Can exercise help with chronic pain?
It is very common for us to recommend exercise to people who are struggling with chronic pain, only to be met with a comment like ‘Exercise! But it hurts when I move!’ In this article, we hope to explain why exercise can be helpful in reducing chronic pain.
What effect does exercise have on pain?
What effect does exercise have on pain?Exercise has been shown to have a direct effect on how the body produces substances that contribute to how we experience pain (1).
In the central nervous system, there are pain pathways that are sensitive to neurotransmitters called endogenous opioids. These opioids have an inhibitory action on areas in our nervous system that let us experience pain, meaning that the more of these opioids we produce, the more it will dull our experience of pain (2)
The body also uses a neurotransmitter called serotonin to help modulate pain. As a painful event occurs in the body, the signal perceiving it travels into the spinal cord and into the brain, serotonin activates pathways that weaken or block those signals, as well as interacting with overactive nerve cells. Both effects have the result of reducing our experience of pain (3). Exercise increases the effect of both endogenous opioids and serotonin.
In healthy pain-free individuals, a single bout of exercise has been shown to have an analgesic effect of up to around thirty minutes after the cessation of the activity. Aerobic exercise (exercise that gets you out of breath) tends to have a more consistent global analgesic effect if performed at higher intensities, resistance exercise (lifting weights or other muscle activation activities) tends to be less predictable and is more localised to the area being exercised (4).
When the same activity is prescribed to people who have chronic pain conditions such as fibromyalgia or osteoarthritis, the picture is less predictable, with some studies showing no analgesic effect or an increase in pain after the activity. This, understandably, leads to people who have chronic pain doing less exercise. People with pain all over their bodies often don’t get the usual pain-relief effect from exercise, and people with pain in just one area don’t tend to get the analgesic response when they exercise the painful spot. However, people who have chronic pain in one area of the body who exercise a part of the body that doesn’t hurt, the analgesic effect does occur, suggesting that exercising non-painful areas of the body may help with chronic pain in other painful parts (5).
Why should I exercise if I have chronic pain?
There is growing evidence that being able to exercise consistently will help reduce pain in many chronic pain conditions, including fibromyalgia (6), osteoarthritis (7), chronic low back and neck pain (8, 9), and some neuropathic pain (10). Exercise will not only help with the pain associated with these conditions but will also have a positive impact on physical performance and mood, as well as reducing the incidence of other conditions such as diabetes and heart problems (11).
How to exercise if you have chronic pain
This is the million-dollar question. As we have explained, people with chronic pain are more likely to have no change or even a worsening of their pain after exercise so how do we achieve the pain-reducing benefits of exercise in the long term?
There is not much evidence in how to accurately prescribe exercise for chronic pain patients; however, there are some methods that, if broadly applied, may enable people in pain to benefit from habitual exercise (4).
People in chronic pain tend to exhibit fear-avoidant patterning, where they minimize activity to avoid the occurrence or worsening of their pain. This then amplifies the subjective experience of the pain, leading to a furthering of the fear and activity avoidance. This ultimately leads to a lowering of the threshold at which the person feels pain (12). To break this cycle, what is needed is education around the nature of a person’s pain in the context of physical activity and then a graded exposure to exercise that takes away the negative association between exercise and pain (13). For example, a person with knee osteoarthritis may be fearful of walking, but education around how walking may actually help, as opposed to exacerbate the pain, alongside some very basic activity targets to hit (e.g. walking to the end of the garden, then street etc) can often help break the cycle of fear avoidance.
As we saw earlier, people with pain in one area of the body may get some pain relief from exercising other areas, so finding an activity that the person can tolerate in the short term can help reduce the chronic pain they are suffering in the long term. A good example would be people who suffer from chronic low back pain can often tolerate water-based activity or weight machines that support the back while being used.
One thing is clear: that people who suffer from chronic pain are likely to benefit from exercising consistently via the analgesic effect of the activity; however, finding the correct exercise regime for their pain can take some trial and error, and can often be greatly assisted by someone who can contextualise their pain and help them try to find solutions.
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References
1 – Sluka KA, Frey-Law L, Hoeger Bement M. Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation. Pain. 2018 Sep;159 Suppl 1(Suppl 1):S91-S97. doi: 10.1097/j.pain.0000000000001235. PMID: 30113953; PMCID: PMC6097240.
2 – Dhaliwal A, Gupta M. Physiology, Opioid Receptor. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546642/
3 – Marks DM, Shah MJ, Patkar AA, Masand PS, Park GY, Pae CU. Serotonin-norepinephrine reuptake inhibitors for pain control: premise and promise. Curr Neuropharmacol. 2009 Dec;7(4):331-6. doi: 10.2174/157015909790031201. PMID: 20514212; PMCID: PMC2811866.
4 – David Rice, Jo Nijs, Eva Kosek, Timothy Wideman, Monika I Hasenbring, Kelli Koltyn, Thomas Graven-Nielsen, Andrea Polli,Exercise-Induced Hypoalgesia in Pain-Free and Chronic Pain Populations: State of the Art and Future Directions,The Journal of Pain,Volume 20, Issue 11,2019,Pages 1249-1266,ISSN 1526-5900,https://doi.org/10.1016/j.jpain.2019.03.005.
5 – N Burrows, J Booth, D Sturnieks, B Barry. Acute resistance exercise and pressure pain sensitivity in knee osteoarthritis: A randomised crossover trial. Osteoarthritis Cartilage, 22 (2014), pp. 407-414
6 – J Bidonde, A Busch, C Schachter, T Overend, S Kim, S Góes, C Boden, H Foulds. Aerobic exercise training for adults with fibromyalgia, Cochrane Database Syst Rev, 6 (2017), Article CD012700
7 – G Hernandez-molina, S Reichenbach, B Zhang, M Lavalley, DT Felson. Effect of therapeutic exercise for hip osteoarthritis pain: Results of a meta-analysis. Arthritis Rheum, 59 (2008), pp. 1221-1228
8 – J Hayden, MW Van Tulder, A Malmivaara, BW Koes, Exercise therapy for treatment of non‐specific low back pain. Cochrane Database Syst Rev (2005)
9 – A Gross, J Paquin, G Dupont, S Blanchette, P Lalonde, T Cristie, N Graham, T Kay, S Burnie, G Gelley. Exercises for mechanical neck disorders: A Cochrane review update, Man Ther, 24 (2016), pp. 25-45
10 – I Boldt, I Eriks-Hoogland, M Brinkhof, R de Bie, D Joggi, E von Elm. Non-pharmacological interventions for chronic pain in people with spinal cord injury. Cochrane Database Syst Rev (2014).
11 – BK Pedersen, B. Saltin. Exercise as medicine: Evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports, 25 (2015), pp. 1-72
12 – Rogers, AH., Farris, SG. A meta-analysis of the associations of elements of the fear-avoidance model of chronic pain with negative affect, depression, anxiety, pain-related disability and pain intensity. Eur J Pain [Internet]. 2022 June 12 [cited 2023 May 22]. 26:1611–1635
13 – A Malfliet, J Kregel, M Meeus, B Cagnie, N Roussel, M Dolphens, L Danneels, J Nijs. Applying contemporary neuroscience in exercise interventions for chronic spinal pain: Treatment protocol. Braz J Phys Ther, 21 (2017), pp. 378-387