Manual Therapy, Posturology & Rehabilitation Journal
Manual Therapy, Posturology & Rehabilitation Journal
Study Protocol

Transcranial magnetic stimulation associated with manual therapy in patients with knee osteoarthritis: a randomized controlled clinical trial protocol

Mannaly Mendonça, Maria das Graças Araújo, Camilla Fonseca, Maíra Lima, Luiz Mèlo, Sérgio Rocha, Marcelo Guerino, Ana Paula Lima, Kátia Monte-Silva

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Background: Persistent pain in knee osteoarthritis (KOA) may generate sensitization of the afferent and central nervous system (CNS) pathways over time. Therefore, for patients with chronic pain derived from KOA, to associate therapies that address peripheral impairment, such as central and manual therapy and transcranial magnetic stimulation seems to be a promising strategy for pain reduction. Objectives: The purpose of this study is to unite rTMS and TM to control the pain of patients with knee OA and to examine the efficacy of this treatment protocol, assuming that this union would be more beneficial than the formally applied therapies isolated. Methods: This clinical trial with three arms interventions, controlled, triple blind and randomized, will allocate patients with KOA in groups (i) transcranial magnetic stimulation; (ii) sham transcranial magnetic stimulation + manual therapy and (iii) transcranial magnetic stimulation + manual therapy. Pain assessment will be performed using the visual analog scale of pain of 100 points, before and after the interventions, and for a maximum of 30 days after the single session. This session will involve the application of real or fictitious transcranial magnetic stimulation followed by manual or home therapy. Discussion: The study is in the recruitment stage and it is expected that after the application of the therapeutic protocol the group that performed the association has a more significant improvement in comparison to the others. Study registry: The protocol of this study was published on the Clinical Trials (, with the registration number NCT03076294.


Knee osteoarthritis; Chronic pain; Musculoskeletal manipulations; Transcranial magnetic stimulation


1. Pollard H, Ward G, Hoskins W, Hardy K. The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomised controlled trial. J Can Chiropr Assoc. 2008; 52(4): 229–42.

2. Tarragó M da GL, Deitos A, Brietzke AP, Vercelino R, Torres ILS, Fregni F, et al. Descending Control of Nociceptive Processing in Knee Osteoarthritis Is Associated With Intracortical Disinhibition. Medicine (Baltimore). 2016; 95(17): e3353.

3. Berenbaum F. Osteoarthritis year 2010 in review: Pharmacological therapies. Osteoarthr Cartil. 2011; 19(4): 361–5.

4. Haavik-Taylor H, Murphy B. Cervical spine manipulation alters sensorimotor integration: A somatosensory evoked potential study. Clin Neurophysiol. 2007; 118(2): 391–402.

5. Courtney CA, Steffen AD, Fernández-de-Las-Peñas C, Kim J, Chmell SJ. Joint Mobilization Enhances Mechanisms of Conditioned Pain Modulation in Individuals With Osteoarthritis of the Knee. J Orthop Sports Phys Ther. 2016; 46(3): 1–30.

6. Xu Q, Chen B, Wang Y, Wang X, Han D, Ding D, et al. The effectiveness of manual therapy for relieving pain, stiffness, and dysfunction in knee osteoarthritis: A systematic review and meta-analysis. Pain Physician. 2017; 20(4): 229–43.

7. NICE. Osteoarthritis: care and management. 2014; (February): 8, 10.

8. O’Connell NE, Wand BM, Marston L, Spencer S, DeSouza LH. Non-invasive brain stimulation techniques for chronic pain. Cochrane Database Syst Rev. 2014; 4: CD008208.

9. Groppa S, Oliviero A, Eisen A, Quartarone A, Cohen LG, Mall V, et al. A practical guide to diagnostic transcranial magnetic stimulation: Report of an IFCN committee. Clin Neurophysiol. 2012; 123(5): 858–82.

10. Santos CL, Oliveira D, Camatti JR, Barbosa A, Xavier FDB, Baptista AF. Exercício e eletroestimulação na dor, função e plasticidade cerebral de indivíduos com osteoartrite de joelho. O estado da arte. Rev Pesqui em Fisioter. 2016; 6(1): 45–55.

11. Altman R, Asch D, Bloch G, Bole D, Borenstein K. Development of Criteria for the Classification and Reporting of Osteoarthritis. Arthritis Rheum. 1986; 29(8).

12. Lourenço R, Veras RP. Mini-Exame do Estado Mental: características psicométricas em idosos ambulatoriais. Rev Saude Publica. 2006; 40(4): 712–9.

13. Lefaucheur JP, Drouot X, Menard-Lefaucheur I, Keravel Y, Nguyen JP. Motor cortex rTMS restores defective intracortical inhibition in chronic neuropathic pain. Neurology. 2006; 67(9): 1568–74.

14. Lefaucheur JP, Andre-Obadia N, Antal A, Ayache SS, Baeken C, Benninger DH, et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clin Neurophysiol. 2014; 125(11): 2150–206.

15. Wassermann EM. Risk and safety of repetitive transcranial magnetic stimulation. Electroencephalogr Clin Neurophysiol. 1998; 108(1): 1–16.

16. Field T, Diego M, Gonzalez G, Funk CG. Knee arthritis pain is reduced and range of motion is increased following moderate pressure massage therapy. Complement Ther Clin Pract. 2015; 21(4): 233–7.

17. Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain. 2005; 113(1–2): 9–19.

18. Lee JS, Hobden E, Stiell IG, Wells GA. Clinically important change in the visual analog scale after adequate pain control. Acad Emerg Med. 2003; 10(10): 1128–30.

19. Mendoza T, Mayne T, Rublee D, Cleeland C. Reliability and validity of a modified Brief Pain Inventory short form in patients with osteoarthritis. Eur J Pain. 2006; 10(4): 353–61.

20. Arendt-Nielsen L, Nie H, Laursen MB, Laursen BS, Madeleine P, Simonsen OH, et al. Sensitization in patients with painful knee osteoarthritis. Pain. 2010; 149(3): 573–81.

21. Suokas AK, Walsh DA, McWilliams DF, Condon L, Moreton B, Wylde V, et al. Quantitative sensory testing in painful osteoarthritis: A systematic review and meta-analysis. Osteoarthr Cartil. 2012; 20(10): 1075–85.

22. Fernandes, MI. Tradução e validação do questionário de qualidade de vida específico para osteoartrose WOMAC (Western Ontario and McMaster Universities) para a língua portuguesa. 2001. 103 f. . Dissertação (Mestrado em Ciências) - Escola Paulista de Medicina, Universidade Federal de São Paulo. São Paulo, 2003.

23. Alexandre TDS, Cordeiro RC, Ramos LR, Al E. Fatores associados à qualidade de vida em idosos com osteoartrite de joelho. Fisioter e Pesqui. 2008; 15(4): 326–32.

24. Podsiadlo D, Richardson S. The Timed “Up & Go”: A Test of Basic Functional Mobility for Frail Elderly Persons. J Am Geriatr Soc. 1991; 39(2): 142–8.

25. Karuka AH, Silva JAMG, Navega MT. Análise da concordância entre instrumentos de avaliação do equilíbrio corporal em idosos. Rev Bras Fisioter 2011; 15(6): 460-6.

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