{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T05:08:46Z","timestamp":1775797726612,"version":"3.50.1"},"reference-count":47,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T00:00:00Z","timestamp":1775779200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"\n Background<\/jats:title>\n Diaphragmatic dysfunction following stroke severely impacts patient prognosis. However, the central neuromodulatory mechanisms of External Diaphragmatic Nerve Stimulation (EDNS) across different stroke subtypes, including ischemic Stroke (IS) and Intracerebral Hemorrhage (ICH), remain unclear.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To investigate the immediate effects of EDNS on peripheral Diaphragm Excursion (DE) and central cortical activation in stroke patients, and to compare the response heterogeneity between IS and ICH subtypes.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n This prospective observational study included 50 convalescent stroke patients (30 IS and 20 ICH) and 15 age- and sex-matched healthy Controls (HC). All participants received a single 20-min EDNS intervention. DE was measured using M-mode ultrasound at three time points (pre-, during, and post-intervention). Concurrently, functional Near-Infrared Spectroscopy (fNIRS) was used to synchronize monitoring of cortical activation across 10 Regions of Interest (ROIs). Data were strictly evaluated using non-parametric tests with false discovery rate (FDR) correction.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n EDNS intervention significantly improved immediate diaphragmatic function across all groups. DE in the IS group increased from 1.67\u202f\u00b1\u202f0.29\u202fcm at baseline to 1.92\u202f\u00b1\u202f0.33\u202fcm during intervention (\n p<\/jats:italic>\n \u202f&lt;\u202f0.01), and in the ICH group from 1.64\u202f\u00b1\u202f0.26\u202fcm to 1.87\u202f\u00b1\u202f0.31\u202fcm (\n p<\/jats:italic>\n \u202f&lt;\u202f0.01). However, t the spatial pattern of central activation exhibited significant heterogeneity: the HC group showed no significant activation in any ROI (\n p<\/jats:italic>\n \u202f&gt;\u202f0.05); the IS group activated a broad \u201ccognitive-sensory\u201d activation pattern, including the bilateral Dorsolateral Prefrontal Cortex (DLPFC) (\n p<\/jats:italic>\n \u202f&lt;\u202f0.05) and bilateral Somatosensory Association Cortex (SAC) (\n p<\/jats:italic>\n \u202f&lt;\u202f0.01); whereas the ICH group activated only a localized sensory region (Right SAC,\n p<\/jats:italic>\n \u202f=\u202f0.046). Furthermore, the magnitude of DE improvement was significantly positively correlated with the intensity of Right DLPFC activation only in the IS group (Spearman\u2019s\n \u03c1<\/jats:italic>\n \u202f=\u202f0.386,\n p<\/jats:italic>\n \u202f=\u202f0.035), with no such correlation observed in the ICH group (\n p<\/jats:italic>\n \u202f&gt;\u202f0.05).\n <\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n Although EDNS universally improves immediate diaphragmatic function in both IS and ICH patients, the underlying central neuromodulatory mechanisms are subtype-specific. IS patients appear to preserve a \u201ctop-down\u201d cognitive-sensory regulation pathway (DLPFC-SAC) and central-peripheral coupling, whereas the central response in ICH patients is limited to basic sensory processing (SAC) with a lack of such coupling. This mechanistic disparity suggests that rehabilitation strategies for IS patients might benefit from integrating cognitive engagement, highlighting the necessity of tailoring personalized respiratory rehabilitation protocols based on stroke pathology.<\/jats:p>\n <\/jats:sec>","DOI":"10.3389\/fneur.2026.1786178","type":"journal-article","created":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T04:27:01Z","timestamp":1775795221000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Effects of external diaphragmatic nerve stimulation on diaphragm and cortical activity in stroke patients: a functional near-infrared spectroscopy study"],"prefix":"10.3389","volume":"17","author":[{"given":"Xiu-nan","family":"Huang","sequence":"first","affiliation":[{"name":"The Second Clinical Medical College of Guangxi Medical University","place":["Nanning, Guangxi, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ya-lin","family":"Huang","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, The Second Affiliated Hospital of Guangxi Medical University","place":["Nanning, Guangxi, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pei-shu","family":"Li","sequence":"additional","affiliation":[{"name":"School of Oncology, Guangxi Medical University","place":["Nanning, Guangxi, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yi-en","family":"Meng","sequence":"additional","affiliation":[{"name":"The Second Clinical Medical College of Guangxi Medical University","place":["Nanning, Guangxi, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jin","family":"Xu","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, The Second Affiliated Hospital of Guangxi Medical University","place":["Nanning, Guangxi, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Chong-wu","family":"Xiao","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, The Second Affiliated Hospital