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FOTO Rehab Outcomes Blog

Should Exercise Be Painful When Managing a Patient with Persistent Pain?

The pain sciences suggest graded exposure and activity pacing, along with education as part of the treatment program for individuals who have persistent pain. There are researchers who specifically study the structures in the periphery (such as tendons) and suggest for tendinopathies that the structures should be loaded. Eccentric strengthening has a bit of a painful quality to it.  It's kind of confusing, isn't it? Should the prescribed activities be painful?

I'll point out that for most patients who have persistent pain there is a high likelihood that these individuals probably do have neurological changes within their brains and may have some amount of central sensitization.  At the same time, it seems that many individuals who have an Achilles tendinopathy (as an example) have peripheral changes in their neovascular structure.  If tendinopathy is addressed via eccentric loading leading to increased discomfort is that perpetuating central sensitization within that the patient and increasing the intensity of the pain experience?

The below study attempted to address the question of whether experiencing pain during the prescribed exercises is detrimental for the patient. I don't know about some of you, but I have been known to offhandedly say with a joking inflection, "you know, I don't feel it."  It seems that the results of this study seem to indicate that it's fine for patients to experience pain.

I think what may be more relevant is defining the expectations. Think of the words patients will use to describe what they feel. If we provide the expectation of the sensations that are reasonable and expected, then the patient probably has a reduction in their level of fear. If we provide the expectation of sensations that are not reasonable, then we allow the patient to communicate that what is being experienced is not reasonable.  

Below you will find a quick view of the abstract.


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




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.


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.


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.


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.

 2017 Jun 8. pii: bjsports-2016-097383. doi: 10.1136/bjsports-2016-097383. [Epub ahead of print]