{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T15:54:34Z","timestamp":1776095674848,"version":"3.50.1"},"reference-count":72,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,2,2]],"date-time":"2026-02-02T00:00:00Z","timestamp":1769990400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Chronic non-specific low back pain (CLBP) imposes a substantial healthcare burden. For CLBP, non-pharmacologic pain management within physical therapy\/rehabilitation commonly relies on therapeutic exercise (exercise therapy). Aquatic interventions such as exercise and balneotherapy are widely prescribed to treat CLBP, but their comparative effectiveness against land-based exercise, and multi-model programs remain unclear. We performed a network meta-analysis of randomized controlled trials to compare the effects of aquatic, land-based exercise, and multi-modal interventions on pain and disability in patients with chronic low back pain.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We searched from inception to May 2025 for randomized controlled trials in adults with chronic non-specific low back pain that evaluated water-based therapies (aquatic exercise, hydrotherapy\/balneotherapy). All randomized arms within eligible trials were retained, allowing comparisons with land-based exercise, combined aquatic\u202f+\u202fland-based programs, and general care\/blank control.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      We included 26 RCTs, forming a 9-node network (blank control, general care, land-based exercise, aquatic exercise, balneotherapy, and their combinations with general care\/land-based exercise). For pain intensity, compared with blank control, balneotherapy\u202f+\u202fgeneral care (SMD\u202f=\u202f2.51, 95% CI 1.26\u20133.76;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001), aquatic exercise\u202f+\u202fgeneral care (SMD\u202f=\u202f1.96, 95% CI 0.44\u20133.48;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.011), balneotherapy\u202f+\u202fland-based exercise (SMD\u202f=\u202f1.68, 95% CI 0.58\u20132.78;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.003), aquatic exercise (SMD\u202f=\u202f1.58, 95% CI 0.83\u20132.32;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001), land-based exercise (SMD\u202f=\u202f1.45, 95% CI 0.56\u20132.34;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.001), and balneotherapy (SMD\u202f=\u202f1.27, 95% CI 0.19\u20132.35;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.021) significantly reduced pain. By contrast, land-based exercise\u202f+\u202fgeneral care (SMD\u202f=\u202f1.55, 95% CI\u202f\u2212\u202f0.18\u20133.27;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.078) and general care (SMD\u202f=\u202f1.02, 95% CI\u202f\u2212\u202f0.13\u20132.17;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.081) did not reach statistical significance. Based on SUCRA for pain, balneotherapy\u202f+\u202fgeneral care ranked first (SUCRA\u202f=\u202f0.92; PrBest\u202f=\u202f61.4%; mean rank\u202f=\u202f1.7), followed by aquatic exercise\u202f+\u202fgeneral care (0.71; 21.5%; 3.3) and balneotherapy\u202f+\u202fland-based exercise (0.62; 3.8%; 4.0), with combined interventions generally ranking above single modalities; blank control ranked last (0.01; 0.0%; 8.9). For clinical context, the observed SMDs correspond approximately to 24\u201348 points of pain reduction across the interventions that showed statistically significant effects. For disability, compared with blank control, balneotherapy\u202f+\u202fgeneral care (SMD\u202f=\u202f2.76, 95% CI 1.12\u20134.40;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.001), balneotherapy (SMD\u202f=\u202f2.48, 95% CI 0.50\u20134.45;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.014), aquatic exercise\u202f+\u202fgeneral care (SMD\u202f=\u202f2.28, 95% CI 0.69\u20133.86;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.005), balneotherapy\u202f+\u202fland-based exercise (SMD\u202f=\u202f2.06, 95% CI 0.64\u20133.48;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.004), aquatic exercise (SMD\u202f=\u202f2.03, 95% CI 1.20\u20132.87;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001), land-based exercise (SMD\u202f=\u202f1.84, 95% CI 0.80\u20132.88;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.001), and general care (SMD\u202f=\u202f1.66, 95% CI 0.11\u20133.21;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.035) significantly reduced disability, whereas land-based exercise\u202f+\u202fgeneral care did not (SMD\u202f=\u202f1.72, 95% CI\u202f\u2212\u202f0.25\u20133.68;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.086). SUCRA rankings for disability again favored multimodal care: balneotherapy\u202f+\u202fgeneral care ranked first (SUCRA\u202f=\u202f0.83; PrBest\u202f=\u202f44.6%; mean rank\u202f=\u202f2.4), followed by balneotherapy (0.71; 29.3%; 3.3) and aquatic exercise\u202f+\u202fgeneral care (0.64; 16.9%; 3.9), with blank control consistently last (0.01; 0.0%; 8.9). Given very high heterogeneity and low-to-very-low certainty for most comparisons, these findings should be interpreted as preliminary directional evidence rather than actionable treatment recommendations. Results suggest multimodal approaches warrant investigation in future rigorously conducted trials.