Content uploaded by Marcus Schiltenwolf
Author content
All content in this area was uploaded by Marcus Schiltenwolf on Sep 29, 2017
Content may be subject to copyright.
CLINICAL UPDATE
Exercise for chronic musculoskeletal pain: A biopsychosocial
approach
John Booth
1
|G. Lorimer Moseley
2
|Marcus Schiltenwolf
3
|Aidan Cashin
1
|
Michael Davies
4
|Markus Hübscher
5,6
1
School of Medical Sciences, University of
New South Wales, Sydney, Australia
2
Sansom Institute for Health Research,
University of South Australia, Adelaide,
Australia
3
Department of Orthopedics, Trauma Surgery
and Paraplegiology, Heidelberg University
Hospital, Germany
4
Figtree Hospital, Figtree, Wollongong,
Australia
5
Neuroscience Research Australia, Sydney,
Australia
6
Prince of Wales Clinical School, University of
New South Wales, Sydney, Australia
Correspondence
Dr John Booth, Department of Exercise
Physiology, School of Medical Sciences,
University of New South Wales, Sydney,
NSW 2052, Australia.
Email: john.booth@unsw.edu.au
Abstract
Chronic musculoskeletal pain (CMP) refers to ongoing pain felt in the bones, joints and tissues of
the body that persists longer than 3 months. For these conditions, it is widely accepted that
secondary pathologies or the consequences of persistent pain, including fear of movement, pain
catastrophizing, anxiety and nervous system sensitization appear to be the main contributors to
pain and disability. While exercise is a primary treatment modality for CMP, the intent is often
to improve physical function with less attention to secondary pathologies. Exercise interventions
for CMP which address secondary pathologies align with contemporary pain rehabilitation
practices and have greater potential to improve patient outcomes above exercise alone.
Biopsychosocial treatment which acknowledges and addresses the biological, psychological and
social contributions to pain and disability is currently seen as the most efficacious approach to
chronic pain. This clinical update discusses key aspects of a biopsychosocial approach concerning
exercise prescription for CMP and considers both patient needs and clinician competencies.
There is consensus for individualized, supervised exercise based on patient presentation, goals
and preference that is perceived as safe and non‐threatening to avoid fostering unhelpful
associations between physical activity and pain. The weight of evidence supporting exercise for
CMP has been provided by aerobic and resistance exercise studies, although there is considerable
uncertainty on how to best apply the findings to exercise prescription. In this clinical update, we
also provide evidence‐based guidance on exercise prescription for CMP through a synthesis of
published work within the field of exercise and CMP rehabilitation.
KEYWORDS
biopsychosocial, chronic pain, exercise, musculoskeletal pain
1|INTRODUCTION
The International Association for the Study of Pain (IASP) defines pain
as ‘an unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such
damage’(Merskey, 1979). Chronic musculoskeletal pain (CMP) refers
to ongoing pain felt in the bones, joints and tissues of the body that
persists longer than 3 months. CMP is the major cause for pain and
disability in western society affecting up to 20% of adults (Woolf,
Erwin, & March, 2012) and is predicted to increase by >50% by 2050
(Access Economics Pty Limited, 2007). CMP includes a diverse range
of diagnoses, some of which imply a driving tissue pathology or
structure (osteoarthritis, discogenic back pain) and some of unknown
pathology ((spinal pain, fibromyalgia, chronic widespread pain); Woolf
& Akesson, 2001). Independent of the primary pathology, the second-
ary pathology or consequences of persistent pain including fear of
movement, pain catastrophizing, anxiety and nervous system
sensitization appear to be the main contributors to pain and disability
in these conditions (Gatchel, Peng, Peters, Fuchs, & Turk, 2007; Siddall
& Cousins, 2004).
Traditionally pain has been viewed as a symptom and warning
signal of an underlying disease process. This conceptualization has
led to the belief that chronic pain treatments which address the
primary pathology underlying the disease process ameliorate pain
(Siddall & Cousins, 2004). However, for many chronic pain conditions
it is often not possible to identify the underlying pathology or, more
commonly, there is no treatment that can reverse the primary pathol-
ogy. Modern conceptualizations of pain consider pain a protector
DOI 10.1002/msc.1191
Musculoskeletal Care. 2017;1–9. Copyright © 2017 John Wiley & Sons, Ltd.wileyonlinelibrary.com/journal/msc 1
rather than a marker of tissue state (Moseley & Butler, 2015a; Moseley
& Vlaeyen, 2015) –a perceptual inference that reflects a ‘best guess’
that tissue is in danger and requires concerted protective action. As
pain persists, the danger transmission system –nociceptive pathways
–and the mechanisms that subserve pain itself become more sensitive
(Moseley & Butler, 2015a). The relationship between pain and the true
need to protect body tissue becomes more tenuous and the
contribution to pain from biopsychosocial factors or secondary
pathology can increase. Contemporary exercise interventions for
CMP that address the secondary pathology of persistent pain have
great potential to improve patient outcomes.
Biopsychosocial treatment that acknowledges and aims to
address the physical, psychological and social factors underpinning
pain and disability is currently accepted as the most effective
approach to chronic pain (Gatchel et al., 2007; Meeus et al., 2016)
and superior to stand‐alone physical therapy such as exercise or
physiotherapy (Kamper et al., 2014). The intention of this clinical
update is to provide evidence‐based guidance on exercise prescrip-
tion using a biopsychosocial treatment approach and exercise
recommendations valid across important CMP conditions that share
common secondary pathology and mechanisms. Pain conditions
associated with significant trauma or surgery or less prevalent condi-
tions such as phantom limb pain and chronic regional pain syndrome
are not considered.
2|EVIDENCE FOR EXERCISE IN THE
TREATMENT OF CMP
It is widely accepted that increased physical activity levels benefit
individuals with CMP (Jordan, Holden, Mason, & Foster, 2010; Meeus
et al., 2016; O'Connor et al., 2015). Exercise as a therapeutic modality
to improve pain and disability has been widely investigated using
randomized controlled trials (RCTs). Systematic reviews of RCTs have
demonstrated that aerobic and resistance exercise were more
effective than no intervention for improving physical function and pain
in fibromyalgia (Bidonde et al., 2014; Busch et al., 2013) and knee
osteoarthritis (Bennell & Hinman, 2011; Fransen et al., 2015). In
patients with non‐specific chronic low back pain (CLBP), the
data support significantly reduced pain and disability, when
compared to minimal care, no treatment or other conservative thera-
pies (e.g. manual therapy, non‐steroidal anti‐inflammatory drugs;
Hayden, van Tulder, & Tomlinson, 2005; van Middelkoop et al.,
2011). For many chronic conditions, it is unclear if aerobic exercise,
resistance exercise or what combination of these modalities might be
superior. Aerobic exercise was more efficacious than resistance exer-
cise for reducing pain in fibromyalgia (Busch, Barber, Overend, Peloso,
& Schachter, 2007), but strengthening and/or stretching exercise was
superior to aerobic exercise for non‐specific CLBP (Hayden et al.,
2005) and neck pain (O'Riordan, Clifford, Van De Ven, & Nelson,
2014). It appears that exercise can produce better pain and disabil-
ity outcomes when combined with pain education (Moseley, 2002;
Pires, Cruz, & Caeiro, 2015). While the majority of studies have
utilized modalities including weights, floor exercise, walking, cycling
and aquatic exercise, research into non‐traditional movement
modalities including pilates (Yamato et al., 2015), yoga and Tai
Chi (Lee, Crawford,, & Schoomaker, 2014) is also increasing.
