Pragmatic RCT Finds SCI Exercise Guidelines Reduce Pain Intensity but Not Primary Composite Score

The trial randomized adults with spinal cord injury and chronic neuropathic or musculoskeletal pain to a personalized program delivered by certified trainers or to usual care. Participants exercised at home or local facilities; the primary endpoint combining pain severity and interference was inconclusive, yet the SCI-specific pain intensity measure showed statistically significant between-group differences at three and six months. Aerobic targets were met more consistently than strength targets, suggesting aerobic volume may drive the observed effect. Responses varied widely, with some participants reporting increased pain, underscoring that exercise is not uniformly effective.

Patient involvement shaped the protocol: more than 150 individuals with spinal cord injury and 50 clinicians contributed to design and outcome selection. COVID-19 restrictions and wildfire evacuations truncated recruitment below the planned 84, reducing statistical power. The pragmatic delivery nevertheless demonstrated that guideline-based prescriptions can be implemented outside laboratories, addressing a gap left by prior efficacy trials conducted in controlled settings.

Prior observational data and smaller non-randomized studies had linked exercise to pain relief in this population, yet lacked standardized dosing. This RCT supplies the first randomized evidence that the international guidelines can be tested for pain endpoints in real-world conditions. Next steps require adequately powered multicenter trials that stratify by pain phenotype and include objective adherence monitoring to identify responders.

Larger studies must also track long-term maintenance and cost-effectiveness, given that medications remain first-line despite incomplete efficacy and side effects. The present findings support exercise as a low-risk adjunct but do not yet justify replacing pharmacotherapy.