Therapy, Pain & Training
Chronic Pain and Exercise

Chronic Pain and Exercise

Chronischer Schmerz und Bewegung


Problem: Worldwide, at least one in four adults do not exercise sufficiently. Inactivity is associated with an increase in disease burden and mortality, whereas exercise can contribute to a longer, healthier life. Chronic musculoskeletal pain is a significant public health concern; in Germany, approximately 15% of the adult population suffers from chronic low back pain. Based on the diagnoses of chronic back pain, chronic joint pain, and chronic widespread pain or fibromyalgia syndrome, this study will evaluate the importance of exercise in the treatment of chronic pain.

Methods: Narrative review based on current treatment guidelines and scientific publications.

Results: Exercise and physical activity are both preventively and therapeutically effective in the treatment of chronic musculoskeletal pain. Individualized, supervised exercise programs that take patients’ preferences and goals into account appear to be particularly effective, regardless of pain location. There is evidence that the positive biopsychosocial effects of movement are more important than the specific form of exercise.
Discussion: In the treatment of chronic pain, exercise and activity should be considered primary therapeutic measures and be prescribed accordingly. Supervision and adaptation of exercise programs to patient needs are critical factors of success, regardless of the type of sport or form of exercise. Even a small dose of physical activity achieves health benefits in patients with chronic pain and contributes to symptom relief.

Key Words: Movement, Fibromyalgia, Back Pain, Joint Pain, Pain Therapy


Problemstellung: Weltweit bewegt sich mindestens ein Viertel der Erwachsenen zu wenig. Inaktivität geht mit einer erhöhten Krankheitslast und Sterblichkeit einher, während Bewegung zu einem längeren, gesünderen Leben beitragen kann. Chronische muskuloskelettale Schmerzen sind ein erhebliches globales Gesundheitsproblem, in Deutschland leiden etwa 15% der erwachsenen Bevölkerung an chronischen Schmerzen des Rückens. Anhand der Diagnosen chronischer Rückenschmerz, chronischer Gelenkschmerz sowie chronisch weit verbreiteter Schmerz bzw. Fibromyalgie-Syndrom soll ermittelt werden, welche Bedeutung Bewegung in der Behandlung chronischer Schmerzen zukommt.

Methoden: Narrative Review-Arbeit auf Grundlage der aktuellen Behandlungsleitlinien und wissenschaftlicher Publikationen.

Ergebnisse: Bewegung und körperliche Aktivität sind sowohl präventiv als auch therapeutisch wirkungsvoll in der Behandlung chronischer muskuloskelettaler Schmerzen. Individualisierte, supervidierte Übungsprogramme unter Berücksichtigung der Vorlieben und Ziele der Patienten scheinen unabhängig von der Schmerzlokalisation besonders effektiv zu sein. Es gibt Hinweise darauf, dass dabei die positiven biopsychosozialen Effekte von Bewegung wichtiger sind, als die konkrete Bewegungsform.

Diskussion: In der Behandlung chronischer Schmerzen sind Bewegung und Aktivität als primäre Therapiemaßnahmen anzusehen und sollten entsprechend verordnet werden. Supervision und die Anpassung der Übungsprogramme auf die Patientenbedürfnisse sind entscheidende Faktoren des Erfolgs, unabhängig von Sportart oder Bewegungsform. Auch eine geringe Dosis an körperlicher Aktivität erzielt bei Patienten mit chronischen Schmerzen gesundheitliche Vorteile und trägt zur Linderung der Beschwerden bei.

Schlüsselwörter: Aktivität, Fibromyalgie, Rückenschmerzen, Gelenkschmerzen, Schmerztherapie


According to the International Association for the Study of Pain (IASP), pain is “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”. Pain is considered chronic if it lasts longer than the usual 3-month period of tissue healing (57). Primary chronic – for example musculoskeletal – pain will also be included in the corresponding ICD-11 definition.

Chronic pain is a global public health concern which is associated with considerable economic costs and strain on health systems (4, 31). The BURDEN 2020 study determined that 61.3% of respondents in Germany suffered from back and 45.7% from neck pain at least once in the previous 12 months, with 15.5% of participants even reporting chronic pain of the lower back (96).

Physical activity in general is defined as “any bodily movement produced by skeletal muscle that requires energy expenditure” (101). This rather mechanistic consideration is based on the concept that activity in many different forms can contribute to health and well-being if it is practiced regularly, of adequate duration and with appropriate intensity (102). In addition to traditional aerobic exercise such as running, cycling or swimming, there are numerous types of sports and forms of combined relaxation and movement like dancing, yoga or tai-chi; one may be physically active even at home or at work.

However, people, especially in industrial nations, do not move sufficiently. The WHO recommends at least 150 minutes of moderate activity per week for adults and 60 minutes of moderate to intense activity daily for adolescents (102). Worldwide, these activity targets are not achieved by one in four adults and three in four adolescents (32, 102). The global financial burden for health care systems resulting from physical inactivity is estimated at 54 billion INT$ per year, which corresponds to at least 1 to 3% of national healthcare expenditure (21) (Figure 1 und 2).

Inactivity and sedentary behavior are associated with increased cardiometabolic disease burden and mortality (67). On the other hand, physical activity has been proven to contribute to a longer life with more quality-adjusted life years (QALYs) (54). For example, brisk walking (4.8 to 6.2 km/h) for at least 3 hours and vigorous exercise (≥6 metabolic equivalents per hour) for at least 1.5 hours per week could reduce the incidence of heart attacks in women significantly by 30 to 40% (53). In elderly people, regular exercise contributes to maintaining physical function and a longer survival – a clear dose-effect relationship could, however, not be determined (86).


When considering chronic pain, the question now arises: What kind of exercise and how much of it is actually beneficial and for whom? What forms of exercise can provide evidence-based pain relief? And what can motivate people to exercise and stay consistent on a day to day basis?


