OBJECTIVE: To estimate the comparative effectiveness of tailored exercise therapies in people with chronic, nonspecific low back pain. DESIGN: Systematic review with network meta-analysis. LITERATURE SEARCH: We searched PubMed, Cochrane Library, Web of Science, and Google Scholar from inception to August 27, 2024. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Only randomized controlled trials (RCTs) studying the effects of any type of tailored exercise therapies in persons with chronic, nonspecific low back pain were included. Outcomes of interest were pain intensity and disability. Usual care was the standard comparator; effect sizes were calculated as Hedges's g. DATA SYNTHESIS: We used the R package netmeta to conduct network meta-analyses. Network plotting and P-scores summarized the intervention hierarchy; usual care was the main comparator. Risk of bias was assessed using the Cochrane risk-of-bias tool. The certainty of evidence was evaluated using the CINeMA (Confidence in Network Meta-Analysis) tool. RESULTS: We included 58 randomized trials (n = 10 510 participants) with 29 different treatment or control categories. Risk of bias for pain intensity and disability was high. Cognitive functional therapy alone (SMDDisability = -0.89 [95% confidence interval = -1.11 to -0.66]; SMDPain = -0.71 [-0.97 to -0.45]) or combined with biofeedback (SMDDisability = -1.00 [-1.36 to -0.64]) were, with moderate-certainty evidence, the most effective treatments for pain intensity (k = 49 RCTs) and disability (k = 45 RCTs) reduction when compared to usual care. CONCLUSION: In comparison to usual care, cognitive functional therapy, alone or with biofeedback, likely results in a large disability reduction. J Orthop Sports Phys Ther 2026;56(1):16-27. Epub 3 December 2025. doi:10.2519/jospt.2025.13281.
| Discipline Area | Score |
|---|---|
| Rehab Clinician (OT/PT) |  |
| Physician |  |
Physician rater
In chronic nonspecific low back pain, cognitive functional therapy (CFT), alone or combined with biofeedback, appears to be the most effective method for reducing pain and disability compared with usual care based on moderate-certainty evidence. These findings support personalised rehabilitation approaches over generic exercises, emphasising the importance of biopsychosocial strategies. It seems advisable to prioritise CFT for patients seeking functional improvements and to combine biological (e.g., movement-based) and psychological tailoring to enhance adherence and outcomes and incorporating biofeedback for greater accuracy.
Physician rater
Cognitive functional therapy, ideally combined with targeted exercises, is more effective than usual care in reducing fear-avoidance strategies and disability in patients with chronic nonspecific low-back pain. Limitations of this review include a high risk of bias in the included studies and reliance on indirect evidence, which restricts the broad applicability of the results.
, McMaster University