Exercise has Little Effect on Pain for Most Chronic Musculoskeletal Conditions

Exercise has long been used by physical therapists to help reduce pain and improve function in patients with chronic musculoskeletal conditions. However, according to the Cochrane Database of Systematic Reviews that reviewed 381 randomized clinical trials involving 37,143 patients, “exercise does not consistently bring about change in pain or physical function in adults with chronic pain.”1 Nevertheless, many academics within the physical therapy profession have spent the past decade demonizing passive manual therapy interventions,2 while at the same time promoting the false claim that exercise should be the primary intervention for the treatment of pain in the vast majority of chronic (and acute) musculoskeletal conditions.

 

CLINICAL PRACTICE GUIDELINES

Exercise has been recognized in many clinical practice guidelines and systematic reviews as superior to various manual therapy approaches for its role as a primary intervention in the treatment of pain for a multitude of musculoskeletal conditions (i.e., Achilles tendinopathy, knee meniscus and articular cartilage lesions, patellofemoral pain, neck pain, low back pain, and lower limb arthritis);3-10  however, the ability of exercise to reduce acute or chronic pain in musculoskeletal conditions appears to have been overstated. Certainly, exercise at various intensity levels has consistently been shown to have a positive effect on delaying chronic diseases, improving mental health disorders, improving cognitive functioning, increasing strength and endurance, and has even been associated with lower mortality.11-16

 

EXERCISE FOR ACUTE LOW BACK PAIN

A 2020 systematic review (n=2,685) examined the effects of exercise on patients with acute low back pain and found that exercise has “little to no important difference in pain reduction” compared to other interventions (manual therapy, spinal manipulation, usual care, and education).17  Additionally, the updated 2023 Cochrane review of 2674 participants concluded exercise has a minimal effect on pain (i.e., a 1% improvement) and a negative effect on function in the short term compared to sham/placebo treatments.18

 

EXERICSE FOR CHRONIC LOW BACK PAIN

A 2021 Cochrane review concluded that exercise may be more beneficial in the treatment of chronic low back pain compared to no treatment, usual care or placebo; however, the difference between exercise compared to other conservative treatments is “small and not clinically relevant”.19 Furthermore, subgroup analysis indicated that exercise is more effective than education or electrotherapy, but the difference between exercise and manual therapy was negligible.19 

 

EXERCISE FOR EXTREMITY PAIN

A recent systematic review that was published in the British journal Lancet analyzed data from 4,241 subjects on the effectiveness of exercise for knee and hip osteoarthritis. In short, compared with the non-exercise control group, pain was reduced in the exercise group by 0.6 points (on a 0-10 pain scale) in the short term, 0.4 points in the medium term (on a 0-10 pain scale), and by just 0.3 points (0-10 pain scale) in the long term. Notably, the authors concluded that there was a “small overall effect of exercise on pain”; furthermore, the effects were of “questionable clinical importance, particularly in the medium and long term” compared to the non-exercise interventions.20 Moreover, the between-group difference (i.e., 0.3/10) found in the Lancet study is much smaller than the MCID (minimum clinically importance difference) of 2.0 points for pain on the 0-10 numeric pain rating scale (NPRS).20,21

Likewise, at the 1-year outcome, the 2023 Danish GLAD clinical trial (n=206) found 8 weeks of exercise and education were no better than 4 placebo injections (intra-articular saline injections) for pain and disability in patients with knee osteoarthritis.22 Notably, there were no statistically significant between-group differences in the primary outcome (KOOS pain subscale) or any of the secondary outcome measures at the 1-year outcome.22

 

EXERCISE FOR CHRONIC PAIN

A 2017 overview of Cochrane reviews (after review of 381 clinical trials) examined the effect of exercise on pain for several chronic neuromusculoskeletal conditions (i.e., rheumatoid arthritis, osteoarthritis, fibromyalgia, low back pain, intermittent claudication, dysmenorrhea, mechanical neck disorders, spinal cord injury, post-polio syndrome, and patellofemoral pain syndrome) compared to no exercise or minimal intervention. This Cochrane review concluded that “exercise does not consistently bring about change in pain or physical function in adults with chronic pain”.1

