## 4 Discussion

Table 2: Effects of intervention on variables in pain intensity, disability level, kinesiophobia, spine mobility, and abdominal and back muscle endurance. Spinal mobility and stiffness are influenced by the active contraction of the spinal muscles and normal lumbar neuromuscular control; in other words, when the trunk is fully flexed, the paraspinal muscles relax [33; 38]. However, in individuals with LBP, increased lumbar paraspinal muscle activity persists after full lumbar flexion, resulting in either an absent or delayed flexion-relaxation phenomenon [33; 38; 39]. Due to impaired lumbar neuromuscular control, the paraspinal muscles redistribute activity to meet movement demands and control the spine during lumbar flexion. Stiff lumbar spines and impaired flexion-relaxation are associated with greater disability in individuals with LBP [33]. In this study, abdominal muscle endurance improved by 29% after MT and 34% after exercise therapy, respectively. Back muscle endurance improved by 18% after MT and 20% after exercise therapy, respectively. Since the most effective exercise components for patients with chronic back pain have not been determined, our study participants underwent different types of exercises: abdominal and back muscle strengthening, stretching, and core stabilization exercises. Patients with LBP had decreased abdominal muscle strength, core flexor and extensor muscle imbalance, and decreased lumbar mobility. We believe that a clinically significant reduction in pain and disability is associated with MT and exercise therapy programs, including home exercises. To ensure positive and long-lasting treatment effects, we motivated people with LBP to change their lifestyle and adopt therapeutic home exercises into their daily routines. The main goal of home exercises was to prolong the positive effects of LBP treatment on functional status and prevent LBP recurrence in the long term. A recent meta-analysis focusing on LBP prevention through exercise found that self-administered exercise resulted in a 33% reduction in back pain risk [10]. Home exercise programs alone have been effective in reducing chronic LBP and improving functional status; however, the effects are minor [40; 41; 42]. We found only a few studies comparing the effects of MT, exercise therapy, and home exercises on chronic LBP [43; 44; 45]. [PERSON] and [PERSON]'s [43] study results showed that after a home-based total body strengthening program (12 weeks, 3 times a week) combined with manual therapy (3 procedures), as well as standard physiotherapy exercises at home combined with MT, functional disability was reduced by about 26% and pain by 32-40 units. These results were considered clinically relevant in treating nonspecific chronic LBP. [PERSON] et al. [44] compared the effectiveness of adding 12 weeks of MT or exercise therapy to a home exercise program for adults with LBP. Pain intensity decreased by 30-40% after treatment in all three groups; the greatest difference was in the MT and home exercise group than in the home exercise group. [PERSON] et al. [46] showed that MT compared to a home exercise program or supervised exercise did not indicate any differences between interventions for pain or disability in either the short or long term. In a study conducted by [PERSON] et al. [45], one group of subjects received MT and 12 physical therapy sessions over 6 months. They performed motor control exercises for transverse abdominal TrA, multifidus, and pelvic floor muscles, as well as postural correction exercises. The same home exercise program was administered to participants every day between sessions. Another group of subjects participated in aerobic and muscle resistance training twice a week for 6 months and exercised at home by walking or jogging. The main study findings were that after six months, pain and disability decreased, lumbar muscle endurance improved, and kinesiophobia decreased in both groups with chronic LBP.