{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T07:01:51Z","timestamp":1790146911854,"version":"4.0.1"},"reference-count":14,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T00:00:00Z","timestamp":1790121600000},"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. Rehabil. Sci."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Extracorporeal shockwave therapy (ESWT) is a core modality for treating myofascial pain and degenerative cervical spine conditions in the nuchal and back regions. However, a subset of patients clinically experiences sudden, transient, and irritative dry coughs when receiving treatment near the seventh cervical vertebra (C7, the Dazhui acupoint region). Traditional perspectives vaguely attribute this to \u201cphysical acoustic waves penetrating and vibrating the lung parenchyma,\u201d which has caused excessive panic regarding iatrogenic pneumothorax and limited the rational titration of treatment intensity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>This perspective aims to refute the traditional \u201clung vibration theory\u201d through quantitative acoustic physics deductions and, for the first time, constructs a novel cross-system \u201cAccessory-Vagal Crosstalk at the Jugular Foramen\u201d hypothesis by integrating recent advancements in microanatomy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Mechanism<\/jats:title>\n                    <jats:p>Recent anatomical studies confirm that the main trunk and dense branches of the accessory nerve (CN XI), which innervate the upper trapezius, are highly concentrated near C7. High-frequency and high-pressure mechanical shear forces released by ESWT strongly irritate the accessory nerve, detonating retrograde conduction of action potentials in the periphery. When this explosive electrical signal ascends to the narrow jugular foramen at the skull base, it breaches the myelin insulation barrier between nerve fibers and erroneously activates the closely aligned sensory fibers of the vagus nerve (CN X) and glossopharyngeal nerve (CN IX) through ephaptic transmission. This leaked electrical signal ascends into the nucleus tractus solitarius (NTS) in the medulla, which the central nervous system instinctively misinterprets as a high-level airway foreign body intrusion, thereby forcibly initiating a reflex dry cough.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Clinical significance<\/jats:title>\n                    <jats:p>This reflex exhibits a distinct \u201cInstantaneous On-Off Effect\u201d. In clinical practice, adjusting the applicator angle to a 15\u00b0 to 30\u00b0 tilt toward the vertebral body (to avoid the main accessory nerve plexus) and implementing a low-energy gradient \u201cstepwise titration\u201d can completely block this cross-system abnormal reflex while ensuring safety.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fresc.2026.1915218","type":"journal-article","created":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T06:20:29Z","timestamp":1790144429000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Accessory\u2013vagal crosstalk at the jugular foramen: a hypothesis for reflex dry cough during posterior cervical extracorporeal shockwave therapy"],"prefix":"10.3389","volume":"7","author":[{"given":"Xuewen","family":"Jia","sequence":"first","affiliation":[{"name":"Department of Joint Surgery and Sports Medicine, The First Affiliated Hospital of Ningbo University","place":["Ningbo, Zhejiang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,23]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"8","DOI":"10.1097\/00003086-200106000-00003","article-title":"Principles of shock wave therapy","volume":"387","author":"Ogden","year":"2001","journal-title":"Clin Orthop Relat Res"},{"key":"B2","doi-asserted-by":"publisher","first-page":"147","DOI":"10.1016\/j.ijsu.2015.11.030","article-title":"Shock wave as biological therapeutic tool: from mechanical stimulation to recovery and healing, through mechanotransduction","volume":"24","author":"d'Agostino","year":"2015","journal-title":"Int J Surg"},{"key":"B3","doi-asserted-by":"publisher","first-page":"165","DOI":"10.21037\/atm-22-295","article-title":"Efficacy of extracorporeal shock waves in the treatment of myofascial pain syndrome: a systematic review and meta-analysis of controlled clinical studies","volume":"10","author":"Wu","year":"2022","journal-title":"Ann Transl Med"},{"key":"B4","doi-asserted-by":"publisher","first-page":"901","DOI":"10.1097\/00003086-200106000-00003","article-title":"Adverse effects of extracorporeal shockwave therapy: a systematic review","volume":"93","author":"Ogden","year":"2014","journal-title":"American Journal of Physical Medicine & Rehabilitation"},{"key":"B5","volume-title":"Fundamentals of Acoustics (4th Edition)","author":"Kinsler","year":"2000"},{"key":"B6","doi-asserted-by":"publisher","first-page":"1689","DOI":"10.1016\/j.ultrasmedbio.2007.05.006","article-title":"What is ultrasound-mediated cavitation in tissue?","volume":"33","author":"Meyberg-Solomayer","year":"2007","journal-title":"Ultrasound Med Biol"},{"key":"B7","doi-asserted-by":"publisher","first-page":"1253","DOI":"10.1007\/s00276-018-2059-4","article-title":"Accessory nerve distribution for aesthetic botulinum toxin injections into the upper trapezius muscle: anatomical study and clinical trial","volume":"40","author":"Bae","year":"2018","journal-title":"Surg Radiol Anat"},{"key":"B8","doi-asserted-by":"publisher","first-page":"383","DOI":"10.1146\/annurev-neuro-093020-120939","article-title":"Physiology and pathophysiology of mechanically activated PIEZO channels","volume":"44","author":"Syeda","year":"2021","journal-title":"Annu Rev Neurosci"},{"key":"B9","doi-asserted-by":"publisher","first-page":"508","DOI":"10.1016\/j.pupt.2013.07.001","article-title":"Regulation of cough and action potentials by voltage-gated na channels","volume":"26","author":"Carr","year":"","journal-title":"Pulm Pharmacol Ther"},{"key":"B10","doi-asserted-by":"publisher","first-page":"217","DOI":"10.1038\/nn.2727","article-title":"Ephaptic coupling of cortical neurons","volume":"14","author":"Anastassiou","year":"2011","journal-title":"Nat Neurosci"},{"key":"B11","doi-asserted-by":"publisher","first-page":"975","DOI":"10.1152\/physrev.00039.2015","article-title":"Vagal afferent innervation of the airways in health and disease","volume":"96","author":"Mazzone","year":"2016","journal-title":"Physiol Rev"},{"key":"B12","doi-asserted-by":"publisher","first-page":"3989","DOI":"10.1002\/j.2040-4603.2022.tb00237.x","article-title":"Structure and functions of the vagus nerve in mammals","volume":"12","author":"Ottaviani","year":"2022","journal-title":"Compr Physiol"},{"key":"B13","doi-asserted-by":"publisher","first-page":"934","DOI":"10.1016\/S2213-2600(16)30373-3","article-title":"Chronic cough and cough hypersensitivity syndrome","volume":"4","author":"Chung","year":"2016","journal-title":"The Lancet. Respiratory Medicine"},{"key":"B14","doi-asserted-by":"publisher","first-page":"e718","DOI":"10.1016\/j.wneu.2020.05.271","article-title":"Intraforaminal dural septations of the jugular foramen: a cadaveric study","volume":"141","author":"Akdag","year":"2020","journal-title":"World Neurosurg"}],"container-title":["Frontiers in Rehabilitation Sciences"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fresc.2026.1915218\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T06:20:30Z","timestamp":1790144430000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fresc.2026.1915218\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,23]]},"references-count":14,"alternative-id":["10.3389\/fresc.2026.1915218"],"URL":"https:\/\/doi.org\/10.3389\/fresc.2026.1915218","relation":{},"ISSN":["2673-6861"],"issn-type":[{"value":"2673-6861","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,23]]},"article-number":"1915218"}}