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Physical Activity in Chronic Pain Management

Original Editor - Ewa Jaraczewska based on the course by Jacquie Kieck

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Rest was once the default treatment for pain. Research has moved on, and we now understand that physical activity has a positive impact on chronic pain, with the European Pain Federation identifying it as a first-line treatment.[1] They note that more physically active people have a lower risk of developing painful conditions, such as low back pain, hip and knee osteoarthritis, and chronic pain.[2] Benefits are not limited to prevention either. A 2017 Cochrane review found probable beneficial effects of exercise across chronic pain conditions for pain severity, physical function, and quality of life.[3] Yet misconceptions about exercise and chronic pain persist, and many people with chronic pain remain inactive.

How Physical Activity Impacts Chronic Pain

There are many mechanisms through which physical activity influences chronic pain, some of which are highlighted in the following sections.

Physical activity and pain modulation
Neurological Modulation

Physical activity modulates pain by activating pathways in the peripheral and central nervous systems. It draws on the body's own pain-relief system, which produces natural analgesics, such as enkephalins, endorphins, and endocannabinoids.[4] Exercise may reduce levels of glutamate, an excitatory neurotransmitter that amplifies pain, while increasing serotonin levels. It also activates central inhibitory pathways via opioid and serotonergic systems, reducing nociceptive transmission, and stimulates brain-derived neurotrophic factor (BDNF).[5][6]

Neuroinflammation

Chronic pain is commonly associated with neuroinflammation, marked by activation of microglia and astrocytes in the spinal cord and brain and a shift towards pro-inflammatory cytokine signalling.[6] This shift increases nociceptive sensitivity and contributes to central sensitisation.[7] Physical activity has been shown to reduce pro-inflammatory cytokines and oxidative stress.[6]

Sleep Quality

Up to 75% of people with chronic musculoskeletal pain report notable sleep disturbances. This relationship is bidirectional: pain interferes with sleep, and poor sleep intensifies the perception of pain.[8] Exercise helps stabilise circadian rhythms, raise melatonin levels, and lower cortisol levels. For people with clinical insomnia, physical activity should be paired with cognitive behavioural therapy, as exercise is insufficient on its own.[9]

Stress Regulation

Chronic pain often leaves people with a dysregulated stress response (sympathetic overactivity paired with reduced parasympathetic activity), where their nervous system remains on high alert for perceived threats.[10] Regular physical activity helps to mitigate this by lowering resting cortisol levels, reducing systemic inflammation, enhancing autonomic balance, and increasing serotonin, endocannabinoids, and endogenous opioids.[6]

Cognition and Mood Regulation

Exercise improves cognition and mood, alleviating symptoms of depression and anxiety while improving cognitive function and self-efficacy.[11] These changes also increase emotional resilience, which contributes to the analgesic effects of exercise.[6]

Chronic Pain and Fear of Movement

No exercise programme will succeed if the person believes that movement will hurt them.[6] Kinesiophobia, or fear of movement, is a key barrier to physical activity in people with chronic pain.[12][13] The core belief driving kinesiophobia is that pain during exercise means damage is being done.

Neurobiological Response to Pain

Normally, when a threat is perceived, a protective response, including pain, is the expected output. In this case, the system is working as it should.[14] In chronic pain, however, this protective system can become over-sensitive, a process known as central sensitisation. A sensitised nervous system has learned to treat movement as a threat, so it continues to produce pain even when movement is no longer dangerous. The problem is not that the system is broken, but that it has become overprotective.

Kinesiophobia Assessment Tools

Addressing kinesiophobia requires a deliberate, structured approach. Fear of movement can be formally assessed using tools such as the Tampa Scale for Kinesiophobia or the Fear Avoidance Belief Questionnaire.[15]

Language Matters for Kinesiophobia

Clinicians must remember that language matters. Words like "degeneration", "instability", "bone on bone", or "slipped disc" can sound catastrophic for many patients. Fear-inducing language and movement-limiting advice should, therefore, be avoided.[6] The clinician needs to convey that physical pain is not a reflection of tissue damage, and that movement, targeted exercise and lifestyle changes are powerful tools for managing symptoms and building resilience.[16]

"Pain does not equal damage" is one of the most powerful messages clinicians can offer to their patients.[6]

Managing Kinesiophobia

When fear is present, graded exposure is a key clinical tool. Start with movements the person already feels safe performing; build gradually, and celebrate small wins. In the early stages, the goal is to restore a sense of safety in the body.[15]

