Hydrotherapy for the Low Back: Twenty Aquatic Exercises for Chronic Back Pain

Before you start: For warming up and getting used to the water, stand beside a handrail on a clear route. No equipment is needed; keep your feet hip-width apart, your trunk upright and your gaze forward.

Water depth and flotation: Water at navel level; no flotation device is needed. If your balance is poor, use shallower water beside the rail.

How to do it:

1. Place your heel on the floor first, then shift your weight from heel to toes.
2. Let your arms move freely in time with your legs; do not lock them across your chest.
3. Keep your trunk upright and do not lean forward to move ahead.
4. At the end of the route, stand beside the handrail and rest before you become tired.

Movement tips: Take short, gentle steps and breathe normally. Keep your trunk upright and let the heel reach the floor before the toes; if your steps become irregular, rest beside the handrail.

Amount, repetitions and progression: Take 10 to 20 steps forward. Start with the shorter distance and stop beside the rail. Only when walking forward feels comfortable and the path behind you is clear should you walk back over the same distance, using the technique in the next exercise. Increase the distance only when your steps are steady and pain-free.

Stop immediately if: Stop exercising if pain travels down your leg or the leg becomes numb.

Common mistakes: Leaning forward and walking on your toes instead of placing your heel on the floor.

Easier version: Use shallower water and a shorter route, or keep one hand on the rail as you walk.

Before you start: When forward walking feels comfortable, practise backward steps. Check the space behind you and stand beside a handrail with your feet hip-width apart.

Water depth and flotation: Water should reach the navel; no flotation device is needed.

How to do it:

1. Take a step backward, placing your toes on the pool floor first, then lowering the heel.
2. Keep your trunk upright and your chest open throughout the route; do not let your pelvis tip forward or your back arch.
3. Every few steps, turn your head slightly and look behind you.
4. Before your steps become irregular, stand beside the handrail and rest.

Movement tips: Walk backward with short steps and normal breathing. Let the toes reach the floor before the heel, and do not increase your lower-back curve; rest if your steps become irregular.

Amount, repetitions and progression: After 10 to 20 forward steps, walk backward over the same distance. Start with the shorter route; increase the distance if you maintain your balance and the natural curve of your lower back.

Stop immediately if: Stop exercising if your back hurts, pain travels down your leg or your balance is disturbed.

Common mistakes: Arching your back and taking long steps while walking backward.

Easier version: Keep one hand on the rail and take backward steps along it.

Before you start: To work the muscles on the sides of your hips, face the handrail and stand with your feet hip-width apart. Keep one hand on the rail; do not use it to pull yourself along.

Water depth and flotation: Water should reach the navel. No flotation device is needed; use the rail for balance.

How to do it:

1. To move right, move the right foot sideways first; to move left, lead with the left foot.
2. Bring the other foot closer until your feet are hip-width apart again; do not cross your feet.
3. Take the number of steps in your plan in one direction, then return along the same route.
4. Stop at the end of the route and return in the other direction in the same way.

Movement tips: Move gently in both directions and breathe normally. Keep your shoulders facing the handrail and both sides of your pelvis level; rest if your feet cross or your pelvis tilts sideways.

Amount, repetitions and progression: Take 10 to 20 steps in each direction and repeat this out-and-back sequence twice. Start with the shorter route; add steps only while maintaining balance and without increasing pain.

Stop immediately if: Stop exercising if pain on the side of your hip increases or pain travels down your leg.

Common mistakes: Pulling your body along with the hand on the handrail and rotating your pelvis instead of stepping sideways.

Easier version: Take shorter steps and hold the rail with both hands.

Before you start: To practise balance and hip-joint movement, stand beside a handrail. Keep your feet hip-width apart and gently tighten your abdomen; do this exercise when standing in water feels comfortable.

Water depth and flotation: The water should reach the breastbone in the middle of your chest (sternum); no flotation device is needed. At this depth, water supports more of your body weight.

