Chronic pain, defined as pain persisting beyond three months or beyond the expected time of tissue healing, is one of the main public health problems in Europe. According to the epidemiological survey by Breivik et al. (2006), published in the European Journal of Pain, approximately 19% of the European adult population suffers from chronic pain of moderate to severe intensity, equivalent to around 95 million people. In Spain, prevalence is estimated at around 17%, with a disproportionate impact on women, older people and lower socioeconomic groups.
Chronic musculoskeletal pain —including chronic low back pain, osteoarthritis, fibromyalgia and myofascial pain syndromes— is the most frequent cause. Neuropathic pain, arising from injury or dysfunction of the nervous system (post-herpetic neuralgia, diabetic neuropathy, central pain after stroke or spinal cord injury), has an estimated prevalence of 7–10% and tends to be more resistant to conventional treatments.
The socioeconomic cost of chronic pain is considerable. Beyond individual suffering, it generates occupational disability, reduced productivity, high consumption of healthcare resources and frequent use of opioids, with the associated risks of dependence and adverse effects. In this context, non-pharmacological strategies —and therapeutic exercise in particular— have gained increasing prominence in clinical practice guidelines.
The recommendation of exercise as a first-line intervention in the management of chronic pain has solid and growing scientific support. The main sources of evidence include:
NICE Guideline NG193 (2021): The National Institute for Health and Care Excellence guideline on primary and secondary chronic pain recommends offering supervised and group exercise programmes as part of initial treatment. The guideline emphasises that exercise should be considered an essential component of the approach, alongside patient education and psychological therapies, and explicitly discourages the isolated prescription of drugs as the sole strategy.
Cochrane Review by Geneen et al. (2017): This systematic review analysed 21 previous Cochrane reviews evaluating the effect of physical activity and exercise on chronic pain in adults. The authors concluded that physical exercise can contribute to reducing the severity of chronic pain and improving physical function, with a favourable safety profile. The quality of evidence varied according to the clinical condition, being most robust for chronic low back pain, knee osteoarthritis and fibromyalgia.
Cochrane Review by Hayden et al. (2021): Specifically for chronic low back pain, this updated review included 249 randomised controlled trials with more than 24,000 participants. Results indicated that exercise, compared with no treatment or minimal treatment, produces clinically relevant improvements in both pain and function. No single type of exercise was identified as clearly superior, suggesting that choice can be individualised according to patient preferences.
“Current evidence supports therapeutic exercise as a safe and effective intervention that can contribute to improving pain and function in people with chronic pain, as a complement to multimodal treatment.”
Additionally, the review by Ambrose and Golightly (2015) highlighted the neurophysiological mechanisms by which exercise can modulate pain: activation of endogenous endorphinergic and endocannabinoid systems, modulation of central sensitisation, reduction of systemic inflammation and improvement of descending inhibitory pain mechanisms.
The scientific literature has evaluated multiple exercise modalities in the context of chronic pain. The main categories are:
Aerobic exercise —walking, stationary cycling, swimming, elliptical training— is probably the most studied modality. Evidence suggests that moderate-intensity aerobic exercise can contribute to reducing pain intensity and improving functional capacity in people with chronic low back pain, fibromyalgia and osteoarthritis. Its mechanisms include activation of exercise-induced hypoalgesia, cardiovascular improvement and reduction of inflammatory markers. Walking is a particularly accessible option that requires no equipment and can be easily adapted to the patient's condition.
Strength training, whether with free weights, machines or elastic bands, has demonstrated benefits in chronic low back pain and osteoarthritis. A progressive strengthening programme can contribute to improving joint stability, muscle function and the patient's confidence in their ability to move. Evidence from Hayden et al. (2021) indicates that strength training produces results comparable to other exercise modalities in terms of pain reduction and functional improvement.
