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MSK Pain – CP – Pain in chronic pain

Evidence Summary (New 2022)

Exercise or physical activity interventions are known to improve pain outcomes compared to non-exercise controls. Whilst the improvement are significant there is significant heterogeneity (I2=86.6%) and the GRADE was found to be of low quality in a systematic review by Belavy et al (6).

A review of self-management interventions for those with chronic musculoskeletal pain that included 46 trials identified that courses run in groups, courses led by healthcare professionals and courses that included a psychological component had beneficial effects on pain, especially in the short-term (7).

Walking interventions have been shown to significantly reduce pain in the short and medium term compared with controls (8). Aerobic interventions have been shown to have a small effect on pain reduction, the evidence supporting this was however from 3 RCTs and of low quality (9).
In those with fibromyalgia, resistance exercises help to reduce pain and tenderness (4). A further review of strength training interventions found a reduction in pain outcomes and one of the included studies by Kayoet et al found that 41.4% of participants in the intervention group were regularly using pain medication compared to 80% of participants in the control group (3).

Whilst a Cochrane review found only a non-statistically significant improvement in pain in those with fibromyalgia undertaking aerobic exercise interventions, there was a statistically significant improvement in tender trigger points (1). Exercise is the only therapy based intervention given a ‘strong for’ recommendation in the latest EULAR fibromyalgia guidelines (10).

Quality of Evidence
Grade B/C – low – moderate quality

Strength of recommendation
Grade 1 – strong recommendation

Conclusion

Regular physical activity, including walking, can improve pain in those with chronic musculoskeletal pain and should be advised as part of their overall management plan as per EULAR guidelines.

Consider referring those with a significant psychosocial contribution to their presentation to exercise intervention programmes with a psychological component, ideally group programmes that are led by an experienced healthcare professional .

References

  1. Busch AJ, Barber KAR, Overend TJ, Peloso PMJ, Schachter CL. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev [Internet]. 2007 [cited 2022 Aug 24];(4). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003786.pub2/full
  2. Estévez-López F, Maestre-Cascales C, Russell D, Álvarez-Gallardo IC, Rodriguez-Ayllon M, Hughes CM, et al. Effectiveness of Exercise on Fatigue and Sleep Quality in Fibromyalgia: A Systematic Review and Meta-analysis of Randomized Trials. Arch Phys Med Rehabil [Internet]. 2021 Apr 1 [cited 2022 Jul 8];102(4):752–61. Available from: https://pubmed.ncbi.nlm.nih.gov/32721388/
  3. Andrade A, de Azevedo Klumb Steffens R, Sieczkowska SM, Peyré Tartaruga LA, Torres Vilarino G. A systematic review of the effects of strength training in patients with fibromyalgia: clinical outcomes and design considerations. Adv Rheumatol (London, England) [Internet]. 2018 Oct 22 [cited 2022 Jul 11];58(1):36. Available from: https://pubmed.ncbi.nlm.nih.gov/30657077/
  4. Busch AJ, Webber SC, Richards RS, Bidonde J, Schachter CL, Schafer LA, et al. Resistance exercise training for fibromyalgia. Cochrane database Syst Rev [Internet]. 2013 Dec 20 [cited 2022 Aug 24];2013(12). Available from: https://pubmed.ncbi.nlm.nih.gov/24362925/
  5. Vilarino GT, Andreato LV, de Souza LC, Branco JHL, Andrade A. Effects of resistance training on the mental health of patients with fibromyalgia: a systematic review. Clin Rheumatol [Internet]. 2021 Nov 1 [cited 2022 Jul 11];40(11):4417–25. Available from: https://pubmed.ncbi.nlm.nih.gov/33987785/
  6. Belavy DL, Van Oosterwijck J, Clarkson M, Dhondt E, Mundell NL, Miller CT, et al. Pain sensitivity is reduced by exercise training: Evidence from a systematic review and meta-analysis. Neurosci Biobehav Rev [Internet]. 2021 Jan 1 [cited 2022 Jul 8];120:100–8. Available from: https://pubmed.ncbi.nlm.nih.gov/33253748/
  7. Carnes D, Homer KE, Miles CL, Pincus T, Underwood M, Rahman A, et al. Effective delivery styles and content for self-management interventions for chronic musculoskeletal pain: a systematic literature review. Clin J Pain [Internet]. 2012 May [cited 2022 Aug 24];28(4):344–54. Available from: https://pubmed.ncbi.nlm.nih.gov/22001667/
  8. O’Connor SR, Tully MA, Ryan B, Bleakley CM, Baxter GD, Bradley JM, et al. Walking exercise for chronic musculoskeletal pain: systematic review and meta-analysis. Arch Phys Med Rehabil [Internet]. 2015 Apr 1 [cited 2022 Aug 24];96(4):724-734.E3. Available from: https://pubmed.ncbi.nlm.nih.gov/25529265/
  9. Ferro Moura Franco K, Lenoir D, dos Santos Franco YR, Jandre Reis FJ, Nunes Cabral CM, Meeus M. Prescription of exercises for the treatment of chronic pain along the continuum of nociplastic pain: A systematic review with meta-analysis. Eur J Pain [Internet]. 2021 Jan 1 [cited 2022 Jul 8];25(1):51–70. Available from: https://pubmed.ncbi.nlm.nih.gov/32976664/
  10. Macfarlane GJ, Kronisch C, Dean LE, Atzeni F, Häuser W, Flub E, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis [Internet]. 2017 Feb 1 [cited 2022 Aug 24];76(2):318–28. Available from: https://pubmed.ncbi.nlm.nih.gov/27377815/