[ literature review ]

RUBÉN FERNÁNDEZ-RODRÍGUEZ, MSc1 • CELIA ÁLVAREZ-BUENO, PhD1 • IVÁN CAVERO-REDONDO, PhD1

ANA TORRES-COSTOSO, PhD2 • DIANA P. POZUELO-CARRASCOSA, PhD1 • SARA REINA-GUTIÉRREZ, MSc1
CARLOS PASCUAL-MORENA, MSc1 • VICENTE MARTÍNEZ-VIZCAÍNO, MD1,3

Best Exercise Options for Reducing Pain

and Disability in Adults With Chronic Low
Back Pain: Pilates, Strength, Core-Based,
and Mind-Body. A Network Meta-analysis
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L
ow back pain (LBP), the most common type of chronic pain,60 Motor control,130 aerobic,140 and stretch-
represents the highest global burden of disease158 and impacts ing or strength exercises57 were effective
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

both social support and health care systems.92 Self-management for managing LBP, although their effect
estimates were not consistent.130,140 One
strategies for LBP include minimizing bed rest, remaining active,
network meta-analysis149 (NMA) includ-
and returning to work and usual activity as soon as possible.155 Exercise ing 41 randomized controlled trials (RCTs)
is recommended as 1 of the best short-term approaches to reducing concluded that an approach combining sta-
pain and disability.29 bilization and strengthening exercises was
likely the most effective exercise approach
U OBJECTIVE: To determine which type of comparisons for disability. Compared with control, for managing LBP. Yet, a more recent
exercise is best for reducing pain and disability in all types of physical exercises were effective for NMA found that Pilates, motor control,
Journal of Orthopaedic & Sports Physical Therapy®

adults with chronic low back pain (LBP).
U DESIGN: Systematic review with a network
meta-analysis (NMA) of randomized controlled
trials (RCTs).
U LITERATURE SEARCH: Six electronic data-
bases were systematically searched from inception
to July 2021.
U STUDY SELECTION CRITERIA: RCTs testing the
effects of exercise on reducing self-perceived pain or
disability in adults (aged 18-65 years) with chronic LBP.
U DATA SYNTHESIS: We followed the PRISMA-NMA
(Preferred Reporting Items for Systematic Reviews
and Meta-Analyses, incorporating NMAs of health
care interventions) statement when reporting our
NMA. A frequentist NMA was conducted. The prob-
ability of each intervention being the most effective
was conducted according to surface under the
cumulative ranking curve (SUCRA) values.
U RESULTS: We included 118 trials (9710 partici-
pants). There were 28 head-to-head comparisons,
7 indirect comparisons for pain, and 8 indirect
improving pain and disability, except for stretching
exercises (for reducing pain) and the McKenzie
method (for reducing disability). The most effective
interventions for reducing pain were Pilates, mind-
body, and core-based exercises. The most effective
interventions for reducing disability were Pilates,
strength, and core-based exercises. On SUCRA
analysis, Pilates had the highest likelihood for
reducing pain (93%) and disability (98%).
U CONCLUSION: Although most exercise
interventions had benefits for managing pain
and disability in chronic LBP, the most beneficial
programs were those that included (1) at least
1 to 2 sessions per week of Pilates or strength
exercises; (2) sessions of less than 60 minutes of
core-based, strength, or mind-body exercises; and
(3) training programs from 3 to 9 weeks of Pilates
and core-based exercises. J Orthop Sports Phys
Ther 2022;52(8):505-521. Epub: 19 June 2022.
doi:10.2519/jospt.2022.10671
U KEY WORDS: chronic low back pain, disability,
network meta-analysis, pain, therapeutic exercise
resistance training, and aerobic exercise
were the most effective interventions for
adults with nonspecific chronic LBP.109
Prior reviews did not consider chronic LBP
diagnostic triage categories,12 and some
potentially relevant trials did not meet the
inclusion criteria.31,101,102,147 Understand-
ing more about whether participant or
exercise characteristics influence pain and
disability can help clinicians best support
adults with LBP.
Therefore, we aimed to determine the
best type of exercise for reducing pain and
disability in adults with chronic LBP. We
considered potential effect modifiers that
were not examined previously (ie, age; sex;
sample size; exercise prescription vari-
ables such as frequency, volume, and dura-
tion; specific cause for chronic LBP; data
extraction; and small-studies effects)109

1
Health and Social Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain. 2Facultad de Fisioterapia y Enfermería, Universidad de Castilla-La Mancha, Toledo,
Spain. 3Universidad Autónoma de Chile, Talca, Chile. This work was supported by the Consejería de Educación, Cultura y Deportes-Junta de Comunidades de Castilla-La Mancha
and FEDER funds (SBPLY/17/180501/000533). The authors have declared that no conflict of interest exist. Address correspondence to Dr Celia Álvarez-Bueno, Universidad de
Castilla La-Mancha, Health and Social Research Center, Santa Teresa Jornet s/n, 16071, Cuenca, Spain. E-mail: Celia.AlvarezBueno@uclm.es t Copyright ©2022 JOSPT®, Inc

