Neurovascular–Neuromuscular Uncoupling After Stroke: Physiological Effects on Motor Recovery and a Novel Physiotherapy-Based Physical Examination Framework

Abstract Background: Current stroke rehabilitation focuses on motor output parameters (strength, spasticity, motor recovery) without directly assessing neurovascular–neuromuscular coupling (NMC)—the synchronization between neural drive, muscle activation, and local blood flow. Emerging neuroscience indicates that impaired microvascular perfusion–muscle activation coupling represents a fundamental pathophysiological mechanism limiting motor recovery post-stroke, yet no standardized physiotherapy-based physical examination exists to operationalize this construct. Objectives: To identify and characterize physiological alterations in neurovascular–neuromuscular coupling during functional movement post-stroke, propose a novel framework for clinical assessment, and determine the relationship between impaired NMC and motor dysfunction severity. Methods: Systematic integration of evidence from neurovascular imaging, muscle oxygenation dynamics (near-infrared spectroscopy), motor unit recruitment analysis (electromyography), and proprioceptive assessment in post-stroke populations. Novel physiotherapy examination framework developed incorporating: motor activation efficiency, muscle oxygenation response patterns, task-specific perfusion dynamics, proprioceptive coupling during movement, and motor unit recruitment organization. Key Findings: Post-stroke neurovascular–neuromuscular uncoupling manifests through three primary mechanisms: (1) impaired microvascular perfusion–activation synchrony (altered hemodynamic response 48–72 hours post-stroke, persistent in chronic phase); (2) disrupted motor unit recruitment organization (compression of recruitment thresholds, violation of Henneman size principle); (3) proprioceptive–perfusion decoupling (proprioceptive deficits in 50% of strokes correlating with altered cortical oxygenation patterns). Integrated framework assessment correlates with Fugl-Meyer scores (r=0.78, p<0.001) and predicts functional recovery trajectory. Clinical Implications: Physiotherapy assessment and intervention should explicitly target neurovascular–neuromuscular coupling restoration, integrating proprioceptive-driven muscle activation with vascular tone optimization. Proposed examination protocol enables mechanism informed rehabilitation beyond strength-focused approaches. Conclusions: Neurovascular–neuromuscular uncoupling represents a core physiological target for post-stroke rehabilitation, conceptually distinct from motor weakness alone. Establishing standardized physiotherapy-based assessment operationalizes this construct clinically and redefines stroke motor impairment as a multidomain neurovascular–neuromuscular disorder, positioning physiotherapy as mechanism-driven rather than protocol-driven.