How Should You Exercise With Pain?

Specific, practical, and doable approaches from a physical therapist

If you’ve ever grappled with chronic pain, the idea of exercising might seem daunting. How can you exercise if it hurts simply bending over, getting out of a chair, or carrying groceries in from the car?

It’s a fair question and one I have been asked by many of my physical therapy patients. Fortunately, exercise can help reduce pain. In a 2024 narrative review published in the journal Healthcare, the research team sheds light on a crucial link between specific exercise strategies and reducing pain intensity over time.

Exercise can provide immediate pain relief by influencing hormones and the nervous system. Exercise can cause an immediate reduction in pain sensitivity and severity, as outlined in a 2019 review paper in The Journal of Pain. That’s great, but what if you can’t exercise because of the pain? Furthermore, exercise can worsen pain. This is all true, so let me help you navigate that challenge.

Finding the right type of exercise

The phrase “no pain, no gain” is nonsense and does not apply to actual musculoskeletal pain. It’s fine for muscle burn discomfort during the final reps of a lifting set or the end of an exhausting run, but the phrase does not apply to traditional pain. If you have pain from an injury, that pain is akin to a warning bell notifying you that the stress is too high and may cause further harm.

With chronic pain, the pain is driven by a myriad of causes, including anxiety and fear. Pushing through often worsens the pain severity and sensitivity. Instead, find an exercise variation that doesn’t cause pain, such as reducing the range of motion, or reducing the intensity.

The safest bets are isometrics and moderate-intensity cardiovascular exercise, as studies in Medicine & Science in Sports & Exercise show that both can reduce pain severity and sensitivity. An isometric example is a wall sit. You are straining the muscle against resistance but your body is not moving. You can replicate this with any resistance exercise. Start an exercise, such as a seated row or leg extension, and stop halfway.

For cardiovascular exercise, find the type that doesn’t cause pain but still elevates your heart rate. This can be swimming, brisk walking, hiking, cycling, stairs, running, or rowing. Traditional resistance exercise that elevates the heart rate can as well, you just need to find the exercise type that doesn’t cause pain in the moment.

Reducing the range of motion is my primary focus with patients. Perform a half or box squat instead of a full squat. Use bands for chest press since the resistance is light at the beginning of the motion. Do step-ups on stairs instead of lunges. Over time, you will be able to push the range of motion.

A sample program validated by research

A 2024 study published in BMJ Open Sport & Exercise Medicine had adults with chronic LBP (that’s long-lasting back pain) participate in a general strength and conditioning program. The researchers closely examined various exercise training factors like time under tension (how long each rep lasted), perceived exertion, session duration, and frequency to see how they influenced pain intensity over six months.

This targeted training program focuses on individuals with chronic low back pain and involves a strategic combination of supervised gym sessions and recommended home-based exercises. The aim is to enhance overall strength, conditioning, and proprioception (your sense of body position, closely tied to balance) to alleviate pain over 6 months.

The program breaks down to 2 sessions per week for the first 13 weeks followed by 1–2 sessions per week for the second 13 weeks. This volume fits well with the WHO physical activity guidelines of two strength training sessions per week.

If you want to build muscle and compete in athletic competitions, your volume must increase. But for general wellness and tackling chronic pain, two times a week is an ideal frequency.

These exercise sessions include a mix of aerobic conditioning, progressive resistance training, and proprioceptive exercises. Here is the breakdown of each session:

Aerobic conditioning (20 Minutes at the start of each session)

• 5-minute warm-up with increasing intensity.
• 15 minutes of sustained effort, starting at 65%-70% maximal heart rate (weeks 1–2) and progressing to 65%-85% from week three onwards. A rough estimate of your max heart rate (HR)is 220 — your age. For example, a 35-year-old would have a max HR of 185 beats per minute (bpm), meaning the target intensity is 120–158 bpm.

