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

Musculoskelet Sci Pract. 2026 Jan 30;82:103508. doi: 10.1016/j.msksp.2026.103508. Online ahead of print.

ABSTRACT

INTRODUCTION: Manual therapy and therapeutic exercise are both recommended for chronic non-specific low back pain, the additional benefit of combining them is uncertain.

OBJECTIVE: 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.

METHODS: 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.

RESULTS: 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, I² = 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, I² = 0 %) and long-term follow-up (SMD = -1.13, 95 % CI: -2.06 to -0.19, I² = 80 %).

CONCLUSION: 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 PROSPERO REGISTRATION: CRD42023413778.

PMID:41643247 | DOI:10.1016/j.msksp.2026.103508