Elephant in the room: how much pain is ok? If physiotherapy exercise RCTs do not report it, we will never answer the question

> Different therapists have said different things [contradictory advice on pain with exercise]…and it makes you wonder which therapist to believe. Exercise is a proven treatment for managing at least some persistent pain, including musculoskeletal-related pain.1 2 But an area often overlooked is what type of pain and what intensity of pain should be associated with exercise. What would achieve the best results? No pain? A little pain? A moderate amount of pain? How does the patient judge what is ‘a little’ or ‘moderate’? How much pain is too much? Is there ‘good pain’ as patients often tell us when stretching or massaging a muscle, as well as ‘bad pain’ (presumably thought to be harmful)? Qualitative research tells us that many individuals with persistent pain are uncertain when it comes to pain and exercise.3 4 This is closely linked to pain-related fear and questions as to whether exercise is helpful or harmful. As one patient framed it, ‘Are you making it worse? And that’s the crux of it really…if this is hurting should I really be doing this?’.3 There are few …