(Golden Oldie) Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis

The verdict

Is it safe and helpful to do exercises that hurt when treating long-term muscle and joint pain?

Exercises that allow some pain gave a small but real extra benefit over pain-free exercises in the short term, but no added benefit at medium or long term. Pain during exercise does not appear to be a barrier to good outcomes.

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Meta-analysis7 TrialsModerate evidence

Key points

Compared painful versus pain-free exercise for chronic musculoskeletal pain in randomised controlled trials
Found a small, significant short-term benefit for protocols that allowed painful exercise
No difference between approaches at medium-term or long-term follow-up
Whether pain is advised, allowed, or avoided made no difference across all outcomes
Authors conclude pain during therapeutic exercise need not prevent successful recovery

How it was conducted

Design: Systematic review and meta-analysis of randomised controlled trials
Population: Patients with chronic musculoskeletal pain
Comparison: Painful exercises versus pain-free exercises
Outcomes: Pain, function, or disability
Included studies: Nine papers from seven trials, identified from 9,081 screened records
Quality appraisal: Cochrane risk of bias tool and GRADE system

What they found

The literature search identified 9,081 potentially eligible studies; nine papers from seven different trials met inclusion criteria
For short-term pain, the standardised mean difference favoured painful exercise with a small effect size of 0.27 (moderate quality evidence)
No difference was found at medium-term follow-up (SMD 0.32) or long-term follow-up (SMD 0.13)
Quality of evidence was rated as moderate to low across follow-up periods

Limitations

Only seven trials were included, with overall evidence graded moderate to low quality
Effect sizes were small, even where statistically significant
Reported as a conference poster abstract, so full methods and complete confidence intervals are not available
No difference at medium or long term limits confidence in any lasting advantage

Why it matters

For patients: If an exercise temporarily aggravates your chronic pain, that does not mean it is harming you or that you should stop.
For clinicians: Clinicians can reassure patients that short-term exacerbation during exercise is not a barrier to recovery, as physical inactivity itself is a major health risk.
For readers: The evidence suggests fear of pain should not automatically rule out loading or resistance exercise, though the measured benefit over pain-free exercise is small and short-lived.

Source

doi:10.1016/j.physio.2017.11.005

Read the original paper