Managing Flares During Physical Activity

Many people fear that physical activity will worsen their pain or cause it to "flare up". A flare is essentially a temporary increase in symptoms, but the term means different things to different people, and it is not always about pain alone. Some people with low back pain experiencing a flare might not report higher-than-average pain. Instead, they might experience a greater psychosocial impact.[17] For people with knee osteoarthritis, the term is also used inconsistently, but it is often reserved for more severe episodes, which are associated with reduced confidence and feelings of vulnerability rather than higher pain intensity alone.[18] High-quality evidence on how best to manage flares during exercise is limited, so guidance is largely practical: prepare the person in advance so a flare is expected rather than alarming, keep moving at a reduced level rather than stopping altogether where it is safe to do so, and seek review if new symptoms appear, such as neurological changes. Reviewing a flare together afterwards, rather than treating it as a setback, can help reduce the threat it carries.[6]

[19]

The Boom-Bust Cycle

The boom-bust cycle is a common pattern in chronic pain: doing too much on good days, then crashing and resting for days or weeks afterwards. This cycle can reinforce the belief that activity causes harm, worsen deconditioning, and erode self-efficacy.

Pacing is widely used as a strategy to address the boom-bust cycle. It means setting a baseline activity level that is comfortably achievable on a moderate day, and building gradually and systematically, regardless of daily pain levels. The aim is to separate physical activity from pain. This may mean doing a little less than feels possible on good days, and doing a little more than feels comfortable on hard days, ultimately working towards a stable baseline rather than a pain-free window.[20][21]

Physical Activity Prescription Principles

Several principles guide the prescription of physical activity for chronic pain.

Before any movement or exercise is prescribed, the clinician must understand what physical activity means to this particular person:[6]

  • Ask appropriate questions: What do they fear? What have they been told? What do they enjoy? Where are they emotionally in relation to their condition?
  • Share decision-making by asking: What feels realistic? What would they enjoy? What fits into their life?

There is no single correct exercise modality. The best exercise for a person with chronic pain is the one they will actually do.[6] Walking, swimming, gardening, dancing, resistance training, and Tai Chi can all be therapeutic, and an activity a person enjoys is more likely to be sustained. Movement snacks and incidental activity also count, and small amounts done regularly add up. Starting small and building gradually is often more sustainable than attempting too much too soon. These small, sustainable movements are a foundation for lasting change.[6]

Effects of physical activity

Exercise is most effective when integrated with other interventions. Adding pain science education to an exercise programme can help to reduce catastrophising, anxiety and kinesiophobia.[22] Combined with sleep hygiene support, nutritional guidance, and stress management, physical activity becomes part of a broader biopsychosocial approach to managing chronic pain.[6]

How the clinician communicates is part of the intervention, not an addition to it. The language they use and the trust they build shape whether a person with chronic pain engages with physical activity at all.[6] This continues beyond the initial prescription, as ongoing support helps sustain change.[6]

Summary

Physical activity is a key intervention for chronic pain. There are, however, many barriers to exercise, and adherence is rarely linear. Flares and setbacks are expected. Pacing, graded exposure, personalised exercise prescription, and a genuine therapeutic relationship are the foundations of effective practice. The aim is not perfection, but a sustainable relationship with movement and exercise.

