Repetitive transcranial magnetic stimulation combined with cognitive training for cognitive function and activities of daily living in patients with post-stroke cognitive impairment: A systematic review and meta-analysis

Background: Despite the potential effect of repetitive transcranial magnetic stimulation (rTMS) combined with cognitive training for post-stroke cognitive impairment (PSCI), there is uncertainty regarding rTMS combined with cognitive training for PSCI.Objective: To determine the effectiveness of rTMS combined with cognitive training for improving global cognitive function, specific domains of cognitive function and activities of daily living (ADL) in patients with PSCI.Methods: Databases including Cochrane Central, EMBASE (Ovid SP), CHINAL, APA PsycINFO, EBSCO, Medline, Web of science and other sources were systematically searched on March 23, 2022, and updated on December 5, 2022. All randomized controlled trials (RCTs) applied rTMS + cognitive training for patients with PSCI were screened for inclusion.Results: A total of 8 trials was finally included and 336 participants provided data for meta-analyses. Large effects were found for rTMS + cognitive training on global cognition (g=0.780, 95 % CI=0.477-1.083), executive function (g=0.769, 95 % CI=0.291-1.247), working memory (g=0.609, 95 % CI=0.158-1.061) and medium improvement on ADL (g=0.418, 95 % CI=0.058-0.778) were seen. While, no effects were found on memory or attention. Subgroup analyses showed that combinations of phase of stroke onset, rTMS frequency, stimulation site and stimulation sessions were potent factors that modulate the effects of rTMS + cognitive training for cognitive function. Conclusions: The pooled data showed more positive effects of rTMS + cognitive training for global cognition, executive function, working memory and ADL in patients with PSCI. While, robust evidence of rTMS + cognitive training for global cognition, executive function, working memory and ADL from the Grade recommendations is lacking. Further, rTMS + cognitive training did not show no better effects on memory. Future definitive trials are needed to determine the benefits of rTMS + cognitive training for cognitive function and ADL in the field of PSCI.