TYPE Review

PUBLISHED 17 November 2023

DOI 10.3389/fpubh.2023.1155225

Exercise intervention for patients

OPEN ACCESS with chronic low back pain: a
systematic review and network
EDITED BY
Jun Zou,
Shanghai University of Sport, China

REVIEWED BY
Manuela Deodato,
meta-analysis
University of Trieste, Italy
Ljubica Konstantinovic,
University of Belgrade, Serbia
Ying Li 1†, Lei Yan 2,3†, Lingyu Hou 4†, Xiaoya Zhang 5, Hanping Zhao 6,
Indrani Poddar, Chengkun Yan 7, Xianhuang Li 8, Yuanhe Li 6, Xiaoan Chen 1* and
University of Minnesota Twin Cities,
United States Xiaorong Ding 4*
*CORRESPONDENCE 1
College of Sports Science, Jishou University, Jishou, Hunan, China, 2 Department of Orthopaedic
Xiaorong Ding Surgery, Shanxi Medical University Second Affiliated Hospital, Taiyuan, China, 3 Second Clinical Medical
[email protected] College, Shanxi Medical University, Taiyuan, China, 4 Department of Nursing, Peking University Shenzhen
Xiaoan Chen Hospital, Shenzhen, China, 5 School of Nursing, Nanjing University of Chinese Medicine, Nanjing,
[email protected] Jiangsu, China, 6 College of Nursing, Weifang University of Science and Technology, Weifang,
Shandong, China, 7 School of Nursing, Nanchang University, Nanchang, Jiangxi, China, 8 Digestive
These authors have contributed equally to this
†
Endoscopy Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
work

RECEIVED 31 January 2023

ACCEPTED 04 October 2023
PUBLISHED 17 November 2023
Purpose: Chronic low back pain (CLBP) is an aging and public health issue that
CITATION
Li Y, Yan L, Hou L, Zhang X, Zhao H, Yan C, Li X,
is a leading cause of disability worldwide and has a significant economic impact
Li Y, Chen X and Ding X (2023) Exercise on a global scale. Treatments for CLBP are varied, and there is currently no study
intervention for patients with chronic low back with high-quality evidence to show which treatment works best. Exercise therapy
pain: a systematic review and network
meta-analysis.
has the characteristics of minor harm, low cost, and convenient implementation.
Front. Public Health 11:1155225. It has become a mainstream treatment method in clinics for chronic low back
doi: 10.3389/fpubh.2023.1155225 pain. However, there is insufficient evidence on which specific exercise regimen
COPYRIGHT is more effective for chronic non-specific low back pain. This network meta-
© 2023 Li, Yan, Hou, Zhang, Zhao, Yan, Li, Li, analysis aimed to evaluate the effects of different exercise therapies on chronic
Chen and Ding. This is an open-access article
distributed under the terms of the Creative low back pain and provide a reference for exercise regimens in CLBP patients.
Commons Attribution License (CC BY). The Methods: We searched PubMed, EMBASE, Cochrane Library, and Web of Science
use, distribution or reproduction in other
forums is permitted, provided the original from inception to 10 May 2022. Inclusion and exclusion criteria were used for
author(s) and the copyright owner(s) are selection. We collected information from studies to compare the effects of 20
credited and that the original publication in this exercise interventions on patients with chronic low back pain.
journal is cited, in accordance with accepted
academic practice. No use, distribution or Results: This study included 75 randomized controlled trials (RCTs) with 5,254
reproduction is permitted which does not participants. Network meta-analysis results showed that tai chi [standardized
comply with these terms.
mean difference (SMD), −2.11; 95% CI, −3.62 to −0.61], yoga (SMD, −1.76; 95% CI
−2.72 to −0.81), Pilates exercise (SMD, −1.52; 95% CI, −2.68, to −0.36), and sling
exercise (SMD, −1.19; 95% CI, −2.07 to −0.30) showed a better pain improvement
than conventional rehabilitation. Tai chi (SMD, −2.42; 95% CI, −3.81 to −1.03) and
yoga (SMD, −2.07; 95% CI, −2.80 to −1.34) showed a better pain improvement
than no intervention provided. Yoga (SMD, −1.72; 95% CI, −2.91 to −0.53) and
core or stabilization exercises (SMD, −1.04; 95% CI, −1.80 to −0.28) showed a
better physical function improvement than conventional rehabilitation. Yoga
(SMD, −1.81; 95% CI, −2.78 to −0.83) and core or stabilization exercises (SMD,
−1.13; 95% CI, −1.66 to −0.59) showed a better physical function improvement
than no intervention provided.
Conclusion: Compared with conventional rehabilitation and no intervention
provided, tai chi, toga, Pilates exercise, sling exercise, motor control exercise, and
core or stabilization exercises significantly improved CLBP in patients. Compared
with conventional rehabilitation and no intervention provided, yoga and core or
stabilization exercises were statistically significant in improving physical function
in patients with CLBP. Due to the limitations of the quality and quantity of the

