DID YOU KNOW DYSFUNCTIONAL BREATHING CAN BE LINKED WITH GASTROINTESTINAL (GI) CONDITIONS & SYMPTOMS?
For some, a dysfunctional breathing pattern can contribute towards GI conditions and in other circumstances, the condition and its associated symptoms can contribute to the BPD.
The anatomical link
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The dome-shaped diaphragm muscle is positioned directly above the gastrointestinal system. As the diaphragm contracts during inhalation, the muscle flattens, pulling downwards towards the abdominal content, this movement is known as diaphragm excursion. The reverse occurs during passive exhalation, creating a compression/relaxation cycle influencing digestion and the GI system. |
This blog post looks at current evidence to support breathing intervention in the management of four GI conditions we commonly see at Breathing Works.
1. IRRITABLE BOWEL SYNDROME (IBS)
Individuals with a diagnosis of IBS may benefit from learning how to breath diaphragmatically for 2 reasons:
- The mechanical pumping action of the diaphragm moving up and down above the intestinal organs works to have a ‘massaging’ effect, promoting peristaltic motion. Therefore, if the individual has reduced diaphragm excursion, peristaltic function may be impaired leading to symptoms such as constipation and bloating. The reverse relationship can also occur where other IBS symptoms such as abdominal pain and cramping can lead to protective abdominal bracing where the individual holds increased abdominal muscle tone, creating resistance for the diaphragm to descend against. The result is often a compensatory upper chest breathing pattern.
- Diaphragmatic breathing facilitates the activation of the parasympathetic nervous system (PSNS), the bodies “rest and digest” response. IBS is commonly seen alongside other chronic conditions including, chronic pain and anxiety (Bordoni & Morabito, 2018), furthermore chronically stressed or anxious patients will often present with a BPD and reduced diaphragm excursion. Therefore, breathing retraining can help manage their anxiety AND enhance their digestive function through the upregulation of the PSNS, helping to reduce IBS related symptoms.
Respiratory system and IBS links – the Gut-Lung axis
Much is still not understood about the Gut-Lung axis with many gut and lung bacteria thought to ‘cross talk’ and be important in the development of asthma, cystic fibrosis and IBS disorders (Enaud et al, 2020). Meta analysis of recent research has confirmed that asthmatics have twice the risk of having IBS, and patients with IBS have the twice the risk of having asthma (Deshmukh et al., 2019), furthermore recent mendelian randomisation also supported these findings showing that childhood asthma does increase the risk of developing GORD, peptic ulcer disease and IBS (Freuer et al 2022).
Evidence based treatment for IBS
Yoga which commonly involves deep breathing and stretching - has been shown to reduce symptoms of IBS and is as effective as a low- FODMAP diet (Schumann et al., 2018). Furthermore, constipation based IBS had been shown to improve with 6 weeks of specific slow deep breathing exercises with reduced constipation compared to the control group (Liu et al, 2022).
2. GASTROESOPHAGEAL REFLUX DISORDER (GORD)
The bodies anti-reflux barriers include two "sphincter" mechanisms: the lower esophageal sphincter (LES), reinforced by the crural diaphragm that functions as part of the external sphincter. The main role of this valve mechanism is to create a high-pressure zone (15-30 mmHg above intragastric pressures), to prevent the reflux of gastric content. Weakness of the diaphragm can therefore be one of the predisposing factors of GORD.
Evidence based treatment for GORD
Retraining breathing patterns and strengthening the diaphragm can play a role in the management of GORD.
Halland et al. (2021) found diaphragmatic breathing reduced the number of post-prandial reflux events compared to controls. Similarly, Ahmadi et al. (2021) found DB improved LES pressure and quality of life in patients with moderate to severe GORD.
Inspiratory muscle training (IMT), focused on strengthening the diaphragm has also been found to reduce symptoms of GORD via improving esophagogastric junction pressure and function of the LES (Fonseca et al., 2014; Nobre e Souza et al., 2013).
3. RUMINATION SYNDROME
Rumination syndrome involves the effortless regurgitation of recently ingested foods and fluids. Behavioural interventions, including diaphragmatic breathing have the greatest evidence base for treatment of Rumination Syndrome (Sasegbon et al., 2022).
It has been found, patients with rumination syndrome subconsciously and habitually contract their intercostal and anterior abdominal muscles, which along with relaxation of the LES leads to reversal of the esophagogastric pressure gradient leading to rumination (Barba et al., 2015; Sasegbon et al., 2022).
A study by Halland et al. (2016) showed diaphragmatic breathing significantly reduced the frequency of regurgitation, by increasing the pressure at the oesophagogastric junction and reducing intragastric pressures by disrupting the postprandial abdominal contractions.
4. SUPRAGASTRIC BELCHING (SGB)
Excessive belching can be classified as gastric belching (gas refluxed from the stomach), or supragastric belching (gas from the oesophagus, which has not entered the stomach). SGB is a learned and self induced behavioural phenomenon with no organic cause (Popa et al., 2022). Psychological factors including stress and anxiety tend to worsen symptoms. There is also a bidirectional relationship between SGB and GORD.