There is proof that physicians focus mostly on mechanistic, biomedical origins when patients express pain. This may result in the primary prescription of drugs and analgesics without recommendations for exercise to maintain daily activities or analyzing potential biopsychosocial aspects (78).

Accordingly, many patients suffering from pain assume that the sensory experience of it must always occur due to some bodily impairment. This may be why a targeted, cause-related treatment is then demanded while biopsychosocial approaches to pain are rejected. However, the biopsychosocial model is essential in understanding the origin of chronic pain and the elaboration of treatment recommendations.

Multidisciplinary approaches which consider psychological and social factors in addition to the prescription of exercise have been found to be particularly effective in chronic musculoskeletal pain (30, 94). Moreover, when therapeutic interventions are combined with patient education, they are even more effective in the reduction of pain and disability (61, 69). The assurance that the bodily tissues are sound and can be actively utilized results in additional positive effects (88). Patients need to develop self-efficacy, learn to actively intervene when they are confronted with painful sensations and take responsibility for their own bodies.  

Physical activity is generally recognized as beneficial in the treatment of patients with chronic pain, which has also been adopted as a central recommendation in treatment guidelines (13, 20, 42, 66, 71, 76). There is widespread agreement especially for individualized exercise programs with focus on aerobic and resistance training which must respect the patients’ complaints as well as their preferences (12).

So far, it remains unclear which type of movement is the most effective. In several studies, pain levels did not correlate with the actual improvement of physical functions (85). This finding may support the theory that secondary effects of training such as better mood, reduction of anxiety or improved self-efficacy have a greater influence on the experience of pain than the actual enhancement of physical capacities (e.g. range of motion, strength, endurance) (85, 98). Some studies indicate that the adherence to training recommendations is essential for the effect of the therapeutic intervention (37, 91). If, indeed, the positive biopsychosocial effects of training are paramount in chronic musculoskeletal pain, the question arises if the form of movement and its dose are perhaps less relevant than the performance of the physical activity itself.

Back and Neck Pain
Back and neck pain are widespread conditions. With a lifetime prevalence of up to 94% in certain sports such as rowing (89) and a more than 60% 12-month prevalence in Germany, at least every second person will suffer from back pain during their lifetime (96). At a global level, back pain results in more years lived with disability (YLDs) than any other disease (40). Precisely, low back pain was responsible for 60.1 million disability-adjusted life years (DALYs) worldwide in 2015, a 54% increase compared to 1990 (34). In Germany, 10.8% of YLDs in 2019 were attributed to low back pain – more than any other disease (23).
Although the symptoms of acute episodes rapidly improve in most patients, back pain becomes chronic in 4 to 25% of patients (58). High levels of pain, being overweight or obese, carrying heavy loads at work, physically demanding work in general, as well as psychological factors such as depression, anxiety and avoidance behavior are known risk factors of chronification (65). A sedentary, inactive lifestyle is associated with disability and a more intense experience of pain (39, 51).

Solid evidence has been established for the therapeutic benefits of exercise in back pain (36, 93). The German national treatment guidelines thus recommend the prescription of exercise therapy in combination with educative or behavior therapeutic measures (13). Interventions based on exercise are significantly more effective than alternative treatment methods (e.g. manual therapy, NSAR) in the reduction of pain and disability (37, 92).

However, forms of movement that put strain on the body such as heavy physical labor and extreme athletic activities are factors suspected to contribute to back pain (41, 47, 60). In particular, one-sided, asymmetric postures, lifting heavy weights, poor working conditions and bad weather are associated with a higher prevalence of back pain (77).

These apparently contradictory results support the hypothesis that an appropriate amount of physical activity is necessary to prevent and ameliorate back pain. Several studies indicate that the relationship between exercise and back pain may be best visualized as a U-shaped correlation, and that a moderate level of activity can reduce the risk of chronic low back pain (17, 38, 80, 82) (Figure 3). This relation appears to apply both in exercise performed during sports as well as at work. To be precise, 1 to 2.5 hours of exercise per week appear to significantly reduce the risk of chronic low back pain (38).

In a 2020 systematic review and meta-analysis, stabilization/motor control training, Pilates, resistance training and aerobic exercise were found to be most effective; the authors, however, explicitly voiced the necessity of further studies of higher quality (68). According to current knowledge, progressive endurance and resistance training appear to be equally beneficial for the perception of pain, physical function and quality of life, whereby strength training had an additional positive effect on emotional well-being (100). Walking in itself also appears to have a positive and comparable effect as training on pain, function, quality of life and avoidance behavior (95).

Multidisciplinary therapy approaches such as multimodal pain therapy appear to be superior to unimodal therapy approaches, especially in chronic pain (29, 45). Multimodal pain therapy is an integrative concept characterized by the close interaction of individual therapeutic components and the health professions involved along with high treatment intensity (62). A multidisciplinary team allows for the combination of activating interventions such as endurance, mobility or strength training with psychotherapeutic treatment approaches (patient education, cognitive behavior therapy) and medical as well as psychological one-to-one sessions, which has been shown effective on the long term (74, 106). It appears to be paramount that multiple factors are addressed in such a treatment setting and that the patient’s biopsychosocial environment is considered (8, 25, 43, 73).

Joint Pain
Chronic joint pain, especially of the knee, is frequent and continuously increasing in prevalence, independent of age and BMI (27, 64). In a survey conducted by Robert Koch Institute, 57.9% of women and 52.2% of men reported episodes of joint pain in the preceding 12 months, more than one-quarter of them even within the preceding 24 hours; in most cases, pain was perceived in multiple joints at once (27). Osteoarthritis and rheumatoid arthritis are considered the most common causes of joint pain, but together they affect just under half of people with pain complaints (105).

