train with pain – to avoid or a benefit?

Sebastian Löscher

We all learned that pain is a quite bad indicator for tissue damage. Despite this, we often hear/read that therapists tend to recommend painfree exercises for patients with chronic musculoskeletal disorders. Ben Smith and colleagues performed a systematic review with meta-analysis and compared painfree vs painful exercises in those patients. They found several papers including patients with achillodynia, shoulder pain, plantar fascitis and low back pain. Below is a critical appraised paper on that systematic review.


Have fun reading ;)



Thanks to Jan Herman van Minnen and Nils Runge for critial re-reading!


Background Chronic musculoskeletal disorders are a prevalent and costly global health issue. It has been proposed that modern treatment therapies for chronic musculoskeletal pain and disorders should be designed around loading and resistance training targeting movements and activities that can temporarily reproduce and aggravate patients pain and symptoms. Up to now there has been no systematic review about the benefits of allowing pain during these exercise programs or if it should be avoided.

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

Design A systematic review and meta-analysis

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

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.

Conclusions 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.

Limitations Only one reviewer screened the titles and abstracts during the literature search. This could be indicative for selection bias on the included studies for the systematic review. Additionally, there was a preselection by including only studies in English language. Patients with widespread pain disorders like fibromyalgia, headache or migraine were not included in this paper. Therefore, the results of this systematic review cannot be applied to this group of patients.


Commentary Musculoskeletal disorders are one of the most prevalent and costly disorders globally [2,3]. Low back pain for example is considered to be the leading cause of years lived with disability worldwide, ahead of other non-musculoskeletal disorders like depression, diabetes, cancer and cardiovascular diseases [4,5] and the prevalence of chronification of low back pain is rising [6]. Active exercise interventions have been shown to be effective in the management in chronic musculoskeletal disorders [7,8] but the exact underlying mechanisms are still unclear [9] and it seems like it is not related to changes in physical capacities. [10]


Some patients suffering from chronic musculoskeletal pain belief that certain activities are harmful for their bodies [11-13]. One potential mechanism how exercise therapy works could be a change of this belief system, by confronting them with graded exposure to mechanical stimuli. A qualitative study with patient interviews by Boutevillain et al. [12] gives us examples, how people getting fearful about doing exercises:

“It can be harmful, I give you an example: I have a colleague with low back problems, similar to mine, and she loves to take step classes, but each time she exercises too much, she is in pain but continues. I think she should stop, it is quite dangerous for her”

“Sometimes I try to exercise and then I’m in pain, looking back had I known it would hurt I would probably not have done it”

Patients often belief that pain relates to damage [14-16] and therefore feeling pain during an exercise could raise the idea that this exercise will hurt their body. Controversially, the systematic review by Smith et al. [1] and also a recent study [17] are highlighting that feeling pain during exercises doesn’t seem to be harmful for patients. The systematic review even shows benefits for pain in the short-term compared to pain-free exercises. A reason to choose painful exercises could be the circumstance, that a patient is fearful that exercises or activities that hurt will harm their bodies in the long-term. So, the exercise therapy could act as graded exposure to loading the body and pointing up that pain will not necessarily correlate with tissue damage or associated long-term damages.


Additionally, it is important to note that the systematic review by Smith et al [1] should should be a guidance for therapists working with patients with chronical musculoskeletal pain. It should encourage them not to abort an active intervention if it’s painful for the client but maybe to continue it and collect new information. That seems a quite reasonable idea because the beliefs and attitudes of the therapist affect the beliefs, attitudes and outcomes of patients [18]. A healthcare practioner being fearful of pain occurring during the patients’ active intervention could therefore slow down the process of rehabilitation.


On the other hand, painful exercises doesn’t seem to be more beneficial in the medium and in the long-term compared with pain-free exercises. This information in turn leaves us with two different therapy approaches leading to a quite similar outcome. Therefore, we can see pain itself as an optional variable during exercises.


When we include pain as a variable during exercises, an occurring question could be: how much pain is acceptable during the intervention?

