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Gastroesophageal Reflux Disease and Physical Activity

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Abstract

Gastroesophageal reflux disease (GERD) is one of the most common disorders in the general population. In recent years, a marked increase in the occurrence of the disease worldwide has been noted. Intense exercise belongs to factors that are known to exacerbate symptoms of GERD. Episodes of reflux seem to be associated with the length and the intensity of the physical activity undertaken. Experimental studies suggest that the gastroesophageal reflux may be increased in athletes due to: decreased gastrointestinal blood flow; alterations of hormone secretion; changes in the motor function of the oesophagus and the ventricle; and the constrained body position during exercise. Disturbances of the balance between two areas of opposite pressure: intra-abdominal and intrathoracic, have also been proven to influence GERD events. GERD is found in sportspeople of various disciplines, but specific types of exercise may have significantly different impacts on the gastroesophageal reflux. Basic prevention of GERD comprise lifestyle and dietary interventions. Adjustments of the exercise load and avoiding meals and drinks about the time of physical effort may ease the symptoms. Unfortunately, in most patients, pharmacological measures are necessary. These include occasional application of antacids and blockers of histamine H2 receptors in mild forms of the disease, and a regular therapy with proton pump inhibitors (PPI) in the majority of other cases. An average dose of PPI varies from 20 to 40 mg/day and should be continued for 4–8 weeks. Unfortunately, symptoms of GERD frequently return and in these situations long-term acid suppression with PPI is usually necessary. As regular physical activity exerts beneficial health effects, the necessity of establishing associations between moderate, recreational exercise and GERD is needed.
LrRorwo ARncu
Sports Med 2006;
36
(5):
38$391
o
| 1
2-1 U2
/
06
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OO05-0385/S39,95/0
O
2006 Adis Doto Informotion BV. All rights reserved.
Gastroesophageal
Reflux
Disease
and
Physical Activity
Parnel
lozkow,r
Dorota
Wasko-Czopnik,z
Mnrek Medrasl
and Leszek Paradowski2
L
Department
of Sports Medicine, Wroclaw University
of
Physical Education, Wroclaw, Poland
2 Department
of Gastroenterology, Wroclaw Medical
University,
Wroclaw, Poland
Absfrocl
Gastroesophageal
reflux disease
(GERD)
is one of the most common disorders
in the
general population.
In recent
years,
a marked increase in the occurrence
of
the disease worldwide has been noted.
Intense exercise belongs
to
factors
that are known to exacerbate symptoms
of
GERD. Episodes
of
reflux
seem to be associated with the length and the intensity
of the
physical
activity undertaken. Experimental
studies suggest that the
gas-
troesophageal reflux
may be increased in athletes due to: decreased
gastrointesti-
nal
blood flow; alterations of hormone secretion; changes in
the motor function of
the oesophagus and the ventricle;
and
the
constrained body
position
during
exercise. Disturbances of the balance
between two areas of opposite
pressure:
intra-abdominal and intrathoracic, have
also been
proven
to influence
GERD
events.
GERD
is found in
sportspeople of various disciplines, but
specific types of
exercise may have significantly
different impacts on the
gastroesophageal
reflux.
Basic
prevention
of GERD
comprise
lifestyle and dietary interventions.
Adjustments of the
exercise
load
and avoiding meals and drinks about the time of
physical
effort
may
ease the symptoms. Unfortunately, in most
patients, pharma-
cological
measures are necessary. These include
occasional application of
antacids
and blockers of histamineHzreceptors in mild forms of the disease,
and a
regular therapy
with
proton pump
inhibitors
(PPD
in the majority of
other cases.
An average dose of PPI varies from 20
to
40
mg/day and should be continued for
4-8
weeks. Unfortunately, symptoms of
GERD
frequently
return and in these
situations long-term acid suppression with PPI is usually necessary.
As regular
physical
activity exerts beneficial health effects, the necessity
of
establishing associations between moderate, recreational exercise
and GERD is
needed.
Gastroesophageal reflux
disease
(GERD)
is one
of the most common
disorders of the upper
gastroin-
testinal tract and a frequent
ailment of our 1lpes.t1-31
It
is
typically described
as a burning sensation ra-
diating up
from
the sternum,
commonly
referred
to
as a heartburn and
acid
regurgitation. About l07o
of
the
adult American
population
report daily heart-
burn, while
3040Vo complain of symptoms compat-
ible with the disease
on
a monthly
basis.tll What
seems striking is that
the
quality
of
life
of
patients
with GERD can be compared with
those with
is-
chaemic heart
disease or
mild
heart failure.tal
386 lozkow
et al.