Resources

References

  1. ↑ Vaegter HB, Kinnunen M, Verbrugghe J, Cunningham C, Meeus M, Armijo‐Olivo S, Bandholm T, Fullen BM, Wittink H, Morlion B, Reneman MF. Physical activity should be the primary intervention for individuals living with chronic pain. A position paper from the European Pain Federation (EFIC)‘On the Move’Task Force. European Journal of Pain. 2024 Sep;28(8):1249-56.
  2. ↑ European Pain Federation (EFIC). EFIC on the move. Available from: https://europeanpainfederation.eu/current-projects/efic-on-the-move/ (accessed 26 June 2026).
  3. ↑ 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 Apr 24;4(4):CD011279.
  4. ↑ Núñez-Cortés R, Salazar-Méndez J, Nijs J. Physical Activity as a Central Pillar of Lifestyle Modification in the Management of Chronic Musculoskeletal Pain: A Narrative Review. J Funct Morphol Kinesiol. 2025 May 20;10(2):183.
  5. ↑ Ni W, Kuang X, Zhu Z. Pain Chronicity and Relief: From Molecular Basis to Exercise-Based Rehabilitation. Biology (Basel). 2025 Aug 23;14(9):1116.
  6. ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 6.14 Kieck J. Physical Activity and Chronic Pain Course. Physiopedia Plus, 2026.
  7. ↑ McKenzie A, Dombrower R, Theeraphapphong N, McKenzie S, Hijazin MA. Glial activation, neuroinflammation, and loss of neuroprotection in chronic pain: cellular mechanisms and emerging therapeutic strategies. Biomedicines. 2025 Dec 26;14(1):58.
  8. ↑ Runge N, Ahmed I, Saueressig T, Perea J, Labie C, Mairesse O, et al. The bidirectional relationship between sleep problems and chronic musculoskeletal pain: a systematic review with meta-analysis. Pain. 2024 Nov 1;165(11):2455-2467.
  9. ↑ Kim N, Ka S, Park J. Effects of exercise timing and intensity on physiological circadian rhythm and sleep quality: a systematic review. Phys Act Nutr. 2023 Sep;27(3):52-63.
  10. ↑ Yeater TD, Clark DJ, Hoyos L, Valdes-Hernandez PA, Peraza JA, Allen KD, Cruz-Almeida Y. Chronic Pain is Associated With Reduced Sympathetic Nervous System Reactivity During Simple and Complex Walking Tasks: Potential Cerebral Mechanisms. Chronic Stress (Thousand Oaks). 2021 Jul 7;5:24705470211030273.
  11. ↑ Pujari V. Moving to Improve Mental Health - The Role of Exercise in Cognitive Function: A Narrative Review. J Pharm Bioallied Sci. 2024 Feb;16(Suppl 1):S26-S30.
  12. ↑ Leese C, Gupte D, Christogianni A, Higgins C, Adair P, Dall P, et al. Barriers and facilitators for physical activity in people living with chronic pain: a systematic review and combined analysis. Pain. 2024 Dec 1;165(12):2721-2732.
  13. ↑ Goubran M, Farajzadeh A, Lahart IM, Bilodeau M, Boisgontier MP. Relationship between fear of movement and physical activity in patients with cardiac, rheumatologic, neurologic, pulmonary, or pain conditions: a systematic review and meta-analysis. Phys Ther. 2025 Jun 2;105(6):pzaf050.
  14. ↑ Greenwald JD, Shafritz KM. An Integrative Neuroscience Framework for the Treatment of Chronic Pain: From Cellular Alterations to Behavior. Front Integr Neurosci. 2018 May 23;12:18.
  15. ↑ 15.0 15.1 Bordeleau M, Vincenot M, Lefevre S, Duport A, Seggio L, Breton T, Lelard T, Serra E, Roussel N, Neves JFD, Léonard G. Treatments for kinesiophobia in people with chronic pain: A scoping review. Front Behav Neurosci. 2022 Sep 20;16:933483.
  16. ↑ Niederstrasser NG, Attridge N, Slepian PM. Indirect associations of pain resilience and kinesiophobia with the relationship between physical activity and chronic pain. PLoS One. 2025 Oct 22;20(10):e0334144.
  17. ↑ Costa N, Smits EJ, Kasza J, Salomoni SE, Ferreira M, Hodges PW. Low back pain flares: how do they differ from an increase in pain?. The Clinical journal of pain. 2021 May 1;37(5):313-20.
  18. ↑ Parry E, Dikomitis L, Peat G, Chew-Graham CA. How do people with knee osteoarthritis perceive and manage flares? A qualitative study. BJGP Open. 2022 Aug 30;6(2):BJGPO.2021.0086.
  19. ↑ Dr Deepak Ravindran. When chronic pain flares up, this is what you should do..... Available from: https://www.youtube.com/watch?v=AzC63ZFKbQE [last accessed 1/6/2026]
  20. ↑ Antcliff D, Keenan AM, Keeley P, Woby S, McGowan L. “Pacing does help you get your life back”: The acceptability of a newly developed activity pacing framework for chronic pain/fatigue. Musculoskeletal care. 2022 Mar;20(1):99-110.
  21. ↑ Devan D. A review of current therapeutic practice for the management of chronic pain. South African Journal of Occupational Therapy. 2014 Jan;44(1):48-50.
  22. ↑ Núñez-Cortés R, Salazar-Méndez J, Calatayud J, Malfliet A, Lluch E, Mendez-Rebolledo G, Guzmán-Muñoz E, López-Bueno R, Suso-Martí L. The optimal dose of pain neuroscience education added to an exercise programme for patients with chronic spinal pain: a systematic review and dose–response meta-analysis. Pain. 2024 Jun 1;165(6):1196-206.
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