Optimization of Stroke Rehabilitation with a Combination of Repetitive Transcranial Magnetic Stimulation, Brainwave Entrainment, and Dry Needling: A Case Report

Optimization of Stroke Rehabilitation with a Combination of Repetitive Transcranial Magnetic Stimulation, Brainwave Entrainment, and Dry Needling: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Optimization of Stroke Rehabilitation with a Combination of Repetitive Transcranial Magnetic Stimulation, Brainwave Entrainment, and Dry Needling: A Case Report Jumraini Tammasse, Virza Chairunnisa Latuconsina, Hikmawati Hikmawati This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6900440/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Ischemic stroke is a leading cause of global disability, often resulting in persistent motor and cognitive impairments. Recent advances in neurorehabilitation emphasize multimodal approaches to enhance neuroplasticity. This case report explores the clinical effects of combining Repetitive Transcranial Magnetic Stimulation (rTMS), Brainwave Entrainment (BWE), and Dry Needling (DN) for post-stroke recovery. Case Report A 46-year-old male presented with right-sided hemiparesis and dysarthria one year post-ischemic stroke. Clinical evaluation and quantitative EEG (qEEG) revealed persistent motor deficits and cerebral wave asymmetry. A tailored rehabilitation program incorporating rTMS targeting motor and prefrontal areas, BWE using alpha-frequency binaural beats, and DN to alleviate spasticity was administered. After two cycles of intervention, the patient demonstrated improvements in muscle tone (Modified Ashworth Scale reduced from 2 to 1+) and motor coordination. qEEG analysis showed neurophysiological changes consistent with cortical reorganization. Conclusion This case underscores the potential of integrating rTMS, BWE, and DN in stroke rehabilitation. The multimodal approach facilitated functional and neurophysiological improvements, suggesting its value in enhancing recovery pathways for chronic stroke patients. Ischemic Stroke Repetitive Transcranial Magnetic Stimulation Brainwave Entrainment Dry Needling qEEG Modified Ashworth Scale Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Rehabilitation following ischemic stroke is an essential domain focused on facilitating recovery and augmenting the quality of life for stroke survivors. Ischemic stroke, a primary contributor to global mortality and long-term disability, frequently leads to various physical and cognitive deficits. Consequently, the formulation of appropriate rehabilitation techniques is crucial to reduce long-term disability and enhance functional independence. A novel and progressive method entails the amalgamation of Repetitive Transcranial Magnetic Stimulation (rTMS), Brainwave Entrainment (BWE), and Dry Needling (DN). This multimodal strategy aims to augment neuroplasticity, enhance motor function, and mitigate prevalent post-stroke sequelae, including spasticity.( 1 , 2 ) rTMS is a non-invasive neuromodulation method that enhances cortical excitability and has shown promise in aiding motor recovery after ischemic stroke. This method, when integrated with brainwave entrainment—synchronizing neural activity via rhythmic sensory stimulation—and dry needling—a therapeutic technique aimed at myofascial pain and muscle tension—provides a holistic strategy for tackling the complex issues associated with stroke rehabilitation.( 2 – 4 ) The combined use of these modalities may result in enhanced motor function and improved rehabilitation outcomes. The incorporation of quantitative electroencephalography (qEEG) serves as an essential instrument for assessing brain activity and connection, enabling physicians to formulate individualised rehabilitation strategies specific to each patient's neurological condition. In conclusion, optimising therapy through the integration of rTMS, BWE, and DN has substantial potential for optimising recovery pathways and elevating the overall quality of life for patients recuperating from ischemic stroke.( 2 ) CASE REPORT A 46-year-old male patient reported to the outpatient department of Dr. Wahidin Sudirohusodo General Hospital with complaints of right-sided hemiparesis and severe dysarthria, which had remained since January 2024 because of an ischemic stroke. One year after the stroke, the patient persists in experiencing weakness and stiffness, especially in the right hand and foot. Despite ongoing speech challenges, he has commenced independent mobility, although with a dragging movement. The patient has a history of a prior stroke impacting the left side of the body, from which he completely recovered, as well as a history of hypertension. The general examination indicated that her general physical condition and vital signs were within normal limits. She was completely alert and had no history of diminished consciousness. The neurological examination indicated weakness and rigidity on the right side of the body, with a Modified Ashworth Scale was 2, along with a central right-sided paresis of the facial nerve (VII) and hypoglossal nerve (XII). Cognitive abnormalities were identified based on the