It has been documented
that strenuous
exercise
induces GERD.ts-zl
However,
relationships between
GERD and
regular,
moderate exercise
are
not suffi-
ciently
explored.
The
question
seems
especially
in-
triguing
in the context
of the
multiple
beneficial
health
effects of
recreational
physical
activity.
l.
Gosfroesophogeol
Reflux
Diseose
(GERD)
Gastroesophageal
reflux
means movement
of
gastric
contents
from the
stomach
into the oesopha-
gus.
This
phenomenon is
found
practically in
all
healthy
individuals.
GERD
is diagnosed
when the
exposure
of the oesophagus
to
gastric
acids
exceeds
physiological limits, occurs
at night and
is
not relat-
ed to
meals. Most
recently
it has been
defined as
symptoms
or
mucosal damage
produced
by the
ab-
normal
reflux.t8l An episode
of GERD
is
a
period
of
time
in which oesophageal
pH
is <4.0
(acid
GERD)
or >7.0
(non-acid
GERD).
The necessity of
differen-
tiating between
GERD
and dyspepsia
is important
because
the
management of
patients differs consid-
erably
in
these
two disorders.tel
Repeated
gastroesophageal
reflux may cause
ero-
sions of the
oesophageal
mucosa
(erosive
GERD)
or
no overt
mucosal
damage
(non-erosive
reflux dis-
ease).
In both situations,
typical
and atypical
mani-
festations
of GERD
may be
present.
Among the
typical
symptoms
of GERD
are
heartburn
and
regurgitations,
but the
disease
can also
reveal as
laryngitis, dry
cough or
dental erosions.tlol
Exercise-induced
chest discomfort
requires spe-
cial
attention
because establishing
the origin
of the
complaint
may not be easy.ttt'tzl
Close
relationships
between
gastroesophageal and cardiac
disorders
should be
considered
when an
active
lifestyle
is
to
be
promoted. In
patients
with coronary
artery
dis-
ease, cardioesophageal
reflexes
lead to
reduced cor-
onary
blood
flow as a consequence
of oesophageal
acid
exposure.tl3l
On
the other
hand,
myocardial
ischaemia
may lead to
transient
lower oesophageal
sphincter
relaxation
(tLESR)
and eventually
GERD.tr4l
Although
GERD
is often
the
primary
reason
for
bronchoconstriction.
an
association
be-
O
2006 Adis
Dqtq lnformotion
BV. All rights
reserved,
tween
exercise-induced
GERD
and asthma
has not
been
proven.tl5'161
Complications
of GERD
have been
reported to
develop
in up to
21.67o of
patients
with GERD.
These
may include ulcer
(2-77o),
haemorrhage
(<27o),
stricture
(4-20Vo),
Barret(s oesophagus
Q}-lSVo)
and,
in
some
cases,
formation of
the
oesophageal
adenocarcinoma.tlTl
Although the
pro-
gression
from GERD
through
Barrett's oesophagus
(a
precancerous
lesion)
to the adenocarcinoma
of the
oesophagus
is well documented,
patients
with
GERD
have low
individual
risk
of
developing this
type of
cancer.[l8]
Slow oesophageal
clearance
of
refluxed
material,
diminished epithelial
defence
and an
incompetence
of the
lower oesophageal
sphincter
(LES)
are
impor-
tant
mechanisms
underlying
GERD. Up
to 807o of
reflux episodes
are associated
with
tLESRIIe'2ol
and
a
coexisting
hiatal hernia appears
to
increase the
frequency of
tLESR.t2rl TLESR
occurs
less often
in
the supine
position
and during
sleep,
more often
in
men than
in women, and
the
length of a single
episode
tends to be
longer with
advancing age.t22l
The relationship
between GERD
and body
mass
is
controverriul.t23'24)
Body mass
index
(BMI)
is not an
indicator of the
disease, but
it may be a
risk factor
for GERD.r2s'26t
In a study of
middle-aged
subjects,
there was
found an association
between
BMI and
GERD,
which
was
independent of diet
and exer-
cise.t27l Copious
meals
(especially
containing
fat),
alcohol
drinking
(especially
wine),
cigarette
smok-
ing and
intense
physical
exercise
have been
reported
to exacerbate
reflux .t28'2el
Diagnostic strategies
for
GERD
may
differ
de-
pending
on the
history of
symptoms,
coexisting
disorders,
patients'
age or
medical
resources.
Among studies
that are widely
accepted
as standards
for the diagnosis of
GERD
is 24-hour
pH-metry
and
endoscopy.t8l
Dynamic
position
testing
has been
proposed
to
improve detection
of GERD.t3or
A1-
though
in
the
majority of
patients
the diagnosis
can
be made clinically,
the
simplest
procedures have
serious limitations.t3ll
Establishing the diagnosis
can
be especially
difficult
for atypical
presentations
of
GERD.
