Abstract / Summary
Motor recovery after stroke is associated with changes in corticospinal integrity, intracortical excitability, and interhemispheric interactions. Transcranial magnetic stimulation (TMS) provides neurophysiological measures of these processes, but their relationship with motor recovery across randomized controlled trials remains uncertain. This systematic review synthesized evidence from randomized controlled trials investigating TMS-derived neurophysiological measures associated with motor recovery following TMS-based neuromodulation after stroke. PubMed/MEDLINE, Scopus, and Embase were searched for studies published between January 1, 2016, and July 10, 2026. Eligible trials enrolled adults with ischemic or hemorrhagic stroke, assessed at least one TMS-derived neurophysiological measure, and reported a motor or functional outcome. Study selection followed PRISMA 2020, risk of bias was assessed using Cochrane RoB 2, and certainty of evidence was evaluated using GRADE. Owing to methodological heterogeneity, findings were synthesized narratively. The search identified 1441 records; after removal of 519 duplicates, 922 records were screened, 55 full-text reports were assessed, and 16 randomized controlled trials were included. Motor evoked potential (MEP) amplitude, MEP status, and resting motor threshold were the most frequently reported measures. Several trials found that changes in corticospinal excitability accompanied improvements in upper-limb function, activities of daily living, gait, or balance. One trial found greater motor gains among participants with preserved baseline MEPs; however, the contemporary randomized-trial evidence is insufficient to establish MEP status as a predictor of differential response to neuromodulation. In contrast, short-interval intracortical inhibition, cortical silent period, and interhemispheric inhibition were assessed in very few trials, whereas intracortical facilitation was not directly evaluated in any eligible RCT. Most studies raised some risk-of-bias concerns, and one study had high overall risk. Certainty was moderate for clinical motor recovery, low for MEP- and motor-threshold-based measures, and very low for intracortical and interhemispheric measures. Overall, MEP-derived measures and resting motor threshold were the most frequently reported neurophysiological domains, whereas baseline MEP status was evaluated in only one stratified trial. Standardized TMS protocols are needed to clarify their monitoring, prognostic, and treatment-response value.