Background: Persistent (chronic or recurrent) low back pain represents a major societal burden. Physiotherapists play a key role in its management, and clinical guidelines usually recommend combining several therapeutic components. However, despite numerous trials evaluating multimodal physiotherapy, no meta-analysis has specifically quantified its effects compared with no treatment or sham interventions in adults with persistent low back pain.

Objectives: To assess the benefits and harms of multimodal physiotherapy, defined as an individualised intervention combining at least two therapeutic components, compared with no treatment or sham interventions in adults with persistent low back pain.

Methods: We performed a systematic review and meta-analysis. CENTRAL, Embase, PubMed, and PEDro were searched from inception to May 4 ^th , 2025. Eligible randomised controlled trials assessed multimodal physiotherapy (≥2 modalities among exercise therapy, manual therapy, education, psychological intervention, and needling therapy) in adults with persistent low back pain. Comparators were sham, no intervention, waiting-list, or usual care. Co-primary outcomes were pain intensity and functional limitations. Follow-up period includes short term (6-18 weeks, closest to 12) and long term (48 weeks or more, closest to 52). Two reviewers independently screened studies, extracted data, assessed risk of bias (RoB 2) and certainty of evidence (GRADE). Random effects meta-analysis was performed where appropriate. The review protocol was registered prior to study conduct in PROSPERO (CRD420251047213).

Results: Eighteen trials including 2,496 participants were analysed. Most studies were judged at high risk of bias (85%). Compared with no treatment or sham interventions, multimodal physiotherapy was associated with reductions in pain intensity and improvements in functional limitations at short term (pain: SMD −0.62 [95% CI −0.91 to −0.33]; function: SMD −0.61 [95% CI −0.90 to −0.32]) and at long term (pain: SMD −0.38 [95% CI −0.70 to −0.05]; function: SMD −0.45 [95% CI −0.77 to −0.14]), with substantial heterogeneity. Stratified analyses suggested larger short-term effects when multimodal interventions included a psychological component. Exploratory post hoc analyses focusing on Cognitive Functional Therapy showed reduced heterogeneity and moderate-to-large short-term effects on pain and function. No differences were observed in serious or non-serious adverse events between groups.

Conclusions: Multimodal physiotherapy, specifically those including psychological component and CFT approach, is associated with moderate short-term improvement in pain intensity and functional limitations compared with no treatment or sham interventions in adults with persistent low back pain, without an increase of adverse events. Effects appear smaller but persist at long term. Further high-quality trials are needed to reduce uncertainty and disentangle the contribution of individual components.

REFERENCES: NIL.

Acknowledgments: NIL.

Disclosure of Interests: None declared.