Sports
Med 2006; 36
(5)
Gastroesophageal
Reflux
Disease
and
Physical
Activity
In
young
patients
with
fresh
onset
of common
symptoms,
a trial
therapy
of up
to 2
weeks
with
a
high-dose proton
pump
inhibitor
(PPI)
[40mg
twice
dailyl
may
be sufficient
to recognise
GERD
('PPI
test').t321
In
older patients,
endoscopy
is
an impor-
tant
measure
to identify
complications
or
alternative
diagnosis,
whereas
in patients
with
extraoe-
sophageal
manifestations
of
GERD
(e.g.
noncardiac
chest
pain,
asthma,
dry
cough, laryngitis),
24-hour
pH
recording
may
be
the most
appropriate
investiga-
tion.t33'341
Recently,
a self-assessed
symptomatic
re-
flux
questionnaire
(ReQuestrM)l
has
been
designed
and internationally
validated
for
symptoms
assess-
ment
and monitoring.t3sl
2.
Pofhophysiology
of
Exercise-lnduced
GERD
Exercise
affects
gastrointestinal
function
in
mul-
tiple
ways.
One of the
suggested,
although
not fully
explored,
mechanisms
in
which
physical
activity
could
intensify
GERD
symptoms
is exercise-in-
duced
decrease
of
gastrointestinal
blood flow.t36,371
In
both
trained
and
untrained
subjects,
sympathetic
stimulation
accompanying
exercise
may
lead
to
80Vo flow
reduction,tsl
which
may
be additionally
worsened
by
dehydration.t38l
Physical
activity
leads
to
alterations
in
motor
function
within
the
oesophagus
and
the ventricle.t3el
In
studies
of well
trained
athletes,
contraction pres-
sure
at
the mid-oesophagus
and
peristaltic
motility
at the
mid-
and
distal
oesophagus
were lower
during
cycling.t+ol
Gastric
emptying
was
delayed
during
exercise
at
90Vo
maximal
oxygen
uptake
(VOzmax)t+tl
while
at
exercise
of moderate
intensity
(25-757o
VOz*a*)
it
was either
unaffected
or
en-
hanced.t3Tl
Exercise
influences
concentrations
of hormones
that increase
(motilin,
gastrin)
or
decrease
(catecho-
lamines) gastrointestinal
motiliry.t42l
Nevertheless,
in
a study
of
trained
and
untrained
subjects,
plasma
levels
of
gastrin,
pancreatic
polypeptide,
vasoactive
intestinal polypeptide,
motilin
and
glucagon
were
not
affected
bv
the exercise.[41'43]
The
vertical position
of the
body facilitates
trans-
port
of
oesophageal
content
to the
ventricle,
but
interestingly
reflux
occurs
most
often
when
subjects
are upright
or
sitting.
The
different
to
upright
posi-
tion
during
weightlifting
or cycling
leads
to an in-
crease
of ventricle
content
pressure
on LES
and
thus
could facilitate
transient
relaxations
of LES.
How-
ever,
a
study
conducted
in
weightlifters
exercising
horizontally
and
upright
revealed
that there
are no
statistically
significant
differences
in
the number
of
reflux
episodes
between
these
two
positions.tTl
LES may
be considered
as a
valve-like
barrier
between
two
areas
of opposite
pressure:
intratho-
rucic
(negative)
and intra-abdominal (positive).
It
acts
together
with the
diaphragmatic part
of
the
oesophagogastric
junction
to
prevent
a backflow
of
gastric
contents
to
the oesophagus.t44l
LES pressure
of
2-3mm
Hg
above intragastric
pressure
is
suffi-
cient
to
prevent
reflux.
In
one
study,tasJ
exffinsic
abdominal
compressions
of 60 and
80mm
Hg
were
strong
enough
to cause
significant
differences
in
pressure
gradients
in the
oesophagus.
An increase
of
intra-abdominal
pressure (e.g.
during
Valsalva
ma-
noeuvre)
may
enable
reflux
episodes
by overcoming
the
pressure
of LES,
especially
if it is
simultaneous
to
TLESR
or happens
in
subjects
with
hypotensive
LES.
The
importance
of changes
of
the intra-ab-
dominal pressure
seems
to
be stronger
than
changes
in
body
position.tzl
It
has
been
demonstrated
that
GERD
symptoms
are more
likely
to
occur
with increasing
intensity
of
exercise
and
at longer periods
of
physical
ef-
fsft.I7,a1,a3l
Another
factor
that may
stimulate
exer-
tional
GERD is
food
and
beverage
intake
prior
to
sXslqiss.
t28'a6l
3.
