Efficacy of Repetitive Transcranial Magnetic Stimulation on Lower Extremity Motor Function in Spinal Cord Injury: A Meta-Analysis of Randomized Controlled Trials

Background Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation therapy used to improve lower extremity motor function in patients with spinal cord injury (SCI). However, its efficacy remains inconsistent. Objective This meta-analysis aimed to comprehensively assess the effectiveness and safety of rTMS for lower extremity motor function, spasticity, and walking ability in SCI patients. Methods Up to April 30, 2025, randomized controlled trials (RCTs) were searched by PubMed, Web of Science, MEDLINE, Ovid, and the Cochrane Central Register of Controlled Trials. Primary outcomes were Lower Extremity Motor Score (LEMS) and Lower Modified Ashworth Scale (LMAS); secondary outcomes included Spinal Cord Assessment Tool for Spasticity (SCATS), Hmax/Mmax amplitude ratio (H/M ratio), 10-Meter Walking Test (10 WMT), Walking Index for Spinal Cord Injury-II (WISCI-II), and gait velocity. Subgroup analyses were performed by injury duration. Results Fifteen RCTs (260 participants) were included. rTMS significantly improved lower extremity strength measured by LEMS (SMD = 0.98, 95% CI = 0.61 to 1.36, P < 0.00001) regardless of injury duration and decrease spasticity measured by LMAS (SMD = −0.46, 95% CI = −0.85 to −0.08, P = 0.02). No significant changes were found for spasticity assessed by SCATS or H/M ratio, or for walking outcomes (10MWT, WISCI-II, gait velocity). Conclusion rTMS effectively enhances muscle strength and reduces spasticity in SCI patients, but its impact on walking ability is limited. Further high-quality trials are needed to confirm these findings.