results of the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment-Indonesian Version (MoCA-Ina). The non-contrast CT scan of the head revealed encephalomalacia in the centrum semiovale, corona radiata, and nucleus lentiformis, extending to the left external capsule & also brain atrophy. qEEG results reveal an asymmetry in cerebral wave activity between the left and right hemispheres, characterised by heightened slow waves (delta and theta) on the left and diminished activity on the right, suggesting disruptions in motor, sensory, visuospatial, cognitive, and affective modulation. Rapid waves (beta and high beta) exhibit a decline on the left side and an elevation on the right side, suggesting a potential functional overreaction. Shows hypodense infarction in the left corona radiata, confirming subacute ischemic stroke. This radiological finding corresponds to the patient's right-sided motor deficit. Demonstrates significant interhemispheric asymmetry, with reduced alpha activity and elevated theta/beta ratio in the left hemisphere. These patterns are associated with impaired sensorimotor integration and executive dysfunction. The patients receive multimodal therapy, encompassing not just pharmaceuticals but also restorative rehabilitation management, which includes rTMS, brainwave entrainment, and dry needling. The employed stimulation techniques include intermittent Theta Burst Stimulation (iTBS) targeting the motor cortex (M1) and the left Dorsolateral Prefrontal Cortex (DLPFC), along with continuous Theta Burst Stimulation (cTBS) applied to the M1 and right DLPFC. Simultaneously, patients underwent brainwave entrainment with the administration of alpha frequency binaural beats for a duration of 30 minutes. qEEG results following two cycles of rTMS and BWE revealed an elevation in slow wave activity (delta and theta) in the left hemisphere, signifying disruptions in motor, sensory, linguistic, visuo-spatial, cognitive, and affective control. Fast waves (beta and high beta) diminished on the left side and some bilateral regions, whereas an increase in fast waves was observed on the right temporal side, signifying functional overreaction. Subsequently, following two dry needling interventions administered to the brachioradialis, flexor digitorum superficialis, and thenar dextra muscles on the affected side, the Modified Ashworth Scale (MAS) score improved from 2 to 1+. Interventions were initiated on Day 1 and continued over two treatment cycles within a 3-week period. Shows improved alpha band power and reduced delta-alpha ratio post-treatment, especially in F3–C3 regions. This indicates improved cortical synchrony and reduced functional asymmetry. This chart displays changes in quantitative EEG metrics: Delta-Alpha Ratio (DAR), alpha power, and theta/beta ratio, comparing baseline to post-treatment. Notable improvements include a 44% reduction in DAR and a 74% increase in alpha power, indicating neurophysiological recovery. Table 1 Summary of Clinical and qEEG Outcomes Parameter Pre-Intervention Post-Intervention Change Modified Ashworth Scale (MAS) 2 1+ ↓ Improved Tone Resting DAR (F3-C3) 1.8 1.2 ↓ Improved Alpha Power (µV²) 4.3 7.5 ↑ Enhanced Sync Theta/Beta Ratio (Fz) 2.9 1.7 ↓ Cognitive Reg DISCUSSION This case highlights the potential synergistic effects of combining repetitive transcranial magnetic stimulation (rTMS), brainwave entrainment (BWE), and dry needling (DN) in chronic stroke rehabilitation. The observed clinical improvements, reduction in spasticity (MAS score), enhanced coordination, and improved qEEG parameters are consistent with existing literature suggesting the role of neuroplasticity in post-stroke recovery. The patient’s qEEG profile showed reduced alpha asymmetry and increased synchrony in bilateral frontal and central regions following intervention, indicating potential cortical reorganization. Prior studies have documented similar electrophysiological changes following rTMS and neurofeedback-based training. The use of BWE with alpha-range binaural beats may have further modulated thalamocortical activity, promoting sensorimotor integration and attention regulation. While dry needling is primarily used for myofascial pain, its application in this case aimed to reduce focal hypertonicity, thereby complementing the effects of rTMS and BWE. The integrative strategy is supported by evidence that multimodal approaches can engage multiple neurophysiological pathways simultaneously, potentially enhancing recovery outcomes beyond single interventions. However, this case must be interpreted with caution. The single-subject design, absence of long-term follow-up, and early stage of intervention limit generalizability. Moreover, while qEEG provides real-time cortical activity insights, its correlation with long-term functional outcomes remains to be validated. Further studies with control groups and larger cohorts are essential to confirm efficacy and mechanisms. CONCLUSION This case demonstrates preliminary evidence that a multimodal neurorehabilitation protocol integrating rTMS, BWE, and DN may facilitate both neurophysiological and clinical improvements in chronic