Effectiveness of Painful Versus Non-painful Exercise on Pain Intensity, Disability, and Other Patient-Reported Outcomes in Adults With Chronic Musculoskeletal Pain: An Updated Systematic Review With Meta-Analysis

OBJECTIVE: The purpose of this study was to determine the effect of painful versus nonpainful exercise on pain, disability, and other patient-reported outcomes in adults with chronic musculoskeletal pain. DESIGN: This study is an intervention systematic review with 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: We included randomized controlled trials that compared painful exercise to nonpainful exercise in adults with chronic musculoskeletal pain. DATA SYNTHESIS: Data were analyzed using random-effects meta-analysis and narrative synthesis. We assessed risk of bias using the Cochrane RoB2 tool and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations framework. RESULTS: We included 16 trials (reported across 18 studies). There was no difference in the effect of painful versus nonpainful exercise on pain intensity or disability in the short, medium, or long term or pain catastrophizing or fear avoidance in the short term. 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. CONCLUSION: The effect of painful versus nonpainful exercise on patient-reported outcomes in adults with chronic musculoskeletal pain was unclear. Pain during exercise may not need to be avoided to allow for symptomatic and functional improvement. J Orthop Sports Phys Ther 2025;55(8):1-11. Epub 10 June 2025. https://doi.org/10.2519/jospt.2025.13253.