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Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis
  1. Benjamin E Smith1,2,
  2. Paul Hendrick3,
  3. Toby O Smith4,
  4. Marcus Bateman1,
  5. Fiona Moffatt3,
  6. Michael S Rathleff5,6,
  7. James Selfe7,
  8. Pip Logan2
  1. 1Department of Physiotherapy, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
  2. 2Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
  3. 3Division of Physiotherapy and Rehabilitation Sciences, School of Health Sciences, University of Nottingham, Nottingham University Hospitals (City Campus), Nottingham, UK
  4. 4University of East Anglia, Norwich, UK
  5. 5Research Unit for General Practice in Aalborg, Department of Clinical Medicine at Aalborg University, Aalborg, Denmark
  6. 6Department of Occupational Therapy and Physiotherapy, Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
  7. 7Manchester Metropolitan University, Manchester, UK
  1. Correspondence to Benjamin E Smith, Department of Physiotherapy, London Road Community Hospital, Derby Teaching Hospitals NHS Foundation Trust, Derby DE1 2QY, UK; benjamin.smith3{at}


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 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.

Conclusion 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.

PROSPERO registration CRD42016038882.

  • Systematic review
  • Meta-analysis
  • musculoskeletal pain
  • musculoskeletal disorder
  • treatment
  • exercise
  • effectiveness

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  • Contributors BES was responsible for conception and design, publication screening, acquisition of data, analysis and interpretation, and drafting and revising the manuscript. PH was responsible for conception and design, publication screening, acquisition of data, data interpretation, and reviewing and revising the manuscript. TOS was responsible for conception and design, data interpretation, and reviewing and revising the manuscript. All authors were involved in interpretation, reviewing revisions to the manuscript and final approval of the version to be published. All have read and approved the final version.

  • Funding This report is an independent research arising from a Clinical Doctoral Research Fellowship, Benjamin E Smith, ICA-CDRF-2015-01-002, supported by the National Institute for Health Research (NIHR) and Health Education England (HEE).

  • Disclaimer The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR, HEE or the Department of Health.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Correction notice This paper has been amended since it was published Online First. The authors have noticed that figure 4 was a duplication of figure 6. The correct figure 4 has now been uploaded.

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