Transdiagnostic efficacy, durability, and optimal parameters of rTMS for cognitive rehabilitation: A comprehensive meta-analysis
6 affiliations
- 1Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK; Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- 2Anatomy & Neurosciences, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Cancer Center Amsterdam, Brain Tumor Center, Amsterdam, the Netherlands
- 3Department of Pain Medicine, The Walton Centre NHS Foundation Trust, UK
- 4Cancer Center Amsterdam, Brain Tumor Center, Amsterdam, the Netherlands; Medical Psychology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- 5Cancer Center Amsterdam, Brain Tumor Center, Amsterdam, the Netherlands; Neurosurgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- 6Anatomy & Neurosciences, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Cancer Center Amsterdam, Brain Tumor Center, Amsterdam, the Netherlands; Amsterdam Neuroscience, Amsterdam, the Netherlands; Corresponding author. Anatomy & Neurosciences Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
Abstract
Aim: Repetitive Transcranial Magnetic Stimulation (rTMS) is a promising non-invasive neuromodulation technique for cognitive rehabilitation. We evaluated the cognitive effects of rTMS on neurological and psychiatric diseases to determine moderators of efficacy. Methods: A meta-analysis of Randomized Controlled Trials (RCTs) comparing real versus sham rTMS to July 2025 was performed. Objective cognition reported as primary or secondary outcomes were extracted and Hedges’ g effect sizes computed. Univariate and multivariate three-level meta-analyses were performed to estimate pooled effect sizes and assess moderator influence. Results: 748 measures from 137 studies (5972 participants) were extracted. Real rTMS produced a significant cognitive enhancement (g = 0.28, p < 0.0001, I 2 = 37.3%). This was durable over 2-52 weeks follow-up. There was efficacy across all cognitive domains (g > 0.20, I 2 = 35.8). Neurodegenerative (g = 0.35) and focal (g = 0.44) conditions demonstrated stronger effects than psychiatric conditions (g = 0.20). Although stimulation target was not a significant moderator overall, the Inferior Frontal Gyrus showed the largest effect (g = 0.45), with significant effects also at the left and right DLPFC and left parietal cortex (g = 0.29–0.45), all nodes of the Frontoparietal Network. 1-Hz stimulation produced a significantly larger effect (g = 0.39) than the 10-Hz reference (g = 0.19); 5-Hz, 20-Hz and iTBS were also significantly positive (g = 0.30–0.49). In multivariate models, adding 10 rTMS sessions improved cognitive outcomes (Δg = +0.077), whereas increasing the number of pulses per session trended toward reduced efficacy. All effects were confirmed in a left dorsolateral prefrontal cortex subgroup analysis. Subjective cognition was measured in only 6% of studies. A multivariate prediction tool is introduced: https://amsali.shinyapps.io/tms_cognition_prediction/ Conclusion: This meta-analysis demonstrates the sustained efficacy of rTMS in enhancing cognitive function, with small-to-moderate effect sizes across diverse clinical populations and stimulation protocols. However, a significant gap remains regarding whether these objective neurocognitive gains translate into meaningful improvements in subjective cognition or functional outcomes.
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BibTeX
@article{ali2026transdiagnostic,
title = {{Transdiagnostic efficacy, durability, and optimal parameters of rTMS for cognitive rehabilitation: A comprehensive meta-analysis}},
author = {Ahmad M.S. Ali and Maxine Gorter and Rasheed Zakaria and Michael D. Jenkinson and Bernhard Frank and Martin Klein and Philip C. de Witt Hamer and Linda Douw},
journal = {Brain Stimulation},
year = {2026},
month = oct,
doi = {10.1016/j.brs.2026.103226},
url = {https://doi.org/10.1016/j.brs.2026.103226},
note = {CC BY},
}
RIS
TY - JOUR
TI - Transdiagnostic efficacy, durability, and optimal parameters of rTMS for cognitive rehabilitation: A comprehensive meta-analysis
AU - Ahmad M.S. Ali
AU - Maxine Gorter
AU - Rasheed Zakaria
AU - Michael D. Jenkinson
AU - Bernhard Frank
AU - Martin Klein
AU - Philip C. de Witt Hamer
AU - Linda Douw
PY - 2026
DA - 2026/10/30
JO - Brain Stimulation
DO - 10.1016/j.brs.2026.103226
UR - https://doi.org/10.1016/j.brs.2026.103226
AB - Aim: Repetitive Transcranial Magnetic Stimulation (rTMS) is a promising non-invasive neuromodulation technique for cognitive rehabilitation. We evaluated the cognitive effects of rTMS on neurological and psychiatric diseases to determine moderators of efficacy. Methods: A meta-analysis of Randomized Controlled Trials (RCTs) comparing real versus sham rTMS to July 2025 was performed. Objective cognition reported as primary or secondary outcomes were extracted and Hedges’ g effect sizes computed. Univariate and multivariate three-level meta-analyses were performed to estimate pooled effect sizes and assess moderator influence. Results: 748 measures from 137 studies (5972 participants) were extracted. Real rTMS produced a significant cognitive enhancement (g = 0.28, p < 0.0001, I 2 = 37.3%). This was durable over 2-52 weeks follow-up. There was efficacy across all cognitive domains (g > 0.20, I 2 = 35.8). Neurodegenerative (g = 0.35) and focal (g = 0.44) conditions demonstrated stronger effects than psychiatric conditions (g = 0.20). Although stimulation target was not a significant moderator overall, the Inferior Frontal Gyrus showed the largest effect (g = 0.45), with significant effects also at the left and right DLPFC and left parietal cortex (g = 0.29–0.45), all nodes of the Frontoparietal Network. 1-Hz stimulation produced a significantly larger effect (g = 0.39) than the 10-Hz reference (g = 0.19); 5-Hz, 20-Hz and iTBS were also significantly positive (g = 0.30–0.49). In multivariate models, adding 10 rTMS sessions improved cognitive outcomes (Δg = +0.077), whereas increasing the number of pulses per session trended toward reduced efficacy. All effects were confirmed in a left dorsolateral prefrontal cortex subgroup analysis. Subjective cognition was measured in only 6% of studies. A multivariate prediction tool is introduced: https://amsali.shinyapps.io/tms_cognition_prediction/ Conclusion: This meta-analysis demonstrates the sustained efficacy of rTMS in enhancing cognitive function, with small-to-moderate effect sizes across diverse clinical populations and stimulation protocols. However, a significant gap remains regarding whether these objective neurocognitive gains translate into meaningful improvements in subjective cognition or functional outcomes.
SN - 1935-861X
SN - 1876-4754
ER -