Does the addition of manual therapy to exercise therapy improve pain and disability outcomes in chronic low back pain: A systematic review

Background: Low back pain (LBP) is a common musculoskeletal problem and the leading cause of disability worldwide. Manual therapy and exercise therapy are used by physiotherapists to treat LBP. The evidence base for exercise is strong, however less so for manual therapy. We investigated whether manual therapy in addition to exercise provides improvements in pain and disability outcomes over exercise alone for LBP. Methods: A PRISMA guided systematic review protocol was developed. PubMed, Ovid and Web of Science were searched for randomised controlled trials (RCTs) which compared manual therapy plus exercise with exercise alone for LBP patients. Participants consisted of adults and older adults suffering from chronic back pain for over three months, recruited by researchers following examination by a health professional. Exercise prescriptions consisted of strengthening, stretching and stabilisation exercises. Manual therapies included spinal manipulation, massage, soft tissue mobilisation, myofascial release and muscle energy technique. The main outcome measures were pain (VAS, The McGill Pain Questionnaire) and disability (ODI, Quebec Back Pain Disability Scale). Secondary outcome measures included quality of life, flexibility, strength, spinal mobility, satisfaction. Results: Ten studies met the inclusion criteria: eight reported pain and/or disability improvements with the addition of manual therapy, two reported no benefit. Conclusions: This systematic review found that manual therapy as an adjunct to exercise provides increased improvements in short-term pain, function and disability outcomes than exercise alone in the management of LBP. The addition of manual therapy is recommended for at least short-term pain and disability relief in LBP patients.