ArticlePDF Available

Oral neuromuscular training relieves hernia-related dysphagia and GERD symptoms as effectively in obese as in non-obese patients

Authors:

Abstract and Figures

Background: Many physicians insist patients lose weight before their hiatal hernia (HH) condition and related symptoms including intermittent esophageal dysphagia (IED) and gastroesophageal reflux disease (GERD) can be treated, but it is not proven that body mass index (BMI) has an impact on exercise-based treatment of HH-related symptoms. Aims/Objectives: To investigate whether BMI has significance on IQoro® neuromuscular training (IQNT) effectiveness in treating HH-related symptoms. Material and Methods: Eighty-six patients with sliding HH and enduring IED and GERD symptoms, despite proton pump inhibitor medication, were consecutively referred for 6 months’ IQNT comprising 11/2 minutes daily. They were grouped by BMI which was recorded before and after IQNT, as were their symptoms of IED, reflux, heartburn, chest pain, globus sensation, non-productive cough, hoarseness, and misdirected swallowing. They were also assessed on food swallowing ability, water swallowing capacity and lip force both before and after treatment. Results: After IQNT, all BMI groups showed significant improvement (p < .001) of all assessments’ and symptoms; and heartburn, cough and misdirected swallowing were significantly more reduced in the severely obese. Conclusions and significance: IQNT can treat HH-related IED and GERD symptoms as successfully in moderately or severely obese patients as in those with normal bodyweight.
Content may be subject to copyright.
Full Terms & Conditions of access and use can be found at
http://www.tandfonline.com/action/journalInformation?journalCode=ioto20
Acta Oto-Laryngologica
ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage: http://www.tandfonline.com/loi/ioto20
Oral neuromuscular training relieves hernia-
related dysphagia and GERD symptoms as
effectively in obese as in non-obese patients
Thomas Franzen, Lita Ingrid Tibbling & Mary Karin Hägg
To cite this article: Thomas Franzen, Lita Ingrid Tibbling & Mary Karin Hägg (2019): Oral
neuromuscular training relieves hernia-related dysphagia and GERD symptoms as effectively in
obese as in non-obese patients, Acta Oto-Laryngologica, DOI: 10.1080/00016489.2018.1503715
To link to this article: https://doi.org/10.1080/00016489.2018.1503715
Published online: 10 Jan 2019.
Submit your article to this journal
View Crossmark data
RESEARCH ARTICLE
Oral neuromuscular training relieves hernia-related dysphagia and GERD
symptoms as effectively in obese as in non-obese patients
Thomas Franzen
a
, Lita Ingrid Tibbling
b
and Mary Karin H
agg
c
a
Experimental Medicine, Surgery, Link
oping University, Vrinnevi Hospital, Norrk
oping, Sweden;
b
Experimental Medicine, Surgery, Link
oping
University, University Hospital, Link
oping, Sweden;
c
Speech and Swallowing Centre, ENT, Hudiksvall Hospital, Hudiksvall, Sweden
ABSTRACT
Background: Many physicians insist patients lose weight before their hiatal hernia (HH) condition and
related symptoms including intermittent esophageal dysphagia (IED) and gastroesophageal reflux dis-
ease (GERD) can be treated, but it is not proven that body mass index (BMI) has an impact on exer-
cise-based treatment of HH-related symptoms.
Aims/Objectives: To investigate whether BMI has significance on IQoroV
Rneuromuscular training
(IQNT) effectiveness in treating HH-related symptoms.
Material and Methods: Eighty-six patients with sliding HH and enduring IED and GERD symptoms,
despite proton pump inhibitor medication, were consecutively referred for 6 monthsIQNT comprising
11/2 minutes daily. They were grouped by BMI which was recorded before and after IQNT, as were
their symptoms of IED, reflux, heartburn, chest pain, globus sensation, non-productive cough, hoarse-
ness, and misdirected swallowing. They were also assessed on food swallowing ability, water swallow-
ing capacity and lip force both before and after treatment.
Results: After IQNT, all BMI groups showed significant improvement (p<.001) of all assessmentsand
symptoms; and heartburn, cough and misdirected swallowing were significantly more reduced in the
severely obese.
Conclusions and significance: IQNT can treat HH-related IED and GERD symptoms as successfully in
moderately or severely obese patients as in those with normal bodyweight.
ARTICLE HISTORY
Received 28 June 2018
Revised 11 July 2018
Accepted 18 July 2018
KEYWORDS
BMI; GERD; hiatal hernia; lip
force; neuromuscular
training; reflux; obesity; oral
screen; swallowing capacity;
visual analogue scale
Introduction
Many physicians have considered obesity a cause of gastroe-
sophageal reflux disease (GERD) [1], and many more have
advised that treatment of GERD patients will be less suc-
cessful if they are severely overweight. Over time, research
into the pathophysiology of GERD has been characterized
by differing opinions on these subjects [19], and reports
describing that obesity per se predisposes to GERD have
been variously both supported and questioned [2]. Clinical
treatment effort for obese patients with GERD has been
focused on weight loss [3]. Understanding the pathophysi-
ology of GERD is important for future targets of therapy
[10], given that proton pump inhibitor-refractory GERD
symptoms are an increasing problem [11]. There is a clear
need for clarity on the effectiveness of treatment for GERD
and other hiatal hernia (HH) symptoms in the over-
weight population.
Recent studies [12,13] using esophageal high-resolution
manometry (HRM) show significant improvement in HH
patients, in GERD, esophageal retention symptoms, misdir-
ected swallowing, and significantly increased pressure in the
diaphragmatic hiatus after IQoro
V
R
(Figure 1) neuromuscular
training (IQNT). It has not been established however
whether there is a difference in the improvement rate
between obese and normal-weight patients with these symp-
toms when treated with IQNT. The present study therefore
aimed to investigate whether body mass index (BMI) has
any impact on IQNT results in HH-related intermittent
esophageal dysphagia (IED) and other GERD symptoms.