How to do it:

1. Shift your weight onto one leg and gently lift the other knee.
2. Raise the knee until the thigh is nearly horizontal, no higher.
3. Lower the leg with control and immediately lift the other leg.
4. Alternate knee lifts while your trunk stays still, and rest before you become tired.

Movement tips: Lift the knee gently, keeping the thigh no higher than horizontal. Keep your trunk still and both sides of your pelvis level, and breathe normally; if you cannot maintain this position, lower your feet and rest.

Amount, repetitions and progression: Gently lift your knees in turn and rest before maintaining balance or trunk control becomes difficult. Continue after the tiredness has passed; increase repetitions gradually only if symptoms do not increase.

Stop immediately if: Stop if pain travels down the leg, your groin hurts or you lose balance.

Common mistakes: Raising the thigh above horizontal and leaning your trunk sideways as the knee rises.

Easier version: Keep one hand on the rail and lift the knee less.

Before you start: To practise pelvic control, stand with your back toward the wall and your feet slightly forward. Keep your knees slightly bent and your hands on your pelvis; the movement should be small and pain-free.

Water depth and flotation: Water should reach the sternum. No flotation device is needed; keep the pool wall behind you.

How to do it:

1. Gently tighten your abdomen and tip your pelvis backward so your lower back moves closer to the wall.
2. Then gently tip your pelvis forward to increase your lower-back curve slightly; keep the movement small.
3. Return to the middle position with your natural lower-back curve.
4. Repeat the small movement while keeping your knees and shoulders still.

Movement tips: Move your pelvis gently and breathe normally. Keep your knees and shoulders still and your feet on the floor; return to your natural lower-back curve each time, and rest before you become tired.

Amount, repetitions and progression: Move your pelvis forward and backward in small movements, returning to your natural lower-back curve each time. Rest before you become tired; increase repetitions when the movement is pain-free and your knees stay still.

Stop immediately if: Stop exercising if pain becomes sharp or travels down your leg.

Common mistakes: Moving your knees up and down instead of moving your pelvis, and pressing your lower back hard against the wall.

Easier version: Use a smaller movement and practise only the backward pelvic tilt.

Before you start: For a gentle stretch behind your pelvis and in your lower back, stand beside a handrail and hold it with one hand. Keep your weight on the supporting leg; your free hand holds the back of the other thigh.

Water depth and flotation: The water should reach the sternum. No flotation device is needed; keep the handrail within reach and hold it for balance.

How to do it:

1. Keep one hand on the handrail; raise one knee and hold the back of that thigh with your free hand.
2. Gently bring the knee toward your chest until you feel a mild stretch in your buttock or lower back.
3. Breathe gently in the mild stretch position and do not pull the knee farther with extra force.
4. Lower the leg gently; keep holding the handrail and repeat with the other leg.

Movement tips: Bring the knee closer only as far as a gentle stretch, and breathe slowly. Keep the supporting foot on the floor and your trunk upright; return to standing between sides and rest.

Amount, repetitions and progression: Hold the gentle stretch without forcing it, then lower your foot and change sides. Release the stretch if it becomes painful; increase the number of rounds only while maintaining balance and without increasing symptoms.

Stop immediately if: Stop exercising if the stretch becomes painful, pain travels into the lower leg or sole of the foot, numbness occurs or pain becomes sharper.

Common mistakes: Pulling the knee from the front of the joint and bending your trunk forward to bring your chest toward your knee.

Easier version: Rest your back against the pool wall and lift the knee less.

Before you start: To stretch the back of your thigh, stand beside a low, non-slip step and hold the handrail. Place one heel on the step and keep the other foot on the floor; the step must not make your back round.

Water depth and flotation: Use groin-deep water beside the pool steps. No flotation device is needed; hold the step rail.

How to do it:

1. Place one heel on the first step and keep that knee nearly straight.
2. Preserve your natural lower-back curve and keep your trunk facing forward.
3. Lean slightly forward from the hip joint until you feel a gentle stretch behind the thigh.
4. Breathe gently in the mild stretch position; then stand upright and change legs.

