Exercise for chronic musculoskeletal pain: time to prescribe with precision

Introduction

Approximately 1.7 billion people worldwide live with musculoskeletal (MSK) pain,¹ contributing to a high socioeconomic burden exceeding €250 billion in Europe² and US$180 billion in the USA.³ Beyond financial costs, individuals experience lost productivity, early retirement and reduced social well-being due to limitations in mobility and participation in society.⁴ Current clinical practice guidelines emphasise non-pharmacological and non-surgical treatments for managing chronic MSK conditions like back pain, neck pain and osteoarthritis.⁵ Among these, exercise-based treatment options are inexpensive, easily accessible and induce small-to-moderate yet clinically relevant improvements in chronic MSK pain disorders.⁶ Improvements observed with exercise training can be comparable to, or even exceed, those achieved with other conservative interventions such as manual therapy, education, electrophysical and psychological therapies.^{6 7} Despite the recognised benefits of exercise training, the translation of research into clinical practice is impaired by ongoing deficiencies in study reporting, as evidenced in our recent umbrella review.⁸

What are the issues?

While exercise training recommendations (eg, frequency per week, duration, intensity and volume) for healthy populations are well established,⁹ optimal exercise parameters for the various chronic MSK pain conditions remain poorly defined.⁸ Our recent umbrella review⁸ pooled evidence from 274 systematic reviews and meta-analyses on exercise training in MSK pain. Most (94.2%) of the included systematic reviews had a ‘low or critically low’ methodological quality. The poor methodological quality could be attributed to the absence of key information on critical aspects of the AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews 2) tool.¹⁰ Moreover, adverse events were rarely evaluated in systematic reviews (6.9%, n=12), limiting interpretation of the potential risks associated with exercise interventions. Davidson et al¹¹ showed that only one-third of trials adequately reported interventions according to the Consensus on Exercise Reporting Template (CERT) in their recent systematic review, indicating a lack of reporting on the dose used in trials. Likewise, Innocenti et al highlighted that a high risk of bias in outcome assessment, particularly when outcome assessors are non-blinded, can lead to overestimated effect sizes.¹² The evidence base in systematic reviews is further distorted by the under-reporting of studies with non-significant results (file drawer effect or publication bias).¹³ Combined, this lack of reporting in primary studies and poor methodological quality of systematic reviews creates a double barrier. First, inadequately reported primary studies limit their utility in both real-world settings and evidence synthesis, as clinicians cannot determine the precise exercise parameters to prescribe. Second, low-quality systematic reviews limit the confidence in the evidence base, even when well-conducted primary studies exist. The result is an evidence base that struggles to produce clear, actionable recommendations for individualised care across MSK disorders, ultimately widening the gap between research evidence and clinical decision-making.

What needs to be done next?

The reporting quality of primary studies and the methodological quality of systematic reviews need to improve simultaneously for advancing the evidence base for exercise in chronic MSK pain (figure 1).

Figure 1. A bidirectional framework for strengthening exercise evidence in musculoskeletal pain. CERT, Consensus on Exercise Reporting Template; TIDieR, Template for Intervention Description and Replication.

Mandate intervention reporting

At the primary study level, pre-established reporting frameworks (table 1), including the CERT¹⁴ and the Template for Intervention Description and Replication (TIDieR)¹⁵ should be used at both the protocol and publication stages. Trial protocols should be prospectively registered in recognised trial registries such as ClinicalTrials.gov (US National Library of Medicine), International Standard Randomized Controlled Trial Number Registry or the WHO International Clinical Trials Registry Platform. Detailed reporting of exercise dose prescription variables (frequency, intensity, duration, progression), mode of delivery, supervision, adherence strategies and contextual factors is essential. Moreover, comparators should be described in sufficient detail to provide readers with a clear understanding of the reference group when interpreting the observed efficacy. Generic terms such as ‘standard care’ or ‘usual care’ should be avoided or clearly defined, as their meanings can vary across geographical locations, clinical conditions and temporal changes in healthcare practice.

Table 1. Recommendations for improving reporting, transparency and reproducibility in exercise dose research.

