Research Review By Dr. Ceara Higgins©


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Date Posted:

May 2023

Study Title:

The Relationship Between Physical Activity and Pain in U.S. Adults


Ray BM, Kelleran KJ, Eubanks JE, et al.

Author's Affiliations:

Department of Health and Human Sciences, Bridgewater College, Bridgewater, VA; Department of Emergency Medicine, University at Buffalo, Buffalo, NY; Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA; Private practice, Cincinnati, OH, USA

Publication Information:

Medicine & Science in Sports & Exercise 2023; 55(3): 497-506.

Background Information:

The International Association for the Study of Pain (IASP) defines pain as “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (1). We generally divide pain into acute or chronic based on duration/time (2), and generally assume acute pain to be related to noxious stimuli causing nociceptive activation which can give rise to pain experiences to protect the organism (3). Chronic pain (CP) is generally considered to be persistent or recurring pain lasting longer than 3-6 months, and often lacking any identifiable pathophysiological or pathoanatomical cause (2). CP is experienced by approximately 1.5 billion people worldwide (4), with about 20.5% of US adults experiencing CP daily or on most days (5).

Physical activity (PA) is often recommended for those with CP, however, most individuals, with or without CP, do not meet the PA guidelines, currently defined as follows (6):
  1. 150-300 minutes of moderate-intensity cardiorespiratory activity/week or;
  2. 75-150 minutes of vigorous cardiorespiratory activity/week or:
  3. An equivalent combination of 1 and 2, and;
  4. 2 days per week of resistance training for all major muscle groups.
The Centers for Disease Control (CDC) states that only 23.2% of US adults over 18 years of age meet these guidelines (7). Data from other countries have found that individuals with CP also fail to meet the minimal recommendations for PA (8). Prior data also shows that PA can help to modulate individuals’ pain experience and mitigate the risk of the development of CP (9). Finally, meeting PA guidelines and minimizing sedentary behavior is an important variable in the overall holistic health and well-being of individuals with pain to minimize their long-term risk for chronic disease and maintain functional ability throughout life (10).

This study aimed to assess the relationship between PA levels and pain. In addition, the authors aimed to assess the prevalence of pain based on frequency and intensity, PA levels, healthcare-seeking behaviors, and pain impact on daily living and working activities. Finally, they aimed to explore how descriptive characteristics can moderate PA engagement and pain reporting. The authors hypothesized that individuals living with pain were less likely to meet PA guidelines compared to those without pain.

Pertinent Results:


62.88% of those surveyed reported pain over the past 3 months. This included 39.37% reporting pain on some days, 8.75% on most days, and 14.76% every day. Pain intensity was reported as a little by 27.08%, a lot by 10.78%, and somewhere in between by 24.94%. 17.60% reported that pain limited their life or work activities on some days over the past 3 months, 3.64% reported most days, and 4.14% reported every day.

Pain Management Strategies:

Of those with pain, 48.35% reported managing their pain using over-the-counter pain medication, 12.16% had taken prescription opioids in the past 12 months, and 6.9% in the past 3 months. 9.70% had received physical therapy, rehabilitative therapy, or occupational therapy, and 6.24% had received chiropractic care. 1.24% reported seeking help through talk therapies. 6.24% participated in Yoga, Tai Chi, or Qi Gong to manage pain, and 9.27% used relaxation techniques such as meditation.

Unadjusted Model Results:

Unadjusted model 1 showed a stepwise decrease in the odds of engaging in PA with a higher frequency of pain reporting. Unadjusted model 2 found that participants who were meeting PA criteria had higher odds of reporting less frequent pain, with the odds of less frequent pain at 1.38 for those meeting only the strength criteria, 1.63 for those only meeting the aerobic criteria, and 2.27 for those meeting both (i.e. more exercise = less pain).

Model 1 – Outcome of meeting PA guidelines with predictors of pain, sex, age, race, and BMI:

The available sample for the analysis was 28,293, with 1045 participants excluded because of incomplete data. Only 24.1% met both criteria, 24.11% met only the aerobic guidelines, and 6.82% met only the resistance training guidelines.

With other predictors constant, those reporting pain over the prior 3 months had lower odds of being more physically active compared to individuals reporting no pain, with odds of PA decreasing as the frequency of pain reported increased. As well, the intensity of pain had a negative impact on the odds of engaging in PA.

Differences in PA participation were also seen with respect to gender, race, BMI, and age. Females were 31% less likely to be physically active than males. One major contributor to this discrepancy is sociocultural expectations. As early as childhood, females have reported less enjoyment from PA, which is related to socially imposed gender roles and norms which affect the willingness and time available to participate in PA. In addition, women’s sports often receive less funding, and attention, and are harder to access. These factors can influence PA behaviors into adulthood, where many of these sociocultural norms and expectations are maintained (12).

African Americans, Asians, and American Indian Alaskan Native (AIAN) individuals had a 17-26% lower chance of being more physically active than Caucasians. These odds lower even further for females (by 25%, 38% and 37% for African American, Asian, and other single or multiple race categories, respectively).

