The relationship between diaphragmatic dysfunction and sleep, emotional state, quality of life, and functional status in patients with chronic ischemic stroke

Stroke is a leading cause of disability worldwide, resulting in motor deficits and psychosocial impairments that negatively affect quality of life in survivors.[1][2][3] In addition to limb motor deficits, respiratory muscle dysfunction-particularly involving the diaphragm-has gained increasing attention in stroke populations.The diaphragm is the primary muscle of respiration.Any lesion that disrupts neural stimulation, muscle fibers, or the mechanical connection to the thoracic cage may lead to diaphragmatic dysfunction.This condition may manifest as exertional dyspnea and reduced exercise tolerance.[2,4] Recent studies have demonstrated that the diaphragm muscle also plays a significant role in swallowing, postural stability, balance, regulation of emotional states (emotional autonomy), and modulation of pain threshold.[5] The diaphragm is prone to atrophy in central nervous system disorders and often remains asymptomatic.[6,7] Studies conducted in stroke patients have shown that post-stroke hemiplegic diaphragmatic mobility and thickening fraction are significantly reduced during deep inspiration.[6] In healthy adults, diaphragm ABSTRACT Objectives: To examine whether hemiplegic diaphragm thickening fraction (DTF, %) is associated with functional status, walking capacity, sleep quality, mood, and stroke-specific quality of life (SS-QoL) in chronic ischemic stroke, and to determine a clinically useful DTF threshold. Materials and Methods:This single-center cross-sectional study included 68 patients with chronic ischemic stroke (≥6 months).Hemiplegic DTF was quantified by ultrasonography.Outcome measures were the Barthel index (BI), Functional Ambulation Category, 6-minute walk test (6-MWT), SS-QoL, Pittsburgh sleep quality index (PSQI), Hospital Anxiety and Depression Scale-Anxiety (HADS-A) and Hospital Anxiety and Depression Scale-Depression (HADS-D) scales, and Fugl-Meyer upper extremity (FMA-UE).Statistical analyses included non-parametric comparisons (DTF ≤20% vs. >20%), Spearman correlations, and multivariable regression adjusted for age, sex, body mass index, and stroke duration.Receiver operating characteristic and logistic regression analyses examined PSQI >5.Results: Hemiplegic diaphragm dysfunction (DTF ≤20%) was present in 36.8% of participants.Higher DTF was independently associated with better BI, 6-MWT, and SS-QoL scores, and with lower PSQI, HADS-A, and HADS-D scores (all p<0.05), but not with FMA-UE.DTF showed good discrimination for poor sleep [area under the curve: 0.779, 95% confidence interval (CI): 0.649-0.892],with an optimal threshold around 21% (sensitivity 0.77, specificity 0.83).Each 1% increase in DTF reduced the odds of poor sleep by approximately 7% (odds ratio ≈ 0.93; 95% CI: 0.89-0.98). Conclusion:In chronic ischemic stroke, greater hemiplegic DTF is independently associated with better function, mobility, and quality of life, and fewer sleep and mood problems.A DTF around 21% may serve as a practical threshold for risk stratification and rehabilitation targeting.