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Completion rate and safety of non-invasive brain stimulation for upper limb dysfunction after stroke: a systematic review and network meta-analysis.

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Title: Completion rate and safety of non-invasive brain stimulation for upper limb dysfunction after stroke: a systematic review and network meta-analysis.
Authors: Sun J; Xinxiang Medical University, Xinxiang, China., Wang Z; Xinxiang Medical University, Xinxiang, China., Huang Y; Xinxiang Medical University, Xinxiang, China., Du Y; Xinxiang Medical University, Xinxiang, China., Zhang S; Xinxiang Medical University, Xinxiang, China., Shen H; Xinxiang Medical University, Xinxiang, China., Zhang H; Xinxiang Medical University, Xinxiang, China., Feng S; Xinxiang First People's Hospital, Xinxiang, China.
Source: Frontiers in neurology [Front Neurol] 2026 Sep 09; Vol. 17, pp. 1853609. Date of Electronic Publication: 2026 Sep 09 (Print Publication: 2026).
Publication Type: Journal Article; Systematic Review; Network Meta-Analysis
Language: English
Journal Info: Publisher: Frontiers Research Foundation Country of Publication: Switzerland NLM ID: 101546899 Publication Model: eCollection Cited Medium: Internet ISSN: 1664-2295 (Electronic) Linking ISSN: 16642295 NLM ISO Abbreviation: Front Neurol Subsets: MEDLINE
Imprint Name(s): Original Publication: [Lausanne : Frontiers Research Foundation, 2010]-
MeSH Terms: Stroke*/therapy , Stroke*/complications , Stroke*/physiopathology , Upper Extremity*/physiopathology , Transcranial Magnetic Stimulation*/methods , Transcranial Magnetic Stimulation*/adverse effects , Stroke Rehabilitation*/methods , Transcranial Direct Current Stimulation*/methods , Transcranial Direct Current Stimulation*/adverse effects, Humans
Abstract: Non-invasive brain stimulation (NIBS), including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), has been widely used as an adjunctive intervention for upper limb motor recovery after stroke; however, the treatment completion rates and comparative safety profiles across different NIBS modalities have not been systematically evaluated. This systematic review and network meta-analysis aimed to assess and compare the treatment completion rates of various NIBS interventions for post-stroke upper limb rehabilitation. We systematically searched six databases and trial registries (PubMed, Embase, Cochrane CENTRAL, CINAHL, WHO ICTRP, and ClinicalTrials.gov) for randomized controlled trials (RCTs) published up to January 20, 2025, with an updated search conducted to April 15, 2026. Random-effects single-arm meta-analyses using the Freeman-Tukey double arcsine transformation were performed to pool completion rates, and a Bayesian random-effects network meta-analysis estimated relative risks (RRs) with 95% credible intervals (CrIs); treatments were ranked using surface under the cumulative ranking curve (SUCRA) values. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. The protocol was registered with PROSPERO (CRD420261309536). Fifty-five RCTs comprising 68 comparisons and 2,640 participants were included. The pooled intervention group completion rate was 94.9% (95% CI: 93.3-96.4%; I2 = 46.8%). The network meta-analysis showed no statistically significant differences in completion rate between any NIBS intervention and sham/control (all 95% CrIs included 1.00). SUCRA rankings indicated that intermittent theta burst stimulation (iTBS; 71.1%), bilateral rTMS (BL-rTMS; 60.9%), and dual transcranial direct current stimulation (Dual-tDCS; 58.1%) ranked highest. The overall adverse event (AE) rate was 16.4% (95% CI: 8.5-26.2%) in intervention groups, predominantly mild headache and skin tingling, with an AE-related dropout rate of only 1.1%. Subgroup analyses showed higher completion rates for tDCS (96.8%) than rTMS (93.9%), with the chronic phase highest (97.1%) and the mixed phase lowest (89.1%). The LFK index was 0.04, indicating no publication bias. In conclusion, NIBS for post-stroke upper limb rehabilitation demonstrates favorable tolerability and safety, with an overall completion rate of approximately 95%. Exploratory SUCRA rankings placed iTBS, BL-rTMS, and Dual-tDCS in the top three positions; however, these rankings should be considered hypothesis-generating rather than definitive, as four interventions were informed by only a single study, absolute differences in completion rates were minimal, and all pairwise credible intervals included 1.00. These observed phase-specific differences suggest that stroke phase may be an important factor to consider when designing adherence strategies, although prospective evaluation of tailored interventions is needed.
Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420261309536, PROSPERO (Registration ID: CRD420261309536).
(Copyright © 2026 Sun, Wang, Huang, Du, Zhang, Shen, Zhang and Feng.)
Competing Interests: The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Contributed Indexing: Keywords: network meta-analysis; non-invasive brain stimulation; repetitive transcranial magnetic stimulation; safety; stroke; transcranial direct current stimulation; treatment completion rate; upper limb
Entry Date(s): Date Created: 20260924 Date Completed: 20260924 Latest Revision: 20260926
Update Code: 20260926
PubMed Central ID: PMC13597372
DOI: 10.3389/fneur.2026.1853609
PMID: 42780542
Database: MEDLINE
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  Data: Completion rate and safety of non-invasive brain stimulation for upper limb dysfunction after stroke: a systematic review and network meta-analysis.