Materials and methods
Study population
A total of 86 adult patients (46 women and 40 men,
Table 1) with a verified HH (Figure 2A) and long-standing
IED and other GERD symptoms were consecutively referred
during 20142016 to an otorhinolaryngological clinic for
IQNT, 30 s 3-times per day in 6 months. Before entry into
the study, a HH without any esophageal stenosis was con-
firmed in each patient by radiology or gastroscopy. A test of
the orofacial muscle function (OFMT) [12] including the
cranial nervesstatus (the intra- and inter-rater reliability of
the test has a high kappa coefficient of 0.90) [12], an oral
sensory test (OST) [12], and a velopharyngeal closure test
(VCT) [12] were performed in order to exclude symptoms
of any central nervous lesion. Patients with neurological dis-
eases were excluded. The patients were partitioned into
three groups according to BMI [1] at the start of the study:
CONTACT Mary Karin H
agg mary.hagg@regiongavleborg.se Speech and Swallowing Centre, ENT, Hudiksvall Hospital, Hudiksvall 824 81, Sweden
ß2018 Acta Oto-Laryngologica AB (Ltd)
ACTA OTO-LARYNGOLOGICA
https://doi.org/10.1080/00016489.2018.1503715
Group A, normal weight, BMI <25 (n¼37: 19 women of
median age 68 years, 18 men of median age 72 years);
Group B, moderately obese, BMI 2529 (n¼28: 16 women
of median age 59 years, 12 men of median age 56 years);
Group C, severely obese, BMI 30-37 (n¼21: 11 women of
median age 52 years, 10 men of median age 70 years). All
patients had received PPI medication for at least a median
3-year period (Table 1) and were still on this medication at
the start of the study. All patients were interviewed by tele-
phone 23 times during the six-month IQNT period in
order to check training compliance. PatientsBMI was cal-
culated at entry to the study and at completion of the
IQNT. Similarly, a self-assessed questionnaire regarding IED
and GERD symptoms [14] was recorded, and the patients
ability to swallow food was self-assessed from 0 (normal) to
100 mm (total inability) on a visual analogue scale (VAS)
[15] on both occasions. Timed water swallowing capacity
test (SCT, ml/s) [12] and a lip force test (LFT, Newton) [12]
were performed at baseline and at end of training to con-
firm training compliance.
Self-assessment IED and GERD symptoms
All patients were required to complete a pre- and a post
training questionnaire regarding their IED and GERD
symptoms [14](Figure 2A;Table 2) scored from 0 to 3
(0 ¼none, 1 ¼slight, 2 ¼moderate, and 3 ¼severe). The
eight symptoms were defined as follows: IED ¼intermittent
sensation of solid food retention in the chest at swallowing;
reflux ¼acid regurgitation; heartburn ¼burning sensation in
the chest; chest pain ¼substernal pain at meals; Globus sen-
sation ¼sensation of a lump in throat; cough ¼irritating
and dry cough; hoarseness ¼husky voice; misdirected
swallowing ¼cough when swallowing is the clinical symp-
tom as well as a diagnosis by esophageal HRM.
IQoro
V
R
neuromuscular training (IQNT)
The IQoro
V
R
neuromuscular training (IQNT) device manu-
factured of acrylic is crescent-shaped, and convex in both
the vertical and horizontal planes (Figure 1). The surface is
rigid, with raised dimples interfacing with the inside of the
lips; and has a stable handle (Figure 1). The design makes it
universally suitable for varying bite and jaw anatomies.
IQoro
V
R
is located pre-dentallybehind the lips and in front
of the teeth the patient grips the handle, presses the lips
firmly together and applies a horizontal forward pulling
force for 5 to maximally 10 s whilst resisting with the sealed
lips. The exercise is repeated three times per session, with a
3-s rest between each pull. This three-pull session is
repeated three times daily, preferably before mealtimes.
IQoro
V
R
(Figure 1), placed behind the lips, immediately
triggers sensory input by stimulating the intra-oral mem-
branes (n V), [12]. The sensory-motor reflex arc is engaged
by the stimuli conducted by the afferent nerve pathways to
the brain stem and the cortex and, in turn, the efferent sig-
nals transmitted from the brain stem to the musclesthe
natural neurological process [16]. The relevant muscles are
also activated by the mechanical flexing initiated by the
Figure 1. Image of IQoro
V
R
, a medical device for Neuromuscular Training
(IQNT). This image is kindly provided by MYoroface AB.
Table 1. Age, gender, symptom duration, and BMI in groups
A, B, and C.
Items Group A; n¼37 Group B; n¼28 Group C; n¼21
Median age 69 years (2085) 57 years (2285) 62 years (4487)
Gender 19 women, 18 men 16 women, 12 men 11 women, 10 men
GERD symptom duration 5 years (175) 6 years (115) 3 years (129)
BMI before/after IQNT 23 (1724)/23 (2025) 28 (2629)/27 (2429) 33 (3037)/31 (2738)
Ranges in parentheses. BMI and GERD: median values; IQNT: Neuromuscular training with an oral IQoro
V
R
.
Figure 2. (A) Sliding hiatal hernia. When swallowing, the longitudinal esopha-
geal muscles contract and shorten which provokes the upper part of the stom-
ach to slide up through the hiatal canal. This causes difficulties with opening
the PES and with gastroesophageal reflux.This image is kindly provided by
MYoroface AB. (B) Effect of IQNT. Recent studies [12,13] show significant
improvement in symptoms in hiatal hernia patients after IQoro
V
R
Neuromuscular
Training (IQNT). Esophageal high-resolution manometry shows significantly
increased pressure in the diaphragmatic hiatus after the treatment.This image
is kindly provided by MYoroface AB.