Several mechanisms might explain the beneficial effects of exer-
cise on pain and disability in CMP. It is widely believed that exercise
exerts its effects on pain and disability via improvements in physical
function or performance (e.g. range of motion, strength, muscular
endurance; Steiger, Wirth, de Bruin, & Mannion, 2012). However, the
empirical evidence underpinning this belief is lacking and indeed there
are contrasting results. In CLBP, improvements in pain and disability
during an exercise programme were unrelated to changes in physical
function (e.g. range of motion, strength, muscular endurance; Steiger
et al., 2012). It follows then that other exercise‐induced changes in
secondary pathologies, improved psychological status and cognitions
(e.g. reduction in fear, anxiety and catastrophization, increased pain
self‐efficacy), exercise‐induced analgesia, and functional and structural
adaptions in the brain (Moseley, Gallace, & Spence, 2012a; Wallwork,
Butler, Wilson, & Moseley, 2015; Wand et al., 2011) may influence
pain and disability more than physical function. This might also explain
why research to date has not shown any specific exercise to be
superior –it may be that psychological and/or neurophysiological
factors that are common to all exercise approaches have the greatest
mediating effects on pain and disability. If changes in pain and
disability can occur without changes in strength, endurance or
flexibility, then specific types and dosages that have been recommended
to improve these parameters in healthy people (Garber et al., 2011)
seem to be less relevant in CMP.
In summary, for CMP there is consistent evidence that exercise
has clinically relevant effects on pain and function compared to no
intervention, minimal care or other conservative therapies.
3|APPLYING A BIOPSYCHOSOCIAL
APPROACH TO EXERCISE TREATMENT
Patients with CMP can have remarkably similar pathology but
dissimilar clinical presentations encompassing different thoughts,
beliefs, behaviours and expectations which require different exercise
treatment approaches. Tailoring exercise to individual patients has
been recommended for CMP (Bennell & Hinman, 2011; Meeus et al.,
2016; O'Riordan et al., 2014), which requires an initial assessment to
understand the biological, psychological and social factors contributing
to pain and disability.
3.1 |Initial assessment
While comprehensive biopsychosocial assessment is beyond the scope
of this position paper and detailed elsewhere (Turk & Melzack, 2011),
several aspects most relevant to exercise prescription are discussed.
The initial assessment provides an opportunity to lay the foundation
for a positive clinician–patient therapeutic alliance, which refers to a
sense of collaboration, understanding and support between the
clinician and the patient and is a key factor in determining rehabilita-
tion outcomes (Ferreira et al., 2013; Lion, Mangione‐Smith, & Britto,
2014). Patient‐centred communication engages the patient and
strengthens the therapeutic alliance (Ferreira et al., 2013; Lion et al.,
2BOOTH ET AL.
2014) and should commence in the initial assessment and be ongoing
throughout treatment. All initial assessments require a comprehensive
pain assessment because aspects of the pain itself, including intensity,
location, and aggravating and relieving factors (e.g. posture, move-
ments) will influence exercise prescription. Understanding the patient's
thoughts, beliefs and behaviours concerning physical activity and pain
assists clinicians in implementing combined patient‐tailored exercise
and targeted education (for review see Moseley & Butler, 2015a; for
the key text and patient‐targeted workbook for ‘explaining pain’see
Butler & Moseley, 2013 and Moseley & Butler, 2015b).
Yellow flags traditionally refer to psychological distress in patients
with low back pain and suggest an increased risk of progression to
long‐term distress, disability and pain. In principle these risk factors,
including fear avoidance behaviour, catastrophization and low mood,
can be applied more broadly to CMP and are critical treatment targets
for exercise prescription. Supplementing the patient interview with
screening questionnaires (e.g. distress and risk assessment method
questionnaire (DRAM), pain self‐efficacy questionnaire, fear avoidance
questionnaire; see Yeomans, 2000) allows some quantification of the
patient's beliefs, thoughts and behaviours and informs treatment. For
a fear avoidant, inactive patient with low pain self‐efficacy, higher
levels of supervision and graded exposure exercise to fearful activities
is preferred above a self‐managed aerobic and resistance exercise
programme prescribed for an active patient not displaying fear
avoidance behaviour or low pain self‐efficacy. As yellow flags become
more prevalent and/or other significant factors impact on rehabilita-
tion (e.g. substance misuse, diagnosed psychopathology), exercise
invention alone is unlikely to be beneficial and requires a move
towards multi or inter/disciplinary treatment. For example, the DRAM
comprises two short questionnaires, the Modified Zung Depression
Index (modified Zung) and Modified Somatic Perceptions Questionnaire
(MSPQ), validated in patients with chronic musculoskeletal pain
(Main, Woods, Hollis, Spanswick, & Waddell, 1999) which take about
5–10 min to complete. The DRAM does not require specialist
training to administer or interpret and uses a scoring system that
permits patients to be classified as normal (modified Zung <17), at
risk (modified Zung 17–33 and MSPQ <12), distressed depressive
(modified Zung >33) or distressed somatic (modified Zung 17–33
and MSPQ >12) (Main et al., 1999; Yeomans, 2000). The DRAM
provides the clinician with a more objective method than clinical
impression for deciding if a patient would benefit from a multi‐or
inter‐disciplinary treatment approach. A patient classified ‘at risk’
according to the DRAM should respond to an exercise intervention
implemented solely by a clinician competent with biopsychosocial
treatment. In contrast, for a patient classified as ‘distressed’according
to the DRAM, combining exercise and a psychological assessment/
intervention provided by a Clinical Psychologist is recommended
above exercise alone.