A pain-monitoring system dividing a numeric analogue scale into 3 subdivisions was already introduced by Roland Thomeé in 1998 [19]. Up-to-date several variations of this pain-monitoring system exist [20,21] but all of them use a pre-set division of pain-levels that should be accepted and pain-levels that should be avoided. For scientific reasons, a pre-set cut-off between acceptable and non-acceptable pain intensity seems useful. For clinical practice, an individually modifiable tool that gives the patient the ability to self-determine their acceptable pain-level could be beneficial as it integrates the patient into the rehabilitation process. It also gives her/him the opportunity to learn that pain doesn’t have to be harmful, in a self-selected speed of progression during the treatment sessions. This in turn could raise the perceived self-efficacy and locus of control, which are associated with better rehabilitation outcomes [22-25].


It is also conceivable to change the variable being measured with the monitoring system. Asking for pain can raise the attention to it and that has been shown to increase the pain experience itself [26-28]. Using a comfort-scale instead of a pain-scale has been shown to shift the thoughts of pain as tissue damage to pain as part of healing and recovery [29]. But that have just been studied in women after Caesarean section where a specific tissue damage is identifiable and can therefore yet not be transferred to patients with chronic musculoskeletal disorders. Another disadvantage using a comfort scale could be the missing practical educational link that pain is not necessarily harmful.


A way to start an active intervention with patients with chronic musculoskeletal pain disorders could be to educate them that pain is not a sign of a poor outcome during exercises and that it doesn’t imply tissue damage. Another important aspect to talk about is that they do not have to wait to begin with training until the pain settled down by time or with a passive treatment. Active therapies have a hypo-algetic effect that even could be increased when people get this explained [30]. With this knowledge and the patients’ ability to steer the intensity of his exercise plan on his own, the patients’ self-efficacy could be increased. Enhancing self-efficacy in patients with chronical musculoskeletal pain is an important predictor for less pain and less disability in the future [24,31] and should therefore be recommended.


Further research could clarify if a pre-set or an individual pain monitoring system lead to different outcomes and if the usage of a comfort-scale has advantages over a pain-scale when exercising with patients with chronical musculoskeletal pain disorders.


Thanks to Jan Herman van Minnen and Nils Runge for critial re-reading


[1] Smith BE, Hendrick P, Smith TO, et al. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br J Sports Med 2017;51:1679–87.


[2] Lawrence RC, Helmick CG, Arnett FC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum 1998;41:778–99.


[3] Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the global burden of disease study 2010. Lancet 2012;380:2197–223.


[4] Hoy D, March L, Brooks P, et al. The global burden of low back pain: estimates from the global burden of disease 2010 study. Ann Rheum Dis 2014;73:968–74.


[5] Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the global burden of disease study 2010. Lancet 2012;380:2163–96.


[6] Freburger JKHolmes GMAgans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med. 2009 Feb 9;169(3):251-8.


[7] Geneen LJ, Moore RA, Clarke C, et al. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2017;1:CD011279.


[8] Booth J, Moseley GL, Schiltenwolf M, et al. Exercise for chronic musculoskeletal pain: a biopsychosocial approach. Musculoskeletal Care 2017;15:413–21.


[9] Nijs J, Kosek E, Van Oosterwijck J, et al. Dysfunctional endogenous analgesia during exercise in patients with chronic pain: to exercise or not to exercise? Pain Physician 2012;15:ES205–13.


[10] Steiger F, Wirth B, de Bruin ED, et al. Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. Eur Spine J. 2011;21(4):575-98.


[11] Wallis JAWebster KELevinger P, et al. Perceptions about participation in a 12-week walking program for people with severe knee osteoarthritis: a qualitative analysis. Disabil Rehabil. 2017 Nov 30:1-7.


[12] Boutevillain LDupeyron ARouch C, et al. Facilitators and barriers to physical activity in people with chronic low back pain: A qualitative study. PLoS One. 2017 Jul 25;12(7):e0179826.


