Should exercises be painful in the management of chronic musculoskeletal pain?

This is a SR and M-A on an interesting topic, which is whether exercises should be painful when treating chronic musculoskeletal pain. The paper came out in June earlier this year, but this is the latest version and has just been published online recently.

Open access: YES

Published online: 17 Nov 2017, BJSM

Published first: 8 June 2017, BJSM

“Background: Chronic musculoskeletal disorders are a prevalent and costly global health issue. A new form of exercise therapy focused on loading and resistance programmes that temporarily aggravates a patient’s pain has been proposed. The object of this review was to compare the effect of exercises where pain is allowed/encouraged compared with non-painful exercises on pain, function or disability in patients with chronic musculoskeletal pain within randomised controlled trials.

“Results: The literature search identified 9081 potentially eligible studies. Nine papers (from seven trials) with 385 participants met the inclusion criteria. There was short- term significant difference in pain, with moderate quality evidence for a small effect size of −0.27 (−0.54 to −0.05) in favour of painful exercises. For pain in the medium and long term, and function and disability in the short, medium and long term, there was no significant difference.


“Conclusion: Protocols using painful exercises offer a small but significant benefit over pain-free exercises in the short term, with moderate quality of evidence. In the medium and long term there is no clear superiority of one treatment over another. Pain during therapeutic exercise for chronic musculoskeletal pain need not be a barrier to successful outcomes. Further research is warranted to fully evaluate the effectiveness of loading and resistance programmes into pain for chronic musculoskeletal disorders.”

I guess the first thing we need to keep in mind is that we are talking about CHRONIC conditions here. It is not really a surprise I think in terms of the results of this SR and M-A. By now we know that there are multiple adaptation processes that occur in people who have chronic pain, central sensitisation to brain changes and adaptations that happen in the proprioception and sensory systems. Which is why pain is poorly correlated to structural damage in the body, especially in chronic pain populations.

We also know that movement and exercise are good for a whole host of reasons. But it was still great to see that exercising into pain showed better outcomes in the short term, albeit it was a very small effect it must be said (effect size 0.28).


What was disappointing for me was that there were no significant difference for the medium or long term outcomes. One would expect that by allowing patients to exercise into pain that they would slowly adapt and be able to do more with less pain. But it seems from this review that the current evidence does not support that at the moment.

It’s an interesting topic indeed that certainly needs more research. Please click on the link below to read the full-text article:

Smith, B.E. et al (2017) Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. BJSM


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