Patients usually expect a thorough physical assessment and
although specific to each patient's presentation, several variables
should be explored in all assessments due to their influence on exer-
cise prescription. A thorough assessment can also serve as a compel-
ling mechanism to provide reassurance that the tissues are
structurally sound –such reassurance has established beneficial
effects (Traeger et al., 2015). Extra variables that should be considered
include understanding the impact that pain and injury is having on the
patient's function, daily activity and movement. This information is
garnered through the patient interview, self‐report questionnaires of
function and disability (e.g. Roland Morris disability questionnaire
(Roland & Morris, 1983), neck pain and disability scale (Wheeler,
Goolkasian, Baird, & Darden, 1999)) and the physical tests undertaken.
The rationale for the tests selected is to provide information on activ-
ity, functional tolerances and movement from which the commencing
exercise baseline is formulated. The patient's pain behaviour, confi-
dence with movement and activity, and their movement quality should
also be noted during the physical assessment.
3.2 |Commencing treatment and explaining pain
Several practices known to improve treatment outcomes can be
implemented in the first supervised exercise session. It is imperative
that clinicians understand contemporary pain biology concepts so they
can engage in meaningful and positive pain dialogue and ‘explain pain’
to patients (Butler & Moseley, 2013; Moseley & Butler, 2015a).
Explaining pain refers to a range of educational techniques that aim
to change how the patient makes sense of their pain (Moseley &
Butler, 2015a; see also Moseley, Butler, Beams, & Giles, 2012b for
the integration of explaining pain with a graded activity‐based
rehabilitation approach). The targeted conceptual change is from ‘pain
as a sign of structural damage or pathology’to ‘pain as a protective
mechanism modulated by all credible evidence of tissue damage and
safety’(Moseley & Butler, 2015a). Explaining pain should commence
immediately, remain ongoing and be reviewed throughout rehabilita-
tion. Associating exercise and movement with pain and injury can
heighten anxiety and increase pain. A guiding principle is that all
exercise and activity be perceived as safe and meaningful by the
patient (Lotze & Moseley, 2015). It is imperative that patients under-
stand and believe it is safe to exercise with discomfort that: plateaus
and does not continue to rise significantly; they can cope with and feel
is manageable; and gradually decreases after they have finished
exercise. Exercises can be performed as tolerated by the patient and
stopped temporarily/modified with intolerance. Exercise prescription
should be time contingent as opposed to pain contingent (Meeus
et al., 2016), as it is not possible to dose exercise proportional to pain
threshold. Assessment of pain intensity using a numerical rating scale
or visual analogue scale is recommended throughout treatment to
monitor progress from baseline. It is not necessary to assess pain
intensity during every exercise session as this does not provide any
additional benefit beyond a tolerable/not tolerable dichotomy. Pain‐
intensity ratings do not accurately reflect tissue damage or nociception
in patients with chronic pain. Over time, pain intensity ratings are less
influenced by nociception and more by emotional and psychosocial
factors (Ballantyne & Sullivan, 2015). Frequent attention to the
patient's pain intensity as a marker of potential tissue damage or
tissue/exercise safety bears potential risk of increasing the patient's
vigilance to pain, thereby facilitating unhelpful cognitions such as fear
avoidance behaviour or pain catastrophizing. Frequent reassurance is
required throughout treatment that despite persisting symptoms, it is
safe to gradually become active. Principles of graded exposure are
BOOTH ET AL.3
critical and should be implemented with a sound understanding of
biological adaptations that are likely to be present in people with CMP.
3.3 |Treatment expectation and goal setting
Evidence suggests that pre‐treatment expectations significantly influ-
ence treatment outcomes including pain and disability (Cormier,
Lavigne, Choinière, & Rainville, 2016). If a patient's primary treatment
expectation is pain abolition, failure to achieve this can increase frus-
tration and anxiety and contribute to pain and disability (Colloca &
Benedetti, 2007). This can be avoided by fostering treatment
expectations around improving function, quality of life and reducing
the impact of pain on the patient's life. This is not to say that the
patient should not expect pain relief with exercise. A better approach
is for pain relief to become a secondary goal supported by suggestions
such as ‘when people with chronic pain slowly pace up and become
more active pain often reduces’. Goal setting should also be completed
before commencing exercise and involve a collaborative approach with
the clinician assisting the patient to identify meaningful goals not only
related to exercise, physical activity and function but other
biopsychosocial aspects (Gardner et al., 2015). Patient‐centred goal
setting promotes informed, individualized exercise interventions that
are more meaningful and engaging to the patient. Clinicians should
emphasize that exercising in itself is not the final treatment goal but
regular exercise can help patients to enhance life quality through
improvements in physical function and performance of activities of
daily living. Critically, the patient should be reminded that the biologi-
cal adaptations that occur as pain persists are difficult to reverse and
will take time –they should be embarking on a journey of recovery
and mastery of their situation, not a quick fix solution.
3.4 |Baseline activity and pacing up
As previously mentioned, it has been well established that cognitions
such as fear, anxiety and pain catastrophization are strongly correlated
with pain and disability (Meeus, Nijs, Van Oosterwijck, Van Alsenoy, &
Truijen, 2010; Moseley, 2004; Vlaeyen, Kole‐Snijders, Boeren, &
van Eek, 1995). It is imperative that before commencing exercise,
clinicians have identified the altered cognitions contributing to each
patient's pain and disability. This permits individualized treatment
combining exercise and education which addresses maladaptive
thoughts and beliefs with the intention of decreasing pain and disabil-
ity. An objective of the first supervised exercise session is to establish a
baseline of activity that can be completed without causing a significant
increase in symptoms. Unadventurous exercise prescription in the first
session will be less likely to cause a marked increase in pain during and
after exercise, as factors including altered cognitions and disuse
through inactivity can result in a seemingly innocuous exercise session
evoking a marked increase in pain. Activity pacing is a widely accepted
pain management strategy and refers to dividing the patient's daily
activities/exercise into manageable portions that do not exacerbate
their symptoms (Andrews, Strong, & Meredith, 2012). Effective pacing,
i.e. finding the appropriate amount and intensity of physical activity,
promotes confidence and reassurance that it is safe to engage in activ-
ity and provides the foundation for progressive overload or pacing up
throughout treatment. Clinicians should endeavour to avoid pacing
up (increasing physical activity/exercise) too quickly and exacerbating
the patient's symptoms. Significantly increasing the patient's pain
during and following the first exercise session has the potential to:
further erode confidence with movement and exercise; strengthen
the relationship between movement and pain; and decrease patient
motivation to engage in exercise treatment. In instances where the
therapist is unsure about exercise prescription, patients should be
allowed to self‐select exercise dosage (Jones, Adams, Winters‐Stone,
& Burckhardt, 2006). Helping patients understand pain and the factors
that can modulate pain reduces the likelihood and intensity of flare‐
ups. Having ready‐made responses to unexpected flare‐ups should
also reduce their intensity, duration and impact. For example, patients
can be reminded that a flare‐up reflects a protective strategy, not a
sign of damage, and that one can repeat the previous dose (which they
know was safe) and halve the increment of progression. This simple
rule can have profoundly reassuring effects (Traeger et al., 2015). Fur-
thermore, it is important to frequently provide positive reinforcement
for the efforts and achievements of patients. This is important for
the clinician–patient relationship and patients are more likely to trust
a clinician who is genuinely supportive and engaged.
