Background: Chronic low back pain (CLBP) impairs functionality, gait, and postural control. Conventional land-based physical therapy relies on stretching, strengthening, and core stabilization exercises, whereas hydrotherapy exploits the physiological and biomechanical properties of water. As their relative effectiveness remains debated, an updated synthesis of recent evidence is needed. Aim: To compare the efficacy of conventional land-based physical therapy and hydrotherapy in CLBP rehabilitation. Methods: A narrative review was conducted using PubMed/MEDLINE and Consensus AI. The search initially identified 20 studies. To prioritize contemporary evidence, only studies published within the last five years were considered. Studies involving swimming, postoperative rehabilitation, hot baths, or duplicate records were excluded. Twelve English-language studies were ultimately included: 8 systematic reviews, 1 umbrella review, and 3 randomized controlled trials. Search terms included "aquatic", "lumbar", and "low back pain". All AI-assisted findings were manually verified against the original sources. Results: Land-based therapy requires careful axial load management, whereas hydrotherapy uses buoyancy to allow exercise with minimal joint stress. Hydrostatic pressure and water temperature stimulate mechanoreceptors, reducing nociceptive signaling, promoting vasodilation, and facilitating muscle relaxation. The aquatic environment also reduces kinesiophobia, an important barrier to rehabilitation. Water viscosity and drag provide resistance that enhances muscle strengthening without gravitational impact. Current evidence indicates that hydrotherapy is at least as effective as land-based exercise and may provide greater pain reduction, improved adherence, and better outcomes in deconditioned individuals. Conclusions: Both modalities are effective for CLBP rehabilitation. However, hydrotherapy offers advantages in safety, disability reduction, and long-term functional recovery, with benefits lasting up to 12 months. Combined aquatic and land-based programs appear to provide the greatest overall rehabilitation efficacy.
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