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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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