The knee is the joint most often experienced as painful; in patients older than 60, knee pain is even the most common musculoskeletal pain in general, sometimes with no detectable signs of osteoarthritis (27, 55, 90). While the prevalence of knee pain has been increasing in recent decades, the proportion of radiological signs of osteoarthritis of the joint has not (64). In young adults suffering from unspecific pain of the knee, chronification has evolved in about 20% of the patients over a period of 6 years (46).
Recreational sports appear to have a protective effect in the development of knee pain, and being physically active in their leisure time did not correlate with the risk of hip and knee arthrosis in elderly and middle-aged people (1, 7, 24). In contrast, very high levels of physical strain, especially on the job, seem to increase the risk of chronic knee pain (82, 87).

Being overweight or obese, female gender and previous trauma to the joint are among the main risk factors for developing knee pain; about 5% of new-onset knee pain can be attributed to injury and about 25% to excess body weight (81). Therefore, weight loss is a relevant therapeutic tool in the treatment and prevention of knee pain in overweight and obese patients (59). A reduction in body weight by 10% appears to result in lasting pain relief (99). In addition to nutritional medical support, movement and exercise are key factors for achieving and maintaining a healthy body weight.

These findings are also reflected in the treatment guidelines for knee osteoarthritis which strongly recommend (guided) endurance and resistance training based on current evidence (9, 19, 26). An additional primary treatment recommendation are physiotherapeutic measures to strengthen the muscles surrounding the joint (19, 70). For the best effect, a systematic review on knee osteoarthritis in 2014 recommended supervised training three times a week, which should focus on the improvement of aerobic capacity, performance of the lower extremities and strengthening especially of the quadriceps muscle (44). It is recognized that exercise in itself has beneficial effects on pain and function, but larger randomized controlled studies analyzing the impact of specific training forms and their long-term effects are imperative (63).

Finally, the biopsychosocial model is also applicable for chronic pain of the joints and should be implemented in diagnostic and therapeutic measures. Patients with osteoarthritis do also benefit from the promotion of self-efficacy, composure and resilience (72).

Chronic Widespread Pain and Fibromyalgia Syndrome

The point prevalence of chronic widespread pain as part of the fibromyalgia syndrome in Germany is 2.1% (104). To diagnose chronic widespread pain, by definition, it must occur in multiple parts of the body or at least 11 of 18 specific tender points must be sensitive to pressure (22). Apart from chronic pain, the fibromyalgia syndrome is characterized by insomnia or non-restorative sleep, along with fatigue and exhaustion (76). The pain usually manifests as myalgia in alternating localizations, back pain or joint pain (35).

Aerobic exercise has been shown to be effective in relieving pain, improving overall well-being and body function (10, 56, 103). In a systematic review comprising 16 randomized studies, aerobic training was found to be superior to resistance training with respect to relief of pain and symptoms (14). However, with supplementary strengthening and stabilizing exercises at low to moderate intensity, fatigue and health-related impairment could be significantly reduced (16). Aquatic exercise resulted in significant improvements in pain, insomnia and disability (50) and was superior to land-based training concerning the reduction of pain levels (11). Sports with spiritual and mental elements such as yoga can also be beneficial (49). In current meta-analyses, aerobic as well as resistance training are currently considered the most effective interventions regarding pain relief and improvement of overall well-being; moreover, stretching and endurance exercises may improve health-related quality of life (10, 83). However, the authors emphasize that it is not possible to recommend specific forms of training based on the data currently available.

Multimodal therapy is considered effective in the short and long-term and recommended in current treatment guidelines for patients with fibromyalgia syndrome (76). Such a program should comprise at least 24 hours of treatment as significant effects on pain, fatigue and quality of life can only be achieved with an appropriate volume of therapy (76).


The majority of people are not as active as they should be. In order to prevent disability and promote self-efficacy by prescribing active treatment modalities, it is essential to motivate patients to exercise and move early on. Passive measures of therapy and the prescription of bed rest have been proven ineffective (3, 52, 97) while instructed exercise is not less effective than, for example, the referral to manual therapy (33).
Exercise may initiate complex neurobiological pathways which leads to the endogenous release of endorphins, stimulates opioid receptors and thereby enables direct analgesic effects (79). In animal models, training on a regular basis caused sustainable anti-nociceptive effects (84). The specific modality of movement appears to be less important than the steady encouragement of patients with chronic pain to maintain activity and exercise regularly on the long term. It must be considered the physician’s responsibility to combat lethargy and passivity and educate patients thoroughly about the multiple benefits of exercise.

An individual optimum of the amount of exercise depending on physical constitution, age and personal preferences should be determined for everyone. Patients who enjoy exercise and do so to achieve their individual goals have been shown to be more adherent to training interventions (42). Conversely, the correlation between mental illness and chronic pain has been known for years (18) and pain intensity over time is less influenced by nociception than by emotional and psychosocial factors (6).

On the basis of biopsychosocial considerations, activity should be integrated into the patient’s respective private and occupational environment. For example, avoiding motorized transport in favor of cycling and walking will facilitate the achievement of daily activity goals. In general, even a small dose of physical activity can protect against chronic pain and is associated with health benefits in affected patients (28, 75), e.g. 20 to 60 minutes of aerobic exercise at least 2 days per week (15, 66). As higher-intensity exercise (>/= 70% HRmax/1RM) can also relieve pain and improve function, patients with chronic pain who prefer more intense training modalities should be motivated to do so as well (9, 48). Even though the evidence for aerobic exercise and resistance training is very good, any sport that patients enjoy and that maintains motivation for exercise should be considered (12).

Adherence also appears to be less influenced by the specific type of exercise (2, 42). Bachmann, Oesch and Bachmann determined the following aspects as relevant to a patient’s adherence to home exercise programs in a 2018 systematic review: family and social support, guidance, limited number of exercises (3 and less), self-motivation, self-efficacy, previous adherent behavior, level of physical activity and aerobic endurance at baseline, attentiveness, worsening of pain during exercise, and the degree of helplessness, depression and anxiety (5). Supervised as well as individualized exercise programs appear to be particularly effective for chronic musculoskeletal pain and can help to effectively increase weekly exercise frequency (42).

