Neurophysiological assessment of stroke recovery after repetitive transcranial magnetic stimulation

Abstract

Stroke is a major cerebrovascular disorder that commonly causes motor and cognitive impairments, significantly affecting the quality of life of stroke survivors. Upper-limb dysfunction is one of the most frequent complications after stroke, affecting nearly 77% of patients and limiting their ability to perform daily activities independently. In recent years, repetitive transcranial magnetic stimulation (rTMS), a non-invasive brain stimulation technique, has gained increasing attention as a potential therapeutic approach for improving upper-limb motor recovery after stroke. This narrative review aims to discuss the neurophysiological basis of rTMS-induced motor recovery and examine the role of neurophysiological biomarkers in evaluating treatment outcomes. Relevant literature was identified through searches of electronic databases, including PubMed, Scopus, and Google Scholar, focusing on studies related to rTMS, cortical excitability, electroencephalography (EEG), heart rate variability (HRV), and post-stroke motor recovery. Current evidence suggests that rTMS may promote recovery by modulating cortical excitability, restoring interhemispheric balance, and influencing functional connectivity and autonomic regulation. Neurophysiological measures such as TMS-derived cortical excitability parameters, EEG activity, and HRV indices may help understand the mechanisms underlying recovery and the therapeutic effects of rTMS. However, studies integrating these neurophysiological measures remain limited. This review highlights the importance of combining neurophysiological assessments with rTMS to better understand post-stroke recovery mechanisms and support the development of more targeted rehabilitation strategies.