Oral Presentation Sydney Spinal Symposium 2026

Is More Exercise Better? A Dose-Response Network Meta-Analysis of 239 Randomised Trials in Chronic Low Back Pain (141720)

Nitin Kumar Arora 1 , Tobias Saueressig 2 , Tim Schleimer 3 , Hugo Pedder 4 , Xiaolong Chen 5 6 , Aminu A Ibrahim 7 , Lars Donath 8 , Katja Ehrenbrusthoff 1 , Jon J Ford 9 10 , Andrew J Hahne 9 , Ludwig Hammel 11 , Eva-Maria Huessler 12 , Ashish Diwan 5 13 , Svenja Kaczorowski 1 8 , Clint Miller 14 , Niamh Mundell 14 , Heike Norda 15 , Patrick J Owen 16 17 , Shikha Sharma 18 , Scott D Tagliaferri 19 20 , Sam Vickery 1 , Tomer Yona 21 , Xiaohui Zhao 22 , Daniel L Belavy 1
  1. FPHT, Hochschule Bochum Gesundheitcampus, Bochum, NRW, Germany
  2. Physio Meets Science GmbH, Leimen, Germany
  3. Graduate School for Applied Research in North Rhine-Westphalia (Graduate School NRW), Bochum, Germany
  4. Population Health Sciences, University of Bristol, Bristol, United Kingdom
  5. Department of Orthopaedic Surgery, Spine Service, University of New South Wales, St. George Hospital, New South Wales, Australia
  6. Department of Orthopaedic Surgery, Xuanwu Hospital Capital Medical University, Beijing, China
  7. Physiotherapy Department, Tishk International University, Erbil, Iraq
  8. Department of Intervention Research in Exercise Training, German Sport University Cologne, Cologne, NRW, Germany
  9. Discipline of Physiotherapy, School of Allied Health, Human Services & Sport, La Trobe University, Bundoora, Victoria, Australia
  10. Advance Healthcare, Victoria, Australia
  11. Deutsche Vereinigung Morbus Bechterew e.V. (DVMB), Schweinfurt, Germany
  12. Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
  13. Royal Adelaide Hospital and Adelaide University, Adelaide, SA, Australia
  14. Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
  15. UVSD SchmerzLOS e.V. (Unabhängige Vereinigung aktiver Schmerzpatienten in Deutschland), Neumünster, Germany
  16. Eastern Health Emergency Medicine Program, Melbourne, Victoria, Australia
  17. Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
  18. Lung Health Centre, Aelira Lung Care, New Delhi, Delhi, India
  19. Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
  20. Orygen, Parkville, Victoria, Australia
  21. Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
  22. Xi’an University of Architecture & Technology, Beilin, Xi'an, China

Aims: To investigate exercise dose-response relationships and estimate optimal exercise dose associated with clinically meaningful improvements in pain intensity and disability in adults with chronic low back pain disorders (CLBDs).

Methods: A systematic review with non-linear dose-response network meta-analysis was conducted. We searched six databases, two trial registries, and performed citation searches from inception to 3 June 2025. Randomised controlled trials evaluating exercise interventions in adults (≥18 years) with CLBDs were included. Outcomes were disability and back pain intensity measured at short-term (>1 day to ≤3 months), intermediate-term (>3 months to <12 months), and long-term (≥12 months) follow-up. Risk of bias was assessed using Cochrane RoB2 and certainty of evidence using the minimally contextualised GRADE framework. A 5-point change on a 0-100 scale was considered clinically meaningful.

Results: A total of 239 trials (252 reports) were included. Most studies (99.2%) included participants with chronic non-specific low back pain and only two trials included radicular presentations. Our analysis indicated that the greatest short-term improvements in disability were achieved with a frequency of four sessions per week, with a per-session duration of 25 minutes, delivered over 13 weeks. For pain intensity, the model-predicted optimal dose was three sessions per week, 30 minutes per session, over eight weeks. Credible intervals overlapped across most dose levels, indicating considerable uncertainty regarding a single optimal dose. Majority of studies (84%) were at high risk of bias with a very low to low GRADE certainty. 28.5% of trials reported adverse events and were predominantly non-serious musculoskeletal complaints.

Conclusions: Exercise training provides clinically meaningful short-term benefits for chronic non-specific low back pain across a range of low-to-moderate doses. Current evidence does not support a single optimal exercise dose suggesting flexibility in tailoring prescription for patient preferences and clinical context. Evidence for radicular low back pain remains limited.