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Physical Activity for Pain Prevention

Physical activity and exercises have broad economic as well as health benefits due to their impact on the musculoskeletal, cardiovascular, and central nervous system.

Pain, especially chronic pain, remains an important medical and socioeconomic problem affecting populations from childhood to the elderly and is responsible for a significant proportion of healthcare resource utilization worldwide [9,15,16,19]. Chronic musculoskeletal pain conditions such as low back and neck pain are the most prevalent and the most costly in terms of daily and work related disability [4,15].

The literature provides robust evidence that, in general populations, physical activity and exercises have broad economic as well as health benefits due to their impact on the musculoskeletal, cardiovascular and central nervous system [7,22].. Conversely, insufficient physical activity is detrimental to health and has been identified as a risk factor for noncommunicable diseases (including chronic pain) [20] and the fourth leading risk factor for global mortality [8,14]. Although physical inactivity was initially considered to be a characteristic of older populations, it is common in all ages [10]. 

Physical activity has been defined by the World Health Organization (WHO) as “any bodily movement produced by skeletal muscles that requires energy expenditure” [26]. Exercise is defined as “planned, structured, and repetitive bodily movements that are performed to improve or maintain one or more components of physical fitness” [26].  Multiple guidelines advocate physical activity and exercise as effective treatment interventions to reduce pain and fatigue, and improve patients’ function in a wide variety of chronic pain conditions including chronic neck pain, osteoarthritis, headache, fibromyalgia, and chronic low back pain [13]. Regular physical activity and exercise may help in the prevention of pain. One recent systematic review found moderate-quality evidence supporting the effectiveness of an exercise program for reducing the risk of a new episode of neck pain [5]. There is also evidence that exercise (combined with education) reduces the risk of an episode of low back pain [25]. Indeed, patients with acute or sub-acute pain might be an important target group for intervention aiming to prevent a large individual and economic impact. 

For healthcare providers, recommending physical activity is known to reduce pain intensity and disability as well as provide a range of other benefits including improvements in strength, flexibility, and endurance, a decrease in cardiovascular and metabolic syndrome risk, improved bone health, and improved cognition and mood [18]. Physical activities and exercises may also be considered as a valuable mental health promotion strategy in reducing the risk of developing mental health disorders, which are frequently associated with chronic pain [2,6,21].

Thus, when prescribing physical activity health care providers should [3,7,24]: 

  • Consider not only biomedical aspects, but also psychological and social aspects. 
  • Make it individualized, enjoyable, and related to the patient’s goals.
  • Provide supervision according to specific needs to improve adherence to physical activity / exercise. 
  • Personalise patient education to include information about the impact of physical activity / exercise on the body, the benefits, including addressing misconceptions about physical activity / exercise and pain.  
  • Recognise and address barriers to compliance with physical activity / exercise that include individual barriers (pain intensity, movement-related fear and avoidance, low levels of health literacy, depression) as well as environmental barriers (lack of access to a place to exercise, lack of time to exercise, and lack of support for exercise. 
  • Prime patients and move them along the stages of behavioral change to ensure therapy adherence and success can be achieved. 
Box 1. Summary of exercise and physical activity recommendations for pain.   
Prevention of persistent pain [5,11,25] Exercises are effective (combined with education) in secondary prevention of low back and neck pain 
Benefits of exercise and physical activity [12] Improve:

  • level of functioning in daily and work-related activities
  • mental health
  • physical fitness 
  • health-related quality of life 
  • strength 
  • flexibility
  • endurance
Facilitators and barriers to exercise [18] Facilitators: 

  • Capacity of organization
  • Engagement of health care providers
  • Communication
  • Previous experience of being physically active


  • Lack of access to a place to exercise 
  • Lack of time to exercise
  • Lack of communication
  • Lack of support for exercise 
  • Lack of sufficient supervision
Strategies to engage in a physical activity or exercise program [1,17,23] Adopt biopsychosocial model of health


Individual exercise prescription

Group exercise sessions

Performance enhanced by video-taping exercises

Address maladaptive beliefs: 

Understand the fears and maladaptive beliefs, educate on impact of exercise, address barriers to exercise

Offer support regarding education, encouragement, advice and prescription


Exercise characteristics  Level of supervision: 

  • One‐on‐one supervision, 
  • Group supervision 
  • Home exercise program 

WHO recommendation

Children and youth aged 5–17:  

Should accumulate at least 60 minutes of moderate- to vigorous-intensity physical activity daily.

Adults aged 18–64: 

Should accumulate at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous intensity activity. 

Aerobic activity should be performed in bouts of at least 10 minutes duration.

Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.

Adults of the 65 years and above:

Should accumulate at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week, or an equivalent combination of moderate- and vigorous-intensity activity.

Aerobic activity should be performed in bouts of at least 10 minutes duration.

Muscle-strengthening activities, involving major muscle groups, should be done on 2 or more days a week.

When older adults cannot do the recommended amounts of physical activity due to health conditions, they should be as physically active as their abilities and conditions allow.

*More details on WHO website: https://www.who.int/dietphysicalactivity/pa/en/

WHO – World Health Organization 

Healthcare providers should use each patient consultation as an opportunity to discuss the physical and mental health benefits of physical activity. When necessary, and where available, patients should engage with appropriately-trained healthcare practitioners who can assist with the development of progressive and sustained program of physical activity.


[1] Aitken D, Buchbinder R, Jones G, Winzenberg T. Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Aust Fam Physician 2015.

[2] Bailey AP, Hetrick SE, Rosenbaum S, Purcell R, Parker AG. Treating depression with physical activity in adolescents and young adults: A systematic review and meta-analysis of randomised controlled trials. Psychol Med 2018.

