Introduction
Gastroesophageal reflux disease (GERD) is a concerning chronic disorder of the digestive system with worldwide prevalence and a tendency to affect a growing population. Although GERD rates vary among different countries, it is currently one of the most common health conditions within the clinical practice (Diniz et al., 2014). This health condition is accompanied by a wide range of symptoms that substantively deteriorate the health-related quality of life. Conventional treatment of GERD consists of medication therapy and, in severe cases, surgical intervention. Nonetheless, medication and surgical procedures may result in insufficient efficiency, drug resistance or side and adverse effects (Bjørnæs et al., 2019). Mentioned risks and disadvantages emphasise the necessity of alternative or supplementary therapy methods, and osteopathic manipulative treatment (OMT) is considered a reasonable and valuable approach to improving GERD-associated symptoms and patients’ quality of life.
To date, few investigations have been conducted in order to explore the efficiency of OMT in patients with GERD. However, several variously designed studies were carried out and reported statistically significant positive effects of osteopathic therapy in treating GERD symptoms and enhancing the life’s quality of patients (Bjørnæs et al., 2019; Bjørnæs et al., 2017; Bjørnæs et al., 2016; Diniz et al., 2014; Eguaras et al., 2019; Goyal et al., 2019; Lynen et al., 2022). Research has shown that osteopathic interventions appear to be beneficial in decreasing GERD symptoms in the long term; therefore, OMT may be an additional or alternative treatment in patients suffering from this health disorder.
Overview of GERD
GERD is a multisymptom disorder conditioned by stomach contents with acidic juices frequently flowing from the stomach back into the oesophagus. The disease can be categorized into erosive or non-erosive GERD and manifests in a wide range of symptoms divided into three groups: typical, atypical, and extraesophageal (Goyal et al., 2019). The most predominant typical symptoms include heartburn, the taste of acid in the mouth, and painful feelings in the chest, epigastric and thoracic areas (Bjørnæs et al., 2019). Extraesophageal and atypical symptoms that may accompany GERD are epigastric fullness, dental erosion, burping, wheezing, cough, asthma, laryngitis and sinusitis (Eguaras et al., 2019; Goyal et al., 2019). Secondary symptoms may include indigestion, vomiting and sleeping problems (Bjørnæs et al., 2019). Consequently, GERD interferes with and compromises patients’ well-being and life’s quality since it requires modification of eating habits and sleeping patterns due to the lasting recurrent symptoms that may limit patients’ daily activities (Diniz et al., 2014; Goyal et al., 2019). The disease’s chronic nature presupposes that GERD’s adverse effects can persist for the long term.
There is no primary determined cause of the GERD occurrence, but several factors contribute to this disorder. The possible key factor for the GERD development is a failure or excessive relaxation of the lower esophageal sphincter (LES) (Bjørnæs et al., 2016; Eguaras et al., 2019). For instance, in normal conditions, LES allows the passing of food and fluids into the stomach and prevents stomach contents from rising up back into the oesophagus. Nevertheless, when the functioning of LES is disordered, stomach acids and contents move backwards and at high frequency resulting in GERD. Besides concerning symptoms, GERD may be accompanied by various comorbidities: the increasing influence of stomach acid potentially results in the destruction of mucosal defence mechanisms. The mucosa damage leads to erosions, inflammations and ulcerations (Bjørnæs et al., 2016). Thus, it is crucial to identify GERD in the early stages and select the appropriate treatment accordingly to the severity of the disorder.
Treatment Options
The treatment methods for GERD have significantly developed over the past several decades, yet considerable disadvantages are still prevalent. Back in the time, the common medication therapy included antacids frequently supplemented with anticholinergic agents in order to “reduce the output of gastric acid” (Bjørnæs et al., 2016, p. 1). The following improvement implied the pharmacological treatment consisted of histamine H2-receptor antagonists (Bjørnæs et al., 2016). Most of the reviewed literature emphasises a modern medication approach to treating GERD that occurs with proton pump inhibitors (PPI) (Bjørnæs et al., 2019; c., 2017; Bjørnæs et al., 2016; Eguaras et al., 2019; Goyal et al., 2019; Larsen et al., 2019; Lynen et al., 2022). The purpose of PPI medication is to increase the pH of stomach juice and “thus cure the esophagitis” (Larsen et al., 2019, p. 76). Research has shown that PPI is the most prevalent and standard treatment of GERD.
Nonetheless, several weaknesses of this pharmaceutical approach were identified throughout various studies. Bjørnæs et al. (2017) claim that PPI treatment is “not curative and requires continuous medication” and demands lifestyle changes (p. 1). Moreover, long-term PPI therapy does not cure GERD but may only contribute to symptoms’ relief and is associated with the risk of adverse events and low response rates (Larsen et al., 2019; Lynen et al., 2022; Malfertheiner et al., 2017). Thus, modern medication in treating GERD appears insufficient and related to substantial disadvantages.
Another option implies surgical intervention and appears to be the only approved efficient and curative treatment of GERD. This surgery is called fundoplication, performed laparoscopically and involves that “the gastric fundus of the stomach is wrapped or plicate around the lower end of the oesophagus” (Bjørnæs et al., 2017, p. 1). The purpose of the surgical procedure is to reinforce the LES’s closing function (Bjørnæs et al., 2017). However, the literature review has shown that this intervention is associated with several crucial flaws: irreversibility, failure to achieve expected outcomes and the risk of severe adverse effects (Bjørnæs et al., 2019; Bjørnæs et al., 2017; Bjørnæs et al., 2016; Diniz et al., 2014; Larsen et al., 2019). Thereby, the potential mentioned disadvantages of medication and surgical treatment emphasise the necessity to apply other treatment strategies. Literature review reveals that OMT has shown its efficacy and may be used as an alternative or additional therapy to traditional approaches.
