Repetitive Transcranial Magnetic Stimulation for Post-Stroke Rehabilitation: A Systematic Review and Meta-Analysis

BackgroundStroke is the leading cause of adult-onset disability, with impairments across motor, language, cognitive, swallowing, mood, and gait domains. Non-invasive brain stimulation techniques like repetitive transcranial magnetic stimulation (rTMS) have emerged as promising tools to augment rehabilitation therapies to improve post-stroke impairments. This systematic review and meta-analysis will evaluate the efficacy of rTMS for post-stroke recovery across multiple functional domains and identify moderators of treatment response. MethodsWe systematically searched five databases for randomized controlled trials (RCTs) published from February 16, 2004 to July 1, 2024. Eligible studies compared active rTMS with sham rTMS in stroke survivors and reported validated outcomes. Risk of bias was assessed using the Cochrane Collaboration tool. Random-effects meta-analyses were conducted for each outcome domain. Subgroup analyses examined timing of intervention (acute/subacute, early chronic, late chronic). Meta-regression evaluated continuous moderators, including stimulation intensity (% resting motor threshold), number of sessions, age, and sex. ResultsFifty-two studies met inclusion criteria (2,472 participants, mean age 59.8 years; 35.1% female). rTMS was associated with significant improvements in motor function (UE-FMA, MD = 4.68, 95% CI [2.18, 6.54]), language (CCAT, MD = 0.62, 95% CI [0.22, 1.01]), cognition (MMSE, MD = 2.12, 95% CI [1.34, 2.92]), dysphagia (PAS, MD = -1.50, 95% CI [-2.40, -0.57]), and mood (HAMD-17, MD = -2.34, 95% CI [-4.38, -0.30]), but not gait. Subgroup analyses showed significantly larger treatment effects when rTMS was delivered within 3 months post-stroke, particularly for motor outcomes. Meta-regression indicated that stimulation intensity, number of sessions, and participant demographic distribution were not significant moderators. ConclusionsrTMS improves post-stroke outcomes across multiple functional domains, with the strongest evidence for motor recovery in the acute/subacute phase. Standardization of protocols and larger trials in understudied domains are needed to maximize therapeutic outcomes.