At Breathing Works, we have long been interested in the relationship between complex gastrointestinal conditions and breathing pattern disorders. Over the past decade, our physiotherapists have increasingly incorporated breathing rehabilitation into the management of patients experiencing persistent gastrointestinal symptoms.
More recently, we have developed a collaborative approach with gastroenterology specialists, including the Allevia GI Institute on Auckland’s North Shore. This has led to an increase in referrals for people whose symptoms may involve an interaction between their gastrointestinal, respiratory and nervous systems.
Emerging research suggests that physiotherapy may have an important role in managing selected gastrointestinal conditions—particularly when altered breathing patterns, impaired diaphragm function or autonomic nervous system dysregulation are present.
The gut–brain–respiratory connection
The emerging literature on the gut–brain–respiratory axis highlights a two-way relationship between breathing and gastrointestinal function:
- The way a person breathes may contribute to gastrointestinal symptoms.
- An underlying gastrointestinal condition may alter breathing patterns.
- Stress and autonomic nervous system dysregulation may aggravate both systems.
Breathing pattern disorders can affect gastrointestinal function through three main pathways: biomechanical, biochemical and autonomic.
The biomechanical role of the diaphragm
The diaphragm is the primary muscle of breathing, but its function extends well beyond respiration. It also contributes to lower oesophageal sphincter control, pressure regulation within the abdomen and gastrointestinal motility.
The dome-shaped diaphragm sits directly above the abdominal organs. During inhalation, it contracts, flattens and descends towards the abdominal contents. During a relaxed exhalation, it rises back towards the chest.
This creates a natural compression-and-release cycle that may support gastrointestinal movement and coordination. If diaphragm movement is reduced, poorly coordinated or excessive, these beneficial mechanical effects may also be disrupted.
Autonomic and biochemical influences
The autonomic nervous system helps regulate both breathing and gastrointestinal function.
During periods of chronic stress, the nervous system may remain in a prolonged state of sympathetic activation—the familiar “fight, flight or freeze” response. This can contribute to altered breathing behaviours such as:
- Rapid or excessive breathing
- Breath-holding
- Frequent sighing
- Breath stacking
- Persistent mouth breathing
- Upper-chest-dominant breathing
When these patterns become habitual, they may help sustain a state of physiological arousal.
Chronic over-breathing can also produce hypocapnia, meaning that carbon dioxide levels become lower than normal. Hypocapnia causes systemic vasoconstriction, including reduced blood flow within the gastrointestinal system. This may contribute to altered motility, visceral hypersensitivity and symptoms such as abdominal discomfort, constipation, bloating and nausea.
Gastro-oesophageal reflux disease
The oesophagus passes through the diaphragm via an opening called the oesophageal hiatus. When the diaphragm contracts effectively, it provides external support to the lower oesophageal sphincter by compressing the junction between the oesophagus and stomach.
People who breathe with a shallow, upper-chest-dominant pattern may have reduced diaphragm excursion. This may decrease support around the lower oesophageal sphincter and potentially increase the likelihood of reflux.
How physiotherapy may help
Research suggests that diaphragmatic breathing performed after meals may reduce reflux events. Inspiratory muscle training may also strengthen the diaphragm and improve the anti-reflux barrier.
Physiotherapy treatment may include:
- Diaphragmatic breathing retraining
- Post-meal breathing strategies
- Inspiratory muscle training
- Improved coordination between the diaphragm and abdominal wall
- Management of contributing breathing pattern disorders
Rumination syndrome
Rumination syndrome is characterised by the effortless regurgitation of recently eaten food. It is considered a disorder of gut–brain interaction involving involuntary abdominal muscle contraction and relaxation of the lower oesophageal sphincter. Together, these actions allow food to move back into the oesophagus and mouth.
Breathing pattern disorders commonly coexist with rumination syndrome because both conditions can involve poor coordination between the diaphragm, abdominal wall and thoracic muscles. Altered breathing may produce abnormal pressure changes within the chest and abdomen, potentially facilitating regurgitation.
How physiotherapy may help
Diaphragmatic breathing is an established component of rumination syndrome management. It may help by:
- Reducing inappropriate abdominal wall contraction
- Improving lower oesophageal sphincter control
- Regulating pressure between the chest and abdomen
- Promoting relaxation during and after meals
- Re-establishing coordinated breathing and abdominal movement
Abdominophrenic dyssynergia
Abdominophrenic dyssynergia is a disorder of gut–brain interaction associated with visible abdominal distension and bloating, despite there being little or no increase in the volume of abdominal contents.
Instead of the diaphragm and abdominal wall responding normally, the diaphragm contracts and descends while the abdominal muscles relax. This pushes the abdominal wall outwards and can contribute to visible distension, bloating and discomfort.
How physiotherapy may help
Behavioural treatment aimed at restoring normal coordination between the diaphragm and abdominal wall is considered central to management.
Breathing rehabilitation may help reduce excessive diaphragm activity, improve abdominal wall recruitment and restore more efficient thoraco-abdominal coordination.
