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Positive Effect of Abdominal Breathing Exercise on Gastroesophageal Reflux
Disease: A Randomized, Controlled Study
Article in The American Journal of Gastroenterology · December 2011
DOI: 10.1038/ajg.2011.420 · Source: PubMed
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ESOPHAGUS
372
ORIGINAL CONTRIBUTIONS
nature publishing group
Positive Effect of Abdominal Breathing Exercise on
Gastroesophageal Reflux Disease:
A Randomized, Controlled Study
A.J. Eherer, MD1, F. Netolitzky1, C. Högenauer, MD1, G. Puschnig1, T.A. Hinterleitner, MD1, S. Scheidl, MD2, W. Kraxner, MD1,
G.J. Krejs, MD1 and Karl Martin Hoffmann, PD, MD3
OBJECTIVES:
The lower esophageal sphincter (LES), surrounded by diaphragmatic muscle, prevents gastroesophageal reflux. When these structures become incompetent, gastric contents may cause gastroesophageal reflux disease (GERD). For treatment, lifestyle interventions are always recommended. We
hypothesized that by actively training the crura of the diaphragm as part of the LES using breathing
training exercises, GERD can be positively influenced.
METHODS:
A prospective randomized controlled study was performed. Patients with non-erosive GERD or healed
esophagitis without large hernia and/or previous surgery were included. Patients were randomized
and allocated either to active breathing training program or to a control group. Quality of life (QoL),
pH-metry, and on-demand proton pump inhibitor (PPI) usage were assessed at baseline and after
4 weeks of training. For long-term follow-up, all patients were invited to continue active breathing
training and were further assessed regarding QoL and PPI usage after 9 months. Paired and unpaired
t-test was used for statistical analysis.
RESULTS:
Nineteen patients with non-erosive GERD or healed esophagitis were randomized into two groups
(10 training group and 9 control group). There was no difference in baseline patient characteristics
between the groups and all patients finished the study. There was a significant decrease in time
with a pH < 4.0 in the training group (9.1±1.3 vs. 4.7±0.9%; P < 0.05), but there was no change in
the control group. QoL scores improved significantly in the training group (13.4±1.98 before and
10.8±1.86 after training; P < 0.01), but no changes in QoL were seen in the control group. At longterm follow-up at 9 months, patients who continued breathing exercise (11/19) showed a significant
decrease in QoL scores and PPI usage (15.1±2.2 vs. 9.7±1.6; 98±34 vs. 25±12 mg/week,
respectively; P < 0.05), whereas patients who did not train had no long-term effect.
CONCLUSIONS: We show that actively training the diaphragm by breathing exercise can improve GERD as assessed
by pH-metry, QoL scores and PPI usage. This non-pharmacological lifestyle intervention could help
to reduce the disease burden of GERD.
SUPPLEMENTARY MATERIAL is linked to the online version of the paper at http://www.nature.com/ajg.
Am J Gastroenterol 2012; 107:372–378; doi:10.1038/ajg.2011.420; published online 6 December 2011
INTRODUCTION
Gastroesophageal reflux disease (GERD) places an increasing
burden on our health-care system. GERD presents with a wide
spectrum of symptoms and in less than half of the patients with
endoscopically detectable changes at the gastroesophageal junction (1,2). Non-erosive reflux disease (NERD) is as difficult to treat
as the ulcero-erosive variant of the disease. When lifestyle modification fails, treatment of GERD is mainly medical, in selected
cases surgical. Both approaches are highly effective. Proton pump
inhibitors (PPIs) are today’s standard therapy. However, some concern has increasingly been raised about long-term intake of PPIs.
