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

Background: 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. Methods: 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 + land-based programs, and general care/blank control. Results: = 0.086). SUCRA rankings for disability again favored multimodal care: balneotherapy + general care ranked first (SUCRA = 0.83; PrBest = 44.6%; mean rank = 2.4), followed by balneotherapy (0.71; 29.3%; 3.3) and aquatic exercise + general 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. Conclusion: > 85%) 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. Systematic review registration: Registered on PROSPERO. Unique Identifier: CRD42023432018. Public URL: https://www.crd.york.ac.uk/PROSPERO/view/CRD42023432018.