GERD in the
Physicolly
Active
Populofion
Upper
gastrointestinal
symptoms
are often
found
in
athletes,
especially
those
engaged
in
endurance
sports.tT'3eJ
In
young
and middle-aged
men,
GERD is
one
of the
primary
causes
of chest
pain.I4tt
A
survey
of
606
well trained
sportsmen
showed
that
36Vo
of
I
The
use
of trade
names
is for product
identification
purposes
only
and does
not imply
endorsement.
@ 2006
Adis
Dotq Informqtion
BV.
All rights
reserved,
Sports Med
2006;
36
(5)
388
lozkozo
et
aI.
runners,
67Vo
of
cyclists
and
52-547o
of
triathletes
experienced
symptoms
from
the
upper
part
of
the
gastrointestinal
tract
during
exercise
(e.g.
heartburn,
chest
pain). Statistical
analysis
revealed
that
young-
er
athletes
experienced
such
ailments
more
often
than
older
ones
and
that
symptoms
were
more
likely
to
occur
during
longer
bouts
of
exerciss.t+al
11 It
worth
noting
that
decreased
gastric
pH
during
physi-
cal
activity
may
also
be
present
without
distinctive
symptoms
of
GERD.tall
There
is evidence
that
physical
activity
induces
significant
amounts
of
gastroesophageal
reflux
in
healthy
adult
volunteers.
In one
study,
vigorous
exercise
(30
minutes
of
running
and
30
minutes
of
resistance
exercises)
induced
a 3-fold
increase
of
acid
exposure
when
compared
with
the
periods of
rest.taal
In untrained
subjects
exercising
at 9OVo
VO2*u^,
the
number
of
reflux
episodes
was signifi-
cantly
higher
and
the
length
of
a single
event
longer
than
in
the same
men
exercising
at
lower
intensi-
ties.ta3l
In another
study,
the
total
length
of
GERD
episodes
was
longer
during
exercise
than
at
baseline
and
it was
found
that
15
minutes
of
running
pro-
duced
more
reflux
than
the
same
period of
cy-
cling.t+ol
Subjects
who
experience
GERD
at
rest
are
more
prone to
have symptoms
during
exercisetsl
and
some
patients with
exertional
GERD
do
not
have
symptoms
during
inactivity.tsol
Among
athletes,
oesophageal
pH
monitoring
proved the
presence
of GERD
during
and
after
exer-
cise
in
707o
of
rowers,
457o
of
fasted
runners
and
907o
of
fed runners.t6l
On
the
other
hand,
there
are
authors
indicating
no
difference
of
gastric
pH,
the
number
and
the
length
of
GERD
episodes
between
periods of
rest
and cyclin
g
at 707o
VO2*ur
in well
trained
men.t40l
In another
report,
the same
authors
found
no
significant
differences
in the
number
of
reflux
episodes
and
the
decrease
of
intragastric
pH
in well
trained
men
exercising
after
the
consumption
of
water,
sports
drink
and sports
drink
with
caf-
feine.t36l
Most
authors
agree
that
the
occuffence
of
GERD
symptoms
depends
on
the
intensity
and
the
type
of
@
2006
Adis
Doto
Informoiion
BV' All
rights
reserved.
exercise
undertaken.
In eight
trained
cyclists
exer-
cising
at
607o,757o
and
907o
YOzmax
the
number
and
length
of
GERD
episodes
increased
only
at
the
highest
intensity
of
the
exercise.tall
In another
study,
the
gastroesophageal
reflux
was
evaluated
in ath-
letes
while
in rest
and
after
a
standardised
meal.
They
related
a
history
of
exercise-related
heartburn
of
at
least 3-months'
duration
and
with
a
minimum
of
twice
weekly
occuffence.
The
subjects
underwent
an
exercise
test
at 657o
and 85Vo
VO2max.
Among
representatives
of
three
sport
disciplines,
episodes
of GERD
and
chest
pain
were
found
most
often
in
weightlifters.
In this
group, during
2 hours
of
oesophageal
monitoring,
pH
was
<4.0
for an
aver-
age
18.51
+
17.347o
(when
fasting)
and
35.81
+
34.337o
(when
fed)
of
the
exercise
time.
In
runners,
symptoms
were
mildly
expressed
and
pH-metry
ful-
filled
above
criteria
for
4.90
!3.967o
atd
t7-t6
X
7.907a,
respectively,
of
the
time.
