Physical activity as a central pillar of lifestyle modification in the management of chronic musculoskeletal pain: a narrative review

Key points

1. 01Exercise triggers endorphin, endocannabinoid, serotonin, and dopamine release, reducing pain sensitivity and improving mood
2. 02Meta-analyses confirm exercise improves sleep quality in chronic musculoskeletal pain, but effect sizes are small and may not reach clinical significance
3. 03Physical activity lowers resting cortisol and sympathetic tone, improving stress tolerance in chronic pain patients
4. 04Exercise modulates appetite hormones (ghrelin, leptin, insulin) and improves insulin sensitivity, supporting healthier dietary habits
5. 05Exercise reduces smoking cravings and withdrawal symptoms by stimulating dopamine and endorphin release, though evidence in chronic pain populations is limited

How it was conducted

Design

Narrative structured review

Databases

MEDLINE/PubMed, Embase, Cochrane Reviews, searched from inception to 19 November 2024

Study types included

Randomized controlled trials, systematic reviews, meta-analyses, observational studies, and narrative reviews

Records screened

641 records after duplicate removal; 6 primary RCTs and systematic reviews formally included via flowchart, plus additional studies via narrative synthesis

Topics covered

Physical activity and: pain modulation, sleep quality, stress reduction, diet and metabolic regulation, smoking reduction

Synthesis method

Qualitative narrative synthesis organized by predefined thematic framework

What they found

• A systematic review with network meta-analysis of 107 RCTs (n = 8121 adults) found that aerobic exercise and mind-body exercise significantly improved sleep quality in chronic musculoskeletal pain.
• A systematic review of 17 RCTs (n = 591) found therapeutic exercise had positive effects on sleep quality, but concluded more research is needed on optimal exercise parameters.
• A systematic review with meta-analysis of 6 RCTs (n = 636, mean age 54 +/- 9.7) found most exercise interventions improved sleep and pain qualitatively, but the meta-analysis showed no statistically significant effects; a correlation between pain and sleep improvements was noted.
• A secondary analysis of one RCT (n = 51, mean age 43.6) found high-intensity training reduced perceived stress at 6 months, with stronger effects in participants with clinically elevated Central Sensitization Inventory scores, and a small but significant correlation with improvements in disability and pain.
• An RCT of 46 women with premenstrual syndrome found home-based Pilates (2x/week, 8 weeks) significantly reduced central sensitization symptoms, perceived stress, and pain intensity compared to controls.
• An RCT of 55 adults with chronic low back pain found a mindful walking program (8 weekly 60-minute sessions) showed no statistically or clinically significant differences in pain, stress, or function at 8 weeks, with only a slight improvement tendency at 12 weeks.
• An 18-month RCT (n = 454) found that combined diet plus exercise resulted in greater weight loss (11.4%), lower IL-6 levels, and improvements in pain, function, and quality of life compared to diet or exercise alone in overweight/obese older adults with knee osteoarthritis.
• Meta-analyses confirm exercise improves sleep in chronic musculoskeletal pain but effect sizes are small and may not reach clinically meaningful levels.

Limitations

• Narrative review design limits the robustness of conclusions; no formal risk-of-bias assessment was conducted.
• Heterogeneity in included study populations, interventions, and outcome measures limits generalizability.
• Some biological mechanisms discussed are based on preclinical or animal studies not yet fully validated in chronic pain clinical populations.
• Evidence on exercise effects on stress, diet, and smoking specifically in chronic pain populations is sparse; most smoking-related evidence comes from non-chronic-pain populations.

Why it matters

For patients

People living with chronic musculoskeletal pain can benefit from regular physical activity not just for pain relief, but also for better sleep, less stress, improved eating habits, and support for quitting smoking.

For clinicians

Clinicians should position exercise as a central, multimodal intervention in chronic pain management, integrating it with sleep therapy (such as cognitive-behavioral therapy for insomnia), nutrition counseling, and stress management rather than treating it as a standalone modality.

For readers

This review synthesizes the neurobiological pathways linking physical activity to multiple lifestyle domains that perpetuate chronic pain, providing a framework for holistic, lifestyle-based pain rehabilitation programs.