The prescription of physical activity should allow patients to develop body awareness by testing and pushing their own limits, build self-efficacy, and take individual needs into consideration. Especially for patients with chronic pain, it has been shown to be helpful to repeatedly reassure them that structures are sound and that exercise is safe (88). In this context, exercise therapy should be seen as a supportive measure intended to help patients become more active on their own. They should become introduced to sports and exercise, with a focus on reducing fear of movement and promoting self-efficacy.

Conflict of Interest
The authors have no conflict of interest.


  1. AGEBERG E, ENGSTROM G, GERHARDSSON DE VERDIER M, ROLLOF J, ROOS EM,LOHMANDER LS. Effect of leisure time physical activity on severe kneeor hip osteoarthritis leading to total joint replacement: a populationbasedprospective cohort study. BMC Musculoskelet Disord. 2012; 13:73.
  2. AITKEN D, BUCHBINDER R, JONES G, WINZENBERG T. Interventions toimprove adherence to exercise for chronic musculoskeletal pain inadults. Aust Fam Physician. 2015; 44: 39-42.
  3. ALLEN C, GLASZIOU P, DEL MAR C. Bed rest: a potentially harmfultreatment needing more careful evaluation. Lancet. 1999; 354: 1229-1233.
  4. ANDREW R, DERRY S, TAYLOR RS, STRAUBE S, PHILLIPS CJ. The costs andconsequences of adequately managed chronic non-cancer pain andchronic neuropathic pain. Pain Pract. 2014; 14: 79-94.
  5. BACHMANN C, OESCH P, BACHMANN S. Recommendations for ImprovingAdherence to Home-Based Exercise: A Systematic Review. Phys MedRehab Kuror. 2018; 28: 20-31.
  6. BALLANTYNE JC, SULLIVAN MD. Intensity of Chronic Pain—TheWrong Metric? N Engl J Med. 2015; 373: 2098-2099.
  7. BARBOUR KE, HOOTMAN JM, HELMICK CG, MURPHY LB, THEIS KA, SCHWARTZTA, KALSBEEK WD, RENNER JB, JORDAN JM. Meeting physical activityguidelines and the risk of incident knee osteoarthritis: a populationbasedprospective cohort study. Arthritis Care Res (Hoboken). 2014;66: 139-146.
  8. BENDIX T, BENDIX A, LABRIOLA M, HAESTRUP C, EBBEHOJ N. Functionalrestoration versus outpatient physical training in chronic low backpain: a randomized comparative study. Spine. 2000; 25: 2494-2500.
  9. BENNELL KL, HINMAN RS. A review of the clinical evidence for exercisein osteoarthritis of the hip and knee. J Sci Med Sport. 2011; 14: 4-9.
  10. BIDONDE J, BUSCH AJ, SCHACHTER CL, OVEREND TJ, KIM SY, GÓES SM,BODEN C, FOULDS HJ. Aerobic exercise training for adults withfibromyalgia. Cochrane Database Syst Rev. 2017; 6: CD012700.
  11. BIDONDE J, BUSCH AJ, WEBBER SC, SCHACHTER CL, DANYLIW A, OVEREND TJ,RICHARDS RS, RADER T. Aquatic exercise training for fibromyalgia.Cochrane Database Syst Rev. 2014; CD011336.
  12. BOOTH J, MOSELEY GL, SCHILTENWOLF M, CASHIN A, DAVIES M, HUBSCHER M. Exercise for chronic musculoskeletal pain: A biopsychosocialapproach. Musculoskelet Care. 2017; 15: 413-421.
  14. BUSCH AJ, BARBER KA, OVEREND TJ, PELOSO PM, SCHACHTER CL. Exercisefor treating fibromyalgia syndrome. Cochrane Database Syst Rev.2007; CD003786.
  15. BUSCH AJ, WEBBER SC, BRACHANIEC M, BIDONDE J, BELLO-HAAS VD,DANYLIW AD, OVEREND TJ, RICHARDS RS, SAWANT A, SCHACHTER CL. Exercise therapy for fibromyalgia. Curr Pain Headache Rep. 2011; 15:358-367.
  16. BUSCH AJ, WEBBER SC, RICHARDS RS, BIDONDE J, SCHACHTER CL, SCHAFER LA,DANYLIW A, SAWANT A, DAL BELLO-HAAS V, RADER T, OVEREND TJ. Resistance exercise training for fibromyalgia. Cochrane DatabaseSyst Rev. 2013; CD010884.
  17. CAMPELLO M, NORDIN M, WEISER S. Physical exercise and low back pain.Scand J Med Sci Sports. 1996; 6: 63-72.
  18. DEMYTTENAERE K, BRUFFAERTS R, LEE S, POSADA-VILLA J, KOVESS V,ANGERMEYER MC, LEVINSON D, DE GIROLAMO G, NAKANE H, MNEIMNEH Z,LARA C, DE GRAAF R, SCOTT KM, GUREJE O, STEIN DJ, HARO JM, BROMET EJ,KESSLER RC, ALONSO J, VON KORFF M. Mental disorders amongpersons with chronic back or neck pain: results from the WorldMental Health Surveys. Pain. 2007; 129: 332-342.
  19. DGOOC. S2k-Leitlinie Gonarthrose. 2018. [14 March 2022].
  20. DGOOC. S2k-Leitlinie Koxarthrose. 2019.[14 March 2022].
  21. DING D, LAWSON KD, KOLBE-ALEXANDER TL, FINKELSTEIN EA, KATZMARZYK PT,VAN MECHELEN W, PRATT M; LANCET PHYSICAL ACTIVITY SERIES 2EXECUTIVE COMMITTEE. The economic burden of physical inactivity: aglobal analysis of major non-communicable diseases. Lancet. 2016;388: 1311-1324.
