Is progressive overload always required to move out of pain?

This one’s a question for the practitioners out there:

If tissue “health” and pain are not well correlated, why would an intervention need to alter the state of tissue in order to affect pain?

The Strength & Conditioning industry in particular can get accused of proclaiming strength to be king for everything, while the Rehabilitation industry can get accused of underloading athletes and patients during their rehab journeys.

When it comes to rehabilitation, there is definitely a need to first deload, and then reload. If we want athletes or patients to build tolerance to movements or load, they need to be exposed to those kinds of movements or loads. Gradually, and progressively over time, of course.

This is where the athletes doing clamshells forever can get a bad rap – the majority of people will get strong enough to do a nice clamshell pretty quickly, and adding reps forever won’t build strength effectively.

But is strength always king in the rehabilitative process? Do we need to actually alter the state of tissue to see a decrease in pain, and increase in function?

Different kinds of pain have been shown to decrease force production. So is it that we’re seeing athletes get stronger, and that’s reducing their pain? Or is it simply that the pain decreases over time due to the natural history of the injury, and therefore their strength increases?

As a practitioner trained in exercise and rehabilitation science, I am a huge proponent of resistance training for everyone. At every age, in every condition. There is always some way to do strength training, and the health benefits are extensive and well-documented.

But: We know that tissue state and pain levels are not well-correlated. We know that this can particularly be the case with persistent pain. So I think it’s extremely important as professionals to think twice before we look down on interventions that “don’t do anything” at the tissue level. Interventions like stretching, foam rolling, massage, and neural glides.

Some of these interventions may indeed not induce structural changes at the level of the muscle or connective tissue, but we also know that movement of any kind can help decrease pain, and especially can help decrease fear-avoidance, which can in turn help individuals re-engage with physical activity (and therefore the “loading” they need for tissue changes, whether that affects their pain, or simply improves their ability to function in spite of, and after, pain!).