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

Smith, Benjamin E.; Hendrick, Paul; Smith, Toby O.; Bateman, Marcus; Moffatt, Fiona; Rathleff, Michael Skovdal; Selfe, James; Logan, Pip

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


Benjamin E. Smith

Paul Hendrick

Toby O. Smith

Marcus Bateman

Fiona Moffatt

Michael Skovdal Rathleff

James Selfe

Professor of Rehabilitation Research


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.
PROSPERO Registration: CRD42016038882

Journal Article Type Article
Acceptance Date Apr 1, 2017
Online Publication Date Jun 8, 2017
Publication Date Dec 1, 2017
Deposit Date Apr 5, 2017
Publicly Available Date Jun 8, 2017
Journal British Journal of Sports Medicine
Print ISSN 0306-3674
Electronic ISSN 1473-0480
Publisher BMJ Publishing Group
Peer Reviewed Peer Reviewed
Volume 51
Issue 23
Keywords Systematic review, Meta-analysis, musculoskeletal pain, musculoskeletal disorder, treatment, exercise, effectiveness
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