2 T. FRANZEN ET AL.
IQoro
V
R
traction effect and the ensuing low-pressure thus
created [12]. The entire chain of striated muscles from the
lips to the upper third of the esophagus, and then to
the diaphragm, are activated by both the neurological and
the mechanical processes, whilst the smooth muscle is acti-
vated solely by the neurological commands from the sen-
sory-motor reflex arc [17]. The positive results of this
complex sensory-motor activity support earlier findings that
IQNT improves lip force (LF) and swallowing capacity (SC)
[12,18] and strengthens the striated muscles around the hia-
tal canal (Figure 2B) and improves hiatal competence simi-
larly to HH surgery [19].
Statistical analysis
A professional statistician from Uppsala Clinical Research
Centre (UCR) was involved and the Good Clinical Practice
(GCP) was used to consolidate all study data and for all
analyses, which were performed according to the initial
protocol. The MannWhitney U-test was used for compari-
son of all symptoms: BMI, self-assessment IED and GERD
symptoms, VAS, SCT, and LFT between the three BMI
groups. The Wilcoxon signed rank test was used for com-
parison of symptoms and investigation parameters within
the groups. p<.05 was considered significant. All statistical
analyses were performed using SAS version 9.1 software
(SAS Institute, Inc., Cary, NC).
Study design
This study is a prospective, therapeutic and clinical study
investigating whether BMI has an impact on IQNTs effect
on HH-related IED and GERD symptoms.
Ethical considerations
The 86 patients in this study were referred to a swallowing
centre, as part of an otorhinolaryngological department for
the investigation and treatment of IED and GERD symp-
toms. They were examined and treated according to normal
practice and therefore, no ethical considerations arose. The
study was performed according to the Helsinki declaration.
Results
After IQNT, all symptom scores were significantly improved
or reduced within all three BMI groups (Table 2) and there
was no significant change of median BMI in any of the
groups (Table 1). At entry into the study, there were no sig-
nificant differences in IED and GERD symptom severity
(Table 2) between the three BMI groups except that heart-
burn and cough were significantly more common in Groups
B and C, and that misdirected swallowing was significantly
more common in Group C. No significant difference in self-
assessed IED and GERD symptom improvement was found
between the three BMI groups except for heartburn, cough
and misdirected swallowing which were significantly
(p<.01) more reduced in obese patients (Group C) than in
normal bodyweight patients (Group A; Table 2). In all BMI
groups IQNT provided significant improvement (p<.0001)
of median values of VAS score, SCT, and LFT (Table 3)
with no significant difference between the BMI groups
except for the value of SCT, which was significantly
(p<.01) more improved in Group C than in Group A, and
for the value of LFT, which was significantly (p<.05) more
improved in Group B than in Group A (Table 3). At entry
Table 2. Mean symptom scores in groups A, B, and C at entry (E) and after IQNT and p-value changes between group A/B, group A/C, and group B/C at entry
(E) and after IQNT.
GERD Group A Group B Group C Groups A versus B Groups A versus C Groups B versus C
Symptoms E (% Sympt) E (% Sympt) E (% Sympt) E, p-value E, p-value E, p-value
After (% Imp) n¼37 After (%Imp) n¼28 After (%Imp) n¼21 After p-value After p-value After p-value
Reflux (E) 1.3 (68) 1.5 (82) 1.8 (86) p<.587 p<.109 p¼.201
After IQNT 0.2 (100) 0.5 (96) 0.5 (100)
p<.0001 p<.0001 p<.0001 p<.581 p<.381 p¼.062
Heartburn (E) 0.9 (54) 1.4 (71) 1.6 (81) p<.043 p<.011 p¼.486
After IQNT 0.2 (85) 0.5 (95) 0.4 (100)
p<.0001 p<.0001 p<.0001 p<.185 p<.008 p¼.101
Chest pain (E) 1.0 (54) 1.4 (61) 1.2 (57) p<0.267 p<.528 p¼.750
After IQNT 0.2 (95) 0.3 (100) 0.2 (100)
p<.0001 p<.0001 p<.0005 p<.501 p<.384 p¼.840
Dysphagia (E) 2.3 (100) 2.3 (100) 2.3 (100) p<.897 p<0.772 p¼.719
After IQNT 0.6 (97) 0.8 (93) 0.6 (100)
p<.0001 p<.0001 p<.0001 p<.342 p<.842 p¼.505
Globus (E) 2.1 (92) 2.2 (89) 2.2 (91) p<.489 p<0.514 p¼.896
After IQNT 0.5 (100) 0.6 (96) 0.4 (100)
p<.0001 p<.0001 p<.0001 p<.483 p<.168 p¼.418
Cough (E) 1.1 (70) 1.7 (75) 1.9 (76) p<.044 p<.012 p¼.427
After IQNT 0.4 (96) 0.5 (91) 0.3 (100)
p<.0001 p<.0001 p<.0001 p<.184 p<.006 p¼.213
Hoarseness (E) 1.4 (76) 1.0 (54) 1.3 (62) p<.188 p<.847 p¼.406
After IQNT 0.4 (89) 0.3 (100) 0.2 (100)
p<.0001 p<.0001 p<.0002 p<.223 p<.726 p¼.202
Misdir sw (E) 1.2 (65) 1.4 (68) 2.1 (86) p<.530 p<0.007 p¼.038
After IQNT 0.2 (100) 0.3 (100) 0.3 (100)
p<.0001 p<.0001 p<.0001 p<.619 p<.005 p¼.030
Group A: (non-obese) BMI <25; Group B: (moderately obese) BMI ¼2529; and Group C: (severely obese) BMI¼3037. (% Symt): frequency of symptom; (% Imp):
frequency of improved or normalized symptoms; IQNT: Neuromuscular training with an oral IQoro
V
R
; Misdir sw: misdirected swallowing. p-values (Wilcoxon signed
rank test) refer to symptom improvements within groups after IQNT. p-values (MannWhitney U-test) refer to symptom changes between groups after IQNT.