Exercise in an aquatic environment offers specific advantages: buoyancy reduces joint load, water temperature (generally 33–34°C) facilitates muscle relaxation, and the resistance of the medium allows adaptable muscle work. The Cochrane review by Bartels et al. (2016) found that aquatic exercise can produce small but clinically relevant improvements in pain and function in people with knee and hip osteoarthritis. This modality may be especially suitable for patients with significant functional limitations, obesity or marked joint pain that makes weight-bearing exercise difficult.
Mind-body exercise modalities integrate components of movement, postural control, breathing and mindfulness. Evidence suggests that yoga can contribute to improving pain and function in chronic low back pain (Cochrane review by Wieland et al., 2017) and that tai chi may be beneficial in knee osteoarthritis and fibromyalgia. Pilates, with its emphasis on motor control and trunk stability, has shown promising results in chronic low back pain, although the quality of evidence is variable. These modalities may be particularly useful for patients with a marked psychosocial component, as they simultaneously address physical and emotional factors.
Motor control exercises, aimed at improving coordination, proprioception and muscle activation patterns, are relevant in chronic pain associated with neurological damage. After a stroke or spinal cord injury, central or neuropathic pain may coexist with alterations in muscle tone (spasticity), balance deficits and compensatory movement patterns. In these cases, neuromotor exercise —including robot-assisted therapy such as robotic gait training systems or upper limb rehabilitation robots— allows motor function to be addressed in a controlled manner, with precise monitoring of load and assistance.
The prescription of therapeutic exercise for chronic pain must be structured following the FITT principles (Frequency, Intensity, Time and Type), adapting them to the individual characteristics of each patient:
Frequency: Most clinical guidelines recommend between 2 and 5 sessions per week. For chronic low back pain, evidence from Hayden et al. (2021) suggests that 2–3 supervised sessions per week, complemented by home exercise, can be an appropriate starting point. Frequency should allow recovery between sessions, especially at the start of the programme.
Intensity: Moderate intensity is the most recommended starting point. In aerobic exercise, this equates to 40–60% of heart rate reserve or a level of 4–6 on a perceived exertion scale of 0 to 10. In strength training, it is recommended to start with loads of 40–60% of one repetition maximum (1RM), with 2–3 sets of 10–15 repetitions. A gradual start is essential: progression should be guided by patient tolerance and not by rigid predefined targets.
Time (duration): Sessions typically range between 20 and 60 minutes, including warm-up and cool-down. For patients with chronic pain who have been inactive, it may be necessary to start with 10–15 minute sessions and increase progressively. Evidence suggests that accumulating small blocks of activity throughout the day can be as effective as a continuous session, which facilitates adherence in patients with low initial tolerance.
Type: As described, no modality is clearly superior. The choice of exercise type should consider the specific clinical condition, functional abilities, patient preferences and available resources. Multimodal programmes combining aerobic, strength and flexibility components may be particularly suitable.
Progression: Gradual progression is an essential principle. It is recommended to increase load by no more than 10–15% per week, following the principle of “start low and go slow.” Progression should be based on function rather than pain: the goal is to progressively increase functional capacity, accepting that some level of discomfort may be expected during the adaptation process.
Supervised therapeutic exercise has a favourable safety profile. The review by Geneen et al. (2017) did not identify serious adverse effects associated with exercise in people with chronic pain. Nevertheless, safe prescription requires prior clinical assessment and knowledge of certain principles:
Red flags: Before starting any exercise programme, it is essential to rule out warning signs suggesting serious underlying pathology: cauda equina syndrome (sphincter dysfunction, saddle anaesthesia), pathological fractures (history of neoplasm, unexplained weight loss, severe nocturnal pain), infections (fever, history of immunosuppression) or vascular pathology (chest pain, dyspnoea). The presence of red flags requires immediate medical referral and constitutes a contraindication to starting exercise without prior assessment.
Pain during exercise: It is essential to educate the patient about the difference between “acceptable” pain during exercise and pain indicating a problem. An evidence-based approach is the pain monitoring model: a transient increase in pain of up to 2 points on a numerical scale of 0 to 10 during exercise is considered acceptable, provided pain returns to baseline within 24 hours. If pain does not normalise within that period, load should be reduced.
