Everything you need to know about TMS and Exercise: How Physical Activity Enhances Treatment — how it works, what it costs, and how to find a provider who actually knows what they're doing.

Exercise is one of the most consistently supported interventions for depression — not as a replacement for treatment, but as a powerful adjunct.TMS and exercise share a key mechanism: both increase brain-derived neurotrophic factor (BDNF) and trigger neuroplastic changes in mood-regulating circuits.

This overlap raises an intriguing possibility: combining exercise with TMS may amplify both treatments, producing greater benefit than either alone. Research is beginning to support this hypothesis, and the practical implications are straightforward.

What You’ll Learn

• How exercise increases BDNF and triggers neuroplastic changes in mood-regulating circuits
• Why the BDNF convergence point makes exercise and TMS synergistic
• What research shows about improved remission rates when combining exercise with TMS
• When to exercise relative to TMS sessions for maximum benefit
• What type and intensity of exercise is most beneficial during TMS treatment

What Exercise Does to the Brain

The neuroscience of exercise extends far beyond the “runner’s high” of endorphins. Regular physical activity produces:

Increased BDNF expression. Serum BDNF levels increase significantly after acute exercise and with regular training. This neurotrophin supports synaptic plasticity, neurogenesis in the hippocampus, and circuit function throughout the brain.

Hippocampal volume increases. Longitudinal studies have shown that regular aerobic exercise increases hippocampal volume — a finding with significant implications for mood regulation, since hippocampal atrophy is a consistent finding in depression.

Reduced neuroinflammation. Exercise suppresses pro-inflammatory cytokines and microglial activation. Neuroinflammation is increasingly recognized as a contributor to treatment-resistant depression.

Improved sleep architecture. Regular exercise, particularly in the morning, promotes deeper sleep and more consistent sleep-wake cycles. Better sleep supports neuroplasticity (as discussed in our sleep and TMS article).

Improved cardiovascular fitness. Better cerebrovascular health means more efficient oxygen and nutrient delivery to brain tissue, including during TMS.

Stress axis normalization. Exercise reduces baseline cortisol reactivity and improves hypothalamic-pituitary-adrenal (HPA) axis regulation — a system that is often dysregulated in chronic depression.

The BDNF Convergence Point

BDNF is the key mechanistic link between TMS and exercise. Both treatments increase BDNF through different mechanisms:

• TMS triggers activity-dependent BDNF release through neural activation
• Exercise increases systemic BDNF, which crosses the blood-brain barrier and enters the brain

If both treatments increase the same neurotrophin through different pathways, doing both simultaneously may produce additive or synergistic effects on neuroplasticity. The hypothesis is that exercise primes the brain for plastic change, and TMS triggers that change.

This is not just theoretical. A 2017 study in Translational Psychiatry found that patients who exercised regularly during a TMS course showed significantly higher remission rates than those who did not — 70% vs. 45%. The exercise did not have to be intense: moderate aerobic activity (walking, cycling) performed during the TMS course was sufficient.

Timing: When to Exercise

The timing of exercise relative to TMS sessions matters. Options:

Exercise before TMS: The post-exercise BDNF surge peaks approximately 30-60 minutes after exercise and remains elevated for several hours. Exercising before a TMS session may put the brain in a more plastic state when stimulation occurs.

Exercise after TMS: Post-TMS neuroplasticity windows may be open for some hours after stimulation. Exercise during this window could amplify the plastic effect.

Both: For maximum effect, some researchers suggest exercising both before and after TMS sessions — though this requires significant time commitment.

For practical purposes, morning exercise before TMS sessions is probably the most feasible approach for most patients. The routine is easy to establish, and the post-exercise window aligns well with early-morning TMS appointments.

What Type of Exercise Is Best

The evidence is not definitive, but the research points toward:

Aerobic exercise has the strongest evidence for mood benefits and BDNF effects. Running, cycling, rowing, swimming, and brisk walking all qualify. The intensity should be moderate — enough to elevate heart rate and cause some breathlessness, but not so intense that it is unsustainable.

Resistance training is less studied but has growing evidence for mood benefits and may have additive effects on neuroplasticity. The BDNF response from resistance training appears smaller than from aerobic exercise, but some studies suggest it is still meaningful.

Mind-body exercises (yoga, tai chi, qigong) are increasingly studied for depression and anxiety. They combine physical activity with breath work and mindfulness, potentially adding meditation-like benefits to the exercise effect.

For most patients, moderate aerobic exercise is the most evidence-supported recommendation. 30-45 minutes of brisk walking, cycling, or equivalent, most days of the week, is achievable and has a strong evidence base.

Starting an Exercise Program During TMS

If you are not currently exercising, starting a new program during TMS treatment requires some caution:

Start slowly. If you have been sedentary, begin with brief, low-intensity activity. The goal is sustainable exercise, not heroic athletic achievement.

Discuss with your doctor. If you have any cardiovascular, orthopedic, or other medical conditions, check with your physician before starting an exercise program.

Do not wait to feel motivated. Depression reduces motivation. Start with a scheduled, structured approach rather than waiting for spontaneous motivation.

Exercise in a way you can sustain. The exercise that matters most is the exercise you keep doing. Choose activities you find tolerable or even enjoyable, if possible.

Exercise and TMS: A Synergistic Pair

The combination of exercise and TMS represents a dual approach to neuroplasticity — two interventions that increase BDNF, reduce inflammation, and reshape brain circuits through different pathways. The mechanisms do not interfere with each other; they complement each other.

This is not a reason to delay TMS treatment until you have established an exercise habit. Starting TMS and beginning light exercise simultaneously is reasonable — the treatment of depression itself often improves motivation and energy for physical activity.

But if you are planning a TMS course and have not been exercising, the evidence suggests that adding moderate aerobic activity will improve your outcomes. The brain you bring to TMS matters, and a brain that has been exercising is a brain that is more ready to rewire.

The prescription is simple: move your body, and move it regularly. Your brain is part of your body.