ischemic stroke patients. The observed gains in cortical function and muscle tone support the hypothesis that simultaneous neuromodulation and physical therapy can activate synergistic plasticity mechanisms. Nonetheless, broader trials with structured protocols are required to establish replicability and long-term efficacy. Patient Perspective "As someone who had been struggling with weakness and stiffness for over a year after my stroke, I felt as though my progress had reached a plateau. Despite physical therapy and medication, my right side remained difficult to control, and I still had trouble speaking clearly. When my neurologist introduced the idea of combining brain stimulation (rTMS), sound therapy (brainwave entrainment), and dry needling, I was hopeful but cautious. After the treatments, I noticed a real difference. My hand felt looser, and I could move it with more ease. Even my steps became lighter and more stable. I was surprised when my doctor showed me the brain scan changes—it was encouraging to know that healing was happening not just on the outside, but inside my brain as well. This experience gave me new hope. I realized that recovery is not only possible, but can continue even after many months post-stroke. I’m grateful for the team that guided me through this innovative therapy. It gave me back not just movement, but confidence in myself." — Muhammad Faisal, Stroke Survivor Declarations Ethics Approval and Consent to Participate The patient provided written informed consent to participate in this case study and for all interventions involved. Ethics Based on a certificate issued by the Hasanuddin University Research Ethics Committee with letter number 435/H4.8.4.5.31/PP36/2025 that this case report does not require ethical permission because it is not a research report and there is already informed consent from the patient. Consent for Publication Written informed consent for publication of clinical details, images, and results was obtained from the patient. Data Availability Statement Modified Ashworth Scale (MAS) score and clinical evaluation data have also been newly generated. These data are available in this manuscript. Competing Interests The authors declare that they have no competing interests. Funding This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ Contributions Jumraini Tammasse was responsible for study conception, patient management, data analysis, and manuscript preparation. All authors reviewed and approved the final manuscript. ACKNOWLEDGEMENTS The authors thank the patient and family for their cooperation, and the teams at Inggit Medical Centre and Wahidin Sudirohusodo Hospital for their clinical and technical support. References Du J, Tian L, Liu W, Hu J, Xu G, Ma M, et al. Effects of repetitive transcranial magnetic stimulation on motor recovery and motor cortex excitability in patients with stroke: a randomized controlled trial. Eur J Neurol. 2016 Nov;23(11):1666–72. Li X, He Y, Wang D, Rezaei MJ. Stroke rehabilitation: from diagnosis to therapy. Front Neurol. 2024 Aug 13;15:1402729. Sheng R, Chen C, Chen H, Yu P. Repetitive transcranial magnetic stimulation for stroke rehabilitation: insights into the molecular and cellular mechanisms of neuroinflammation. Front Immunol. 2023 May 22;14:1197422. Dionísio A, Duarte IC, Patrício M, Castelo-Branco M. The Use of Repetitive Transcranial Magnetic Stimulation for Stroke Rehabilitation: A Systematic Review. J Stroke Cerebrovasc Dis. 2018 Jan;27(1):1–31. www.stroke.org [Internet]. [cited 2025 Apr 27]. Ischemic Stroke (Clots). Available from: https://www.stroke.org/en/about-stroke/types-of-stroke/ischemic-stroke-clots Cegah Stroke dengan Aktivitas Fisik [Internet]. 2024 [cited 2025 Apr 27]. Available from: https://kemkes.go.id/id/rilis-kesehatan/cegah-stroke-dengan-aktivitas-fisik Han PP, Han Y, Shen XY, Gao ZK, Bi X. Enriched environment-induced neuroplasticity in ischemic stroke and its underlying mechanisms. Front Cell Neurosci. 2023 Jul 7;17:1210361. Kim S, Park HY. Update on Non-invasive Brain Stimulation on Stroke Motor Impairment: A Narrative Review. Brain Neurorehabilitation. 2024;17(1):e5. Malfait I, Gijsbers S, Smeets A, Hanssen B, Pick A, Peers K, et al. Safety of dry needling in stroke patients: a scoping review. Eur J Phys Rehabil Med. 2024;60(2). Aparecido-Kanzler S, Cidral-Filho FJ, Prediger RD. Effects of binaural beats and isochronic tones on brain wave modulation: Literature review. Rev Mex Neurocienc. 2021 Nov 24;22(6):6604. Luu P, Tucker DM, Englander R, Lockfeld A, Lutsep H, Oken B. Localizing acute stroke-related EEG changes: assessing the effects of spatial undersampling. J Clin Neurophysiol Off Publ Am Electroencephalogr Soc. 2001 Jul;18(4):302–17. Finnigan S, van Putten MJAM. EEG in ischaemic stroke: quantitative EEG can uniquely inform (sub-)acute prognoses and clinical management. Clin Neurophysiol Off J Int Fed Clin Neurophysiol. 2013 Jan;124(1):10–9. Vatinno AA, Simpson A, Ramakrishnan V, Bonilha HS, Bonilha L, Seo NJ. The Prognostic Utility of Electroencephalography in Stroke Recovery: A Systematic Review and Meta-Analysis. Neurorehabil Neural Repair. 