What are the recommended swallowing exercises for patients with Gastroesophageal Reflux Disease (GERD) and low esophageal motility?

Swallowing Exercises for GERD and Low Esophageal Motility

The Shaker head lift exercise is strongly recommended as the primary swallowing exercise for patients with GERD and low esophageal motility, as it has the strongest evidence for improving upper esophageal sphincter function and reducing aspiration risk. 1

Evidence-Based Swallowing Exercises

Primary Recommended Exercises

1. Shaker Head Lift Exercise

   • Description: Consists of two components:
     • Isometric phase: Three head lifts held for 60 seconds with 60-second rest periods between each lift
     • Isokinetic phase: 30 consecutive head lifts without holding
   • Benefits: Improves strength and endurance of suprahyoid muscles, increases upper esophageal sphincter opening, reduces residues and aspiration events 1
   • Evidence Grade: A (strong consensus, 100% agreement) 1

2. Bridge Swallowing Exercise

   • Description: Dry swallowing in the bridge (hip lift) position, performed 10 times daily for 4 weeks
   • Benefits: Strengthens esophageal contractions, increases lower esophageal sphincter pressure, and improves GERD symptoms as measured by FSSG scores 2, 3
   • Evidence: Recent studies show significant improvement in GERD symptoms without adverse events 3

3. Chin-Down Maneuver

   • Description: Patient brings chin to chest and maintains this posture throughout the swallow
   • Benefits: Expands vallecular recesses, improves tongue base approximation to pharyngeal wall, narrows entrance to laryngeal vestibule, reduces aspiration risk by approximately 50% 1
   • Evidence Grade: B (strong consensus, 94% agreement) 1

Additional Beneficial Exercises

1. Expiratory Muscle Strength Training (EMST)

   • Description: Exhaling forcefully into a mouthpiece with a one-way valve that blocks airflow until sufficient expiratory pressure is produced
   • Benefits: Strengthens expiratory and submental muscles, improves swallowing safety 1
   • Recommended for: Patients with motor-neuron disorders and Parkinson's disease, but may benefit GERD patients with dysmotility 1

2. Tongue Strength Training

   • Description: Exercises to improve tongue strength and control
   • Benefits: Improves bolus formation, control, and propulsion; reduces vallecular residues and improves swallowing safety 1
   • Relevance: Particularly important as reduced tongue strength is a risk factor for aspiration 1

Comprehensive Management Approach

Assessment Before Starting Exercises

Prior to initiating swallowing therapy, patients should undergo:

• Clinical swallowing examination or preferably instrumental testing (VFSS, FEES) 1
• Regular re-evaluation of treatment effects 1

Complementary Management Strategies

1. Diaphragmatic Breathing

   • Helps strengthen the crural diaphragm, which is part of the anti-reflux barrier 1
   • Facilitates understanding of the role of the diaphragm in GERD management

2. Lifestyle Modifications

   • Elevate head of bed for patients with hiatal hernia and/or nighttime symptoms 1
   • Avoid meals within 3 hours of bedtime 1
   • Weight management to improve intra-abdominal to intra-thoracic pressure gradient 1

3. Medication Management

   • PPI therapy remains the standard pharmaceutical treatment for GERD 1, 4
   • For patients with partial response to PPI, surgical or emerging endoscopic therapies may be considered 4

Important Considerations and Pitfalls

1. Exercise Frequency and Duration

   • Perform weekly or two-weekly sessions until symptomatic improvement is achieved 1
   • Systematic and sufficiently frequent swallowing therapy is recommended 1

2. Potential Challenges

   • Patients with severe esophageal dysmotility may require tailored approaches 5
   • Some patients may need additional interventions beyond exercises, such as PPI therapy or surgical options 4

3. Monitoring Progress

   • Regular reassessment of swallowing function is essential 1
   • FSSG questionnaire can be used to track improvement in GERD symptoms 3

By implementing these evidence-based swallowing exercises, particularly the Shaker head lift and bridge swallowing exercises, patients with GERD and low esophageal motility can experience significant improvement in symptoms and function, potentially reducing their dependence on medication and improving their quality of life.