Is it okay for exercises to be painful?

According to a quite recent systematic review published in the British Journal of Sports Medicine, exercise into pain might be beneficial in the management of persistent musculoskeletal pain.  Does this mean we should stop using phrases like “as pain allows” etc when prescribing therapeutic exercises?

Researchers undertook a systematic search for studies where exercise therapy was the primary treatment arm. They included only RCTs where subjects were adults with musculoskeletal pain. To be included in the review the participants in the intervention group were advised to exercise into pain or that pain was allowed/tolerated. The control group needed to perform the exercises pain-free. Pain, function or disability were required to be outcomes.

They initially found 9081 studies and in the end 37 full-texts were reviewed. Nine articles were included in the final review. The musculoskeletal pain in the studies were LBP, shoulder pain, Achilles pain and heel pain.

The researchers found moderate evidence that it can be beneficial in terms of pain reduction to allow exercise into pain. However, the effect size was small. In long or medium-term follow-up, there seemed not to be any difference whether the participants exercised into pain or performed the exercises pain free.

So, it seems that in the short term it might be beneficial to at least allow pain during/after exercises when the objective is to decrease pain. In addition, it seems that there are no apparent adverse effects in exercising into pain when the aim is to manage musculoskeletal pain. In other words, there is no need to be afraid of the pain that is provoked by exercise.

Pain, disability and function were reported with different measures in different studies, also the instructions in the interventions were different. Some only allowed pain, when others recommended pain. Therefore, the researchers could unfortunately not conclude whether one approach was superior to another. The researchers speculated possible reasons behind the findings and suggested that exercise into pain might modulate CNS. The researchers pointed out that the effect might also be partly due to the intervention group having higher load and intensity. For example, Nørregaard et al. (2007) compared stretching (pain-free) with strengthening (pain allowed) in adults with Achilles pain. However, the key point here is that hurt does not equal harm and musculoskeletal pain can be decreased by doing exercises even if painfulExercise into pain might possibly give quicker pain reduction in the short term.

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References:

Smith BE, Hendrick P, Smith TO, et al. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br J Sports Med 2017 Published Online First doi:10.1136/ bjsports-2016-097383

Studies included in the review:

Aasa B, Berglund L, Michaelson P, et al. Individualized low-load motor control exercises and education versus a high-load lifting exercise and education to improve activity, pain intensity, and physical performance in patients with low back pain: a randomized controlled trial. J Orthop Sports Phys Ther 2015;45:77–85.

Holmgren T, Björnsson Hallgren H, Öberg B, et al. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. BMJ 2012;344:e787.

Hallgren HC, Holmgren T, Oberg B, et al. A specific exercise strategy reduced the need for surgery in subacromial pain patients. Br J Sports Med 2014;48:1431–6.

Littlewood C, Mawson S, May S, et al. Understanding the barriers and enablers to implementation of a self-managed exercise intervention: a qualitative study. Physiotherapy 2015;101:279–85.

Maenhout AG, Mahieu NN, De Muynck M, et al. Does adding heavy load eccentric training to rehabilitation of patients with unilateral subacromial impingement result in better outcome? A randomized, clinical trial. Knee Surg Sports Traumatol Arthrosc 2013;21:1158–67.

Michaelson P, Holmberg D, Aasa B, et al. High load lifting exercise and low load motor control exercises as interventions for patients with mechanical low back pain: a randomized controlled trial with 24-month follow-up. J Rehabil Med 2016;48:456–63.

Nørregaard J, Larsen CC, Bieler T, et al. Eccentric exercise in treatment of Achilles tendinopathy. Scand J Med Sci Sports 2007;17:133–8.

Rathleff MS, Molgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: a randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports 2015;25:e292–300.

Silbernagel KG, Thomeé R, Thomeé P, et al. Eccentric overload training for patients with chronic Achilles tendon pain–a randomised controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports 2001;11:197–206.

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