Individualized Exercise in Chronic Non-Specific Low Back Pain: A Systematic Review with Meta-Analysis on the Effects of Exercise Alone or in Combination with Psychological Interventions on Pain and Disability

  • Johannes Fleckenstein
    Address reprint requests to Johannes Fleckenstein, Goethe-University Frankfurt, Institute of Sports Sciences, Department of Sports Medicine and Exercise Physiology, Ginnheimer Landstr. 39, 60487 Frankfurt am Main, Germany.
    Goethe-University Frankfurt, Institute of Sports Sciences, Department of Sports Medicine and Exercise Physiology, Frankfurt am Main

    Department of Pain Medicine, Klinikum Landsberg am Lech, Landsberg am Lech, Germany
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  • Philipp Floessel
    TU Dresden- University Hospital Carl Gustav Carus, University Center of Orthopedics, Trauma and Plastic Surgery, Dresden, Germany
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  • Tilman Engel
    University of Potsdam, University Outpatient Clinic, Sports Medicine and Sports Orthopedics, Potsdam, Germany
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  • Laura Krempel
    University of Wuppertal, Department of Clinical Psychology and Psychotherapy, Wuppertal, Germany
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  • Josefine Stoll
    University of Potsdam, University Outpatient Clinic, Sports Medicine and Sports Orthopedics, Potsdam, Germany
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  • Martin Behrens
    Department of Sport Science, Institute III, Otto-von-Guericke University Magdeburg, Magdeburg, Germany

    Department of Orthopedics, University Medicine Rostock, Rostock, Germany
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  • Daniel Niederer
    Goethe-University Frankfurt, Institute of Sports Sciences, Department of Sports Medicine and Exercise Physiology, Frankfurt am Main

    Institute of Occupational, Social and Environmental Medicine, Goethe University Frankfurt, Frankfurt am Main, Germany
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      • This meta-analysis is based on 58 RCTs with 10084 patients with chronic non-specific low back pain.
      • Individualising exercise has an overall small but relevant effect on pain intensity and disability.
      • Individualised exercise has small to medium effects compared to other active or passive controls.
      • Combining exercise with cognitive-behavioural interventions promotes largest clinical differences.
      • Motor-control trainings seem to be most promising exercises on an individualised level.
      • Most findings are based on low to moderate certainty of evidence.


      This systematic review, meta-analysis and meta-regression investigated the effects of individualized interventions, based on exercise alone or combined with psychological treatment, on pain intensity and disability in patients with chronic non-specific low-back-pain. Databases were searched up to January 31, 2022 to retrieve respective randomized controlled trials of individualized and/or personalized and/or stratified exercise interventions with or without psychological treatment compared to any control. Fifty-eight studies (n = 10084) were included. At short-term follow-up (12 weeks), low-certainty evidence for pain intensity (SMD -0.28 [95%CI -0.42 to -0.14]) and very low-certainty evidence for disability (-0.17 [-0.31 to -0.02]) indicates effects of individualized versus active exercises, and very low-certainty evidence for pain intensity (-0.40; [-0.58 to -0.22])), but not (low-certainty evidence) for disability (-0.18; [-0.22 to 0.01]) compared to passive controls. At long-term follow-up (1 year), moderate-certainty evidence for pain intensity (-0.14 [-0.22 to -0.07]) and disability (-0.20 [-0.30 to -0.10]) indicates effects versus passive controls. Sensitivity analyses indicates that the effects on pain, but not on disability (always short-term and versus active treatments) were robust. Pain reduction caused by individualized exercise treatments in combination with psychological interventions (in particular behavioral-cognitive therapies) (-0.28 [-0.42 to -0.14], low certainty) is of clinical importance. Certainty of evidence was downgraded mainly due to evidence of risk of bias, publication bias and inconsistency that could not be explained. Individualized exercise can treat pain and disability in chronic non-specific low-back-pain. The effects at short term are of clinical importance (relative differences versus active 38% and versus passive interventions 77%), especially in regard to the little extra effort to individualize exercise. Sub-group analysis suggests a combination of individualized exercise (especially motor-control based treatments) with behavioral therapy interventions to booster effects.


      The relative benefit of individualized exercise therapy on chronic low back pain compared to other active treatments is approximately 38% which is of clinical importance. Still, sustainability of effects (> 12 months) is doubtable. As individualization in exercise therapies is easy to implement, its use should be considered.

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