Combined repetitive transcranial magnetic stimulation and mirror therapy for upper limb rehabilitation in stroke survivors: A systematic review and meta-analysis

Upper limb impairments are among the most prevalent consequences of stroke. Recently, repetitive transcranial magnetic stimulation (rTMS) and mirror therapy (MT) have been used in stroke rehabilitation. This systematic review aims to examine the effects of combining rTMS and MT on the upper limb in patients with stroke and define the optimal treatment parameters, if possible. “PubMed, MEDLINE, Scopus, CINAHL, PEDro, EMBASE, REHABDATA, and Web of Science” were searched until March 2026. Randomized controlled trials evaluating the effectiveness of combined rTMS and MT on the upper limb poststroke were included. The Cochrane Risk of Bias 2 (RoB 2) and the GRADE were employed to evaluate risk of bias and certainty of evidence, respectively. Meta-analysis and subgroup analysis were performed. Seven RCTs (402 participants) met the inclusion criteria. Significant improvements in the Fugl–Meyer Assessment for Upper Extremity (FMA-UE) (SMD = 0.92, 95% CI: 0.43–1.41, p = 0.0002) and the Box and Block Test (BBT) (SMD = 1.09, 95% CI: 0.49–1.68, p = 0.0003) were reported. Other outcomes demonstrated improvements in pinch grip, hand grip, functional performance, motor impairment, and muscle tone. The preliminary findings suggest that combining rTMS and MT has potential effects on enhancing upper limb function poststroke; however, these results should be interpreted with caution. The most effective treatment parameters remain unclear. Further high-quality studies are warranted. © Fondazione Società Italiana di Neurologia 2026.