3.5 |Exercise type
There is little evidence supporting one particular type of exercise over
another for CMP (Bennell & Hinman, 2011; Fransen et al., 2015; Jones
et al., 2006). Exercise modalities that patients enjoy and associate with
achieving their goals improve treatment adherence (Jordan et al.,
2010). Other factors influencing modality choice include the patient's
level of function, aggravating and relieving postures and movements,
and the ability to self‐manage the exercise. It is important that clini-
cians demonstrate exercise accompanied by explanation of what mus-
cles it engages and how the exercise can be helpful, observe and
monitor exercise practice, provide feedback and correct poor tech-
nique (Slade, Patel, Underwood, & Keating, 2014). As stated earlier,
aerobic and/or resistance exercise can be beneficial for CMP (Bennell
& Hinman, 2011; Bidonde et al., 2014; Busch et al., 2013; Fransen
et al., 2015) and should thus be considered for exercise prescription.
3.6 |Aerobic exercise
Aerobic exercise performed between 20 and 60 min, ≥2 days/week for
6 weeks or longer can be sufficient to positively impact on symptoms
and function (Busch et al., 2011; O'Connor et al., 2015). The benefits
of aerobic training also include improved psychological well‐being
and better cognitive and metabolic function, which holds promise for
CMP patients who often have co‐morbidities. Aerobic exercise has
also been shown to decrease pain perception and pain sensitivity in
healthy individuals and CMP cohorts (Naugle, Fillingim, & Riley,
2012). Performed at an intensity to improve cardiovascular fitness,
aerobic training might also augment pain tolerance (Soriano‐
Maldonado, Ortega, & Munguía‐Izquierdo, 2015). Explaining to
patients that aerobic activity such as walking, swimming and cycling
has the potential to ‘turn down the pain volume or dampen the pain
response’can be reassuring and motivating to patients. Given the
4BOOTH ET AL.
potential benefits of aerobic exercise to pain, function, health and
wellbeing, an aerobic component will be an integral component of
most exercise programmes for CMP.
3.7 |Resistance exercise
In contrast to aerobic exercise, resistance training generally involves
a smaller muscle mass with increased local tissue and joint loading.
For some patients, this can be an unfamiliar and worrisome sensation
with the potential to evoke a protective pain response. The likeli-
hood of this occurring can be reduced through adapted exercise
prescription at the commencement of treatment, with the purpose
of familiarizing the patient to the exercise and providing reassurance
that it is safe to perform. Exercise using weights has been widely
investigated and is a commonly prescribed resistance exercise
that is easily quantified and progressively upgraded in clinic and
home exercise programmes. Resistance training that engages
non‐painful body parts can have a positive global impact on pain
(Burrows, Booth, Sturnieks, & Barry, 2014; Vaegter, Handberg, &
Graven‐Nielsen, 2014) offering alternative exercise strategies for
patients experiencing flare‐ups.
3.8 |Land versus aquatic exercise
Pain changes movement, and patients with CMP often present with
abnormal movement patterns and tissue loading (Sterling, Jull, &
Wright, 2001). A primary objective of exercise treatment is restoring
movement and normalizing tissue loading, which might also be more
responsive to land as opposed to aquatic exercise. Positive outcomes
for CMP have been demonstrated with supervised land‐based exercise
programmes that either simulate or duplicate work and/or functional
tasks (Schonstein, Kenny, Keating, & Koes, 2003). While resistance
aquatic exercise can also improve pain and function in CMP conditions
(Barker et al., 2014), muscle function may be more responsive to land‐
based exercise (Bidonde et al., 2014). Exercise specificity also dictates
that a patient's tolerance for their normal daily activities and move-
ments might be more amenable to land rather than aquatic exercise.
While clinicians will mostly prescribe land‐based exercise for CMP,
aquatic exercise might be preferred for individuals with very poor
functional tolerances and/or heightened levels of pain and distress
(Busch et al., 2011). In this instance, the treatment goals can include
a gradual transition to land‐based exercise as function and pain
improves. Ultimately the choice of exercise modality will be strongly
influenced by the patient's preference.
3.9 |Level of supervision
Exercise programmes that are individualized and supervised have
been recommended for CMP (Jones et al., 2006; Jordan et al.,
2010; Meeus et al., 2016). However, the optimal type and level of
supervision is unclear as one‐on‐one supervision, group supervision
and a home exercise programme with review have all been shown
to improve pain and function (Jordan et al., 2010). Supervised
exercise promotes treatment adherence and supplementing super-
vised sessions with home exercise, educational worksheets and
materials can further improve adherence (Jordan et al., 2010).
Patients should be encouraged to keep daily/weekly recordings of
their physical/exercise activities. Ongoing self‐monitoring can be
helpful to identify barriers and facilitators to exercise participation,
motivate positive exercise behaviour and increase participation
(Moseley, 2006). Monitoring can be performed with activity
diaries/log books and instrumented activity trackers. There is no
minimum number of supervised exercise sessions before progressing
to self‐managed home exercise. As for all facets of treatment, the
level of supervision chosen by the clinician will depend on patient
presentation, preferences and goals. For traits such as low pain or
low exercise self‐efficacy, fear avoidant behaviour, heightened
anxiety and poor functional tolerances, higher levels of supervision
should be considered.
3.10 |Treatment dosage
There is considerable uncertainty regarding exercise dosage for CMP
(Fransen et al., 2015; Hayden et al., 2005; Jones et al., 2006).
Establishing definitive guidelines is further complicated by the need
to individualize treatment so that even within seemingly specific
subgroups (e.g. CLBP, fibromyalgia) exercise prescription can vary
greatly between patients. In contrast to the American College of
Sports Medicine guidelines to improve musculoskeletal fitness and
health in healthy individuals (Garber et al., 2011), people with CMP
appear responsive to lower exercise dosage. In the clinic, exercise
intensity is best monitored using a Borg 6–20 scale rating of
perceived exertion (RPE) or combined RPE and heart rate (Demoulin,
Verbunt, Winkens, Knottnerus, & Smeets, 2010). Higher scores on
the Borg scale indicate increasing perceived exertion with physical
activity/exercise, from 6 –no exertion –to 20 –maximal exertion
(Borg, 1998; see Table 1). RPE can also be monitored in instances
where one repetition maximum (1RM) is not applicable such as fear
avoidant and deconditioned patients and non‐weight‐training resis-
tance modalities including floor, body weight and functional exercise.