ACTA OTO-LARYNGOLOGICA 3
into the study, there were no significant differences in VAS,
SCT, or LFT values between the BMI groups.
Discussion
This study shows that obese as well as non-obese patients,
with a sliding HH and with IED and PPI-resistant GERD
symptoms, can be equally and significantly improved by a
non-surgical IQNT intervention. At baseline, heartburn and
cough were significantly more prevalent in patients who
were overweight or obese, and misdirected swallowing was
significantly more common in patients with severe obesity.
However, symptoms of heartburn, cough, and misdirected
swallowing were significantly more relieved in these severely
obese patients. These findings are contradictory to the for-
mer belief that obesity is a handicap to successful treatment
of IED or GERD, or of weight loss being necessary before
treatment can be started. The results indicate that both IED
and GERD symptoms can be equally improved by IQNT
irrespective of normal or pathological BMI, and indeed that
improvement of some symptoms is even more successful in
the higher BMI categories. Additionally, Mora et al. [4] did
not find any correlation between the degree of obesity and
the severity of symptoms or objective tests for IED and
reflux. In another study, by Vakil et al. [5], PPI-treated
patients who achieved heartburn relief were similar across
BMI categories. The link between GERD and obesity has
also been called into question by other authors [20]. Three
earlier studies from 1995, 1996, and 2005 showed that being
severely overweight was not associated with an increased
prevalence of gastroesophageal reflux [6], that weight loss
did not improve the subjective or objective manifestations
of reflux [7] and that obesity was an independent risk factor
for GERD symptoms and erosive esophagitis [8].
GERD is primarily associated with heartburn and acid
regurgitation. At entry of this study, these symptoms were
present in all patients, despite their all being on a course of
PPI medication. Significantly, the acid symptoms were
greatly improved by IQNT even those in this study who had
GERD symptoms but were resistant to PPI treatment.
Moraes [11] has described nine possible explanations for
GERD refractory symptoms but did not consider impaired
function of the striated swallowing muscles. Irrespective of
which the cause was IQNT was shown in this study to pro-
mote significant improvement of all eight symptoms (Table
2) as defined in the self-assessed questionnaire regarding
IED and GERD symptoms. These symptoms were measured
in the same way at both baseline and at end-of-training,
and for all patients irrespective of BMI value.
The results achieved by IQNT reinforce the hypothesis
that oral neuromuscular training triggers the afferent reflex
arc up to the brainstem and brain cortex [16], and then pro-
motes the efferent reflex arc to activate both the striated and
smooth muscles [17]. The motoric effect is executed neuro-
logically via the Nucleus Ambiguus and the Nucleus Dorsalis
Nervi Vagiboth in the Formatio Reticulariswhich are key
components in the normal swallowing process (Figure 2B)
[16,17]. BMI values appear to have no effect on the ability of
IQNT to bring about the improvement of GERD and IED
symptoms by both muscular and neurological improvements.
Conclusion
IQNT, a non-surgical treatment for IED and other GERD
symptoms in HH patients, is equally successful in treating
moderately- or severely obese patients as in treating suffer-
ers of normal weight. Obesity in itself does not therefore
seem to be a handicap in treating IED and other GERD
symptoms by IQNT.
Disclosure of interest
No potential conflict of interest was reported by
the authors.
ORCID
Thomas Franzen http://orcid.org/0000-0001-8661-2523
Lita Ingrid Tibbling http://orcid.org/0000-0003-4505-4750
Mary Karin H
agg http://orcid.org/0000-0003-3923-5475
Table 3. Changes for SCT, LFT and VAS in groups A, B and C after IQNT, and difference between group A/B, group A/C, and group B/C at entry (E) and after
(a) IQST.
Group A Group B Group C Groups A versus B Groups A versus C Groups B versus C
n¼37 n¼28 n¼21
Median (95% CI) Median (95% CI) Median (95% CI) Median (95% CI) Median (95% CI) Median (95% CI)
Items p-value p-value p-value p-value p-value p-value
SCT (E) 13.5 (8.7 to 16.7) 10.0 (6.7 to 16.2) 15.0 (8.2 to 19.1) p<.900 P<.196 p<.895
ml/s (a) 17.3 (12.7 to 20.0) 18.7 (12.4 to 27.7) 21.7 (16.7 to 29.3)
Change 5.0 (3.3 to 5.7) 7.7 (3.7 to 10.3) 6.6 (4.2 to 10.4) 2.5 (0.2 to 5.3) 2.8 ( 0.6 to 5.1) 0.4 (3.3 to 3.4)
p<.0001 p<.0001 p<.0001 p<0.066 p<0.014 p<0.848
LFT (E) 31.0 (26.0 to 42.0) 35.5 (24.0 to 46.0) 38.0 (25.0 to 44.0) p<0.817 p<0.903 p<0. 192
N (a) 53.0 (48.0 to 60.0) 63.5 (55.0 to 80.0) 52.0 (45.0 to 68.0)
Change 20.0 (14.0 to 24.0) 28.0 (14.0 to 34.0) 18.0 (5.0 to 44.0) 8.0 ( 0.0 to 15.0) 0.0 (10.0 to 13.0) 6.0 (19.0 to 6.0)
p<.0001 p<.0001 p<. 0001 p<.048 p<.891 p<.196
VAS (E) 80.0 (60.0 to 80.0) 80.0 (70.0 to 80.0) 70.0 (60.0 to 80.0) p<.479 p<.616 p<.241
mm (a) 20.0 (0.0 to 25.0) 17.5 (10.0 to 20.0) 20.0 (10.0 to 25.0)
Change 50.0 (60.0 to 40.0) 56.0 (66.0 to 50.0) 50.0 (60.0 to 40.0) 5.0 (12.0 to 5.0) 0.0 (10.0 to 10.0) 6.0 (5.0 to 15.0)
p<.0001 p<.0001 p<.0001 p<.288 p<.844 p<.267
Group A: (non-obese) BMI <25; Group B: (moderately obese) BMI ¼25-29; and Group C: (severely obese) BMI ¼3037. Median values, range in parentheses.