journal of orthopaedic & sports physical therapy | volume 52 | number 8 | august 2022 | 505
 [ literature review
and different nonexercise interventions
(as control nodes) to support clinical
recommendations.
METHODS
O
ur NMA was conducted based
on the Cochrane Handbook for Sys-
tematic Reviews of Interventions61
and reported according to the Preferred
Reporting Items for Systematic Reviews
and Meta-Analyses, incorporating NMAs
of health care interventions (PRISMA-
NMA68). The protocol was registered in
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the PROSPERO database (registration
number CRD42019121564).
Deviation From the Protocol
This review deviates from the protocol on
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
the following issue: we did not define the
categories of exercises in the PROSPERO
protocol before our preliminary searches
(December 2018). Before commencing
data extraction, we defined categories of
exercises and revaluated our classifica-
tion through the peer-review process such
that our final classification was defined in
July 2021 (supplementary decision tree
Journal of Orthopaedic & Sports Physical Therapy®
process). Some subgroup and additional
analyses were unplanned analyses, sug-
gested through the peer-review process.
Search Strategy
Two reviewers (R.F.-R. and C.A.-B.) in-
dependently searched the MEDLINE,
Embase, SPORTDiscus, CINAHL, Physio-
therapy Evidence Database (PEDro), and
Cochrane Central Register of Controlled
Trials (CENTRAL) databases, from incep-
tion to July 2021, to identify RCTs testing
the effectiveness of exercise for reducing
pain or disability in adults with chronic LBP.
The search strategy combined the follow-
ing terms: “back pain” or back pain[MeSH
Terms] or low back pain[MeSH Terms]
OR back pain*[Title/Abstract] or lumb*
pain[Title/Abstract] or lumbago[Title/Ab-
stract] or backache*[Title/Abstract] OR
back ache*[Title/Abstract]) and “exercise
movement techniques”[Mesh] or “resis-
tance training”[Mesh] or “exercise”[Mesh]
or exercise or “physical exercise” or aerobic
506 | august 2022 | volume 52 | number 8 | journal of orthopaedic & sports physical therapy
or endurance or strength or resistance or
core or stretch* or “mind-body” or pilates
or yoga or “tai-chi” (further details of the
search strategy employed for each database
are available in SUPPLEMENTAL TABLE S1). Ad-
ditionally, the list of references of previous
systematic reviews and meta-analyses in
the field was reviewed.109,149,168 No language
restrictions were applied. The Mendeley
Desktop “find and merge duplicated” tool
was used to search for duplicates, and a
third reviewer peer-reviewed the search
process (D.P.P.-C.).
Eligibility Criteria
Inclusion criteria were determined fol-
lowing the PICOS (participants, inter-
ventions, comparators, outcomes, study
design) strategy.
We included the following:
1. Type of studies: RCTs.
2. Participants: adults aged between 18
and 65 years with chronic LBP. We
defined chronic LBP as pain that per-
sisted for 12 weeks or longer117; those
adults with specific spinal pathologies
that caused or involved chronic pain
as well as those at pre- or post-surgery
phases were also considered.
3. Type of intervention: any structured
physical exercise intervention (exer-
cise had to account for at least 50%
of the intervention)130 categorized as
aerobic, strength, combined, core-
based, McKenzie, Pilates, stretching,
or mind-body at any frequency, dura-
tion, or intensity. We included trials
that compared 2 or more interven-
tions in separate arms.
4. Comparator: control participants do-
ing no exercise or usual practice as
well as any of the structured physical
exercise above-mentioned.
5. Outcomes: pain or disability mea-
sured with self-reported outcomes.
When more than 1 trial provided data
referring to the same sample, we priori-
tized the trial providing more detailed
data or with the largest sample size.23
We excluded the following:
1. Trials where 1 of the interventions in-
cluded an unbalanced physical therapy
]
for at least 1 of the trial arms (studies
in which physical therapy or passive
treatments were only applied in 1 of
the trial arms and not in the others;
the differences could be based on this
and not in exercise application).
2. Trials that reported the same type of
exercise intervention with minor dif-
ferences in their protocol of applica-
tion (ie, frequency, dose, or intensity)
without a control group or another
exercise group to make comparisons.
Studies excluded after full-text reading
and their specific reasons for exclusion are
available in SUPPLEMENTAL TABLE S2.
Classification of Available Evidence
Physical exercise interventions were clas-
sified into 8 categories, according to the
main type of exercise performed: (1) aero-
bic, (2) strength, (3) combined (or multi-
modal), (4) core-based, (5) McKenzie, (6)
Pilates, (7) stretching, and (8) mind-body.
Further information about the categories
is available in the supplemental file.
Data Extraction and
Risk-of-Bias Assessment
Two reviewers (R.F.-R. and C.A.-B.) in-
dependently extracted the following in-
formation from included trials: (1) author
name, (2) publication year, (3) country,
(4) sample characteristics (mean age,
percentage of female) and size (total
number of randomly assigned partici-
pants or with outcome measurement) for
each trial arm, and (5) different physical
exercise interventions and comparators
(including available details of frequency,
period, and intensity).
Multiple-group trials were included in
the analyses. The data from studies with
multiple arms categorized by authors as
the same intervention (ie, exercise inter-
ventions with differences in training load
or frequency) were pooled.
Regarding outcomes, we considered
pain and disability measures at baseline
and at the end of each intervention pe-
riod. We extracted data from the visual
analog scale (VAS) or the numeric rating
scale (NRS) for pain as well as from the
 Roland-Morris Disability Questionnaire
(RMDQ), the Oswestry Disability Index
(ODI), or the Patient-Specific Functional
Scale for disability. When different mea-
sures were reported to measure the same
construct in the same sample, we selected
the between-study heterogeneity in the
treatment estimates, predictive distribu-
tions were reported.63 A frequentist NMA
was conducted to calculate the effect of
each intervention.
The detailed protocol for data analy-
eligible studies, and full text was exam-
ined (FIGURE 1). Excluded studies with
their corresponding reasons for exclusion
are available in SUPPLEMENTAL TABLE S2. A
total of 118 trials1–3,5,7,9,10,13,15–22,24–26,28,31–37,
39,41–46,48,49,51–56,58,59,64–67,69–88,90,93–97,99,101–105,

the most valid and reliable measure accord- ses is available in the supplemental file 108,110–116,118,120,121,123–126,128,129,131–139,141–148,150–153,

ing to the literature.89 A third researcher (p. 34; heterogeneity and coherence as- conducted between 1999
157,159,160,162,166

(V.M.-V.) independently appraised the ac-
curacy of the extracted information.
Two reviewers (R.F.-R. and C.A.-B.) in-
dependently assessed the risk of bias of the
included RCTs using the revised Cochrane
risk-of-bias tool for randomized trials.62
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sessments, assumption of transitivity,
relative ranking of treatments and the
surface under the cumulative ranking
curve [SUCRA], sensitivity and sub-
group analyses, and publication bias).
Analyses were conducted in Stata 15.0
and 2021 were included in the NMA
(see SUPPLEMENTAL TABLE S3). From the
included trials, 111 had pain as outcome
and 100 had disability, resulting in 151
and 131 comparisons of interventions for
pain and disability, respectively. A total

Disagreements were solved by consensus
or a third reviewer (V.M.-V.). Further in-
formation about the data extraction and
risk-of-bias assessment is in SUPPLEMENTAL
TABLES S3 and S4.
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
(StataCorp LLC, College Station, TX) and
with the CINeMA (Confidence in Net-
work Meta-Analysis) software.107
RESULTS
of 9710 patients from 35 countries were
enrolled. The mean age of the partici-
pants ranged from 18 to 61 years. Partic-
ipants were distributed by intervention
as follows: 20 groups of aerobic exercises

with 545 participants (5.7%), 30 groups

Data Synthesis Study Search and Study Characteristics of strength exercises with 855 partici-
The included studies were summarized The search identified 7985 articles, of pants (8.8%), 36 groups of combined ex-
qualitatively in a table containing the which 191 were considered potentially ercises with 1888 participants (19.4%),
direct and indirect comparisons. We in-
cluded trials that compared an exercise
intervention with either a control group
(as defined previously) or another exer-
cise training intervention for NMA and
Journal of Orthopaedic & Sports Physical Therapy®

pairwise meta-analysis, without any re-

striction of total sample size.
The NMA was reported following
the PRISMA-NMA statement. First, the
strength of the available evidence was as-
sessed using a network geometry graph in
which the size of the node indicates the
number of trials included for each inter-
vention and the thickness of the continu-
ous line to connect nodes is proportional
to the number of trials directly compar-
ing the 2 interventions.127 Second, consis-
tency was assessed by checking whether
the intervention effects estimated from
direct comparisons were consistent with
those estimated by indirect comparisons.
The Wald test was conducted, and due to
the low statistical power, the arm-based,
sidesplitting model was used with the
symmetrical method assumption.167
Pairwise meta-analyses were con-
ducted for direct comparisons using the
random-effects DerSimonian and Laird38
FIGURE 1. Flow diagram of the study selection process.
method, and to appropriately incorporate

