Is therapeutic exercise as a standalone intervention effective in reducing kinesiophobia in adults with nonspecific chronic low back pain? A systematic review and meta-analysis with meta-regression.

Abstract

Kinesiophobia is a psychosocial factor associated with pain persistence and disability in individuals with nonspecific chronic low back pain (NSCLBP). Although exercise therapy is commonly recommended, its isolated effect on kinesiophobia remains unclear. This systematic review and meta-analysis aimed to evaluate the effectiveness of standalone exercise in reducing kinesiophobia in adults with NSCLBP. A systematic search was conducted in MEDLINE, Cochrane Library, Web of Science, and Scopus without date or language restrictions. Randomized controlled trials including adults with NSCLBP (≥3 months) receiving standalone exercise were eligible. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and certainty of evidence was evaluated using GRADE. Random-effects meta-analyses calculated mean differences (MD) and standardized mean differences (SMD). Meta-regression explored heterogeneity. Eight randomized controlled trials involving 854 participants were included. Studies presented some concerns regarding risk of bias, and certainty of evidence was rated as low. Standalone exercise significantly reduced kinesiophobia compared with passive controls and usual care (MD = -5.38; 95% CI -7.63 to -3.13; SMD = -1.03), exceeding the minimal clinically important difference. However, considerable heterogeneity was observed (I² ≈ 94%), and meta-regression did not identify significant moderators. These findings were exploratory and limited by the small number of studies. Standalone exercise may reduce kinesiophobia in adults with NSCLBP; however, heterogeneity, methodological concerns, and low-certainty evidence limit confidence in the pooled effect estimate. Therefore, the observed effect should be interpreted as an overall trend rather than a consistent effect across populations and interventions.