Physiotherapy theory and practice · 2026
Discussing pain increases at the point of exercise prescription: a clinical commentary for persistent musculoskeletal conditions.
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Ganesh G Shankar
Аннотация
BACKGROUND: Patients with persistent musculoskeletal pain frequently perform prescribed exercise without direct supervision. When exercise increases symptoms, patients may be uncertain whether to continue, modify the session, or seek advice. A prescription that specifies exercises and dosage but provides no guidance about possible symptom aggravation may therefore leave an important gap in preparation.
PURPOSE: This commentary proposes that, when prescribed exercise may increase pain, the possible response should be discussed at the point of prescription and that clinicians should prepare patients for how symptom aggravation will be interpreted and reviewed.
DISCUSSION AND RECOMMENDATIONS: Trials comparing painful and nonpainful exercise, including an updated 2025 systematic review, show no consistent advantage for either approach and provide no basis for a universal adjustment rule. Pain-monitoring protocols developed for Achilles tendinopathy indicate that continued loading can be compatible with recovery in that condition, but their thresholds have not been validated for other presentations and should not be transferred by default. Features of altered nociceptive processing may further complicate interpretation of symptom aggravation but do not remove the need for assessment. What is proposed is a conversation rather than an algorithm: an explicit discussion, established when exercise is prescribed, about what a symptom increase might mean, how it will be interpreted, and when and how the plan will be reviewed. The evidence considered spans low back pain, osteoarthritis, and tendinopathy; extension to other persistent musculoskeletal conditions remains a reasonable but untested proposition.
CONCLUSION: Research should establish what instructions clinicians currently provide when exercise increases pain, whether patients understand them, and which responses lead patients to continue, modify, or abandon exercise. Future studies should also determine whether discussing possible aggravation before it occurs improves adherence, confidence, function, and timely reassessment.
PURPOSE: This commentary proposes that, when prescribed exercise may increase pain, the possible response should be discussed at the point of prescription and that clinicians should prepare patients for how symptom aggravation will be interpreted and reviewed.
DISCUSSION AND RECOMMENDATIONS: Trials comparing painful and nonpainful exercise, including an updated 2025 systematic review, show no consistent advantage for either approach and provide no basis for a universal adjustment rule. Pain-monitoring protocols developed for Achilles tendinopathy indicate that continued loading can be compatible with recovery in that condition, but their thresholds have not been validated for other presentations and should not be transferred by default. Features of altered nociceptive processing may further complicate interpretation of symptom aggravation but do not remove the need for assessment. What is proposed is a conversation rather than an algorithm: an explicit discussion, established when exercise is prescribed, about what a symptom increase might mean, how it will be interpreted, and when and how the plan will be reviewed. The evidence considered spans low back pain, osteoarthritis, and tendinopathy; extension to other persistent musculoskeletal conditions remains a reasonable but untested proposition.
CONCLUSION: Research should establish what instructions clinicians currently provide when exercise increases pain, whether patients understand them, and which responses lead patients to continue, modify, or abandon exercise. Future studies should also determine whether discussing possible aggravation before it occurs improves adherence, confidence, function, and timely reassessment.