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included studies, it is difficult to make a definitive recommendation before more

large-scale and high-quality RCTs are conducted.

KEYWORDS

exercise therapy, chronic low back pain, network meta-analysis, CLBP, aging and public
health

Introduction Network Meta-Analysis (PRISMA-NMA) (19), registered in the

PROSPERO database (CRD42023388526).
Low back pain is a more severe low back pain syndrome that can
be classified by duration as acute (pain lasting for less than 6 weeks),
subchronic (6–12 weeks), or chronic (more than 12 weeks) (1, 2). Only Search strategy
39–76% of patients fully recover after an acute pain episode, suggesting
that a significant proportion suffer from chronic low back pain (CLBP) PubMed, Web of Science, Embase, and Cochrane Library were
(3). CLBP is a common and effective public health problem worldwide searched to identify studies published as of 10 May 2022 associated
and is the second most common reason for medical visits in people aged with RCT of exercise therapy for CLBP. The search takes a combination
65 years or older (4, 5). Studies have found that the incidence and of subject words and free words. The search strategy is shown in
prevalence of CLBP increase with age (6–8). CLBP imposes an enormous Supplementary Appendix 1.
economic and social burden, which will become even more onerous in
the coming decades as the number of patients with CLBP is expected to
increase significantly (9). In addition, a study of nearly 200,000 people in Study selection
43 countries found that those with CLBP were twice as likely to suffer
from depression, anxiety, psychosis, or sleep deprivation (10, 11). Two independent reviewers (Chengkun Yan and Xian Huang Li)
CLBP can lead to disability, high treatment costs, absenteeism, screened the titles and abstracts of publications retrieved by the search
and sick leave (10). Exercise therapy is based on kinematics, strategy to identify those eligible for inclusion. The full text of
biomechanics, physiology, and pathology to improve body function, potentially eligible studies was evaluated according to the inclusion
regulate physiological state, improve mental quality, and eliminate and exclusion criteria. The disagreements between reviewers were
mental disorders. Exercise therapy is characterized by low harm, low resolved through discussion. The NoteExpress software is used to
cost, and easy implementation and has become the first choice in the manage this phase.
clinical treatment of CLBP (12). There are many kinds of exercise
therapy (12), and it is unclear which exercise therapy is the best. Direct
comparative evidence of exercise therapy suggests that core stability Inclusion criteria
training is more effective than aerobic and stretching exercises in
treating CLBP (13). Inclusion and exclusion criteria are based on PICOS standards,
A review by Hayden reported that exercise therapy might be more see Table 1 for specific inclusion and exclusion criteria.
effective than education and non-exercise physiotherapy alone in
improving pain and function (14). However, Pilates remains
controversial for CLBP pain, as reported in paired meta-analyses (15). Data extraction
In a previous net meta-analysis, studies found that exercise and heat
were the best modalities for relieving CLBP pain (16). However, Data extraction pairs of reviewers independently extracted the
we found that the current study needs a detailed breakdown of exercise following data: first author, year of publication, country, sample size,
modalities (16) as it does not describe the effects of all current exercise CLBP time, age, weight, height, intervention, and intervention time.
modalities, such as tai chi and water sports, on the effects of CLBP (17, Data were expressed as mean ± standard deviation (SD). If outcome
18). We wanted to better explore the effects of other exercises on CLBP measures report multiple time points, we extract the data for the latest
patients. We performed a complex variety of exercise therapies, time point.
included more exercise modalities in our network meta-analysis, and
analyzed RCTs on the effects of different exercise therapies on patients
with CLBP to evaluate their therapeutic effects comprehensively and Risk of bias assessment
suggest the best exercise therapy for selecting exercise programs.
The risk of bias was assessed independently by two reviewers and
adjudicated by a third reviewer using the Cochrane Collaboration’s
Materials and methods tools (22), which include sequence generation, assignment hiding,
blinding, incomplete results data, non-selective results reporting, and
This network meta-analysis was designed according to the other sources of bias. Each criterion was judged to have a low, unclear,
guidelines for Preferred Reporting Items of Systems Review and or high risk of bias.