 

CONCLUSIONS

While exercise has been found to improve function, strength, stability, quality of life, and overall health, its use as the primary treatment in the management of pain for chronic musculoskeletal conditions is not well supported. Exercise has a “small effect” on pain for chronic musculoskeletal conditions. Nevertheless, many academics within the physical therapy profession (who often haven’t seen real patients in 20 years) continue to promote exercise (with various innovative names or acronyms, often from Australia or the Netherlands) as the preferred primary intervention for the treatment of pain in most chronic musculoskeletal conditions.

Seven years of university education and over $200,000 for a DPT degree should amount to more than recommendations for exercise and education—both of which have little effect on pain in patients with chronic musculoskeletal conditions. Perhaps the APTA and academics within professional DPT programs should stop hiding behind exercise and attempt to find an independent body of knowledge that has more impactful outcomes on pain and disability for chronic musculoskeletal conditions.

The principle of informed consent requires healthcare providers to disclose the risks, likely benefits, and alternatives to any intervention. That is, physical therapists should not overstate the benefit of exercise (for pain) to patients with chronic musculoskeletal conditions. Patients should be informed that the effect size of exercise on pain is small for most individuals in most chronic musculoskeletal conditions.

AUTHORS

Paul Bliton, DPT, NCS, OCS, SCS, FAAOMPT, Dip. Osteopractic
Associate Director, AAMT Fellowship in OMPT
William S. Middleton Veterans Hospital, Madison, WI

Sam Fischer, DPT, OCS, FAAOMPT, Dip. Osteopractic
Senior Instructor, AAMT Fellowship in OMPT
ActivePT, Rochester, MN

James Dunning, PhD, DPT, MSc, FAAOMPT, Dip. Osteopractic
Director, AAMT Fellowship in OMPT
President, American Academy of Manipulative Therapy
Montgomery Osteopractic Physical Therapy & Acupuncture, Montgomery, AL

Ian Young, DSc, OCS, SCS, Dip Osteopractic, RMSK
Senior Faculty, AAMT Fellowship in Musculoskeletal Sonography
Director of Clinical Research, AAMT Fellowship in OMPT
Tybee Wellness & Osteopractic, Tybee Island, GA

Patrick Gorby, DPT, MPH, FAAOMPT, Dip. Osteopractic
Assistant Director, AAMT Fellowship in OMPT
Gorby Osteopractic Physiotherapy & Wellness, Colorado Springs, CO

James Escaloni, DPT, OCS, FAAOMPT, Dip. Osteopractic, RMSK
Senior Faculty, AAMT Fellowship in Musculoskeletal Sonography
Associate Director of Clinical Research, AAMT Fellowship in OMPT
Wellward Regenerative Medicine, Lexington, KY

 