  22. EICH W, BÄR KJ, BERNATECK M, BURGMER M, DEXL C, PETZKE F, SOMMER C,WINKELMANN A, HÄUSER W. Definition, Klassifikation, klinischeDiagnose und Prognose des Fibromyalgiesyndroms: AktualisierteLeitlinie 2017 und Übersicht von systematischen Übersichtsarbeiten[Definition, classification, clinical diagnosis and prognosis offibromyalgia syndrome: Updated guidelines 2017 and overview ofsystematic review articles]. Schmerz. 2017; 31: 231-238.
  23. EVALUATION, INSTITUTE FOR HEALTH METRICS AND EVALUATION (2019). GBD2019. Both sexes, All ages, 2019, YLDs. Both sexes, All ages, 2019, YLDs [8 January 2022].
  24. FELSON DT, NIU J, CLANCY M, SACK B, ALIABADI P, ZHANG Y. Effectof recreational physical activities on the development of kneeosteoarthritis in older adults of different weights: the FraminghamStudy. Arthritis Rheum. 2007; 57: 6-12.
  25. FLOR H, FYDRICH T, TURK DC. Efficacy of multidisciplinary paintreatment centers: a meta-analytic review. Pain. 1992; 49: 221-230.
  26. FRANSEN M, MCCONNELL S, HARMER AR, VAN DER ESCH M, SIMIC M,BENNELL KL. Exercise for osteoarthritis of the knee: a Cochranesystematic review. Br J Sports Med. 2015; 49: 1554-1557.
  27. FUCHS J, PRÜTZ F. Prävalenz von Gelenkschmerzen in Deutschland.Journal of Health Monitoring. 2017; 2: 66-71.
  28. GARBER CE, BLISSMER B, DESCHENES MR, FRANKLIN BA, LAMONTE MJ,LEE IM, NIEMAN DC, SWAIN DP; AMERICAN COLLEGE OF SPORTS MEDICINE. American College of Sports Medicine position stand. Quantity andquality of exercise for developing and maintaining cardiorespiratory,musculoskeletal, and neuromotor fitness in apparently healthyadults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43: 1334-59.
  29. GATCHEL RJ, MAYER TG. Evidence-informed management of chroniclow back pain with functional restoration. Spine J. 2008; 8: 65-69.
  30. GATCHEL RJ, PENG YB, PETERS ML, FUCHS PN, TURK DC. Thebiopsychosocial approach to chronic pain: scientific advances andfuture directions. Psychol Bull. 2007; 133: 581-624.
  31. GOLDBERG DS, MCGEE SJ. Pain as a global public health priority. BMCPublic Health. 2011; 11: 770.
  32. GUTHOLD R, STEVENS GA, RILEY LM, BULL FC. Worldwide trends ininsufficient physical activity from 2001 to 2016: a pooled analysis of358 population-based surveys with 1.9 million participants. LancetGlob Health. 2018; 6: e1077-e1086.
  33. HANCOCK MJ, MAHER CG, LATIMER J, MCLACHLAN AJ, COOPER CW, DAY RO,SPINDLER MF, MCAULEY JH. Assessment of diclofenac or spinalmanipulative therapy, or both, in addition to recommended first-linetreatment for acute low back pain: a randomised controlled trial.Lancet. 2007; 370: 1638-1643.
  35. HAUSER W, KUHN E, WOLF B, NOTHACKER M, PETZKE F. Twelve years of theS3 guideline Fibromyalgia Syndrome-a never-ending war? Schmerz.2017; 31: 197-199.
  36. HAYDEN JA, ELLIS J, OGILVIE R, MALMIVAARA A, VAN TULDER MW. Exercisetherapy for chronic low back pain. Cochrane Database Syst Rev.2021; 9: CD009790.
  37. HAYDEN JA, VAN TULDER MW, TOMLINSON G. Systematic review: strategiesfor using exercise therapy to improve outcomes in chronic low backpain. Ann Intern Med. 2005; 142: 776-785.
  38. HENEWEER H, VANHEES L, PICAVET HS. Physical activity and low backpain: a U-shaped relation? Pain. 2009; 143: 21-25.
  39. HILDEBRANDT VH, BONGERS PM, DUL J, VAN DIJK FJ, KEMPER HC. The relationship between leisure time, physical activities andmusculoskeletal symptoms and disability in worker populations.Int Arch Occup Environ Health. 2000; 73: 507-518.
  40. HOY D, MARCH L, BROOKS P, BLYTH F, WOOLF A, BAIN C, WILLIAMS G, SMITH E,VOS T, BARENDREGT J, MURRAY C, BURSTEIN R, BUCHBINDER R. The globalburden of low back pain: estimates from the Global Burden ofDisease 2010 study. Ann Rheum Dis. 2014; 73: 968-974.
  41. JANSEN JP, MORGENSTERN H, BURDORF A. Dose-response relationsbetween occupational exposures to physical and psychosocialfactors and the risk of low back pain. Occup Environ Med. 2004; 61:972-979.
  42. JORDAN JL, HOLDEN MA, MASON EE, FOSTER NE. Interventions to improveadherence to exercise for chronic musculoskeletal pain in adults.Cochrane Database Syst Rev. 2010; CD005956.
  43. JOUSSET N, FANELLO S, BONTOUX L, DUBUS V, BILLABERT C, VIELLE B,ROQUELAURE Y, PENNEAU-FONTBONNE D, RICHARD I. Effects of functionalrestoration versus 3 hours per week physical therapy: a randomizedcontrolled study. Spine. 2004; 29: 487-493, discussion 494.
