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

Benjamin Smith, Paul Hendrick, Toby Smith, Marcus Bateman, Fiona Moffatt, Michael Rathleff, James Selfe, Pip Logan

Research output: Contribution to journalArticlepeer-review

87 Citations (Scopus)
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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.

Methods: Two authors independently selected studies and appraised risk of bias. Methodological quality was evaluated using the Cochrane risk of bias tool and the GRADE system was used to evaluate the quality of evidence.

Results: The literature search identified 9,081 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 at medium and long term; and function and disability at 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 at short term, with moderate quality of the evidence. At 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.
Original languageEnglish
Pages (from-to)1679-1687
Number of pages9
JournalBritish Journal of Sports Medicine
Issue number23
Early online date8 Jun 2017
Publication statusPublished - Dec 2017


  • systematic review
  • meta-analysis
  • musculoskeletal pain
  • musculoskeletal disorder
  • treatment
  • exercise
  • effectiveness

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