journal of orthopaedic & sports physical therapy | volume 52 | number 8 | august 2022 | 507
 [ literature review
48 groups of core-based exercises with
1374 participants (14.1%), 6 groups of
McKenzie exercises with 222 partici-
pants (2.3%), 11 groups of stretching
exercises with 363 participants (3.7%),
11 groups of mind-body exercises with
745 participants (7.7%), 24 groups of
Pilates with 758 participants (7.8%), and
80 in control groups with 2960 partici-
pants (30.5%).
According to the reductionist meta-
analytic approach, 6 trials in pain re-
ported different measures for the same
construct,42,43,52,80,95,157 and 10 trials re-
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ported disability with 2 different tools.2,21,
32,75,80,95,102,110,136, 153
We considered the VAS
and the NRS as the most valid and reli-
able measures for pain and the RMDQ
or the ODI for disability.
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Transitivity Assessment
After testing the transitivity assumption
according to different effect modifiers on
pain and disability comparisons, there
were no substantial modifications on the
meta-regression and subgroup analyses
performed. Further details are available
in SUPPLEMENTAL TABLE S5.
Journal of Orthopaedic & Sports Physical Therapy®
Risk-of-Bias Assessment
Thirty-six of the 118 trials (30%) were
assessed as low risk of bias, 42 were as-
sessed as some concerns (36%), and 40
were assessed as high risk of bias (34%)
in the overall risk-of-bias assessment
(SUPPLEMENTAL TABLE S4). Risk of bias,
heterogeneity, indirectness, and incoher-
ence in NMAs were assessed with the
CINeMA107 web application to compute
the confidence report and are available in
SUPPLEMENTAL FIGURES S1 and S2.
SUPPLEMENTAL FIGURES S5 and S6 dis-
played the ratings of certainty for pain
and disability among the exercise com-
parisons; most were rated as very low–
certainty evidence.
Network Meta-analyses
Network diagrams showed the relative
amount of evidence on physical exer-
cise interventions for each outcome as
well as the risk of bias for comparisons
508 | august 2022 | volume 52 | number 8 | journal of orthopaedic & sports physical therapy
( FIGURES 2 and 3). The NMAs involved
28 direct comparisons as well as 7 in-
direct comparisons for pain (aerobic vs
McKenzie, mind-body vs McKenzie, Pi-
lates and stretching, McKenzie vs strength
and stretching, and Pilates vs stretching)
and 8 indirect comparisons for disability
(aerobic vs mind-body).
Pain Compared with the control, the
standardized mean difference (SMD)
values from the NMA were as follows:
aerobic (−0.35; 95% confidence interval
[CI]: −0.59, −0.11; prediction interval
[PrI]: −0.72, 1.43; Grading of Recom-
mendations Assessment, Development
and Evaluation [GRADE]: very low),
strength (−0.74; 95% CI: −0.97, −0.52;
PrI: −1.81, 0.33; GRADE: very low),
combined (−0.55; 95% CI: −0.76, −0.34;
PrI: −1.62, 0.52; GRADE: very low),
core-based (−0.76; 95% CI: −0.96, −0.57;
PrI: −1.83, 0.30; GRADE: very low),
stretching (−0.26; 95% CI: −0.61, 0.09;
PrI: −1.36, 0.85; GRADE: very low),
McKenzie (−0.50; 95% CI: −0.9, −0.03;
PrI: −1.64, 0.65; GRADE: low), Pilates
(−0.83; 95% CI: −1.08, −0.58; PrI: −1.91,
0.24; GRADE: low), and mind-body
(−0.97; 95% CI: −1.27, −0.66; PrI: −2.05,
FIGURE 2. Network diagram for pain. The size of the
circle is proportional to the number of trials included
of each intervention, and the line width corresponds
to trials directly comparing the 2 interventions.
Green, yellow, and red colors refer to low, moderate
(some concerns), and high risk of bias. Abbreviations:
A, aerobic; C, control; Cb, core-based; Cm, combined;
MB, mind-body; Mc, McKenzie; Pi, Pilates; S,
strength; St, stretching.
]
FIGURE 3. Network diagram for disability. The size
of the circle is proportional to the number of trials
included of each intervention, and the line width
corresponds to trials directly comparing the 2
interventions. Green, yellow, and red colors refer to
low, moderate (some concerns), and high risk of bias.
Abbreviations: A, aerobic; C, control; Cb, core-based;
Cm, combined; MB, mind-body; Mc, McKenzie; Pi,
Pilates; S, strength; St, stretching.
0.12; GRADE: moderate) ( TABLE 1A ).
None of the comparisons showed signifi-
cant results when PrIs were considered
(TABLE 1A and SUPPLEMENTAL FIGURE S9).
When considering direct and indirect
evidence, mind-body showed greater
reductions in pain compared to aerobic,
as well as core-based, combined, mind-
body, Pilates, and strength compared
to control (TABLE 1A and SUPPLEMENTAL
FIGURE S11). Differences between direct
and indirect evidence were only signifi-
cant for stretching vs core-based (n = 3
studies), when potential sources of het-
erogeneity were explored; small-studies
effects could explain this (SUPPLEMENTAL
TABLE S10).
Ratings for Pain Pilates had the high-
est probability of being the most effec-
tive intervention for reducing pain and
the highest SUCRA (93%). Mind-body
and core-based exercises also had a high
probability to be the best intervention
following Pilates with a high SUCRA
(82.9% and 66.2%, respectively). The
ranking for probability was consistent
when the control node was split. Pilates,
mind-body, and core-based exercises had
 Comparisons for Network Meta-analysis and Direct
TABLE 1A
and Indirect Evidence for Pain

Difference Between Direct

Comparison Evidence NMA SMDa (95% CI) NMA 95% PrI Direct SMDa (95% CI) Indirect SMDa (95% CI) and Indirect (95% CI)
A:C Mixed 0.35 (0.11, 0.59) −0.72, 1.43 0.30 (−0.03, 0.64) 0.41 (0.06, 0.76) −0.10 (−0.59, 0.38)
A:Cb Mixed −0.41 (−0.70, −0.12) −1.50, 0.67 −0.27 (−1.60, 1.06) −0.42 (−0.71, −0.12) 0.15 (−1.21, 1.51)
A:Cm Mixed −0.20 (−0.48, 0.09) −1.28, 0.89 −0.27 (−0.87, 0.32) −0.18 (−0.50, 0.15) −0.09 (−0.77, 0.58)
A:MB Mixed −0.61 (−0.96, −0.27) −1.72, 0.49 −0.64 (−1.27, −0.004) −0.61 (−1.02, −0.19) −0.03 (−0.79, 0.73)
A:Pi Mixed −0.48 (−0.81, −0.16) −1.58, 0.62 −0.32 (−1.13, 0.49) −0.51 (−0.87, −0.16) 0.19 (−0.69, 1.08)
A:S Mixed −0.39 (−0.69, −0.09) −1.48, 0.70 −0.08 (−0.80, 0.64) −0.46 (−0.79, −0.13) 0.38 (−0.41, 1.17)
A:St Mixed 0.09 (−0.32, 0.50) −1.03, 1.22 −0.30 (−1.59, 0.99) 0.14 (−0.29, 0.57) −0.44 (−1.80, 0.92)
C:Cb Mixed −0.76 (−0.96, −0.57) −1.83, 0.30 −0.74 (−1.01, −0.46) −0.79 (−1.07, −0.52) 0.06 (−0.33, 0.44)
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C:Cm Mixed −0.55 (−0.76, −0.34) −1.62, 0.52 −0.60 (−0.93, −0.27) −0.52 (−0.79, −0.25) −0.08 (−0.51, 0.34)
C:MB Mixed −0.97 (−1.27, −0.66) −2.05, 0.12 −0.83 (−1.23, −0.43) −1.14 (−1.59, −0.68) 0.31 (−0.30, 0.92)
C:Mc Mixed −0.50 (−0.96, −0.03) −1.64, 0.65 −0.39 (−1.23, 0.45) −0.54 (−1.10, 0.02) 0.15 (−0.86, 1.16)
C:Pi Mixed −0.83 (−1.08, −0.58) −1.91, 0.24 −0.83 (−1.13, −0.54) −0.83 (−1.27, −0.38) −0.01 (−0.54, 0.53)
C:S Mixed −0.74 (−0.97, −0.52) −1.81, 0.33 −0.88 (−1.22, −0.53) −0.65 (−0.94, −0.35) −0.23 (−0.69, 0.22)
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

