Does Adding Manual Therapy to Exercise Help Chronic Low Back Pain? Five Trials Say Sometimes
dos Santos and colleagues pooled five RCTs (260 patients) testing the addition of joint-based manual therapy on top of structured exercise for chronic non-specific low back pain. Pain intensity did not improve significantly. Functional disability did, both short-term and long-term. The split between pain and disability outcomes is becoming the recurring story of this evidence base.
Key Points
- dos Santos and colleagues asked a clinically focused question: when patients with chronic non-specific low back pain are already doing structured exercise, does adding joint-based manual therapy (mobilization or manipulation) provide additional benefit?
- 5 RCTs were included with a combined n=260. Search closed February 2025. PROSPERO-registered, GRADE-rated.
- Short-term pain intensity: SMD -0.87 (95% CI -1.87 to 0.12), confidence interval crosses zero, low-quality evidence, very high heterogeneity (I-squared 90%). Translation: no statistically reliable benefit on pain.
- Short-term disability: SMD -0.73 (95% CI -1.05 to -0.42), I-squared 0%, moderate to low certainty. Translation: a real benefit on disability.
- Long-term disability: SMD -1.13 (95% CI -2.06 to -0.19), I-squared 80%, moderate to low certainty. Translation: benefit persists, with wider confidence interval.
- The pain-versus-disability split mirrors the PACBACK trial pattern. Manual therapy and exercise combinations are showing reliable disability gains and unreliable pain gains. The functional outcome is the more honest signal.
Many patients with long-term back pain are already doing some kind of exercise program, with or without supervision. The question this paper asks is simple: if you add hands-on manual therapy (joint mobilization or manipulation) to that exercise, do you get better outcomes than exercise alone?
The answer, from five trials and 260 patients pooled together, is that you do not get a reliable additional improvement in pain. You DO get a real additional improvement in functional ability, your capacity to bend, lift, sit, walk, and do daily activities. That benefit shows up in the short term and persists into the long term.
This fits a pattern showing up across multiple recent papers in our issue. Pain and function are not the same outcome. Manual therapy moves function more reliably than it moves pain. Clinicians should track both, but should expect the function gain first.
The Question
The dos Santos team asked a question with direct clinical relevance. Most patients with chronic non-specific low back pain are not coming to a chiropractor or physical therapist as their first intervention. Many have already tried exercise, whether self-directed, gym-based, or under supervision. The clinical decision is rarely "exercise OR manual therapy." It is "exercise alone, OR exercise plus manual therapy." This review targets exactly that comparison.
The team registered a protocol with PROSPERO (CRD42023413778), searched five databases through February 2025, included only RCTs of adults aged 18 to 65 with chronic non-specific LBP (12 weeks or more of symptoms), and pooled outcomes using GRADE-rated evidence certainty.
Manual therapy was operationalized as joint-based: spinal mobilization, manipulation, or both. Exercise was operationalized as therapeutic, including stretching, strengthening, motor control, and endurance training. The active comparator (exercise alone) had to use comparable exercise components to the combined arm.
What They Found
| Outcome | SMD (95% CI) | I-squared | Certainty | Significant? |
|---|---|---|---|---|
| Pain intensity, short-term | -0.87 (-1.87 to 0.12) | 90% | Low | NO |
| Disability, short-term | -0.73 (-1.05 to -0.42) | 0% | Moderate to low | YES |
| Disability, long-term | -1.13 (-2.06 to -0.19) | 80% | Moderate to low | YES |
The disability findings are the cleanest part of the picture. Short-term I-squared of 0% is unusual in this literature, suggesting the included trials measured something genuinely consistent across populations. The point estimate of SMD -0.73 is a moderately large effect by Cohen's convention (-0.5 to -0.8 = medium), and the upper confidence limit of -0.42 keeps the effect well above clinically negligible.
The long-term disability finding is directionally similar but with substantially wider uncertainty (-2.06 to -0.19) and high heterogeneity (80%). The benefit appears to persist, but the precision around the persistence is modest. The data supports a directional claim that long-term function is probably better with combined care than exercise alone, without precision on the magnitude.
