Effectiveness of Abdominal Breathing Exercise to Control Gastroesophageal Reflux Disease, a Randomized Controlled Trial

Abstract

Objectives

To determine the effect of actively training the crura of diaphragm which is a part of lower esophageal sphincter using abdominal breathing exercises to treat gastroesophageal reflux disease.

Methodology

With a randomized controlled study design, a total of 22 (11 in each group) clinically diagnosed patients of GERD presenting to the gastroenterology outpatient department at Holy Family Hospital in Pakistan were assessed using GERD related “quality of life index (QoLI)” questionnaire and their on-demand proton pump inhibitors (PPI) usage. Single blinding technique will be used. Patients ages 18–60 years with GERD were included. However, those with hiatal hernia > 2 cm, previous surgeries on LES and those with who could not undergo the breathing exercise training were excluded. The data was collected via interviews. The intervention group was trained to do a 5-min breathing exercise and advised to perform it 5 times a day for 4 continuous weeks. On demand PPI usage was self-recorded. The control group was also trained to perform a breathing exercise that had no effect on LES and was asked to self-record on demand PPI usage. After 4 weeks the data was collected from both groups and compared quality-of-life index and PPI usage. Data was retrieved and analyzed using SPSS version 22. Descriptive analysis was used for describing the study variables. Paired t-test was used for in group comparison before and after intervention and independent t test was used for between group comparison, p value of <0.05 was taken as significant. Mean PPI usage of the two groups was also compared.

Results

An improved QoLI and reduced PPI usage was seen in the intervention group as compared to control group. Paired t test confirmed a statistically significant difference, but the independent t test did not. Linear regression test showed that F (1,20) = 32.822, p = 0.000. Adjusted R value is 0.603. y = 13.182x +2.812. The beta value is 0.789 and p value is 0.000.

Conclusion

The study concludes that abdominal breathing exercises can improve the GERD symptoms as assessed by QoLI score and on demand PPI usage. It advocates for an alternative treatment option for GERD patients that is more efficacious as compared to no breathing exercises and has less potential side effect as compared to continuous PPI use, enabling us to lead our way towards revolution in medicine providing more effective and less invasive treatment options to facilitate our patients.

1. Introduction

Gastroesophageal reflux disease (GERD) is a common condition seen by primary care physicians. The main symptoms associated with GERD are heartburn, regurgitation, a feeling of a lump in the throat (globus sensation), difficulty swallowing (dysphagia), chest pain, and belching.1 There is a valve mechanism between the esophagus and the stomach, comprising the lower esophageal sphincter (LES), the diaphragm, the His angle, the Gubaroff valve, and the phrenoesophageal membrane. 2 Physiologically, the LES is a 3-4 cm-long segment of tonically contracted smooth muscle at the distal end of the esophagus.3 A functional (frequent transient LES relaxation) or mechanical (hypotensive LES) problems of LES is the most common cause of GERD. Treatment options available for GERD include; life style modifications, over the counter and prescription medications (antacids, PPIs, H2 blockers) and surgical treatment.4 (see Table 1, Figs. 1–3)

Table 1.

Independent Samples t-test after 4 weeks.

Independent Samples Test
		Levene’s test for equality of variances		t-test for equality of means
		F	Sig.	t	df	Sig. (2-Tailed)	Mean difference	Std. Error difference	95% confidence interval of the difference
									Lower	Upper
QoLI	Equal variances assumed	0.059	0.811	−5. 734	20	0.000	−13.18182	2.29876	−17.97695	−8.38669
	Equal variances not assumed			−5.734	19.788	0.000	−13.18182	2.29876	−17.98024	−8.38339

Linear regression test showed that F (1, 20) = 32.822, p-value = 0.000. Adjusted R value is 0.603. y = 13.182x +2.812. The Beta value of 0.789 and p value of 0.000 shows a positive effect of abdominal breathing exercises on reducing the symptoms of GERD.

Fig. 1.

QoLI for control group before and after intervention.

Fig. 2.

QoLI for interventional group before and after intervention.

Fig. 3.

Linear regression test.

