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Comparative Study
. 2025 Jun;46(6):2479-2498.
doi: 10.1007/s10072-025-08000-5. Epub 2025 Feb 5.

Comparison of the efficacy of different protocols of repetitive transcranial magnetic stimulation and transcranial direct current stimulation on motor function, activities of daily living, and neurological function in patients with early stroke: a systematic review and network meta-analysis

Xueyi Ni  1 , Zinan Yuan  1 , Ruimou Xie  1 , Xiaoxue Zhai  1 , Xiang Cheng  1 , Yu Pan  2
Affiliations
Comparative Study

Comparison of the efficacy of different protocols of repetitive transcranial magnetic stimulation and transcranial direct current stimulation on motor function, activities of daily living, and neurological function in patients with early stroke: a systematic review and network meta-analysis

Xueyi Ni et al. Neurol Sci. 2025 Jun.

Abstract

Background: The application of transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) in patients with early stroke has recently received considerable attention, but the optimal protocol remains inconclusive. This study intends to evaluate and compare the effects of different protocols of tDCS and rTMS on improving motor function, activities of daily living (ADL), and neurological function in patients with early stroke, and to comprehensively assess their efficacy and safety.

Methods: MEDLINE, Embase, Cochrane Library, and Web of Science were searched. Risk of bias (RoB) was assessed using the Cochrane Risk of Bias 2.0 tool, and Bayesian NMA was conducted using R4.3.1 and Stata16.

Results: The results of NMA showed that after early intervention, bilateral application of high- and low-frequency rTMS (BL-rTMS) performed best in improving the upper extremity motor function at the end of intervention (SUCRA: 92.8%) and 3 months (SUCRA: 95.4%). Besides, low-frequency rTMS (LF-rTMS) performed best in improving the lower extremity motor function (SUCRA: 67.7%). BL-rTMS was the most effective in ameliorating the ADL at the end of intervention (SUCRA: 100%) and 3 months (SUCRA: 85.6%). In terms of the NIHSS scores, BL-rTMS had the highest probability of being the most effective measure at the end of intervention (SUCRA: 99.7%) and 3 months (SUCRA: 97.05%). Besides, LF-rTMS (0%), 5 Hz-rTMS (0%), and intermittent theta-burst stimulation (iTBS) (0%) all exhibited a good safety profile.

Conclusion: BL-rTMS is the optimal stimulation protocol for improving upper extremity motor function, ADL, and neurological function in early stroke, with long-term efficacy.

Keywords: ADL; Early stroke; Motor function; Network meta-analysis; rTMS; tDCS.

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Conflict of interest statement

Declarations. Ethical statement: As this was a systematic review and meta-analysis, ethical approval was not necessary. Consent to participate: Not applicable. Competing interests: The authors have no competing interests to declare that are relevant to the content of this article.

Figures

Fig. 1
Fig. 1
Flowchart of the study selection process
Fig. 2
Fig. 2
Quality assessment of selected studies by the Cochrane Risk of Bias Tool. A Risk of bias graph: review authors’ judgments about each risk of bias item presents as percentages across all included studies; B Risk of bias summary: review authors’ judgments about each risk of bias item for each included study
Fig. 3
Fig. 3
Network meta-analysis results for FMA-UE (end of treatment). A: Network plot; B: Forest plot; C: Cumulative probability ranking curve of different interventions; D: Funnel plot. HF-rTMS, high-frequency repetitive transcranial magnetic stimulation; LF-rTMS, low-frequency repetitive transcranial magnetic stimulation; BL-rTMS, bilateral application of HF- rTMS and LF-rTMS; cTBS, continuous theta-burst stimulation; iTBS, intermittent theta-burst stimulation; tDCS, transcranial direct current stimulation
Fig. 4
Fig. 4
Network meta-analysis results for FMA-UE (3 month follw-up). A: Network plot; B: Forest plot; C: Cumulative probability ranking curve of different interventions; D: Funnel plot. HF-rTMS, high-frequency repetitive transcranial magnetic stimulation; LF-rTMS, low-frequency repetitive transcranial magnetic stimulation; BL-rTMS, bilateral application of HF- rTMS and LF-rTMS; cTBS, continuous theta-burst stimulation; iTBS, intermittent theta-burst stimulation; tDCS, transcranial direct current stimulation
Fig. 5
Fig. 5
Network meta-analysis results for FMA-LE (end of treatment). A: Network plot; B: Forest plot; C: Cumulative probability ranking curve of different interventions; D: Funnel plot. HF-rTMS, high-frequency repetitive transcranial magnetic stimulation; LF-rTMS, low-frequency repetitive transcranial magnetic stimulation; tDCS, transcranial direct current stimulation
Fig. 6
Fig. 6
Network meta-analysis results for mBI (end of treatment). A: Network plot; B: Forest plot; C: Cumulative probability ranking curve of different interventions; D: Funnel plot. HF-rTMS, high-frequency repetitive transcranial magnetic stimulation; LF-rTMS, low-frequency repetitive transcranial magnetic stimulation; BL-rTMS, bilateral application of HF- rTMS and LF-rTMS; cTBS, continuous theta-burst stimulation; iTBS, intermittent theta-burst stimulation; tDCS, transcranial direct current stimulation
Fig. 7
Fig. 7
Network meta-analysis results for mBI (3 month follw-up) (A): Network plot; B: Forest plot; C: Cumulative probability ranking curve of different interventions; D: Funnel plot. HF-rTMS, high-frequency repetitive transcranial magnetic stimulation; LF-rTMS, low-frequency repetitive transcranial magnetic stimulation; BL-rTMS, bilateral application of HF- rTMS and LF-rTMS; cTBS, continuous theta-burst stimulation; iTBS, intermittent theta-burst stimulation; tDCS, transcranial direct current stimulation
Fig. 8
Fig. 8
Network meta-analysis results for NIHSS (end of treatment). A: Network plot; B: Forest plot; C: Cumulative probability ranking curve of different interventions; D: Funnel plot. HF-rTMS, high-frequency repetitive transcranial magnetic stimulation; LF-rTMS, low-frequency repetitive transcranial magnetic stimulation; BL-rTMS, bilateral application of HF- rTMS and LF-rTMS; iTBS, intermittent theta-burst stimulation; tDCS, transcranial direct current stimulation
Fig. 9
Fig. 9
Network meta-analysis results for NIHSS (3 month follw-up). A: Network plot; B: Forest plot; C: Cumulative probability ranking curve of different interventions; D: Funnel plot. HF-rTMS, high-frequency repetitive transcranial magnetic stimulation; LF-rTMS, low-frequency repetitive transcranial magnetic stimulation; BL-rTMS, bilateral application of HF- rTMS and LF-rTMS; iTBS, intermittent theta-burst stimulation; tDCS, transcranial direct current stimulation
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