Transdiagnostic Efficacy, Durability, and Optimal Parameters of rTMS for Cognitive Rehabilitation: A Comprehensive Meta-Analysis.
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 (5,972 participants) were extracted. Real rTMS produced a significant cognitive enhancement (g=0.28, p<0.0001, I2=37.3%). This was durable over 2-52 weeks follow-up. There was efficacy across all cognitive domains (g>0.20, I2=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.