2022 Apr;36(4–5):255–68. Liew KL. Exploring the role of quantitative electroencephalography in ischaemic stroke through spectral and topographic mapping. 2025;80(1). Li KP, Wu JJ, Zhou ZL, Xu DS, Zheng MX, Hua XY, et al. Noninvasive Brain Stimulation for Neurorehabilitation in Post-Stroke Patients. Brain Sci. 2023 Mar 6;13(3):451. Sun X, Xu K, Shi Y, Li H, Li R, Yang S, et al. Discussion on the Rehabilitation of Stroke Hemiplegia Based on Interdisciplinary Combination of Medicine and Engineering. Si W, editor. Evid Based Complement Alternat Med. 2021 Mar 17;2021:1–11. Ingendoh RM, Posny ES, Heine A. Binaural beats to entrain the brain? A systematic review of the effects of binaural beat stimulation on brain oscillatory activity, and the implications for psychological research and intervention. De Pascalis V, editor. PLOS ONE. 2023 May 19;18(5):e0286023. Orozco Perez HD, Dumas G, Lehmann A. Binaural Beats through the Auditory Pathway: From Brainstem to Connectivity Patterns. eneuro. 2020 Mar;7(2):ENEURO.0232-19.2020. Chaieb L, Wilpert EC, Reber TP, Fell J. Auditory Beat Stimulation and its Effects on Cognition and Mood States. Front Psychiatry [Internet]. 2015 May 12 [cited 2025 May 3];6. Available from: http://www.frontiersin.org/Neuropsychiatric_Imaging_and_Stimulation/10.3389/fpsyt.2015.00070/abstract Babazadeh-Zavieh SS, Ansari NN, Ghotbi N, Naghdi S, Jafar Haeri SM, Shaw BS, et al. Effects of dry needling and exercise therapy on post-stroke spasticity and motor function– protocol of randomized clinical trial. Contemp Clin Trials Commun. 2022 Aug;28:100921. Surya N, Ramamurthy G. Dry needling in stroke. Explor Neuroprotective Ther. 2022 Feb 17;2(1):28–35. Jia D mei, Li X, Zhang B cang, Zhang B ran, Zhang Q juan, Liu M wei, et al. Therapeutic efficacy of repetitive transcranial magnetic stimulation on gait and limb balance function in patients with lower limb dysfunction post-cerebral infarction: a systematic review and meta-analysis. BMC Neurol. 2025 Mar 24;25(1):126. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6900440","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":482135648,"identity":"dafb4be6-fd78-49ed-9d91-dd429ef0ec47","order_by":0,"name":"Jumraini Tammasse","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBACxgYQacDAww+kJIA4ASohAZHBp0WygVgtcGBwAFULA04tzDOy0z78KLgjY3zt8MEbjG138vj7DzB++MFgIYvTYTNyN8/sMXjGY3Y7LdmCse1ZscSNBGbJHgYJY3xaGHgMDgO15JhJMLYdTmy4wcAgDXRkIj4tjH+AWoxn538Da5l//gDzb0JamEG2GEjnsIG1bDiQwIbflp63m5llgFokbqcZWyScO5y48UZim2WPAW6/GLYDHfbmz2F7/tnJD298KDucOO/84cM3flTU4QwxQxSJBIjNDaDIxQnkcUuNglEwCkbBKIACADZTWXPQXBGaAAAAAElFTkSuQmCC","orcid":"","institution":"Hasanuddin University","correspondingAuthor":true,"prefix":"","firstName":"Jumraini","middleName":"","lastName":"Tammasse","suffix":""},{"id":482135649,"identity":"12963f8c-2a2f-4659-9440-ef4869f8b6db","order_by":1,"name":"Virza Chairunnisa Latuconsina","email":"","orcid":"","institution":"Hasanuddin University","correspondingAuthor":false,"prefix":"","firstName":"Virza","middleName":"Chairunnisa","lastName":"Latuconsina","suffix":""},{"id":482135650,"identity":"a71b060f-1e86-49e9-b112-f2b945a89dcd","order_by":2,"name":"Hikmawati Hikmawati","email":"","orcid":"","institution":"Hasanuddin University","correspondingAuthor":false,"prefix":"","firstName":"Hikmawati","middleName":"","lastName":"Hikmawati","suffix":""}],"badges":[],"createdAt":"2025-06-16 00:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6900440/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6900440/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86646467,"identity":"ab4cc537-6810-48ae-b3f0-2969a6de3314","added_by":"auto","created_at":"2025-07-14 08:58:42","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":384359,"visible":true,"origin":"","legend":"\u003cp\u003eComputed tomography of the head without contrast demonstrating encephalomalacia in the centrum semiovale, corona radiata, and nucleus lentiformis, extending to the left external capsule \u0026amp; also brain atrophy\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6900440/v1/329367b75c9573cd96d18622.jpeg"},{"id":86647066,"identity":"920c20e4-4e90-42eb-a39a-fddcdf9ec7cf","added_by":"auto","created_at":"2025-07-14 09:06:42","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":666684,"visible":true,"origin":"","legend":"\u003cp\u003eQuantitative EEG findings prior to neurorestoration intervention\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6900440/v1/a636532a58d8649021a0f38e.jpeg"},{"id":86647071,"identity":"68642ec9-06d4-4a6e-80dc-cc3cda4a94c5","added_by":"auto","created_at":"2025-07-14 09:06:42","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":395990,"visible":true,"origin":"","legend":"\u003cp\u003ePatients underwent rehabilitation with rTMS, BWE, and dry needling interventions\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6900440/v1/93d546a9cfc3770d5686e729.jpeg"},{"id":86648487,"identity":"5a4cf7f2-4f03-4e73-b1eb-d95a4d1e6450","added_by":"auto","created_at":"2025-07-14 09:14:42","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":429076,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of quantitative EEG results following two cycles of rTMS and brainwave entrainment Left side before rTMS and brainwave entrinment right side after rTMS and brainwave entrinment\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6900440/v1/69f1b4cd1936077e72d0bbae.jpeg"},{"id":98945472,"identity":"ca24ffb4-7e65-4ca0-8175-8e24953fb67c","added_by":"auto","created_at":"2025-12-24 12:10:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2266896,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6900440/v1/bb331e9b-626b-4ce9-8816-5efab9a9e933.