**4. Hiatus hernia: the root cause of reflux**

Reflux of stomach contents can allow the body's own acids to attack the vulnerable soft membranes and tissues in the oesophagus, pharynx, larynx, throat, vocal cords, tongue, and more. Refluxed stomach acids can worsen a pre-existing condition of esophagitis.

The underlying cause of reflux is a muscular weakness in and around the diaphragm where the oesophagus passes through it; this is a Hiatal hernia (HH). Medication will not address this, whereas surgical intervention will, and we will describe later how a new, non-invasive neuromuscular treatment will allow these delinquent muscles to be strengthened and rebuilt as an alternative to surgical intervention.

Many people suffer from reflux but were never diagnosed with HH in earlier internal examinations. The condition is difficult to diagnose with certainty, a sliding HH (90% of all cases) [3, 4] is by its nature intermittent and does not always exhibit at the time of examination. Cuffing of the abdomen to try to provoke herniation is sometimes required to make a diagnosis more certain, especially when using hypopharynx-oesophageal X-ray. It is also the case that the main reason for an internal examination using gastroscopy with biopsy will have been to rule out other serious conditions; not to confirm a HH. Continual pH-monitoring is also used to measure prevalence of acidic reflux but does not aim to identify its cause.

Scientific studies [16–18] have looked at treatment of HH. When recruiting patients to these studies the researchers have always distinguished between those with the symptoms of a HH and a confirmed diagnosis; and those with the symptoms but no confirmation. In these studies, these two groups have the same symptoms, treatment and positive results. In reality there is no difference between the two groups.

In an IQoro customer questionnaire analysis [19] in June 2020 directed at people in Sweden and the UK, self-treating the symptoms of reflux with a neuromuscular device, they were asked how many knew that they had a HH. Most had reflux symptoms and were asked if they had a confirmed diagnosis. More than 2 700 responded: 37% had a confirmation of the condition after examination, and 37% suspected a Hiatal hernia or did not know and had no confirmed diagnosis. In other words, less than 40% of a cohort that probably had a HH had had it confirmed by examination. To add to this uncertainty people were 25% more likely to have had confirmed diagnosis in the UK than in Sweden; suggesting that diagnosis is difficult or not prioritised. Given the paucity of options to treat such a condition it perhaps not surprising that its diagnosis is not deemed important.

#### **4.1 What is hiatus hernia?**

Hiatus hernia is not a disease, it is a condition that allows reflux to occur.

The diaphragm is the thin but powerful muscle below the ribcage that divides the chest cavity – where the heart and lungs reside, from the stomach cavity. It is attached to the base of the sternum (breastbone) and follows the base of the ribcage and ends at the spine.

The aperture where the oesophagus passes through the diaphragm is called the Hiatus canal, here the diaphragm muscle grips around the oesophagus and ensures that mouth of the stomach cannot normally intrude upwards into the chest cavity. When the stomach intrudes at other times, in an uncontrolled and undesired way, stomach acids can be refluxed into the oesophagus. During the day, gravity aids the effect of holding the stomach down below the diaphragm, when lying down this effect is not present and is a factor in increased acidic reflux at night.

The valve at the top or mouth of the stomach is called the Lower Oesophageal Sphincter (LES), its job is to remain tightly closed except when swallowing and admitting food and drink into the stomach. An exception to this is when we need to belch, or when we are ill and need to vomit. In these cases, the neck of the stomach slides up through the diaphragm to allow the LES to open upwards to discharge gases or liquids. In its natural position below the diaphragm, it cannot do this. The LES is normally only able to flex open in a downward direction and permit one-way traffic into the stomach. The cause of this uncontrolled intrusion of the neck of the stomach is that the muscle gripping the oesophagus in the Hiatus canal is weakened or ruptured. When held in place below the diaphragm the LES cannot open upwards and allow stomach contents into the oesophagus. The underlying cause of reflux is therefore always a HH.

All babies are born with part of their stomach in the chest cavity; this is normal and usually does not cause a problem. Some, especially those who were born prematurely or in difficult circumstances, may exhibit the symptoms of reflux and projectile vomiting. They may also reject oral feeding; this is due to immaturity of the musculature in the digestive system. At the age of around 6 months the baby's oesophagus starts to grow and lengthen allowing the stomach to descend, and at around 12 months the stomach usually has achieved its correct position below the diaphragm.

*Introducing an Innovative Oral Neuromuscular Treatment of the Underlying Reason… DOI: http://dx.doi.org/10.5772/intechopen.96773*

### **5. The weakened diaphragm muscle can be trained like any other**

If reflux is allowed by a HH, and this is only a muscle weakness, then why do we treat with medication or by surgical intervention?