Low‐to moderate‐intensity aerobic exercise (40 < 70% of maximum
heart rate (HR
max
)) can improve pain and function in CMP (Bennell &
Hinman, 2011; Häuser et al., 2010; O'Connor et al., 2015). Likewise,
low‐to moderate‐intensity resistance exercise (40–60% 1RM) has
shown to be sufficient to evoke positive changes (Bennell & Hinman,
2011; Busch et al., 2013; Kristensen & Franklyn‐Miller, 2012). While
most exercise interventions for CMP will involve low‐to moderate‐
intensity exercise, higher intensity training (≥70% HR
max
/1RM) can
improve pain and function without adverse effects (Bennell &
Hinman, 2011; Kristensen & Franklyn‐Miller, 2012; Limke, Rainville,
Peña, & Childs, 2008) and should be prescribed when the goal is a
return to more physically demanding work, sport or recreation. While
clinicians should aim to gradually increase exercise intensity and
apply the principles of progressive overload as the patient's
confidence and exercise tolerance improve, it is important not to lose
sight of the fact that simply assisting patients to become more active
and setting goals around increasing their activity levels can be
beneficial. We have thus taken a practical, evidence‐based approach
to aerobic and resistance exercise prescription for CMP using the
FITT principle (frequency, intensity, time, type), with suggestions
based on findings from pertinent systematic reviews and established
BOOTH ET AL.5
exercise guidelines for healthy individuals presented in Table 1. A
summary of key points concerning exercise prescription for CMP is
provided in Table 2.
4|SPECIAL CONSIDERATIONS
Health screening before commencing exercise is mandatory for all
patients, with the physical activity readiness questionnaire being the
minimal standard screening tool (American College of Sports
Medicine, 1995). Relative contraindications include red flags such as
acute injury or trauma, history of cancer, systemic steroids and drug
misuse. In addition, the relative and absolute contraindications of exer-
cise apply (American College of Sports Medicine, 1995). When exercise
is poorly tolerated and continues to increase symptoms despite several
revisions, shift the focus from structured exercise to gradually pacing up
daily activities. When an exercise intervention continues to worsen the
patient's symptoms and/or function, cease or suspend treatment and
encourage the patient to remain as active as their symptoms permit.
5|FUTURE RESEARCH TO ADVANCE
EXERCISE TREATMENT FOR CMP RESEARCH
Clinical trials with a rigorous analysis of causal mechanisms are
required. Innovative methods for causal mediation analysis allow
identification of the intermediate factors through which physical
activity/exercise exert their effects on pain and/or disability
(treatment effect modifiers). A better understanding of the biological
(e.g. increased muscle strength, greater range of motion, normalized
pain processing) psychological (e.g. reduced fear of movement,
improved mood) and social (e.g. earlier return to work) mechanisms
of exercise will help refine exercise interventions. As the response to
increased physical activity/exercise can vary considerably between
patients, it is important to understand the individual factors that are
associated with favourable patient outcomes (e.g. which subgroup(s)
of patients is/are more likely to respond to an increase in physical
activity/exercise intervention –‘what works for whom?’). A better
understanding of strategies to improve treatment adherence such as
goal setting, self‐monitoring and professional feedback is required.
TABLE 1 General guidelines for aerobic and resistance exercise prescriptions using the FITT principle (frequency, intensity, time, type) for people
with chronic musculoskeletal pain
Aerobic exercise Intensity HR equivalents: low intensity: 40 < 55% HRmax; moderate intensity: 55 < 70% HRmax;
high intensity: 70 < 90% HRmax
Frequency ≥2 times/week; ≥6 weeks
Intensity Low intensity (RPE 8–10) to moderate intensity (RPE 11–13). Higher intensity (RPE 14–16) for goals involving more
demanding work, sport or recreation where tolerated
Time 20–60 min and <20 min with exercise intolerance. Consider shorter intervals interspersed with other exercise modalities
(e.g. 3 × 7 min walking separated by resistance exercise)
Type Modalities involving continuous and rhythmic exercises that engage major muscle groups but do not exacerbate
symptoms (walking, jogging, swimming, dancing, etc.)
Progression Commence RPE 8–10 grading to RPE 11–13 as tolerance increases; RPE ≥14 for high‐intensity training. Increase duration
before intensity (e.g. for treadmill walking increase duration and walking speed before incline)
Resistance exercise Intensity 1RM equivalents: low intensity: 40 < 60% 1RM; moderate intensity: 60–70% 1RM; high intensity: ≥70% 1RM
Frequency 2–3 times/week; ≥6 weeks
Intensity Low‐intensity (RPE 8–10) to moderate‐intensity exercise (RPE 11–13). For more demanding work, sport or recreation
consider high‐intensity training (RPE 14–16)
Time For low‐to moderate‐intensity exercise 1–2 sets of 15–20 reps reduced/adapted for exercise intolerance. For high‐
intensity exercise 1–2 sets of 8–12 reps
Type Modalities that engage muscles of affected body part(s) and/or major muscle groups (weight‐bearing activity, free
weights, floor exercise; machines, resistance bands, motor control exercise, etc.) that do not exacerbate symptoms
Progression Commence RPE 8–10 grading to 11–13 as tolerance and function increases; RPE ≥14 for higher intensity training. Increase
reps before load; commence floor exercise with short holds and higher reps and increase hold duration before exercise
difficulty. For functional exercise commence at a level specific to patient's presentation and increase reps before load
ex, exercise; HR
max
, age‐predicted heart rate maximum; 1RM, 1 repetition maximum; RPE, rating of perceived exertion assessed using Borg 6–20 RPE scale;
reps, repetitions.
TABLE 2 Key points concerning exercise prescription for CMP
•Understanding contemporary pain biology and ‘explaining pain’are key competencies required for biopsychosocial treatment
•Frequently reassure patients that it is safe to move/pace up despite their symptoms
•Exercise prescription should be time, as opposed to pain, contingent using a tolerable/not tolerable dichotomy
•Have ready‐made responses to flare‐ups can reduce severity
•Exercise should be individualized, enjoyable, related to patient goals and with a level of supervision specific to the patient
•Many patients with CMP will respond to lower exercise dosage than recommended for healthy individuals (i.e. graded low to moderate intensity)
•Closely observe and monitor exercise practice, seek and provide feedback and correct poor technique
•Encourage patients to self‐monitor exercise (diaries, activity trackers, etc.)
•Place emphasis on developing/restoring movement confidence and quality
6BOOTH ET AL.
Research to identify the optimal exercise intensity, frequency, duration
and modality is also warranted.