Other gastrointestinal presentations that may benefit from physiotherapy assessment include aerophagia, gastrointestinal dysmotility, persistent abdominal pain, chronic constipation, IBS-like symptoms and autonomic conditions such as postural orthostatic tachycardia syndrome (POTS).
A case study from our clinic
A 17-year-old female was referred with effortless regurgitation of undigested food approximately 15 minutes after eating. She was highly active but also experienced shortness of breath during sport.
Real-time ultrasound imaging showed reduced diaphragm excursion of 9 mm at rest. Her breathing rate was elevated at 20 breaths per minute, and her breathing pattern was predominantly upper-chest based.
Inspiratory muscle testing also identified weakness. Her maximal inspiratory pressure was 75 cmH₂O, compared with a predicted value of approximately 97 cmH₂O.
Her physiotherapy programme included:
- Diaphragmatic breathing and relaxation training
- Breathing strategies before, during and after meals
- Nasal hygiene and nasal-breathing education
- Structured inspiratory muscle training using a POWERbreathe device
Following respiratory rehabilitation, her breathing measurements returned towards normal and her rumination episodes reduced substantially. She was able to return comfortably to sport and more normal eating patterns.
This case is an example from clinical practice. Individual responses to treatment will vary.
Quick signs of a possible breathing pattern disorder
During a consultation, several visual or behavioural signs may suggest that a breathing assessment would be helpful:
- Persistent mouth breathing
- Frequent sighing or yawning
- Audible inhalation or exhalation
- Prominent upper-chest movement with minimal abdominal movement
- Rapid or breathless speech
- Visible rib flare or altered chest and rib shape
- Shortness of breath associated with gastrointestinal symptoms
- A Nijmegen Questionnaire score above 23 out of 64
The Nijmegen Questionnaire can support clinical screening but should not be used as a stand-alone diagnostic test.
A helpful starting point
For appropriate patients, a simple starting strategy is to practise relaxed nasal and diaphragmatic breathing for 10–15 minutes after eating.
The exercise should feel comfortable and unforced. Patients with significant or unexplained gastrointestinal symptoms should first receive appropriate medical assessment, and breathing rehabilitation should complement—not replace—gastroenterology or medical care.
When to consider a referral
A physiotherapy assessment for breathing rehabilitation may be appropriate when:
- Signs of a breathing pattern disorder are present alongside gastrointestinal symptoms.
- Symptoms have shown minimal improvement with conservative, medical or specialist treatment.
- Rumination continues despite dietary modification.
- Gastro-oesophageal reflux has not responded adequately to proton pump inhibitor therapy.
- A patient is seeking additional non-pharmacological management options.
- A medically supervised reduction in long-term reflux medication is being considered.
- Abdominal bloating or pain remains prominent despite reassuring medical investigations.
- Chronic constipation has not responded to usual dietary measures.
- Anxiety-related breathing dysregulation appears to be aggravating gastrointestinal symptoms.
How Breathing Works can help
Our physiotherapists assess breathing mechanics, diaphragm movement, respiratory muscle function, thoraco-abdominal coordination and factors contributing to autonomic nervous system dysregulation.
Treatment is individualised and may include breathing pattern retraining, real-time ultrasound assessment, mealtime breathing strategies, relaxation training and inspiratory muscle training.
If you are a patient or healthcare professional and would like to discuss whether breathing rehabilitation may be appropriate, please contact the Breathing Works team.
References
Damianos JA, Tomar SK, Azpiroz F, Barba E. Abdominophrenic dyssynergia: a narrative review. American Journal of Gastroenterology. 2023. doi:10.14309/ajg.0000000000002044.
Guzman JA, Kruse JA. Splanchnic hemodynamics and gut mucosal-arterial PCO₂ gradient during systemic hypocapnia. Journal of Applied Physiology. 1999. doi:10.1152/jappl.1999.87.3.1102.
Ong AM, Chua LT, Khor CJ, et al. Diaphragmatic breathing reduces belching and proton pump inhibitor refractory gastroesophageal reflux symptoms. Clinical Gastroenterology and Hepatology. 2018. doi:10.1016/j.cgh.2017.10.038.
Sasegbon A, Hasan SS, Disney BR, et al. Rumination syndrome: pathophysiology, diagnosis and practical management. Frontline Gastroenterology. 2022;13:440–446.
Schwartges I, Schwarte LA, Fournell A, Scheeren TW, Picker O. Hypercapnia induces a concentration-dependent increase in gastric mucosal oxygenation in dogs. Intensive Care Medicine. 2008. doi:10.1007/s00134-008-1183-8.
Souza MÂ, Lima MJ, Martins GB, et al. Inspiratory muscle training improves antireflux barrier in GERD patients. American Journal of Physiology–Gastrointestinal and Liver Physiology. 2013. doi:10.1152/ajpgi.00054.2013.
Villoria A, Azpiroz F, Burri E, et al. Abdomino-phrenic dyssynergia in patients with abdominal bloating and distension. American Journal of Gastroenterology. 2011. doi:10.1038/ajg.2010.408.
Zdrhova L, Bitnar P, Balihar K, et al. Breathing exercises in gastroesophageal reflux disease: a systematic review. Dysphagia. 2023. doi:10.1007/s00455-022-10494-6.