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TABLE 1 Inclusion and exclusion criteria.

Category Inclusion criteria Exclusion criteria

Population Patients diagnosed with chronic low back pain (20, 21) Patients with severe high
blood pressure, heart
disease, or other serious
systemic diseases

Interventions Core or stabilization exercises (CSE), yoga, McKenzie exercise (MKE), aerobic exercise (AE), water-based
physical activity (WPA), physical therapies (PT), manual treatment (MAT), sling exercise (SE), tai chi (TC),
Pilates exercise (PE), other exercise (OE), motor control exercise (MCE), muscle training (MUT), multimodal
exercise (MUE), conventional rehabilitation (COR), no intervention provided (NIP), home exercise (HE),
stretching exercise (STE), virtual reality exercise (VR), and education (ED).

Comparisons No intervention provided (NIP) and conventional rehabilitation (COR).

Outcomes The primary analysis for this study was to assess the intensity of the pain [Visual Analog Scale (VAS) or
Numerical Rating Scale (NRS)]. The second analysis was the Roland Morris Disability Questionnaire (RMDQ) or
the Oswestry Disability Index (ODI) for treatment response to back-related functional limitations.

Study Randomized controlled trial; published in English or Chinese

Each intervention is defined in Supplementary Appendix 2. Each result outcome measure is defined in Supplementary Appendix 3.

Data analysis intervention lasted from 7 days to 24 weeks. A total of 5,254 patients
were reported in the included studies. Of all the included studies, 46
We used the “netmeta” package of R-4.2.1 software to conduct a reported VAS, 16 reported NRS, 41 reported ODI, and 13 reported
network meta-analysis. The STATA 15.1 “networkplot” function is RMDQ. The average age ranged from 20.1 ± 0.7 to 70.4 ± 3.2 years, the
used to draw and generate network diagrams to describe and present average weight ranged from 54.7 ± 7.6 kg to 81 ± 18.6 kg, and the
different forms of exercise. We used nodes to represent various average height ranged from 156.11 ± 9.44 cm to 177.60 ± 9.98 cm. The
interventions and edges to represent head-to-head comparisons characteristics of the studies and the participants are shown in Table 2
between interventions. The node split method was used to assess and Supplementary Appendix 4. The risk of bias assessment for each
inconsistency between direct and indirect comparisons (23). The individual study is presented in Supplementary Appendix 5 and
pooled estimates and 95% confidence intervals (95% CI) were summary data in Figure 2. In addition, we conducted regression
calculated using random effects network element analysis. When analyses of age and gender, as shown in Supplementary Appendix 9.
we are interested in outcomes that use the same unit of measurement
in the study, consider mean difference (MD) as a therapeutic effect to Outcomes
analyze the results or evaluate standardized mean difference (SMD).
A pairwise random-effects meta-analysis was performed to compare Pain
various exercise treatments. Heterogeneity was assessed for all In total, 62 studies (24–30, 33, 35–50, 52–56, 58, 60, 61, 63–65,
pairwise comparisons using the I2 statistic and publication bias using 67–71, 73–79, 82–84, 86–92, 94–98) assessed pain, involving a total of
the value of p of Egger’s test. Funnel plots were conducted to determine 3,123 participants. We included the following 20 interventions in our
publication bias and minor study effects measured by results reported network meta-analysis (Figure 2): TC, yoga, PE, SE, MCE, WPA, CSE,
in more than 10 studies. MUE, MKE, HE, MAT, MUT, STE, ED, OE, AE, PT, VR, COR, and
NIP. TC (SMD, −2.11; 95% CI, −3.62 to −0.61), yoga (SMD, −1.76;
95% CI, −2.72 to −0.81), PE (SMD, −1.52; 95% CI, −2.68, to −0.36),
Results SE (SMD, −1.19; 95% CI, −2.07 to −0.30), MCE (SMD, −1.02; 95%
CI, −1.86 to −0.18), CSE (SMD, −0.95; 95% CI, −1.56 to −0.33), MUE
Literature selection (SMD, −0.94; 95% CI, −1.71 to −0.18), and MKE (SMD, −0.91; 95%
CI, −1.81 to −0.01) showed a better pain improvement than COR. TC
After deleting duplicates, 9,087 records were retrieved, and 8,608 (SMD, −2.42; 95% CI, −3.81 to −1.03), yoga (SMD, −2.07; 95% CI,
studies were discarded. The full text of the remaining 479 records was −2.80 to −1.34), PE (SMD, −1.83; 95% CI, −2.72 to −0.93), SE (SMD,
examined, and 404 records did not meet the inclusion criteria: 274 −1.49; 95% CI, −2.20 to −0.79), MCE (SMD, −1.33; 95% CI, −2.12 to
were non-RCTs, 89 were wrong interventions, 32 were no relevant −0.54), WPA (SMD, −1.36; 95% CI, −2.59 to −0.14), CSE (SMD,
outcomes, and 9 were duplicate studies. In the end, 75 studies (24–98) −1.25; 95% CI, −1.71 to −0.79), MUE (SMD, −1.25; 95% CI, −1.84 to
were included. The research flow chart is shown in Figure 1. −0.65), MKE (SMD, −1.22; 95% CI, −1.98 to −0.45), HE (SMD,
−1.20; 95% CI, −2.19 to −0.22), MAT (SMD, −1.16; 95% CI, −1.89 to
−0.42), MUT (SMD, −1.08; 95% CI, −1.67 to −0.49), STE (SMD,
Study and participant characteristics −1.02; 95% CI, −3.07 to −1.03), ED (SMD, −0.93; 95% CI, −1.84 to
−0.01), OE (SMD, −0.97; 95% CI, −1.52 to −0.43), and AE (SMD,
The included studies, published between 1998 and 2021, −0.82; 95% CI, −1.54 to −0.10) showed a better pain improvement
compared the effects of 20 different therapies on CLBP. The than NIP (Figure 3A). The comparison adjusted funnel plot did not

