Objective: To determine the effect of painful versus non-painful exercise on pain, disability, and other patient-reported outcomes in adults with chronic musculoskeletal pain (CMP).
Design: Systematic review and 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: Randomized controlled trials that compared painful exercise to non-painful exercise in adults with CMP.
Data synthesis: Data was analyzed using random effects meta-analysis and narrative synthesis. We assessed risk of bias using the Cochrane tool and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations framework.
Results: We included 16 trials (reported across 18 studies). Meta-analyses showed no difference in the effect of painful versus non-painful exercise on pain intensity or disability in the short-, medium-, or long-term, nor pain catastrophizing or fear avoidance in the short-term, however 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.
Conclusions: The effect of painful versus non-painful exercise on patient-reported outcomes in adults with CMP is unclear. Pain during exercise may not need to be avoided to allow for symptomatic and functional improvement, but higher quality studies are needed to determine this. Clinicians could be guided by patient preference when making shared decisions about exercising into pain.