Exercise Therapy Versus Manual Therapy for the Management of Pain Intensity, Disability, and Physical Function in People With Chronic Low Back Pain: A Systematic Review With Meta-Analysis and Meta-Regression.

The short version

This systematic review and meta-analysis asked a practical question for people with chronic low back pain (CLBP, pain lasting more than three months): if you had to choose between exercise therapy and hands-on manual therapy alone, which works better? Clinical guidelines actually recommend combining both approaches with psychological support, but in real clinics, people often receive just one or the other, so the researchers pooled every trial that tested exercise against manual therapy head-to-head, without either being combined with the other. After a comprehensive search of five research databases, the researchers found six qualifying randomized trials, covering 743 people with CLBP total, published between 2007 and 2022. The exercise treatments ranged from general aerobic and strengthening exercise to specific 'motor control' exercises that retrain deep core muscles; the manual therapies ranged from joint mobilization and massage to formal osteopathic and chiropractic spinal manipulation. The researchers combined the trial results statistically and also checked whether results changed depending on how long people had been followed up, and whether patient characteristics like age or sex explained some of the differences. Overall, there was no clear winner. For pain relief, exercise and manual therapy performed about the same across all six trials, though when two trials involving chiropractic or osteopathic-style manipulation were set aside, manual therapy showed a small edge in the first three months. For disability (how much back pain limits a person's daily activities), the two treatments were also similar in the short and medium term, but exercise therapy showed a small advantage after six months or longer. Neither treatment stood out for physical function, based on the two trials that measured it. Notably, trials with more women in them tended to show exercise working somewhat better for disability but manual therapy working somewhat better for pain, and older participants tended to respond somewhat better to exercise for pain — though these are patterns across studies, not conclusions about any one person. The researchers rate the overall quality of this evidence as very low, mainly because there are still very few well-designed trials that isolate exercise from manual therapy without mixing the two, and the studies used inconsistent doses and often didn't fully describe what patients actually received. Their bottom line is that picking exercise or manual therapy alone is not clearly better-supported than the other, and that combining exercise, manual therapy, and psychological support, as major clinical guidelines already recommend, remains the better-evidenced path rather than choosing one alone.

Key findings

• Pooling 6 randomized trials (743 people) with chronic low back pain, neither exercise therapy nor manual therapy alone was clearly better than the other overall for pain, disability, or physical function.
• Manual therapy (joint mobilization, massage, or spinal manipulation) showed a small statistically significant advantage for pain relief in the first 3 months, but only when two trials using chiropractic- or osteopathy-based approaches were excluded from the analysis.
• Exercise therapy showed a small statistically significant advantage for reducing disability after 6 months or longer, though not in the shorter term.
• Trials with a higher proportion of women tended to show exercise working somewhat better for disability, and manual therapy working somewhat better for pain - a pattern across studies, not a rule for any individual.
• The researchers rate the overall certainty of this evidence as very low (GRADE), reflecting the small number of eligible trials, inconsistent dosage reporting, and high risk of bias in the underlying studies.

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