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FIGURE 1
Flow of trials throughout the review.

provide evidence for apparent publication bias and Egger’s test improvement than NIP (Figure 3B). The comparison-adjusted funnel
(p = 0.601) (Supplementary Appendix 6.1). Heterogeneity, plot did not provide evidence for apparent publication bias and Egger’s
intransitivity, and inconsistency of the network meta-analysis were test (p = 0.616) (Supplementary Appendix 6.2). Heterogeneity,
also evaluated (Supplementary Appendix 7). Direct pain was also intransitivity, and inconsistency of the network meta-analysis (NMA)
evaluated (Supplementary Appendix 8.1). were evaluated (Supplementary Appendix 7). Direct comparisons of
physical function were also evaluated (Supplementary Appendix 8.2
and Figure 4).
Physical function

In total, 54 studies (28, 30–35, 38, 39, 41, 44–55, 57–64, 66, 67, 72, Discussion
74, 76–82, 85–88, 90–98) assessed physical function, involving a total
of 4,355 participants. We included the following 18 interventions in CLBP is a global aging and public health problem. The global
our network meta-analysis (Figure 2), including the NIP, VR, SE, 1-year prevalence of CLBP in older adults is 13–50% (99, 100).
MCE, OE, WAP, MKE, PT, MUE, HE, MAT, AE, MUT, PE, COR, CSE, The medical burden associated with CLBP is high, not only due
yoga, and ED. Yoga (SMD, −1.72; 95% CI, −2.91 to −0.53), CSE to direct costs (medical appointments, tests, medications, and
(SMD, −1.04; 95% CI, −1.80 to −0.28) showed a better physical hospitalizations) but also due to loss of work productivity (101,
function improvement than COR. Yoga (SMD, −1.81; 95% CI, −2.78 102). Exercise therapy can relieve pain and improve dysfunction
to −0.83), CSE (SMD, −1.13; 95% CI, −1.66 to −0.59), SE (SMD, in CLBP. Nevertheless, there are many types of exercise therapy,
−1.10; 95% CI, −2.06 to −0.15), OE (SMD, −1.05; 95% CI, −1.66 to and it needs to be clarified which exercise is the best training
−0.43), PE (SMD; −1.08, 95% CI, −1.85 to −0.31), and MCE (SMD, method. In this study, we assessed the relative effects of 20
−0.90; 95% CI, −1.76 to −0.04) showed a better physical function different interventions on pain and physical function in patients

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TABLE 2 General characteristics of all included studies.