Movement tips: Preserve your natural lower-back curve as you lean slightly forward from the hip joint, and breathe normally. Seek only a gentle stretch behind the thigh; stand upright between sides and rest.

Amount, repetitions and progression: Hold the gentle stretch behind your thigh without bouncing, then stand upright and change legs. Release it if your back rounds or the stretch becomes painful; increase the number of rounds only without increasing symptoms.

Stop immediately if: Stop exercising if the stretch becomes painful, pain travels into the lower leg or sole of the foot, or you feel burning behind the knee.

Common mistakes: Rounding your back to reach your toes and placing your heel on a step that is too high.

Easier version: Use a lower step or keep the knee slightly bent.

Before you start: To stretch the muscles at the front of your thigh and pelvis, stand beside a wall or handrail. Place one foot forward and the other behind you; keep both sets of toes facing forward and the front knee slightly bent.

Water depth and flotation: Water should reach the navel. No flotation device is needed; use the wall for balance.

How to do it:

1. Contract your abdominal muscles to tip the pelvis slightly backward and reduce your lower-back curve.
2. Gently move your pelvis forward until the front of the thigh of the back leg stretches; do not arch your back.
3. Breathe gently in the mild stretch position and keep your lower-back curve unchanged.
4. Return to the starting position and change legs.

Movement tips: Gently move your pelvis forward until you feel a mild stretch at the front of the thigh of the back leg. Do not increase your lower-back curve, and breathe normally; return to a comfortable position and rest between sides.

Amount, repetitions and progression: Hold the gentle stretch at the front of your thigh without increasing your lower-back curve, then change legs. Release the stretch if your back position changes; increase the number of rounds only when the stretch is pain-free and controlled.

Stop immediately if: Stop if the groin hurts or back pain becomes sharper.

Common mistakes: Arching your lower back instead of moving your pelvis forward, and turning the toes of the back foot outward.

Easier version: Take a shorter backward step and place both hands on the wall.

Before you start: To practise gentle trunk rotation, stand in a clear space with your feet slightly wider than hip-width apart. Keep your knees slightly bent and your hands in front of your chest; move within a comfortable range.

Water depth and flotation: Water should reach the sternum; no flotation device is needed.

How to do it:

1. Gently tighten your abdomen and keep your natural lower-back curve.
2. Slowly turn your trunk to one side and let your hands move the water aside; your pelvis and feet remain facing forward.
3. Return to the middle, then turn to the other side.
4. Repeat on alternating sides, returning to the middle between movements.

Movement tips: Gently turn to both sides and do not hold your breath. Keep your pelvis and feet facing forward and avoid sudden trunk movements; return to the middle between movements and rest if you become tired.

Amount, repetitions and progression: Gently turn to one side and return to the middle, then repeat on the other side. Rest before you become tired; increase repetitions only while keeping your pelvis facing the same direction and without increasing pain.

Stop immediately if: Stop exercising if you feel sharp pain while turning or pain travels down your leg.

Common mistakes: Turning the pelvis with the trunk and speeding up the movement to increase its range.

Easier version: Keep your hands closer to your body and reduce the rotation range.

Before you start: To stretch the side of your lower back, stand in a clear space with your feet shoulder-width apart. Keep your knees slightly bent and your arms by your sides; maintain weight on both feet.

Water depth and flotation: Water should reach the sternum; no flotation device is needed.

How to do it:

1. Gently tighten your abdominal muscles and keep equal weight on both feet.
2. Slide one hand down the side of your thigh toward the knee and bend your trunk toward the same side.
3. Return to the middle gently without jerking.
4. Bend toward the other side and stand upright again.

Movement tips: Bend gently to each side and breathe normally. Do not lean forward or backward or take weight off one foot; move only within a comfortable range and rest before your balance is disturbed.

