PAIN+ CPN

OBJECTIVES: To (1) assess the efficacy of combining repetitive transcranial magnetic stimulation (rTMS) and motor control exercise on pain intensity compared to each intervention alone or a placebo in patients with nonspecific chronic low back pain (CLBP), and (2) evaluate the effects of motor control exercise versus no-motor control exercise, and active rTMS versus sham rTMS. DESIGN: Factorial randomized controlled trial. METHODS: Adults aged 18 to 65 years with nonspecific CLBP were randomly assigned in a 1:1:1:1 ratio to 1 of 4 groups: active rTMS, sham rTMS, active rTMS + motor control exercise, and sham rTMS + motor control exercise. Participants received 10 sessions of their allocated intervention over 8 weeks. Active and sham rTMS were performed over the primary motor cortex (10 Hz, 2000 pulses/session). The primary outcome was the average pain intensity at 8 weeks. RESULTS: One hundred forty participants (80 females; mean age, 38.4 years) were recruited. Pain intensity significantly reduced over time, with no difference between groups. At 8 weeks, active rTMS + motor control exercise was not better than active rTMS (mean difference [MD], 0.1; 95% confidence interval [CI]: -1.0, 1.1; P = .89), sham rTMS (MD, 0.1; 95% CI:-0.9, 1.1; P = .83), or sham rTMS + motor control exercise (MD, 0.8; 95% CI: -0.3, 1.8; P = .15) to reduce pain. No significant differences in pain intensity were found between active and sham rTMS groups, with or without motor control exercise at 8 weeks. CONCLUSIONS: Combining rTMS and motor control exercise did not significantly reduce pain intensity compared to each intervention used alone or placebo in participants with CLBP. J Orthop Sports Phys Ther 2026;56(1):1-10. Epub 30 October 2025. doi:10.2519/jospt.2025.13681.

Physician rater

The clinical implications of this trial indicate that it is unwise to recommend repetitive transcranial magnetic stimulation for routine CLBP management given its lack of efficacy relative to sham. It may be better to prioritise evidence-based motor control exercises or guideline-recommended practice exercises.

Physician rater

There is no additional benefit in combining repetitive transcranial magnetic stimulation with motor control exercise compared with sham or individual interventions for pain relief in nonspecific CLBP. This reinforces scepticism toward noninvasive brain stimulation for nociplastic-dominant pain like CLBP. Methodological limitations of the RCT restrict the generalisability of the results.

Rehab Clinician (OT/PT) rater

The abstract and conclusions state that adding TMS to motor control exercises had no additional effect. The important findings that are NOT mentioned in either abstract or conclusions is that neither motor control or TMS on their own had any significant therapeutic effect.

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