6|SUMMARY
Exercise can improve symptoms, decrease disability and improve
function and wellbeing in a range of CMP conditions. No one exercise
modality has proven superior with considerable uncertainty regarding
exercise modality and dosage. The weight of evidence is for aerobic
and resistance exercise modalities. However, if patients prefer, non‐
traditional forms such as pilates, yoga and tai chi should not be
excluded. There is consensus for individualized, supervised exercise
based on patient presentation, goals and preferences, and exercise that
patients perceive as safe and non‐threatening. To align with
contemporary pain rehabilitation practice, clinician competency is
required with implementing exercise interventions using a
biopsychosocial treatment approach. It is also important for clinicians
to understand that in some instances, irrespective of exercise, simply
engaging with the patient, developing their confidence with
movement, assisting them to become more active and pace up their
daily activities has the potential to reduce the impact of pain and
improve quality of life. Finally, the clinician needs to understand
mechanisms and contemporary conceptualization of pain and be able
to impart this understanding to their patients –failure to do so will
leave the patient confused as to why a biopsychosocial approach is
required for a structural–pathology‐based problem.
CONFLICT OF INTEREST
In the last five years, G. Lorimer Moseley has received support from
Pfizer, Workers' Compensation boards in Australia and Europe, Kaiser
Permanente, Agile Physiotherapy, Results Physiotherapy, the Interna-
tional Olympic Committee and Port Adelaide Football Club. He
receives speaker fees for lectures on pain and rehabilitation and royal-
ties for several books about pain and rehabilitation.
REFERENCES
Access Economics Pty Limited. (2007). The high price of pain: The eco-
nomic impact of persistent pain in Australia. Available at https://
www.bupa.com.au/staticfiles/BupaP3/Health%20and%20Wellness/
MediaFiles/PDFs/MBF_Foundation_the_price_of_pain.pdf.
American College of Sports Medicine. (1995). In W. Larry Kenney (Ed.),
ACSM's Guidelines for Exercise Testing and Prescription (5th ed.).
Baltimore: MD: Williams & Wilkins.
Andrews, N. E., Strong, J., & Meredith, P. J. (2012). Activity pacing,
avoidance, endurance, and associations with patient functioning in
chronic pain: A systematic review and meta‐analysis. Archives of
Physical Medicine and Rehabilitation,93(11), 2109–2121.e7. https://
doi.org/10.1016/j.apmr.2012.05.029
Ballantyne, J. C., & Sullivan, M. D. (2015). Intensity of chronic pain —The
wrong metric? New England Journal of Medicine,373(22), 2098–2099.
https://doi.org/10.1056/NEJMp1507136
Barker, A. L., Talevski, J., Morello, R. T., Brand, C. A., Rahmann, A. E., &
Urquhart, D. M. (2014). Effectiveness of aquatic exercise for musculoskeletal
conditions: A meta‐analysis. Archive s of Physical Medicine and Rehabilita-
tion,95(9), 1776–1786. https://doi.org/10.1016/j.apmr.2014.04.005
Bennell, K. L., & Hinman, R. S. (2011). A review of the clinical evidence for
exercise in osteoarthritis of the hip and knee. Journal of Science and Medi-
cine in Sport,14(1), 4–9. https://doi.org/10.1016/j.jsams.2010.08.002
Bidonde, J., Busch, A. J., Webber, S. C., Schachter, C. L., Danyliw, A.,
Overend, T. J., …Rader, T. (2014). Aquatic exercise training for fibromy-
algia. Cochrane Database of Systematic Reviews, CD011336. https://doi.
org/10.1002/14651858.CD011336
Borg, G. (1998). Borgs perceived exertion and pain scales. Champaign, IL,
USA: Human Kinetics Publishers.
Burrows, N. J., Booth, J., Sturnieks, D. L., & Barry, B. K. (2014). Acute resis-
tance exercise and pressure pain sensitivity in knee osteoarthritis: A
randomised crossover trial. Osteoarthritis and Cartilage,22(3),
407–414. https://doi.org/10.1016/j.joca.2013.12.023
Busch, A. J., Barber, K. A., Overend, T. J., Peloso, P. M., & Schachter, C. L.
(2007). Exercise for treating fibromyalgia syndrome. Cochrane Database
of Systematic Reviews,4, .CD003786
Busch, A. J., Webber, S. C., Brachaniec, M., Bidonde, J., Bello‐Haas, V. D.,
Danyliw, A. D., …Schachter, C. L. (2011). Exercise therapy for fibromy-
algia. Current Pain and Headache Reports,15(5), 358–367. https://doi.
org/10.1007/s11916‐011‐0214‐2
Busch, A. J., Webber, S. C., Richards, R. S., Bidonde, J., Schachter, C. L., …
Overend, T. J. (2013). Resistance exercise training for fibromyalgia.
Cochrane Database of Systematic Reviews,12, .CD010884
Butler, D., & Moseley, G. L. (2013). Explain pain (2nd ed.). Adelaide,
Australia: Noigroup Publications.
Colloca, L., & Benedetti, F. (2007). Nocebo hyperalgesia: How anxiety is
turned into pain. Current Opinion in Anaesthesiology,20(5), 435–439.
https://doi.org/10.1097/ACO.0b013e3282b972fb
Cormier, S., Lavigne, G. L., Choinière, M., & Rainville, P. (2016). Expecta-
tions predict chronic pain treatment outcomes. Pain,157(2), 329–338.
https://doi.org/10.1097/j.pain.0000000000000379
Demoulin, C., Verbunt, J. A., Winkens, B., Knottnerus, J. A., & Smeets, R. J.
(2010). Usefulness of perceived level of exertion in patients with
chronic low back pain attending a physical training programme. Disabil-
ity and Rehabilitation,32(3), 216–222. https://doi.org/10.3109/
09638280903071842
Ferreira, P. H., Ferreira, M. L., Maher, C. G., Refshauge, K. M., Latimer, J., &
Adams, R. D. (2013). The therapeutic alliance between clinicians and
patients predicts outcome in chronic low back pain. Physical Therapy,
93(4), 470–478. https://doi.org/10.2522/ptj.20120137
Fransen, M., McConnell, S., Harmer, A. R., Van der Esch, M., Simic, M., &
Bennell, K. L. (2015). Exercise for osteoarthritis of the knee. Cochrane
Database of Systematic Reviews,1, .Cd004376
Garber, C. E., Blissmer, B., Deschenes, M. R., Franklin, B. A., Lamonte, M. J.,
Lee, I. M., …Swain, D. P. (2011). American College of Sports Medicine
position stand. Quantity and quality of exercise for developing and
maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness
in apparently healthy adults: Guidance for prescribing exercise. Medi-
cine and Science in Sports and Exercise,43(7), 1334–1359. https://doi.
org/10.1249/MSS.0b013e318213fefb
Gardner, T., Refshauge, K., McAuley, J., Goodall, S., Hübscher, M., &
Smith, L. (2015). Patient led goal setting in chronic low back pain –
What goals are important to the patient and are they aligned to what
we measure? Patient Education and Counseling,98(8), 1035–1038.
https://doi.org/10.1016/j.pec.2015.04.012
Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007).