Amount, repetitions and progression: Alternate side bends, standing upright between movements. Rest if you take weight off one foot or your trunk rotates; increase the number of rounds only while maintaining balance and without increasing pain.

Stop immediately if: Stop if sharp pain develops in the side or back, or pain travels down the leg.

Common mistakes: Rotating your trunk while bending and taking weight off one foot.

Easier version: Reduce the range and keep one hand on the rail.

Before you start: To strengthen the outer hip muscles, stand side-on to the handrail and hold it with the nearer hand. Keep your weight on the leg nearest the rail so the outer leg can move freely; do not attach resistance equipment to your ankle.

Water depth and flotation: Water should reach the sternum. Hold the rail for balance; this version uses no flotation device around the ankle.

How to do it:

1. Keep the outer leg straight and gently move it sideways.
2. Move it only as far as you can keep your pelvis level without leaning your trunk to the opposite side.
3. Bring the leg back along the same path at a gentle speed.
4. After resting, change the side you stand on and move the other leg.

Movement tips: Gently move the outer leg sideways and bring it back at the same speed; breathe normally. Keep both sides of your pelvis level and your trunk upright, raising the leg only as far as you can maintain this position; rest between sides.

Amount, repetitions and progression: Gently move the leg sideways and bring it back; rest before your pelvis tilts, then change sides. If pain does not increase and your trunk stays still, gradually increase repetitions; do not add resistance equipment.

Stop immediately if: Stop if the outer hip or groin hurts, or pain travels down the leg.

Common mistakes: Leaning your trunk to the opposite side and letting the leg go uncontrolled on its return.

Easier version: Stay side-on to the rail and hold it with the nearer hand. Move the leg farther from the rail a smaller distance out to the side.

Before you start: To strengthen your buttock muscles, face the handrail and place both hands on it. Keep your feet hip-width apart and your abdomen gently tightened; the moving leg goes backward from the hip joint.

Water depth and flotation: Water should reach the sternum. No flotation device is needed; use the rail for balance.

How to do it:

1. Before moving, gently tighten your abdomen and preserve your natural lower-back curve throughout the movement.
2. Gently move one straight leg backward, only as far as your lower-back curve remains unchanged.
3. Return the leg gently to the starting position with control.
4. After resting, repeat with the other leg.

Movement tips: Gently move the leg backward and bring it back, breathing normally. Keep your lower-back curve and pelvic alignment unchanged, with the supporting foot on the floor; rest if controlling the movement becomes difficult.

Amount, repetitions and progression: Gently move the leg backward and bring it back; rest before your lower-back curve changes, then move the other leg. Increase repetitions only when the movement is controlled and symptoms do not increase.

Stop immediately if: Stop exercising if your lower-back curve increases, pain develops or pain travels down your leg.

Common mistakes: Moving the leg too far backward by arching your back, and pulling your body forward with your hands.

Easier version: Keep the knee slightly bent and reduce the range.

Before you start: To strengthen your thighs and buttocks, hold a firm handrail and stand with your feet slightly wider than hip-width apart. Turn your toes slightly outward and keep both heels on the floor.

Water depth and flotation: Start with water at the lower tip of the sternum. As the knees bend slightly, the surface rises toward the underarms; keep your head and face fully above water.

How to do it:

1. Move your hips back as if sitting onto a high chair.
2. Bend the knees slightly; the thighs must remain clearly above horizontal.
3. Keep your weight over the middle of the feet and the knees aligned with the toes.
4. Press the heels into the floor to stand, without locking the knees at the top.

Movement tips: Bend your knees only slightly; keep your thighs above horizontal and your head and face above water. Lower yourself gently and breathe out as you stand up; rest if your knees move inward or you become tired.

Amount, repetitions and progression: Gently repeat the shallow sitting-and-standing movement and rest before you become tired. Increase repetitions if your heels stay on the floor, your knees stay aligned with your toes and pain does not increase; do not deepen the movement.

Stop immediately if: Stop exercising if your back or the front of your knee hurts, or pain travels down your leg.