of Guangxi Medical University","place":["Nanning, Guangxi, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yao-bin","family":"Long","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, The Second Affiliated Hospital of Guangxi Medical University","place":["Nanning, Guangxi, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2026,4,10]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"1001","DOI":"10.1093\/eurjpc\/zwae281","article-title":"Global burden of cardiovascular diseases: projections from 2025 to 2050","volume":"32","author":"Chong","year":"2025","journal-title":"Eur J Prev Cardiol"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"795","DOI":"10.1016\/S1474-4422(21)00252-0","article-title":"Global, regional, and national burden of stroke and its risk factors, 1990\u20132019: a systematic analysis for the global burden of disease study 2019","volume":"20","author":"Feigin","year":"2021","journal-title":"Lancet Neurol"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"2003196","DOI":"10.1183\/13993003.03196-2020","article-title":"Lung function and cardiovascular disease: a two-sample Mendelian randomisation study","volume":"58","author":"Higbee","year":"2021","journal-title":"Eur Respir J"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"1383","DOI":"10.1183\/09031936.00010510","article-title":"Acute ischaemic hemispheric stroke is associated with impairment of reflex in addition to voluntary cough","volume":"36","author":"Ward","year":"2010","journal-title":"Eur Respir J"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"474","DOI":"10.1136\/thoraxjnl-2015-207810","article-title":"Higher cough flow is associated with lower risk of pneumonia in acute stroke","volume":"71","author":"Kulnik","year":"2016","journal-title":"Thorax"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"131","DOI":"10.12965\/jer.2550256.128","article-title":"Effects of inspiratory muscle training on pulmonary function, trunk stability, and balance in stroke patients: a stratified randomized controlled trial","volume":"21","author":"Lee","year":"2025","journal-title":"J Exerc Rehabil"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"967","DOI":"10.1152\/jappl.2000.89.3.967","article-title":"Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm","volume":"89","author":"Hodges","year":"2000","journal-title":"J Appl Physiol"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"e362","DOI":"10.1097\/CCM.0000000000004256","article-title":"Initial assessment of the percutaneous electrical phrenic nerve stimulation system in patients on mechanical ventilation","volume":"48","author":"O\u2019Rourke","year":"2020","journal-title":"Crit Care Med"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"1968","DOI":"10.1111\/aor.14325","article-title":"The international functional electrical stimulation society (IFESS): current and future developments","volume":"46","author":"Street","year":"2022","journal-title":"Artif Organs"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"9812","DOI":"10.3390\/s22249812","article-title":"Transcutaneous functional electrical stimulation controlled by a system of sensors for the lower limbs: a systematic 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patients with mechanical ventilation","volume":"45","author":"Liu","year":"2022","journal-title":"Int J Rehabil Res"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"333","DOI":"10.1038\/s41583-025-00920-7","article-title":"Global coordination of brain activity by the breathing cycle","volume":"26","author":"Tort","year":"2025","journal-title":"Nat Rev Neurosci"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"444","DOI":"10.1177\/1747493017711816","article-title":"Agreed definitions and a shared vision for new standards in stroke recovery research: the stroke recovery and rehabilitation roundtable taskforce","volume":"12","author":"Bernhardt","year":"2017","journal-title":"Int J Stroke"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"2375","DOI":"10.1113\/JP278298","article-title":"Neuromuscular electrical stimulation-promoted plasticity of the human brain","volume":"599","author":"Carson","year":"2021","journal-title":"J 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exercise\u2013cognition science: a systematic, methodology-focused review","volume":"7","author":"Herold","year":"2018","journal-title":"J Clin Med"},{"key":"ref43","doi-asserted-by":"publisher","first-page":"167","DOI":"10.1146\/annurev.neuro.24.1.167","article-title":"An integrative theory of prefrontal cortex function","volume":"24","author":"Miller","year":"2001","journal-title":"Annu Rev Neurosci"},{"key":"ref44","doi-asserted-by":"publisher","first-page":"135","DOI":"10.1007\/s002219900269","article-title":"Changes in muscle responses to stimulation of the motor cortex induced by peripheral nerve stimulation in human subjects","volume":"131","author":"Ridding","year":"2000","journal-title":"Exp Brain Res"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"64","DOI":"10.1038\/264","article-title":"Long-term reorganization of human motor cortex driven by short-term sensory stimulation","volume":"1","author":"Hamdy","year":"1998","journal-title":"Nat 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