Tolerability and acceptable time frames of treadmill walking in low back pain rehabilitation: A systematic review

BACKGROUND: Treadmill walking is commonly used in chronic low back pain (CLBP) rehabilitation for safety and functional benefits. However, tolerable walking duration remains unclear due to protocol variability and limited reporting. OBJECTIVE: The objective of this study was to systematically review tolerability and acceptable walking durations of treadmill-based rehabilitation in adults with CLBP. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, this review was prospectively registered with PROSPERO (CRD420251055326). PubMed, Cochrane Library, and Physiotherapy Evidence Database (PEDro) were searched until 31 December 2024. Randomized controlled trials (RCTs) of adults aged 19–65 years with nonspecific low back pain (LBP) or disc pathology reporting treadmill walking duration or tolerability were included in the study. Neurological, postsurgical, cardiovascular-limited, nontreadmill interventions, and non-RCT designs were excluded from the study. Methodological quality was assessed using the PEDro scale, and findings were synthesized narratively. RESULTS: Three RCTs ( n = 122) were included in the study. Sessions lasted 20–45 min, 2–3 times/week for 6–8 weeks. No serious adverse events were reported, and adherence was high. Two studies reported reduced pain (Visual Analog Scale) and improved function (Oswestry Disability Index, LBP Functional Scale), whereas all reported improved walking endurance. Meta-analysis was not performed due to substantial heterogeneity ( I 2 > 85%). CONCLUSION: Treadmill walking appears safe and well tolerated in adults with CLBP within 20–45-min sessions. However, few trials with small samples and high heterogeneity limit generalizability and preclude definitive clinical recommendations. Further high-quality, adequately powered RCTs are needed to establish standardized protocols and define tolerability thresholds for clinical practice.