Common mistakes: Lowering too far and rounding the low back, or lifting the heels off the floor.

Easier version: Reduce the range and hold the rail with both hands.

Before you start: To strengthen your calves, face the handrail and hold it. Keep your feet hip-width apart with weight on both feet; the handrail is for balance, so do not pull yourself up with your hands.

Water depth and flotation: Water should reach the sternum. No flotation device is needed; use the rail for balance.

How to do it:

1. Gently raise both heels so your weight moves onto your forefeet.
2. At the top, keep your ankles straight and do not let them roll outward.
3. Lower your heels gently with control.
4. Repeat the movement gently and rest before your balance is disturbed.

Movement tips: Gently raise both heels by the same amount and lower them with control. Do not let your ankles roll outward or increase your lower-back curve; breathe normally and rest before your balance is disturbed.

Amount, repetitions and progression: Gently raise and lower your heels; rest before your balance is disturbed. Gradually increase repetitions when both legs move equally and pain does not increase.

Stop immediately if: Stop exercising if the area behind your heel or the sole of your foot hurts, or your balance is disturbed.

Common mistakes: Pulling your body up with your hands and suddenly dropping your heels.

Easier version: Reduce the range and hold the rail with both hands.

Before you start: Once walking in water feels comfortable, try gentle jogging in place to develop endurance. Stand in a clear space beside a handrail; keep your trunk upright and your elbows bent and close to your body.

Water depth and flotation: Water should reach the lower tip of the sternum; no flotation device is needed. Choose a depth where you can maintain balance.

How to do it:

1. Alternate your feet with short steps; lift your knees only a little and keep your pelvis and natural lower-back curve steady.
2. Move your bent arms forward and backward in time with your legs, as in running; do not slap the water surface.
3. Keep your trunk upright and do not lean forward to move faster.
4. Between jogging rounds, walk gently in place until breathing feels comfortable and you have good balance.

Movement tips: Take short steps, lift your knees only a little and move your arms in time with your legs. Keep your trunk upright and your lower-back curve steady, and be able to say a short sentence; walk gently between rounds until breathing feels comfortable.

Amount, repetitions and progression: Jog gently in place for 30 seconds, then walk in place for 30 seconds; continue this cycle for up to 5 minutes. Finish earlier if you become tired; increase speed only while maintaining balance and comfortable breathing.

Stop immediately if: Stop exercising if breathlessness, chest pain, dizziness or pain radiating into the leg occurs.

Common mistakes: Leaning your trunk forward and raising your knees high enough to rotate your pelvis.

Easier version: March instead of jogging and shorten each interval.

Before you start: To practise keeping your trunk steady, hold a pool noodle (a long foam flotation tube) on the water with both hands. Place one foot slightly ahead of the other and keep your elbows straight; the device must offer resistance you can control.

Water depth and flotation: Water should reach the lower tip of the sternum. Hold the foam tube to provide resistance; do not rely on it to keep you afloat.

How to do it:

1. Before moving, gently tighten your abdominal muscles and do not hold your breath.
2. With your elbows straight, gently press the foam tube underwater to the front of your pelvis.
3. Keep your trunk still; do not lean backward or arch your back.
4. Gently guide the tube back to the water surface with control.

Movement tips: Gently lower the tube to the front of your pelvis, no farther, and guide it back up with control. Keep both ends at the same height and your lower-back curve unchanged; breathe normally and rest before you become tired.

Amount, repetitions and progression: Lower the tube gently and bring it back with control; rest before you become tired. Increase the number of rounds only if your trunk stays still and pain does not increase; do not add a larger device or one with more resistance.

Stop immediately if: Stop exercising if your back or shoulder hurts, or pain travels down your leg.

Common mistakes: Arching your back and leaning your trunk backward, or bending your elbows instead of lowering the device with control.

Easier version: Press the foam tube less deeply. If resistance remains too high, choose a more suitable device with your physiotherapist.