  44. JUHL C, CHRISTENSEN R, ROOS EM, ZHANG W, LUND H. Impact of exercisetype and dose on pain and disability in knee osteoarthritis: asystematic review and meta-regression analysis of randomizedcontrolled trials. Arthritis Rheumatol. 2014; 66: 622-636.
  45. KAMPER SJ, APELDOORN AT, CHIAROTTO A, SMEETS RJ, OSTELO RW, GUZMAN J,VAN TULDER MW. Multidisciplinary biopsychosocial rehabilitationfor chronic low back pain: Cochrane systematic review and metaanalysis.BMJ. 2015; 350: h444.
  46. KASTELEIN M, LUIJSTERBURG PA, BELO JN, VERHAAR JA, KOES BW, BIERMAZEINSTRASM. Six-year course and prognosis of nontraumatic kneesymptoms in adults in general practice: a prospective cohort study.Arthritis Care Res (Hoboken). 2011; 63: 1287-1294.
  47. KOPEC JA, SAYRE EC, ESDAILE JM. Predictors of back pain in a generalpopulation cohort. Spine. 2004; 29: 70-77, discussion 77-78.
  48. KRISTENSEN J, FRANKLYN-MILLER A. Resistance training inmusculoskeletal rehabilitation: a systematic review. Br J Sports Med.2012; 46: 719-726.
  49. LANGHORST J, KLOSE P, DOBOS GJ, BERNARDY K, HAUSER W. Efficacy andsafety of meditative movement therapies in fibromyalgia syndrome: asystematic review and meta-analysis of randomized controlled trials.Rheumatol Int. 2013; 33: 193-207.
  50. LIMA TB, DIAS JM, MAZUQUIN BF, DA SILVA CT, NOGUEIRA RM, MARQUES AP,LAVADO EL, CARDOSO JR. The effectiveness of aquatic physicaltherapy in the treatment of fibromyalgia: a systematicreview with meta-analysis. Clin Rehabil. 2013; 27: 892-908.
  51. LIN CC, MCAULEY JH, MACEDO L, BARNETT DC, SMEETS RJ, VERBUNT JA. Relationship between physical activity and disability in low backpain: a systematic review and meta-analysis. Pain. 2011; 152: 607-613.
  52. MALMIVAARA A, HÄKKINEN U, ARO T, HEINRICHS ML, KOSKENNIEMI L,KUOSMA E, LAPPI S, PALOHEIMO R, SERVO C, VAARANEN V, HERNBERG S. The treatment of acute low back pain—bed rest, exercises, orordinary activity? N Engl J Med. 1995; 332: 351-355.
  53. MANSON JE, HU FB, RICH-EDWARDS JW, COLDITZ GA, STAMPFER MJ,WILLETT WC, SPEIZER FE, HENNEKENS CH. A prospective study ofwalking as compared with vigorous exercise in the prevention ofcoronary heart disease in women. N Engl J Med. 1999; 341: 650-658.
  54. MAY AM, STRUIJK EA, FRANSEN HP, ONLAND-MORET NC, DE WIT GA, BOER JM,VAN DER SCHOUW YT, HOEKSTRA J, BUENO-DE-MESQUITA HB, PEETERS PH,BEULENS JW. The impact of a healthy lifestyle on Disability-AdjustedLife Years: a prospective cohort study. BMC Med. 2015; 13: 39.
  55. MCALINDON TE, COOPER C, KIRWAN JR, DIEPPE PA. Knee pain anddisability in the community. Br J Rheumatol. 1992; 31: 189-192.
  56. MEIWORM L, JAKOB E, WALKER UA, PETER HH, KEUL J. Patients withfibromyalgia benefit from aerobic endurance exercise. ClinRheumatol. 2000; 19: 253-257.
  57. MERSKEY H, BOGDUK N. Classification of Chronic Pain, Part III: PainTerms, A Current List with Definitions and Notes on Usage. SecondEdition, IASP Task Force on Taxonomy, IASP Press, Seattle, 2011;209-214.
  58. MEUCCI RD, FASSA AG, FARIA NM. Prevalence of chronic low back pain:systematic review. Rev Saude Publica. 2015; 49.
  59. MILLS K, HUBSCHER M, O’LEARY H, MOLONEY N. Current concepts in jointpain in knee osteoarthritis. Schmerz. 2019; 33: 22-29.
  60. MIRANDA H, VIIKARI-JUNTURA E, MARTIKAINEN R, TAKALA EP, RIIHIMAKI H. Individual factors, occupational loading, and physical exerciseas predictors of sciatic pain. Spine. 2002; 27: 1102-1109.
  61. MOSELEY L. Combined physiotherapy and education is efficaciousfor chronic low back pain. Aust J Physiother. 2002; 48: 297-302.
  62. NAGEL B, PFINGSTEN M, BRINKSCHMIDT T, CASSER HR, GRALOW I, IRNICH D,KLIMCZYK K, SABATOWSKI R, SCHILTENWOLF M, SITTL R, SÖLLNER W,ARNOLD B; AD-HOC-KOMMISSION MULTIMODALE INTERDISZIPLINÄRESCHMERZTHERAPIE DER DEUTSCHEN SCHMERZGESELLSCHAFT. Struktur undProzessqualität multimodaler Schmerztherapie. Ergebnisseeiner Befragung von schmerztherapeutischen Einrichtungen[Structure and process quality of multimodal pain therapy. Resultsof a survey of pain therapy clinics]. Schmerz. 2012; 26: 661-669.
  63. NEWBERRY SJ, FITZGERALD J, SOOHOO NF, BOOTH M, MARKS J, MOTALA A,APAYDIN E, CHEN C, RAAEN L, SHANMAN R, SHEKELLE PG. Treatment ofOsteoarthritis of the Knee: An Update Review [Internet]. Rockville(MD): Agency for Healthcare Research and Quality (US); 2017 May.Report No.: 17-EHC011-EF. PMID: 28825779.