Cyclists
exhibited
reflux
through
3.97
+
5.447o
and6.49
+
6.227o
of
the
total
exercise
time.
The
authors
suggested
that
an
increase
of
the
abdominal
pressure
(reflux
most
often
in
weightlifters)
influences
the
number
of
GERD
episodes
more
than
body
position during
exercise
(symptoms are
more
frequent
in runners
than
cyclists).tzJ
Published
data
on
low
or
moderate
everyday
physical activity
and
GERD
are
limited.
For exam-
ple,
the
effects
of
a standardised
meal
and
moderate
exercise
on
gastroesophageal
symptoms
were
stud-
ied in
ten
healthy
volunteers
with
the
use of
24-hour
recordings.
It was
noted
that
66Vo
of
reflux
episodes
occurred
within
3
hours
after
a
meal
(81
in 123
episodes)
and
only
1.67o
(2
in
123)
during
exer-
cise.lsol
Interesting
are
the
results
of
a
recent
population
study
in
Norway
(>65
000
participants).tstJ
GERD
symptoms
were
reported
by 3I.47o
of
the surveyed
subjects
and
astonishingly
an
inverse
relationship
among
frequent
physical exercise
and
risk of
reflux
was
found.l3l
Confirmation
of
these
data
in
other
environments
would
be
necessary
before
recom-
mending
physical activity
to
patients with
GERD.
Soorts
Med
2006;
36
(5)
Gastroesophageal
Reflux Disease
and Physical
Activity
389
4. Prevenfion
qnd
Treqtment
of
Exercise-lnduced
GERD
Patients
who
experience
episodes
of
heartburn
or
chest
pain
during
exercise
should not
undertake
activities
that may
stimulate
gastroesophageal
re-
flux.
The
highest
risk
of GERD is
connected
with
disciplines
such as weightlifing,
running,
rowing
and cycling.
In
trained
subjects,
the
probability
of
evoking
GERD may
be diminished
by shorter
time
and lower
intensity
of
exercise.u,37,3el
To
our
knowl-
edge,
influence
of
low-
or moderate-intensity
exer-
cise
on
GERD symptoms
in
the
general
population
is ambiguous.l3,27l
Among
dietary factors
associated
with
upper
gas-
trointestinal
tract symptoms
are: eating
within
30
minutes
before
exercise;
eating
solid food,
protein
or fat
before
exercise;
eating
chocolate
or mint;
drinking
substances
such
as orange
juice,
coffee,
hypertonic
solutions
or alcohol;
or
eating fibre-rich
food
during
physical
activity.14T'48,521
Exercise
after a
carbohydrate
drink
makes reflux
episodes last
long-
er than
after
water ingestion.t+6J
Besides
lifestyle
and
dietary
modifications,
there
are
effective
pharmacological
strategies
to
treat
GERD.
Medical
therapy
of
GERD should
be aimed
at both
alleviating
symptoms
and healing
mucosal
injury.
In mild
and occasional
reflux
episodes,
antacids
alone
or in
combination
with histamine
Hz
blockers
are
often used
(also
as a
preventive
measure).
Block-
ade
of histamine
H2 receptors
was
proved
to be
effective
in reducing
exercise-induced
GERD epi-
sodes;t2el
however,
at
present,
PPI
are
preferred.tsl
PPI
are indicated
in
the vast majority
of cases,
but
unfortunately
long-terrn
management
is
usually nec-
essary.ts3J
PPI
can
be used in
a standard
dose
of
20mg
once
daily for
2 weeks.
Reduction
of
symp-
toms
(occurring
during
the day) is
best achieved
by
administering
the drug
in the morning.
If
the therapy
works,
it
should
be maintained
for
another 4-6
weeks.t3el
The
healing rate
is
about
60-707o and it
reaches
807o
when
prolonged
to 8 weeks.
For mod-
erate
or
severe forms
of
GERD, 40
mg/day
of a PPI
may
be the
proper
treatment.lsal
Relapse
of the
dis-
O 2006 Adis
Doto Informqtion
BV.
All rights reserved,
ease, which
is very
often,
usually
requires
the
same
PPI
dosage
as it was initially
effective.
In the
minority
of cases
that
do not respond
to
lifestyle
changes
and
pharmacotherapy,
surgical
op-
tions
still exist.t8l
They
are also
offered
to
patients
who do not
want
to take
long-term
medication.
Generally, long-term
results
of surgery
in
patients
with
GERD
are
good.
The most
widespread
form
of
the antireflux procedure
is the laparoscopic
Nissen
fundoplication.
Unfortunately,
apart
from
an opera-
tion risk
and
postoperative
adverse
effects, there
are
concerns
about its
durability.
