Pain Matters: But How Much?
Painful vs Non-Painful Exercise for Chronic Pain
"Should this hurt?"
It's one of the most common questions we get as rehab professionals. For years, the debate has gone back and forth: should we push patients into pain, or is "pain-free" the only way to go? It's a key question in rehab, and getting it right can make all the difference for our patients with chronic musculoskeletal (MSK) pain.
We all want to be evidence-based, right? Well, a new 2025 meta-analysis just published in JOSPT (Tran et al.) tackles this question head-on. It systematically reviews the effectiveness of painful versus non-painful exercise for chronic MSK pain.
The findings might surprise you and will definitely sharpen your clinical reasoning. Check out the infographic below.
PAIN MATTERS: Exercise for Chronic Musculoskeletal Pain
A Modern Manual Therapy Update for Rehab Professionals
The Evidence: Painful vs. Non-Painful Approaches
Painful Exercise
- Often involves moderate pain (up to 5/10 NPRS).
- IMPROVES pain intensity.
- IMPROVES disability.
- **NO DIFFERENCE** in Quality of Life (QoL) or Kinesiophobia vs. non-painful.
- Provides SHORT-TERM BENEFITS (4-12 weeks).
- May be SUPERIOR for SOME, but not all patients.
Non-Painful Exercise
- Aims for pain-free to mild pain (<3/10 NPRS).
- IMPROVES pain intensity.
- IMPROVES disability.
- **NO DIFFERENCE** in Quality of Life (QoL) or Kinesiophobia vs. painful.
- Provides SHORT-TERM BENEFITS (4-12 weeks).
- Generally EFFECTIVE for MOST patients.
Key Finding (Tran et al., 2025):
Both painful and non-painful exercise approaches are effective in improving pain and disability in the short-term for chronic MSK pain.
There were no major differences in outcomes between the two strategies!
Dr. E's Take: What This Means for Your Practice
- Focus on Patient Beliefs & Context: The "level" of pain matters less than the patient's interpretation and your education around it. Avoid fear-mongering.
- Pain as a Guide, Not a Stop Sign: Mild-to-moderate pain during exercise (e.g., up to 5/10) that subsides quickly is generally acceptable and effective.
- Optimal Strategy is Individualized: Respect patient preference. For highly kinesiophobic patients, pain-free is often the best starting point. For others, controlled, slightly painful movement can be part of their graded exposure.
- The Best Exercise is the *Done* Exercise: Consistency and adherence are paramount. This review reinforces that both strategies work, so find what resonates and can be sustained by your patient.
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