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Musculoskeletal pain and exercise—challenging existing paradigms and introducing new
  1. Benjamin E Smith1,2,
  2. Paul Hendrick3,
  3. Marcus Bateman1,
  4. Sinead Holden4,5,
  5. Chris Littlewood6,
  6. Toby O Smith7,
  7. Pip Logan2
  1. 1 Physiotherapy Department (Level 3), Derby Hospitals NHS Foundation Trust, London Road Community Hospital, Derby, UK
  2. 2 Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
  3. 3 Division of Physiotherapy and Rehabilitation Sciences, School of Health Sciences, University of Nottingham, Nottingham University Hospitals, Nottingham, UK
  4. 4 Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
  5. 5 SMI, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
  6. 6 Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences and Keele Clinical Trials Unit, Keele University, Staffordshire, UK
  7. 7 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
  1. Correspondence to Benjamin E Smith, Physiotherapy Department (Level 3), London Road Community Hospital, Derby DE1 2QY, UK; benjamin.smith3{at}

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Chronic musculoskeletal pain remains a huge challenge for clinicians and researchers. Exercise interventions are the cornerstone of management for musculoskeletal pain conditions,1 with the benefits being well-established.1 2 Exact mechanisms underpinning this effect on musculoskeletal pain are currently unclear.3 Little is known on the optimal dose and type of exercise, with therapists’ and patients’ behaviour and beliefs around pain during exercise often overlooked in exercise prescription. Exercise-based treatments may be promising, but effect sizes remain small to modest with large variability in exercise prescriptions.

The need for pain to be avoided or alleviated as much as possible has been challenged, with a paradigm shift from traditional biomedical models of pain towards a biopsychosocial model of pain, which is particularly relevant in the context of performing therapeutic exercise.4 Indeed, a recent systematic review and meta-analysis of painful exercises versus pain free exercises for chronic musculoskeletal pain that included seven randomised controlled trials found that protocols allowing painful exercises offered a small, but statistically significant, benefit over pain-free exercises in the short-term.4 The improvements in patient-reported pain were achieved with a range of contextual factors, such as varying degrees of pain experienced (ranging from pain being allowed to advised, with/without recommended pain scale) and recovery time (ranging from pain subsiding immediately to within 24 hours). Specifically, we define painful exercises when: exercises are prescribed with instructions for patients to experience pain or where patients are told that it is acceptable and safe to experience pain.

Understanding the potential mechanisms behind the effects of therapeutic exercise, in the context of factors associated with chronic musculoskeletal pain, is key to optimising current exercise prescriptions for managing musculoskeletal pain. The aim of the review is to provide an understanding on the potential mechanisms behind exercise and to build on this into …

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