N: Newton; IQNT: Neuromuscular training with an oral IQoro
V
R
.pvalues (Wilcoxon signed rank test) refer to symptom improvements within groups after IQNT.
p-values (MannWhitney U-test) refer to symptom changes between groups after IQST.
4 T. FRANZEN ET AL.
References
[1] Icitovic N, Onyebeke L, Wallenstein S. The association between
body mass index and gastroesophageal reflux disease in the
World Trade Center Health Program General Responder
Cohort. Am J Ind Med. 2016;59:761.
[2] Senapeschi GF, Pellicano R, Fagoonee S, et al. Obesity and gas-
troesophageal reflux disease: a 2009 update. Minerva Med
2009;100:213219.
[3] Khan A, Kim A, Sanossian C, et al. Impact of obesity treatment
on gastroesophageal reflux disease. WJG. 2016;22:16271638.
[4] Mora F, Cassinello N, Mora M, et al. Esophageal abnormalities
in morbidly obese adult patients. Surg Obes Relat Dis.
2016;12:622628.
[5] Sharma P, Vakil N, Monyak JT, et al. Obesity does not affect
treatment outcomes with proton pump inhibitors. J Clin
Gastroenterol. 2013;47:672677.
[6] Lundell L, Ruth M, Sandberg N, et al. Does massive obesity
promote abnormal gastroesophageal reflux?. Dig Dis Sci.
1995;40:16321635.
[7] Kjellin A, Ramel S, R
ossner S, et al. Gastroesophageal reflux in
obese patients is not reduced by weight reduction. Scand J
Gastroenterol. 1996;31:10471051.
[8] El-Serag HB, Graham DY, Satia JA, et al. Obesity is an inde-
pendent risk factor for GERD symptoms and erosive esopha-
gitis. Am J Gastroenterology. 2005;100:124312450.
[9] Savarino E, DeBortoli N, De Cassan C, et al. The natural his-
tory of gastro-esophageal reflux disease: a comprehensive
review. Dis Esophagus. 2017;30:19.
[10] Frazzoni M, Piccoli M, Conigliaro R, et al. G. Refractory gas-
troesophageal reflux disease as diagnosed by impedance-pH
monitoring can be cured by laparoscopic fundoplication. Surg
Endosc. 2013;27:29402946.
[11] Moraes-Filho JP. Refractory gastroesophageal reflux disease.
Arq Gastroenterol. 2012;49:296301.
[12] H
agg M, Tibbling L, Franz
en T. Effect of IQoro
V
R
training
in hiatal hernia patients with misdirected swallowing and
esophageal retention symptoms. Acta Otolaryngol. 2015;135:
635639.
[13] H
agg M, Tibbling L, Franz
en T. Esophageal dysphagia and
reflux symptoms before and after oral IQoro
V
R
training. WJG.
2015;21:75587562.
[14] Franz
en T, Bostr
om J, Tibbling Grahn L, et al. Prospective
study of symptoms and gastro-oesophageal reflux 10 years
after posterior partial fundoplication. Br J Surg.
1999;86:956960.
[15] Joyce CR, Zutshi DW, Hrubes VF, et al. Comparison of fixed
interval and visual analogue scales for rating chronic pain. Eur
J Clin Pharmacol. 1975;8:415420.
[16] Ertekin C, Aydogdu I. Neurophysiology of swallowing. Clin
Neurophysiol. 2003; 114:22262244.
[17] Goyal RK, Chaudhury A. Physiology of normal esophageal
motility. J Clin Gastroenterol. 2008;42:610619.
[18] H
agg M, Tibbling L. Longstanding effect and outcome differen-
ces of palatal plate and oral screen training on stroke-related
dysphagia. Open Rehab J 2013;6:2633.
[19] Tibbling L, Johansson M, Mj
ones AB, et al. Globus jugularis
and dysphagia in patients with hiatus hernia. Eur Arch
Otorhinolaryngol. 2010;267:251254.
[20] Emerenziani S, Rescio MP, Guarino MP, et al. Gastro-esopha-
geal reflux disease and obesity, where is the link? World J
Gastroenterol. 2013;19:65366539.
ACTA OTO-LARYNGOLOGICA 5
... Continual pH-monitoring is also used to measure prevalence of acidic reflux but does not aim to identify its cause. Scientific studies [16][17][18] have looked at treatment of HH. When recruiting patients to these studies the researchers have always distinguished between those with the symptoms of a HH and a confirmed diagnosis; and those with the symptoms but no confirmation. ...
... In all three studies [16][17][18] quoted here the patients were long-term users of PPI medication before the studies began. In a Medtech Innovation Briefing [21] produced by the UK's National Institute for Health and Care Excellence in 2019 they quoted, "all patients continued with their PPI medication as advised. ...
... Neuromuscular exercise is a safe, natural and simple treatment that can be carried out by the patient his or herself, and the underlying cause of the reflux is proven to be treated in 97% [16][17][18] of cases. ...