Withdrawal of PPIs may be difficult (3). The surgical approach
1
Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University Graz, Graz, Austria; 2Division of Pulmonary Medicine,
Department of Internal Medicine, Medical University Graz, Graz, Austria; 3Division of General Pediatrics, Department of Pediatric and Adolescent Medicine,
Medical University Graz, Graz, Austria. Correspondence: Karl Martin Hoffmann, PD, MD, Division of General Pediatrics, Department of Pediatric and Adolescent
Medicine, Medical University Graz, A-8036 Graz, Austria. E-mail: hoffmaka@mac.com
Received 26 April 2011; accepted 1 September 2011
The American Journal of GASTROENTEROLOGY
VOLUME 107 | MARCH 2012 www.amjgastro.com
can be accompanied by considerable side effects and endoscopic
methods have largely failed to treat GERD (4,5).
Lifestyle modifications as supportive measure are always recommended, their mechanisms and effects, however, have not been
well studied. Although there is limited data for a positive effect
of a change of sleeping position with elevation of the head of the
bed and weight loss, there are no or only short-term studies using
manometry or pH-metry for most recommended lifestyle changes,
such as modification of eating behavior, chewing of gum, and other
measures (6). The long-term effect of such measures on the course
of the disease is mainly unknown.
We wanted to pursue an alternative treatment approach for
patients with NERD or healed esophagitis with persistent GERD
symptoms by offering a breathing training program in addition
to standard acid-suppressive therapy. We chose NERD patients
for our study because on-demand PPI therapy is an accepted and
recommended approach for these patients (2). For the majority
of patients, the pathogenesis of GERD is considered to be an
impairment of the closing mechanism of the lower esophageal
sphincter (LES). This is due to an increased number of transient
LES relaxations and/or low LES pressure. In advanced disease,
the LES is destroyed and the tubular part of the esophagus cannot clear refluxed gastric contents (7). The pathophysiology of
early stages of the disease, however, is not well characterized,
and persons susceptible for GERD have not been carefully investigated. The nature of early events in the pathogenesis of GERD
remains to be elucidated. It is believed that synergy of the function of the LES and its surrounding crura of the diaphragm,
when superimposed, are of importance for competent closure
(8). Even after the surgical removal of the LES, a pressure zone is
detectable due to contractions of the crura of the diaphragm (9).
Like any other striated muscle of the body, the crura of the dia-
phragm should be amenable to improved performance by physical exercise. Our hypothesis is that training of the diaphragm
with a breathing exercise could decrease reflux and improve
symptoms of GERD.
METHODS
We included adult (18 years and above) GERD patients using ondemand acid-suppressive therapy. Reflux was proven by a positive pH-metry (see below). Exclusion criteria were hiatal hernia
>2 cm, previous operation at the LES, actual erosive esophagitis
proven endoscopically, and concomitant conditions preventing patients from training. Erosive esophagitis that was proven
to be healed did not constitute an exclusion criterion (see Consort diagram).
The study started in November 2004 when consecutive patients
attending our gastroenterology clinic were invited to participate.
For further recruitment, we advertised the study in a local newspaper, which resulted in calls from some 200 interested persons. If
patients could not provide a recent upper gastrointestinal endoscopy report, such a study was done to exclude a large hiatal hernia and erosive disease. Inclusion of patients ended in February
2006, follow-up in December 2006. The study was registered retrospectively with the UMIN Clinical Trials Registry (Registration
Number: R000005808).
The study design
The study design is outlined in Figure 1.
Controlled study
After endoscopy, a period of at least 4 weeks followed to
continue or establish on-demand therapy for GERD symptoms.
Endoscopy
4 Weeks
On-demand Rx
Manometry
pH-metry
7 Days
PPI and H2 Blocker
Randomization
QoL scores
Drug use assessment
7 Days
PPI and H2 Blocker
4 Weeks
On-demand Rx
and
No breathing exercise
7 Days
PPI and H2 Blocker
QoL scores
Drug use
assessment
After at least 9 months:
QoL scores and drug use
assessment
Long-term
follow-up
Breathing exercise for both groups
and
Request to continue this Rx
Randomized controlled
period
4 Weeks
On-demand Rx
and
Breathing exercise
Manometry
pH-metry
QoL scores
Drug use assessment
Figure 1. Outlines the study design. PPI, proton pump inhibitor; QoL, quality of life.
