To the Editor:

In their review of chronic low back pain, Maharty, et al. state that “there are no data to support the benefit of one exercise modality over another.”¹

A 2021 Cochrane review found moderate-certainty evidence that exercise treatment is effective for the management of chronic low back pain.² This review was not designed to evaluate whether there were relative benefits of one exercise modality over another; however, the authors subsequently performed a network meta-analysis to answer that question.³ Their conclusions were that Pilates, McKenzie therapy, and functional restoration were more effective than other types of exercise for reducing pain and improving functional limitations. Personally, I have found that McKenzie exercises are helpful in relieving pain from lumbar radiculopathy, and I recommend them to my patients.

In Reply:

We thank Dr. Skully for highlighting the potential positive effects of specific exercises (ie, Pilates, McKenzie therapy, and functional restoration) on managing chronic low back pain.

Outcomes used in the 2021 Cochrane review only show available follow-up for the short-term (4 weeks to 3 months). Long-term follow-up was not completed.¹ In large network meta-analyses, the probability (P value) can be greatly affected by the number of studies and patients involved, rather than by the significance of the results. The aforementioned network meta-analysis reveals gaps due to the restrictive use of only a few exercise modalities. This analysis is not comprehensive and excludes many types of exercise.¹

Because of this, care should be taken when interpreting the results of this meta-analysis.² Systematic reviews of randomized controlled trials are generally considered the highest level of evidence for the relative effectiveness of interventions such as these types of exercises.^3,4

A 2022 systematic review found that some exercise types for chronic low back pain are disproportionately studied more than others; there is more research on motor control exercises, Pilates, and yoga compared with other exercise types. The review included 45 systematic reviews that investigated pain and disability as primary outcomes in short-, intermediate- and long-term follow-up.⁵ Many of the trials appeared to have a high risk of bias. They concluded that the effect of different exercises used in chronic low back pain for functional disability and pain outcomes varies, with no major difference between exercise types. These results support our initial statement that there is no definitive data to support the benefit of one exercise modality over another.