C:St Mixed −0.26 (−0.61, 0.09) −1.36, 0.85 −0.30 (−0.77, 0.18) −0.21 (−0.73, 0.31) −0.09 (−0.79, 0.62)
Cb:Cm Mixed 0.21 (−0.01, 0.44) −0.86, 1.28 0.29 (−0.06, 0.63) 0.16 (−0.14, 0.46) 0.13 (−0.33, 0.58)
Cb:MB Mixed −0.20 (−0.54, 0.13) −1.30, 0.90 −0.49 (−1.34, 0.35) −0.15 (−0.51, 0.22) −0.35 (−1.27, 0.58)
Cb:Mc Mixed 0.27 (−0.21, 0.74) −0.88, 1.42 0.37 (−0.49, 1.22) 0.22 (−0.35, 0.79) 0.14 (−0.88, 1.17)
Cb:Pi Mixed −0.07 (−0.36, 0.23) −1.16, 1.02 −0.15 (−1.05, 0.76) −0.06 (−0.37, 0.25) −0.09 (−1.04, 0.87)
Cb:S Mixed 0.02 (−0.23, 0.27) −1.05, 1.09 −0.16 (−0.58, 0.26) 0.11 (−0.19, 0.42) −0.27 (−0.79, 0.25)
Cb:St Mixed 0.51 (0.13, 0.88) −0.61, 1.62 1.22 (0.45, 1.98) 0.28 (−0.14, 0.71) 0.93 (0.06, 1.81)
Cm:MB Mixed −0.42 (−0.76, −0.07) −1.52, 0.69 −0.83 (−1.96, 0.30) −0.37 (−0.73, −0.01) −0.46 (−1.65, 0.73)
Cm:Mc Mixed 0.05 (−0.43, 0.54) −1.10, 1.21 −0.32 (−1.41, 0.77) 0.14 (−0.39, 0.68) −0.47 (−1.68, 0.75)
Journal of Orthopaedic & Sports Physical Therapy®

Cm:Pi Mixed −0.28 (−0.58, 0.02) −1.37, 0.81 −0.28 (−1.14, 0.58) −0.28 (−0.60, 0.04) 0.01 (−0.91, 0.93)
Cm:S Mixed −0.19 (−0.45, 0.06) −1.27, 0.88 −0.04 (−0.48, 0.39) −0.27 (−0.58, 0.04) 0.23 (−0.31, 0.76)
Cm:St Mixed 0.29 (−0.09, 0.68) −0.82, 1.41 −0.07 (−1.37, 1.23) 0.33 (−0.08, 0.73) −0.40 (−1.76, 0.96)
MB:S Mixed 0.22 (−0.13, 0.57) −0.88, 1.33 0.29 (−0.82, 1.40) 0.21 (−0.16, 0.59) 0.08 (−1.09, 1.24)
Mc:Pi Mixed −0.33 (−0.83, 0.16) −1.49, 0.82 −0.36 (−1.27, 0.55) −0.32 (−0.91, 0.26) −0.03 (−1.11, 1.05)
Pi:S Mixed 0.09 (−0.23, 0.41) −1.01, 1.18 0.25 (−1.04, 1.54) 0.08 (−0.25, 0.41) 0.17 (−1.16, 1.51)
S:St Mixed 0.49 (0.10, 0.88) −0.63, 1.60 −0.06 (−1.02, 0.90) 0.59 (0.17, 1.02) −0.65 (−1.70, 0.40)
A:Mc Indirect - −1.31, 1.02 - −0.15 (−0.66, 0.37) -
MB:Mc Indirect - −0.71, 1.65 - 0.47 (−0.08, 1.01)
MB:Pi Indirect - −0.98, 1.25 - 0.13 (−0.25, 0.52)
MB:St Indirect - −0.43, 1.85 - 0.71 (0.25, 1.16) -
Mc:S Indirect - −1.41, 0.92 - −0.25 (−0.75, 0.26) -
MC:St Indirect - −0.95, 1.44 - 0.24 (−0.33, 0.81)
Pi:St Indirect - −0.55, 1.70 - 0.57 (0.15, 1.00)
Abbreviations: A, aerobic; C, control; Cb, core-based; CI, confidence interval; Cm, combined; MB, mind-body; Mc, McKenzie; NMA, network meta-analysis;
Pi, Pilates; PrI, prediction interval; S, strength; SMD, standardized mean difference; St, stretching.
a
Positive SMDs favor T1, and negative values favor T2. Bold SMD means significant at P<.05. - (Dash) Significant at P < 0.05.

the highest probabilities of effect, and no
intervention and medication if needed
had the lowest probability of effect. More
details are available in FIGURE 4 and SUP-
PLEMENTAL FIGURE S13 as well as in the rank-
heat plot in SUPPLEMENTAL FIGURE S15.
Disability Compared with the control,
the SMD values from the NMA were as
follows: aerobic (−0.40; 95% CI: −0.64,
−0.15; PrI: −0.45, 1.24; GRADE: very
low), strength (−0.61; 95% CI: −0.80,
−0.41; PrI: −1.44, 0.22; GRADE: moder-
ate), combined (−0.35; 95% CI: −0.52,
−0.17; PrI: −1.17, 0.48; GRADE: very
low), core-based (−0.50; 95% CI: −0.67,
−0.32; PrI: −1.32, 0.33; GRADE: very
low), stretching (−0.34; 95% CI: −0.62,
−0.05; PrI: −1.20, 0.52; GRADE: very

journal of orthopaedic & sports physical therapy | volume 52 | number 8 | august 2022 | 509