© 2012 by the American College of Gastroenterology
The American Journal of GASTROENTEROLOGY
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Eherer et al.
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Table 1. Characteristics of patients perfoming breathing exercises
and control group at the time of inclusion in the study
Exercise group
(n =10)
Age
48 ± 4 years
♀: ♂
5:5
BMI
22.0 ± 1.0
Control group
(n =9)
n.s.
55 ± 4 years
4:5
n.s.
24.9 ± 0.6
Smoker
1
0
Any lifestyle modification
10
8
Exclusion of certain food
7
3
Elevated bed
4
6
Omitting tight cloths
2
4
Sports
5
8
Duration of symptoms
11.6±1.7 years
n.s.
7.4±1.7 years
BMI, body mass index; n.s., not significant.
Values are expressed as absolute numbers or mean±s.e.m.
Patients took their acid-suppressant drugs (PPI, H2 blockers,
and antacids) as needed to guarantee their comfort. Patients did
not change drug brands during the study. After quality of life
(QoL) scores and an assessment of drug usage had been obtained,
patients were asked to abstain for 1 week from acid-suppressant
therapy except antacids to allow for an accurate pH-metry without influence of medication. pH-metry followed manometry,
and when patients showed pathologic reflux on pH-metry they
were considered suitable for the study and randomized for either
breathing exercise or no breathing exercise. Blocked randomization was performed in blocks of four closed envelopes (two with
the training option and two with the control group option) that
were brought into random order by a person who had not personally sealed the envelopes and was not involved in study design or
treating study patients. The groups of four were then consecutively
numbered and used to randomize the study patients. None of the
treating physicians were aware of the initial choice of treatment.
The randomized controlled study period lasted 4 weeks with or
without breathing exercise; all patients were taking on-demand
their anti-reflux medication. The groups were not blinded to treatment due to the lack of plausible sham procedures, which possibly also would have influenced the outcome measurements. QoL
scores and drug use assessment were again obtained, followed by
another week without acid-suppressant drugs to allow for correct
pH-metry, preceded by a manometry. Primary outcome was a
change in pH-metry after training and secondary outcomes were
changes in manometry, QoL, or PPI usage.
Long-term follow-up
After the study period, patients who had not practiced the
breathing exercises underwent the same training program as the
former training group. For long-term follow-up, patients in both
groups, now having the same treatment, were dismissed and were
requested to continue on-demand acid-suppressant therapy as
The American Journal of GASTROENTEROLOGY
well as breathing exercise. After at least 9 months after dismissal,
patients were again contacted to provide further QoL scores,
assess their drug usage and to state whether they were still performing the breathing exercises.
Manometry
Manometry was performed with a standard Dent sleeve catheter
(Dentsleeve International, Mississauga, ON, Canada). A slow
pull through established lower and upper margins of the LES,
and basal pressure of the LES. A 30-min period followed with
the sleeve in LES position, the patients on their right side and air
inflation through the abdominal port of the manometry tube at a
rate of 15 ml/min. The insufflation was intended to trigger transitory LES relaxations, which were judged visually using the criteria
of Holloway (10).
pH-metry
PPIs or other acid-suppressant therapies except antacids were
discontinued for 1 week. A standard pH catheter (VersaFlex,
Alpine Biomed Medical Devices, CA) was placed 5 cm above the
upper margin of the LES. The pH was recorded during normal
daily activities for at least 20 h. pH-metry was considered abnormal when the time fraction with pH < 4.0 was >4.5% of the study
period (2).
