Background: Chronic nonspecific low back pain involves complex neuromuscular and biomechanical deficits. This systematic review objectively compared the biomechanical and neuromuscular mechanisms of motor control exercises versus manual therapy interventions in patients with this condition.

Methods: The study followed PRISMA guidelines and was registered in PROSPERO (CRD420261483877). A systematic search of PubMed, Scopus, Web of Science, and Google Scholar was conducted up to August 1, 2026. Methodological quality was assessed using the modified Downs and Black checklist, and data synthesis followed the Synthesis Without Meta-analysis (SWiM) framework.

Findings: Out of 192 full-text articles evaluated, 22 studies (mean quality score 20.0 out of 27) met the eligibility criteria. Active exercises significantly produced long-term structural adaptations, including increased cross-sectional area of the lumbar multifidus muscle (p < 0.001), increased activation ratio of the transversus abdominis (p < 0.05), and decreased neuromuscular activation delay (p = 0.01). Conversely, manual therapy induced immediate reflex effects, significantly reducing the activation amplitude of spinal extensor muscles during the flexion phase (p = 0.008) and restoring the flexion-relaxation ratio (p = 0.007).

Conclusion: Manual therapy and motor control exercises are highly complementary approaches. Manual therapy provides immediate inhibition of defensive reflexes and spasms, whereas motor control interventions produce stable structural and motor adaptations. A staged and integrated treatment model is recommended to optimally improve neuromuscular coordination in these patients.