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eOptimization of Stroke Rehabilitation with a Combination of Repetitive Transcranial Magnetic Stimulation, Brainwave Entrainment, and Dry Needling: A Case Report\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eRehabilitation following ischemic stroke is an essential domain focused on facilitating recovery and augmenting the quality of life for stroke survivors. Ischemic stroke, a primary contributor to global mortality and long-term disability, frequently leads to various physical and cognitive deficits. Consequently, the formulation of appropriate rehabilitation techniques is crucial to reduce long-term disability and enhance functional independence. A novel and progressive method entails the amalgamation of Repetitive Transcranial Magnetic Stimulation (rTMS), Brainwave Entrainment (BWE), and Dry Needling (DN). This multimodal strategy aims to augment neuroplasticity, enhance motor function, and mitigate prevalent post-stroke sequelae, including spasticity.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003erTMS is a non-invasive neuromodulation method that enhances cortical excitability and has shown promise in aiding motor recovery after ischemic stroke. This method, when integrated with brainwave entrainment—synchronizing neural activity via rhythmic sensory stimulation—and dry needling—a therapeutic technique aimed at myofascial pain and muscle tension—provides a holistic strategy for tackling the complex issues associated with stroke rehabilitation.(\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e–\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThe combined use of these modalities may result in enhanced motor function and improved rehabilitation outcomes. The incorporation of quantitative electroencephalography (qEEG) serves as an essential instrument for assessing brain activity and connection, enabling physicians to formulate individualised rehabilitation strategies specific to each patient's neurological condition. In conclusion, optimising therapy through the integration of rTMS, BWE, and DN has substantial potential for optimising recovery pathways and elevating the overall quality of life for patients recuperating from ischemic stroke.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e"},{"header":"CASE REPORT","content":"\u003cp\u003eA 46-year-old male patient reported to the outpatient department of Dr. Wahidin Sudirohusodo General Hospital with complaints of right-sided hemiparesis and severe dysarthria, which had remained since January 2024 because of an ischemic stroke. One year after the stroke, the patient persists in experiencing weakness and stiffness, especially in the right hand and foot. Despite ongoing speech challenges, he has commenced independent mobility, although with a dragging movement. The patient has a history of a prior stroke impacting the left side of the body, from which he completely recovered, as well as a history of hypertension.\u003c/p\u003e\u003cp\u003eThe general examination indicated that her general physical condition and vital signs were within normal limits. She was completely alert and had no history of diminished consciousness. The neurological examination indicated weakness and rigidity on the right side of the body, with a Modified Ashworth Scale was 2, along with a central right-sided paresis of the facial nerve (VII) and hypoglossal nerve (XII). Cognitive abnormalities were identified based on the results of the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment-Indonesian Version (MoCA-Ina).\u003c/p\u003e\u003cp\u003eThe non-contrast CT scan of the head revealed encephalomalacia in the centrum semiovale, corona radiata, and nucleus lentiformis, extending to the left external capsule \u0026amp; also brain atrophy. qEEG results reveal an asymmetry in cerebral wave activity between the left and right hemispheres, characterised by heightened slow waves (delta and theta) on the left and diminished activity on the right, suggesting disruptions in motor, sensory, visuospatial, cognitive, and affective modulation. Rapid waves (beta and high beta) exhibit a decline on the left side and an elevation on the right side, suggesting a potential functional overreaction.\u003c/p\u003e\u003cp\u003eShows hypodense infarction in the left corona radiata, confirming subacute ischemic stroke. This radiological finding corresponds to the patient's right-sided motor deficit.\u003c/p\u003e\u003cp\u003eDemonstrates significant interhemispheric asymmetry, with reduced alpha activity and elevated theta/beta ratio in the left hemisphere. These patterns are associated with impaired sensorimotor integration and executive dysfunction.