SignificanceInterhemispheric imbalance after stroke impedes motor recovery. Although repetitive transcranial magnetic stimulation (rTMS) shows therapeutic potential, the neural mechanisms underlying its effects—particularly on cortical excitability and interhemispheric interaction—remain unclear. Understanding these mechanisms is essential for optimizing personalized neuromodulation strategies in stroke rehabilitation.AimTo explore how low-frequency rTMS facilitates motor recovery post-stroke, especially in regulating interhemispheric inhibition (IHI), functional connectivity, and cortical excitability, we used a multimodal approach that included paired-pulse TMS, functional near-infrared spectroscopy (fNIRS), and motor outcomes.ApproachA total of 27 patients with stroke were randomized to receive 2 weeks of either real (n=14) or sham (n=13) 1 Hz rTMS over the contralesional primary motor cortex (M1). Paired-pulse TMS was used to measure IHI and laterality quotient (LQ), whereas fNIRS was used to measure resting-state functional connectivity (RSFC). Clinical scales were also used to assess behavioral-level motor functioning.ResultsCompared with the sham group, rTMS significantly modulated IHI, as evidenced by a reduction in inhibitory drive from the stimulated contralesional M1 to ipsilesional M1 (mean difference = 15.57%, p=0.048). In parallel, RSFC analysis revealed decreased connectivity from contralesional M1 to ipsilesional premotor and supplementary motor areas [F(2,50)=7.704, p=0.006, false discovery rate–corrected]. Between-group comparisons further showed greater LQ improvements in the rTMS group than in the sham group. Changes in selected neurophysiological measures were significantly correlated with improvements in upper limb motor function.ConclusionsWe showed that low-frequency rTMS promotes motor recovery after stroke by rebalancing cortical excitability and reducing maladaptive connectivity patterns. The integration of TMS and fNIRS provides converging evidence for rTMS-induced cortical plasticity and highlights the potential of these tools for guiding personalized neuromodulation strategies in stroke rehabilitation.

Background/Objectives: Upper limb rehabilitation in chronic stroke is often suboptimal, and somatosensory integration is frequently neglected. The aim of this study was to investigate the feasibility and potential effects of an integrated sensorimotor therapy. Methods: Individuals with chronic stroke and persistent sensorimotor and functional upper limb deficits were included. For four weeks, participants received standard care (control), followed by 48 h of integrated sensorimotor upper limb therapy (ROBUST) over four weeks in addition to their standard care (intervention). ROBUST combined robotic, therapist-led, and home exercises. Feasibility was assessed through adherence, motivation, experiences, and adverse events. Potential effects of the intervention were evaluated via a multimodal assessment approach at baseline (T1), post-control (T2), and post-intervention (T3), with the Action Research Arm Test (ARAT) as the primary outcome. Results: Ten participants were included in this study, of whom nine completed the protocol. Therapy session adherence was 100%, and home program adherence 67%. Motivation remained stable over the intervention period, participants were positive, and no adverse events occurred. Six participants (67%) improved more than the minimal clinically important difference for ARAT, with further relevant improvements in clinical, kinematic, and patient-reported outcomes observed. Conclusions: The novel integrated sensorimotor upper limb therapy (ROBUST) is feasible and shows promising potential for people after stroke in the chronic stage. A randomised controlled trial is warranted. Trial registration: (identifier: NCT06870682).