Exercise, manipulation and traction physiotherapy in the conservative management of lumbar disc herniation: A systematic review and meta-analysis.

Introduction: Lumbar disc herniation (LDH) is a leading cause of global back pain with significant socioeconomic impact. Conservative physiotherapy, including exercise, manipulation, and traction therapies, is a common first-line treatment. However, their relative efficacy and applicability to specific subgroups remain unclear. Research question: This systematic review and meta-analysis evaluated the efficacy of these three modalities, identified factors influencing variability, and explored subgroup-specific applications. Material and methods: Following PRISMA guidelines, a systematic review was conducted with searches of PubMed, MEDLINE, EMBASE, OVID, Scopus, and grey literature. Forty-three studies were included in the qualitative synthesis and 20 in the meta-analysis. Random-effects models estimated pooled standardized mean changes (SMCs), and meta-regression examined covariates influencing variability. Results: The pooled SMC across modalities was 2.28 (95 % CI: 1.51, 3.05), indicating large treatment effects, though heterogeneity was high (I Discussion and conclusion: Conservative therapies may effectively reduce LDH-related pain and disability, with traction therapy demonstrating the largest pooled effect size. High heterogeneity and methodological inconsistencies limit subgroup-specific recommendations. Rigorous trials and standardized methodologies are essential for optimizing evidence-based care for LDH patients.