Exercise therapy and rehabilitation for chronic pain

Active treatment beats passive treatment. Exercise and staying active anchor rehabilitation for back pain, osteoarthritis, tendinopathy and CRPS; passive modalities, rest and immobilization are add-ons at best and harmful at worst.

1. Chronic low back pain: exercise first. The ACP recommends initial nonpharmacologic treatment, with exercise, multidisciplinary rehabilitation, acupuncture and mindfulness-based stress reduction supported by moderate-quality evidence, and motor control exercise, tai chi, yoga and others by low-quality evidence ¹.
2. Acute low back pain: stay active, add heat. Superficial heat has moderate-quality evidence for acute low back pain ¹. Advice to stay active gives small gains in pain and function over advice to rest in bed ².
3. Osteoarthritis: exercise is strongly recommended. ACR/AF strongly recommends exercise for knee, hip and hand osteoarthritis and weight loss when overweight; tai chi is strongly recommended for knee and hip disease, and aquatic exercise is an option when land-based exercise flares symptoms ³⁴.
4. Tendinopathy: load education plus exercise. In gluteal tendinopathy, education plus exercise produced better global improvement than corticosteroid injection at 52 weeks ⁵.
5. CRPS: functional restoration is the core. CRPS guidelines place graded physical and occupational therapy at the center of care, graded exposure and normalization of movement, with drugs, sympathetic blocks and psychotherapy used mainly when progress stalls or pain prevents engagement ⁶.
6. Myofascial pain: recognize trigger points. Trigger points are hyperirritable spots in taut bands that reproduce local and referred pain, with reproduction of the patient's pain on pressure and sometimes a local twitch response when the band is needled; it is regional, unlike the widespread pain of fibromyalgia ⁷.

Immobilization perpetuates CRPS: casting healthy volunteers for 28 days produced CRPS-like features, so rest and disuse should be reversed, not prescribed ⁶.

• ACP chronic low back pain: exercise and multidisciplinary rehabilitation are moderate-quality first-line options ¹.
• Lumbar traction, TENS and lumbar supports are not among ACP's recommended low back pain treatments ¹.
• ACR/AF strongly recommends against TENS for knee or hip osteoarthritis ³.
• Lateral and medial wedged insoles are conditionally recommended against for knee osteoarthritis ³.
• Aquatic exercise has small, short-term, clinically relevant effects in knee and hip osteoarthritis (moderate quality) ⁴.
• In sciatica, advice to rest in bed or stay active makes little or no difference ².
• LEAP: both active arms beat wait-and-see at 8 weeks; only education plus exercise stayed superior at 1 year ⁵.

• Anchoring a program on passive modalities such as traction or TENS instead of exercise ¹.
• Resting a CRPS limb until pain settles before starting therapy ⁶.
• Assuming a steroid injection outperforms exercise for gluteal tendinopathy over a year ⁵.
• Telling a patient with acute back pain to rest in bed until pain-free ².