From Functional Mapping to Functional Recovery: The Emerging Role of Neuronavigated rTMS in Neurorehabilitation

Background/Objectives: Repetitive transcranial magnetic stimulation (rTMS) has been increasingly investigated as an adjunctive intervention in neurorehabilitation, particularly for motor recovery after stroke. However, conventional rTMS protocols remain limited by variability in target localization, inter-individual anatomical differences, lesion-related network reorganization, and limited reproducibility across treatment sessions. Neuronavigated repetitive transcranial magnetic stimulation (nrTMS) integrates structural neuroimaging with real-time coil tracking, enabling more precise and reproducible stimulation of patient-specific cortical targets. This approach may be especially relevant in patients with focal brain lesions, postoperative anatomical distortion, or functionally reorganized networks. Methods: This narrative review summarizes the biological rationale, current clinical evidence, practical workflow, and limitations of nrTMS in neurorehabilitation, with particular attention to the distinction between conventional rTMS and neuronavigated protocols. Results: The strongest evidence for rTMS-based rehabilitation remains in post-stroke motor recovery, although most studies have used non-navigated protocols. In contrast, postoperative neuro-oncological rehabilitation represents a clinically relevant but still investigational context for nrTMS, as preoperative functional mapping, postoperative deficits, and early rehabilitation can be integrated within a patient-specific therapeutic pathway. Early studies suggest feasibility when stimulation is combined with structured physiotherapy; however, the available evidence is based on small and heterogeneous cohorts, and clinically meaningful superiority over conventional rTMS or standard rehabilitation has not yet been established. Data in traumatic brain injury, multiple sclerosis, ataxias, and neurodegenerative disorders are still preliminary and heterogeneous. Conclusions: Neuronavigation should not be interpreted as an independent therapeutic breakthrough, but rather as a precision-enhancing component of rTMS-based rehabilitation. Its main potential value lies in improving targeting accuracy, session-to-session reproducibility, and integration with individualized neuroimaging and rehabilitation goals. Accordingly, nrTMS should currently be considered a precision-enhancing and hypothesis-generating framework rather than an established rehabilitation standard.