100
Pilates
Mind-body
80
Core-based
SUCRA for Pain
60
40
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FIGURE 4. Ranking for each intervention on pain (SUCRA). Abbreviation: SUCRA, surface under the cumulative
ranking curve.
low), McKenzie (−0.44; 95% CI: −0.91,
0.04; PrI: −1.38, 0.50; GRADE: low),
Pilates (−0.60; 95% CI: −0.82, −0.38;
PrI: −1.44, 0.24; GRADE: low), and
Journal of Orthopaedic & Sports Physical Therapy®
mindbody (−0.45; 95% CI: −0.73, −0.18;
PrI: −1.31, 0.40; GRADE: low) (TABLE 1B).
None of the comparisons showed signifi-
cant results when PrIs were considered
(TABLE 1B and SUPPLEMENTAL FIGURE S10).
When considering direct and indirect evi-
dence, core-based, combined, mind-body,
Pilates, and strength showed greater re-
ductions in disability compared to the
control condition (TABLE 1B and SUPPLE-
MENTAL FIGURE S12).
Rankings for Disability Pilates had the
highest probability of being the most
effective intervention for reducing dis-
ability and the highest SUCRA (98%).
Strength and core-based exercises also
had a high probability of effects (77.7%
and 69.8%, respectively). The ranking
for probability was consistent when the
control node was split. Pilates, strength,
and core-based exercises had the highest
probabilities of effect, and no interven-
tion (11% and 9.6%, respectively) and
medication if needed (7.2% and 1.2%,
510 | august 2022 | volume 52 | number 8 | journal of orthopaedic & sports physical therapy
[ literature review
Strength
Combined
Stretching
McKenzie
Aerobic
Control
3 4 5 6 7 8
Rank
respectively) had the lowest probabilities
for both pain and disability. More details
are available in FIGURE 5 and SUPPLEMENTAL
FIGURE S14 as well as in the rank-heat plot
in SUPPLEMENTAL FIGURE S15.
Sensitivity Analysis, Heterogeneity, and
Publication Bias
The sensitivity analyses according to
the cause of chronic pain and by data
extraction are available in SUPPLEMENTAL
TABLES S6 and S7. Overall, the summary
estimates were not substantially altered.
The sensitivity analyses considering the
overall risk of bias among exercise com-
parisons are available in SUPPLEMENTAL
TABLES S8 and S9, and those for the small-
studies effects are displayed in SUPPLE-
MENTAL TABLES S10 and S11.
Regarding risk-of-bias categories,
exercise seems to be an effective inter-
vention to reduce pain when compared
to control, with an overall SMD of 0.58
(95% CI: 0.35, 0.80), as well as to re-
duce disability, with an overall SMD of
0.51 (95% CI: 0.33, 0.69). For pain, low–
risk-of-bias trials had higher SMDs than
high–risk-of-bias trials. For disability,
]
trials at low risk of bias had lower SMDs
than trials at high risk of bias. Exercise
interventions seem to be slightly more ef-
fective for reducing pain than for reduc-
ing disability, and the risk of bias might
influence disability estimates to a greater
extent (SUPPLEMENTAL FIGURES S1-S4).
Subgroup analysis results examining
comparisons among types of exercise
when considering exercise programming
characteristics are available in SUPPLEMEN-
TAL TABLES S12 and S13.
Heterogeneity results (assessed by I2)
have been extensively explained in the
supplemental file (p. 76). When CINeMA
heterogeneity reports were considered
according to PrIs, 42% of comparisons
had major concerns, 47% had some con-
9
cerns, and 11% had no concerns for pain
(SUPPLEMENTAL FIGURE S5). For disability,
CINeMA heterogeneity reports according
to PrIs showed major concerns for 19%
of comparisons, some concerns for 56%,
and no concerns for 25% (SUPPLEMENTAL
FIGURE S6).
For pain, there was evidence of pub-
lication bias in funnel plot asymmetry
and Egger’s test for core-based vs control
(P<.01), mind-body vs control (P = .03),
and Pilates vs control (P = .06). For dis-
ability, there was evidence of publication
bias in funnel plot asymmetry and Egg-
er’s test for core-based vs control (P<.01)
and core-based vs strength (P = .05) (see
SUPPLEMENTAL FIGURES S3 and S4).
DISCUSSION
T
his NMA, based on 118 RCTs in-
cluding 9710 patients, aimed to
compare the effectiveness of dif-
ferent modalities of exercise on reduc-
ing pain and disability among patients
with chronic LBP. Our NMA suggests
that all types of exercise were effective
for improving pain and disability, except
for stretching exercises for pain and the
McKenzie method for disability. Pilates
was the most effective intervention for
reducing pain and disability, followed
by mind-body and core-based exercises
for pain and by strength and core-based
 Comparisons for Network Meta-analysis and Direct
TABLE 1B
and Indirect Evidence for Disability

Difference Between Direct

Comparison Evidence NMA SMDa (95% CI) NMA 95% PrI Direct SMDa (95% CI) Indirect SMDa (95% CI) and Indirect (95% CI)
A:C Mixed 0.40 (0.15, 0.64) −0.45, 1.24 0.58 (0.24, 0.92) 0.20 (−0.15, 0.55) 0.38 (−0.11, 0.87)
A:Cb Mixed −0.10 (−0.38, 0.18) −0.956, 0.76 0.04 (−1.11, 1.19) −0.11 (−0.39, 0.18) 0.15 (−1.04, 1.33)
A:Cm Mixed 0.05 (−0.22, 0.32) −0.80, 0.90 −0.25 (−0.74, 0.25) 0.17 (−0.14, 0.49) −0.42 (−1.01, 0.17)
A:Pi Mixed −0.20 (−0.51, 0.10) −1.07, 0.66 −0.06 (−0.72, 0.61) −0.24 (−0.59, 0.10) 0.19 (−0.56, 0.94)
A:S Mixed −0.21 (−0.50, 0.08) −1.07, 0.65 −0.78 (−1.63, 0.07) −0.14 (−0.45, 0.17) −0.65 (−1.55, 0.26)
A:St Mixed 0.06 (−0.30, 0.42) −0.83, 0.94 0.02 (−1.09, 1.13) 0.06 (−0.32, 0.44) −0.04 (−1.22, 1.13)
C:Cb Mixed −0.50 (−0.67, −0.32) −1.32, 0.33 −0.36 (−0.61, −0.10) −0.61 (−0.84, −0.38) 0.25 (−0.10, 0.60)
C:Cm Mixed −0.35 (−0.52, −0.17) −1.17, 0.48 −0.29 (−0.56, −0.01) −0.39 (−0.62, −0.16) 0.10 (−0.26, 0.46)
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C:MB Mixed −0.45 (−0.73, −0.18) −1.31, 0.40 −0.37 (−0.71, −0.04) −0.61 (−1.08, −0.14) 0.24 (−0.34, 0.82)
C:Mc Mixed −0.44 (−0.91, 0.04) −1.38, 0.50 −0.10 (−0.96, 0.77) −0.58 (−1.15, −0.01) 0.48 (−0.55, 1.52)
C:Pi Mixed −0.60 (−0.82, −0.38) −1.44, 0.24 −0.64 (−0.91, −0.38) −0.49 (−0.91, −0.08) −0.15 (−0.64, 0.34)
C:S Mixed −0.61 (−0.80, −0.41) −1.44, 0.22 −0.66 (−0.95, −0.37) −0.56 (−0.83, −0.30) −0.10 (−0.49, 0.29)
C:St Mixed −0.34 (−0.62, −0.05) −1.20, 0.52 −0.57 (−1.00, −0.13) −0.16 (−0.54, 0.22) −0.40 (−0.98, 0.17)
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Cb:Cm Mixed 0.15 (−0.04, 0.34) −0.68, 0.98 0.28 (0.005, 0.55) 0.03 (−0.23, 0.29) 0.25 (−0.13, 0.63)
Cb:MB Mixed 0.04 (−0.27, 0.35) −0.83, 0.91 0.16 (−0.76, 1.08) 0.03 (−0.30, 0.35) 0.14 (−0.84, 1.11)
Cb:Mc Mixed 0.06 (−0.41, 0.53) −0.88, 1.00 −0.16 (−0.88, 0.55) 0.23 (−0.40, 0.86) −0.40 (−1.35, 0.56)
Cb:Pi Mixed −0.11 (−0.37, 0.16) −0.96, 0.75 0.17 (−0.61, 0.94) −0.14 (−0.42, 0.14) 0.31 (−0.52, 1.13)
Cb:S Mixed −0.11 (−0.33, 0.10) −0.95, 0.72 −0.20 (−0.57, 0.17) −0.07 (−0.34, 0.19) −0.13 (−0.58, 0.33)
Cb:St Mixed 0.16 (−0.14, 0.46) −0.71, 1.02 0.42 (−0.12, 0.96) 0.04 (−0.33, 0.40) 0.39 (−0.26, 1.04)
Cm:MB Mixed −0.11 (−0.42, 0.20) −0.97, 0.76 −0.77 (−1.69, 0.15) −0.02 (−0.35, 0.30) −0.75 (−1.72, 0.23)
Cm:Mc Mixed −0.09 (−0.57, 0.39) −1.03, 0.85 −0.10 (−0.96, 0.76) −0.09 (−0.66, 0.49) −0.02 (−1.05, 1.02)
Cm:Pi Mixed −0.25 (−0.52, 0.01) −1.10, 0.60 −0.01 (−0.75, 0.73) −0.29 (−0.57, −0.01) 0.28 (−0.51, 1.07)
Journal of Orthopaedic & Sports Physical Therapy®