  64. NGUYEN US, ZHANG Y, ZHU Y, NIU J, ZHANG B, FELSON DT. Increasingprevalence of knee pain and symptomatic knee osteoarthritis:survey and cohort data. Ann Intern Med. 2011; 155: 725-732.
  65. NIEMINEN LK, PYYSALO LM, KANKAANPAA MJ. Prognostic factors for painchronicity in low back pain: a systematic review. Pain Rep. 2021; 6:e919.
  66. O‘CONNOR SR, TULLY MA, RYAN B, BLEAKLEY CM, BAXTER GD, BRADLEY JM,MCDONOUGH SM. Walking exercise for chronic musculoskeletal pain:systematic review and meta-analysis. Arch Phys Med Rehabil. 2015;96: 724-734.e3.
  67. OWEN N, HEALY GN, MATTHEWS CE, DUNSTAN DW. Too much sitting: thepopulation health science of sedentary behavior. Exerc Sport Sci Rev.2010; 38: 105-113.
  68. OWEN PJ, MILLER CT, MUNDELL NL, VERSWIJVEREN SJJM, TAGLIAFERRI SD,BRISBY H, BOWE SJ, BELAVY DL. Which specific modes of exercisetraining are most effective for treating low back pain? Networkmeta-analysis. Br J Sports Med. 2020; 54: 1279-1287.
  69. PIRES D, CRUZ EB, CAEIRO C. Aquatic exercise and painneurophysiology education versus aquatic exercise alone for patientswith chronic low back pain: a randomized controlled trial. ClinRehabil. 2015; 29: 538-547.
  70. RICHTER K, MULLER-LADNER U, DISCHEREIT G, UWE L. Potentials andLimits of Physiotherapy in Osteoarthritis. Curr Rheumatol Rev. 2018;14: 117-122.
  71. ROENNEBERG C, SATTEL H, SCHAEFERT R, HENNINGSEN P, HAUSTEINERWIEHLE C. Functional Somatic Symptoms. Dtsch Arztebl Int. 2019;116: 553-560.
  72. SCHILTENWOLF M. Joint pain. Schmerz. 2019; 33: 1-3.
  73. SCHILTENWOLF M, BUCHNER M, HEINDL B, VON REUMONT J, MULLER A,EICH W. Comparison of a biopsychosocial therapy (BT) with aconventional biomedical therapy (MT) of subacute low back painin the first episode of sick leave: a randomized controlled trial. EurSpine J. 2006; 15: 1083-1092.
  74. SCHILTENWOLF M, EIDMANN U, KÖLLNER V, KÜHN T, OFFENBÄCHER M,PETZKE F, SARHOLZ M, WEIGL M, WOLF B, HÄUSER W. Multimodal therapyof fibromyalgia syndrome: Updated guidelines 2017 and overview ofsystematic review articles. Schmerz. 2017; 31: 285-288.
  75. SCHILTENWOLF M, SCHNEIDER S. Activity and low back pain: a dubiouscorrelation. Pain. 2009; 143: 1-2.
  76. DEUTSCHE SCHMERZGESELLSCHAFT. Definition, Pathophysiologie,Diagnostik und Therapie des Fibromyalgiesyndroms. 2017. [14 March 2022].
  77. SCHNEIDER S, SCHMITT H, ZOLLER S, SCHILTENWOLF M. Workplace stress,lifestyle and social factors as correlates of back pain: a representativestudy of the German working population. Int Arch Occup EnvironHealth. 2005; 78: 253-269.
  78. SCHOFIELD P. Working with older adults to manage pain. Pain Manag.2011; 1: 11-13.
  79. SHARAN D, RAJKUMAR JS, MOHANDOSS M, RANGANATHAN R. Myofasciallow back pain treatment. Curr Pain Headache Rep. 2014; 18: 449.
  80. SHIRI R, FALAH-HASSANI K, HELIÖVAARA M, SOLOVIEVA S, AMIRI S,LALLUKKA T, BURDORF A, HUSGAFVEL-PURSIAINEN K, VIIKARI-JUNTURA E. Risk Factors for Low Back Pain: A Population-Based LongitudinalStudy. Arthritis Care Res (Hoboken). 2019; 71: 290-299.
  81. SILVERWOOD V, BLAGOJEVIC-BUCKNALL M, JINKS C, JORDAN JL, PROTHEROE J,JORDAN KP. Current evidence on risk factors for knee osteoarthritis inolder adults: a systematic review and meta-analysis. OsteoarthritisCartilage. 2015; 23: 507-515.
  82. SOLOVEV A, WATANABE Y, KITAMURA K, TAKAHASHI A, KOBAYASHI R, SAITO T,TAKACHI R, KABASAWA K, OSHIKI R, PLATONOVA K, TSUGANE S, IKI M,SASAKI A, YAMAZAKI O, WATANABE K, NAKAMURA K. Total physical activityand risk of chronic low back and knee pain in middle-aged andelderly Japanese people: The Murakami cohort study. Eur J Pain.2020; 24: 863-872.
  83. SOSA-REINA MD, NUNEZ-NAGY S, GALLEGO-IZQUIERDO T, PECOS-MARTIN D,MONSERRAT J, ALVAREZ-MON M. Effectiveness of Therapeutic Exercisein Fibromyalgia Syndrome: A Systematic Review and Meta-Analysisof Randomized Clinical Trials. BioMed Res Int. 2017; 2356346.
  84. STAGG NJ, MATA HP, IBRAHIM MM, HENRIKSEN EJ, PORRECA F,VANDERAH TW, PHILIP MALAN T JR. Regular exercise reversessensory hypersensitivity in a rat neuropathic pain model: role ofendogenous opioids. Anesthesiology. 2011; 114: 940-948.
  85. STEIGER F, WIRTH B, DE BRUIN ED, MANNION AF. Is a positive clinicaloutcome after exercise therapy for chronic non-specific low backpain contingent upon a corresponding improvement in the targetedaspect(s) of performance? A systematic review. Eur Spine J. 2012; 21:575-598.