Level	Focus	Established frameworks
Primary study level	Intervention reporting and transparency	CERT TIDieR ClinicalTrials.gov ISRCTN WHO ICTRP
Systematic review level	Methodological rigour and reporting quality	AMSTAR-2 PROSPERO OSF
Journals and peer reviewers	Ensuring compliance and standardisation	CERT TIDieR AMSTAR-2 checklists Journal editorial systems
Funding agencies	Incentivising transparent and high-quality research	CERT TIDieR

AMSTAR-2, A MeasurementTool to Assess Systematic Reviews, version 2; CERT, Consensus on Exercise Reporting Template; ISRCTN, International Standard Randomized Controlled Trial Number Registry; OSF, Open Science Framework; PROSPERO, International Prospective Register of Systematic Reviews; TIDieR, Template for Intervention Description and Replication; WHO ICTRP, WHO International Clinical Trials Registry Platform.

Despite the availability of reporting frameworks, adherence remains inconsistent. Barriers include a lack of awareness, limited journal mandates and the additional time required for comprehensive reporting. Journals and funding agencies could mandate structured reporting checklists for submission or funding approval. Likewise, digital repositories could host intervention manuals, fidelity data and session logs for transparent sharing to facilitate replication and data extraction for evidence synthesis. Collectively, these strategies offer sustainable innovations to improve reproducibility and accelerate evidence synthesis.

Systematic reviews

At the systematic review level, various steps are needed to improve the methodological quality and transparency. The AMSTAR-2 checklist should be integrated as a planning tool rather than applied solely post hoc as a quality appraisal instrument. Systematic review protocols should be prospectively registered on publicly accessible platforms such as PROSPERO (International Prospective Register of Systematic Reviews) or the Open Science Framework. Trials lacking sufficient intervention detail should be flagged to maintain the validity of evidence synthesis and to highlight the need for improved reporting in primary studies. Implementation of these practices requires more than guidance—it requires system-level change. Journals and funding bodies could mandate AMSTAR-2 compliance and prospective registration as prerequisites for submission or funding approval. Training initiatives and capacity-building workshops may improve awareness and competence among early-career researchers. The use of open-source software and standardised data-extraction templates can support transparent, reproducible synthesis. Moreover, establishing multidisciplinary review consortia that include clinicians and exercise scientists will ensure accurate interpretation of exercise parameters and facilitate peer accountability.

As journals and funders

At the journal and peer-reviewer levels, authors should be asked to submit completed intervention-reporting and quality-assessment checklists (eg, CERT, TIDieR, AMSTAR-2) alongside their manuscripts. These checklists would serve both as a submission requirement and as a tool for reviewers, ensuring that essential dose variables, supervision details and adherence strategies are reported in a standardised way. Structured abstract templates could also be adapted to include explicit fields for exercise dose variables, which would immediately enhance accessibility and comparability for readers. In addition, automated reporting tools integrated into manuscript systems may guide authors in real time to meet reporting standards.

At the funding body level, compliance with reporting frameworks could be made a prerequisite for grant approval, with monitoring built into project milestones. Currently, many primary exercise studies are poorly reported, particularly regarding dose prescription variables such as frequency, intensity, duration and progression. This limits the ability to conduct sophisticated dose–response analyses, as the necessary data are incomplete or inconsistent. Funding bodies could incentivise replication studies or secondary analyses that adhere to high-quality reporting standards, ensuring that complete and accurate intervention data are available. Such well-documented studies would provide a robust foundation for investigating dose–response relationships and optimising exercise prescription.

Conclusions

We propose a three-step approach to improve both reporting and methodological standards, ensuring the future of exercise prescription for MSK pain is both evidence-driven and patient-specific: (a) integrate reporting frameworks like CERT and TIDieR in trial design and publication; (b) strengthen review methodology through prospective registration, rigorous synthesis plans and multidisciplinary teams and (c) enforce reporting compliance via journals, peer reviewers and funders. Improving these domains will unlock high-quality, detailed data suitable for advanced analyses such as dose–response model-based network meta-analysis.

Improving exercise reporting in primary studies will provide a stronger evidence base for systematic reviews. Likewise, high-quality reviews will lead to improvements in trial design and reporting by identifying common missing themes and disseminating best-practice examples. This bidirectional improvement in reporting and methodological quality is essential to building a trustworthy and clinically applicable body of evidence. Once both domains are strengthened, we will have the robust, detailed primary data to determine the optimal exercise prescription for different chronic MSK pain presentations. This will give us more specific exercise tailoring than the current, simplified notion from the WHO that ‘some exercise is better than none’.¹⁶ Ultimately, the suggested approach will advance the MSK field towards precision exercise prescriptions that are tailored, evidence-driven, safe and clinically meaningful.