Effects of transcranial direct current stimulation associated or combined with exercise on musculoskeletal pain: systematic review

Souza, Ricardo Vinicius Silva; Maciel, Daniel Germano; Cerqueira, Mikhail Santos

doi:10.5935/2595-0118.20210029

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REVIEW ARTICLE • BrJP 4 (2) • Apr-Jun 2021 • https://doi.org/10.5935/2595-0118.20210029 copy

Effects of transcranial direct current stimulation associated or combined with exercise on musculoskeletal pain: systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND AND OBJECTIVES:

Aerobic/resistance exercises and transcranial direct current stimulation (tDCS) can produce analgesic effects in patients with musculoskeletal pain, however, the summed effect of these two therapeutic resources remains unclear. The present study aimed to verify the effects of tDCS associated or combined with aerobic/resistance exercise on musculoskeletal pain.

The search was carried out in the databases: Pubmed, LILACS, Scielo. The intervention considered was tDCS associated or combined with exercises and the comparison was exercise without tDCS or with sham tDCS. Randomized controlled trials enrolling patients with musculoskeletal pain were included. There were no restrictions on the language and year of publication and the methodological quality was verified with PEDro Scale. Three trials were included with a total of 110 participants. The methodological quality was high, with an average of 9 points on the PEDro Scale. The studies used tDCS in the primary motor cortex with an intensity of 1 or 2 mA, for 20 minutes. The participants included were aged between 18 and 75 years and had the following diseases: fibromyalgia, osteoarthritis or chronic low back pain.

CONCLUSION:

Overall, tDCS did not overcome the sham tDCS to enhance the effects of exercise in reducing musculoskeletal pain.

Keywords:
Aerobic exercise; Analgesia; Musculoskeletal pain; Transcranial direct current stimulation

Study	Population	Intervention			Comparison
Study	Population	General protocol	tDCS parameters	Exercise parameters
Mendonça et al.⁶6 Mendonça ME, Simis M, Grecco LC, Battistella LR, Baptista AF, Fregni F. Transcranial direct current stimulation combined with aerobic exercise to optimize analgesic responses in fibromyalgia: a randomized placebo-controlled clinical trial. Front Hum Neurosci. 2016;10;10:68.	45 patients with fibromyalgia; Age between 18 and 65 years. G1 (n=15): ACT tDCS combined with ACT aerobic exercises. G2 (n=15): S tDCS combined with ACT aerobic exercises. G3 (n=15): ACT tDCS combined with S aerobic exercises.	4 weeks OF treatment (tDCS during aerobic exercise). Week 1: tDCS for 5 consecutive days and aerobic exercises 3 days a week. Weeks 2 to 4: aerobic exercises only, 3x per week.	20 minutes of application with 2mA intensity. Anodic electrode at point C3 of the M1 region. Cathodic electrode positioned on the supraorbital region, contralateral to the anodic electrode.	30 minutes on treadmill with 60% MHR intensity.	S tDCS: same parameters as the active group, but tDCS were applied only for the first 30s. S Aerobic exercise: same parameters as the active group, but with minimum treadmill speed.
Chang et al.²⁶26 Chang W-J, Bennell KL, Hodges PW, et al. Addition of transcranial direct current stimulation to quadriceps strengthening exercise in knee osteoarthritis: a pilot randomised controlled trial. PLoS ONE. 2017;12(6):e0180328.	30 patients with knee osteoarthritis. Age over 50 years. G1 (n=15): ACT tDCS associated with resistance exercise. G2 (n=15): S tDCS associated with resistance exercise.	8 weeks of treatment. 2 days a week (tDCS associated with resistance exercise). Application of tDCS 30 minutes before the exercise program.	20 minutes with 1 mA intensity. Anodic electrode positioned at M1, contralateral to the most symptomatic knee. Cathodic electrode positioned on the contralateral supraorbital region.	30 minutes of strengthening with ankle braces or elastic bands. 3 series of 10 repetitions; 30s interval between series for each of the following exercises: 1) knee extension, 2) hip abduction, 3) partial squatting on the wall, 4) knee flexion while sitting, 5) step ups/ step downs.	S tDCS: same parameters as the active group, but tDCS were applied only for the first 15s. Exercise protocol and guidelines similar to the intervention group.
Straudi et al.²⁵25 Straudi S, Buja S, Baroni A, Pavarelli C, Pranovi G, Fregni F, et al. The effects of transcranial direct current stimulation (tDCS) combined with group exercise treatment in subjects with chronic low back pain: a pilot randomized control trial. Clin Rehabil. 2018;32(10):1348-56.	35 patients with chronic low back pain. Age between 18 and 75 years. G1 (n=18): ACT tDCS associated with resistance and stretching exercises (in groups). G2 (n=17): S tDCS associated with resistance and stretching exercises (in groups).	4 weeks of treatment (tDCS associated with resistance exercise). Application of tDCS for 5 consecutive days before the exercise program.	20 minutes with 2mA intensity. In central or bilateral low back pain: anodic electrode positioned at M1 (dominant hemisphere). In unilateral pain: anodic electrode positioned in the M1 region, contralateral to the pain side. The cathode electrode was positioned in the contralateral supraorbital area.	Resistance exercises (8 to 10 submaximal actions maintained for 5 to 6s with intensity of 40 to 60% of the maximum voluntary contraction) for extensors of the spine, buttocks, abdomens, iliopsoas and paraspinals. Stretching maintained for 15 to 20s, with intensity controlled through subjective perception.	tDCS: same parameters as the active group, but tDCS was applied only for the first 30s. Exercise protocol and guidelines similar to the intervention group.z

