Effectiveness of thoracic interventions on psychological factors in low back pain: a systematic review and meta-analysis

Fear of movement and anxiety are major psychological contributors to disability in individuals with low back pain (LBP). Thoracic-focused rehabilitation, including breathing and chest mobility exercises, has been proposed to improve both physical and psychological outcomes. This systematic review and meta-analysis evaluated the effectiveness of these interventions on psychological outcomes in LBP. Seven databases (PubMed, Scopus, Web of Science, ProQuest, Ovid, PEDro, Google Scholar) were searched without language restrictions. Randomized controlled trials assessing thoracic mobility or breathing interventions in adults with LBP were eligible. Primary outcomes were fear of movement and depression/anxiety. The study followed PRISMA guidelines and was registered in PROSPERO (CRD42024558753). Eleven RCTs met inclusion. Pooled analysis showed thoracic interventions reduced fear of movement compared with controls (<i>N</i> = 441; SMD = −1.45; 95% CI: −2.45 to −0.45; 95% PI: −4.43 to 1.52), though heterogeneity was high (I² = 93.4%). No significant effects were observed for depression/anxiety (<i>N</i> = 173; SMD = −1.10; 95% CI: −2.28 to 0.09; 95% PI: −3.34 to 1.15; I² = 90.4%). Thoracic interventions may reduce fear of movement in LBP, but evidence for effects on depression and anxiety is inconclusive. Further high-quality, standardized trials are needed to clarify clinical value. Incorporating thoracic mobility and breathing exercises into rehabilitation programs may effectively reduce fear of movement—a critical psychological barrier that limits participation and recovery in individuals with low back pain.Reducing fear of movement can enhance patient engagement with physical therapy and improve functional outcomes, potentially accelerating return to activity and work.Rehabilitation professionals may consider thoracic exercises as part of multidisciplinary care for low back pain, though their role in managing anxiety and depression remains supportive rather than direct.Rehabilitation professionals should consider assessing psychological factors such as fear of movement routinely and integrating targeted thoracic techniques when appropriate. Incorporating thoracic mobility and breathing exercises into rehabilitation programs may effectively reduce fear of movement—a critical psychological barrier that limits participation and recovery in individuals with low back pain. Reducing fear of movement can enhance patient engagement with physical therapy and improve functional outcomes, potentially accelerating return to activity and work. Rehabilitation professionals may consider thoracic exercises as part of multidisciplinary care for low back pain, though their role in managing anxiety and depression remains supportive rather than direct. Rehabilitation professionals should consider assessing psychological factors such as fear of movement routinely and integrating targeted thoracic techniques when appropriate.