Before you start: To work your arm and trunk muscles, stand with your feet slightly wider than hip-width apart and your knees slightly bent. Keep your forearms underwater and close to your body; this version uses no resistance gloves.

Water depth and flotation: Water should reach the lower tip of the sternum. Keep forearms and hands submerged and shoulders relaxed. No flotation device is needed.

How to do it:

1. Keep your forearms underwater and close to your body, with palms facing forward.
2. Push the water forward with your palms. To return, turn your palms to face behind you and gently push the water back.
3. Keep your shoulders down and do not let your trunk turn with your hands; only your arms move.
4. Rest before you become tired; start the next round when your hands can move gently and steadily again.

Movement tips: Gently move your hands forward and backward like paddles, and breathe normally. Keep your hands within shoulder width, with your pelvis and shoulders facing forward; rest before your shoulders rise.

Amount, repetitions and progression: Gently move your hands forward and backward, and rest before your shoulders rise or your trunk turns. Gradually increase the time when the movement is steady and symptoms do not increase.

Stop immediately if: Stop if your shoulder or neck hurts, or pain travels down the leg.

Common mistakes: Turning your trunk with your hands and raising your shoulders toward your ears.

Easier version: Reduce arm range, speed and the time of each round.

Before you start: Once slow walking feels comfortable, add changes in speed to work on endurance. Choose an uncrowded route; keep your trunk upright, shoulders relaxed and gaze forward.

Water depth and flotation: Use water between navel level and the lower tip of the sternum, without a flotation device. Changing depth changes both buoyancy and resistance.

How to do it:

1. Walk at a comfortable pace to warm up.
2. Walk a little faster; you should still be able to say a short sentence.
3. Return to a slower pace until breathing becomes easier.
4. Repeat these changes in speed, and finish with slow walking.

Movement tips: To walk faster, take more steps without lengthening them. You should still be able to say a short sentence. During slow walking, reduce your speed until breathing feels comfortable and keep your trunk from leaning forward.

Amount, repetitions and progression: Start with slow walking, increase your speed a little, then slow down again before you become out of breath. Start the next round once breathing is comfortable; increase the time spent walking faster only if your symptoms do not increase.

Stop immediately if: Stop the exercise if you develop breathlessness, chest pain, dizziness or pain radiating into the leg.

Common mistakes: Taking longer steps to increase speed, and leaning the trunk forward.

Easier version: Shorten the faster section and reduce the number of cycles, or use only gentle walking for now.

Before you start: This exercise is for someone who has learnt how to float and leave the water safely with a therapist. A belt that fits your body must be fastened correctly, and a trained person must supervise. First find your balance beside the pool wall.

Water depth and flotation: Water should reach the upper chest and underarms, with the head and face fully clear. Feet do not touch the floor, and a flotation belt is required.

How to do it:

1. Practise fastening the belt and entering safely with your physiotherapist; first find your balance beside the pool wall under the physiotherapist’s supervision.
2. Once you are balanced, raise one knee and move the other leg backward from beneath your body.
3. Move your arms in coordination with your legs, keeping your head and face out of the water.
4. Ask for help before you become tired, and return to the wall and a safe place to rest.

Movement tips: Stay almost upright and do not raise your thigh above horizontal. Keep your feet off the floor, preserve your natural low-back curve and keep your face out of the water. If breathing or balancing becomes difficult, ask for help and return to the wall.

Amount, repetitions and progression: Do short rounds under the supervision of a trained person, and rest beside the wall before you become tired. Increase the duration only while you can keep your balance, breathe comfortably and keep your face out of the water; do not wait until the round ends if you become tired.

Stop immediately if: If you feel unsafe or develop breathlessness, dizziness, chest pain or radiating pain, stop and go to the exit with help.

Common mistakes: Fastening the belt too loosely, and leaning the trunk too far forward.

Easier version: Return to jogging in place or walking in shallow water. Do not exercise while floating in deep water until you have the necessary training and readiness.