![\"Image](\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2021\/10\/image-1.png\")
<\/figure>\n\n\n\nA pain monitoring model is often used during exercise, which describes a scale from 0 to 10, where 0 is indicating \u201cno pain\u201d and 10 indicates \u201cworst imaginable pain\u201d (Thomee et al. 1997<\/a>). Pain between 0 and 2 is considered \u201csafe\u201d, between 2 and 5 is \u201cacceptable\u201d and above 5 is \u201chigh risk\u201d. Moreover, pain is allowed to reach 5 after exercise but it should decrease by the next morning. These are general guidelines that have been applied in clinical practice, studies, and with a variety of indications in shoulder rehabilitation (Holmgren et al. 2012<\/a>, Maenhout et al. 2012<\/a>, Valles-Carrascocsa et al. 2018<\/a>).<\/p>\n\n\n\n The lack of clear evidence-based guidelines reflects also on the current clinical practice. Several surveys on the physiotherapeutic management of subacromial shoulder pain have been performed in 4 different countries (United Kingdom, Belgium, The Netherlands, and Italy)(Bury et al. 2018<\/a>, Pieters et al. 2019<\/a>, Brindisino et al. 2018<\/a>) and showed variable results on the instructions about pain during exercise. Most physiotherapists instructed their patients not to have any pain or at least not more than acceptable discomfort. Experts in the field recently suggested using different types of exercises according to symptoms\u2019 acceptability as long as they could sufficiently challenge weakness and train to fatigue (Littlewood et al. 2019).<\/p>\n\n\n\n Physiotherapists usually don\u2019t encourage patients to train in pain. However, there is no strong scientific basis for this fear of \u201cexercising into pain\u201d. Indeed, considering the principle that \u201churt does not equal harm, a recent systematic review challenges this belief and suggests that painful exercises are more beneficial in short term compared to pain-free exercise in chronic musculoskeletal pain (Smith et al. 2017<\/a>). Considering that pain does not always correspond to tissue damage (such as a tear or tendon degeneration), other factors such as fear of movement and central sensitization can play an important role in the development or maintenance of pain. If painful exercises are allowed with suitable \u201csafety cues\u201d, the physiotherapist can gradually reduce the threat perception of the painful movement (Smith et al. 2018<\/a>). If the shoulder is considered \u201cde-conditioned\u201d and the purpose is to strengthen the shoulder muscles, the patients will re-think and re-modulate under the guidance of the treating physiotherapist.<\/p>\n\n\nWhat is the current practice among physiotherapists in shoulder rehabilitation?<\/h2>\n\n\n\n
![\"Pain](\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2021\/10\/Pain-free-shoulder-training.jpg\")
<\/figure>\n\n\n\nHurt \u2260 Harm<\/h2>\n\n\n\n
![\"Hurt](\"https:\/\/www.physiotutors.com\/wp-content\/uploads\/2021\/10\/Hurt-harm.jpg\")
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