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  Data: <searchLink fieldCode="AU" term="%22Sun+J%22">Sun J</searchLink>; Xinxiang Medical University, Xinxiang, China.<br /><searchLink fieldCode="AU" term="%22Wang+Z%22">Wang Z</searchLink>; Xinxiang Medical University, Xinxiang, China.<br /><searchLink fieldCode="AU" term="%22Huang+Y%22">Huang Y</searchLink>; Xinxiang Medical University, Xinxiang, China.<br /><searchLink fieldCode="AU" term="%22Du+Y%22">Du Y</searchLink>; Xinxiang Medical University, Xinxiang, China.<br /><searchLink fieldCode="AU" term="%22Zhang+S%22">Zhang S</searchLink>; Xinxiang Medical University, Xinxiang, China.<br /><searchLink fieldCode="AU" term="%22Shen+H%22">Shen H</searchLink>; Xinxiang Medical University, Xinxiang, China.<br /><searchLink fieldCode="AU" term="%22Zhang+H%22">Zhang H</searchLink>; Xinxiang Medical University, Xinxiang, China.<br /><searchLink fieldCode="AU" term="%22Feng+S%22">Feng S</searchLink>; Xinxiang First People's Hospital, Xinxiang, China.
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  Data: <searchLink fieldCode="JN" term="%22101546899%22">Frontiers in neurology</searchLink> [Front Neurol] 2026 Sep 09; Vol. 17, pp. 1853609. <i>Date of Electronic Publication: </i>2026 Sep 09 (<i>Print Publication: </i>2026).
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  Data: Journal Article; Systematic Review; Network Meta-Analysis
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  Data: <i>Publisher: </i><searchLink fieldCode="PB" term="%22Frontiers+Research+Foundation%22">Frontiers Research Foundation </searchLink><i>Country of Publication: </i>Switzerland <i>NLM ID: </i>101546899 <i>Publication Model: </i>eCollection <i>Cited Medium: </i>Internet <i>ISSN: </i>1664-2295 (Electronic) <i>Linking ISSN: </i><searchLink fieldCode="IS" term="%2216642295%22">16642295 </searchLink><i>NLM ISO Abbreviation: </i>Front Neurol <i>Subsets: </i>MEDLINE
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  Data: <i>Original Publication</i>: [Lausanne : Frontiers Research Foundation, 2010]-
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  Data: <searchLink fieldCode="MM" term="%22Stroke%22">Stroke*</searchLink>/<searchLink fieldCode="MM" term="%22Stroke+therapy%22">therapy</searchLink> <br /><searchLink fieldCode="MM" term="%22Stroke%22">Stroke*</searchLink>/<searchLink fieldCode="MM" term="%22Stroke+complications%22">complications</searchLink> <br /><searchLink fieldCode="MM" term="%22Stroke%22">Stroke*</searchLink>/<searchLink fieldCode="MM" term="%22Stroke+physiopathology%22">physiopathology</searchLink> <br /><searchLink fieldCode="MM" term="%22Upper+Extremity%22">Upper Extremity*</searchLink>/<searchLink fieldCode="MM" term="%22Upper+Extremity+physiopathology%22">physiopathology</searchLink> <br /><searchLink fieldCode="MM" term="%22Transcranial+Magnetic+Stimulation%22">Transcranial Magnetic Stimulation*</searchLink>/<searchLink fieldCode="MM" term="%22Transcranial+Magnetic+Stimulation+methods%22">methods</searchLink> <br /><searchLink fieldCode="MM" term="%22Transcranial+Magnetic+Stimulation%22">Transcranial Magnetic Stimulation*</searchLink>/<searchLink fieldCode="MM" term="%22Transcranial+Magnetic+Stimulation+adverse+effects%22">adverse effects</searchLink> <br /><searchLink fieldCode="MM" term="%22Stroke+Rehabilitation%22">Stroke Rehabilitation*</searchLink>/<searchLink fieldCode="MM" term="%22Stroke+Rehabilitation+methods%22">methods</searchLink> <br /><searchLink fieldCode="MM" term="%22Transcranial+Direct+Current+Stimulation%22">Transcranial Direct Current Stimulation*</searchLink>/<searchLink fieldCode="MM" term="%22Transcranial+Direct+Current+Stimulation+methods%22">methods</searchLink> <br /><searchLink fieldCode="MM" term="%22Transcranial+Direct+Current+Stimulation%22">Transcranial Direct Current Stimulation*</searchLink>/<searchLink fieldCode="MM" term="%22Transcranial+Direct+Current+Stimulation+adverse+effects%22">adverse effects</searchLink><br /><searchLink fieldCode="MH" term="%22Humans%22">Humans</searchLink>
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Non-invasive brain stimulation (NIBS), including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), has been widely used as an adjunctive intervention for upper limb motor recovery after stroke; however, the treatment completion rates and comparative safety profiles across different NIBS modalities have not been systematically evaluated. This systematic review and network meta-analysis aimed to assess and compare the treatment completion rates of various NIBS interventions for post-stroke upper limb rehabilitation. We systematically searched six databases and trial registries (PubMed, Embase, Cochrane CENTRAL, CINAHL, WHO ICTRP, and ClinicalTrials.gov) for randomized controlled trials (RCTs) published up to January 20, 2025, with an updated search conducted to April 15, 2026. Random-effects single-arm meta-analyses using the Freeman-Tukey double arcsine transformation were performed to pool completion rates, and a Bayesian random-effects network meta-analysis estimated relative risks (RRs) with 95% credible intervals (CrIs); treatments were ranked using surface under the cumulative ranking curve (SUCRA) values. