Repetitive Transcranial Magnetic Stimulation and Motor Control Exercise for Chronic Low Back Pain: The ExTraStim Randomized Placebo-Controlled Trial

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):28-37. Epub 30 October 2025. doi:10.2519/jospt.2025.13681