Effectiveness of Theta Burst Stimulation For Upper and Lower Extremity Recovery in Stroke

• Continuous Theta Burst Stimulation (cTBS) (Device): Continuous theta burst stimulation will be applied over the contralesional primary motor cortex (M1) at 80% of the resting motor threshold. A total of 600 pulses will be delivered over 40 seconds as triplets at 50 Hz repeated every 200 ms.
• Intermittent Theta Burst Stimulation (iTBS) (Device): Intermittent theta burst stimulation will be applied over the ipsilesional primary motor cortex (M1) at 80% of the resting motor threshold. A total of 600 pulses will be delivered over approximately 190 seconds using 2-second trains repeated every 10 seconds.
• Sham Continuous Theta Burst Stimulation (Device): Sham continuous theta burst stimulation will be delivered over the contralesional primary motor cortex using a sham coil for 40 seconds.
• Sham Intermittent Theta Burst Stimulation (Device): Sham intermittent theta burst stimulation will be delivered over the ipsilesional primary motor cortex using a sham coil for approximately 190 seconds.

Primary outcomes

• Change in Upper Extremity Motor Function Assessed by the Fugl-Meyer Assessment - Upper Extremity Motor Subscale (FMA-UE) [Baseline, Week 2, and Week 6]: Upper extremity motor function will be assessed using the motor subsection of the Fugl-Meyer Assessment. The FMA-UE motor score ranges from 0 to 66, with higher scores indicating better upper extremity motor function. Each item is scored on a 3-point ordinal scale: 0 = cannot perform, 1 = performs partially, and 2 = performs fully
• Change in Lower Extremity Motor Function Assessed by the Fugl-Meyer Assessment - Lower Extremity Motor Subscale [Baseline, Week 2, and Week 6]: Lower extremity motor recovery will be assessed using the lower extremity motor subsection of the Fugl-Meyer Assessment.
• Change in Motor Recovery Stage Assessed by the Brunnstrom Motor Recovery Stages [Baseline, Week 2, and Week 6]: Motor recovery of the upper and lower extremities will be evaluated using the Brunnstrom Motor Recovery Stages. Each assessed region is rated separately from stage I (1) to stage VI (6), with higher stages indicating better motor recovery.

Secondary outcomes

• Change in Spasticity Assessed by the Modified Ashworth Scale [Baseline, Week 2, and Week 6]: Spasticity of the upper and lower extremities will be assessed using the Modified Ashworth Scale (MAS). Scores range from 0 (no increase in muscle tone) to 4 (rigidity in flexion or extension), with six ordinal categories: 0, 1, 1+, 2, 3, and 4. Higher scores indicate greater muscle tone and resistance to passive movement, representing a worse outcome.
• Change in Sensory Function Assessed by the Fugl-Meyer Assessment - Sensory Subscale [Baseline, Week 2, and Week 6]: Sensory function of the upper and lower extremities will be assessed using the sensory subsection of the Fugl-Meyer Assessment. This subsection evaluates light touch and joint position sense, with each item scored on a three-point ordinal scale (0-2). The combined sensory score for the upper and lower extremities ranges from 0 to 24, with higher scores indicating better sensory function.
• Change in Cortical Excitability Assessed by Motor Evoked Potential Amplitude [Baseline, Week 2, and Week 6]: Cortical excitability will be evaluated by measuring motor evoked potential (MEP) amplitude.
• Change in Cortical Excitability Assessed by Motor Evoked Potential Latency [Baseline, Week 2, and Week 6]: Cortical excitability will be evaluated by measuring motor evoked potential (MEP) latency.
• Change in Functional Ambulation Assessed by the Functional Ambulation Scale [Baseline, Week 2, and Week 6]: Functional ambulation will be assessed using the Functional Ambulation Scale (FAS). The scale consists of six ordinal categories ranging from 0 to 5. A score of 0 indicates an inability to walk or the need for assistance from two or more people, whereas a score of 5 indicates independent walking on level and uneven surfaces, including stairs. Higher scores indicate greater independence in walking and a better functional outcome.
• Change in Independence in Activities of Daily Living Assessed by the Modified Barthel Index [Baseline, Week 2, and Week 6]: Independence in activities of daily living and mobility will be assessed using the Modified Barthel Index. The index consists of 10 items, with item scores summed to yield a total score ranging from 0 to 100. A score of 0 indicates total dependence, whereas a score of 100 indicates independence in all assessed activities. Higher scores indicate greater functional independence and a better outcome.
• Change in Stroke-Specific Quality of Life [Baseline, Week 2, and Week 6]: Stroke-specific quality of life will be assessed using the Turkish version of the Stroke-Specific Quality of Life Scale (SS-QOL). The scale consists of 48 items across eight domains. Each item is rated on a five-point scale ranging from 1 to 5. The mean item score will be calculated by averaging the scores of all 48 items, resulting in an overall score ranging from 1 to 5, with higher scores indicating better health-related quality of life.

Sex: All, ages: 45 Years to any

Inclusion Criteria:

* Diagnosis of ischemic stroke due to middle cerebral artery (MCA) occlusion confirmed by magnetic resonance imaging (MRI).
* Within the first 3 months after stroke.
* First-ever stroke.
* Age ≥45 years.
* Brunnstrom stage 1, 2, or 3 for the upper extremity and hand.
* No previous physical therapy after the current stroke.
* Ability to maintain at least minimal semi-sitting balance.
* Medically and neurologically stable.
* Mini-Mental State Examination score >24.
* Native Turkish speaker who voluntarily agrees to participate and provides written informed consent.

Exclusion Criteria:

* History of epilepsy.
* Presence of a pacemaker.
* Pregnancy.
* Neurological disease other than stroke.
* Metallic implants in the brain or scalp, including cochlear implants.
* History of brain surgery.
* Comorbid disease that may significantly impair general health, such as heart f-failure or chronic obstructive pulmonary disease, and/or severe infection.
* Diagnosis of malignancy.
* Peripheral nerve injury and/or musculoskeletal disorder affecting motor function of the upper or lower extremities, such as fracture.
* Cardiac arrhythmia.
* Aphasia, spatial neglect, or visual field loss.
* Visual or hearing impairment that prevents communication.
* Alcohol and/or drug dependence.
* Refusal to participate or failure to provide informed consent.

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