5 steps to take control of back pain.

Most back pain is not caused by serious damage. But a small number of signs need a doctor straight away, so check these first.

• Numbness around the groin, buttocks or inner thighs, or new bladder or bowel problems. This is a medical emergency: call 999 or go to A&E.
• Leg weakness that is getting worse.
• Fever, unexplained weight loss, or night pain that does not ease with rest or changing position.
• Pain after a significant fall or accident, or if you have osteoporosis.

If none of these apply, the next four steps are where most people should start. If you are unsure, contact your GP or NHS 111.

Pain is your nervous system's best guess about threat. It is shaped by what's happening in your tissues, but also by sleep, stress, past experience and what you believe is happening. It is not a damage meter.

Those findings come from a review of over 3,000 people with no back pain (Brinjikji et al., 2015). Scan changes are closer to grey hair than to an injury. For ordinary back pain without the warning signs above, routine imaging has not been shown to improve pain or function (Chou et al., 2009).

Bed rest used to be standard advice. The research changed that: people with acute low back pain who stayed active recovered faster than those prescribed bed rest (Malmivaara et al., 1995).

• Keep doing your normal day, adjusted rather than stopped. Shorter walks, lighter loads, more breaks.
• Move little and often. Sitting or lying still for long periods tends to make backs stiffer and more sensitive.
• Notice avoidance. If you have stopped bending, lifting or training "to protect your back", that protection can become the problem.

Avoiding movement leads to weaker muscles, stiffer joints and a more sensitive nervous system, which makes the next movement feel worse. That is the fear-avoidance cycle (Vlaeyen & Linton, 2000), and it is one of the most consistent predictors of pain hanging around.

Tissue adapts to load. What it struggles with is a sudden change it has not been prepared for. Progressive loading is the treatment, not an optional extra.

• Find your true baseline: what you can do right now without a flare the next day. Not what you used to do.
• Change one thing per week: how often, how much, or how heavy. Not all three.
• Progress in small steps. Around 10% at a time is a rough guide that keeps most people out of trouble.
• Every 4 to 6 weeks, take a lighter week. Your body adapts during recovery, not during the session.

Some discomfort while you rebuild is normal and acceptable. What matters is how your body responds afterwards.

• Discomfort during or after exercise that settles within 24 hours: usually fine. Keep going.
• Worse the next morning, or climbing week on week: the dose was too high. Scale back a little, don't stop.
• Count the invisible load. Poor sleep, stress and a physical job all draw from the same account. A rough week is not the week to push for a new personal best.