Comparative effects of different exercise training modalities on exercise capacity, pulmonary function, and health-related quality of life in patients with interstitial lung disease: a systematic review and network meta-analysis

IntroductionExercise training is central to pulmonary rehabilitation for interstitial lung disease (ILD), but the comparative effects of different exercise modalities remain uncertain. We compared their effects on exercise capacity, pulmonary function, and health-related quality of life.MethodsSix databases were searched from inception to June 11, 2026. Randomized controlled trials of exercise training in adults with ILD were included. Interventions were classified as aerobic training (AER), aerobic plus resistance training (AER_RES), respiratory-focused training comprising breathing exercises or inspiratory muscle training (BREATH_IMT), aerobic plus resistance plus breathing training (AER_RES_BREATH), mind–body exercise (MIND_BODY), or control (CON). Frequentist random-effects network meta-analyses evaluated changes in 6-min walk distance (6MWD), percentage predicted forced vital capacity (FVC% predicted), and St George's Respiratory Questionnaire (SGRQ) total score. Mean differences (MDs) with 95% confidence intervals (CIs) were estimated. RoB 2 and CINeMA were used to assess risk of bias and confidence in the evidence.ResultsTwenty-six trials involving 1,409 participants were included. Compared with CON, all active modalities improved 6MWD, with MDs ranging from 29.46 m for AER (95% CI 11.82–47.10) to 57.12 m for AER_RES_BREATH (95% CI 41.76–72.48). AER_RES_BREATH produced greater estimated improvements than AER (MD 27.67 m, 95% CI 4.25–51.08) and AER_RES (MD 25.18 m, 95% CI 6.69–43.68), although these comparisons relied mainly on indirect evidence. Only AER_RES_BREATH showed a small improvement in FVC% predicted versus CON (MD 3.08 percentage points, 95% CI 0.05–6.12), with limited robustness and low confidence. AER_RES, AER_RES_BREATH, and MIND_BODY improved SGRQ total scores (MDs 10.08–15.20 points). Findings for 6MWD were the most robust across sensitivity analyses.DiscussionExercise training improves functional exercise capacity and may improve health-related quality of life in adults with ILD. AER_RES_BREATH showed the strongest signal for 6MWD, but limited direct comparisons preclude its designation as the optimal intervention. Evidence for FVC% predicted was less robust and should not be interpreted as evidence of disease modification.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD420261399024, identifier PROSPERO CRD420261399024.