Therefore the object of this review was to compare the effect of exercises into pain compared with non-painful exercises on pain, function or disability in patients with chronic musculoskeletal pain within randomised controlled trials (RCTs), specifically exercises that were prescribed with instructions for patients to experience pain, or where patients were told it was acceptable and safe to experience pain, and to compare any difference in contextual factors and prescription parameters of the prescribed exercise intervention.Įach included study was appraised independently by two reviewers (BES and PH) for methodological quality using the Cochrane risk of bias tool for randomised clinical trials. No previous systematic reviews have evaluated the effectiveness of exercises into pain for chronic musculoskeletal pain. 31 37 38 We define ‘exercise into pain’ as a therapeutic exercise where pain is encouraged or allowed. 36 37 Through this, proponents support the prescription of exercises into pain for chronic musculoskeletal pain and disorders. 35 It is thought that such an exercise programme could facilitate the reconceptualisation of pain by addressing fear avoidance and catastrophising beliefs within a framework of ‘hurt not equalling harm’.
31–33 Pain does not correlate with tissue damage, 34 and psychological factors such as catastrophising and fear avoidance behaviours play an important role in the shaping of the physiological responses to pain, and therefore the development and maintenance of chronic pain. It has been proposed that modern treatment therapies for chronic musculoskeletal pain and disorders should be designed around loading and resistance programmes targeting movements and activities that can temporarily reproduce and aggravate patients’ pain and symptoms. 25 Experimental studies have also demonstrated that stimulus context and the emotional response to pain affect the experience of pain, 26–28 and have led to the development of desensitisation interventions for chronic musculoskeletal disorders. A systematic review of self-management interventions for chronic musculoskeletal pain concluded that strong evidence existed that changes in the psychological factors, self-efficacy and depression were predictors of outcomes, irrespective of the intervention delivered, and strong evidence existed that positive changes in patients’ pain catastrophising and physical activity were mediating factors. There is a high level of uncertainty and lack of sufficient level 1 evidence on which to base treatment for people with musculoskeletal disorders. 16 20–24 These have all presented poor to moderate results in terms of effectiveness at improving pain and function, and have identified limitations in the quality of included trials when drawing conclusions.
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Previous systematic reviews have assessed the effectiveness of various interventions for musculoskeletal disorders, including pharmaceutical therapies, 9–12 psychological-based therapies 13–16 and physical-based therapies, including manual therapy 17–19 and exercise. 5 6 In the UK, an estimated one in four people suffer from chronic musculoskeletal disorders, 7 with an estimated economic consequence of 8.8 million working days lost. 3 4 Neck pain and other musculoskeletal pain ranks fourth and sixth in terms of years lived with disability, with a global point prevalence of 5% and 8%, respectively. 1 2 Low back pain is considered the leading cause of years lived with disability worldwide, ahead of conditions such as depression, diabetes, cardiovascular disease and cancer, with a global point prevalence of 9.4%. Musculoskeletal disorders are one of the most prevalent and costly disorders globally.
6 Department of Occupational Therapy and Physiotherapy, Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark.
5 Research Unit for General Practice in Aalborg, Department of Clinical Medicine at Aalborg University, Aalborg, Denmark.4 University of East Anglia, Norwich, UK.3 Division of Physiotherapy and Rehabilitation Sciences, School of Health Sciences, University of Nottingham, Nottingham University Hospitals (City Campus), Nottingham, UK.2 Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK.1 Department of Physiotherapy, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK.