Bridging the activation gap: a physical activity intensity scale informed by elite athletes yet inclusive for musculoskeletal pain patients

Physical activity (PA) is a cornerstone of public health, with the World Health Organization’s (WHO) PA/sedentary behavior (SB) guidelines recommending at least 150 min per week of moderate or 75 min per week of vigorous activity per week, plus resistance training (1). Despite ongoing promotion of PA/SB guidelines, there has been a global increase in population estimates of insufficient PA levels from 2000 to 2022, rising from 23% to 31% (2). Musculoskeletal disorders like osteoarthritis, low-back pain and neck pain are a major public health concern (3). While PA is generally safe, people with musculoskeletal pain may perceive it as threatening, leading to avoidance and inactivity (4). Pain no longer refects tissue damage but a learned, sensitized neural pattern amplifying the ongoing pain e4perience (5). Prolonged inactivity also worsens health. 5or instance, chronic infammation and weight gain6chiefy in osteoarthritis6raises cardiovascular risk, creating a tough cycle for those in pain. 7n the 1880’s, PA/SB guidelines shifted from vigorous e4ercise for fitness targeting moderate-intensity activities of daily living (AD9s) to stay healthy (:). ;ecently, new 24 h movement guidelines emphasize total PA across the day, factoring in sedentary time and sleep (7)., and along with wearable technology, has attempted to further promote and leverage the benefits of light as well as intense, but short PAs (<). 7n this piece, we propose combining two intensity strategies to support inclusive PA promotion6supporting healthcare professionals in promoting movement for those with musculoskeletal disorders and/or chronic pain. Drawing from two decades of research in well trained to elite athletes, we aim to categorize PA intensity within the framework of the PA/SB recommendations. We propose a non-structured dominance of low or light-intensity PA that resonates for not only sedentary, often =PA fearful> individuals with musculoskeletal disorders, but also for athletes recovering from injury, and others with chronic conditions.