Quality of life scores
We used two scores to assess QoL. The GERD Health-Related
Quality of Life Scale (11) (German translation and validation
by Kamolz T) provides 10 questions regarding heartburn symptoms (such as severity and respect to position, daytime or meals),
dysphagia, side effects of medication, and satisfaction with current situation and effect of therapy. Every question is graded 0
(no impairment) to 5 (severe impairment); the results are summarized. The Gastrointestinal Quality of Life Index (GIQLI) (12)
is a more general index with 36 questions regarding symptoms,
emotional, psychological and social situation, and stress under
the ongoing therapy.
Patients themselves filled in the forms at home without outside help. Help was, however, provided as needed when patients
reported to the clinic for the manometry procedure.
Breathing exercise
The purpose of the training was to induce a change from thoracic
to abdominal breathing, which involves diaphragmatic contraction. Abdominal breathing techniques are used by many professional singers as a basic training method. Our program was
developed by a professional vocal coach (Professor Karl Ernst
Hoffmann, Graz, Austria) and modified by our physiotherapist.
Exercises were performed in a standing, sitting, or supine position. Subjects were instructed to practice without exertion or
discomfort. The breathing exercises were taught by a professional
physiotherapist. Patients had individual one-on-one training for
1 h; follow-up training was continued until patients performed to
the physiotherapist’s satisfaction. They were given a booklet with
a detailed description of the exercises and as a help for timing, a
VOLUME 107 | MARCH 2012 www.amjgastro.com
Breathing Exercise and GERD
a
375
University of Graz; written informed consent was obtained from
all patients.
Time fraction pH < 4
25
n.s.
20
P < 0.05
RESULTS
After interviews and gastroscopy, 19 patients with established
NERD or healed esophagitis agreed to participate and were
enrolled in the study and then randomly divided into two groups.
Patient characteristics for the two treatment groups are given in
Table 1; their mean age and body mass index were not significantly different. Both groups had suffered from GERD for many
years. All 19 patients finished the controlled study period.
15
10
5
0
1 Month
1 Month
After
Before
Before
Training
After
Controlled trial
No training
Mean ± s.e.m.
b
30
GERD HRGIQLI in patients with and without exercise
n.s.
n.s.
P < 0.01
GERD HRGIQLI
25
20
15
pH-metry. At baseline, there was no difference in the time fraction of pH < 4.50 (9.1±1.3% vs. 10.7±1.8%) in both groups
(Figure 2a). After 1 month, pH-metry showed a significant
decrease in acid exposure in patients in the breathing exercise
group (4.7±0.9%, P < 0.05; power 0.6). There was no significant
change in the control group (9.7±2.1%). Between-group comparisons were not significant. In the training group, four out of nine
patients reached normal values of the fraction time with pH < 4,
whereas in the non-training group only one subject had normal
values. One patient in each group refused follow-up pH-metry
because of discomfort. There was no correlation between severity
of reflux in pH-metry and GERD symptoms.
10
5
1 Month
0
1 Month
After
Before
Training
Before
After
No training
Mean ± s.e.m.
Figure 2. pH-metry data and quality of life score. (a) Results of pH-metry
given as % time with pH < 4.0 of training and non-training groups before
and after the controlled study period are shown. Green circles denote
individual patients; red circles with vertical bars denote mean±s.e.m. In
each group, one patient refused pH-metry after the study period. (b) Quality of life (QoL) scores specific for gastroesophageal reflux disease (GERD)
(GERD-HRGIQLI) of training and non-training groups before and after the
controlled study period are shown. The higher the score, the poorer the
quality of life, i.e., a patient with a higher score is worse off. Green circles
denote individual patients; red circles with vertical bars denote mean±
s.e.m. HRGIQLI, Health-Related Quality of Life Scale.
CD covering 30 min with an audio explanation of the exercises
and accompanying music. Training then entailed daily practice
for at least 30 min. After the first week, a session was again supervised by the physiotherapist. Exercises are described in detail in
the Supplementary Appendix.
