31/12/2025
Just published in BJSM 🔥
𝗜𝘁 𝗶𝘀 𝗻𝗼𝘁 𝗮𝗹𝗹 𝗮𝗯𝗼𝘂𝘁 𝘀𝘁𝗿𝗲𝗻𝗴𝘁𝗵: 𝗿𝗲𝘁𝗵𝗶𝗻𝗸𝗶𝗻𝗴 𝗺𝗲𝗰𝗵𝗮𝗻𝗶𝘀𝘁𝗶𝗰 𝗮𝘀𝘀𝘂𝗺𝗽𝘁𝗶𝗼𝗻𝘀 𝗶𝗻 𝗲𝘅𝗲𝗿𝗰𝗶𝘀𝗲-𝗯𝗮𝘀𝗲𝗱 𝗿𝗲𝗵𝗮𝗯𝗶𝗹𝗶𝘁𝗮𝘁𝗶𝗼𝗻 𝗳𝗼𝗿 𝗺𝘂𝘀𝗰𝘂𝗹𝗼𝘀𝗸𝗲𝗹𝗲𝘁𝗮𝗹 𝗽𝗮𝗶𝗻 𝗿𝗲𝗹𝗶𝗲𝗳
📘 This brand-new editorial by Powell and colleagues argues that although exercise therapy is consistently effective for reducing musculoskeletal pain, improvements in muscle strength are rarely the primary mechanism responsible for pain relief. (https://bjsm.bmj.com/content/early/2025/12/30/bjsports-2025-110372)
✅ Drawing on evidence from systematic reviews and mediation analyses across conditions such as tendinopathy (https://pubmed.ncbi.nlm.nih.gov/36990866/, https://pubmed.ncbi.nlm.nih.gov/39718487/), rotator cuff–related shoulder pain (https://pubmed.ncbi.nlm.nih.gov/33789431/), patellofemoral pain (https://pubmed.ncbi.nlm.nih.gov/34847699/), osteoarthritis (https://pubmed.ncbi.nlm.nih.gov/33789431/), the authors demonstrate that changes in strength explain little to none of the observed clinical benefit.
💪 The persistence of strength-based explanations is attributed to intuitive but outdated biomechanical assumptions rather than robust causal evidence.
The authors emphasize that understanding mechanisms of action is essential for scientific validity, ethical clinical communication, and responsible research design.
▶️ Overemphasizing strength as the causal pathway risks misleading patients, reinforcing unhelpful beliefs about fragility or weakness, and limiting clinicians’ flexibility in tailoring exercise interventions.
▶️ Emerging evidence instead supports a biopsychosocial framework in which exercise-induced pain relief is mediated by factors such as improved pain self-efficacy, reduced catastrophizing and kinesiophobia, changes in inflammatory biomarkers, enhanced motivation, and the quality of the therapeutic relationship (s. figure below).
💡 The editorial concludes that while strength gains remain important for general health, function, and long-term outcomes, they should not be presented as a prerequisite for pain relief in most musculoskeletal conditions. The authors call for a shift in both clinical messaging and research priorities toward testing and targeting multidimensional mechanisms, using prospectively designed mediation analyses, and adopting more nuanced explanations of how exercise supports recovery from musculoskeletal pain.
