Exercise in Chronic Musculoskeletal Pain

Exercise works on chronic pain through several mechanisms that go well beyond simply strengthening muscles. Over time, regular activity can reduce the sensitivity of the pain system, an effect sometimes called exercise-induced hypoalgesia, although responses to a single session of exercise vary between people; the more consistent gains are in function, confidence and symptoms with repeated activity. It restores the strength, mobility and fitness that pain and inactivity erode, breaking the cycle of deconditioning, and it improves mood, sleep and self-efficacy, which are powerful drivers of how much pain affects daily life. It also directly counters fear-avoidance, the understandable but unhelpful belief that hurting means harming, by giving people graded, successful experiences of movement. UK guidance on chronic primary pain reflects this: it recommends offering a supervised group exercise programme, taking the person's needs, preferences and abilities into account, and encouraging continued physical activity for long-term health. No single type of exercise is superior, which is reassuring, because it means the activity a person values and will keep doing is a legitimate and effective choice. What matters is regular, progressive movement delivered within a supportive, educational framework.

A useful distinction guides management. Chronic secondary pain arises from an underlying condition, such as osteoarthritis or rheumatoid arthritis, and is managed according to the guidance for that specific condition, with exercise commonly a core part. Chronic primary and secondary pain can also coexist in the same person. Chronic primary pain has no clear underlying cause, or the pain and its impact are out of proportion to any observable damage, and includes conditions such as fibromyalgia, chronic primary low back pain and chronic widespread pain. For chronic primary pain, current UK guidance is striking in what it recommends and what it advises against. It recommends a supervised group exercise programme, psychological therapy in the form of acceptance and commitment therapy (ACT) or cognitive behavioural therapy (CBT), and a single course of acupuncture or dry needling. For medicines in chronic primary pain, it suggests that only certain antidepressants such as amitriptyline, duloxetine or sertraline should be considered, and it advises against starting paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, gabapentinoids or benzodiazepines, because the evidence shows little benefit and real potential for harm. These medicines may still have a role in specific chronic secondary conditions. Recognising which pattern a person has helps set realistic expectations and steers treatment towards active, evidence-based approaches.

Prescribing activity for chronic pain is as much about how it is introduced as what is chosen. Because no single type of exercise is best, the choice is guided by preference, access and enjoyment: walking, aerobic exercise, resistance training, aquatic exercise, yoga, Tai Chi and structured group programmes are all reasonable, and combining education with exercise, as in programmes such as ESCAPE-pain for hip and knee pain, works well. Two principles run through successful programmes. The first is graded activity: starting at a manageable level and increasing gradually and steadily, so the body adapts without repeated overload. The second is pacing, spreading activity through the day and avoiding the boom-and-bust pattern of doing too much on good days and paying for it afterwards. Pain neuroscience education, explaining in plain terms that hurt does not always mean harm and that movement is safe, underpins the whole approach and reduces fear. Flare-ups are expected, and managing them involves reviewing the plan, considering any new symptoms or contributors, and adjusting activity, often by temporarily reducing rather than stopping it before returning to baseline, with setbacks framed as a normal part of progress rather than a sign of damage.

Exercise for chronic musculoskeletal pain is safe for the great majority of people, but a small number of warning features need to be excluded before reassuring and encouraging activity. Red flags are interpreted as patterns rather than single findings. Features suggesting cauda equina syndrome, in particular new bladder or bowel dysfunction, saddle sensory change and severe or progressive neurological deficit, need urgent assessment. Combinations of features such as fever, significant unexplained weight loss, a relevant history and night pain raise concern about infection, fracture or malignancy and are assessed together rather than in isolation. Where such features are absent, routine imaging is usually unnecessary for non-specific pain and can be unhelpful by encouraging a focus on structure. Psychosocial factors, sometimes called yellow flags, such as distress, low mood, fear of movement and unhelpful beliefs, strongly influence outcome and are addressed alongside the physical programme. Referral is appropriate to physiotherapy for supervised, graded exercise, to a pain management service for people with complex or highly disabling pain, and for psychological support where distress is prominent. Throughout, the guiding principle is consistent with the rest of exercise medicine: keep people active, build up gradually, treat the person rather than a scan, and avoid the long-term painkillers that offer little and can cause harm.

• •Exercise is first-line for chronic musculoskeletal pain, improving pain, function, mood and sleep, and staying active is safe.
• •UK guidance on chronic primary pain recommends a supervised group exercise programme, and psychological therapy such as acceptance and commitment therapy or cognitive behavioural therapy.
• •For chronic primary pain, avoid starting paracetamol, non-steroidal anti-inflammatory drugs, opioids, gabapentinoids and benzodiazepines, and consider only certain antidepressants; these may still have a role in specific secondary conditions.
• •Distinguish chronic primary pain from chronic secondary pain, which is managed per its underlying condition.
• •Use graded activity, pacing and pain education, and manage flare-ups by reviewing the plan and adjusting activity rather than stopping altogether.
• •Exclude red flags (cauda equina, infection, fracture, malignancy), avoid routine imaging for non-specific pain, and address psychosocial yellow flags.