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Elephant in the room: how much pain is ok? If physiotherapy exercise RCTs do not report it, we will never answer the question
  1. Benjamin E Smith1,2,
  2. Henrik Riel3,
  3. Bill Vicenzino4,
  4. Chris Littlewood5
  1. 1 Physiotherapy Outpatients, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
  2. 2 Division of Rehabilitation, Ageing and Well-being, School of Medicine, University of Nottingham, Nottingham, UK
  3. 3 Center for General Practice at Aalborg University, Aalborg Universitet, Aalborg, Denmark
  4. 4 School of Health and Rehabilitation Sciences: Physiotherapy: Sports Injury Rehabilitation and Prevention for Health, University of Queensland, Brisbane, Queensland, Australia
  5. 5 Department of Health Professions, Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, UK
  1. Correspondence to Dr Benjamin E Smith, University Hospitals of Derby and Burton NHS Foundation Trust, Derby DE1 2QY, UK; benjamin.smith3{at}

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Exercise-related pain: why is it important?

Different therapists have said different things [contradictory advice on pain with exercise]…and it makes you wonder which therapist to believe.

Exercise is a proven treatment for managing at least some persistent pain, including musculoskeletal-related pain.1 2 But an area often overlooked is what type of pain and what intensity of pain should be associated with exercise. What would achieve the best results? No pain? A little pain? A moderate amount of pain? How does the patient judge what is ‘a little’ or ‘moderate’? How much pain is too much? Is there ‘good pain’ as patients often tell us when stretching or massaging a muscle, as well as ‘bad pain’ (presumably thought to be harmful)?

Qualitative research tells us that many individuals with persistent pain are uncertain when it comes to pain and exercise.3 4 This is closely linked to pain-related fear and questions as to whether exercise is helpful or harmful. As one patient framed it, ‘Are you making it worse? And that’s the crux of it really…if this is hurting should I really be doing this?’.3

How should clinicians address patients’ questions about whether to heed pain or not?

There are few …

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  • Twitter @benedsmith, @Henrik_Riel, @Bill_Vicenzino, @ChrisLittlew00d

  • Contributors BES and HR discussed the idea. BES drafted the editorial. HR, BV and CL provided feedback. All authors approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

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