Relative contraindications: These include acute inflammatory processes (rheumatoid arthritis flares), haemodynamic instability, unevaluated acute pain and uncontrolled medical conditions (severe hypertension, unstable cardiac disease). In these cases, exercise should be postponed until the clinical situation is stabilised.
Adaptation: In patients with neurological damage and comorbid chronic pain, adaptations are particularly relevant. Spasticity, balance deficits, neurological fatigue and cognitive impairment may require specific programme modifications. Robotic technology allows precise adaptation of load and assistance, which can contribute to safety in these patients.
Adherence to exercise is possibly the greatest challenge in the management of chronic pain. Dropout rates in exercise programmes for chronic pain can reach 50–70% within the first six months. Understanding and addressing the psychosocial factors that determine adherence is as important as designing the exercise programme itself.
Kinesiophobia: Fear of movement due to fear of causing pain or damage (assessable using the Tampa Scale of Kinesiophobia) is one of the main predictors of inactivity and disability in chronic pain. Pain neuroscience education and graded exposure to movement are key strategies for addressing this factor.
Catastrophising: The tendency to magnify the threat of pain, feel helpless in the face of it and ruminate on the pain experience (assessable with the Pain Catastrophizing Scale) is associated with poorer exercise outcomes. Programmes integrating cognitive-behavioural components alongside exercise may contribute to improving outcomes in patients with high catastrophising.
Self-efficacy: The patient's confidence in their ability to exercise despite pain is a key determinant of adherence. Strategies to improve self-efficacy include setting achievable goals, positive reinforcement of achievements, education about the mechanisms of action of exercise and active patient involvement in decision-making about their programme.
Expectations and therapeutic alliance: The patient's expectations about treatment outcomes and the quality of the therapeutic relationship with the physiotherapist are contextual factors that significantly modulate outcomes. Empathic, transparent and person-centred communication contributes to generating trust and commitment to the programme.
At GNeuro, the approach to chronic pain is framed within a model of individualised, evidence-based care, with particular attention to patients with neurological damage and comorbid chronic pain (central pain after stroke, neuropathic pain from spinal cord injury, musculoskeletal pain secondary to compensatory patterns).
The programme includes:
At GNeuro we design individualised exercise programmes, supervised by specialist physiotherapists and supported by robotic technology. If you would like information about our approach to chronic pain, please contact us.
Request informationWhat type of exercise is most recommended for chronic pain?
There is no single type of exercise superior for all cases of chronic pain. Available evidence indicates that aerobic exercise, strength training, aquatic exercise and mind-body modalities (yoga, tai chi) can all contribute to reducing pain intensity and improving function. The NICE NG193 guideline recommends programmes combining different modalities adapted to each person's preferences and abilities. Individualisation of the programme is a key factor for adherence and outcomes.
Is it safe to exercise when you have chronic pain?
Yes, supervised therapeutic exercise is generally safe for people with chronic pain, and evidence suggests that prolonged inactivity can worsen the situation. It is normal to experience a transient increase in pain when starting an exercise programme, which does not imply tissue damage. However, it is essential to rule out red flags (warning signs of serious pathology) beforehand and to progress intensity gradually. Supervision by a qualified physiotherapist contributes to the safety of the programme.
How much exercise is needed to obtain benefits in chronic pain?
Clinical guidelines and evidence from Cochrane reviews suggest that exercise programmes of 2 to 5 sessions per week, lasting 20 to 60 minutes per session, at moderate intensity, can contribute to reducing pain and improving functional capacity. The FITT principles (frequency, intensity, time and type) allow prescription to be structured on an individualised basis. Benefits are usually observed progressively over several weeks of continued adherence.
Can exercise replace analgesic medication?
Therapeutic exercise should not be considered a substitute for medication, but rather a complement within a multimodal approach to chronic pain. NICE guidelines recommend exercise as part of first-line treatment, but any modification to the pharmacological regimen must be supervised by the responsible physician. In certain cases, a well-structured exercise programme may contribute to reducing the need for analgesics, but this must be evaluated on an individual basis.