When considering BMI, individuals who were underweight, overweight, or obese were less likely to be more physically active than healthy weight comparators, with the largest reduction in the obesity category at 56%. Those who were female and overweight, obese, or healthy weights had lower odds of being more physically active by 43%, 46%, and 25% respectively when compared to their male counterparts. However, underweight females were 99.8% more likely to be physically active compared to underweight males.

The current study did not consider socioeconomic status (SES), however, the roles of gender, race, and SES are interrelated. The combination of female, non-white, and low SES is much less likely to meet the PA guidelines, only meeting them 9.8% of the time (13). In contrast, Caucasian males, in the highest income quartile met PA guidelines 48% of the time (13).

Model 1a – Odds of meeting PA guidelines based on predictor interactions comparing females to males:

Females who reported pain on most days and who were African American, Asian, or Other single and multiple-race categories had lower odds of being more physically active than males. When considering BMI, females who were underweight were 2 times more likely to engage in PA than males, but those classified as healthy weight, overweight, or obese had lower odds of engaging in PA than males. Sex and age interaction had no significant effect on PA.

Model 2 – Outcome of prevalence of chronic pain with predictors of meeting PA guidelines, sex, age, race, and BMI:

PA was found to be an important correlate affecting pain reporting. Subjects who engaged in PA had increased odds of less frequent pain reporting with those meeting both strength and aerobic criteria showing 2 times higher odds of reporting less frequent pain than those not meeting either criterion. Those meeting only the aerobic criteria were 52% less likely to report frequent pain, and those meeting the strength only criteria were 31% less likely to report frequent pain.

Females were 23% more likely to report frequent pain than males. African Americans, Asians, and other single and multiple races were less likely to report frequent pain than Caucasians, but American Indian Alaskan Native (AIAN) and any other group were more likely to report more frequent pain when compared to Caucasians. However, African Americans, Asians, and Other single and multiple races were less likely to report frequent pain compared to Caucasians. Overweight and obese individuals were likely to report more frequent pain than healthy-weight individuals. Finally, those over 85 were less likely to report less frequent pain compared to other age groups.

Model 2a – Odds of pain based on predictor interactions comparing females to males:

This model explored if pain reporting was affected by the interaction between sex and each predictor (age, PA, race, and BMI). Female participants who did not meet either PA criteria were more likely to report more frequent pain compared to males in the same categories. As well, Asian-only, White-only, and obese females were more likely to report more frequent pain than their male counterparts by 27%, 18%, and 25% respectively.

When looking at pain management strategies in the data, there was a preference for medication with approximately 71% of individuals using some form of medication in the prior 12 months. This included over-the-counter medication (48.35%), opioids (12.16%), and prescription pain medications (12.06%). Only 7.27% sought physical therapy, rehabilitative therapy, and occupational therapy, while 6.24% received chiropractic care. As well, PA is under-utilized in those experiencing pain with only 6.24% engaging in Yoga, Tai Chi, or Qi Gong, and 36.12% engaging in other forms of exercise.

Clinical Application & Conclusions:

The 2020 NHIS survey was unique, as questions on pain and physical activity were both addressed in one survey. This survey showed a high prevalence of pain over the prior 3 months with 23.51% reporting chronic pain (pain on most or every day). 25.38% of participants reported being limited by their pain during their daily life or work activities, which is a significant increase from the 8% reporting these limitations in the 2016 data (11).

Much of the population is not meeting PA guidelines of any type. Only 24.1% of subjects met both aerobic and resistance training guidelines, 24.11% met aerobic criteria only, and 6.82% met resistance training criteria only.

This study identified a correlation between pain reporting and PA outcomes. Specifically, the odds of an individual participating in PA decreased stepwise with increased pain frequency reporting. Those who reported pain daily had 50% lower odds of being more physically active than those reporting no pain. Pain intensity also showed the same pattern with those reporting a lot of pain having 33% lower odds of being more physically active than those reporting little pain. While almost half of those reporting pain used over-the-counter or prescription medications for pain control, less than 10% sought conservative care.

Although causation cannot be established between CP and not meeting PA guidelines, there is enough evidence to make the broad recommendation that individuals should engage in regular PA to help mitigate and treat CP. Prior data has shown that PA can modulate the pain experience and help mitigate the risk of developing CP (4). As well, meeting PA guidelines over time and minimizing sedentary behavior is important for the overall health and well-being of individuals with pain to minimize their long-term risk for chronic disease states and maintain functional ability throughout their lives (10). Even small increases in PA can have an important effect on increasing the health of the population and decreasing mortality (14).

