DESIGN: Systematic review. BACKGROUND: Manual therapy is used for the treatment of chronic low back pain. Although manual therapy is more expensive than exercise therapy in the Netherlands, its added value in the treatment of chronic low back pain has yet to be determined. OBJECTIVE: To evaluate the effectiveness of adding manual therapy to exercise therapy compared with exercise therapy alone in the treatment of patients with chronic low back pain. METHODS: Medical electronic databases were searched up to January 2008 for randomized controlled trials (RCTS) and clinical controlled trials (CCTS) comparing manual therapy in combination with exercise therapy with exercise therapy alone, methodological quality was assessed using the PEDro checklist. The available results were summarized according to a best-evidence synthesis, in which the studies were weighted according to their methodological quality. Clinical relevance was assessed using the list of the Cochrane Collaboration Back Review Group. RESULTS: Five RCTS were included. Of the three RCTS receiving high PEDro scores, one found no effect of additional mobilization and manipulation, and two showed a positive effect on both pain and limitations in activity and participation. The two studies with a low PEDro score both showed no benefit. The improvement in pain did not reach preset criterion for clinical relevance, whereas the improvement in limitations in activity and participation was considered clinically relevant in the two studies with a high PEDro score. CONCLUSION: Evidence regarding the effectiveness of manual therapy plus exercise therapy for the treatment of chronic low back pain was contradictory. Results for limitations in activity and participation were considered more clinically relevant than those for pain.

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