Chapter
Full-text available
Esophagitis is a debilitating disease often leading to more serious conditions. It is aggravated by refluxed stomach acids for which the usual treatment is PPI drugs that at best treat the symptoms, not the underlying cause of reflux. Surgical interventions address the root - Hiatal muscular incompetence - but are invasive and expensive. Both treatments have proven unwanted side-effects. Neuromuscular treatment is a new and innovative alternative that addresses the root cause of reflux. The science and evidence behind this treatment is presented here. Reflux cannot happen when the diaphragm functions properly and maintains adequate pressure in the Hiatal canal, otherwise the neck of the stomach can intrude through the diaphragm into the chest cavity allowing reflux and conditions such as GERD, LPR, silent reflux, dyspepsia and more. This is especially common at night, when in bed. Training with a simple and inexpensive neuromuscular medical device takes 90 seconds per day, self-administered by the patient without medication or surgical intervention. No negative side effects are recorded for this treatment. Currently, 40 000 individuals have treated with the device. It is deployed in healthcare institutions in several countries and is recognised in the UK by NICE in a briefing to the NHS as a treatment for Hiatal hernia.
... Lip muscle training is used in rehabilitating oral function after stroke, and has also been used to facilitate improvements in swallowing outcomes [99]. The principles behind IQoro ® lip muscle training are based on neuroplasticity, which is different from many of the muscle strength based approaches in these other dysphagia treatments [99][100][101]. ...
Article
Full-text available
Background Optimal exercise doses for exercise-based approaches to dysphagia treatment are unclear. To address this gap in knowledge, we performed a scoping review to provide a record of doses reported in the literature. A larger goal of this work was to promote detailed consideration of dosing parameters in dysphagia exercise treatments in intervention planning and outcome reporting.Methods We searched PubMed, Scopus[Embase], CINAHL, and Cochrane databases from inception to July 2019, with search terms relating to dysphagia and exercises to treat swallowing impairments. Of the eligible 1906 peer-reviewed articles, 72 met inclusionary criteria by reporting, at minimum, both the frequency and duration of their exercise-based treatments.ResultsStudy interventions included tongue exercise (n = 16), Shaker/head lift (n = 13), respiratory muscle strength training (n = 6), combination exercise programs (n = 20), mandibular movement exercises (n = 7), lip muscle training (n = 5), and other programs that did not fit into the categories described above (n = 5). Frequency recommendations varied greatly by exercise type. Duration recommendations ranged from 4 weeks to 1 year. In articles reporting repetitions (n = 66), the range was 1 to 120 reps/day. In articles reporting intensity (n = 59), descriptions included values for force, movement duration, or descriptive verbal cues, such as “as hard as possible.” Outcome measures were highly varied across and within specific exercise types.Conclusions We recommend inclusion of at least the frequency, duration, repetition, and intensity components of exercise dose to improve reproducibility, interpretation, and comparison across studies. Further research is required to determine optimal dose ranges for the wide variety of exercise-based dysphagia interventions.
Chapter
There is a clear need for new advances in treating dysphagia; healthcare professionals currently have a restricted range of options to treat swallowing problems and related conditions. Usual treatments for dysphagia are based on compensatory measures which allow patients to live within the limitations of their condition. These measures do not address the underlying cause of dysphagia: neurological and physiological dysfunction. A senior speech and language therapist working with young people with Cerebral Palsy bemoans the fact that official care pathway guidelines list only medication and surgical intervention as alternatives to treat drooling. Neither of which, she contends, is effective or desirable. Esophageal dysphagia causes reflux-based diseases, which are also poorly served by current treatment alternatives and are currently managed by medication, or remedied by surgical intervention. Medication reduces the symptoms of reflux but does nothing to address the underlying pathophysiology, muscular dysfunction, at the root of the problem. That now changes with IQoro: a simple, innovative treatment that is available to patients and healthcare professionals to address all of the above conditions. The chapter explains the physiological and neurological process of the functional swallow in detail, with illustrations and explanations. The efficacy of IQoro treatment is proven with evidence from internationally published scientific studies, case studies, an NHS service evaluation, and NICE briefings.
Article
Full-text available
Gastroesophageal reflux disease (GERD) is a common disorder of the upper gastrointestinal tract which is typically characterized by heartburn and acid regurgitation. These symptoms are widespread in the community and range from 2.5% to more than 25%. Economic analyses showed an increase in direct and indirect costs related to the diagnosis, treatment and surveillance of GERD and its complications. The aim of this review is to provide current information regarding the natural history of GERD, taking into account the evolution of its definition and the worldwide gradual change of its epidemiology. Present knowledge shows that there are two main forms of GERD, that is erosive reflux disease (ERD) and non-erosive reflux disease (NERD) and the latter comprises the majority of patients (up to 70%). The major complication of GERD is the development of Barrett esophagus, which is considered as a pre-cancerous lesion. Although data from medical literature on the natural history of this disease are limited and mainly retrospective, they seem to indicate that both NERD and mild esophagitis tend to remain as such with time and the progression from NERD to ERD, from mild to severe ERD and from ERD to Barrett's esophagus may occur in a small proportion of patients, ranging from 0 to 30%, 10 to 22% and 1 to 13% of cases, respectively. It is necessary to stress that these data are strongly influenced by the use of powerful antisecretory drugs (PPIs). Further studies are needed to better elucidate this matter and overcome the present limitations represented by the lack of large prospective longitudinal investigations, absence of homogeneous definitions of the various forms of GERD, influence of different treatments, clear exclusion of patients with functional disorders of the esophagus.
