Acid Reflux: It's not Just From Your Gut.
Acid reflux, or Gastroesophageal Reflux Disease (GERD), is an all too common experience and a very common complaint within clinics. It occurs when stomach acid backs up from your stomach, through the esophagus, and sometimes back into the mouth. Of course, this is a problem because it is the opposite of what is supposed to happen.
When you swallow, a circular band of muscle around the bottom part of your esophagus
called the Lower Esophageal Sphincter (LES), temporarily relaxes to allow food and liquid to pass into your stomach. When functioning properly, it closes again thus preventing the stomach contents from passing back into the esophagus.
Problems arise when this mechanism fails to work properly, and based on self-reported symptoms, between 14-20% of adults are affected by GERD (1). GERD can have long ranging implications not only on digestion, diet and lifestyle, but also on the health of the esophagus, with Barrett's Esophagus (a pre-cancerous condition) and Esophageal cancer being very serious complications if left untreated.
What are the Symptoms of GERD?
The symptoms arise from stomach acid being in the wrong place, namely the esophagus, which is directly surrounded by the diaphragm (see below diagram). A properly functioning Diaphragm muscle and LES keeps stomach acid in the stomach, where it belongs. When this acid goes up instead of going down, certain symptoms arise such as:
Heartburn
Regurgitation
Belching & Bitter taste
Chronic coughing
Wheezing
Hoarseness
Sore Throat
Epigastric Pain
Non-Cardiac related Chest Pain
Conventional treatment of GERD is to neutralize acid production with drugs known as proton pump inhibitors (PPI). This is a symptom based approach and is not curative as this requires continuous treatment [2]. These drugs are not without risk, however, as evidence is now arising that shows PPI use is associated with Dementia. (3)
Osteopathy aims to treat structural issues that lie at the root of dysfunction and are based on anatomy and function, as opposed to simply providing medication to suppress the symptoms of dysfunction. Osteopathic manipulative treatment (OMT) and OMTh, which are considered by some to be a complementary or alternative medicine, are based on concepts and unique approaches that enable the self-healing and self-regulating process within the body. (4).
In order to understand how we do this, we need to know a bit more about related Diaphragm anatomy, how it's innervated, and how the state of the body will influence it's ability to function.
What is the Diaphragm?
The Diaphragm is a muscle that separates the thoracic cavity (chest) from the abdominal cavity, which houses the viscera. Three important structures pass through the diaphragm:
The Esophagus, which transports food from the mouth to the stomach
Inferior Vena Cava which passes blood from the abdomen to the heart
Descending Aorta which passes blood from the heart to the abdomen, pelvis and legs
Why it Matters to Assess and Treat the Entire Body:
Any osteopathic treatment of GERD should include the Diaphragm because of it's direct contact and relationship with the Esophagus. As you can see from the above and below images, the diaphragm is attached to both the thoracic and lumbar vertebrae. Due to it's anatomical relationship to the ribs, the Sternum may also play a role in influencing the diaphragm. Also, the diaphragm is primarily innervated by the Phrenic nerve which is formed from the cervical nerves C3, C4 and C5 and travels down to the diaphragm.
The Vagus nerve, a cranial nerve, exits from the cranial base and innervates the stomach, and effects acid secretion, gastric emptying time, satiation and stomach contraction. Thus, it is imperative that the spine and head be assessed and treated for any mal-alignment in order to effectively find and treat the root cause of dysfunction.
The viscera are connected to the musculoskeletal system by connective tissue (fascia) forming functional chains that connect all of the anatomic elements from head to toe (5). This is how a sprained ankle can translate into low back pain and even headaches. In this same manner, issues with the Left Shoulder, can translate into GERD related symptoms by way of fascial tension referral. The fascia is the philosophy of the body, meaning that each body region is connected to another, whereas osteopathy is the philosophy of medicine, meaning that the entire human body must work in harmony (6).
Treating only locally (the diaphragm) in an attempt to reduce symptoms is remiss and does not adhere to Osteopathic principles. It may yield moderate results (as in this study), which found approximately 75% of patients receiving osteopathic treatment on the diaphragm alone reported moderate improvement, but will most likely miss the mark. The only way to effectively treat any presenting dysfunction is to globally assess and treat posture, structure, and tissue status throughout the body.
Given all of this, it is easy to see how focusing only on reduction of stomach acid with a pill, or even simply dietary modifications, not only misses the key structural components causing GERD, it sets the individual up for a lifetime of medication and discomfort.
Which is more compelling - a pill and it's side effects or manual medicine? You decide.
1. Kahrilas PJ. Gastroesophageal reflux disease. N Engl J Med. 2008;359(16):1700-1707. doi:10.1056/NEJMcp0804684. [CrossRef] [PubMed]
2. Cheskin LJ, Lacy BE (2002) Healing Heartburn. (1st edition), Baltimore: John Hopkins University Press, London, 150-152 p.
3. Posadzki P, Ernst E. Osteopathy for musculoskeletal pain patients: a systematic review of randomized controlled trials. Clin Rheumatol. 2011;30(2):285-291. doi:10.1007/s10067-010-1600-6. [CrossRef] [PubMed]
4. Gomm W, von Holt K, Thomé F, Broich K, Maier W, Fink A, Doblhammer G, Haenisch B. Association of Proton Pump Inhibitors With Risk of DementiaA Pharmacoepidemiological Claims Data Analysis. JAMA Neurol. 2016;73(4):410–416. doi:10.1001/jamaneurol.2015.4791
5. Lossing K. Visceral manipulation. In: Chila AG, executive ed. Foundations of Osteopathic Medicine. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2011:845-849.
6. Bordoni B, Zanier E. Clinical and symptomatological reflections: the fascial system. Journal of Multidisciplinary Healthcare. 2014;7:401-411. doi:10.2147/JMDH.S68308.
7. Bjørnæs et al., Int J Clin Pharmacol Pharmacother 2016, 1: 116
