Exercise Therapy and Chronic Pain – What’s Missing?

Chronic pain aerobic exercise

Penny, a 40 year old graphic designer had been seeing her physiotherapist on and off for low back pain for 3 years. Things were still pretty up and down. She’d been consistent with her strengthening and mobility exercises making sure she put aside 15 minutes every day to get that done. She had also made sure her workstation was set up well and she took frequent breaks to walk around and move. But she could never fully shift the pain in her back and she’d started to accept that maybe it would never go.

Does this sound familiar? And while Penny and her physiotherapist believes she is doing all that she should, she can be doing more that could make a big difference.

Systemic inflammation and exercise

It is becoming more and more accepted that chronic musculoskeletal pain, such as low back pain and arthritis, is at least partially driven by low-grade systemic inflammation. And research evidence is also showing that for low back pain, just general aerobic exercises can go a long way to improving pain outcomes (Meng et al. 2015).

Why is this? It is thought that it is due to IL-6, an anti-inflammatory cytokine that is consistently released after physical exercise. This assists in reducing the pro-inflammatory cytokine profile in those with chronic musculoskeletal pain. And IL-6 production is dependent on the type of exercise.

In particular, higher IL-6 production is induced if exercise is of a longer duration and of moderate intensity (Runhaar et al. 2016). So the 15 minutes of back specific strengthening and mobility exercises is probably not enough for sufficient release of IL-6. Rather, Penny should introduce moderate and longer duration aerobic exercise into her regime.

Furthermore, those 15 minutes of exercises are probably not sufficient to induce muscle atrophy. As greater muscle mass induces higher IL-6 production, it is wise for Penny to also have a carefully planned strengthening program that does not exacerbate her back but induces hypertrophy, particularly of the larger muscle groups such as the glutes.

And with a simple program of aerobic exercise and strengthening to increase muscle mass, Penny will begin to lose some visceral fat, which reduces her risk of developing other metabolic disorders that contribute to the pro-inflammatory cycle that many patients get trapped in (Benatti et al. 2015).

Clinical implications

In light of this, we should all educate and encourage our patients to improve their general conditioning, in terms of moderate intensity all-round strengthening and aerobic exercises, as part of their rehabilitation for specific musculoskeletal conditions. As well as improving their general health, it can reduce systemic inflammation that at least partially contributes to their pain.


Benatti, F. B., & Pedersen, B. K. (2015). Exercise as an anti-inflammatory therapy for rheumatic diseases [mdash] myokine regulation. Nature reviews rheumatology, 11(2), 86-97.

Meng, X. G., & Yue, S. W. (2015). Efficacy of aerobic exercise for treatment of chronic Low back pain: a meta-analysis. American Journal of Physical Medicine & Rehabilitation, 94(5), 358-365.

Runhaar, J., & Bierma-Zeinstra, S. M. A. (2016). Should exercise therapy for chronic musculoskeletal conditions focus on the anti-inflammatory effects of exercise? bjsports-2016.

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