Ninety-six adults with nonspecific low back pain were randomized to receive dry needling plus exercise (n=31), spinal manipulative therapy plus exercise (n=32), or combined dry needling and spinal manipulative therapy plus exercise (n=33). All participants received four treatment sessions over two weeks, followed by a two-week home exercise program. The primary outcomes were pain intensity (numeric pain rating scale) and low back pain–related disability (Oswestry Disability Index). Secondary outcomes included lumbar multifidus, erector spinae, and gluteus medius muscle activation measured by ultrasound, and exercise compliance. Assessments occurred at baseline, two weeks, and four weeks. Overall, results revealed that the combined treatment group achieved significantly greater reductions in pain and disability, and greater muscle activation, compared with either single treatment group at both two and four weeks. Exercise compliance was also highest in the combined group. These findings suggest that a short course of combined dry needling and spinal manipulation before exercise may optimize early pain relief, muscle activation, and adherence to exercise programs in nonspecific low back pain.