Article
Full-text available
To examine whether muscle training with an oral IQoro(R) screen (IQS) improves esophageal dysphagia and reflux symptoms. A total of 43 adult patients (21 women and 22 men) were consecutively referred to a swallowing center for the treatment and investigation of long-lasting nonstenotic esophageal dysphagia. Hiatal hernia was confirmed by radiologic examination in 21 patients before enrollment in the study (group A; median age 52 years, range: 19-85 years). No hiatal hernia was detected by radiologic examination in the remaining 22 patients (group B; median age 57 years, range: 22-85 years). Before and after training with an oral IQS for 6-8 mo, the patients were evaluated using a symptom questionnaire (esophageal dysphagia and acid chest symptoms; score 0-3), visual analogue scale (ability to swallow food: score 0-100), lip force test (≥ 15 N), velopharyngeal closure test (≥ 10 s), orofacial motor tests, and an oral sensory test. Another twelve patients (median age 53 years, range: 22-68 years) with hiatal hernia were evaluated using oral IQS traction maneuvers with pressure recordings of the upper esophageal sphincter and hiatus canal as assessed by high-resolution manometry. Esophageal dysphagia was present in all 43 patients at entry, and 98% of patients showed improvement after IQS training [mean score (range): 2.5 (1-3) vs 0.9 (0-2), P < 0.001]. Symptoms of reflux were reported before training in 86% of the patients who showed improvement at follow-up [1.7 (0-3) vs 0.5 (0-2), P < 0.001). The visual analogue scale scores were classified as pathologic in all 43 patients, and 100% showed improvement after IQS training [71 (30-100) vs 22 (0-50), P < 0.001]. No significant difference in symptom frequency was found between groups A and B before or after IQS training. The lip force test [31 N (12-80 N) vs 54 N (27-116), P < 0.001] and velopharyngeal closure test values [28 s (5-74 s) vs 34 s (13-80 s), P < 0.001] were significantly higher after IQS training. The oral IQS traction results showed an increase in mean pressure in the diaphragmatic hiatus region from 0 mmHg at rest (range: 0-0 mmHG) to 65 mmHg (range: 20-100 mmHg). Oral IQS training can relieve/improve esophageal dysphagia and reflux symptoms in adults, likely due to improved hiatal competence.
Article
Full-text available
Misdirected swallowing can be triggered by esophageal retention and hiatal incompetence. The results show that oral IQoro(R) screen (IQS) training improves misdirected swallowing, hoarseness, cough, esophageal retention, and globus symptoms in patients with hiatal hernia. The present study investigated whether muscle training with an IQS influences symptoms of misdirected swallowing and esophageal retention in patients with hiatal hernia. A total of 28 adult patients with hiatal hernia suffering from misdirected swallowing and esophageal retention symptoms for more than 1 year before entry to the study were evaluated before and after training with an IQS. The patients had to fill out a questionnaire regarding symptoms of misdirected swallowing, hoarseness, cough, esophageal retention, and suprasternal globus, which were scored from 0-3, and a VAS on the ability to swallow food. The effect of IQS traction on diaphragmatic hiatus (DH) pressure was recorded in 12 patients with hiatal hernia using high resolution manometry (HRM). Upon entry into the study, misdirected swallowing, globus sensation, and esophageal retention symptoms were present in all 28 patients, hoarseness in 79%, and cough in 86%. Significant improvement was found for all symptoms after oral IQS training (p < 0.001). Traction with an IQS resulted in a 65 mmHg increase in the mean HRM pressure of the DH.
Article
Full-text available
Aim: This study aimed at evaluating (1) if the oral training effect on stroke related dysphagia differs between two different oral appliances, a palatal plate (PP) and an oral screen (OS), and (2) if the training effect remains at a late follow-up. Methods: We included patients with stroke-related dysphagia at two different time periods: the first group of 12 patients studied in 1997-2 002 had to train with a PP, the other one of 14 patients studied in 2003-2008 had to train with an OS. All patients were evaluated by a swallowing capacity test (SCT), and by a self-assessed visual analogue scale (VAS) of water swallowing capacity at entry of the study, after 13 weeks of training, and at a late follow-up. Results: At end of treatment the SCT had normalized in 33% of PP patients and in 71% of OS patients. There was a significant SCT improvement difference between the PP and OS groups in the period from baseline to late follow-up (p < 0.002) in favor of the OS group. VAS as tested at baseline and at end of treatment did not differ significantly between the two groups. Training with PP and with OS produced remaining improvement of SCT and of VAS as assessed at a late follow-up. Conclusion: The outcome of OS training on SCT in patients with stroke-related dysphagia seems to be superior to PP training. The improvement as assessed with VAS did not differ between the two groups. Training with PP or OS gives a longstanding improvement of SCT and VAS.
Article
Full-text available
Context: Gastroesophageal reflux disease (GERD) is a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Its pathophysiology, diagnosis and treatment have frequently been analyzed but it is interesting to review some aspects of the GERD refractory patients to the proton pump inhibitors treatment. The treatment encompasses behavioral measures and pharmacological therapy. The majority of the patients respond well to proton pump inhibitors treatment but 20%-42% of them may not do so well. Patients who are unresponsible to 4-8 weeks' treatment with proton pump inhibitors (omeprazole, pantoprazole, rabeprazole, lansoprazole, esomeprazole, pantoprazole-Mg) might have so-called refractory GERD. Results: In some cases the patients are not real refractory because either they do not have GERD or the disease was not correctly treated, but the term refractory is still employed. Although debatable, the Brazilian GERD Consensus based upon evidences recommends as first step in the diagnosis, the upper digestive endoscopy to exclude the diagnosis of peptic ulcer and cancer and in some cases identify the presence of esophageal mucosa erosions. Conclusions: The main causes of the so-called refractory GERD are: (1) functional heartburn; (2) low levels of adherence to proton pump inhibitors treatment; (3) inadequate proton pump inhibitors dosage; (4) wrong diagnosis; (5) co-morbidities and pill-induced esophagitis; (6) genotypic differences; (7) nonacid gastroesophageal reflux; (8) autoimmune skin diseases; (9) eosinophilic esophagitis.
