Central and Peripheral Neuromodulation Techniques for Optimal Stroke Motor Recovery: A Narrative Review

Stroke is a leading cause of disability with motor impairments, compromising functional independence and quality of life. Neuromodulation approaches targeting both the central nervous system (CNS) and the peripheral nervous system (PNS) have been recommended as effective strategies for enhancing motor recovery in stroke patients by facilitating neural plasticity. Central neuromodulation techniques, including transcranial direct current stimulation and repetitive transcranial magnetic stimulation, readily modulate cortical facilitation and promote the adaptive reorganization of motor networks. Peripheral neuromodulation approaches such as neuromuscular electrical stimulation, functional electrical stimulation, transcutaneous electrical stimulation, and percutaneous electrical stimulation are known to enhance afferent neural pathways and improve neuromuscular connectivity across the motor system. Emerging evidence suggests that integrating CNS and PNS neuromodulation may promote motor recovery by enhancing cortical excitability and afferent-driven neural plasticity. The simultaneous combination of central and peripheral neuromodulation techniques are known to activate neural plasticity mechanisms. Ideally, acquiring new motor actions through the learning process and neural plasticity will promote substantial reorganization involving cortical and spinal networks. This review provides a comprehensive overview of central and peripheral neuromodulation techniques, and proposes a mechanism-oriented framework involving cortical modulation, peripheral afferent input, and voluntary movement for stroke motor recovery. Overall, integrating central and peripheral neuromodulation with task-relevant motor training provides novel rehabilitation approaches post stroke.