Osteopathic Manual Therapy and Management of Gastroesophageal Reflux Disease-GERD
Updated: Jun 3, 2019
By Jocelyn Glover B.Ost
“Canada is in the midst of a digestive health crisis”. These are not my words, but I believe it to be true because I see it everyday in my osteopathic clinical practice. These are the words of Dr. Richard Fedorak, President of the Canadian Digestive Health Foundation (CDHF) (1).
In 2009, the CDHF launched a scientific project to define the incidence, prevalence, mortality and economic impact of digestive disorders across Canada. Some interesting and alarming facts that came out of this project found that digestive disorders affect approximately 60% of the Canadian population or 20 million Canadians. The impact of which results in an annual loss of $18 billion in healthcare costs and lost productivity. What’s even more alarming is that this study indicated these numbers are rising (1)!
One of the most prevalent digestive disorders seen in Canadians and one that I commonly see in my clinical practice is gastroesophageal reflux disease or GERD.
What is GERD? Gastroesophageal reflux disease, or GERD, is a digestive disorder that affects the lower esophageal sphincter (LES), the ring of muscle between the esophagus and stomach. The sphincter (valve) acts as a barrier between the esophagus and stomach and normally should remain tight (or closed) when food is not passing into the stomach. However, when the LES is not functioning properly acidic secretions and partially digested foods can reverse backwards from the stomach up into the esophagus causing what is often referred to as acid reflux.
Common Symptoms of GERD • Heartburn – sensation of burning discomfort or pain behind the chest • Indigestion or occasional regurgitation and mid-thoracic back pain • Belching • Other associated symptoms such as a dysphagia (difficulty swallowing), upper gastrointestinal bleeding, chronic dry cough, wheezing, sore throat, hoarseness, and recurrent pneumonia are considered more alarming and indicate the need for further diagnostic testing (13).
GERD Management with Osteopathy
Through evidence-based research osteopathic manual therapy (OMT) has been shown as a beneficial intervention for GERD management using a whole-body approach (5) (7) (8). From an osteopathic perspective there are a number of factors that influence the functioning of the LES.
The Vagus Nerve– Parasympathetic Nervous System “rest and digest” The Vagus Nerve is part of the Parasympathetic Nervous System and exits the skull through the jugular foramen; passing through the cranial base (occipitoatlanto joint) and the lower part of the esophagus and stomach. Therefore, any compressions of the cranial base may cause impingement of the vagus nerve resulting in ineffective closure of the LES (2).
Sympathetic Nervous System – “fight or flight” The Greater Splanchnic Nerves (visceral nerves) arise from near the middle of the spinal cord at vertebrae T5-T9 and connect to the esophagus and stomach. Dysfunction at these vertebral segments can impact the GI tract and decrease oxygen and nutrients to tissues.
Diaphragm The diaphragm is a dome-shaped muscle separating the thorax from the abdomen. The esophagus is one of many structures that pass through the diaphragm. Spasm or dysfunction of the diaphragm may impair gastric emptying causing heartburn.
Inflammation and the Lymphatic system Inflammation and associated congestion of lymph and venous circulation is another important factor in the OMT approach to the management of GERD. In GERD, acid and pepsin can cause erosion to the esophageal epithelial lining, creating inflammation. (14) Interestingly, research is now showing that up to 70% of GERD patients do not develop esophageal erosions (14). This new variant of GERD is called non-erosive reflux disease (NERD). Some of the differentiating characteristics of NERD from GERD include a normal LES resting pressure, low esophageal acid exposure and minimal nighttime esophageal acid exposure. These patients also have a low response rate to acid suppressive medication therapy and are resistant to proton pump inhibitors.
This is changing the medical perspective on the pathophysiology of GERD and researchers are now suggesting that gastric juice reflux may not directly damage the esophageal mucosa, but instead stimulates the esophageal epithelial cells to secrete chemokines (pro-inflammatory response) that attract and activate immune cells, causing damage to the epithelial cells-(23).
Osteopathic manual practitioners have a long history of appreciation for the lymphatic system and have understood that the lymphatic system has a functional role in the resolution of inflammation and has a potential impact on improving biomarkers of inflammation that enhance the immune response of the body. Lymphatic flow and blood circulation also has a direct relationship to the function of the esophagus by means of the anatomical relationship of the thoracic duct, vena cava and aorta with respect to the hiatus of the diaphragm. Interference to the function of the esophagus may also restrict the passage of the thoracic duct and blood circulating structures, which can block lymph drainage and cause venous congestion.
