Neuromuscular exercise combined with pain neuroscience education for knee osteoarthritis management in older women:...

Knee osteoarthritis is a prevalent chronic condition in older adults, particularly postmenopausal women, affecting physical, psychological, social, and economic aspects of life. Existing neuromuscular exercise programs for knee osteoarthritis are often incomplete, focusing on isolated components such as strength or balance, without simultaneously targeting all key elements, including core stability, balance, and lower-limb strength. Additionally, these programs rarely address psychosocial factors or integrate pain neuroscience principles. Evidence suggests that combining a comprehensive neuromuscular exercise program with Pain Neuroscience Education (PNE) may offer superior benefits in reducing pain, improving function, and decreasing fear of movement compared with conventional exercise alone. This study aims to develop and present a novel integrated protocol and to evaluate its effectiveness compared with usual care in older women with knee osteoarthritis.

This double-blind randomized controlled trial will enroll 60 women aged 60 years and older with knee osteoarthritis, randomly assigned to either an intervention group or a usual-care control group (30 per group). Outcome assessors and the statistician will be blinded to group allocation. The intervention group will receive an 8-week supervised neuromuscular exercise program combined with PNE, while the control group will receive usual care, defined as continuation of any ongoing medical management without any structured exercise or PNE added. The primary outcome is knee pain intensity, measured using the Visual Analog Scale. Secondary outcomes include functional disability, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Knee Injury and Osteoarthritis Outcome Score (KOOS); physical performance, evaluated via the Timed Up and Go and Sit-to-Stand tests; balance assessed through plantar pressure analysis and the Berg Balance Scale; fear of falling; and pain-related psychological factors including catastrophizing, self-efficacy, and kinesiophobia. Knee proprioception, lower-limb muscle strength, and muscle activity will also be assessed.

This protocol describes a novel, integrated approach that simultaneously targets the physical and psychosocial dimensions of knee osteoarthritis in older women. If the findings demonstrate effectiveness, this low-risk, non-pharmacological intervention has the potential to inform clinical rehabilitation guidelines and offer a scalable, accessible treatment option for this growing population.

Study is registered in the Iranian Registry of Clinical Trials (IRCT20190224042827N7), registration date: 17 November 2025.