Guided corticomuscular neuroplasticity for restoration of wrist–hand function post-stroke

After stroke, maladaptive neuroplasticity often presents as excessive recruitment of contralesional motor areas and the adoption of proximal compensatory movement patterns, both of which hinder the recovery of fine wrist–hand control. To address these limitations, this study introduces a guided corticomuscular neuroplasticity training strategy aimed at selectively enhancing ipsilesional cortical control during targeted muscle activations, thereby facilitating precise wrist–hand motor restoration. A corticomuscular coherence (CMC)- and electromyography (EMG)-driven control algorithm was embedded within a neuromuscular electrical stimulation (NMES)-robot system. This system provided task-specific assistance for wrist–hand flexion and extension only when ipsilesional cortical dominance was detected. Twenty-six individuals with chronic stroke were randomly assigned to either a guided group (n = 13) or a control group (n = 13) and completed 20 sessions of NMES-robot–assisted training. In the control group, assistance was delivered regardless of cortical dominance. Rehabilitation outcomes were assessed using standardized clinical scales and neurophysiological measures. Both groups demonstrated significant improvements in Fugl-Meyer Assessment and Action Research Arm Test scores (p < 0.001), which were maintained at the three-month follow-up. The guided group exhibited a slower learning trajectory but showed a progressive ipsilesional shift in the laterality index during training (p < 0.05) and in the 40% maximum voluntary contraction flexion task after training (p < 0.05). In contrast, the control group displayed a faster initial learning pattern but no significant ipsilesional shift during or after training (p > 0.05). Their CMC remained bilaterally distributed and spatially inconsistent, suggesting reinforcement of maladaptive contralesional recruitment, where task success depended on pre-existing compensatory pathways. Although the guided group required more time to achieve task proficiency, they developed targeted ipsilesional reorganization characterized by enhanced corticomuscular coupling and more efficient neuromuscular coordination indicative of genuine restoration of functional motor control. The guided corticomuscular neuroplasticity strategy effectively promotes ipsilesional cortical reorganization and coordinated neuromuscular control, demonstrating its potential as a targeted rehabilitation approach for individuals with chronic stroke. Trial registration: Clinical Trials Registry Identifier: NCT02117089.