Spinal Manipulation, Dynamic Neuromuscular Stabilization, and Their Combination in Chronic Non-Specific Low Back Pain: A Four-Group Randomized Clinical Trial

Spinal manipulation (SM) and stabilization-focused exercise are commonly used in chronic low back pain, yet evidence on their combined effects is limited. This randomized controlled trial compared SM and dynamic neuromuscular stabilization (DNS), alone or combined, in chronic non-specific low back pain. Forty-eight participants were randomized (1:1:1:1; n=12/group) using a computer-generated sequence with opaque sealed-envelope concealment to Control, SM, DNS, or SM+DNS (SMDNS). Interventions (except Control) were delivered twice weekly for 4 weeks. Outcomes (VAS, ODI, RMDQ, DNS-HS, PostureScreen) were assessed at baseline and follow-up. Assessor blinding was not feasible (treating physiotherapist also assessed outcomes); analyses used coded group labels.Within-group analyses showed significant improvements in most outcomes (p<0.05), except for postural deviation in the SM group and frontal postural deviation in the DNS and SMDNS groups. Between-group comparisons indicated greater early pain reduction with SMDNS at the second assessment (p<0.05). By week 4, pain decreased most in DNS and SMDNS (VAS Δ=−3), while SM showed Δ=−2 and Control showed no change. Disability improved most in DNS/SMDNS (ODI Δ=−13.39/−15.38; RMDQ Δ=−5.24/−5.77). Week-4 effect sizes favored SMDNS over Control and SM for key outcomes (VAS D2 g=2.07 vs Control, 1.24 vs SM; ODI PC2 g=1.73 vs Control, 1.05 vs SM; RMDQ PC2 g=1.34 vs Control, 0.23 vs SM). Overall, adding SM to DNS may enhance early pain relief; the magnitude of between-group differences (effect sizes with 95% CIs) supports interpretation, while clinical relevance should be considered alongside established MCIDs and confirmed in larger trials with longer follow-up.