If a patient presented with an arm that had atrophied because it had been in a plaster cast for three months, we would not hesitate to recommend a rehab programme based on weights and exercises – and we would not be surprised when it was 100% successful either.

However, there are key differences between the arm muscles and the muscles that need strengthening in the diaphragm.

The arm is made up of skeletally striated muscles that can be commanded by the individual to flex and can therefore be consciously exercised, whereas many of the muscles in the swallowing chain cannot.

Some muscles in the swallowing chain are smooth muscle which are controlled only by the autonomic system - through different command pathways to our voluntary systems.

So, the answer to our question why doctors do not get patients to train this muscle, is that they think that it cannot be done. A patient can be asked to do sit-ups, or lift weights, but not to shut his epiglottis tightly, make peristaltic waves down his oesophagus or squeeze the muscles around his Hiatal canal tightly. Yet it is just this last exercise which is required. The muscles that we need to exercise include these smooth muscles controlled by the body's autonomic system, not only the striated muscles that we can control voluntarily. But we can successfully exercise this musculature back to full strength if we can stimulate the brain stem to issue commands to these muscles. This is the basis of neuromuscular training: the physical exercise stimulates the brain to activate and strengthen the affected smooth muscle.

#### **6. IQoro**

IQoro (**Figure 2**) is a simple hand-held neuromuscular treatment device consisting of a curved plastic plate which is inserted pre-dentally by the patient – that is, inside the lips and in front of the teeth. The user grips the handle that protrudes out through his lips, seals his lips and then pulls forward strongly. The partial vacuum thus produced thus triggers the neurological and muscular effects described below. It exercises the muscles in the orofacial and swallowing processes

**Figure 2.** *The IQoro neuromuscular training device.*

#### **Figure 3.**

*(A, B). IQoro training regime. (A) the IQoro is inserted pre-dentally, behind closed lips. (B) the patient presses his lips firmly together whilst pulling straight forward strongly for 5–10 seconds, and does this 3 times with 3 seconds rest between each pull. These sessions are performed three times per day, preferably before mealtimes. Video 1 [20].*

from the face, lips, mouth, throat, airways and oesophagus down to the diaphragm and stomach.

By closing your lips tightly against the handle and pulling the device forward, a lowpressure is created in the oral cavity making the tongue rise and retract and seal against the anterior palatal arch and the soft palate. Further, the naso-pharyngeal and upper airways close, the larynx rises, the epiglottis shuts, and the Upper Oesophageal Sphincter (UES) opens. In other words, the exercise action provokes the mechanical components of a swallow. The UES is also known as the Posterior Oesophageal Sphincter (PES).

These physical movements alone are not enough to strengthen the weakened musculature in the diaphragm; indeed the muscles that need to be targeted to repair the hernia lie around and outside the oesophagus. No amount of low pressure flexing the oesophagus can have a direct effect on the muscles in the hiatal canal around the oesophagus.

Instead, they are exercised by proxy, the muscle and organ movements described above promote intense stimuli in the afferent Cranial Nerves to the brainstem. Here they provoke a sensory motoric reflex arc that causes messages to be issued through the efferent, motor nerves to the muscles in the swallowing chain. Crucially, this includes the smooth musculature that can only be commanded by the autonomic system.

In this way, for example, the long outer muscles that run down along the side of the oesophagus and fasten below the diaphragm, by the hiatal canal, are activated. As they flex, they pull on the weakened musculature around the hiatal canal and this musculature is exercised and strengthened.

The training regime (**Figure 3** A, B; Video 1) was developed during research studies; optimal training is three such pulls, each of 10 seconds' duration, and repeated three times per day, totally 90 seconds per day. Some positive effect on reflux symptoms is often noticed within the first month, and more than 60% of respondents reported improvement within 5 months [19, 20].

#### **7. The neurology of the swallowing process**

Understanding the neurology a little more deeply is therefore key for those who wish to understand neuromuscular training more fully.

*Introducing an Innovative Oral Neuromuscular Treatment of the Underlying Reason… DOI: http://dx.doi.org/10.5772/intechopen.96773*

The process of transmitting food and drink into the stomach is called the swallowing process, this also includes the process by which food and drink are held in the stomach and not refluxed. Hence a HH disrupts a normal swallowing process.

When food is to be eaten it is first processed using the voluntary muscles in the jaw, lips and tongue. As the bolus is pushed back to the pharynx by the action of the tongue base rising and retracting, the voluntary part of the process ends; the rest is reflexive.