Characteristics VAS NRS ODI RMDQ

Publication characteristics

Total number of unique studies included 46 16 41 13

Publication year

1991–2000 3 0 1 1

2001–2010 9 6 10 4

2011–2021 34 10 30 8

Study design characteristics

Range of study sample size

1–50 28 6 21 8

51–100 9 4 9 2

101–150 7 3 7 3

151–200 0 2 1 0

>200 2 1 3 0

No. of intervention arms included

2 39 9 34 9

3 7 6 6 4

4 0 1 1 0

No. of studies containing the following treatment nodes

Core or stabilization exercises (CSE) 20 5 18 2

Yoga 4 1 4 0

McKenzie exercise (MKE) 4 1 3 0

Aerobic exercise (AE) 6 0 4 3

Water-based physical activity (WPA) 1 1 1 0

Physical therapies (PT) 8 1 5 3

Manual treatment (MAT) 4 1 3 1

Sling exercise (SE) 3 2 3 0

Tai chi (TC) 2 0 0 0

Pilates exercise (PE) 2 2 2 3

Other exercise (OE) 7 7 11 1

Motor control exercise (MCE) 2 3 3 0

Muscle training (MUT) 9 2 8 5

Multimodal exercise (MUE) 7 2 7 2

No intervention provided (NIP) 12 7 10 9

Conventional rehabilitation (COR) 5 1 4 0

Home exercise (HE) 1 1 1 1

Stretching exercise (STE) 1 0 0 0

Virtual reality (VR) 0 1 1 0

Education (ED) 1 2 2 0

Time of intervention

Unclear 0 0 0 0

7 days 1 0 1 0

10 days 1 0 1 0

4 weeks 10 6 10 2

6 weeks 11 1 11 1

8 weeks 9 7 9 4

(Continued)

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TABLE 2 (Continued)

Characteristics VAS NRS ODI RMDQ

12 weeks 9 2 7 5

13 weeks 1 0 0 0

16 weeks 1 0 0 0

20 weeks 1 0 1 0

24 weeks 1 0 1 0

6 months 1 0 0 1

12 months 0 0 0 0

Intervention frequency

1 times/week 0 2 3 1

2 times/week 12 2 8 5

3 times/week 18 4 14 2

4 times/week 1 0 2 1

5 times/week 4 2 4 0

7 times/week 1 0 0 0

Unclear 10 6 10 4

Countries

Turkey 5 1 5 1

Korea 15 2 9 1

Greece 0 3 2 2

Brazil 1 1 2 1

Israel 2 0 1 2

Thailand 0 1 1 0

Australia 0 2 1 0

USA 3 1 2 0

Netherlands 0 0 0 1

Canada 2 2 4 0

Spain 2 0 2 1

Iran 5 0 2 1

Germany 1 0 0 0

Egypt 0 0 0 1

Lithuania 1 0 1 0

Pakistan 0 0 1 0

India 1 0 1 0

Poland 1 0 1 0

Kosovo 2 0 2 0

Norway 1 1 2 0

Singapore 0 1 0 0

Croatia 0 1 1 0

China 1 0 0 0

Finland 3 0 0 2

Austria 0 0 1 0

Patient characteristics

Range of mean age (years) 20.1–70.4 26.0–68.8 26.0–68.8 23.45–57.19

Range of mean weight (kg) 54.7–82.3 55.6–80.8 55.6–80.8 63.3–80.1

Range of mean height (cm) 156.55–177 160–172.6 156.11–177.60 161.21–173

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FIGURE 2
Percentage of studies examining the efficacy of exercise training in patients with non-specific chronic low back pain with low, unclear, and high risk of
bias for each feature of the Cochrane Risk of Bias Tool.