\u003c/p\u003e\u003cp\u003eThe patients receive multimodal therapy, encompassing not just pharmaceuticals but also restorative rehabilitation management, which includes rTMS, brainwave entrainment, and dry needling. The employed stimulation techniques include intermittent Theta Burst Stimulation (iTBS) targeting the motor cortex (M1) and the left Dorsolateral Prefrontal Cortex (DLPFC), along with continuous Theta Burst Stimulation (cTBS) applied to the M1 and right DLPFC. Simultaneously, patients underwent brainwave entrainment with the administration of alpha frequency binaural beats for a duration of 30 minutes. qEEG results following two cycles of rTMS and BWE revealed an elevation in slow wave activity (delta and theta) in the left hemisphere, signifying disruptions in motor, sensory, linguistic, visuo-spatial, cognitive, and affective control. Fast waves (beta and high beta) diminished on the left side and some bilateral regions, whereas an increase in fast waves was observed on the right temporal side, signifying functional overreaction. Subsequently, following two dry needling interventions administered to the brachioradialis, flexor digitorum superficialis, and thenar dextra muscles on the affected side, the Modified Ashworth Scale (MAS) score improved from 2 to 1+.\u003c/p\u003e\u003cp\u003eInterventions were initiated on Day 1 and continued over two treatment cycles within a 3-week period.\u003c/p\u003e\u003cp\u003eShows improved alpha band power and reduced delta-alpha ratio post-treatment, especially in F3–C3 regions. This indicates improved cortical synchrony and reduced functional asymmetry. This chart displays changes in quantitative EEG metrics: Delta-Alpha Ratio (DAR), alpha power, and theta/beta ratio, comparing baseline to post-treatment. Notable improvements include a 44% reduction in DAR and a 74% increase in alpha power, indicating neurophysiological recovery.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of Clinical and qEEG Outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-Intervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePost-Intervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChange\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModified Ashworth Scale (MAS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e↓ Improved Tone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResting DAR (F3-C3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e↓ Improved\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlpha Power (µV²)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e↑ Enhanced Sync\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheta/Beta Ratio (Fz)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e↓ Cognitive Reg\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis case highlights the potential synergistic effects of combining repetitive transcranial magnetic stimulation (rTMS), brainwave entrainment (BWE), and dry needling (DN) in chronic stroke rehabilitation. The observed clinical improvements, reduction in spasticity (MAS score), enhanced coordination, and improved qEEG parameters are consistent with existing literature suggesting the role of neuroplasticity in post-stroke recovery.\u003c/p\u003e\u003cp\u003eThe patient\u0026rsquo;s qEEG profile showed reduced alpha asymmetry and increased synchrony in bilateral frontal and central regions following intervention, indicating potential cortical reorganization. Prior studies have documented similar electrophysiological changes following rTMS and neurofeedback-based training. The use of BWE with alpha-range binaural beats may have further modulated thalamocortical activity, promoting sensorimotor integration and attention regulation.\u003c/p\u003e\u003cp\u003eWhile dry needling is primarily used for myofascial pain, its application in this case aimed to reduce focal hypertonicity, thereby complementing the effects of rTMS and BWE. The integrative strategy is supported by evidence that multimodal approaches can engage multiple neurophysiological pathways simultaneously, potentially enhancing recovery outcomes beyond single interventions.\u003c/p\u003e\u003cp\u003eHowever, this case must be interpreted with caution. The single-subject design, absence of long-term follow-up, and early stage of intervention limit generalizability. Moreover, while qEEG provides real-time cortical activity insights, its correlation with long-term functional outcomes remains to be validated. Further studies with control groups and larger cohorts are essential to confirm efficacy and mechanisms.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis case demonstrates preliminary evidence that a multimodal neurorehabilitation protocol integrating rTMS, BWE, and DN may facilitate both neurophysiological and clinical improvements in chronic ischemic stroke patients. The observed gains in cortical function and muscle tone support the hypothesis that simultaneous neuromodulation and physical therapy can activate synergistic plasticity mechanisms. Nonetheless, broader trials with structured protocols are required to establish replicability and long-term efficacy.