Quality of life. Figure 2b shows that reflux-specific QoL (GERDHealth-Related Quality of Life Scale) did not differ in the two
groups at the beginning of the study. QoL scores, however, improved significantly after 1 month of daily training (13.4±1.98
before and 10.8±1.86 after training; P < 0.01; power 0.9),
whereas non-training patients showed no change (13.7±2.75
vs. 13.9±2.8). Between-group comparisons were not significant.
The more general Eypasch score, focusing more on psychosocial
aspects, showed no difference between the groups, before and
after treatment (101.5±6.8 before and 110.4±6.5 after training,
99.4±6.2 before and 101.6±7.0 after not training; n.s.).
Proton pump inhibitor usage. On-demand use of PPIs showed
no difference between the groups after 1 month (107±30 mg
PPI/week before and 105±32 mg PPI/week after training, 171±47
before and 140±39 after not training).
Manometry. None of the common measurements showed significant changes to explain how breathing exercise could provide
a benefit in GERD (Table 2). We found no difference in basal
pressure and intra-abdominal and transdiaphragmatic pressure.
We found no difference in transient LES relaxations, which were
induced by insufflation of air into the stomach for half an hour.
Statistics
We used the paired and unpaired t-test after checking for normal distribution for in-group and between-group comparisons. No side effects were observed during the study. The study
protocol was approved by the ethics committee of the Medical
© 2012 by the American College of Gastroenterology
Long-term follow-up
Quality of life. After the controlled study period, all patients
were taught to practice abdominal breathing. Nine months
thereafter only 11 out of 19 still continued training (6 of initial
The American Journal of GASTROENTEROLOGY
ESOPHAGUS
n.s.
376
Eherer et al.
Training group
Basal pressure (mm Hg)
Control group
Baseline
P
4 weeks
Baseline
P
4 weeks
16±2
n.s.
20±2
13±1
n.s.
16±2
3±1
n.s.
6±2
2±1
n.s.
4±1
75±27
n.s.
129±50
21±8
n.s.
87±40
t-LES relaxations
n per 30 min
Duration (s) per 30 min
LES, lower esophageal sphincter; n.s., not significant.
Basal pressure and LES relaxations were measured at baseline and after 4 weeks of breathing training. Numbers are expressed as mean±s.e.m.
PPI usage after 9 months
200
symptom scores after 9 months (11.4±2.3 and 13.5±3.3 before
and after, respectively). Reasons for the cessation of training
were that patients preferred intake of PPIs, that they were too
lazy, did not have the time or thought the training was useless.
Patients still doing exercises adapted the frequency of training
to their individual needs; only six patients kept to a daily time
schedule, six performed training 1–2 times per week, and two on
demand during heartburn episodes.
n.s.
PPl mg/week
150
100
Proton pump inhibitor usage. After 9 months still on training
PPI usage significantly decreased from 98±34 to 25±12 mg/week
(P < 0.05; power 0.6; Figure 3). Patients without long-term training had no PPI usage change (179±31 before to 144±40 after).
50
P < 0.05
0
Start of the study
9 Months
DISCUSSION
QoL after 9 months
15
GERD HRGIQLI
ESOPHAGUS
Table 2. Measured values of manometry of training and control group
10
5
0
Start of the study
9 Months
Figure 3. Proton pump inhibitor (PPI) usage (denoted as mg/week)
and the quality of life (QoL) scores at the beginning of the study and at
9 months of training of patients (both intervention and control group)
who were invited to continue abdominal breathing exercises beyond the
controlled study period are shown. Filled circles with vertical bars denote
mean±s.e.m. GERD, gastroesophageal reflux disease; HRGIQLI, HealthRelated Quality of Life Scale.
training group and 5 of initial non-training group). These 11
patients showed a significant and pronounced decrease in their
reflux symptom score after 9 months training (15.1±2.2 before
to 9.7±1.6 after, P < 0.05; power 0.6; Figure 3). In all, 8 of 19
patients who quit the program had no improvement of reflux
The American Journal of GASTROENTEROLOGY
Lifestyle modifications, although commonly recommended,
lack sufficient data to show objective improvement of reflux (6).
