OBJECTIVE: The purpose of this study was to determine the effect of painful versus nonpainful exercise on pain, disability, and other patient-reported outcomes in adults with chronic musculoskeletal pain. DESIGN: This study is an intervention systematic review with meta-analysis. LITERATURE SEARCH: Electronic databases (CENTRAL, EMBASE, CINAHL, PubMed, and PsycINFO) and trial registers (ClinicalTrials.gov, ANZCTR, World Health Organization International Clinical Trials Registry Platform) were searched from October 2016 to May 2024. STUDY SELECTION CRITERIA: We included randomized controlled trials that compared painful exercise to nonpainful exercise in adults with chronic musculoskeletal pain. DATA SYNTHESIS: Data were analyzed using random-effects meta-analysis and narrative synthesis. We assessed risk of bias using the Cochrane RoB2 tool and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations framework. RESULTS: We included 16 trials (reported across 18 studies). There was no difference in the effect of painful versus nonpainful exercise on pain intensity or disability in the short, medium, or long term or pain catastrophizing or fear avoidance in the short term. The confidence intervals were wide. Narrative synthesis found similar results for quality of life, self-efficacy, mood, and adverse events. All trials were at high risk of bias, and certainty of evidence was very low to low. CONCLUSION: The effect of painful versus nonpainful exercise on patient-reported outcomes in adults with chronic musculoskeletal pain was unclear. Pain during exercise may not need to be avoided to allow for symptomatic and functional improvement. J Orthop Sports Phys Ther 2025;55(8):1-11. Epub 10 June 2025. https://doi.org/10.2519/jospt.2025.13253.
| Discipline Area | Score |
|---|---|
| Rehab Clinician (OT/PT) |  |
| Physician |  |
Physician rater
The findings are based on very low- to low-certainty evidence. Trying to cover different chronic musculoskeletal pain conditions as well as different exercise approaches, which may or may not be harmful, is absurd. This review shows how meta-analysis can be misused by analyzing something that was not the intent of the included studies.
Physician rater
It would be interesting if re-evaluating stressed pre- and post-painful functional muscle testing to determine whether there was a positive or negative result.
Rehab Clinician (OT/PT) rater
The authors to be commended for the rigor of their methodology and clarity in presentation. Limited findings but an important and relevant research question.
Ms. Carolynn Bulmer (8/29/2025 2:55 PM)
CONCLUSION: The effect of painful versus nonpainful exercise on patient-reported outcomes in adults with chronic musculoskeletal pain was unclear. Pain during exercise may not need to be avoided to allow for symptomatic and functional improvement. Pain during exercise is avoided by any patient with chronic pain who has had the pain for any length of time. The emotional roller coaster, medicine regulations, and more pain set off by a painful workout are not worth the patient's limited activity and life involvements resulting. Pain is not the same for everyone. I would not suggest nor be involved in a painful workout of any kind.
Ms. Carolynn Bulmer (8/29/2025 2:43 PM)
When you are living with chronic pain for a long time, the idea of any more pain to be inflicted or set off, as in fibromyalgia, seems ludicrous. There is no cure for fibromyalgia. Should you end up in pain with fibromyalgia, there is a flair up shortly after for about 2-3 days duration. After living with this chronic pain illness for over 50 years, I am the patient that will willingly try any new medication but not any new exercise regime. Chronic pain itself becomes an emotional roller coaster from, "I can do that and will no matter what" to "not happening, why would I set myself back ?" A person learns to pace oneself by pacing their pain activities and setting goals that do not cause more pain but allow as many activities as possible.
, McMaster University