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatient Perspective\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\"As someone who had been struggling with weakness and stiffness for over a year after my stroke, I felt as though my progress had reached a plateau. Despite physical therapy and medication, my right side remained difficult to control, and I still had trouble speaking clearly. When my neurologist introduced the idea of combining brain stimulation (rTMS), sound therapy (brainwave entrainment), and dry needling, I was hopeful but cautious.\u003c/p\u003e\u003cp\u003eAfter the treatments, I noticed a real difference. My hand felt looser, and I could move it with more ease. Even my steps became lighter and more stable. I was surprised when my doctor showed me the brain scan changes\u0026mdash;it was encouraging to know that healing was happening not just on the outside, but inside my brain as well.\u003c/p\u003e\u003cp\u003eThis experience gave me new hope. I realized that recovery is not only possible, but can continue even after many months post-stroke. I\u0026rsquo;m grateful for the team that guided me through this innovative therapy. It gave me back not just movement, but confidence in myself.\"\u003c/p\u003e\u003cp\u003e\u0026mdash; \u003cem\u003eMuhammad Faisal, Stroke Survivor\u003c/em\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics Approval and Consent to Participate\u003c/p\u003e\n\u003cp\u003eThe patient provided written informed consent to participate in this case study and for all interventions involved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on a certificate issued by the Hasanuddin University Research Ethics Committee with letter number 435/H4.8.4.5.31/PP36/2025 that this case report does not require ethical permission because it is not a research report and there is already informed consent from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of clinical details, images, and results was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eModified Ashworth Scale (MAS) score and clinical evaluation data have also been newly generated. These data are available in this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJumraini Tammasse was responsible for study conception, patient management, data analysis, and manuscript preparation. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the patient and family for their cooperation, and the teams at Inggit Medical Centre and \u0026nbsp;Wahidin Sudirohusodo Hospital for their clinical and technical support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDu J, Tian L, Liu W, Hu J, Xu G, Ma M, et al. Effects of repetitive transcranial magnetic stimulation on motor recovery and motor cortex excitability in patients with stroke: a randomized controlled trial. Eur J Neurol. 2016 Nov;23(11):1666\u0026ndash;72. \u003c/li\u003e\n\u003cli\u003eLi X, He Y, Wang D, Rezaei MJ. Stroke rehabilitation: from diagnosis to therapy. Front Neurol. 2024 Aug 13;15:1402729. \u003c/li\u003e\n\u003cli\u003eSheng R, Chen C, Chen H, Yu P. Repetitive transcranial magnetic stimulation for stroke rehabilitation: insights into the molecular and cellular mechanisms of neuroinflammation. Front Immunol. 2023 May 22;14:1197422. \u003c/li\u003e\n\u003cli\u003eDion\u0026iacute;sio A, Duarte IC, Patr\u0026iacute;cio M, Castelo-Branco M. The Use of Repetitive Transcranial Magnetic Stimulation for Stroke Rehabilitation: A Systematic Review. J Stroke Cerebrovasc Dis. 2018 Jan;27(1):1\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003ewww.stroke.org [Internet]. [cited 2025 Apr 27]. Ischemic Stroke (Clots). Available from: https://www.stroke.org/en/about-stroke/types-of-stroke/ischemic-stroke-clots\u003c/li\u003e\n\u003cli\u003eCegah Stroke dengan Aktivitas Fisik [Internet]. 2024 [cited 2025 Apr 27]. Available from: https://kemkes.go.id/id/rilis-kesehatan/cegah-stroke-dengan-aktivitas-fisik\u003c/li\u003e\n\u003cli\u003eHan PP, Han Y, Shen XY, Gao ZK, Bi X. Enriched environment-induced neuroplasticity in ischemic stroke and its underlying mechanisms. Front Cell Neurosci. 2023 Jul 7;17:1210361. \u003c/li\u003e\n\u003cli\u003eKim S, Park HY. Update on Non-invasive Brain Stimulation on Stroke Motor Impairment: A Narrative Review. Brain Neurorehabilitation. 2024;17(1):e5. \u003c/li\u003e\n\u003cli\u003eMalfait I, Gijsbers S, Smeets A, Hanssen B, Pick A, Peers K, et al. Safety of dry needling in stroke patients: a scoping review. Eur J Phys Rehabil Med. 2024;60(2). \u003c/li\u003e\n\u003cli\u003eAparecido-Kanzler S, Cidral-Filho FJ, Prediger RD. Effects of binaural beats and isochronic tones on brain wave modulation: Literature review. Rev Mex Neurocienc. 2021 Nov 24;22(6):6604. \u003c/li\u003e\n\u003cli\u003eLuu P, Tucker DM, Englander R, Lockfeld A, Lutsep H, Oken B. Localizing acute stroke-related EEG changes: assessing the effects of spatial undersampling. J Clin Neurophysiol Off Publ Am Electroencephalogr Soc. 2001 Jul;18(4):302\u0026ndash;17. \u003c/li\u003e\n\u003cli\u003eFinnigan S, van Putten MJAM. EEG in ischaemic stroke: quantitative EEG can uniquely inform (sub-)acute prognoses and clinical management. Clin Neurophysiol Off J Int Fed Clin Neurophysiol. 