A recent position statement paper on the management of GERD
reviewed 407 publications on non-pharmacologic therapies (7).
This paper concluded that evidence is lacking for the positive
effect for most recommended non-pharmacological interventions or lifestyle modifications, such as head of bed elevation,
left lateral decubitus position, weight loss, and avoidance of late
evening meals (6). However, although weight reduction is considered to be of benefit some controlled studies failed to show a
positive effect (13). Nevertheless, many physicians and patients
follow these recommendations and experience a subjective
advantage.
To our knowledge, this is the first controlled study to show that
a non-invasive, non-pharmacological intervention significantly
improved pH-metry and reflux symptoms of GERD patients.
Our intervention was aimed at improving gastroesophageal antireflux mechanisms. It is known that the crural diaphragm has
a critical role in this physiological barrier and functions as an
extrinsic sphincter in addition to the LES (14). The crural diaphragm is innervated independently as a striated muscle that
contracts during inspiration. A breathing technique explicitly
involving the diaphragm can be voluntarily trained and is often
used by professional singers. This led to our hypothesis that
breathing training could train the crural diaphragm, therefore,
positively influencing the anti-reflux barrier. This intervention
VOLUME 107 | MARCH 2012 www.amjgastro.com
showed an improvement in measured acidic reflux, symptoms,
and PPI usage; however, significant changes in classical stationary manometry could not be detected. Discrimination of the LES
and the crura cannot be accomplished by standard manometry
and probably requires special techniques such as pharmacological relaxation of striated muscle under general anesthesia
or more advanced manometric techniques such as reversed
perfusion sleeve catheter or high-resolution manometry (15,16).
We believe that the clinical routine manometric techniques used
in our study are too insensitive to discriminate the influence of
the crura and to detect this mechanism.
This study investigated a subgroup of patients with GERD.
They were NERD patients or had endoscopically healed erosive esophagitis with proven pathological acidic reflux (2). All
patients with significant anatomical abnormalities were excluded
because of the assumption that our intervention would be ineffective in these patients due to a lacking or negative influence of
the diaphragmatic crura on the LES. Recommendations regarding breathing exercise for reflux disease can only be made for this
subgroup of patients, but not for the whole spectrum of GERD
patients. Furthermore, our long-term observation showed that
only those patients who were highly motivated and continued to
perform the exercises showed long-term benefit.
All patients had on-demand PPI therapy for at least 4 weeks
before the study intervention started. On-demand therapy was
used for the following reasons: First, PPI usage served as an additional parameter for control of GERD. On-demand PPI therapy
has been established as an adequate treatment of healed esophagitis and NERD patients (7). Second, the status of the patients was
stable before randomization since an on-demand PPI therapy had
been applied for 4 weeks. Third, a standardized PPI or other antacid therapy would have resulted in a change of a long-existing
therapy in many patients and might have influenced QoL scores
before entering the study. A strictly scheduled PPI therapy might
have further brought some patients in a symptom-free state of
their GERD, making it impossible to assess the effect of breathing
exercise on symptoms in these patients.
PPI usage decreased to less than one third after 9 months of
breathing exercise. This effect was seen in only those patients who
voluntarily continued to perform the training in the open labeled
extension of the study. This drug usage reduction could result in a
substantial economic advantage for our health-care system. Because
abdominal breathing exercises likely reduce PPI consumption, this
non-pharmacological intervention could be considered in patients
who are concerned about long-term drug use and its complications (3). Moreover, the measure is free of side effects except that it
takes more time than swallowing a pill.
Interestingly, some patients who had improvement of QoL
using breathing exercise discontinued their training. On the
other hand, some of our patients chose not to increase their ondemand PPI dosage to be symptom free. Both of these observations show that some patients do not utilize the whole spectrum
of the offered treatment and obviously accept some degree of
persistent GERD symptoms. This aspect of PPI usage is most
likely explained on a psychological level. This may be an expla© 2012 by the American College of Gastroenterology
nation why some authors consider NERD to be more difficult to
treat than erosive GERD (2).