Pain intensity is the messiest cell. The point estimate of -0.87 looks impressive at first glance, but the confidence interval crosses zero (-1.87 to 0.12), and heterogeneity is at 90%, indicating the included trials did not measure a consistent pain effect. Low-quality evidence rating per GRADE. The honest read: no statistically reliable pain benefit from adding manual therapy to exercise.
What This Means Clinically
Three patterns from this paper deserve attention from any clinician who delivers manual therapy.
First, the disability-vs-pain split is now showing up consistently across the recent evidence base. Our commentaries on Shannon et al. 2026 on military LBP, on the de Zoete Cochrane review, and on the Bronfort PACBACK trial all converge on the same finding: manual therapy and adjacent interventions move functional outcomes more reliably than they move pain ratings. dos Santos adds a fourth data point to the same pattern in a different study population (already-exercising chronic LBP patients).
Second, this paper is asking a more honest clinical question than most of the older SMT-versus-control trials. Real-world chronic LBP patients rarely choose between manual therapy and nothing. They often already have an exercise habit and are deciding whether to add hands-on care. The dos Santos comparison reflects that decision more directly than the historical literature does, and aligns with the 2017 American College of Physicians LBP guideline recommendation that conservative care for chronic LBP should center on active treatments.
Third, the small sample size (260 patients across 5 trials) is a real limitation. Five trials is enough to detect a moderate effect but not enough to characterize subgroups, dose response, or technique-specific variation. The pain finding particularly suffers from the small-N problem; a future meta-analysis with 15 to 20 included trials may resolve the heterogeneity and produce a defensible point estimate.
Practical Translation for the Clinic
For my patients who are already doing some form of exercise (gym work, yoga, Pilates, structured PT), the dos Santos evidence supports adding manual therapy with a clear caveat: I am working primarily for functional improvement, not for direct pain reduction. That changes how I frame expectations. Less "this adjustment will lower your pain," more "the combination should help you bend, sit, lift, walk, and tolerate daily activities better, and pain often follows function downstream."
This framing also matches the broader 2026 evidence picture. Patients respond well to honest, function-anchored expectation-setting. They respond poorly to specific pain-reduction promises that the underlying evidence does not support.
5 trials, 260 patients total, is a modest evidence base. Conclusions should be treated as directional, not precise.
Heterogeneity for pain (90%) and long-term disability (80%) is substantial. Some of the variation likely reflects different MT techniques, exercise dosing, and patient phenotypes pooled into single estimates.
GRADE certainty was rated low to moderate across outcomes, primarily for risk of bias and imprecision.
The review is limited to chronic non-specific LBP in adults 18 to 65. Findings cannot be extrapolated to acute or subacute LBP, specific structural diagnoses, or older or pediatric populations.
Manual therapy in the included trials was joint-based (mobilization or manipulation). Soft-tissue techniques (myofascial release, IASTM, ART) are not represented and may have different effect profiles.
Long-term follow-up windows varied across trials and were not standardized in the synthesis. The "long-term" pooled estimate aggregates different durations.
Adding manual therapy to therapeutic exercise produces a reliable functional disability benefit at short and long term, but no statistically reliable pain benefit, in adults with chronic non-specific low back pain. Five trials, 260 patients, modest evidence base. The pattern continues to be that function is the cleaner outcome to track and to promise; pain follows function downstream rather than the other way around.
Editorial Disclosure
The Forward Review is editorial commentary, not peer reviewed. Written by Jason Forward, DC, a licensed chiropractor at Vanguard Chiropractic in Tulsa, Oklahoma. Commentary reflects clinical interpretation and does not represent the views of the original authors.
Conflict of interest: Dr. Forward is a practicing chiropractor whose clinical work includes joint-based manual therapy and exercise prescription. No financial relationships with the cited authors or journal.
Corrections policy: Errors are corrected with a dated correction notice appended to the article.
Level of evidence: Systematic review and meta-analysis (5 RCTs, n=260, GRADE moderate to low certainty).
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