Comparative Effectiveness of Manual Therapy, Exercise Therapy, and Combined Therapy for Chronic Low Back Pain: A Comprehensive Retrospective Cohort Study

Background The best conservative treatment for chronic low back pain (CLBP) remains uncertain. This study aimed to evaluate the effectiveness of manual therapy (MT), exercise therapy (ET), and their combination (MT + ET) in real-world clinical practice. Secondary outcomes and subgroup analyses were also included. Methods A retrospective cohort study was conducted on 302 patients with chronic low back pain (CLBP) treated at the Rehabilitation Department of the National Guard Hospital in Riyadh, Saudi Arabia, between 2023 and 2024. The patients were divided into three groups: manual therapy (MT), exercise therapy (ET), and a combination of both (MT + ET). The main outcomes were pain intensity, measured with the Visual Analog Scale (VAS), and functional disability, assessed with the Oswestry Disability Index (ODI). Secondary outcomes included medication use, recurrence of pain, and follow-up duration. Subgroup analyses examined treatment effects according to age, gender, baseline pain severity, and body mass index (BMI). Results All three groups showed significant improvement in both pain and disability (p < 0.001). The combined therapy group achieved the greatest reductions in pain (mean change − 5.0) and disability (mean change − 15.9), compared to ET (pain − 4.0, disability − 12.4) and MT (pain − 2.3, disability − 6.0) (p < 0.001 for all). The combined therapy group achieved clinically meaningful improvement in 78% of patients compared to 55.5% for exercise therapy and 0% for manual therapy. Combined therapy showed superior medication reduction (72.5% NSAIDs reduction vs 51.2% ET vs 45.5% MT) and lowest recurrence rates (4.7% vs 10.4% vs 18.2%). Patients with severe baseline pain showed significantly greater improvement than those with moderate pain (p = 0.008). BMI analysis revealed that overweight patients showed the greatest response to combined therapy (5.3 points pain reduction), while obese patients had significantly reduced functional improvement (p = 0.003). Conclusion The combination of manual therapy and exercise therapy is more effective than either treatment alone for reducing pain, improving function, lowering medication use, and preventing recurrence in patients with chronic low back pain. The findings also show that treatment outcomes vary according to baseline pain severity and body mass index (BMI). Overweight patients had the best response to combined therapy, which suggests that treatment should be adjusted based on patient characteristics. Trial Registration Not applicable. This study was not prospectively registered as a clinical trial.