  86. STESSMAN J, HAMMERMAN-ROZENBERG R, COHEN A, EIN-MOR E,JACOBS JM. Physical activity, function, and longevity among thevery old. Arch Intern Med. 2009; 169: 1476-1483.
  87. TOIVANEN AT, HELIÖVAARA M, IMPIVAARA O, AROKOSKI JP, KNEKT P, LAUREN H,KRÖGER H. Obesity, physically demanding work and traumatic kneeinjury are major risk factors for knee osteoarthritis—a populationbasedstudy with a follow-up of 22 years. Rheumatology (Oxford).2010; 49: 308-314.
  88. TRAEGER AC, HUBSCHER M, HENSCHKE N, MOSELEY GL, LEE H, MCAULEY JH. Effect of Primary Care-Based Education on Reassurance inPatients With Acute Low Back Pain: Systematic Review andMeta-analysis. JAMA Intern Med. 2015; 175: 733-743.
  89. TROMPETER K, FETT D, PLATEN P. Prevalence of Back Pain in Sports: ASystematic Review of the Literature. Sports Med. 2017; 47: 1183-1207.
  90. URWIN M, SYMMONS D, ALLISON T, BRAMMAH T, BUSBY H, ROXBY M,SIMMONS A, WILLIAMS G. Estimating the burden of musculoskeletaldisorders in the community: the comparative prevalence ofsymptoms at different anatomical sites, and the relation to socialdeprivation. Ann Rheum Dis. 1998; 57: 649-655.
  91. VAN GOOL CH, PENNINX BW, KEMPEN GI, REJESKI WJ, MILLER GD, VAN EIJK JT,PAHOR M, MESSIER SP. Effects of exercise adherence on physicalfunction among overweight older adults with knee osteoarthritis.Arthritis Rheum. 2005; 53: 24-32.
  92. VAN MIDDELKOOP M, RUBINSTEIN SM, KUIJPERS T, VERHAGEN AP, OSTELO R,KOES BW, VAN TULDER MW. A systematic review on the effectiveness ofphysical and rehabilitation interventions for chronic non-specificlow back pain. Eur Spine J. 2011; 20: 19-39.
  93. VAN TULDER MW, KOES BW, BOUTER LM. A cost-of-illness study of backpain in The Netherlands. Pain. 1995; 62: 233-240.
  94. VAN TULDER MW, OSTELO R, VLAEYEN JW, LINTON SJ, MORLEY SJ,ASSENDELFT WJ. Behavioral treatment for chronic low back pain:a systematic review within the framework of the Cochrane BackReview Group. Spine. 2001; 26: 270-281.
  95. VANTI C, ANDREATTA S, BORGHI S, GUCCIONE AA, PILLASTRINI P, BERTOZZIL. The effectiveness of walking versus exercise on pain and functionin chronic low back pain: a systematic review and meta-analysis ofrandomized trials. Disabil Rehabil. 2019; 41: 622-632.
  96. VON DER LIPPE E, KRAUSE L, PORST M, WENGLER A, LEDDIN J, MÜLLER A,ZEISLER M-L, ANTON, A, ROMMEL A. Ergebnisse der Krankheitslast-Studie BURDEN 2020. Journal of Health Monitoring. 2021; 6.
  97. WADDELL G, FEDER G, LEWIS M. Systematic reviews of bed rest andadvice to stay active for acute low back pain. Br J Gen Pract. 1997;47: 647-652.
  98. WALLWORK SB, BUTLER DS, WILSON DJ, MOSELEY GL. Are people who doyoga any better at a motor imagery task than those who do not? Br JSports Med. 2015; 49: 123-127.
  99. WANG Y, WLUKA AE, BERRY PA, SIEW T, TEICHTAHL AJ, URQUHART DM, LLOYDDG,JONES G, CICUTTINI FM. Increase in vastus medialis cross-sectionalarea is associated with reduced pain, cartilage loss, and jointreplacement risk in knee osteoarthritis. Arthritis Rheum. 2012; 64:3917-3925.
  100. WEWEGE MA, BOOTH J, PARMENTER BJ. Aerobic vs. resistance exercisefor chronic non-specific low back pain: A systematic review andmeta-analysis. J Back Musculoskeletal Rehabil. 2018; 31: 889-899.
  101. WHO. Global recommendations on physical activity forhealth. Geneva, 2010. [14 March 2022].
  102. WHO. The global action plan on physical activity 2018 - 2030: moreactive people for a healthier world. Geneva, 2018. [14 March 2022].
  103. WINKELMANN A. Is Aerobic Exercise Training Beneficial forAdults With Fibromyalgia?: A Cochrane Review Summary withCommentary. Am J Phys Med Rehabil. 2019; 98: 169-170.
  104. WOLFE F, BRAHLER E, HINZ A, HAUSER W. Fibromyalgia prevalence,somatic symptom reporting, and the dimensionality ofpolysymptomatic distress: results from a survey of the generalpopulation. Arthritis Care Res (Hoboken). 2013; 65: 777-785.
  105. WOOLF AD, PFLEGER B. Burden of major musculoskeletal conditions.Bull World Health Organ. 2003; 81: 646-656.
  106. ZHUK A, SCHILTENWOLF M, NEUBAUER E. Long-term efficacy ofmultimodal pain therapy for chronic back pain. Nervenarzt. 2018;89: 546-551.
Pia-Elena Frey
Heidelberg University Hospital
Department of Orthopedics and Trauma Surgery
Schlierbacher Landstraße 200 a,
69118 Heidelberg, Germany