2013 Jan;124(1):10\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eVatinno AA, Simpson A, Ramakrishnan V, Bonilha HS, Bonilha L, Seo NJ. The Prognostic Utility of Electroencephalography in Stroke Recovery: A Systematic Review and Meta-Analysis. Neurorehabil Neural Repair. 2022 Apr;36(4\u0026ndash;5):255\u0026ndash;68. \u003c/li\u003e\n\u003cli\u003eLiew KL. Exploring the role of quantitative electroencephalography in ischaemic stroke through spectral and topographic mapping. 2025;80(1). \u003c/li\u003e\n\u003cli\u003eLi KP, Wu JJ, Zhou ZL, Xu DS, Zheng MX, Hua XY, et al. Noninvasive Brain Stimulation for Neurorehabilitation in Post-Stroke Patients. Brain Sci. 2023 Mar 6;13(3):451. \u003c/li\u003e\n\u003cli\u003eSun X, Xu K, Shi Y, Li H, Li R, Yang S, et al. Discussion on the Rehabilitation of Stroke Hemiplegia Based on Interdisciplinary Combination of Medicine and Engineering. Si W, editor. Evid Based Complement Alternat Med. 2021 Mar 17;2021:1\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eIngendoh RM, Posny ES, Heine A. Binaural beats to entrain the brain? A systematic review of the effects of binaural beat stimulation on brain oscillatory activity, and the implications for psychological research and intervention. De Pascalis V, editor. PLOS ONE. 2023 May 19;18(5):e0286023. \u003c/li\u003e\n\u003cli\u003eOrozco Perez HD, Dumas G, Lehmann A. Binaural Beats through the Auditory Pathway: From Brainstem to Connectivity Patterns. eneuro. 2020 Mar;7(2):ENEURO.0232-19.2020. \u003c/li\u003e\n\u003cli\u003eChaieb L, Wilpert EC, Reber TP, Fell J. Auditory Beat Stimulation and its Effects on Cognition and Mood States. Front Psychiatry [Internet]. 2015 May 12 [cited 2025 May 3];6. Available from: http://www.frontiersin.org/Neuropsychiatric_Imaging_and_Stimulation/10.3389/fpsyt.2015.00070/abstract\u003c/li\u003e\n\u003cli\u003eBabazadeh-Zavieh SS, Ansari NN, Ghotbi N, Naghdi S, Jafar Haeri SM, Shaw BS, et al. Effects of dry needling and exercise therapy on post-stroke spasticity and motor function\u0026ndash; protocol of randomized clinical trial. Contemp Clin Trials Commun. 2022 Aug;28:100921. \u003c/li\u003e\n\u003cli\u003eSurya N, Ramamurthy G. Dry needling in stroke. Explor Neuroprotective Ther. 2022 Feb 17;2(1):28\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eJia D mei, Li X, Zhang B cang, Zhang B ran, Zhang Q juan, Liu M wei, et al. Therapeutic efficacy of repetitive transcranial magnetic stimulation on gait and limb balance function in patients with lower limb dysfunction post-cerebral infarction: a systematic review and meta-analysis. BMC Neurol. 2025 Mar 24;25(1):126.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ischemic Stroke, Repetitive Transcranial Magnetic Stimulation, Brainwave Entrainment, Dry Needling, qEEG, Modified Ashworth Scale","lastPublishedDoi":"10.21203/rs.3.rs-6900440/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6900440/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIschemic stroke is a leading cause of global disability, often resulting in persistent motor and cognitive impairments. Recent advances in neurorehabilitation emphasize multimodal approaches to enhance neuroplasticity. This case report explores the clinical effects of combining Repetitive Transcranial Magnetic Stimulation (rTMS), Brainwave Entrainment (BWE), and Dry Needling (DN) for post-stroke recovery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Report\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 46-year-old male presented with right-sided hemiparesis and dysarthria one year post-ischemic stroke. Clinical evaluation and quantitative EEG (qEEG) revealed persistent motor deficits and cerebral wave asymmetry. A tailored rehabilitation program incorporating rTMS targeting motor and prefrontal areas, BWE using alpha-frequency binaural beats, and DN to alleviate spasticity was administered. After two cycles of intervention, the patient demonstrated improvements in muscle tone (Modified Ashworth Scale reduced from 2 to 1+) and motor coordination. qEEG analysis showed neurophysiological changes consistent with cortical reorganization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case underscores the potential of integrating rTMS, BWE, and DN in stroke rehabilitation. The multimodal approach facilitated functional and neurophysiological improvements, suggesting its value in enhancing recovery pathways for chronic stroke patients.\u003c/p\u003e","manuscriptTitle":"Optimization of Stroke Rehabilitation with a Combination of Repetitive Transcranial Magnetic Stimulation, Brainwave Entrainment, and Dry Needling: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 08:58:37","doi":"10.21203/rs.3.rs-6900440/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b25cd011-9e42-41b1-b837-c178483918f8","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-24T12:09:51+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-14 08:58:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6900440","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6900440","identity":"rs-6900440","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}