PURPOSE: Evaluate benefits and harms of structured exercise programs for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline. METHODS: We searched for randomized controlled trials (RCTs) in electronic databases (inception to 17 May 2022). Eligible RCTs targeted structured exercise programs compared to placebo/sham, usual care, or no intervention (including comparison interventions where the attributable effect of exercise could be isolated). We extracted outcomes, appraised risk of bias, conducted meta-analyses where appropriate, and assessed certainty of evidence using GRADE. RESULTS: We screened 2503 records (after initial screening through Cochrane RCT Classifier and Cochrane Crowd) and 398 full text RCTs. Thirteen RCTs rated with overall low or unclear risk of bias were synthesized. Assessing individual exercise types (predominantly very low certainty evidence), pain reduction was associated with aerobic exercise and Pilates versus no intervention, and motor control exercise versus sham. Improved function was associated with mixed exercise versus usual care, and Pilates versus no intervention. Temporary increased minor pain was associated with mixed exercise versus no intervention, and yoga versus usual care. Little to no difference was found for other comparisons and outcomes. When pooling exercise types, exercise versus no intervention probably reduces pain in adults (8 RCTs, SMD -0.33, 95% CI -0.58 to -0.08) and functional limitations in adults and older adults (8 RCTs, SMD -0.31, 95% CI -0.57 to -0.05) (moderate certainty evidence). CONCLUSIONS: With moderate certainty, structured exercise programs probably reduce pain and functional limitations in adults and older people with CPLBP.

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