Article
Background: There is increasing concern about the obesity epidemic in the United States. Obesity is a potential risk factor for a number of chronic diseases, including gastroesophageal reflux disease (GERD). This analysis examined whether body mass index (BMI) was associated with physician-diagnosed GERD in World Trade Center (WTC) general responders. Methods: 19,819 WTC general responders were included in the study. Cox proportional hazards regression models were used to compare time to GERD diagnosis among three BMI groups (normal (<25 kg/m(2) ), overweight (≥25 and <30 kg/m(2) ), and obese (≥30 kg/m(2) )). Results: Among the responders, 43% were overweight and 42% were obese. The hazard ratio for normal versus overweight was 0.81 (95% Confidence Interval (CI), 0.75-0.88); normal versus obese 0.71 (95%CI, 0.66, 0.77); and overweight versus obese 0.88 (95%CI, 0.83-0.92). Conclusion: GERD diagnoses rates were higher in overweight and obese WTC responders. Am. J. Ind. Med. 59:761-766, 2016. © 2016 Wiley Periodicals, Inc.
Article
Gastroesophageal reflux disease (GERD) is a frequently encountered disorder. Obesity is an important risk factor for GERD, and there are several pathophysiologic mechanisms linking the two conditions. For obese patients with GERD, much of the treatment effort is focused on weight loss and its consistent benefit to symptoms, while there is a relative lack of evidence regarding outcomes after novel or even standard medical therapy is offered to this population. Physicians are hesitant to recommend operative anti-reflux therapy to obese patients due to the potentially higher risks and decreased efficacy, and these patients instead are often considered for bariatric surgery. Bariatric surgical approaches are broadening, and each technique has emerging evidence regarding its effect on both the risk and outcome of GERD. Furthermore, combined anti-reflux and bariatric options are now being offered to obese patients with GERD. However, currently Roux-en-Y gastric bypass remains the most effective surgical treatment option in this population, due to its consistent benefits in both weight loss and GERD itself. This article aims to review the impact of both conservative and aggressive approaches of obesity treatment on GERD. Keywords: Obesity, Gastroesophageal reflux disease, Fundoplication, Sleeve gastrectomy, Gastric banding, Gastric bypass Core tip: Obesity and gastroesophageal reflux disease (GERD) have a well-defined relationship, and both the medical and surgical treatment options for both conditions are advancing. However, there is shortage of literature consolidating the effect of obesity treatment on the outcome of GERD. This article aims to detail the evidence behind both standard and novel obesity treatments on the risk and outcome of GERD. Citation: Khan A, Kim A, Sanossian C, Francois F. Impact of obesity treatment on gastroesophageal reflux disease. World J Gastroenterol 2016; 22(4): 1627-1638
Article
Background: An increase in body mass index has been found to be associated with an increase in the prevalence of gastroesophageal reflux disease (GERD) symptoms, esophageal mucosal injury, and GERD complications. Few systematic studies with objective tests have evaluated esophageal disorders in the morbidly obese population. Objectives: To define more precisely in morbidly obese people the incidence of esophageal symptoms and characterize the esophageal disorders using objective data. Setting: University Hospital, Spain. Methods: Two hundred twenty-four presurgical morbidly obese patients were submitted to a protocol including a clinical history and objective tests (endoscopy, stationary esophageal manometry, 24-hour esophageal pH monitoring and isotopic emptying of the esophagus). Results: In a morbidly obese population, heartburn (50.9%) and regurgitation (28.6%) were the most prevalent symptoms of GERD. Endoscopy registered hiatus hernia (12.5%) and reflux esophagitis (17.3%). Manometry was often abnormal (33.4%), with a hypotensive lower esophageal sphincter as the most common finding. Esophageal pH-metry was abnormal in 54.2% of the cases. Finally, 9.1% of the patients presented with abnormal isotopic esophageal emptying. A correlation between the degree of obesity and the severity of symptoms/objective tests for esophageal abnormalities could not be found. Conclusions: In morbidly obese patients, GERD is common, symptoms are unspecific, and there is a high prevalence of pH-metry and manometric abnormalities, unrelated to the degree of obesity.
Article
The reports describing that obesity per se predisposes to gastroesophageal reflux disease (GERD) have brought conflicting results. Establishing a causal link between these two conditions would be of major public health importance, because of their present epidemic proportions. To date, some large studies examining the relationship between obesity and GERD found a strongly positively relationship while others did not. The main cause of this discordance is the vast heterogeneity of such studies: sufficiently powerful design is found only in few investigations, GERD is defined with a low degree of homogeneity, biases are obvious in the choice of diagnostic methods, thus giving room for large variations in the adjustment of potential confounding factors. Future research should take three directions: 1) prospective population-based studies in which the incidence or recurrence of GERD should be evaluated in correlation with body mass index; 2) intervention trials, focusing on the benefit of weight loss in the prevention of GERD and its recurrence; 3) studies of physiopathology (both in the animal models and humans) to understand the potential biological plausibility.
Article
The confluence between the increased prevalence of gastro-esophageal reflux disease (GERD) and of obesity has generated great interest in the association between these two conditions. Several studies have addressed the potential relationship between GERD and obesity, but the exact mechanism by which obesity causes reflux disease still remains to be clearly defined. A commonly suggested pathogenetic pathway is the increased abdominal pressure which relaxes the lower esophageal sphincter, thus exposing the esophageal mucosal to gastric content. Apart from the mechanical pressure, visceral fat is metabolically active and it has been strongly associated with serum levels of adipo-cytokines including interleukin-6 and tumor necrosis factor α, which may play a role in GERD or consequent carcinogenesis. This summary is aimed to explore the potential mechanisms responsible for the association between GERD and obesity, and to better understand the possible role of weight loss as a therapeutic approach for GERD.