Safety issues associated with PPIs and lower efficacy of over-the-counter medications for complete cure of the disease have recently attracted widespread media and lay attention.5 The surgical approach can be accompanied by considerable side effects and endoscopic measures have largely failed to treat GERD.6,7 Life style modifications including losing weight, elevating your head during sleep, quitting smoking and changing your eating habits and diet have not been well studied and the long-term effect of such measures on the course of treatment is mainly unknown.8 However, inspiratory muscle training (IMT) has been shown to increase diaphragm thick-ness and increase the LES pressure9 reducing the chances of gastric reflux and improving symptoms of GERD. Training the diaphragm 1 h after eating may decrease esophageal acid exposure during the 120 min following a meal in GERD patients.10 Since the diaphragm is a skeletal muscle and partially under voluntary control, its dysfunction can be improved with breathing exercises. Diaphragmatic breathing is a type of breathing exercise that helps strengthen your diaphragm. This breathing exercise is also sometimes called belly breathing or abdominal breathing. Diaphragmatic breathing training (DBT) may help reduce symptoms in certain GERD patients.11 The higher its increment, the lower the increment of supine acid exposure.12 Thus, osteopathic manipulative technique on diaphragmatic muscles produces a positive increment in the LES region soon after its performance.13

2. Material and methods

2.1. Study design

Randomize controlled trial.

2.2. Study setting

Holy Family Hospital, a tertiary care hospital in Rawalpindi, Pakistan.

2.3. Study population

Outpatients ages 18–60 with a GERD diagnosis.

2.4. Study duration

6 months.

2.5. Sample size

22 (11 in each group) calculated by G power sample size calculator at 5% alpha error and 80% power of study with an effect size 1.3 using reference study.

2.6. Ethical approval

ERB certificate was obtained from the Ethical Review Board of Rawalpindi Medical University. Reference letter no. 535/IREF/RMU/2023.

2.7. Sampling technique

Random sampling.

2.8. Randomization

Every participant was assigned a unique number. Then, a lottery method to randomly assign each number to a control or experimental group was used.

2.9. Blinding

Single blinding technique was used. Intervention group was taught abdominal breathing exercises while the control group was advised simple thoracic breathing to maintain blindness.

2.10. Inclusion criteria

18–60 years old patients of GERD using on demand PPI therapy.

2.11. Exclusion criteria

Hiatal hernia greater than 2 cm, previous operation on LES and conditions preventing patient from training like respiratory tract pathologies.

2.12. Data collection tool

The data was collected via interviews by asking questions included in GERD health related quality of life questionnaire14 and also about their PPIs usage before and after intervention.

2.13. Intervention

The 11 participants in intervention group were taught the abdominal breathing exercises as follow.

• Lie on your back on a flat surface (or in bed) with your knees bent. You can use a pillow under your head and your knees for support, if that’s more comfortable.

• Place one hand on your upper chest and the other on your belly, just below your rib cage.

• Breathe in slowly through your nose, letting the air in deeply, towards your lower belly. The hand on your chest should remain still, while the one on your belly should rise.

• Tighten your abdominal muscles and let them fall inward as you exhale through pursed lips. The hand on your belly should move down to its original position.

This exercise was to be repeated five times a day, with each session lasting approximately 5 min for continuous 4 weeks along with recording on demand PPI usage. While group 2 (control group) only used on demand PPIs. Group 2 participants were advised to do simple thoracic breathing without any controlled or timed fashion, not exerting much effect on LES15 in order to maintain blinding. After 4 weeks the data was collected again and the intervention group participants were compared to control group for their quality-of-life index and PPI usage.

2.14. Data analysis procedure

Data was retrieved in Microsoft Excel software and analyzed using SPSS version 22. Descriptive analysis was used for describing the study variables. Paired t-test was used for comparison before and after intervention, p value of <0.05 was taken as significant. Frequency, percentage, mean and tables for representation of data was used.

3. Results

3.1. Demographic details

Total of 22 clinically diagnosed patients of GERD were included in the study. Out of these, 7 were males and 15 were females with a mean age of 35 (10.39). Further details about comorbids, residency and personal contact numbers were also collected. Patients with comorbidities like COPD, Asthama, Achalasia, Ppeptic ulcer etc affecting the outcomes of research were not included.

