HIT and Chronic Musculoskeletal Pain: Rationale and Application

High-intensity training (HIT) is gradually finding its place in rehabilitation, even in the context of chronic pain. In this Masterclass, Jonas Verbrugghe will provide you with an up-to-date scientific overview of the potential benefits of HIT in musculoskeletal treatment.

You will discover concrete protocols to incorporate into practice, as well as thoughts on the future development of this approach in the field of rehabilitation.

Optimizing Exercise Effects

Exercise is a well-established therapeutic option for managing chronic musculoskeletal disorders. Yet, research often reports only modest effects. One likely reason: a lack of clarity and consistency regarding how exercise is prescribed, especially in terms of intensity.

Current clinical guidelines are mostly based on studies that have used low-to-moderate-intensity training. However, growing evidence suggests that higher-intensity approaches might deliver stronger and more durable outcomes.

Understanding High-Intensity Training

Exercise intensity refers to the effort exerted relative to an individual’s maximum capacity. HIT is based on exercising at a high, predefined intensity, whether for cardiovascular or musculoskeletal improvement, and it must be objectively measurable.

There is no single “gold standard” to define HIT yet, but key principles are clear: short, intense bouts of effort, repeated with sufficient recovery in between.

Evidence is growing, even in chronic conditions

While HIT is well documented in healthy populations—from sedentary individuals to athletes—it has also shown great potential in clinical populations. Positive outcomes have been reported for overall health, functionality, and even disease-specific symptoms.

One pivotal study from Hasselt University (2019) evaluated HIT in chronic non-specific low back pain. In a 12-week program (24 sessions), patients following HIT experienced greater improvements in pain, disability, and physical function compared to those doing a similar low-intensity protocol. These benefits were still evident at a six-month follow-up.

Who Is HIT For?

Contrary to popular belief, HIT is not just for young, fit, or low-pain patients. The research included highly diverse participants, varying in age, BMI, pain intensity, and psychological profiles.

One secondary analysis even showed greater benefits in patients with high scores on the Central Sensitization Inventory—those often considered more complex or challenging to treat.

What Does a HIT Protocol Look Like?

The 2019 study used a structured, multimodal approach:

1. Cardiorespiratory component: 5 maximum-effort sprints of 60 seconds on a bike, with 60 seconds of active recovery between. Total: 10 minutes.
2. Muscle strengthening: 6 exercises targeting general and core strength, standardized but individually progressed.
3. Progression: training loads and difficulty were adapted over time based on patient responses.

Other studies show that different exercise modalities can also be effective, as long as high intensity is maintained.

How to Apply HIT in Clinical Practice

1. Focus on quality movement: Warm-up, control, progression, and cooldown are essential.
2. Educate your patient: Explain the expected sensations (increased heart rate, soreness), benefits, and goals clearly.
3. Use time-based progression: Especially for chronic pain, a “time-contingent” rather than symptom-contingent approach works best.
4. Stay flexible and collaborative: modify protocols based on patient feedback. Don’t aim for perfection, but co-create and explore.
5. Ensure safety and support: provide a secure, motivating environment. Be present and responsive.
6. Be a coach, not a drill sergeant: build trust. Encourage, motivate, and empower. Don’t push too hard or criticize.
7. Use available tools: protocol sheets for strength and interval training are available to support implementation.

Why does it work?

HIT's success in chronic conditions likely stems from more than just physical effects. In addition to strength and endurance gains, HIT may reduce anxiety and depression, improve cognitive function, modulate pain mechanisms, and impact autonomic and inflammatory responses.

The Future of HIT: Technology and Real-Life Application

One challenge of implementing HIT in daily practice is the level of therapist supervision often required. To address this, new research is exploring tech-assisted approaches.

The Techno Trial, launched in January 2024 in Belgium, is investigating a tech-supported HIT program in hospital settings. After an initial three-month supervised period, patients will continue their program at home using a mobile app. The study will assess clinical effectiveness, cost efficiency, and underlying mechanisms. Results are expected in the coming years.

Conclusion

HIT offers exciting potential in managing chronic musculoskeletal disorders. It is supported by growing evidence and it is applicable to a wide range of patients. With the right principles, proper patient education, and a supportive therapeutic alliance, physical therapists can safely integrate HIT into their daily practice.

For more information and detailed explanations, as well as video demonstrations, we invite you to check out the complete Masterclass on Fullphysio. This content is only a summary of the original video.