Optimal exercise prescription for chronic low back pain in adults: a network meta-analysis

Abstract

OBJECTIVE: Traditional meta-analyses have confirmed that exercise intervention can effectively improve chronic low back pain, but the evidence for which specific exercise method is more effective is still insufficient. Therefore, this article used a network meta-analysis to explore the differences in the effects of different exercise elements on improving chronic low back pain in adults. METHODS: Randomized controlled trials of exercise intervention for nonspecific chronic low back pain were searched in PubMed, Web of Science, Embase, Cochrane, CNKI, WanFang, and VIP databases. The trial group received any type of exercise intervention, while the control group received non-exercise interventions such as drug therapy and physical therapy. The search period was from the database inception to March 1, 2025. Boolean operators (AND/OR) were used to combine keywords for the search. Two reviewers independently completed literature screening, data extraction, and risk of bias assessment. Stata 17.0 software was used for network meta-analysis, and the surface under the cumulative ranking curve (SUCRA) was used to rank the effects of exercise dose variables. RESULTS: A total of 40 randomized controlled trials were included. Network meta-analysis showed that core stability training, mat exercise, traditional Chinese exercises, combined exercise, and other exercises were superior to the control group in improving chronic low back pain [SMD=-0.76, 95%CI(-1.39, -0.13), P < 0.05; SMD=-1.67, 95%CI(-2.48, -0.86), P < 0.05; SMD=-2.09, 95%CI(-3.37, -0.80), P < 0.05; SMD=-1.60, 95%CI(-2.71, -0.49), P < 0.05; SMD=-1.40, 95%CI(-2.40, -0.40), P < 0.05]. Suspension training was less effective than traditional Chinese exercises and mat exercise [SMD=1.50, 95%CI(0.05, 2.95), P < 0.05; SMD=1.09, 95%CI(0.11, 2.06), P < 0.05]. Traditional Chinese exercises were superior to core stability training [SMD=-1.32, 95%CI(-2.64, -0.01), P < 0.05]. Regarding exercise duration, sessions of 15-20 min and 30-40 min were superior to control [SMD=-1.96, 95%CI(-3.55, -0.36), P < 0.05; SMD=-1.44, 95%CI(-2.12, -0.76), P < 0.05]. Regarding frequency, 3 times/week and 6-7 times/week were superior to control [SMD=-1.03, 95%CI(-1.69, -0.37), P < 0.05; SMD=-1.83, 95%CI(-2.75, -0.91), P < 0.05], and 6-7 times/week was superior to 1-2 times/week [SMD=-1.30, 95%CI(-2.61, -0.06), P < 0.05]. Regarding duration of program, 4 weeks, 12-13 weeks, and ≥16 weeks were significantly superior to control [SMD=-0.81, 95%CI(-1.50, -0.12), P < 0.05; SMD=-1.63, 95%CI(-2.82, -0.43), P < 0.05; SMD=-2.14, 95%CI(-3.36, -0.92), P < 0.05], and ≥16 weeks was superior to 6 weeks [SMD=-1.55, 95%CI(-3.03, -0.07), P < 0.05]. SUCRA results showed that traditional Chinese exercises, 15-20 min per session, 6-7 times per week, and ≥16 weeks ranked highest in their respective categories. CONCLUSION: Traditional Chinese exercises (Tai Chi, Qigong, Wuqinxi, Baduanjin), 15-20 min per session, 6-7 times per week, and ≥16 weeks may be the most effective for relieving chronic low back pain in adults. However, due to the limited number of included studies, further research is needed to provide stronger evidence.

1. Introduction

Chronic low back pain is a chronic pain syndrome lasting more than 12 weeks with unclear etiology [1]. As one of the leading causes of disability worldwide, it accounts for 8.1% of the global disability burden. Its high prevalence and long-term disabling nature not only severely affect patients' quality of life but also impose a heavy economic burden on healthcare systems [2]. This 'hidden epidemic' has become one of the most challenging public health issues [3]. Current guidelines advocate non-pharmacological interventions as the core approach, aiming to reduce pain, restore function, and lower disability rates. Existing treatments (e.g., medication, physiotherapy) often lack long-term efficacy, with recurrence rates as high as 60%-80%, necessitating new evidence-based approaches to break through the current therapeutic bottleneck [4].

In recent years, the Chinese Clinical Practice Guidelines for Non-Specific Low Back Pain recommend non-drug treatments and exercise therapy as first-line options [3]. Exercise therapy has become a research hotspot due to its high safety, low cost, and significant benefits [5]. Traditional meta-analyses have fully confirmed the effectiveness of exercise interventions for chronic low back pain. For instance, a 2021 meta-analysis by Hayden et al. [6] demonstrated that mat exercise and McKenzie therapy showed significant advantages in relieving pain in patients with chronic low back pain. However, traditional meta-analyses are limited to pairwise comparisons and cannot quantify the relative efficacy of different exercise types. Network meta-analysis integrates direct and indirect evidence to simultaneously evaluate the pros and cons of multiple interventions, providing more comprehensive evidence for clinical decision-making. This study systematically analyzed the efficacy of different exercise elements by comparing the specific effect sizes of exercise type, session duration, weekly frequency, and program duration, thereby providing a theoretical basis for pain recovery and recurrence risk reduction in patients with chronic low back pain.