Effects of different intervention modalities combined with exercise in patients with insomnia: a systematic review and network meta-analysis

Background: Exercise, as a non-pharmacological intervention, is a promising adjunct for improving sleep outcomes in insomnia. However, a comprehensive assessment of exercise-based combination interventions remains insufficient. This study aimed to systematically evaluate and rank the intervention effects of different modalities combined with exercise on sleep outcomes via network meta-analysis (NMA). Methods: Following the population, intervention, comparator, outcome, and study design (PICOS) framework, literature was searched in PubMed, Web of Science, Cochrane Library, Embase, CNKI, and CQVIP for randomized controlled trials (RCTs) until March 20, 2026. Independent screening and data extraction were conducted. NMA utilized a frequentist framework, with risk of bias assessed by the Cochrane RoB 2 tool and evidence certainty assessed by CINeMA. Results: A total of 31 RCTs involving 2,457 participants were included, evaluating five types of exercise-based combination interventions. Results based on the surface under the cumulative ranking curve (SUCRA) indicated: (1) Pittsburgh Sleep Quality Index (PSQI): exercise plus cognitive behavioral therapy (EX + CBT) > qigong plus CBT (QG + CBT) > exercise plus traditional Chinese medicine interventions (EX + TCM) > qigong plus TCM interventions (QG + TCM) > exercise (EX) > TCM > conventional control (CON) > qigong (QG); (2) sleep onset latency (SOL): EX + CBT > QG + TCM > QG plus active repetitive transcranial magnetic stimulation (QG + ArTMS) > QG + CBT > EX > CON > EX + TCM > QG plus sham repetitive transcranial magnetic stimulation (QG + SrTMS); (3) total sleep time (TST): EX + TCM > EX > QG + SrTMS > QG + ArTMS > EX + CBT > CON > QG + TCM > QG + CBT; (4) wake after sleep onset (WASO): EX + CBT > QG + ArTMS > QG + SrTMS > CON > EX > EX + TCM. Compared with CON, EX + CBT showed significant effects on PSQI, SOL, and WASO, whereas no intervention significantly increased TST. Conclusions: Current evidence suggests that exercise-based combination interventions may improve subjective sleep quality and selected sleep-continuity parameters in insomnia. Of these, EX + CBT appears to be the most consistently supported combination, with advantages for PSQI, SOL, and WASO. However, evidence certainty was generally limited. For other exercise-based combination interventions, further validation in large, high-quality trials is warranted. Systematic review registration: PROSPERO, https://www.crd.york.ac.uk/PROSPERO/view/CRD420251125784, identifier CRD420251125784.