3.2. On demand PPI usage

All the patients were prescribed same PPIs (dexlansoprazole 40 mg) to be used as needed for their symptoms. The interventional group was advised to do abdominal breathing excercises additionally. The mean PPI usage for both groups during 4 weeks was then compared. The mean PPI usage by the control group was 4.63 (1.36) while by the interventional group was 0.72 (0.46) during the 4 weeks of study period implying that those performing abdominal breathing exercises had a less mean on demand PPI usage during the period.

3.3. Quality of life index

The quality of life indexes for participants of both groups at the start of the study were compared by independent samples t-test giving a p value of 0.76 (i.e. insignificant). The QoLI for control group before and after the study compared by paired t test showed a p value of <0.01 implying a positive effect of PPI usage. Similarly p value of paired t test obtained for interventional group was also found to be significant. However, p value of the independent samples t test for comparing the QoLI of participant in both groups after 4 weeks of intervention was <0.01 showing a significant difference of the intervention group from the control group. These result show a positive effect of abdominal breathing exercises on gastroesophageal reflux disease.

4. Discussion

Gastroesophageal reflux disease (GERD) is a widespread chronic gastrointestinal condition, affecting 13.3% of the global population.16 Due to its high prevalence and chronic nature, GERD significantly impacts patients’ quality of life and imposes a considerable economic burden on society.17 Traditional treatments for GERD involve medication, surgery, and endoscopic procedures. Given the limitations of both pharmacologic and surgical approaches, there is increasing interest in using complementary and alternative therapies (CAT) to enhance GERD management.18 One of these alternative therapies is abdominal breathing exercises. A meta-analysis of seven studies (including three randomized controlled trials) involving 194 patients and 16 healthy volunteers found that breathing exercises can increase the pressure generated by the lower esophageal sphincter (LES), with a statistically significant difference noted. This improvement is likely due to the enhancement of the antiregurgitation barrier, particularly by increasing crural diaphragm (CD) tension. Additionally, breathing exercises may benefit GERD patients by reducing the frequency of transient esophageal relaxations and speeding up gastric emptying.19

Our intervention aimed at improving these gastroesophageal anti reflux mechanisms. It is known that the crural muscles of diaphragm function as extrinsic sphincter in addition to LES.20 These are innervated independently as a striated muscle that contracts during breathing.21 This led to our hypothesis that by actively training the diaphragm by abdominal breathing exercises, the gastric acid reflux and symptoms of GERD can be decreased. This intervention showed an improvement in acid reflux symptoms and PPI usage. The mean on demand PPI usage by the control group was significantly higher than the interventional group during the study period of 4 weeks. All those patients of GERD having anatomical abnormality were excluded assuming that the intervention would be ineffective in such cases. Also, those having respiratory anomalies were not included.

All patients were prescribed on demand PPI therapy rather than a strictly scheduled therapy because it might have brought the patient to a symptom free state and interfere with results making it impossible to assess the effect of breathing exercises on GERD symptoms. The decreased PPI demand with breathing exercises can result in a considerable economic advantage for our health system plus a decreased risk to patients’ health because of possible drug side effects like chronic PPI use, diarrhea, osteoporosis and increased Clostridium difficle risk.

5. Conclusion

The study concludes that abdominal breathing exercises can improve the GERD symptoms as assessed by QoLI score and on demand PPI usage. It advocates for an alternative treatment option for GERD patients which is safer and has less side effects enabling us to lead our way towards revolution in medicine providing more effective and less invasive treatment options to facilitate our patients.

5.1. Novelty

The novelty of this study lies in its investigation of abdominal breathing exercises as a non-invasive alternative treatment for gastroesophageal reflux disease (GERD). Unlike traditional approaches that rely on medications like proton pump inhibitors (PPIs) or surgical interventions, this study explores the potential of diaphragm training to reduce GERD symptoms by increasing lower esophageal sphincter (LES) pressure. By directly comparing the effects of these exercises with on-demand PPI usage, the study provides unique insights into reducing medication dependency while improving patients’ quality of life. Conducted in a community hospital, the findings have practical implications for real-world GERD management and suggest a safer and cost-effective alternative for long-term care.

6. Limitations

This study has certain limitations: small sample size, single blinding, short 4-week intervention, strict exclusion criteria, lack of advanced diagnostic tools, reliance on self-reported data, majority female participants in a single hospital, and no long-term follow-up.