REFERENCES

  1. Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane reviews. Cochrane Database Syst Rev. 2017;4(4):CD011279. https://doi.org/10.1002/14651858.CD011279.pub3
  2. Cook CE. The demonization of manual therapy. Musculoskeletal Physiotherapy. 2021;25:125-132.
  3. Verhagen AP, Ferreira M, Reijneveld-van de Vendel EA, et al. Do we need another trial on exercise in patients with knee osteoarthritis?: no new trials on exercise in knee OA. Osteoarthritis Cartilage. 2019;27(9):1266-1269. doi:10.1016/j.joca.2019.04.020.
  4. Martin RL, Chimenti R, Cuddeford T, et al. Achilles pain, stiffness, and muscle power deficits: midportion achilles tendinopathy revision 2018. J Orthop Sports Phys Ther. 2018;48(5):A1-A38. doi:10.2519/jospt.2018.0302.
  5. Logerstedt DS, Scalzitti DA, Bennell KL, et al. Knee pain and mobility impairments: meniscus and articular cartilage lesions revision 2018. J Orthop Sports Phys Ther. 2018;48(2):A1-A50. doi:10.2519/jospt.2018.0301.
  6. Willy RW, Hoglund LT, Barton CJ, et al. Patellofemoral Pain. J Orthop Sports Phys Ther. 2019;49(9):CPG1-CPG95. doi:10.2519/jospt.2019.0302.
  7. Blanpied PR, Gross AR, Elliott JM, et al. Neck pain: revision 2017. J Orthop Sports Phys Ther. 2017;47(7):A1-A83. doi:10.2519/jospt.2017.0302.[6]
  8. Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018;27(11):2791-2803. doi:10.1007/s00586-018-5673-2.
  9. Uthman OA, van der Windt DA, Jordan JL, et al. Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. BMJ. 2013:347:f5555. doi:10.1136/bmj.f5555.
  10. Silbernagel KG, Hanlon S, Sprague A. Current clinical concepts: conservative management of achilles tendinopathy. J Athl Train. 2020;55(5):438-447. doi:10.4085/1062-6050-356-19
  11. Lee DH, Rezende LF, Joh HK, et al. Long-term leisure-time physical activity intensity and all-cause and cause-specific mortality: a prospective cohort of US adults. Circulation. 2022;146:523-534. https://doi.org/10.1161/CIRCULATIONAHA.121.058162
  12. Ruegsegger GN, Booth FW. Health benefits of exercise. Cold Spring Harb Perspect Med. 2018;8(7):a029694. doi:10.1101/cshperspect.a029694
  13. Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006;174(5):801-809. doi:10.1503/cmaj.051351
  14. Mahindru A, Patil P, Agrawal V. Role of physical activity on mental health and well-being: a review. Cureus. 2023;15(1): e33475. doi:10.7759/cureus.33475
  15. Mandolesi L, Polverino A, Montuori S, et al. Effects of physical exercise on cognitive functioning and wellbeing: biological and psychological benefits. Front Psychol. 2018;9:509. doi:10.3389/fpsyg.2018.00509
  16. Hughes DC, Ellefsen S, Baar, K. Adaptations to endurance and strength training. Cold Spring Harb Perspect Med. 2018;8(6):a029769. doi:10.1101/cshperspect.a029769.
  1. Karlsson M, Bergenheim A, Larsson M, Nordeman L, van Tulder M, Bernhardsson S. Effects of exercise therapy in patients with acute low back pain: a systematic review of systematic reviews. Syst Rev. 2020;9(1):182. https://doi.org/10.1186/s13643-020-01412-8
  2. IJzelenberg W, [7] [8] Oosterhuis T, Hayden JA, et al. Exercise therapy for treatment of acute non-specific low back pain. Cochrane Database Syst Rev. 2023;8(8):CD009365. https://doi.org/10.1002/14651858.CD009365.pub2
  3. Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain, Cochrane Database of Systematic Reviews. 2021;9:CD009790. https://doi.org/10.1002/14651858.CD009790.pub2
  4. Holden MA, Hattle M, Runhaar J, et al. Moderators of the effect of therapeutic exercise for knee and hip osteoarthritis: a systematic review and individual participant data meta-analysis. The Lancet Rheumatology.2023;5(7):E386-400. https://doi.org/10.1016/S2665-9913(23)00122-4
  5. Farrar JT, Young JP, LaMoreaux L, Werth JL, Poole MR. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94:149-58. doi:10.1016/S0304-3959(01)00349-9
  6. Henriksen M, Christensen R, Kristensen LE et al. Exercise and education vs intra-articular saline for knee osteoarthritis: a 1-year follow-up of a randomized trial. Osteoarthrtis and Cartilage. 2023;31:627-635.

 

Recent Posts
0
Dry Needling for Spasticity: Neurophysiological MechanismsAAMT Fellowship, acupuncture, American Academy of Manipulative Therapy, chronic-pain, dry needling certification, Osteopractor
AAMT 2024 Year in Review & AwardsAAMT Fellowship, American Academy of Manipulative Therapy, Cert. DN, Cert. SMT, Diploma in Osteopractic, dry needling certification