There are several limitations to the way our study was performed:
First, our group numbers are small due to strict exclusion criteria.
Consequently, in the statistical analysis our study is underpowered and between-group comparisons did not show the significant
results as compared with in-group analysis. Second, we could not
blind our patients to the intervention and we did not use a sham
procedure for the control group. While planning the study we
have considered a sham procedure for the control group, however,
we were not able to design a sham breathing exercise procedure
where we could rule out an influence on the diaphragmatic muscle. Furthermore, sham procedures not related to any breathingrelated exercise would have been implausible for the study patients;
the patients were therefore not blinded. Third, the manometric
method used in our study was probably not sensitive enough to
isolate the crural diaphragmatic contractions. More advanced
manometric developments such as high-resolution manometry or
reverse perfuse sleeve manometry could possibly reveal the underlying mechanisms.
In conclusion, our work showed that a breathing exercise can
improve GERD as assessed by QOL score, pH-metry, and PPI
usage. With increasing prevalence of GERD, a non-pharmacological intervention like breathing exercises could have an important
role in reducing the disease burden of GERD.
ACKNOWLEDGMENTS
We would like to thank Professor emeritus Karl Ernst Hoffmann
for adapting his vocal training techniques for our study. We thank
Mag Dr Sonja Pöllabauer for the English translation of the original
German exercise text for the appendix of the published paper. Many
thanks to Ursula Eherer, MD, for her thoughtful input and countless hours of patience during this study. The assistance and advice of
Professor Karl Ernst Hoffmann, Mag. Dr Sonja Pöllabauer, Ursula
Eherer, MD are gratefully acknowledged.
CONFLICT OF INTEREST
Guarantor of the article: A.J. Eherer, MD.
Specific author contributions: Designed the study with contribution of Karl Martin Hoffmann, conducted the study, performed
pH-metry, manometry, and endoscopy, and wrote the paper:
Andreas J. Eherer; contributed to performing the study: Felix
Netolizky; adapted breathing exercises for physiotherapy, performed
and supervised patient training: Georg Puschnig; performed endoscopy and co-wrote the manuscript: C. Högenauer; co-wrote the
manuscript: S. Scheidl, W. Kraxner, and Karl Martin Hoffmann;
all authors contributed to interpreting the data.
Financial support: None.
Potential competing interests: All authors have completed the
Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the
submitted work; no financial relationships with any organizations
that might have an interest in the submitted work in the previous
3 years; no other relationships or activities that could appear to have
influenced the submitted work.
The American Journal of GASTROENTEROLOGY
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ESOPHAGUS
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Eherer et al.
Study Highlights
ESOPHAGUS
WHAT IS CURRENT KNOWLEDGE
3Gastroesophageal reflux disease (GERD) places an increasing burden on our health-care system.
3Treatment options include medication, surgery, or lifestyle
changing recommendations, which, however, often lack
evidence.
3Part of the lower esophageal sphincter (LES) consists of the
diaphragmatic crurae, which should be actively trainable.
WHAT IS NEW HERE
3We use unique abdominal breathing exercises intended to
train the lower esophageal sphincter (LES) crura of the diaphragm in gastroesophageal reflux disease (GERD) patients.
3These breathing exercises lead to significant improvement
of pH-metry and quality of life (QoL) in GERD patients.
3On long-term follow-up, this intervention leads to a significant reduction in proton pump inhibitor (PPI) usage.
3This non-pharmacological intervention could help to reduce
the disease burden of GERD.
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1. Kahrilas PJ. Clinical practice. Gastroesophageal reflux disease. N Engl J
Med 2008;359:1700–7.
2. Modlin IM, Hunt RH, Malfertheiner P et al. Diagnosis and management of
non-erosive reflux disease—the Vevey NERD Consensus Group. Digestion
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