Chronic pain is one of the most common reasons for medical consultation and a leading cause of reduced quality of life. Unlike acute pain, which acts as a warning signal in response to tissue injury; chronic pain persists over time, often beyond tissue healing, and becomes a complex experience that cannot be explained solely by physical damage.

Understanding this complexity is essential in order to address chronic pain effectively and sustainably. In this context, modern physiotherapy, and particularly therapeutic exercise, has become a cornerstone in the treatment of chronic pain.

Pain: much more than a tissue injury

For many years, pain was understood as a direct consequence of tissue damage. Today we know that this view is incomplete. Pain results from the interaction of biological, psychological, and social factors, a framework known as the biopsychosocial model of pain.

From a biological perspective, an injury can trigger the release of pro-inflammatory cytokines, prostaglandins, and other chemical mediators that sensitize nerve endings and facilitate pain transmission. In acute phases, this mechanism is adaptive. Problems arise when these processes persist over time or when the nervous system becomes excessively reactive.

In chronic pain, the central nervous system may enter a state of sensitization, in which non-painful stimuli are perceived as painful or pain is amplified without a proportional tissue injury. Contextual factors such as stress, anxiety, mood, beliefs about pain, social environment, and previous experiences further modulate how pain is perceived and experienced.

Therefore, treating only the “injury” without considering the broader context and nervous system function often leads to limited and unsatisfactory outcomes.

The role of the physiotherapist in chronic pain management

Physiotherapists are healthcare professionals specialized in the assessment and treatment of the musculoskeletal system and human movement. Their training allows them to identify not only structural alterations, but also movement dysfunctions, overload patterns, and factors that perpetuate pain.

Physiotherapy includes a range of therapeutic tools that may be useful in chronic pain management. Manual therapy, joint mobilizations, soft tissue techniques, or invasive procedures such as dry needling can help modulate pain, improve mobility, and reduce local hypersensitivity in selected patients.

These interventions may relieve symptoms and facilitate movement, particularly in early stages. However, current scientific evidence is clear on one key point: no passive technique alone provides a durable solution for chronic pain.

This is where therapeutic exercise becomes essential.

Therapeutic exercise: the most effective tool against chronic pain

Therapeutic exercise is not simply “doing sport” or recommending general physical activity. It involves an individualized, progressive, and supervised exercise program, tailored to each person’s clinical, functional, and emotional situation.

Scientific evidence consistently shows that both aerobic exercise and strength training are first-line interventions in the treatment of chronic pain, regardless of pain location (low back pain, neck pain, joint pain, fibromyalgia, or persistent pain after injury).

Physical effects of therapeutic exercise

At the peripheral level, regular exercise helps to:

• Reduce systemic inflammation through modulation of pro-inflammatory mediators.
• Improve muscle and connective tissue quality, increasing load tolerance and reducing relapse risk.
• Optimize joint function and neuromuscular coordination.
• Break the cycle of inactivity, weakness, and pain that perpetuates many chronic conditions.

Contrary to widespread beliefs, properly dosed movement does not “wear out” or “damage” tissues; it makes them more resilient and functional.

Effects of exercise on the nervous system and pain perception

One of the most relevant aspects of therapeutic exercise is its impact on the central nervous system. Exercise directly influences the mechanisms that regulate pain perception in the brain and spinal cord.

Exercise has been shown to promote:

• Release of endorphins, endogenous opioids with strong analgesic effects.
• Increased activity of inhibitory neurotransmitters such as GABA, reducing neuronal excitability.
• Modulation of other neurotransmitter systems (serotonin, noradrenaline, dopamine) involved in pain control, mood, and motivation.
• Improved ability of the brain to modulate and filter pain signals, reducing the hypersensitivity characteristic of chronic pain.

In other words, exercise not only acts on the body, it re-educates the nervous system to respond more adaptively to stimuli.

Movement, confidence and autonomy

Beyond biological mechanisms, therapeutic exercise has a profound effect on patients’ beliefs and behaviors. Regaining movement and experiencing that the body can tolerate load, adapt, and improve reduces fear of pain and movement avoidance—two key factors in pain chronification.

This process restores a sense of control, confidence, and autonomy, which are essential for meaningful and sustained recovery.

An integrated and personalized approach

Chronic pain management requires time, individualization, and a broad perspective. Modern physiotherapy is not based on universal recipes or quick fixes, but on actively accompanying patients through a recovery process.

At Clínica SAMON, we advocate for an integrated approach in which rigorous assessment, patient education, and therapeutic exercise play a central role. Because chronic pain is not overcome through passivity, but through knowledge, movement, and strategies grounded in the best available scientific evidence.