Efficacy of Cognitive Behavioral Therapy Combined with Exercise in Patients with Chronic Pain: A Systematic Review and Meta-Analysis

Purpose: To evaluate the effects of cognitive behavioral therapy (CBT) combined with exercise on multidimensional outcomes in adults with chronic pain, and to examine whether these effects were sustained at 3-, 6-, and 12-month follow-up. Patients and methods: PubMed, Embase, Web of Science, the Cochrane Library, and PsycINFO were searched from inception to December 30, 2025. Randomized controlled trials (RCTs) comparing CBT combined with exercise versus usual care or other control interventions were included. Results: Thirteen RCTs involving 1679 participants were included. Compared with controls, CBT combined with exercise produced small-to-moderate improvements in pain intensity and functional disability, although heterogeneity was observed across studies. Specifically, significant improvements were observed in pain intensity (SMD = − 0.44, 95% CI: [− 0.72, − 0.16], P = 0.002), functional disability (SMD = − 0.41, 95% CI: [− 0.68, − 0.15], P = 0.002), pain catastrophizing (MD = − 4.35, 95% CI: [− 7.13, − 1.56], P = 0.002), pain self-efficacy (SMD = 0.30, 95% CI: [0.09, 0.51], P = 0.005), fear of movement (MD = − 1.87, 95% CI: [− 3.02, − 0.72], P = 0.001), anxiety (SMD = − 0.29, 95% CI: [− 0.46, − 0.12], P = 0.0007), depression (SMD = − 0.27, 95% CI: [− 0.42, − 0.12], P = 0.0003), and quality of life (PCS: SMD = 0.26, 95% CI: [0.01, 0.50], P = 0.04; MCS: SMD = 0.23, 95% CI: [0.08, 0.38], P = 0.002). No significant improvements were observed in physical performance assessed by the Timed Up and Go Test (TUG) and 6-Minute Walk Test (6MWT). Improvements in pain intensity and functional disability were maintained at 3- and 6-month follow-up, whereas effects on other outcomes were less consistent and were mostly no longer evident at 12 months. Conclusion: CBT combined with exercise is a feasible multidisciplinary strategy for adults with chronic pain, yielding small-to-moderate improvements in pain intensity and functional disability, with benefits maintained at 3- and 6-month follow-up. Cognitive-behavioral outcomes, mental health, and quality of life also improved, but their long-term maintenance was limited. No significant benefits were observed in physical performance. Future research requires standardized CBT-exercise protocols and broader population representation. Keywords: chronic pain, cognitive behavioral therapy, exercise, systematic review, meta-analysis