[13] Dima A, Lewith GT, Little P, et al. Identifying patients’ beliefs about treatments for chronic low back pain in primary care: a focus group study. Br J Gen Pract. 2013; 63: e490–8.


[14] Bunzli S, Smith A, Schuetze R, et al. Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear. BMJ Open. 2015;19; 5: e008847.

[15] Stenberg GFjellman-Wiklund AAhlgren C. 'I am afraid to make the damage worse'--fear of engaging in physical activity among patients with neck or back pain--a gender perspective. Scand J Caring Sci. 2014 Mar;28(1):146-54.


[16] Setchell JCosta NFerreira M, et al. Individuals' explanations for their persistent or recurrent low back pain: a cross-sectional survey. BMC Musculoskelet Disord. 2017 Nov 17;18(1):466.


[17] Vallés-Carrascosa EGallego-Izquierdo TJiménez-Rejano JJ, et al. Pain, motion and function comparison of two exercise protocols for the rotator cuff and scapular stabilizers in patients with subacromial syndrome. J Hand Ther. 2018 Apr - Jun;31(2):227-237.


[18] Darlow BFullen BMDean S, et al. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review. Eur J Pain. 2012 Jan;16(1):3-17.


[19] Roland Thomeé. A Comprehensive Treatment Approach for Patellofemoral Pain Syndrome in Young Women. Phys Ther. 1997 Dec;77(12):1690-703.


[20] Korakakis VWhiteley REpameinontidis K. Blood Flow Restriction induces hypoalgesia in recreationally active adult male anterior knee pain patients allowing therapeutic exercise loading. Phys Ther Sport. 2018 Jul;32:235-243.


[21] Silbernagel KGThomeé REriksson BI, et al. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007 Jun;35(6):897-906.


[22] Keedy NH, Keffala VJ, Altmaier EM, et al. Health locus of control and self-efficacy predict back pain rehabilitation outcomes. Iowa Orthop J. 2014;34:158-65.


[23] Du SHu LBai Y, et al. The Influence of Self-Efficacy, Fear-Avoidance Belief, and Coping Styles on Quality of Life for Chinese Patients with Chronic Nonspecific Low Back Pain: A Multisite Cross-Sectional Study. Pain Pract. 2018 Jul;18(6):736-747.


[24] Chester RKhondoker MShepstone L, et al. Self-efficacy and risk of persistent shoulder pain: results of a Classification and Regression Tree (CART) analysis. Br J Sports Med. 2019 Jan 9. pii: bjsports-2018-099450.


[25] Miles CL, Pincus T, Carnes D, et al. Can we identify how programmes aimed at promoting self- management in musculoskeletal pain work and who benefits? A systematic review of sub-group analysis


[26] Rode S, Salkovskis PM, Jack T. An experimental study of attention, labelling and memory in people suffering from chronic pain. Pain 2001;94:193–203.


[27] Janssen SA, Arntz A, Bouts S. Anxiety and pain: epinephrine-induced hyperalgesia and attentional influences. Pain 1998;76:309–16.


[28] Arntz A, Dreessen L, Merckelbach H. Attention, not anxiety, influences pain. Behav Res Ther 1991;29:41–50.

[29] Chooi CSWhite AMTan SG, et al. Pain vs comfort scores after Caesarean section: a randomized trial. Br J Anaesth. 2013 May;110(5):780-7.


[30] Jones MDValenzuela TBooth J, et al. Explicit Education About Exercise-Induced Hypoalgesia Influences Pain Responses to Acute Exercise in Healthy Adults: A Randomized Controlled Trial. J Pain. 2017 Nov;18(11):1409-1416.


[31] Alhowimel A, AlOtaibi M, Radford K, et al. Psychosocial factors associated with change in pain and disability outcomes in chronic low back pain patients treated by physiotherapist: A systematic review. SAGE Open Med. 2018;6:2050312118757387. Published 2018 Feb 6


#exercise #train #pain #chronicpain #painmonitoring #painscience #gradedexercise #maitland #imta #sebsebsen #löscher

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