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>\n                      In CLBP, multimodal programs that integrate hydrotherapeutic components with general care or exercise tended to provide greater improvements than single interventions for both pain and disability. Among single modalities, effects were outcome-specific: for pain, aquatic exercise performed best and land-based exercise generally exceeded balneotherapy; for disability, balneotherapy and aquatic exercise showed larger improvements than land-based exercise. Land-based exercise remains a beneficial and pragmatic option where aquatic access is limited, while adding general care to land-based exercise did not show a consistent additional benefit. This analysis is substantially limited by very high heterogeneity (\n                      <jats:italic>I<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      \u202f&amp;gt;\u202f85%) and predominantly very low certainty evidence. Of the 36 comparisons assessed for pain intensity, 94.4% (34\/36) were rated low to very low certainty; for disability, all 36 comparisons were rated very low certainty. These evidence quality profiles severely restrict ranking reliability and recommendation strength.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Systematic review registration<\/jats:title>\n                    <jats:p>\n                      Registered on PROSPERO. Unique Identifier: CRD42023432018. Public URL:\n                      <jats:ext-link>https:\/\/www.crd.york.ac.uk\/PROSPERO\/view\/CRD42023432018<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fmed.2026.1739263","type":"journal-article","created":{"date-parts":[[2026,2,2]],"date-time":"2026-02-02T06:33:32Z","timestamp":1770014012000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["In water or on land? A network meta-analysis of aquatic and land-based exercise interventions for pain and disability in chronic lower back pain"],"prefix":"10.3389","volume":"13","author":[{"given":"Hao","family":"Wu","sequence":"first","affiliation":[{"name":"Sports Institute, Henan University of Technology","place":["Zhengzhou, China"]},{"name":"China Wushu School, Beijing Sport University","place":["Beijing, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Penglin","family":"Diao","sequence":"additional","affiliation":[{"name":"School of Sports Training, Wuhan Sports University","place":["Wuhan, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Juan","family":"Del Coso","sequence":"additional","affiliation":[{"name":"Sport Sciences Research Centre, Rey Juan Carlos University","place":["Fuenlabrada, Spain"]},{"name":"Faculty of Health Sciences, Institute of Health and Sport Sciences, Universidad Francisco de Vitoria","place":["Madrid, Spain"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xiaoyu","family":"Liu","sequence":"additional","affiliation":[{"name":"School of Arts and Sciences, Fuyao University of Science and Technology","place":["Fuzhou, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yiwei","family":"Min","sequence":"additional","affiliation":[{"name":"Department of Kinesiology and Sport Management, Texas A&M University","place":["College Station, TX, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ruimeng","family":"Ran","sequence":"additional","affiliation":[{"name":"College of Education, Beijing Sport University","place":["Beijing, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bopeng","family":"Qiu","sequence":"additional","affiliation":[{"name":"Division of Sports Science and Physical Education, Tsinghua University","place":["Beijing, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yinkai","family":"Zhang","sequence":"additional","affiliation":[{"name":"China Wushu School, Beijing Sport University","place":["Beijing, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ziyu","family":"Wang","sequence":"additional","affiliation":[{"name":"Faculty of Health, University of Canterbury","place":["Christchurch, New Zealand"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carl","family":"Petersen","sequence":"additional","affiliation":[{"name":"Faculty of Health, University of Canterbury","place":["Christchurch, New Zealand"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2026,2,2]]},"reference":[{"key":"ref1","volume-title":"Core curriculum for professional education in 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