SYNTHESIZING THE EVIDENCE ON MANUAL THERAPY FOR CHRONIC NON-SPECIFIC LOW BACK PAIN: AN UMBRELLA REVIEW AND META-ANALYSIS

Abstract

Background: Chronic non-specific low back pain (CNSLBP) is one of the leading causes of disability worldwide and remains a major musculoskeletal health burden. Manual therapy is widely used in rehabilitation; however, uncertainty remains regarding its long-term effectiveness and clinical superiority over active rehabilitation approaches. Objective: To synthesize and quantitatively evaluate the effectiveness of manual therapy interventions in individuals with chronic non-specific low back pain through an umbrella review and meta-analysis. Methods: An umbrella review and meta-analysis were conducted according to PRISMA 2020 guidelines. Electronic databases including PubMed/MEDLINE, Scopus, PEDro, Cochrane Library, and Web of Science were searched from January 2000 to March 2026. Systematic reviews, meta-analyses, and randomized controlled trials evaluating manual therapy interventions in adults with CNSLBP were included. Random-effects meta-analysis was performed using Review Manager (RevMan 5.4). Pooled standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated for pain intensity and functional disability outcomes. Results: A total of 21 systematic reviews and meta-analyses involving approximately 35,000 participants were included in the umbrella review, while 38 randomized controlled trials were included in the quantitative meta-analysis. Quantitative synthesis demonstrated statistically significant short-term reductions in pain intensity (SMD = −0.43; 95% CI: −0.61 to −0.24; p < 0.001; I² = 58%) and functional disability (SMD = −0.36; 95% CI: −0.55 to −0.17; p = 0.002; I² = 49%) following manual therapy interventions. Combined manual therapy and exercise-based rehabilitation demonstrated superior outcomes compared with isolated passive interventions. Conclusion: Manual therapy demonstrates clinically meaningful short-term improvements in pain intensity and functional disability among individuals with chronic non-specific low back pain, particularly when integrated with exercise-based rehabilitation. Evidence supporting long-term effectiveness remains limited because of methodological heterogeneity and variability in intervention protocols.