Only recently
have
new
endoluminal
therapies
been
developed.
The
idea
of these
procedures
is
to create
a mechanical
barrier to
the oesophageal
1sflux.ts51
5. Conclusions
Heartburn
found
in
young
persons
is
a typical
manifestation
of
GERD. It
has
been
proven
in
trained
and untrained
subjects
that certain
types
and
volumes
of exercise
and
particular
sport
disciplines
predispose
to
GERD
(e.g.
weightlifting,
running).
Also,
the length
of exercise
correlates
with GERD
symptoms.
Only
a few
studies have
examined
the
relation-
ships
between
GERD
and everyday physical
activi-
ty. Intense
propagation
of moderate
physical
activity
as a
part
of
a
healthy
lifestyle
justifies
further re-
search
of the
problem.
Acknowledgemenfs
No sources
of funding
were
used to
assist in
the
prepara-
tion
of this review.
The
authors have
no conflicts
of interest
that are directly
relevant
to
the content
of this review.
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Correspondence
and offprints:
P awel
I
ozkow,
Department
of
Sports
Medicine,
Wroclaw
University
of
Physical Educa-
tion, ul.
Paderewskiego
35, 51'-612
Wroclaw,
Poland.
E-mail:
pjozkow@wp.pl
o 2006
Adis Doto Informqtion
BV.
All rights reserved.
Sporis
Med
2006; 36
(5)
... It seems that the influence of physical activity on the occurrence of disease symptoms may be related, with the type of exercise, level of activity, and its duration. It has been found that some types of activity, such as weight lifting, significantly increase heartburn compared to others, such as recreational jogging or cycling [12,44]. In healthy volunteers and sportsmen, it has been shown that postprandial physical activity and intense exercise physical activity favour the development of GERD symptoms [72,78]. ...
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... However, a recent study revealed that frequent physical activity was a risk factor in obese patients, and not in patients with a low BMI [27]. A possible explanation for this is that frequent physical activity might cause a state of stress, which can compress gastric contents, disturb the normal motor function of the lower esophageal sphincter, and reduce blood flow to the stomach [28][29][30]. ...
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The fitness industry, like other occupational industries with high voice demand, increases the risk of voice disorders among its occupational voice users. Athletes, coaches, and fitness instructors, often referred to as sports occupational voice users (SOVU), are exposed routinely during training and competitive events to environmental risk factors. Exposure to outdoor and/or indoor airborne allergens results in upper respiratory symptoms that may cause structural or functional laryngeal disorders. Similarly, noise is a significant threat to voice that may lead to compensatory phonotraumatic behavior. Other significant environment-related risk factors include high altitude and extreme temperatures. Equally important to environment-related risk factors are individual-related risk factors. Voice education/health awareness in SOVU is limited. Dehydration is very common in endurance athletes, and comorbidities such as asthma and gastroesophageal/laryngopharyngeal reflux diseases are major threats to voice, but most SOVU are unaware of their importance.
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Although optimizing sleep with the goal of optimizing athletic performance is gaining support among the athletic community, sleep and its disorders remain under-recognized and underappreciated. This is critically important as athletic performance is impaired by the presence of inadequate sleep and untreated sleep disorders. Athletes are uniquely at a higher risk for certain sleep disorders such as obstructive sleep apnea, including those in collision sports where athletes with larger body mass and neck size have a distinct advantage.
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While commonly presenting in concert in the symptomatic athlete, chest pain, and dyspnea have myriad causes requiring careful workup and evaluation. Traditionally, chest pain is separated into typical, atypical, and noncardiac, whereas dyspnea can be separated into exertional or with rest. Among young athletes (<35 years), the vast majority of those presenting with chest pain will not have a serious life-threatening disease. In contract, atherosclerotic coronary artery disease predominates in older athletes (>35 years) presenting to the emergency department with chest pain. Concerns about shortness of breath can often be masked as patients typically present with more vague complaints such as decreased performance or exercise intolerance. This chapter will discuss the differential diagnosis of chest pain and dyspnea associated with exercise as well as the steps needed to perform a thorough evaluation. Finally, it will discuss management techniques including contraindications to competition as well as decisions surrounding return to play.
