Therapeutic exercise and manual therapy for chronic low back pain: what a new meta-analysis says

Chronic low back pain is one of the most common causes of disability, and there are many treatment options: therapeutic exercise, manual therapy, or a combination of both. Until now, much of the research compared these broad categories rather than specific techniques. A study published in June 2026 in the Journal of Clinical Medicine set out to look in more detail, comparing specific techniques against each other.

It is a network meta-analysis — a type of analysis that allows several techniques to be compared indirectly at once, even if they haven't all been studied against each other in the same trial — which pooled 45 studies of adults with chronic non-specific low back pain, measuring self-reported disability using validated questionnaires (Roland-Morris and Oswestry).

Compared with a control or placebo group, the techniques with the best results were equipment-based Pilates (reformer), motor-control stabilisation exercises, mat Pilates and, within manual therapy, soft tissue manipulation. Equipment-based Pilates and soft tissue manipulation are the two backed by moderate-confidence evidence — the rest of the positive signals still have a low level of certainty.

The authors themselves are clear about the study's limits: heterogeneity between the included studies is high, and the results do not allow for a definitive efficacy ranking, nor do they show that therapeutic exercise is, in general, superior to manual therapy (or vice versa).

The practical takeaway seems useful to us: there is no single technique that works for everyone. It's the individual assessment — and often a combination of approaches, adapted to each case — that makes the difference. It's the approach we've worked with at Centroterapia since 2003.