[3] Booth J, Moseley GL, Schiltenwolf M, Cashin A, Davies M, Hübscher M. Exercise for chronic musculoskeletal pain: A biopsychosocial approach. Musculoskeletal Care 2017.

[4] Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J pain 2006;10:287.

[5] de Campos TF, Maher CG, Steffens D, Fuller JT, Hancock MJ. Exercise programs may be effective in preventing a new episode of neck pain: a systematic review and meta-analysis. J Physiother 2018.

[6] Cooney G, Dwan K, Mead G. Exercise for depression. JAMA – J Am Med Assoc 2014.

[7] Daenen L, Varkey E, Kellmann M, Nijs J. Exercise, not to exercise, or how to exercise in patients with chronic pain? Applying science to practice. Clin J Pain 2015.

[8] Durstine JL, Gordon B, Wang Z, Luo X. Chronic disease and the link to physical activity. J Sport Heal Sci 2013.

[9] Fayaz A, Croft P, Langford RM, Donaldson LJ, Jones GT. Prevalence of chronic pain in the UK: A systematic review and meta-analysis of population studies. BMJ Open 2016.

[10] Flynn MAT, McNeil DA, Maloff B, Mutasingwa D, Wu M, Ford C, Tough SC. Reducing obesity and related chronic disease risk in children and youth: A synthesis of evidence with “best practice” recommendations. Obes Rev 2006.

[11] Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher CG, Buchbinder R, Hartvigsen J, Cherkin D, Foster NE, Underwood M, van Tulder M, Anema JR, Chou R, Cohen SP, Menezes Costa L, Croft P, Ferreira M, Ferreira PH, Fritz JM, Genevay S, Gross DP, Hancock MJ, Hoy D, Karppinen J, Koes BW, Kongsted A, Louw Q, Öberg B, Peul WC, Pransky G, Schoene M, Sieper J, Smeets RJ, Turner JA, Woolf A. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018.

[12] Galloza J, Castillo B, Micheo W. Benefits of Exercise in the Older Population. Phys Med Rehabil Clin N Am 2017.

[13] 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. doi:10.1002/14651858.CD011279.pub3.

[14] Hallal PC, Andersen. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U. Global physical activity levels: surveillance progress, pitfalls and prospects. Lancet 2012; 380: 20–30. Lancet 2012.

[15] Hay SI, Vos T, Abajobir AA, Abate KH, Abbafati C, Abbas KM, Abd-Allah F, Abdulkader RS, Abdulle AM, Abebo TA, Abera SF, Hay SI, Abajobir AA, Abate KH, Abbafati C, Abbas KM, Abd-Allah F, Abdulkader RS, Abdulle AM, Abebo TA, Abera SF, Aboyans V. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017;390:1211–1259.

[16] Jackson T, Thomas S, Stabile V, Han X, Shotwell M, McQueen K. Prevalence of chronic pain in low-income and middle-income countries: a systematic review and meta-analysis. Lancet 2015.

[17] Kanavaki AM, Rushton A, Efstathiou N, Alrushud A, Klocke R, Abhishek A, Duda JL. Barriers and facilitators of physical activity in knee and hip osteoarthritis: A systematic review of qualitative evidence. BMJ Open 2017.

[18] Kroll HR. Exercise Therapy for Chronic Pain. Phys Med Rehabil Clin N Am 2015.

[19] Leadley RM, Armstrong N, Lee YC, Allen A, Kleijnen J. Chronic diseases in the European Union: The prevalence and health cost implications of chronic pain. J Pain Palliat Care Pharmacother 2012.

[20] Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT, Alkandari JR, Andersen LB, Bauman AE, Brownson RC, Bull FC, Craig CL, Ekelund U, Goenka S, Guthold R, Hallal PC, Haskell WL, Heath GW, Inoue S, Kahlmeier S, Kohl HW, Lambert EV, Leetongin G, Loos RJF, Marcus B, Martin BW, Owen N, Parra DC, Pratt M, Ogilvie D, Reis RS, Sallis JF, Sarmiento OL, Wells JC. Effect of physical inactivity on major non-communicable diseases worldwide: An analysis of burden of disease and life expectancy. Lancet 2012.

[21] Mammen G, Faulkner G. Physical activity and the prevention of depression: A systematic review of prospective studies. Am J Prev Med 2013.

[22] Millan MJ. Descending control of pain. Prog Neurobiol 2002.

[23] Nijs J, Lluch Gires E, Lundberg M, Malfliet A, Sterling M. Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories. Man Ther 2015;20:216–220.

[24] Nijs J, Roussel N, van Wilgen CP, Köke A, Smeets R. Thinking beyond muscles and joints: therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Man Ther 2013;18:96–102.

[25] Steffens D, Maher CG, Pereira LSM, Stevens ML, Oliveira VC, Chapple M, Teixeira-Salmela LF, Hancock MJ. Prevention of lowback pain a systematic review and meta-Analysis. JAMA Intern Med 2016.

[26] Welsch P, Üçeyler N, Klose P, Walitt B, Häuser W. Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia. Cochrane Database Syst Rev 2018. doi:10.1002/14651858.CD010292.pub2.



Felipe Reis, PhD
Physical Therapy Department,
Instituto Federal do Rio de Janeiro (IFRJ)
Rio de Janeiro, Brazil

Brona M. Fullen, PhD
Associate Professor
UCD School of Public Health
Physiotherapy and Sports Science
Dublin, Ireland


Jo Nijs, PhD, MT, PT
Vrije Universiteit Brussel
Brussels, Belgium

Mari K. Lundberg, PhD, RPT
Associate Professor
Karolinska Institutet
Stockholm, Sweden

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