day. Decide one sentence for the people around you. Then guard your nights, since a short night can turn the volume up (how to sleep better). For the workplace side, see back pain at work.

Back to the history

O'Sullivan's first question wasn't about your discs or your posture. It was what was going on for you at the time. Start there, and keep your day going in a smaller form. In a 2015 lecture he put the shift he wants to see in one line: "backs should be trusted to move in a normal way" (Evoolve Pain Care Academy, 11:42 to 11:56).

To build this around your own back days, try the 1h Protocol to Manage Back Pain, a wellness program of practical education. Its free first chapter starts with a quick check for warning signs, then finds your back-day pattern (one of four, or the Tune-up) and gives you one thing to do tomorrow. The full program takes about an hour: seven chapters show why it keeps coming back and walk one back day with you at your own times, then plan a flare, the days after it and the days that don't go to plan. You leave with your plan on one page: two or three things to start now, each with an alternative for harder days, your flare plan with one line in your own words, a flare card for your lock screen, and fourteen days to try it, with a sheet, reviews on days 7, 14 and 30, and four one-tap check-ins by email if you're signed in. Start free

Frequently asked questions

What usually causes lower back pain?

In about nine cases out of ten, no single cause can be pinned down (WHO, 2023), and more than 95% of cases have no serious underlying cause (ACSQHC). Studies link more back pain with intense effort, long still days, poor nights and heavy weeks, but none is a proven cause.

How long does lower back pain last?

For many people, a new bout eases a lot within about six weeks: in a 2024 review, average pain in new back pain fell from 56 to 26 out of 100 in that time (Wallwork et al., 2024). Some ache can linger for months, and that doesn't mean something is wrong. If a new flare isn't getting better after a few weeks, keeps getting worse, or worries you, see a doctor.

Why does my lower back pain keep coming back?

It's common: about 1 in 3 people have another bout within a year of getting better (Hartvigsen et al., 2018). Backs cope with what they're used to, so a sudden big day, a long still day, a short night or a heavy week can each go with a flare.

What helps lower back pain day to day?

Keep a smaller version of your day rather than resting in bed, build back up a step at a time, and choose movement you'll keep, often a walk at a pace where you can talk. Change position often on long sits, and protect your nights.

When should I see a doctor about back pain?

Get medical help straight away if your bladder or bowels change, you lose feeling around your genitals or bottom, both legs feel weak or numb, or the pain started after a serious fall or accident. See a doctor first if you have a fever, you've had cancer, you've lost weight without trying, or the pain is worse at night. The full list is in step 1. If a new flare isn't getting better after a few weeks, keeps getting worse, or worries you, see a doctor.

Sources

This article draws on Professor Peter O'Sullivan's interview on Feel Better, Live More and his 2015 lecture for Evoolve Pain Care Academy, and the studies and guidance listed below.

• How to Break Free from Chronic Pain and Reclaim Your Life, with Professor Peter O'Sullivan (podcast episode, Feel Better, Live More, 2024)
• Back pain: separating fact from fiction, with Prof Peter O'Sullivan (lecture video with patient interviews, Evoolve Pain Care Academy, 2015)
• O'Sullivan et al, Cognitive functional therapy (clinical perspective, 2018)
• World Health Organization, Low back pain (fact sheet, 2023)
• Australian Commission on Safety and Quality in Health Care, Low Back Pain Clinical Care Standard, information for consumers (national care standard, 2022)
• NHS inform, Back problems (health information page, Scotland, 2026)
• Dahm et al, Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica (Cochrane systematic review, 10 trials, 2010)
• Malmivaara et al, The treatment of acute low back pain: bed rest, exercises, or ordinary activity? (randomized trial, 186 employees in Helsinki, 1995)
• Hayden et al, Exercise therapy for chronic low back pain (Cochrane systematic review, 249 trials, 2021)
• Pocovi et al, the WalkBack trial (randomized trial, 701 Australian adults, 2024)
• Heneweer et al, Physical activity and low back pain (systematic review, 36 studies, 2011)
• Wallwork et al, Clinical course of acute, subacute and persistent low back pain (systematic review and meta-analysis, 2024)
• Hartvigsen et al, What low back pain is and why we need to pay attention (Lancet series paper, 2018)