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How does the perfect rehab look, Pain-Free or painful?
Most of the time, patients visit physiotherapists for pain relief. Also, they come with a lot of expectations to be pain-free and have lots of questions like:
- Am I causing more damage to my body when I do movements with pain?
- Should I continue doing the movement or exercise even if I feel uncomfortable?
- How much pain is safe during exercise?
So, if physiotherapy is expected to reduce pain, does that mean all rehab sessions should be pain-free? The answer is no. Experiencing some level of pain or discomfort within a tolerable range is not harmful and is acceptable. In some cases, pushing through a certain level of pain or discomfort is necessary to achieve better outcomes, such as improved strength, enhanced range of motion, and a better quality of life. But the patient shouldn’t feel 10 out of 10 pain in every session.
What builds a Patient’s Pain Tolerance?
1.Patient’s Belief: Mind Over Matter
A patient’s understanding and perception of pain directly influence their pain tolerance. If a patient holds negative beliefs about their condition, their pain tolerance may be lower. For example, a chronic low back pain patient who experiences pain and has a fear of movement while bending forward may have reduced tolerance for that particular activity compared to other movements.
2.Contextual factors: Life Factors That Impact Pain Tolerance
Contextual factors—such as a patient’s occupation, financial status, social support, and emotional well-being—play a crucial role in determining pain tolerance. These factors shape how individuals perceive, respond to, and cope with pain.
For example, consider a professional cricket bowler at the peak of the season who developed shoulder pain due to overload. However, his competitive environment, high stakes, financial dependence on performance, and positive mindset toward pain may help him tolerate pain during matches.
In contrast, an IT professional working 60 hours a week in a highly stressful job, dealing with financial pressures, and experiencing intermittent neck pain throughout the day may have a lower pain tolerance. The combination of high mental load, job demands, and fear of worsening symptoms might make them more sensitive to pain, leading to a preference for a slow and steady pain-free rehabilitation approach.
3.Therapist Communication: The Power of Education
Pain is multifactorial and is also influenced by a patient’s understanding of tissue damage, lifestyle, health conditions, psychosocial factors, beliefs, and expectations. That is why the therapist’s communication in educating the patient plays a crucial role in shaping these perceptions and helping patients manage their pain more effectively.
A therapist who actively listens to the patient’s concerns and provides clear, evidence-based explanations can significantly impact recovery. Effective education about diagnosis, treatment, prognosis, goals, and expected outcomes empowers patients, reduces fear, and enhances confidence in their ability to function.
Effective rehabilitation integrates patient education, lifestyle advice, movement encouragement, and exercise therapy, with patient education being the key stone of the process.
Therapists can improve patients’ understanding and engagement in the rehabilitation process by using simple, patient-friendly language and avoiding medical jargon, ultimately leading to better outcomes.
How a Therapist’s Knowledge Drives Effective Rehabilitation:
A therapist’s knowledge about the condition is crucial in balancing pain tolerance and recovery. Key factors include:
- Tissue Healing Timelines – Knowing when tissues can tolerate loading (e.g., tendons vs. fractures).
- Pain Differentiation – Distinguishing between acceptable discomfort and warning signs.
- Condition-Specific Guidelines – Understanding pain thresholds for different injuries (e.g., post-op ACL vs. tendinopathy).
- Patient Context – Adjusting rehab based on the patient’s medical history, activity level, and goals.
- Adaptability – Modifying exercises and intensity to ensure safe, progressive recovery.
Pain during exercise:
Individualizing the pain tolerance level:
Every individual is different. Patients with pain are likely to have two different entities of coping mechanisms.
- Avoidance coping: Avoidance coping involves avoiding movement due to fear of pain or injury. Patients with avoidance coping can be dealt with graded exposure. Graded exposure: Introducing simple movements by reducing fear in the acute phase of rehabilitation, which is then progressed to a compound movement.
If a person avoids functional movements due to pain or fear of worsening the internal damage, the therapists should encourage them to get out of that avoidance and push through the pain to some extent. This is done through patient education and gradual exposure to the movement or exercise.
- Endurance coping: Endurance coping involves pushing through pain despite potential harm. Patients with endurance coping can be dealt with graded activity. Graded activity: This involves introducing movement that is within the patient’s pain threshold and capacity and then progressing slowly.
When someone disregards the potential risk of worsening their condition and continues to push through even with pain or discomfort, the therapist might have to pull back a little and educate them regarding the importance of graded activity.
Graded exposure and graded activity both help a person slowly return to normal function by starting at the right level of exercise that is safe and does not flare up symptoms or trigger fear. Identifying this “entry point” is finding the right intensity, reps, sets, and total workload, based on how hard the exercise feels (RPE) and how many reps they could still do (RIR).
Identifying exercise intensity:
In rehabilitation, monitoring exercise intensity is crucial. Two effective methods are RPE (Rate of Perceived Exertion) and RIR (Reps in Reserve).
RPE (Scale of 1-10): Measures a person’s effort based on perception.
RPE 10 = Maximum effort (no reps left).
RPE 8 = Challenging (approx. 2 reps left).
RPE 6 = Moderate (4 reps left).
RIR: Estimates how many reps a patient could still perform before failure.
RIR 0 = No reps left.
RIR 2 = 2 reps left.
Pain is indirectly proportional to RPE.