Cm:S Mixed −0.26 (−0.48, −0.05) −1.10, 0.58 −0.02 (−0.40, 0.36) −0.38 (−0.64, −0.11) 0.36 (−0.11, 0.82)
Cm:St Mixed 0.01 (−0.30, 0.32) −0.86, 0.88 0.03 (−1.09, 1.15) 0.01 (−0.32, 0.33) 0.02 (−1.15, 1.19)
MB:S Mixed −0.16 (−0.47, 0.16) −1.02, 0.72 −0.15 (−1.04, 0.74) −0.16 (−0.50, 0.18) 0.01 (−0.95, 0.96)
MB:St Mixed 0.18 (−0.25, 0.49) −0.77, 1.01 0.17 (−0.69, 1.03) 0.10 (−0.30, 0.51) 0.07 (−0.88, 1.01)
Pi:S Mixed −0.01 (−0.29, 0.27) −0.87, 0.85 0.79 (−0.34, 1.92) −0.06 (−0.35, 0.23) 0.85 (−0.32, 2.02)
S:St Mixed 0.27 (−0.05, 0.59) −0.60, 1.14 0.44 (−0.41, 1.29) 0.24 (−0.10, 0.59) 0.20 (−0.72, 1.11)
A:MB Indirect - −0.95, 0.83 - −0.06 (−0.42, 0.30) -
A:Mc Indirect - −1.01, 0.93 - −0.04 (−0.57, 0.48) -
MB:Mc Indirect - −0.96, 0.99 - 0.02 (−0.52, 0.56) -
MB:Pi Indirect - −1.03, 0.74 - −0.15 (−0.49, 0.20) -
Mc:Pi Indirect - −1.13, 0.80 - −0.16 (−0.68, 0.36) -
Mc:S Indirect - −1.13, 0.78 - −0.17 (−0.67, 0.33) -
Mc:St Indirect - −0.88, 1.08 - 0.10 (−0.44, 0.64) -
Pi:St Indirect - −0.62, 1.15 - 0.26 (−0.09, 0.62) -
Abbreviations: A, aerobic; C, control; Cb, core-based; CI, confidence interval; Cm, combined; MB, mind-body; Mc, McKenzie; NMA, network meta-analysis;
Pi, Pilates; PrI, prediction interval; S, strength; SMD, standardized mean difference; St, stretching.
a
Positive SMDs favor T1, and negative values favor T2. Bold SMD means significant at P<.05. - (Dash) Significant at P < 0.05.

exercises for disability (FIGURES 6 and 7).
These results seem to be consistent when
age, sex, sample size, specific cause for
chronic LBP, data extraction, small-stud-
ies effects, and different control nodes
were explored as potential effect modifi-
ers. Sensitivity analyses suggest that, re-
gardless of risk of bias, exercise could be
an effective strategy to reduce pain and
disability. According to exercise program-
ming characteristics, it seems that (1) at
least 1 or 2 sessions per week of Pilates or
strength exercises; (2) sessions with less
than 60 minutes of core-based, strength,
or mind-body exercises; and (3) training

journal of orthopaedic & sports physical therapy | volume 52 | number 8 | august 2022 | 511

Pilates
100
Strength
80
Combined
SUCRA for Disability
60
40
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FIGURE 5. Ranking for each intervention on disability (SUCRA). Abbreviation: SUCRA, surface under the
cumulative ranking curve.
programs from 3 to 9 weeks of Pilates
and core-based exercises could be more
effective than other exercise interven-
tions for managing pain and disability.
Journal of Orthopaedic & Sports Physical Therapy®
A Cochrane review165 explored the
effects of Pilates for chronic LBP. More
recently, an NMA109 compared different
types of exercises in chronic LBP. Both
reviews were consistent with our results:
Pilates seems to be a promising type of
exercise for reducing pain and disability
in people with chronic LBP. Pilates might
be an exercise with great acceptance
among patients, which promotes stabil-
ity and control119 in the trunk region, pos-
ture alignment, and body awareness with
a specific respiratory pattern but also a
biopsychosocial approach to LBP.
Previous studies have hypothesized
that mind-body exercises may help pa-
tients with chronic LBP manage their
pain episodes27,91 by reducing self-per-
ceived disability and increasing pain tol-
erance. These benefits may be explained
by the biopsychosocial approach used
during mind-body exercises.91,106 Mind-
body exercise interventions may improve
physical performance by reducing kine-
512 | august 2022 | volume 52 | number 8 | journal of orthopaedic & sports physical therapy
[ literature review
Core-based
Mind-body Stretching
Aerobic
McKenzie
Control
3 4 5 6 7 8
Rank
siophobia34 as well as improve chronic
pain and disability156 by reducing other
psychosocial factors such as anxiety, de-
pression, and mental stress at work.6
Positive effects of trunk strengthen-
ing on pain and disability compared with
general exercise have been reported by pa-
tients with chronic LBP.40 Strengthening
the lumbopelvic muscles maintains spine
stability during upper- and lower-limb
movements and improves neuromus-
cular recruitment patterns.11 Therefore,
clinicians may also consider core-based
exercises when managing chronic LBP.
Although a recent review concluded that
neither aerobic (endurance) nor strength
(resistance) exercises were superior for re-
ducing pain and disability in patients with
chronic nonspecific LBP,161 these opposed
findings should be considered with cau-
tion due to the scarcity of included studies
when compared with our NMA.
Our results showed greater effects
of Pilates, mind-body, core-based, and
strength exercises for pain when com-
pared to aerobic exercises as well as
greater reductions in pain for mind-body
compared to combined and for strength
]
compared to stretching exercises. Our
data suggest greater reductions in dis-
ability with Pilates, strength, and core-
based exercises than with combined
exercises. However, exercise practitio-
ners and clinicians should consider the
individual characteristics of each patient
to prescribe a safe and effective interven-
tion.4 Clinicians should adapt exercise
according to the intensity of symptoms
to minimize central sensitization.106,163,164
Consider the context in which physical
activity or exercise is carried out when
recommending exercise.98 For example,
high levels of household work have been
associated with a higher risk of chronic
back disorders.4 Lastly, tailor exercise to
the patient’s clinical and environmental
9 circumstances98 and consider the pa-
tient’s beliefs of the benefits derived from
exercise.29
Limitations
Because some potential confounders, such
as exercise intensity, barriers for an effec-
tive intervention in chronic pain disor-
ders (ie, insomnia, anxiety, or depression
symptoms),106 analgesic or anti-inflam-
matory drugs prescribed, or diet, were
not reported in most articles, we were not
able to perform these meta-regression or
subgroup analyses to control for poten-
tial biases in our estimates. We did not
find any evidence that the assumption of
transitivity was violated. Thus, it seems
that the population was similar in the
baseline distribution of age, sex, sample
size, frequency and time per training ses-
sion, and length of the intervention. This
criterion should be interpreted with cau-
tion because other confounders or effect
modifiers could have been unreported or
underreported in the primary studies.
We did not include whole-body elec-
trostimulation training, vibration, or
proprioceptive exercises, but the main
types of exercises for managing chronic
LBP were analyzed in our NMA. Because
there were differences among studies in
the time of follow-up at which midpoint
changes were evaluated, we did not con-
sider the intermediate changes in pain
 Comparison (T1 vs T2) SMD (95% CI and PrI)