with CLBP. Regression analyses showed no correlation between improve the absorption of calcium and other minerals by bone
patient age and patients’ pain scores and physical functioning cells, and improve bone density in the lumbar region (108). The
scores. In addition, regression analyses also showed no 2017 American Medical Association’s Authoritative Guidelines for
correlation between patients’ gender and patients’ pain scores and the treatment of low back pain recommend tai chi for the
physical function scores. Tai chi, yoga, Pilates exercise, sling treatment of chronic low back pain (109). Our study further
exercise, motor control exercise, core or stabilization exercises, supports this result.
multimodal exercise, and McKenzie exercise are more beneficial Physical therapies involve whole-body movement that emphasizes
for pain relief than conventional rehabilitation, and no the body posture of the human body standing and enhances the body
intervention is provided. Water-based physical activity, home control and balance ability through the brain consciousness to control
exercise, manual treatment, muscle training, stretching exercise, smooth body movements and correct breathing (110, 111). In addition
education, other exercise, and aerobic exercise are more useful to core strengthening, physical therapies emphasize the coordination
for pain relief than no intervention provided. Yoga and core or of breathing and movement posture, which can reduce joint
stabilization exercises showed better physical function contraction and fatigue of trunk muscles, effectively reduce pain, and
improvement than conventional rehabilitation, and no improve body function, and are widely used in treating CLBP.
intervention was provided. Sling exercise, Pilates exercise, and One study reported that in patients with low back pain, the
motor control exercise, other exercises, showed better physical height of the intervertebral disc and the length and load of the
function improvement than no intervention provided. paravertebral ligament changed, and the adaptability of the
In our study, we found that tai chi can reduce pain in patients proprioceptive receptor decreased, thus reducing the proprioceptive
with chronic low back pain. The results of this study are the same input and weakening the neuromuscular reflex of the paravertebral
as those of Lauche et al. (103). Compared with other forms of muscle, resulting in lumbar instability and decreased postural
exercise, tai chi can increase structural flexibility and mobility, control (112). Sling exercise activates the core muscle group by
improve muscle strength and endurance, increase the tensile suspending part of the body and placing the body in an unstable
strength of ligaments and bursae, enhance cardiopulmonary state, improving muscle imbalance, improving the control ability of
function, and reduce stress, anxiety, and depression (104). Tai chi the neuromuscular system, enhancing the stability of the lumbar
can significantly increase bone density value, improve limb motor spine, and improving physical function. In our study, core
and balance function, and effectively improve the symptoms of stabilization training was found to be effective in reducing pain.
low back pain (103, 105). In addition, CLBP trunk proprioception Changes in plasma β-endorphin levels can indicate efficacy response
is diminished, resulting in deficits in the control of ankle and hip in chronic lower back pain (113). Cortisol is a type of glucocorticoid
strategies during balance control, a phenomenon that exacerbates produced by the hypothalamic–pituitary–adrenal axis activity.
the decreased trunk proprioception in CLBP (106). Tai chi can Uncomfortable physical pain in CLBP can trigger anxiety in
alter brain waves in the brain’s perception of pain areas (parietal patients. Pain and anxiety lead to increased hypothalamic-pituitary-
and prefrontal lobes), and the brain processes relevant information adrenal axis activation, leading to elevated cortisol levels in patients
more efficiently, improving proprioception in the brain centers (114). In addition, pain neuronal excitability releases transmitters
(107). Some studies have reported that tai chi can reduce serum (115). In addition, interleukin 4 (IL-4), an anti-inflammatory
B-type linalool peptide levels, increase per-pulse output, improve cytokine produced by macrophages and monocytes, inhibits the
blood circulation throughout the body, and improved blood synthesis of pro-inflammatory cytokines. It has been found (114,
circulation can transport blood calcium and other nutrients to the 116–118) that the mechanism of action of core stabilization training
lumbar region, increase the metabolism of the lumbar bones, for CLBP is mainly through altering the neurotransmitters

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stretching, flexibility, and balance training, yoga can also

strengthen back muscles, relieve pain, and improve patients with
functional impairment (56). In addition, yoga can effectively
improve the lumbar pain and spinal flexibility of CLBP patients
by stretching the spine vertebra and making the lumbar spine get
strength training. More than half of CLBP patients in the
United States choose yoga as an adjunct therapy (120). Guidelines
developed by the American Pain Society suggest that for CLBP
not alleviated by medication and self-management, consider
recommending yoga as adjunctive therapy to help patients relieve
pain (121).
Fernández-Rodríguez et al. conducted a network meta-analysis of
nine exercises. They found that Pilates was the most effective
intervention for reducing pain (114). Unlike our study, tai chi and
yoga were more effective than Pilates exercises in reducing pain. In
Gianola et al. (16) and Owen et al. (18) network meta-analysis, Tai chi
was not treated as a separate intervention, and conventional
rehabilitation and no intervention provided were not treated as
control groups. However, we have classified, in detail, the different
exercises into 20 other activities, including tai chi, virtual reality
exercises, and conventional rehabilitation, for a more comprehensive
NMA. Our study provides evidence that “active therapies” such as tai
chi, yoga, sling exercise, and core or stabilization exercises, in which
patients are guided and actively encouraged to move and exercise in a
gradual manner, are most effective. In our study, we did not
recommend virtual reality exercise, conventional rehabilitation, and
no intervention provided for CLBP patients. They are less effective in
pain in patients with CLBP.