When it comes to managing pain through exercise, balance is the key. Pain and exertion are like two sides of a seesaw—when pain levels rise, the intensity of exercise drops. Gradual, patient-specific progression is the secret to successful treatment. By listening to the body and adjusting accordingly, we can ensure that exercise is helping, not hurting, leading to better recovery and long-term strength. The right dosage of movement at the right time is the game changer in pain management.
How much level of pain can be allowed during rehab?
There is no direct answer for this because, similar to the pain perception, pain tolerance is also unique to each individual. There is no universally standard pain monitoring system or scale.
5 out of 10 pain will be different from one person to another, as well as from one day to another for the same person. So instead of focusing on the specific number on the pain scale, ask the patient:
- Whether the pain is tolerable or not, during exercise?
- Whether the pain is tolerable after exercise (does it affect your day-to-day activities or work?)
- How is the pain the next day after exercise?
According to the Systematic review and meta-analysis by Smith et al., “Should Exercises Be Painful in the Management of Chronic Musculoskeletal Pain?”, they found that exercising with some pain can provide small but significant short-term benefits in pain and function, but in the medium and long term, there was no clear advantage over pain-free exercises.
How does allowing pain during rehab impact the outcome?
Most of the patients after surgery want rehab to be pain-free and are often hesitant to push through the pain. For example, rotator cuff repair, meniscus repair, and ACL reconstruction surgery involve significant tissue damage that needs to be repaired, and it has to be protected to some extent to have a biological healing process instead of pushing through pain and risking damage to the repair itself.
But in surgeries like knee replacement and hip replacement, the entire joint is replaced instead of just a ligament or muscle, and regaining the function of that joint will naturally involve some pain, implying that it is necessary to push through pain at times.
Proper patient education should be given pre-operatively and postoperatively, and also setting realistic expectations plays a major role in ensuring a successful rehabilitation process.
What should be considered during rehabilitation?
In the case of ACL reconstruction surgery with autograft, therapists should be mindful of the graft site as well, instead of focusing on ACL repair alone.
In post-operative ACL patients, therapists should be cautious while selecting the dosage of exercise. Pushing into intolerable pain has the potential to produce swelling, quad inhibition, and decreased range of motion, thereby limiting the patient’s prognosis.
In the case of regional pain conditions such as subacromial shoulder pain, neck pain, and non-specific low back pain, it is important to reassure the patient to do the movements and provide a treatment with proper load management.
In chronic musculoskeletal pain conditions, exercise with pain offers significant benefits over pain-free exercise in patient-reported outcomes. Pain need not be a barrier to a successful outcome.
It is very important to discuss with patients that acute flare-ups are normal, and sometimes you may have to take a step back in the journey of rehabilitation, and gradual activity/graded exposure is the key to better outcomes in the rehabilitation process.
| When to Push through Pain | When to Back off with Pain |
|---|---|
| Pain is tolerable, subsides after exercise, and improves over time | Pain is progressively intolerable, disabling, or worsens during daily function |
| Mild chronic conditions benefit from continued activity. | Fractures require pain-free rehab to prevent setbacks. |
| Professional athletes in-season may push through tolerable pain due to performance and career demands. | Acute Postoperative cases like ACLR, where pain may indicate inadequate recovery or excessive stress on healing tissues. |
| No increase in swelling or stiffness | When exercise causes swelling and limits the range of motion |
Conclusion
Allowing some pain in rehab is generally safe and can improve strength and quality of life. However, therapists must have a strong understanding of anatomy, pathology, and tissue healing timelines to make informed decisions. Proper exercise prescription, including when to push through pain and when to back off, will depend on the condition, recovery stage, and individual’s tolerance. By monitoring pain progression and adapting rehab strategies accordingly, the therapists can ensure safe and effective rehabilitation without risking setbacks and delayed recovery.
Azarudheen is a passionate physiotherapist and exercise prescriptor with a deeply rooted belief in the transformative power of movement and education. His journey began in 2013 as a first-year physiotherapy student, balancing academics with part-time work to support his ambitions. Early in his career, he sought practical experience and began working at a fitness center, eventually transitioning into roles that expanded his knowledge and skill set in both clinical practice and teaching.
Driven by a relentless curiosity and desire for growth, Azarudheen took on an anatomy tutor position, believing in the value of continuous learning. A pivotal turning point came with his experience in cardiopulmonary rehabilitation at PSG Hospitals, where he worked closely with lung transplant patients. This experience emphasized the life-changing impact of functional movement and patient education, inspiring him to dive deeper into respiratory and cardiovascular physiology.
With strong support and belief in his vision, Azarudheen pursued a Master’s in Exercise and Sports Science at Manipal University—choosing it over conventional MPT programs to focus more on biomechanics, exercise physiology, strength and conditioning, and lifestyle health. His dedication was evident as he spent late nights at the library, worked part-time in gyms and cricket academies, and honed his craft through practical application.
In 2022, despite initial doubts, he opened his first clinic in his hometown—an act of courage and self-belief supported by his family and mentors. Built from the ground up, this clinic marked the start of a new era. Today, Azarudheen leads a growing team of 21 physiotherapists across two thriving clinics in Chennai and Coimbatore. His philosophy centers on patient education, movement optimization, and professional growth, and he continues to evolve both as a clinician and a leader.
Azarudheen’s journey reflects the power of perseverance, vision, and lifelong learning. He is not only a practitioner but also a mentor and advocate for a more thoughtful, movement-centered approach to healthcare.