The biopsychosocial approach to chronic pain: Scientific advances and
future directions. Psychological Bulletin,133(4), 581–624. https://doi.
org/10.1037/0033‐2909.133.4.581
Häuser, W., Klose, P., Langhorst, J., Moradi, B., Steinbach, M.,
Schiltenwolf, M., …Busch, A. (2010). Efficacy of different types of
aerobic exercise in fibromyalgia syndrome: A systematic review and
meta‐analysis of randomised controlled trials. Arthritis Research and
Therapy,12(3), R79. https://doi.org/10.1186/ar3002
Hayden, J. A., van Tulder, M. W., & Tomlinson, G. (2005). Systematic
review: Strategies for using exercise therapy to improve outcomes in
chronic low back pain. Annals of Internal Medicine,142(9), 776–785.
https://doi.org/10.7326/0003‐4819‐142‐9‐200505030‐00014
BOOTH ET AL.7
Jones, K. D., Adams, D., Winters‐Stone, K., & Burckhardt, C. S. (2006). A
comprehensive review of 46 exercise treatment studies in fibromyalgia
(1988–2005). Health and Quality of Life Outcomes,4, 67. https://doi.
org/10.1186/1477‐7525‐4‐67
Jordan, J. L., Holden, H. A., Mason, E. E. J., & Foster, N. E. (2010). Interven-
tions to improve adherence to exercise for chronic musculoskeletal pain
in adults (review). Cochrane Collaboration,1,1–62.
Kamper, S. J., Apeldoorn, A. T., Chiarotto, A., Smeets, R. J., Ostelo, R. W.,
Guzman, J., …van Tulder, M. W. (2014). Multidisciplinary
biopsychosocial rehabilitation for chronic low back pain. Cochrane
Database of Systematic Reviews,9(9) CD000963. https://doi.org/
10.1002/14651858.CD000963.pub3
Kristensen, J., & Franklyn‐Miller, A. (2012). Resistance training in musculo-
skeletal rehabilitation: A systematic review. British Journal of Sports
Medicine,46(10), 719–726. https://doi.org/10.1136/bjsm.2010.079376
Lee, C., Crawford, C., Schoomaker, E., & Active Self‐Care Therapies for
Pain (PACT) Working Group (2014). Movement therapies for the
self‐management of chronic pain symptoms. Pain Medicine,15(Suppl. 1),
S40–S53. https://doi.org/10.1111/pme.12411
Limke, J. C., Rainville, J., Peña, E., & Childs, L. (2008). Randomized
trial comparing the effects of one set vs two sets of resistance
exercises for outpatients with chronic low back pain and leg
pain. European Journal of Physical and Rehabilitation Medicine,44(4),
399–405.
Lion, K. C., Mangione‐Smith, R., & Britto, M. T. (2014). Individualized plans
of care to improve outcomes among children and adults with chronic
illness: A systematic review. Care Management Journals,15(1), 11–25.
https://doi.org/10.1891/1521‐0987.15.1.11 .PubMed: 24761537
Lotze, M., & Moseley, G. L. (2015). Theoretical considerations for chronic
pain rehabilitation. Physical Therapy,95(9), 1316–1320. https://doi.
org/10.2522/ptj.20140581
Main, C. J., Woods, P. L., Hollis, S., Spanswick, C. C., & Waddell, G. (1999).
The distress and risk assessment method. A simple patient classification
to identify distress and evaluate the risk of poor outcome. Spine (Phila
Pa 1976),17,42–52.
Meeus, M., Nijs, J., Van Oosterwijck, J., Van Alsenoy, V., & Truijen, S.
(2010). Pain physiology education improves pain beliefs in patients with
chronic fatigue syndrome compared with pacing and self‐management
education: A double‐blind randomized controlled trial. Archives of Phys-
ical Medicine and Rehabilitation,91(8), 1153–1159. https://doi.org/
10.1016/j.apmr.2010.04.020
Meeus, M., Nijs, J., Van Wilgen, P., Noten, S., Goubert, D., & Huljnen, I.
(2016). Moving on to movement in patients with chronic joint pain.
Pain: Clinical Updates,14, 1 .iasp.files.cms‐plus.com/AM/Images/PCU/
PCU%2024‐1.Meeus.WebFINAL.pdf
Merskey, H. (1979). Pain terms: A list with definitions and notes on usage.
Recommended by the IASP subcommittee on taxonomy. Pain,6(3), 249.
Moseley, L. (2002). Combined physiotherapy and education is efficacious
for chronic low back pain. Australian Journal of Physiotherapy,48(4),
297–302. https://doi.org/10.1016/S0004‐9514(14)60169‐0
Moseley, G. L. (2004). Evidence for a direct relationship between cognitive
and physical change during an education intervention in people with
chronic low back pain. European Journal of Pain,8(1), 39–45. https://
doi.org/10.1016/S1090‐3801(03)00063‐6
Moseley, G. L. (2006). Do training diaries affect and reflect adherence to
home programs? Arthritis and Rheumatism,55(4), 662–664. https://
doi.org/10.1002/art.22086
Moseley, G. L., & Butler, D. S. (2015a). 15 Years of explaining pain –The
past, present and future. Journal of Pain,16, 807–813.
Moseley, G. L., & Butler, D. S. (2015b). The explain pain handbook:
protectometer. Adelaide, Australia: Noigroup Publications.
Moseley, G. L., & Vlaeyen, J. W. S. (2015). Beyond nociception. Pain,156(1),
35–38. https://doi.org/10.1016/j.pain.0000000000000014
Moseley, G. L., Gallace, A., & Spence, C. (2012a). Bodily illusions in health
and disease: Physiological and clinical perspectives and the concept of
a cortical ‘body matrix’.Neuroscience and Biobehavioral Reviews,36(1),
34–46. https://doi.org/10.1016/j.neubiorev.2011.03.013
Moseley, G., Butler, D. S., Beams, T. B., & Giles, T. J. (2012b). The graded
motor imagery handbook. Adelaide, Australia: Noigroup Publications.
Naugle, K. M., Fillingim, R. B., & Riley, J. L. III (2012). A meta‐analytic
review of the hypoalgesic effects of exercise. Journal of Pain,13(12),
1139–1150. https://doi.org/10.1016/j.jpain.2012.09.006
O'Connor, S. R., Tully, M. A., Ryan, B., Bleakley, C. M., Baxter, G. D.,
Bradley, J. M., …McDonough, S. M. (2015). Walking exercise for
chronic musculoskeletal pain: Systematic review and meta‐analysis.