Proprioceptive training

• General balance exercises, such as tandem stance(one foot in front of the other) with eyes closed.
• Weight transfer exercises, such as transferring a dumbbell from one hand to the other while standing on one leg.
• External perturbation exercises, such as bouncing a large ball off of a wall and catching it.

Resistance training (five exercises per session):

Exercises are grouped by action. Here are the groups with some examples (there are more that are not listed)

• Push: Chest press, overhead press, push-up
• Pull: Pull-up, lat pulldown, seated row
• Lift: Squats and their variations
• Trunk Extension: Deadlifts and their variations
• Trunk Flexion: Sit-ups

Each set was completed to two repetitions below volitional fatigue of the target rep range. As I previously covered, this is an ideal reps in reserve value for building muscle and strength.

The program was broken into six mesocycles (4–6 weeks training blocks) with varying loads, reps, sets, and time under tension. You can find progression details here. Keep in mind, that you don’t need to break your programming into mesocycles. Research shows it doesn’t matter which periodization strategy you use. The key is consistency and gradual progression.

Progression

This is a very important aspect of the program. It is time-contingent, not pain-contingent. This means the progression of intensity was based on the amount of time that passed, not how much better or worse the participant was feeling.

In physical therapy, this is a graded activity approach. When working with patients in pain, I gauge how much fear and anxiety play into their pain experience. If psychological and social factors are the primary contributors, or if there is actual tissue damage (the first couple of weeks after a muscle tear or surgery), then I use pain as a guide for intensity.

If fear and anxiety are not an issue, and if the pain is chronic, meaning the tissue damage is not present, then some pain is ok. Our nervous system learns to expect pain when it feels it for a long time. One of the best ways to reduce the pain response is to perform exercise and remain active, despite some pain.

Home-based exercise

The gym sessions are not the maximal allowed exercise. You should incorporate regular aerobic exercise as well. In the program, participants were encouraged to complete 20–40 minutes of cardiovascular exercise at a moderate intensity three times a week. You can include stretching as well. Stretching is not needed to improve mobility and flexibility does not contribute to injury prevention or recovery. It feels good, though, and can be incorporated into a program, if time permits.

How well does it work?

The good news is that, on average, the participants experienced a significant decrease in pain intensity by 10.7 points from the start to the end of the 6-month program. Now, here’s the interesting part: those who reported higher perceived exertion during their exercises, spent more time under tension and had shorter workout sessions tended to have lower pain intensity.

This suggests that, despite having chronic back pain, exercising smartly can help alleviate your discomfort. Instead of pushing yourself too hard, focus on shorter, more intense sessions and pay attention to how you feel during and after each workout.

Personalize the program

This study provides a valuable roadmap for individuals dealing with chronic low back pain, showing that exercise can be a powerful tool when done thoughtfully. As with all research, it needs to be translated into the real world.

A 10.7-point decrease is nice, but most of the participants still had pain at the end of the six months. Two key points here. First, you aren’t limited to six months either. It may take longer, especially if you have experienced pain for years.

It can take a long time to address the underlying causes of chronic pain, which include biological, social, and psychological components. The nervous system becomes hypersensitive when pain persists beyond normal healing times, making pain chronic pain difficult to treat. I’ve worked with some patients for over a year to help them tackle their chronic pain.

The second key point is to personalize your program. Research needs to have strict protocols to reduce the number of variables that may influence the outcomes. That research then needs to be molded and applied to your unique circumstances.

The good news is there are many ways to successfully exercise with pain. As I have written about previously, you can achieve success using light or heavy weights and any type of equipment. If you only have access to bands or prefer using machines, both are great options. Ignore the people who tell you that you have to exercise a specific way.

And make sure you don’t stop when the pain goes away. Regular physical exercise is key to preventing chronic pain, as active individuals show lower levels of pain perception and are better at recovering from injuries. If you stop when the pain is gone and you don’t continue to improve your health, you remain susceptible to a relapse. You don’t want to treat pain with a diet-like strategy.