The literature supports the use of diaphragmatic breathing in the treatment of SGB. Among GORD patients who exhibited a dominant symptom of SGB, 80% of participants receiving diaphragmatic breathing training saw reductions in belching frequency compared to 19% in the control group (Ong et al., 2018). Similarly, Punkkinen et al. (2022) also found after 5 sessions of diaphragmatic breathing exercises, the frequency and severity of SGB decreased in the treatment group compared to the control group at 6 month follow up.
To learn more, or to be seen by any of our team contact us on bw@breathingworks.com, or phone 09 522 1122.
References:
Ahmadi, M., Amiri, M., Rezaeian, T., Abdollahi, I., Rezadoost, A. M., Sohrabi, M., & Bakhshi, E. (2021). Different Effects of Aerobic Exercise and Diaphragmatic Breathing on Lower Esophageal Sphincter Pressure and Quality of Life in Patients with Reflux: A Comparative Study. Middle East J Dig Dis, 13(1), 61-66.
Barba, E., Burri, E., Accarino, A., Malagelada, C., Rodriguez-Urrutia, A., Soldevilla, A., Malagelada, J.-R., & Azpiroz, F. (2015). Biofeedback-guided control of abdominothoracic muscular activity reduces regurgitation episodes in patients with rumination. Clinical Gastroenterology and Hepatology, 13(1), 100-106. e101.
Deshmukh, F., Vasudevan, A., & Mengalie, E. (2019). Association between irritable bowel syndrome and asthma: a meta-analysis and systematic review. Ann Gastroenterol, 32(6), 570-577.
Enaud R, Prevel R, Ciarlo E, Beaufils F, Wieërs G, Guery B and Delhaes L (2020) The Gut-Lung Axis in Health and Respiratory Diseases: A Place for Inter-Organ and Inter-Kingdom Crosstalks. Front. Cell. Infect. Microbiol. 10:9. doi: 10.3389/fcimb.2020.00009
Fonseca, E. S. d., Bezerra, P. C., Farias, M. d. S. Q., Bastos, V. P. D., Nogueira, A. d. N. C., & Souza, M. Â. N. (2014). Effects of inspiratory muscle training in patients with gastroesophageal reflux disease. European Respiratory Journal, 44(Suppl 58), P590.
Freuer, D., Linseisen, J. & Meisinger, C. Asthma and the risk of gastrointestinal disorders: a Mendelian randomization study. BMC Med 20, 82 (2022). https://doi.org/10.1186/s12916-022-02283-7
Halland, M., Bharucha, A. E., Crowell, M. D., Ravi, K., & Katzka, D. A. (2021). Effects of Diaphragmatic Breathing on the Pathophysiology and Treatment of Upright Gastroesophageal Reflux: A Randomized Controlled Trial. Am J Gastroenterol, 116(1), 86-94.
Halland, M., Parthasarathy, G., Bharucha, A. E., & Katzka, D. A. (2016). Diaphragmatic breathing for rumination syndrome: efficacy and mechanisms of action. Neurogastroenterology & Motility, 28(3), 384-391.
Liu J, Lv C, Wang W, Huang Y, Wang B, Tian J, Sun C, Yu Y. Slow, deep breathing intervention improved symptoms and altered rectal sensitivity in patients with constipation-predominant irritable bowel syndrome. Front Neurosci. 2022 Nov 4;16:1034547. doi: 10.3389/fnins.2022.1034547. PMID: 36408402; PMCID: PMC9673479.
Nobre e Souza, M., Lima, M. J., Martins, G. B., Nobre, R. A., Souza, M. H., de Oliveira, R. B., & dos Santos, A. A. (2013). Inspiratory muscle training improves antireflux barrier in GERD patients. Am J Physiol Gastrointest Liver Physiol, 305(11), G862-867.
Ong, A. M., Chua, L. T., Khor, C. J., Asokkumar, R., V, S. O. N., & Wang, Y. T. (2018). Diaphragmatic Breathing Reduces Belching and Proton Pump Inhibitor Refractory Gastroesophageal Reflux Symptoms. Clin Gastroenterol Hepatol, 16(3), 407-416.e402.
Popa, S. L., Surdea-Blaga, T., David, L., Stanculete, M. F., Picos, A., Dumitrascu, D. L., Chiarioni, G., Ismaiel, A., & Dumitrascu, D. I. (2022). Supragastric belching: Pathogenesis, diagnostic issues and treatment. Saudi J Gastroenterol, 28(3), 168-174
Punkkinen, J., Nyyssönen, M., Walamies, M., Roine, R., Sintonen, H., Koskenpato, J., Haakana, R., & Arkkila, P. (2022). Behavioral therapy is superior to follow-up without intervention in patients with supragastric belching-A randomized study. Neurogastroenterol Motil, 34(2), e14171.
Sasegbon, A., Hasan, S. S., Disney, B. R., & Vasant, D. H. (2022). Rumination syndrome: pathophysiology, diagnosis and practical management. Frontline Gastroenterology, 13(5), 440-446.
Schumann D, Langhorst J, Dobos G, Cramer H. Randomised clinical trial: yoga vs a low-FODMAP diet in patients with irritable bowel syndrome. Aliment Pharmacol Ther. 2018 Jan;47(2):203-211. doi: 10.1111/apt.14400. Epub 2017 Oct 27. PMID: 29076171.