Thus, using various manual techniques that address the lymphatic system can improve the outcomes of GERD or NERD by decongesting the lymphatic and venous tissue as well as improving inflammation.
Many dietary and lifestyle modifications are recommended as ways to help yourself manage your symptoms. If you suffer from GERD consider making these suggested changes to help ease your discomfort.
Dietary and Lifestyle Changes Dietary avoidance includes:
o Alcohol o Caffeinated beverages o Carbonated beverages o Chocolate o Citrus foods o Raw onions and garlic o Tomatoes and tomato products o Peppermint o Fatty or fried foods o Spices (such as pepper, chili powder or strong spices)
Lifestyles changes include: o Avoid eating meals 2-3 hours before bedtime o Avoid large meals (Large volume of food and secretions that remain in the stomach creates pressure that can force the stomach content back up into esophagus) o Consume smaller meals more frequently (especially ones low in fat as fatty meals remain in the stomach longer than low-fat meals) o Remain upright 2-3 hours after meals o Elevate head of bed or use a bed wedge (6 inch blocks) o Smoking cessation o Weight reduction for overweight patients or obese (Obesity increases production of estrogen and progesterone which relax the LES) o Avoid tight-fitting garments
1. Canadian Digestive Health Foundation-National Digestive Disorders and Impact Study Report (2009). http://cdhf.ca/bank/document_en/25establishing-digestive-health-as-a-priority-for-canadians.pdf#zoom=100. 2. Lossing, K. (2011) Visceral Manipulation. In: Chila, A.G.,Ed., Foundations of Osteopathic Medicine, 3rd Edition, Lippincott Williams & Wilkins, Baltimore, 845-849. 3. Steele, K.M. (2011) Child with Ear Pain. In: Chila, A.G.,Ed., Foundations of Osteopathic Medicine, 3rd Edition, Lippincott Williams & Wilkins, Baltimore, 918-930. 4. Nwokediuko, S.C. (2012) Current Trends in the Management of Gastroesophageal Reflux Disease: A Review. ISRN Gastroenterol, 2012: 391631. http://dx.doi.org/10.5402/2012/391631 5. Bjornaes, K. E. et al, Does Osteopathic Manipulative Treatment (OMT) have an Effect in the Treatment of Patients Suffering from Gastro Esophageal Reflux Disease (GERD)? Clin Pharmacol Biophram 2015, 4:4. http://dx.doi.org/10.4172/2167-065X.C.1.016 6. Troutman, M.E. Pathophysiology of Clinical Presentation of Gastroesophageal Reflux Disease. JAOA 1997, Vol 97: 9-S1. http://osteomed-dr.contentdm.oclc.org/cdm/ref/collection/myfirst/id/1284 7. Diniz, L.R. et al, Qualitative Evaluation of Osteopathic Manual Therapy in a Patient with Gastroesophageal Reflux Disease: A Brief Report. JAOA 2014, 114, 180-188. http://doi:10.7556/jaoa.2014.036 8. da Silva, R.C.V. et al, Increase of lower esophageal sphincter pressure after osteopathic intervention on the diaphragm in patients with gastroesophageal reflux. Disease of the Esophagus 2013, 26:5, 451-456. http://doi.org/10.1111/j.1442-2050.2012.01372.x 9. Collebrusco, L., Lombardini, R. and Censi, G. (2017) An Alternative Approach to the Gastroesophageal Reflux Disease: Manual Techniques and Nutrition. Open Journal of Therapy and Rehabiliation, 5, 98-106. http://doi.org/10.423/ojtr.2017.53009 10. Esmail, N. (2007). Complementary and Alternative Medicine in Canada: Trends in Use and Public Attitude, 1997-2006. The Fraser Institute No. 87. http://www.fraserinstitute.org/sites/default/files/ComplementaryAlternativeMedicine.pdf 11. Canadian Medical Association. Complementary and Alternative Medicine (Update 2015). Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-09.pdf 12. Branyon, B. (2008). Healing Hands: Using Osteopathic Manipulative treatment to Address Visceral Structure through Somatovisceral Reflexes: A Case Study in Gastroesophageal Reflux Disease. AAO Journal Vol 8:4 29-31. 13. Fass, R: (1999). Advances in the Management of Gastroesophageal Reflux Disease. Hospital Physician: 59-67. http://www.turner-white.com/pdf/hp_aug99_grd.pdf 14. Yoshinda, Norimasa. Inflammation and Oxidative Stress in Gastroesophadeal Reflux Disease. J Clin Biochem Nutr 2007, Jan; 40(1): 13-23.