Beyond biomechanics: a narrative review on the cognitive, emotional, and metacognitive mechanisms of exercise in chronic pain

Chronic pain is increasingly recognized as a multidimensional condition sustained by interacting cognitive, behavioral, emotional, attentional, and metacognitive processes. Within this framework, physical exercise has gained relevance as a non-pharmacological intervention that may influence psychological mechanisms involved in pain persistence and disability. This narrative review provides an updated synthesis of recent evidence on the effects and mechanisms of physical exercise on cognitive, behavioral, emotional, and metacognitive dimensions of chronic pain. A structured literature search was conducted across PubMed/MEDLINE, Scopus and Web of Science, focusing on peer-reviewed studies published between January 2016 and December 2025. Evidence was synthesized narratively across mechanistic domains, integrating findings from rehabilitation science and clinical psychology. The literature suggests that exercise may act as an active experiential intervention capable of targeting several psychosocial factors in chronic pain. Across studies, exercise was associated with reductions in catastrophizing and maladaptive pain beliefs, improvements in pain self-efficacy, and attenuation of kinesiophobia. Exercise may also modulate attentional bias and hypervigilance, and psychologically informed exercise approaches appear particularly relevant for metacognitive processes, including reduced rumination, increased decentering, and improved non-reactive awareness of bodily sensations. In parallel, exercise shows beneficial effects on emotional aspects of chronic pain, likely mediated by both neurobiological and psychosocial mechanisms pathways. Overall, physical exercise should be conceptualized as a comprehensive intervention capable of acting on cognitive, behavioral, emotional, and metacognitive processes that sustain chronic pain. Future research should clarify modality-specific mechanisms, identify moderators of response and incorporate process-based outcomes to support personalized exercise prescriptions.