Aerobic vs
Aerobic_Control CI 0.35 (0.11, 0.59)
Aerobic_Control PrI 0.35 (-0.72, 1.42)
Aerobic_Core-based CI -0.41 (-0.70, -0.12)
Aerobic_Core-based PrI -0.41 (-1.50, 0.67)
Aerobic_Combined CI -0.20 (-0.48, 0.09)
Aerobic_Combined PrI -0.20 (-1.28, 0.88)
Aerobic_Mind-body CI -0.61 (-0.96, -0.27)
Aerobic_Mind-body PrI -0.61 (-1.72, 0.49)
Aerobic_Pilates CI -0.48 (-0.81, -0.16)
Aerobic_Pilates PrI -0.48 (-1.58, 0.62)
Aerobic_Strength CI -0.39 (-0.69, -0.09)
Aerobic_Strength PrI -0.39 (-1.48, 0.70)
Aerobic_Stretching CI 0.09 (-0.31, 0.50)
Aerobic_Stretching PrI 0.09 (-1.03, 1.22)

Control vs
Control_Core-based CI -0.76 (-0.96, -0.57)
Control_Core-based PrI -0.76 (-1.83, 0.30)
Control_Combined CI -0.55 (-0.76, -0.34)
Control_Combined PrI -0.55 (-1.62, 0.51)
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Control_Mind-body CI -0.96 (-1.27, -0.66)

Control_Mind-body PrI -0.96 (-2.05, 0.12)
Control_McKenzie CI -0.50 (-0.96, -0.03)
Control_McKenzie PrI -0.50 (-1.64, 0.65)
Control_Pilates CI -0.83 (-1.08, -0.58)
Control_Pilates PrI -0.83 (-1.91, 0.24)
Control_Strength CI -0.74 (-0.97, -0.52)
Control_Strength PrI -0.74 (-1.81, 0.32)
Control_Stretching CI -0.26 (-0.61, 0.09)
Control_Stretching PrI -0.26 (-1.36, 0.85)
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Core-based vs
Core-based_Combined CI 0.21 (-0.01, 0.44)
Core-based_Combined PrI 0.21 (-0.86, 1.28)
Core-based_Mind-body CI -0.20 (-0.54, 0.13)
Core-based_Mind-body PrI -0.20 (-1.30, 0.90)
Core-based_McKenzie CI 0.27 (-0.21, 0.74)
Core-based_McKenzie PrI 0.27 (-0.88, 1.41)
Core-based_Pilates CI -0.07 (-0.36, 0.23)
Core-based_Pilates PrI -0.07 (-1.15, 1.02)
Core-based_Strength CI 0.02 (-0.23, 0.26)
Core-based_Strength PrI 0.02 (-1.05, 1.09)
Core-based_Stretching CI 0.51 (0.13, 0.88)
Core-based_Stretching PrI 0.51 (-0.61, 1.62)
Journal of Orthopaedic & Sports Physical Therapy®

Combined vs
Combined_Mind-body CI -0.41 (-0.76, -0.07)
Combined_Mind-body PrI -0.41 (-1.52, 0.69)
Combined_McKenzie CI 0.05 (-0.43, 0.54)
Combined_McKenzie PrI 0.05 (-1.10, 1.21)
Combined_Pilates CI -0.28 (-0.58, 0.02)
Combined_Pilates PrI -0.28 (-1.37, 0.81)
Combined_Strength CI -0.19 (-0.44, 0.06)
Combined_Strength PrI -0.19 (-1.27, 0.88)
Combined_Stretching CI 0.29 (-0.09, 0.68)
Combined_Stretching PrI 0.29 (-0.82, 1.41)

Mind-body vs
Mind-body_Strength CI 0.22 (-0.13, 0.57)
Mind-body_Strength PrI 0.22 (-0.88, 1.33)

McKenzie vs
McKenzie_Pilates CI -0.33 (-0.83, 0.16)
McKenzie_Pilates PrI -0.33 (-1.49, 0.82)

Pilates vs
Pilates_Strength CI 0.09 (-0.23, 0.41)
Pilates_Strength PrI 0.09 (-1.00, 1.18)

Strength vs
Strength_Stretching CI 0.49 (0.10, 0.88)
Strength_Stretching PrI 0.49 (-0.63, 1.60)

-2 -1 0 1 2
Favors T2 Favors T1

FIGURE 6. Standardized mean difference of network meta-analysis estimates and their related 95% confidence and prediction intervals for pain. Abbreviations: CI, confidence
interval; PrI, prediction interval; SMD, standardized mean difference.

journal of orthopaedic & sports physical therapy | volume 52 | number 8 | august 2022 | 513
 [ literature review ]
Comparison (T1 vs T2) SMD (95% CI and PrI)

Aerobic vs
Aerobic_Control CI 0.40 (0.15, 0.64)
Aerobic_Control PrI 0.40 (-0.45, 1.24)
Aerobic_Core-based CI -0.10 (-0.38, 0.18)
Aerobic_Core-based PrI -0.10 (-0.95, 0.76)
Aerobic_Combined CI 0.05 (-0.22, 0.32)
Aerobic_Combined PrI 0.05 (-0.80, 0.90)
Aerobic_Pilates CI -0.20 (-0.51, 0.10)
Aerobic_Pilates PrI -0.20 (-1.07, 0.66)
Aerobic_Strength CI -0.21 (-0.50, 0.08)
Aerobic_Strength PrI -0.21 (-1.07, 0.65)
Aerobic_Stretching CI 0.06 (-0.30, 0.42)
Aerobic_Stretching PrI 0.06 (-0.83, 0.94)

Control vs
Control_Core-based CI -0.50 (-0.67, -0.32)
Control_Core-based PrI -0.50 (-1.32, 0.33)
Control_Combined CI -0.35 (-0.52, -0.17)
Control_Combined PrI -0.35 (-1.17, 0.48)
Control_Mind-body CI -0.45 (-0.73, -0.18)
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Control_Mind-body PrI -0.45 (-1.31, 0.40)

Control_McKenzie CI -0.44 (-0.91, 0.04)
Control_McKenzie PrI -0.44 (-1.38, 0.50)
Control_Pilates CI -0.60 (-0.82, -0.38)
Control_Pilates PrI -0.60 (-1.44, 0.24)
Control_Strength CI -0.61 (-0.80, -0.41)
Control_Strength PrI -0.61 (-1.44, 0.22)
Control_Stretching CI -0.34 (-0.62, -0.05)
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Control_Stretching PrI -0.34 (-1.20, 0.52)