Studies	PEDro Scale Items	PEDro Scale (0-10)	Registered	Declared primary outcome	Funded	Sample size calculation
Studies	1 2 3 4 5 6 7 8 9 10 11	PEDro Scale (0-10)	Registered	Declared primary outcome	Funded	Sample size calculation
Mendonça et al.⁶6 Mendonça ME, Simis M, Grecco LC, Battistella LR, Baptista AF, Fregni F. Transcranial direct current stimulation combined with aerobic exercise to optimize analgesic responses in fibromyalgia: a randomized placebo-controlled clinical trial. Front Hum Neurosci. 2016;10;10:68.	Y Y Y Y Y N Y Y Y Y Y	9	Y	Y	Y	N
Chang et al.²⁶26 Chang W-J, Bennell KL, Hodges PW, et al. Addition of transcranial direct current stimulation to quadriceps strengthening exercise in knee osteoarthritis: a pilot randomised controlled trial. PLoS ONE. 2017;12(6):e0180328.	Y Y Y Y Y N Y N Y Y Y	8	Y	Y	Y	Y
Straudi et al.²⁵25 Straudi S, Buja S, Baroni A, Pavarelli C, Pranovi G, Fregni F, et al. The effects of transcranial direct current stimulation (tDCS) combined with group exercise treatment in subjects with chronic low back pain: a pilot randomized control trial. Clin Rehabil. 2018;32(10):1348-56.	Y Y Y Y Y Y Y Y Y Y Y	10	Y	Y	Y	Y

Studies and disease	Instrument and pain measurement moments	Results	Conclusions
Mendonça et al.⁶6 Mendonça ME, Simis M, Grecco LC, Battistella LR, Baptista AF, Fregni F. Transcranial direct current stimulation combined with aerobic exercise to optimize analgesic responses in fibromyalgia: a randomized placebo-controlled clinical trial. Front Hum Neurosci. 2016;10;10:68. Fibromyalgia	VAS 1 week before treatment. After 1 and 4 weeks of treatment. 1 and 2 months after the end of treatment	Decrease in pain intensity at the end of the first and fourth week of intervention in all groups, but the greatest was in the tDCS + ACT EX group. There was no reduction in pain 1 and 2 months after the end of treatment. There was no significant difference in pain intensity between groups.	Authors' conclusion: tDCS + ACT EX produces a greater reduction in pain intensity than the individual use of tDCS or ACT EX. Conclusion of the review: There was no difference between ACT tDCS and S tDCS to improve pain in patients with fibromyalgia. Therefore, the benefits in both groups were probably due to ACT EX.
Chang et al.²⁶26 Chang W-J, Bennell KL, Hodges PW, et al. Addition of transcranial direct current stimulation to quadriceps strengthening exercise in knee osteoarthritis: a pilot randomised controlled trial. PLoS ONE. 2017;12(6):e0180328. Osteoarthritis	VAS 1 week before treatment After 8 weeks of treatment	Pain during walking decreased in both groups after 8 weeks of treatment. The reduction of pain in the ACT tDCS + EX group was twice that observed in the S tDCS + EX group. There was no significant difference between groups.	Authors' conclusion: There was pain reduction after 8 weeks of treatment in both groups. The effect in the ACT tDCS + EX group was more than double compared to the simulated group. However, there was no significant difference in pain reduction compared to the S tDCS + EX group. Conclusion of the review: There was no difference between ACT tDCS and S tDCS to improve pain in patients with osteoarthritis. Therefore, the benefits in both groups were probably due to exercise.
Straudi et al.²⁵25 Straudi S, Buja S, Baroni A, Pavarelli C, Pranovi G, Fregni F, et al. The effects of transcranial direct current stimulation (tDCS) combined with group exercise treatment in subjects with chronic low back pain: a pilot randomized control trial. Clin Rehabil. 2018;32(10):1348-56. Chronic low back pain	VAS; Before treatment; After tDCS application and after group exercise; After 1 month of treatment.	In both groups there was no significant reduction in pain intensity immediately after tDCS, however, there was reduction in pain from the first session on. There was difference between groups after 1 month of treatment, favoring the tDCS + EX group.	Authors' conclusion: tDCS can increase the analgesic effects of the exercise group in patients with chronic low back pain. Conclusion of the review: There was a difference in favor of ACT tDCS compared to S tDCS to improve pain in patients with chronic low back pain. Therefore, the use of tDCS can increase the analgesic effects of exercise in patients with chronic low back pain.

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[1] Correspondence to: Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte Av. Senador Salgado Filho, 3000 - Campus Universitário, Lagoa Nova 59072-970 Natal, RN, Brasil. E-mail: mikalsantosc@hotmail.com

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Effects of transcranial direct current stimulation associated or combined with exercise on musculoskeletal pain: systematic review

ABSTRACT

BACKGROUND AND OBJECTIVES:

CONTENTS:

CONCLUSION: