Fernandez-Rodriguez R, Alvarez-Bueno C, Cavero-Redondo I, et al. 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. J Orthop Sports Phys Ther. 2022 Aug;52(8):505-521. doi: 10.2519/jospt.2022.10671. Epub 2022 Jun 19. (Systematic review)

OBJECTIVE: To determine which type of exercise is best for reducing pain and disability in adults with chronic low back pain (LBP).

DESIGN: Systematic review with a network meta-analysis (NMA) of randomized controlled trials (RCTs).

LITERATURE SEARCH: Six electronic databases were systematically searched from inception to July 2021.

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.

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 probability of each intervention being the most effective was conducted according to surface under the cumulative ranking curve (SUCRA) values.

RESULTS: We included 118 trials (9710 participants). There were 28 head-to-head comparisons, 7 indirect comparisons for pain, and 8 indirect comparisons for disability. Compared with control, all types of physical exercises were effective for 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%).

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.

Discipline Area Score
Rehab Clinician (OT/PT) 7 / 7
Physician 5 / 7
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Comments from MORE raters

Physician rater

The Patient-Reported Outcome Measures used in the included studies all have low measurement properties according to the COSMIN checklist for systematic reviews. Especially content validity is lacing and evidence on unidimensionality and invariant measurement. Therefore, the conclusion of this systematic review is based on doubtful outcomes that might affect its results and conclusion.

Physician rater


Physician rater

The conclusion can not drawn for patients of all ages.

Physician rater

The findings are relevant. However, practical implications are limited by the high-risk of bias in two thirds of studies and small samples.

Rehab Clinician (OT/PT) rater

This is valuable information highlighting the importance of sophisticated central engagement in exercise, assisting the reduction and displacement of a fixated conscious focus on the pain experience.
Comments from PAIN+ CPN subscribers

Ms. Sandy Ketler (9/28/2022 7:38 AM)

Interesting that stretching was not identified to reduce pain in this review. Pilates is highly recommended, but is very unaffordable for many. Targeting core strength and mindfulness doesn’t seem to be new information - current practice is supported.
Deep water aquafit isn’t included in the summary as strongly as pilates - but may be a core strengthening activity more affordable and accessible to older adults.