Core-based vs
Core-based_Combined CI 0.15 (-0.04, 0.34)
Core-based_Combined PrI 0.15 (-0.68, 0.98)
Core-based_Mind-body CI 0.04 (-0.26, 0.35)
Core-based_Mind-body PrI 0.04 (-0.82, 0.91)
Core-based_McKenzie CI 0.06 (-0.41, 0.53)
Core-based_McKenzie PrI 0.06 (-0.88, 1.00)
Core-based_Pilates CI -0.10 (-0.37, 0.16)
Core-based_Pilates PrI -0.10 (-0.96, 0.75)
Core-based_Strength CI -0.11 (-0.33, 0.10)
Core-based_Strength PrI -0.11 (-0.95, 0.72)
Core-based_Stretching CI 0.16 (-0.14, 0.46)
Core-based_Stretching PrI 0.16 (-0.71, 1.02)
Journal of Orthopaedic & Sports Physical Therapy®

Combined vs
Combined_Mind-body CI -0.11 (-0.42, 0.20)
Combined_Mind-body PrI -0.11 (-0.97, 0.76)
Combined_McKenzie CI -0.09 (-0.57, 0.34)
Combined_McKenzie PrI -0.09 (-1.03, 0.85)
Combined_Pilates CI -0.25 (-0.52, 0.01)
Combined_Pilates PrI -0.25 (-1.10, 0.60)
Combined_Strength CI -0.26 (-0.48, -0.05)
Combined_Strength PrI -0.26 (-1.10, 0.57)
Combined_Stretching CI 0.01 (-0.30, 0.32)
Combined_Stretching PrI 0.01 (-0.86, 0.88)

Mind-body vs
Mind-body_Strength CI -0.16 (-0.47, 0.16)
Mind-body_Strength PrI -0.16 (-1.02, 0.71)
Mind-body_Stretching CI 0.18 (-0.25, 0.49)
Mind-body_Stretching PrI 0.18 (-0.77, 1.01)

Pilates vs
Pilates_Strength CI -0.01 (-0.29, 0.27)
Pilates_Strength PrI -0.01 (-0.87, 0.85)

Strength vs
Strength_Stretching CI 0.27 (-0.05, 0.59)
Strength_Stretching PrI 0.27 (-0.60, 1.14)

-2 -1 0 1 2
Favors T2 Favors T1

FIGURE 7. Standardized mean difference of network meta-analysis estimates and their related 95% confidence and prediction intervals for disability. Abbreviations: CI, confidence
interval; PrI, prediction interval; SMD, standardized mean difference.

514 | august 2022 | volume 52 | number 8 | journal of orthopaedic & sports physical therapy
 and disability during the exercise inter-
ventions. However, we performed meta-
regression models based on intervention
length (weeks) to determine the influence
on our estimates.
Two thirds of trials were at high risk
of bias or some concerns, mainly due to
the lack of blinding of the intervention,
instructor, and outcome assessment (as
pain and disability were measured with
self-perceived scales). Although subgroup
analyses were conducted (SUPPLEMENTAL
TABLES S8 and S9), the high proportion
of trials at high risk of bias or some con-
Downloaded from www.jospt.org at on March 15, 2024. For personal use only. No other uses without permission.
cerns should be considered when inter-
preting our results. In some cases, the
standard deviation was calculated from
skewed data (ie, median and interquar-
tile range reported by authors). We used
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
sensitivity analysis to check the effect on
our estimates.
Although funnel plots seem to be
asymmetric and Egger’s test showed sig-
nificant publication bias, publication bias
may not be the only explanation. Smaller
trials usually suffer from greater limita-
tions, and they may have biased over-
estimates of effects.50 Finally, exercise
Journal of Orthopaedic & Sports Physical Therapy®
efficacy may be enhanced by adding the
placebo response due to contextual fac-
tors in patients suffering chronic pain.
This should be explored in future trials.100
Clinical Implications
Our results provide evidence support-
ing the use of exercise for reducing pain
and disability in patients with chronic
LBP. Exercise interventions were more
effective for improving pain and re-
ducing disability than no intervention,
education (booklet or advice), placebo
(only for pain), standard physiotherapy
(only for disability), and pharmacologi-
cal treatment if needed. Policy makers
should consider their implementation
in a clinical context to reduce the use of
pharmacological14,30,98 and surgical op-
tions, which are probably more costly and
with a higher risk of adverse effects.102
Pilates interventions were the most ef-
fective for reducing pain and disability in
patients with chronic LBP. Note that we
journal of orthopaedic & sports physical therapy | volume 52 | number 8 | august 2022 |
used the SMD to standardize the changes
in each scale. We set the minimal impor-
tant difference at 0.30 because of the
self-reported nature of the outcomes.8,122
For decision-making purposes, note that
the SMD could be influenced by error
variation and could vary according to the
type of intervention, trial design, or the
method for sample recruitment.
Despite promising results suggested
by our data, many trials included a small
number of participants, which may re-
duce the higher effectiveness showed by
Pilates, mind-body, strength, and core-
based exercises. Individual differences
in trunk motor control154 might explain
some statistical heterogeneity.47 However,
given the diversity of trunk motor control
in clinical practice, we also consider that
including patients with different motor
control phenotypes could improve the
generalizability of our results. Although
we attempt to give a public health rec-
ommendation of the exercise with the
highest improvements on pain and dis-
ability, for many patients with chronic
LBP, it is necessary to identify individual
characteristics to target a specific exercise
approach during rehabilitation. Future
high-quality trials aimed at exploring this
concern should include in their analyses
potential confounders or effect modifiers,
especially exercise prescription variables
(ie, intensity) and some key chronic pain–
related factors as placebo effects, sleep
disorders, anxiety or depression symp-
toms, and dietary and lifestyle habits.
CONCLUSION
E
xercise was effective for reduc-
ing pain and disability in patients
with chronic LBP, except for stretch-
ing exercises for pain and the McKenzie
approach for disability. The most benefi-
cial programs were those that included
(1) at least 1 to 2 sessions per week of
Pilates or strength exercises; (2) sessions
of less than 60 minutes of core-based,
strength, or mind-body exercises; and (3)
training programs from 3 to 9 weeks of
Pilates and core-based exercises. t
KEY POINTS
FINDINGS: All modalities of exercise, except
for stretching (pain) and the McKenzie
method (disability), significantly reduced
pain and disability in people with chronic
low back pain (LBP).
IMPLICATIONS: Clinicians should feel con-
fident prescribing exercise for adults
who are suffering chronic LBP to help
manage pain and disability. Pilates,
strength, core-based, and mind-body
exercises seem to be the most effective
interventions.
CAUTION: After making a comprehensive
individual assessment of each patient,
clinicians and patients should discuss a
shared tailored target and specific exer-
cise approach for rehabilitation.
STUDY DETAILS
AUTHOR CONTRIBUTIONS: Rubén Fernández-
Rodríguez and Drs Martínez-Vizcaíno and
Cavero-Redondo were involved in study
conception. Rubén Fernández-Rodríguez,
Sara Reina-Gutiérrez, and Drs Álvarez-
Bueno and Pozuelo-Carrascosa were
involved in screening. Rubén Fernández-
Rodríguez and Drs Álvarez-Bueno and
Torres-Costoso were involved in extrac-
tion. Dr Martínez-Vizcaíno (responsible
for the Advanced Statistical Methods
subject in master’s degrees), Dr Cavero-
Redondo, and Carlos Pascual-Morena
were involved in statistical analyses.
Rubén Fernández-Rodríguez and Dr
Álvarez-Bueno drafted the manuscript.
All authors approved the final manuscript.
DATA SHARING: All data relevant to the
study are available as supplemental files.
PATIENT AND PUBLIC INVOLVEMENT: Patients
and members of the public were not in-
volved at any stage of the research.
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journal of orthopaedic & sports physical therapy | volume 52 | number 8 | august 2022 | 521