TABLE 1.

The CCv4^© HRM Protocol can be commenced in the supine or the upright position. If the full protocol is not completed, then a shortened version combining selected HRM tests can be applied. The protocol working groups recommendations for required and optional tests for “supine first” and “upright first” studies are presented

CCv4© HRM Protocol	Supine first study	Upright first study
	Primary position 5–10 ml water ×10a	Required	Required
Alternate position 5–10 ml water ×5–10	Required	Optional
Multiple Repeated Swallow ×1–3b	Required	Optional
Rapid Drink Challenge ×1	Required	Required
Single Solid Swallow ×5–10c	Optional	Required
Solid Test Meal ± Post-prandial Observation	Optional	Optional

^aIf a conclusive diagnosis of achalasia type 1 or 2 is made from 10 wet swallows in primary position, then further maneuvers are not required.

^bThe purpose of MRS is primarily to document peristaltic reserve. Three MRS are required only if an augmented MRS post-contraction is not present after 1 or 2 attempts.

^cIf the purpose of solid swallows is to document peristaltic reserve (eg, in reflux patients), then the presence of an effective esophageal contraction in >2/10 swallows may be adequate. If it is to assess whether abnormal motility is the cause of patient symptoms then a minimum of 10 swallows is required.