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Digestion is a process which takes place in resting conditions. Exercise is characterised by a shift in blood flow away from the gastrointestinal (GI) tract towards the active muscle and the lungs. Changes in nervous activity, in circulating hormones, peptides and metabolic end products lead to changes in GI motility, blood flow, absorption and secretion. In exhausting endurance events, 30 to 50% of participants may suffer from 1 or more GI symptoms, which have often been interpreted as being a result of maldigestion, malabsorption, changes in small intestinal transit, and improper food and fluid intake. Results of field and laboratory studies show that pre-exercise ingestion of foods rich in dietary fibre, fat and protein, as well as strongly hypertonic drinks, may cause upper GI symptoms such as stomach ache, vomiting and reflux or heartburn. There is no evidence that the ingestion of nonhypertonic drinks during exercise induces GI distress and diarrhoea. In contrast, dehydration because of insufficient fluid replacement has been shown to increase the frequency of GI symptoms. Lower GI symptoms, such as intestinal cramps, diarrhoea — sometimes bloody — and urge to defecate seem to be more related to changes in gut motility and tone, as well as a secretion. These symptoms are to a large extent induced by the degree of decrease in GI blood flow and the secretion of secretory substances such as vasoactive intestinal peptide, secretin and peptide-histidine-methionine. Intensive exercise causes considerable reflux, delays small intestinal transit, reduces absorption and tends to increase colonic transit. The latter may reduce whole gut transit time. The gut is not an athletic organ in the sense that it adapts to increased exercise-induced physiological stress. However, adequate training leads to a less dramatic decrease of GI blood flow at submaximal exercise intensities and is important in the prevention of GI symptoms.
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Goals: Review of research directions in the etiology, evaluation, and treatment of patients with noncardiac chest pain. The author proposes a combined practical approach to noncardiac chest pain that incorporates these findings, which is useful in a clinical practice setting. Background: Several major schools of thought have emerged in the etiology of noncardiac chest pain: acid reflux, motor disorder, altered pain threshold/hypersensitivity, and association with psychiatric dysfunction. There is significant overlap among these. Occult gastroesophageal reflux disease (GERD) is more common than motor disorders and is found in 30% to 40% of these patients; a subset has hypersensitivity, with a normal pH profile. Esophageal motility testing and endoscopy have a more limited role than 24-hour pH testing. Impedance planimetry and balloon sensory provocative testing remain research tools. Provocative testing with hydrochloric acid or edrophonium is less helpful than pH monitoring. Gastroesophageal reflux disease-induced chest pain requires high-dose long-term proton pump inhibitors (PPIs): at least 4 to 8 weeks. Psychotropics are superior to placebo, both in patients with and without psychiatric dysfunction. Results: The author found combined PPIs and psychotropics helpful in patients with esophageal hypersensitivity and GERD, although supporting data is scant. Conclusions: A brief 1-week high-dose PPI challenge, i.e., omeprazole test, may be cost-effective in a primary care setting. However, this approach may not be useful in a referral setting, where pH data and diary assessment of associated symptoms provide useful management help. A behavioral model approach, with early emphasis on patient education, integrated with physiologic data helps the most.
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Gastro-oesophageal reflux is commonly found in the general population, and has recently been demonstrated to occur more frequently during exercise than at rest. This fact is significant to the substantial number of athletes who complain of exertional upper gastrointestinal symptoms and exercise-induced chest pain. A diagnosis of exercise-induced gastro-oesophageal reflux can be confirmed by means of ambulatory pH monitoring. A positive diagnosis allows for appropriate management of the individual. This can involve simple measures, such as recommendations for changes in diet, timing of meals, and nature of exercise. However, pharmacological intervention may be required. A decrease in morbidity associated with cardiac origins of exercise-induced pain can also be expected with a more comprehensive understanding of this pathology.
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Study Objective: To test the potential of distance running to induce reflux in healthy subjects and the ability of ranitidine to decrease esophageal acid exposure. Design: A randomized, single-blind, crossover study. Objective assessment of reflux was done using an ambulatory intra-esophageal pH monitor during both a baseline hour and 1 hour of running on 2 days of testing. Subjects: Fourteen normal volunteers (10 men, four women) between 22 and 37 years of age were studied. All volunteers ran regularly, completing an average of 20 miles weekly for at least 6 months. Interventions: Ranitidine, 300 mg orally, or an identical placebo was administered after a low-fat breakfast just before the baseline hour of pH recording. Setting: Esophageal motility and pH probe placement was done in the gastroenterology unit at Bowman Gray Medical Center. Running was done on local jogging trails. Measurements and Main Results: There was more gastroesophageal reflux during running than during the baseline hour when reflux was measured at a pH threshold of 3.0, 4.0, or 5.0 (P < 0.05). Reflux episodes were usually associated with belching. Ranitidine, 300 mg administered orally 1 hour before running, significantly (P < 0.05) reduced the amount of esophageal acid exposure during running. Conclusions: Gastroesophageal reflux occurs during running in healthy volunteers. It is usually associated with belching. Acid suppression with ranitidine decreases intraesophageal acid exposure during running (P < 0.05).