Osteopathic Techniques in GERD Treatment
In the osteopathic treatment of GERD, a wide range of techniques may be applied, though most of them should imply diaphragm and visceral manipulative interventions. Considering that one of the probable key reasons contributing to the development of GERD is “insufficient closing” of LES, the primary goal of OMT is to promote the complete closing of this sphincter (Bjørnæs et al., 2016, p. 1). Recent research has shown that the osteopathic manipulative intervention on the diaphragm “produces a positive increment in the LES region soon after its performance” (da Silva et al., 2013, p. 451). However, the study of da Silva et al. (2013) included the OMT consisted merely of a diaphragm stretching technique accompanied by breathing exercises. In regard to GERD causes and symptoms, visceral techniques supported by diaphragm techniques should be applied.
Current research has shown that most of the studies were carried out with a combination of different techniques. Several studies are based on the same OMT, including techniques “that might influence LES and increasing the effect on the sphincter” (Bjørnæs et al., 2016, p. 2). Mentioned OMT consists of four visceral techniques that are expected to stimulate the LES closing mechanism ((Bjørnæs et al., 2019; Bjørnæs et al., 2017; Bjørnæs et al., 2016). The osteopathic treatment consisted of the following techniques: “traction of the cardia, mobilization of the diaphragm and thoracic spine and posture correction” (Bjørnæs et al., 2016, p. 2). They all presupposed the patient’s lying position, the operator’s intervention in the patient’s epigastric area and appropriate breathing techniques.
Another general osteopathic approach in managing GERB is a visceral osteopathic technique. The technique’s performance involves a patient in a sitting position, an osteopath behind the patient, and the operator’s hands placed on an epigastric area of the patient. When the patient is breathing in and flexing, the practitioner is deepening hands on the area; when the patient is exhaling and straightening, the spine operator pushes their hands caudally (Diniz et al., 2014; Eguaras et al., 2019; Goyal et al., 2019). A technique called sphincter normalization by recoil was applied in two studies (Diniz et al., 2014; Goyal et al., 2019). The purpose of this technique is “to relax the smooth muscle of the sphincters of areas considered as such” (Diniz et al., 2014, p. 184). The balancing of the diaphragms technique is designed to restore the harmonic and fluidic function between the diaphragms. This technique was also used at least in two research (Diniz et al., 2014; Goyal et al., 2019). Thus, a number of different visceral and diaphragm osteopathic interventions and their combinations were used to treat GERD.
Patient Response to OMT
Osteopathic therapy in GERD treatment appears to be a natural, sparing and restoring treatment option that promotes significant improvement and positive effects. Several differently designed studies were examined, and the results were compared. Two reports exploring the individual cases of OMT utilization with techniques directed at the oesophagus and diaphragm in a patient suffering from GERD showed that osteopathic treatment improved symptoms (Diniz et al., 2014; Goyal et al., 2019). Interestingly. that the same results were obtained in the studies with larger samples (Bjørnæs et al., 2019; Bjørnæs et al., 2017; Bjørnæs et al., 2016; da Silva et al., 2013; Eguaras et al., 2019; vzc; Lynen et al., 2022). However, further research is required to conduct a more specified study and reinforce the findings through additional investigations.
The number of interventions among the studies ranged from three to twelve, with a diverse follow-up system. However, Larsen et al. (2019) investigated the minimum efficacy dose (MED) of OMT in the treatment of GERD and concluded that the estimated MED was three sessions with 48 hours between treatments. The study of Bjørnæs et al. (2019) was shaped accordingly to MED findings. The osteopathic intervention was carried out within three sessions with two-days intervals in between, and a follow-up period was one year. This study achieved outstanding results since almost 47% of the patients had no related GERD symptoms one year after the intervention (Bjørnæs et al., 2019). Such duration of lasting benefits underscores the effectiveness of this treatment approach.
Considering the efficacy of OMT and the positive patient response, it may be concluded that anti-reflux OMT significantly decreases the GERD symptoms and the need and use of PPI. Another outstanding finding related to the efficiency of OMT is that in a recent study no differences in GERD symptoms were identified between the OMT group and those who additionally continued medication intake (Bjørnæs et al., 2016). According to Lynen et al. (2022), besides positive improvement in GERD symptoms, secondary outcomes of the OMT in treating GERD include improved life quality and patients’ well-being. Thereby, existent literature reinforces the effectiveness of osteopathic treatment in patients with GERD and provides satisfactory results, evidencing the improved health outcomes.
Conclusion
Literature research on the topic of the effectiveness of OMT in patients suffering from GERD has shown that such a treatment approach is appropriate as a supplementary or alternative treatment. Patients with GERD are forced to modify their lifestyle and experience lower life quality, poor health conditions and a lack of overall well-being. Thus, the topic is highly concerning, and beneficial treatment approaches should be developed. Traditional pharmaceutical therapy is associated with several disadvantages that include a low response rate to the prescribed medication, resistance to the drugs and severe side effects. PPI use does not cure the disease itself but only decreases the manifestation of symptoms. Moreover, since GERD is a chronic disorder, medication treatment is expected to be long-term. In the case of discontinuation of therapy, there is a severe risk of recurrence of all symptoms. Fundoplication also has several drawbacks involving adverse events, irreversibility and failure to achieve the expected outcomes.
On the other hand, OMT is a favouring approach with no adverse effects registered and identified as potentially positively affecting GERD-associated symptoms. Current literature research has revealed several studies that reinforce the effectiveness of osteopathic treatment in patients with GERD. Compared to continuous medication treatment and the complexity of the surgical intervention, OMT has shown beneficial health outcomes in the long term and after a low number of sessions.
References
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