Effectiveness of adding manual therapy to exercise for pain and disability in chronic non-specific low back pain: A systematic review and meta-analysis

Manual therapy and therapeutic exercise are both recommended for chronic non-specific low back pain, the additional benefit of combining them is uncertain. To systematically review the effects of adding manual therapy to therapeutic exercise compared to exercise alone on pain intensity and functional disability in adults with chronic non-specific low back pain. A systematic review and meta-analysis of randomized controlled trials included adults aged 18–65 years with chronic non-specific low back pain (≥12 weeks). Interventions combined joint-based manual therapy (spinal mobilization and/or manipulation) with therapeutic exercise involving stretching, strengthening, motor control, and endurance training. Main outcomes were pain intensity and functional disability at short-, medium-, and long-term follow-up. PubMed, PEDro, Cochrane Library, CINAHL, and Web of Science were searched up to February 2025. Evidence certainty was rated using GRADE. Five trials (n = 260) were included. Low-quality evidence indicated no significant short-term pain reduction with manual therapy plus exercise versus exercise alone (SMD = -0.87, 95% CI: -1.87 to 0.12, I 2 = 90%). Moderate- to low-certainty evidence showed greater improvement in disability with combined therapy at short- (SMD = -0.73, 95% CI: -1.05 to -0.42, I 2 = 0%) and long-term follow-up (SMD = -1.13, 95% CI: -2.06 to -0.19, I 2 = 80%). Manual therapy combined with therapeutic exercise does not appear to provide substantial additional short-term improvements in pain intensity when compared to exercise alone. However, significant benefits were identified for functional disability in both short- and long-term outcomes CRD42023413778. • Effectiveness of adding manual therapy to exercise remains inconclusive. • No added pain reduction from manual therapy with exercise. • Manual therapy improved function short- and long-term. • Evidence certainty rated moderate to low (GRADE).