Four sensory Cranial Nerves (*CN*) are primarily involved in the swallowing process. Stimulation of the *CN (V) Trigeminus* in the lips is the first step. In short order thereafter, the *CN (IX) Glossopharyngeus* and *CN (X) Vagus* nerves are also triggered, and then in turn the *CN (V) Trigeminus and CN (VII) Facialis* nerve too in the soft palate and anterior palate (**Figure 4**).

In the brain stem we find the *Nucleus Tractus Solitarius* (NTS), the afferent nucleus. The NTS is the core that gathers all incoming sensory signals from the lips, oral cavity and pharynx via the afferent nerve pathways, and transmits them either to the brain's cortex or directly to the network-like system in the brain stem called the *Formatio Reticularis* (FR). The FR not only controls the swallowing process, but also the respiratory and swallowing processes, cough reflex, orofacial and postural control, vomiting, bowel and bladder evacuation, these are all indivisibly interlinked at the neurological level, where the *Formatio Reticularis* plays a central role in governing all the muscles involved in these functions.

The three swallowing centres in the brain stem are triggered in the following sequence. The first swallowing centre interprets that something is to be swallowed, and this instruction is sent to the second swallowing centre.

The second swallowing centre transmits signals to the muscles via the motor nerves – the downward-transmitting efferent nerve pathways. Here, there is a preprogrammed 'go/no-go' decision: 'swallow' or 'do not swallow' - a so-called stereotypical muscle response. When something is to be swallowed the command is first sent to the *Nucleus Ambiguus* (NA) an efferent nucleus which, in its turn, sends the instruction to swallow to the major components of the swallowing musculature via the motor, efferent nerve pathways to the skeletally striated muscles. Concurrently, impulses are also sent to the third swallowing centre.

**Figure 4.** *Cranial nerves and reflex points in the oral cavity.*

The five motor nerves that are important for swallowing are: *CN Trigeminus (V)*, *CN Facialis (VII)*, *CN Glossopharyngeus (IX)*, *CN Vagus (X)* and *CN Hypoglossus (XII)*. The first four are both sensory (afferent) and motor (efferent) nerve pathways.

The third swallowing centre transmits information to the *Nucleus Dorsalis Nervi Vagi* (NDNV) an efferent nucleus, and then onwards to the smooth muscles including those in the oesophagus (**Figures 5** and **6**).

The three swallowing centres' interactions - from brain stem to muscles.

These signals are transmitted via efferent nerves that can be thought of as cables containing various fibres, motor neurons, to the muscles and glands. There are three different kinds of motor neurons that are important in the swallowing process.


#### **Figure 5.**

*The sensory-motor reflex arc (level 1). The three swallowing centres' interactions - from brain stem to muscles.*

#### **Figure 6.**

*The sensory-motor reflex arc (level 1–3). The three swallowing centres´ interactions from: - the 2nd Centre to the striated muscles - the 3rd Centre to the smooth muscles.*

*Introducing an Innovative Oral Neuromuscular Treatment of the Underlying Reason… DOI: http://dx.doi.org/10.5772/intechopen.96773*

the mouth, chewing muscles, facial musculature, pharynx, larynx, oesophagus and diaphragm.

• The *General Visceral Efferent (GVE)* motor neurons act via *CN Facialis (VII)* and *CN Glossopharyngeus (IX)* which transmit signals to the glands, blood vessels and smooth muscles in the pharynx, stomach and rectum.

The signal pathways from the above-named motor neurons are: *CN (V) Trigeminus* – signals via the SVE. *CN (VII) Facialis* – signals via the SVE and the GVE. *CN (IX) Glossopharyngeus* – signals via the SVE and GVE. *CN (X) Vagus* – signals via the SVE. *CN (XII) Hypoglossus* – signals via the GSE.

The sum of all the above signals initiates a pre-programmed cooperation between the 148 muscles that are involved in the transport of each food bite from the mouth down to the stomach. Controlled by these circuits and executed by these muscles. Breathing and postural control function are stimulated and strengthened, as are the tongue, soft palate and When using IQoro as a neuromuscular training device it triggers the sensory-motor reflex arc described earlier. This manifests itself in improvement in swallowing including the weakened diaphragm muscles that allow reflux, and then successively in other functions pharynx (**Figure 7**).

So, we have two effects of IQoro on the muscles. One is both neurological and physiological (the upper muscle chain from the lips to the upper part of the oesophagus) promoting movement, flexion and strengthening; and a second one, with only a neurological effect (the lower part of the oesophagus to the rectum).


#### **Figure 7.** *The three motor neuron fibres, their nerves and effect organ connections.*
