Effect of repetitive transcranial magnetic stimulation modulating supplementary motor area in stroke rehabilitation: Systematic review of randomized controlled trials

Ayesha Juhi; Shreya Sharma; Dinesh Bhatia; Suman Dhaka; Rajesh Kumar; Deepak Kumar; Rintu Kumar Gayen; Himel Mondal; Ayesha Juhi; Shreya Sharma; Dinesh Bhatia; Suman Dhaka; Rajesh Kumar; Deepak Kumar; Rintu Kumar Gayen; Himel Mondal

doi:10.3934/Neuroscience.2026003

AIMS Neuroscience

2026, Volume 13, Issue 1: 50-63. doi: 10.3934/Neuroscience.2026003

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Review

Effect of repetitive transcranial magnetic stimulation modulating supplementary motor area in stroke rehabilitation: Systematic review of randomized controlled trials

1.
Department of Physiology, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
2.
Neuromodulation Laboratory, Department of Physiology, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
3.
Department of Biomedical Engineering, North-Eastern Hill University, Shillong, Meghalaya, India
4.
School of Liberal Arts and Center for Brain Science and Application, Indian Institute of Technology, Jodhpur, India
5.
Department of Internal Medicine, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
6.
Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
7.
Electronics and Communication Engineering, Institute of Engineering and Management, Kolkata, India

Received: 25 September 2025 Revised: 01 December 2025 Accepted: 06 January 2026 Published: 28 January 2026

Background
Repetitive transcranial magnetic stimulation (rTMS) is a promising adjunct in stroke rehabilitation, with increasing focus on the supplementary motor area (SMA) for its role in motor and language network reorganization. This systematic review evaluated randomized controlled trials (RCTs) assessing rTMS targeting the SMA or modulating its connectivity to improve motor and language outcomes in adults after ischemic or hemorrhagic stroke.
Methods
A comprehensive literature search was performed across PubMed, Web of Science, and Google Scholar, focusing on peer-reviewed RCTs published in English. Studies were eligible if they involved adults with stroke at any recovery stage and assessed rTMS targeting or analyzing the SMA. Two independent reviewers screened records, extracted data, and assessed risk of bias using the Cochrane Risk of Bias 2.0 tool. The review adhered to PRISMA guidelines and was registered in PROSPERO (CRD420251051684).
Results
Among 74 screened for full text, five RCTs were included. Across studies, rTMS interventions targeting the SMA or modulating SMA-related networks improved motor and language outcomes in stroke patients. Neuroimaging measures consistently demonstrated increased SMA activation and strengthened SMA-primary motor cortex (M1) connectivity after rTMS, which correlated with clinical improvements. Balance and postural control outcomes showed the most consistent benefits, while upper-limb motor and language improvements varied in magnitude and follow-up duration.
Conclusion
Heterogeneity in studies, small sample sizes, and concerns about randomization and reporting limit our ability to draw definitive conclusions. SMA-targeted or network-level rTMS appears to facilitate functional recovery after stroke, supported by neuroimaging evidence of brain network reorganization. Further large, standardized RCTs are necessary to establish optimal protocols, confirm efficacy, and assess long-term outcomes.
- stroke rehabilitation,
- supplementary motor area,
- repetitive transcranial magnetic stimulation,
- functional connectivity,
- balance,
- motor recovery
Citation: Ayesha Juhi, Shreya Sharma, Dinesh Bhatia, Suman Dhaka, Rajesh Kumar, Deepak Kumar, Rintu Kumar Gayen, Himel Mondal. Effect of repetitive transcranial magnetic stimulation modulating supplementary motor area in stroke rehabilitation: Systematic review of randomized controlled trials[J]. AIMS Neuroscience, 2026, 13(1): 50-63. doi: 10.3934/Neuroscience.2026003

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Abstract

Background

Repetitive transcranial magnetic stimulation (rTMS) is a promising adjunct in stroke rehabilitation, with increasing focus on the supplementary motor area (SMA) for its role in motor and language network reorganization. This systematic review evaluated randomized controlled trials (RCTs) assessing rTMS targeting the SMA or modulating its connectivity to improve motor and language outcomes in adults after ischemic or hemorrhagic stroke.

Methods

A comprehensive literature search was performed across PubMed, Web of Science, and Google Scholar, focusing on peer-reviewed RCTs published in English. Studies were eligible if they involved adults with stroke at any recovery stage and assessed rTMS targeting or analyzing the SMA. Two independent reviewers screened records, extracted data, and assessed risk of bias using the Cochrane Risk of Bias 2.0 tool. The review adhered to PRISMA guidelines and was registered in PROSPERO (CRD420251051684).

Results

Among 74 screened for full text, five RCTs were included. Across studies, rTMS interventions targeting the SMA or modulating SMA-related networks improved motor and language outcomes in stroke patients. Neuroimaging measures consistently demonstrated increased SMA activation and strengthened SMA-primary motor cortex (M1) connectivity after rTMS, which correlated with clinical improvements. Balance and postural control outcomes showed the most consistent benefits, while upper-limb motor and language improvements varied in magnitude and follow-up duration.

Conclusion

Heterogeneity in studies, small sample sizes, and concerns about randomization and reporting limit our ability to draw definitive conclusions. SMA-targeted or network-level rTMS appears to facilitate functional recovery after stroke, supported by neuroimaging evidence of brain network reorganization. Further large, standardized RCTs are necessary to establish optimal protocols, confirm efficacy, and assess long-term outcomes.

Acknowledgments

This work is part of an Indian Council of Medical Research-funded project with project number IIRP–2023–4339.

Conflict of interest

The authors declare no conflict of interest.

Authors' contributions

Ayesha Juhi: Contributed to data acquisition and collection; critically revised the manuscript for intellectual content; approved the final version; agrees to be accountable for all aspects of the work; Shreya Sharma: Led conceptualization, study design, data analysis, and interpretation; drafted and critically revised the manuscript; approved the final version; agrees to be accountable for all aspects of the work; Dinesh Bhatia: Contributed to study design, data analysis, and interpretation; critically revised the manuscript; approved the final version; agrees to be accountable for all aspects of the work; Suman Dhaka: Contributed to data acquisition and collection; critically revised the manuscript; approved the final version; agrees to be accountable for all aspects of the work; Rajesh Kumar: Contributed to data acquisition and collection; critically revised the manuscript; approved the final version; agrees to be accountable for all aspects of the work; Deepak Kumar: Contributed to data acquisition and collection; critically revised the manuscript; approved the final version; agrees to be accountable for all aspects of the work; Rintu Kumar Gayen: Contributed to data acquisition and collection; critically revised the manuscript; approved the final version; agrees to be accountable for all aspects of the work; Himel Mondal: Led conceptualization, study design, data analysis, and interpretation; drafted and critically revised the manuscript; supervised the project; approved the final version; agrees to be accountable for all aspects of the work. All authors approved the final version for publication.

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