Exercise prescription and monitoring of heart rate parameters in people with chronic pain: a systematic review

Clinical Snapshot

Key Findings

• P Value: p<0.05 reported across five of six studies for HRV outcomes; pain outcome findings described as mixed

• Effect Size: No pooled effect size calculated; five of six included RCTs reported statistically significant improvements in HRV following exercise interventions

• Primary Outcome: Heart rate variability (HRV) as a measure of autonomic nervous system function following exercise interventions in chronic pain populations

• Nnt Or Sensitivity: Not calculable from available data; no NNT, standardised mean difference, or other summary statistic reported at the review level

• Confidence Interval: Not reported; no meta-analytic pooling performed

Clinical Application

Exercise interventions are broadly feasible in chronic pain populations, though the optimal modality, intensity, frequency, and duration for HRV improvement remain undefined by this review. The lack of standardised HRV measurement protocols across studies means that clinical monitoring of HRV as a treatment response biomarker cannot yet be operationalised reliably. Physiotherapists and exercise physiologists would require clearer HRV measurement guidelines before incorporating this metric into routine practice. In Australia, exercise physiology and physiotherapy services for chronic pain management are partially funded through Medicare (Chronic Disease Management plans, up to five allied health visits per calendar year) and the NDIS for eligible individuals. The RACGP's 2019 guidelines on chronic pain management emphasise multimodal approaches including physical activity, but do not currently specify HRV monitoring as a standard clinical metric. Exercise interventions for chronic pain are consistent with TGA-independent, non-pharmacological first-line management strategies endorsed by Australian pain societies. PBS-listed pharmacological agents for chronic pain (e.g., pregabalin, duloxetine) carry significant adverse effect profiles, reinforcing the clinical relevance of evidence-based exercise alternatives. However, this review does not provide sufficient evidence to support specific exercise prescription changes within Australian clinical guidelines at this time. Adults with chronic pain conditions of diverse aetiology. The evidence base is too limited and heterogeneous to specify which chronic pain subpopulations (e.g., fibromyalgia, chronic low back pain, neuropathic pain) are most likely to benefit from exercise-based HRV improvement strategies. Clinicians should exercise caution in extrapolating findings beyond the narrow demographic profiles of the six included trials.

Abstract

INTRODUCTION: Chronic pain affects over 50 million adults in the United States and is associated with autonomic nervous system dysfunction assessed through measurements of heart rate variability (HRV). While exercise has been shown to improve HRV in healthy individuals, the effects of different exercise protocols in chronic pain populations on HRV remain underexplored. CONTENT: The purpose of this systematic review investigated how exercise interventions influence HRV and pain in individuals with chronic pain. A literature search was conducted in accordance with PRISMA guidelines across four electronic databases. Six randomized controlled trials met the inclusion criteria and were critically appraised for methodological quality. Studies were included if they involved an exercise intervention and reported HRV. If pain was assessed, it was included as an outcome measure. SUMMARY AND OUTLOOK: Six randomized controlled trials were identified with 283 participants. All studies measured HRV, while four reported pain outcomes. Five studies reported significant improvements in HRV following exercise interventions (p <0.05), while findings related to pain outcomes were mixed. Methodological reporting of HRV procedures was generally insufficient. Due to heterogeneity across studies, it remains unclear whether exercise improves pain or HRV sufficiently. While pain outcomes are commonly reported, HRV is the only measure specific to \autonomic function, and its reliability as a clinical metric in individuals with chronic pain remains uncertain. Limited research across diverse chronic conditions, sexes, and methodological approaches restricts generalizability. This highlights the need for greater methodological rigor and broader inclusion to strengthen the use of HRV metrics in chronic pain populations.

References

1. 1.Pellow, K., Harrison, J., & Harper, B. A. (2026). Exercise prescription and monitoring of heart rate parameters in people with chronic pain: a systematic review. Scandinavian Journal of Pain. https://doi.org/10.1016/s2665-9913(23)00324-7