Healthcare professionals (including chiropractors!) should be assessing and advocating for PA. Although we do not yet have enough data to state a specific type or dosage of PA for aiding or mitigating the development of chronic pain (4), even small increases above baseline have shown health benefits (15). Data suggests that interventions by primary healthcare providers can increase the odds of PA participation by as much as 33%, with an average increase in an individual’s activity of 14 minutes per week (16).
Visual Abstract:
Physical Activity and Pain Graphical Abstract

Study Methods:

The authors conducted an epidemiological assessment of the National Health Interview Survey (NHIS) 2020 cross-section data. This annual household interview survey was conducted in person, targeting non-institutionalized individuals from the 50 United States and the District of Columbia. The 2020 NHIS survey sample was 31,568, of which 46% were male and 53.99% were female. The average age was 52.27. The largest age groups represented were 30-39 (15.47%), 50-59 (16.6%), and 60-69 (19.37%).

Excluded individuals were those lacking a household address, active-duty military personnel and civilians residing on military bases, residents of long-term care facilities, and US nationals living outside of the US.

In 2019, the NHIS performed a questionnaire redesign, adding a pain section to the survey. Different sections of the survey are included on a rotating basis. The 2020 survey included sections on both PA and pain. Based on the current rotation schedule, this will not occur again. The authors primarily examined data on self-reported adherence to the current PA guidelines, the prevalence of pain, and the relationship between the two. Pain prevalence and frequency were assessed by asking, “In the past 3 months, how often did you have pain? Never, some days, most days, or every day?” Pain intensity was assessed with a verbal pain rating scale of a little, a lot, or somewhere in between.

The relationship between PA levels and pain was assessed using two models. Participants with incomplete data were excluded. The first model looked at predictors of pain, their impact on meeting PA guidelines, and the impact of sex, age, race, and body mass index (BMI). The second model looked at the frequency of pain, its impact on meeting PA guidelines, and the impact of sex, age, race, and BMI. Finally, 2 additional models were created to look at the interactions between the predictors and effects on PA and pain reporting.

Study Strengths / Weaknesses:

  • This study utilized a large sample size from a well-established data set.
  • The NHIS survey did not capture data from several marginalized groups, including imprisoned individuals, active-duty military personnel on base, and those with no fixed address. This would naturally lead to the under-representation of these groups in the data.
  • Due to the retrospective nature of the data collection and the inability to determine causation, it is impossible to determine if the relationship between pain and PA is unidirectional or bidirectional.

Additional References:

  1. Raja SN, Carr DB, Cohen M, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain 2020; 161(9): 1976-1982.
  2. Conix S, Stilwell P. Pain and the field of affordances: and inactive approach to acute and chronic pain. Synthese 2021; 199; 7835-7863.
  3. Wall PD. On the relation of injury to pain. The John J. Bonica lecture. Pain 1979; 6(3); 253-264.
  4. Polaski AM, Phelps AL, Kostek MC, et al. Exercise-induced hypoalgesia: A meta-analysis of exercise dosing for the treatment of chronic pain. PLoS One 2019; 14(1); e0210418.
  5. Yong RJ, Mullins PM, Bhattacharyya N. Prevalence of chronic pain among adults in the United States. Pain 2022; 163(2); e328-e332.
  6. Bull FC, Al-Ansari SS, Biddle S, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med 2020; 54; 1451-1462.
  7. Centers for Disease control and Prevention. 2022. FastStats. [online] Available at: <>
  8. Damato TM, Oliveria CB, Franco MR, et al. Characteristics Associated with People with Chronic Low Back Pain Meeting Physical Activity Guidelines and Recommendations for Sedentary Behaviour: A Cross-Sectional Study. J Manipulative Physio There 2021; S0161-4754(21)00039-7.
  9. Landmark T, Romundstad P, Borchgrevink PC, et al. Associations between recreational exercise and chronic pain in the general population: evidence from the HUNT study. Pain 2011; 152(10); 2241-2247.
  10. Nyberg ST, Singh-Manoux A, Pentti J, et al. Association of Healthy Lifestyle with Years Lived Without Major Chronic Diseases. JAMA Intern Med 2020; 180(5); 760-768.
  11. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults - United States 2016. MMWR More Mortal Wkly Rep 2018; 67; 1101-1106.
  12. The Lancet Public Health. Time to tackle the physical activity gender gap. Lancet Public Health 2019; 4(8); e360.
  13. Mielke GI, Malta DC, Nunes BP, et al. All are equal, but some are more equal than others: social determinants of leisure time physical activity through the lens of intersectionality. BMC Public Health 2022; 22(1); 36.
  14. Hupin D, Roche F, Gremeaux V, et al. Even a low-dose of moderate-to-vigorous physical activity reduces mortality by 22% in adults aged >60 years: a systematic review and meta-analysis. Br J Sports Med 2015; 49(19); 1262-1267.
  15. Arem H, Moore S, Patel A, et al. Leisure time physical activity and mortality a detailed pooled-analysis of the dose-response relationship. JAMA Int Med 2015; 175(6); 959-967.
  16. Kettle VE, Madigan CD, Coombe A, et al. Effectiveness of physical activity interventions delivered or prompted by health professionals in primary care settings: systematic review and meta-analysis of randomized controlled trials. BMJ 2022; 376; e068465.

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