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. The protocol was registered with PROSPERO (CRD420261309536). Fifty-five RCTs comprising 68 comparisons and 2,640 participants were included. The pooled intervention group completion rate was 94.9% (95% CI: 93.3-96.4%; I<superscript>2</superscript> = 46.8%). The network meta-analysis showed no statistically significant differences in completion rate between any NIBS intervention and sham/control (all 95% CrIs included 1.00). SUCRA rankings indicated that intermittent theta burst stimulation (iTBS; 71.1%), bilateral rTMS (BL-rTMS; 60.9%), and dual transcranial direct current stimulation (Dual-tDCS; 58.1%) ranked highest. The overall adverse event (AE) rate was 16.4% (95% CI: 8.5-26.2%) in intervention groups, predominantly mild headache and skin tingling, with an AE-related dropout rate of only 1.1%. Subgroup analyses showed higher completion rates for tDCS (96.8%) than rTMS (93.9%), with the chronic phase highest (97.1%) and the mixed phase lowest (89.1%). The LFK index was 0.04, indicating no publication bias. In conclusion, NIBS for post-stroke upper limb rehabilitation demonstrates favorable tolerability and safety, with an overall completion rate of approximately 95%. Exploratory SUCRA rankings placed iTBS, BL-rTMS, and Dual-tDCS in the top three positions; however, these rankings should be considered hypothesis-generating rather than definitive, as four interventions were informed by only a single study, absolute differences in completion rates were minimal, and all pairwise credible intervals included 1.00. These observed phase-specific differences suggest that stroke phase may be an important factor to consider when designing adherence strategies, although prospective evaluation of tailored interventions is needed.<br />Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420261309536, PROSPERO (Registration ID: CRD420261309536).<br /> (Copyright © 2026 Sun, Wang, Huang, Du, Zhang, Shen, Zhang and Feng.)
– Name: Abstract
  Label: Competing Interests
  Group: Ab
  Data: The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
– Name: Ref
  Label: References
  Group: RefInfo
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– Name: SubjectMinor
  Label: Contributed Indexing
  Group:
  Data: <i>Keywords: </i>network meta-analysis; non-invasive brain stimulation; repetitive transcranial magnetic stimulation; safety; stroke; transcranial direct current stimulation; treatment completion rate; upper limb
– Name: DateEntry
  Label: Entry Date(s)
  Group: Date
  Data: <i>Date Created: </i>20260924 <i>Date Completed: </i>20260924 <i>Latest Revision: </i>20260926
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  Label: Update Code
  Group: Date
  Data: 20260926
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  Data: PMC13597372
– Name: DOI
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  Group: ID
  Data: 10.3389/fneur.2026.1853609
– Name: AN
  Label: PMID
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  Data: 42780542
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=cmedm&AN=42780542
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    Identifiers:
      – Type: doi
        Value: 10.3389/fneur.2026.1853609
    Languages:
      – Code: eng
        Text: English
    PhysicalDescription:
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        StartPage: 1853609
    Subjects:
      – SubjectFull: Humans
        Type: general
      – SubjectFull: Stroke therapy
        Type: general
      – SubjectFull: Stroke complications
        Type: general
      – SubjectFull: Stroke physiopathology
        Type: general
      – SubjectFull: Upper Extremity physiopathology
        Type: general
      – SubjectFull: Transcranial Magnetic Stimulation methods
        Type: general
      – SubjectFull: Transcranial Magnetic Stimulation adverse effects
        Type: general
      – SubjectFull: Stroke Rehabilitation methods
        Type: general
      – SubjectFull: Transcranial Direct Current Stimulation methods
        Type: general
      – SubjectFull: Transcranial Direct Current Stimulation adverse effects
        Type: general
    Titles:
      – TitleFull: Completion rate and safety of non-invasive brain stimulation for upper limb dysfunction after stroke: a systematic review and network meta-analysis.
        Type: main
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            NameFull: Sun J
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          Dates:
            – D: 09
              M: 09
              Text: 2026 Sep 09
              Type: published
              Y: 2026
          Identifiers:
            – Type: issn-electronic
              Value: 1664-2295
          Numbering:
            – Type: volume
              Value: 17
          Titles:
            – TitleFull: Frontiers in neurology
              Type: main
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