Effects of rTMS Combined With Dual-Task Gait Training on Walking and Cognition After Stroke

This randomized, double-blind, placebo-controlled trial will investigate whether repetitive transcranial magnetic stimulation (rTMS) applied to the dorsolateral prefrontal cortex (DLPFC) can enhance the effects of dual-task gait training in people with chronic stroke. Participants will be randomly allocated to receive either active rTMS or sham rTMS immediately before the same standardized dual-task gait training program. The intervention includes 12 sessions over 3 weeks. Outcomes will be assessed at baseline, immediately after training, and at 4-week follow-up. Co-primary outcomes are dual-task mobility and cognitive performance during walking, quantified using dual-task cost (DTC) for gait speed and cognitive-task performance during dual-task walking (e.g., Serial 7s; Shopping List Recall). Secondary outcomes include balance/mobility, community participation, mood/sleep measures, and fall incidence. To explore mechanisms, prefrontal cortex activity during single- and dual-task walking will be recorded using functional near-infrared spectroscopy (fNIRS), and mediation analyses will examine whether changes in PFC activity explain intervention effects.

Inclusion Criteria: * Unilateral ischemic or hemorrhagic hemispheric stroke * Age ≥ 50 years -≥ 6 months post-stroke * Medically stable * Able to walk independently ≥ 1 minute (assistive device allowed) * Able to follow commands * mRS 1-3 * MoCA ≥ 22 Exclusion Criteria: * Other neurological disorders * Cerebellar/brainstem injury * TMS contraindications (e.g., pacemaker, intracranial metal, seizure history, pregnancy) * Contraindications to exercise (e.g., unstable angina) * Severe aphasia (NIHSS item 9 ≥ 2) * Pain/illness limiting performance * Concurrent formal rehabilitation elsewhere * RMT cannot be determined * Fails TMS safety screening