Expert consensus on neuro-musculoskeletal functional reconstruction for post-stroke spastic hemiplegia

Persistent motor dysfunction in post-stroke spastic hemiplegia may result from impaired voluntary motor control, abnormal muscle overactivity, fixed structural restriction, muscle force imbalance, or their combination. Advances in brain-computer interfaces (BCIs), peripheral nerve surgery, and tendon and soft-tissue reconstruction have expanded therapeutic options, yet optimal indications and sequencing remain unclear. A multidisciplinary expert panel reviewed current evidence, addressed key clinical questions, and developed consensus recommendations for noninvasive BCI, diagnostic motor nerve block (DNB), selective or hyperselective peripheral nerve surgery, and reconstructive procedures. The consensus emphasizes evaluation of four major components: central voluntary motor impairment, dynamic abnormal muscle overactivity, fixed structural limitations, and muscle force imbalance. Treatment should be guided by the patient's functional goals and the primary factor restricting performance. Task-oriented motor training remains fundamental when voluntary motor control is impaired, with BCI-based closed-loop training as a potential adjunct in selected patients. Focal, functionally significant muscle overactivity caused by abnormal neural drive may be considered for selective or hyperselective peripheral nerve surgery, with DNB assisting patient selection. Fixed structural restrictions may require tendon or soft-tissue procedures, while muscle force imbalance may benefit from tendon transfer or other dynamic reconstruction. When multiple impairments coexist, combined reconstruction followed by targeted motor retraining and comprehensive reassessment may be appropriate. Overall, neuro-musculoskeletal functional reconstruction should follow an individualized pathway linking functional goals, dominant pathophysiology, treatment targets, and outcomes. Given the variable evidence quality, no universal treatment sequence or combination strategy is currently supported.