Strengths and limitations

Our review has several strengths. First, we used the network
meta-analysis design to synthesize direct and indirect evidence from
various exercise interventions that can be used to treat
CLBP. Importantly, we used a nuanced approach to categorize
FIGURE 3 exercise interventions. Previous reviews have often grouped different
Network plots of pain and Physical function. The size of the nodes exercise interventions, potentially leading to heterogeneous
represents how many times the exercise appears in any comparison
aboutthat treatment and the width of the edges represents the total comparisons and inaccurate estimates of therapeutic effectiveness in
sample size in the comparisons it connects. Core or stabilization a single comparison. Interventions were divided into 20 types, and
exercises (CSE), Yoga, McKenzie exercise (MKE), Aerobic exercise various interventions were defined. However, we also have certain
(AE), Water-based physical activity (WPA), Physical therapies (PT),
Manual treatment (MAT), Sling exercise (SE), Tai chi (TC), Pilates limitations. First, we did not take the intervention period, intensity,
exercise (PE), Other exercise (OE), Motor control exercise (MCE), and frequency into consideration. Second, the implementation
Muscle training (MUT), Multimodal exercise (MUE), Conventional quality of the blind method included in the literature is not high, and
rehabilitation (COR), No intervention provided (NIP), Home exercise
(HE), Stretching exercise (STE).Virtual Reality exercise (VR), pain and functional improvement are subjective indicators, which
Education (ED). may lead to the bias of the results due to the different focus of
researchers. Third, we only included English literature, which may
lead to heterogeneity. Fourth, the study did not analyze differences
by initial categories that are important for both VAS and physical
β-endorphin, cortisol, and IL-4 levels. Ko et al. (74) proved that function. Fifth, CLBP was not considered in terms of the presence of
both suspension and stability training could effectively relieve pain a neuropathic or nocioplastic component. Sixth, biomarkers showing
and enhance lumbar muscle strength and flexibility in the effects of different exercise interventions were unavailable in the
CLBP patients. study. Finally, gender considerations were missing from the study
In our study, we found that Yoga can reduce pain in patients reports. There are some gender differences in abdominal and lumbar
with chronic low back pain. The results of this study are the same muscle characteristics between female and male subjects (122), which
as those of Zhu et al. (119). Yoga originated in India and has a can lead to differences in response to post-exercise emerging in
history of more than 4,000 years. While promoting spinal tissue gender-specific CLBP patients.

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FIGURE 4
League tables of outcome analyses. Data are mean differences and 95% credibility intervals for continuous data. Core or stabilization exercises
(CSE), Yoga, McKenzie exercise (MKE), Aerobic exercise (AE), Water-based physical activity (WPA), Physical therapies (PT), Manual treatment (MAT),
Sling exercise (SE), Tai chi (TC), Pilates exercise (PE), Other exercise (OE), Motor control exercise (MCE), Muscle training (MUT), Multimodal exercise
(MUE), Conventional rehabilitation (COR), No intervention provided (NIP), Home exercise (HE), Stretching exercise (STE).Virtual Reality exercise (VR),
Education (ED).

Conclusion article. All authors contributed to the article and approved the
submitted version.
This systematic review examined pain reduction and physical
function improvement in patients with CLBP treated with exercise.
Compared to COR and NIP, exercise is effective in relieving pain and Funding
improving physical function. In conclusion, understanding the
benefits of exercise versus non-exercise therapy is essential to better This study was supported by the Sanming Project of Medicine in
serve patients with CLBP. Shenzhen (no. SZSM202111013).

Author contributions Supplementary material

YuL and LH designed the study. CY and XL acquired, The Supplementary material for this article can be found online
analyzed, and interpreted the data. XD, YiL, YH, and YuL revised at: https://www.frontiersin.org/articles/10.3389/fpubh.2023.1155225/
the manuscript. XZ and XC contributed to the revision of the full#supplementary-material

Frontiers in Public Health 09 frontiersin.org

Li et al. 10.3389/fpubh.2023.1155225

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