Comparative effectiveness of digital health interventions for low back pain: systematic review and network meta-analysis of randomised controlled trials

Abstract

ObjectiveTo determine the comparative effectiveness of different digital health interventions for adults with low back pain. DesignSystematic review and network meta-analysis of randomised controlled trials. Data sourcesPubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, APA PsycINFO, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), from inception to 19 March 2026 (updated to 8 August 2026). Study selectionRandomised controlled trials enrolling adults with low back pain. Interventions were classified as telemedicine, web-based applications (Web-App), mobile applications (Mobile-App), virtual reality (VR), exergaming, biofeedback devices, face-to-face care, and control. Paired reviewers independently screened records, extracted data, and assessed risk of bias using the Cochrane Risk of Bias 2 tool. MethodsFrequentist random-effects network meta-analyses synthesised pain intensity and physical function (primary outcomes), and pain-related fear avoidance, health-related quality of life, self-efficacy, anxiety, and depression (secondary outcomes), assessed at post-intervention (from the end of treatment to < 2 months post-intervention), short-term ([≥]2 to <6 months), mid-term ([≥]6 to <12 months), and long-term ([≥]12 months) follow-up. Effects were reported as standardised mean differences with 95% confidence intervals. Transitivity was examined across potential effect modifiers, and Confidence in Network Meta-Analysis (CINeMA) informed confidence ratings. ResultsNinety-two reports representing 84 trials involving 11 649 participants were included. At post-intervention, compared with control, VR showed the largest estimated reduction in pain intensity (SMD -1.43, 95% CI -1.87 to -0.98; moderate confidence) and improvement in physical function (-0.86, -1.45 to -0.26; very low confidence). VR was also associated with lower pain-related fear avoidance (-1.14, -1.68 to -0.61) and better health-related quality of life (0.97, 0.57 to 1.36) (both moderate confidence). Exergaming, Mobile-App, Web-App and telemedicine were also associated with lower pain intensity, while Mobile-App, Web-App, telemedicine, and biofeedback devices were associated with better physical function. For self-efficacy, exergaming (0.77, 0.05 to 1.49) showed favourable post-intervention effects, although confidence in this estimate was very low. No intervention showed a clear effect on anxiety, with confidence ranging from very low to moderate across comparisons, whereas telemedicine was associated with lower depression (-0.22, -0.44 to 0.00; low confidence). Networks became progressively sparse at later follow-up, and evidence of sustained effects was inconsistent across interventions and outcomes. Global inconsistency was detected in the post-intervention pain-intensity network, with local inconsistency identified for selected exergaming comparisons, and substantial heterogeneity was present in several networks. ConclusionsAmong adults with low back pain, VR showed the largest estimated post-intervention effects versus control for pain intensity, physical function, pain-related fear avoidance, and health-related quality of life, although comparative effects differed across outcomes. Self-efficacy showed favourable estimates for selected interventions, whereas evidence for anxiety and depression was limited. Evidence beyond treatment completion was increasingly sparse, and confidence in many network estimates was low or very low; firm comparative recommendations therefore remain premature. Systematic review registrationPROSPERO CRD420261339841 HighlightO_ST_ABSWHAT IS ALREADY KNOWN ON THIS TOPICC_ST_ABSO_LIPrevious systematic reviews have generally assessed mobile applications, telemedicine or telerehabilitation, and virtual reality separately, most often using conventional pairwise meta-analysis. C_LIO_LIExisting network meta-analyses have compared a narrower range of digital approaches, leaving uncertainty about their comparative effects across clinical outcomes and follow-up periods. C_LI WHAT THIS STUDY ADDSO_LIThis network meta-analysis compared six major digital health modalities for adults with low back pain across pain intensity, physical function, psychosocial outcomes, and multiple follow-up periods. C_LIO_LIVirtual reality showed favourable post-intervention estimates across the widest range of outcomes, with moderate confidence for pain intensity, pain-related fear avoidance, and health-related quality of life, but not physical function. C_LI