Comparative effectiveness of interventions incorporating physical activity in individuals with comorbid low back pain and depressive symptoms: a systematic review with network meta-analysis

Abstract

This systematic review with network meta-analysis aimed to identify the most effective intervention incorporating a substantial physical activity component in individuals with comorbid depressive symptoms and nonspecific chronic low back pain (LBP). A search of six databases (PubMed/Medline, PsycINFO, Web of Science Core Collection, EMBASE, CINAHL, CENTRAL) was conducted up to July 30, 2025. Randomised controlled trials on participants > 15 years with comorbid clinically relevant depressive symptoms (e.g., Beck Depression Inventory (BDI)-II > 13) and chronic (> 12 weeks) LBP were included. Interventions involved ≥ 33% active movement and lasted ≥ 2 weeks. Outcome-wise risk of bias (RoB) for the self-reported outcomes was assessed using the Cochrane RoB 2 tool. Primary outcomes were (i) changes in depressive symptoms (mandatory) and (ii) pain intensity, disability and quality of life, with each study required to include at least one of three additional outcomes. We calculated frequentist-based network meta-analysis. Of 2138 studies, five studies (N = 834, 50.1% female, mean age: 52.8 years) with eight treatments were included. Overall RoB ranged from low to some concerns. Yoga with education was most effective at mid-term follow-up (intervention duration closest to 12 weeks, k = 9), showing improvements in pain (SMD=−1.05 [95%CI=−1.38 to −0.72]) and clinically relevant improvements in depressive symptoms (SMD=−1.48 [95%CI=−1.81 to −1.14]), all vs. usual care. Antidepressant therapy with pain self-management (e.g., physical activity, relaxation, breathing) moderately affected depressive symptoms (SMD=−0.56 [95%CI=−0.60 to −0.53]) and pain (SMD=−0.53 [95%CI=−0.56 to −0.49]). At long-term follow-up, antidepressant therapy with pain self-management, and online- and mobile-based therapy showed superiority over usual care. The overall certainty of evidence across outcomes was low to very low. With very low certainty evidence, yoga combined with education yielded the most favourable effects across outcomes. However, these findings should be interpreted with caution and require adequately powered future trials. While other approaches showed small to moderate effects, their clinical relevance remains uncertain.