Archives of Physical Medicine and Rehabilitation,96(4), 724–734.e3.
https://doi.org/10.1016/j.apmr.2014.12.003
O'Riordan, C., Clifford, A., Van De Ven, P., & Nelson, J. (2014). Chronic
neck pain and exercise interventions: Frequency, intensity, time, and
type principle. Archives of Physical Medicine and Rehabilitation,95(4),
770–783. https://doi.org/10.1016/j.apmr.2013.11.015
Pires, D., Cruz, E. B., & Caeiro, C. (2015). Aquatic exercise and pain
neurophysiology educationversus aquatic exercisealone for patients with
chronic low backpain: A randomized controlled trial.Clinical Rehabilitation,
29(6), 538–547. https://doi.org/10.1177/0269215514549033
Roland, M., & Morris, R. (1983). A study of the natural history of back pain.
Part I: Development of a reliable and sensitive measure of disability in
low‐back pain. Spine,8(2), 141–144. https://doi.org/10.1097/
00007632‐198303000‐00004
Schonstein, E., Kenny, D. T., Keating, J., & Koes, B. W. (2003). Work condi-
tioning, work hardening and functional restoration for workers with
back and neck pain. Cochrane Database of Systematic Reviews,2105(1)
CD001822. https://doi.org/10.1002/14651858.CD001822
Siddall, P. J., & Cousins, M. J. (2004). Persistent pain as a disease entity:
Implications for clinical management. Anesthesia and Analgesia,99(2),
510–520. https://doi.org/10.1213/01.ANE.0000133383.17666.3A
Slade, S. C., Patel, S., Underwood, M., & Keating, J. L. (2014). What are patient
beliefs and perceptions about exercise for nonspecific chronic low back
pain? A systematic review of qualitative studies. Clinical Journal of Pain,
30(11), 995–1005. https://doi.org/10.1097/AJP.0000000000000044
Soriano‐Maldonado, A., Ortega, F. B., & Munguía‐Izquierdo, D. (2015).
Association of cardiorespiratory fitness with pressure pain sensitivity
and clinical pain in women with fibromyalgia. Rheumatology Interna-
tional,35(5), 899–904. https://doi.org/10.1007/s00296‐014‐3203‐z
Steiger, F., Wirth, B., de Bruin, E. D., & Mannion, A. F. (2012). Is a positive
clinical outcome after exercise therapy for chronic non‐specific low
back pain contingent upon a corresponding improvement in the
targeted aspect(s) of performance? A systematic review. European Spine
Journal,21(4), 575–598. https://doi.org/10.1007/s00586‐011‐2045‐6
Sterling, M., Jull, G., & Wright, A. (2001). The effect of musculoskeletal pain
on motor activity and control. Journal of Pain,2(3), 135–145. https://
doi.org/10.1054/jpai.2001.19951
Traeger, A. C., Hübscher, M., Henschke, N., Moseley, G. L., Lee, H., &
McAuley, J. H. (2015). Effect of primary care‐based education on
reassurance in patients with acute low back pain: Systematic review
and meta‐analysis. JAMA Internal Medicine,175(5), 733–743. https://
doi.org/10.1001/jamainternmed.2015.0217
Turk, D. C., & Melzack, R. (2011). Handbook of pain assessment (3rd ed.).
New York: Guilford Press.
Vaegter,H. B., Handberg, G., & Graven‐Nielsen,T. (2014). Similaritiesbetween
exercise‐induced hypoalgesia andconditioned pain modulation in humans.
Pain,155(1), 158–167. https://doi.org/10.1016/j.pain.2013.09.023
van Middelkoop, M., Rubinstein, S. M., Kuijpers, T., Verhagen, A. P.,
Ostelo, R., Koes, B. W., …van Tulder, M. W. (2011). A systematic
review on the effectiveness of physical and rehabilitation interventions
for chronic non‐specific low back pain. European Spine Journal,20(1),
19–39. https://doi.org/10.1007/s00586‐010‐1518‐3
Vlaeyen, J. W., Kole‐Snijders, A. M., Boeren, R. G., & van Eek, H. (1995).
Fear of movement/(re)injury in chronic low back pain and its relation
to behavioral performance. Pain,62(3), 363–372. https://doi.org/
10.1016/0304‐3959(94)00279‐N
8BOOTH ET AL.
Wallwork, S. B., Butler, D. S., Wilson, D. J., & Moseley, G. L. (2015). Are
people who do yoga any better at a motor imagery task than those
who do not? British Journal of Sports Medicine,49(2), 123–127.
https://doi.org/10.1136/bjsports‐2012‐091873
Wand, B. M., Parkitny, L., O'Connell, N. E., Luomajoki, H., McAuley, J. H.,
Thacker, M., …Moseley, G. L. (2011). Cortical changes in chronic low back
pain: Current state of the art and implications for clinical practice. Manual
Therapy,16(1), 15–20. https://doi.org/10.1016/j.math.2010.06.008
Wheeler, A. H., Goolkasian, P., Baird, A. C., & Darden, B. V. 2nd. (1999).
Development of the neck pain and disability scale. Item analysis, face,
and criterion‐related validity. Spine (Phila Pa 1976),24(13), 1290–1294.
Woolf, A. D., & Akesson, K. (2001). Understanding the burden of musculo-
skeletal conditions. The burden is huge and not reflected in national
health priorities. BMJ,322(7294), 1079–1080. https://doi.org/
10.1136/bmj.322.7294.1079
Woolf, A. D., Erwin, J., & March, L. (2012). The need to address the burden of
musculoskeletal conditions. Best Practice and Research in Clinical Rheu-
matology,26(2), 183–224. https://doi.org/10.1016/j.berh.2012.03.005
Yamato, T. P., Maher, C. G., Saragiotto, B. T., Hancock, M. J., Ostelo, R. W.,
Cabral, C. M., …Costa, L. O. (2015). Pilates for low back pain. Cochrane
Database of Systematic Reviews,7(7) CD010265. https://doi.org/
10.1002/14651858.CD010265.pub2
Yeomans, S. G. (2000). The clinical application of outcomes assessment.
Maiden Head, USA: McGraw‐Hill Education.
How to cite this article: Booth J, Moseley GL, Schiltenwolf M,
Cashin A, Davies M, Hübscher M. Exercise for chronic muscu-
loskeletal pain: A biopsychosocial approach. Musculoskeletal
Care. 2017. https://doi.org/10.1002/msc.1191
BOOTH ET AL.9