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The effects of different types of exercise on gastroesophageal reflux were evaluated during fasting and postprandially in 12 asymptomatic volunteers (7 men and 5 women; mean age, 28 years) using an ambulatory intraesophageal pH monitor. The 1-hour exercise period included stationary bicycling (aerobic exercise with little agitation of the body), running (aerobic exercise with a high degree of agitation of the body), and a weight routine (nonaerobic exercise). Each exercise was performed for 15 minutes with 5 minutes of rest between exercises. The weight routine consisted of five different exercises (sit-ups, bench press, sitting arm press, prone leg curls, and sitting leg press) chosen to compare upper-body vs lower-body exercise and supine vs upright position. Each exercise hour was preceded by a 1-hour baseline period on 2 days (fasting and postprandial). The results indicate that vigorous exercise can induce gastroesophageal reflux in normal subjects. Running induced the most reflux, and aerobic exercises with less bodily agitation (bicycle) produced less reflux and may offer an alternate form of exercise for patients with reflux. The weight routine induced gastroesophageal reflux in some subjects, although no particular exercise was associated with more reflux. Postprandial exercise showed a similar pattern of induced gastroesophageal reflux, although of greater amount. (JAMA. 1989;261:3599-3601)
Article
Einleitung/Fragestellung: Der Einfluss des Übergewichtes auf die gastroösophageale Refluxkrankheit (GERD) wird kontrovers diskutiert. Ziel der vorliegenden Studie ist die Untersuchung des Zusammenhanges zwischen BMI und der Häufigkeit von Sodbrennen in einer Population mit typischen Refluxbeschwerden. Methodik: Im Rahmen einer deutschlandweiten GERD-Aufklärungskampagne haben 5 000 Bürger über eine Telefonhotline Kontakt aufgenommen. Es wurden diejenigen in die Studie aufgenommen, die typische Refluxsymptome (Sodbrennen, saures Aufstoßen) angaben. Bei diesen Probanden wurden telefonisch Alter, Geschlecht, Körpergröße und -gewicht sowie die Häufigkeit von Sodbrennen abgefragt. Ergebnisse: 1 296 Probanden (668 weiblich) mit einem mittleren Alter von 54 ± 14 J. und einem mittleren BMI von 26 ± 4 wurden in die Studie eingeschlossen. 41,2 % der Probanden waren normgewichtig (BMI < 25), 41,4 % übergewichtig (BMI 25-30) und 13 % adipös (BMI > 30). 74,5 % des Gesamtkollektives gaben mehrmals wöchentlich Sodbrennen an. Bei 74,6 % bestanden die Refluxsymptome seit > 1 Jahr. Der BMI hatte statistisch keinen Einfluss auf die Häufigkeit von Sodbrennen (p > 0,05). Diskussion: Im vorliegenden Patientenkollektiv, bei dem über 70 % mehrmals in der Woche Sodbrennen beklagten, zeigte der Bodymass-Index keinen Einfluss auf die Häufigkeit von Refluxsymptomen. Das Übergewicht scheint somit kein Risikoindikator für die Refluxkrankheit zu sein. Ob das Übergewicht auch keinen Risikofaktor darstellt, müssen zukünftige Interventionsstudien zeigen.
Article
An acid-induced, cholinergic esophagobronchial reflex has been described whereby acid refluxing into the esophagus causes bronchospasm. Reports of exertional gastroesophageal acid reflux prompted us to study the possibility that exercise-induced asthma (EIA) could be related to gastroesophageal reflux (GER). Following an overnight fast, 10 athletes with a history of EIA (nine men, one woman; mean age 31) were studied. Continuous monitoring of intraesophageal pH and motility, ECG, and arterial oxygen saturation was done. After baseline monitoring at rest for 15 min, subjects underwent treadmill exercise for 10 min followed by continuous monitoring for 30 min after exercise. Spirometry was done at baseline prior to exercise, then repeated every 5 min after exercise for 30 min. Two subjects were retested at a later date following a standard test meal. All 10 subjects demonstrated a decrease in FEV1 in response to exercise, but only half met criteria for EIA. Although 60% (6/10) showed some evidence of GER, only three subjects demonstrated a pathologic degree of GER. In the two subjects retested postprandially, change in FEV1 was no different in one and improved in the other despite worsening of GER in both. There was no significant correlation between GER and EIA (P=0.2). EIA correlated inversely with amplitude of esophageal contractions (P=0.029) and was directly related to the percentage of multi-peaked contractions and the duration of peristaltic contractions (P=0.08). EIA is not associated with exertional GER.