*5.1.1 Prevalence and symptoms*

Reflux-based diseases are thought to affect around 20% of the world's population [33, 34]. Reflux is a condition in which stomach acids sometimes bubble up from the stomach, through the esophagus, and into the throat, larynx, and pharynx. The effect of these acids is to cause the symptoms of [35]:


It should be noted that if some of the above symptoms are chronic, and especially if they do not respond to medication, they could be caused by cancer or other diseases [36], and this should be considered before diagnosing reflux as the sole cause.

Refluxing stomach acids is the underlying cause of several conditions: LPR, GERD (or GORD), Silent Reflux, IED, Dyspepsia, etc. These conditions are sometimes known by their full names: Laryngopharyngeal Reflux, Gastroesophageal Reflux Disease, and Intermittent Esophageal Dysphagia. These various conditions exhibit some or all of the symptoms listed above, they vary slightly but are all caused by the corrosive effect of the refluxed stomach acids.

#### *5.1.2 Cause of reflux*

These symptoms occur when stomach acids reflux into the esophagus. The normal position of the stomach and the LES - the valve at the mouth of the stomach - is below the diaphragm. The esophagus passes through the diaphragm muscle through an aperture called the hiatus canal. In functional anatomy the muscle grips tightly around the esophagus and holds the stomach down in its correct position. The LES behaves like a trapdoor in this position, swinging downwards to let food and drink into the stomach before closing again. The LES cannot open upwards to allow reflux. An exception to this is if we need to belch or vomit; then the LES intrudes through the diaphragm slightly into the chest cavity and can flap open upwards and allow stomach gases, liquids or solids to reflux.

A Hiatal hernia is a weakening in the muscle that grips around the esophagus where it passes through the diaphragm. When this occurs the mouth of the stomach and the LES can intrude in an unwanted and uncontrolled fashion and allow reflux to occur.

#### *5.1.3 Existing treatments for reflux-based diseases*

The treatment options for reflux-based diseases fall into two broad camps: reducing the symptoms, or addressing the underlying cause.

In the former category, symptom reduction can be achieved by lifestyle changes or medication. Changing poor living, smoking, drinking, eating and diet habits can improve the impact of reflux, but lifestyle changes have an inconclusive effect [37].

Many Over the Counter (OTC) medications have a base pH and address the problem of reflux by reducing the acidity of the stomach acids which are being refluxed. Although the unpleasant sensations of reflux are reduced, the harmful effects on the vulnerable esophagus and other organs continue. Long-term use of OTC medication is generally regarded to be free from harmful side effects.

Prescribed PPI medications act by inhibiting the amount and strength of the acids produced in the stomach. PPI medications have significant known side effects and hence long-term PPI usage is generally discouraged and several countries insist that clinicians perform a medication review before renewing PPI prescriptions. At least once per year is recommended in the UK [38]. PPI medication is usually not expensive in itself, but the costs of repeat Healthcare Professional (HCP) interventions build to a considerable amount when prescribed for rest-of-life.

PPI drugs belong to one of the safest medication groups, but some research suggests a list of unwanted side effects [39, 40] include increased risk of

#### *Introducing IQoro: A Clinically Effective Oral Neuromuscular Treatment for Dysphagia DOI: http://dx.doi.org/10.5772/intechopen.101144*

cardiovascular disease, osteoporosis, dementia, male infertility, diabetes, and increased vulnerability to severe covid19 infection.

In addition, harmful bacteria in the stomach like Helicobacter pylori (HP) that would not survive in normal circumstances, can thrive in the weakened acids after PPI treatment. These germs can enter the body and live in the digestive tract. After many years, they can cause sores, called ulcers, in the lining of the stomach or the upper part of the small intestine. For some people, an infection can lead to stomach cancer.

In the case of all medications, there is no expectation that the underlying cause of the reflux – the weakened diaphragm musculature [34, 41]– will be addressed, merely the severity of the reflux symptoms.

The muscular deficiency at the root of the problem can sometimes be remedied by a surgical operation [42] that re-wraps muscles in the hiatal canal around the esophagus, or a similar procedure. Clearly, addressing the underlying cause is preferable in many ways to long-term medication and IQoro, as presented here, offers a simple non-invasive alternative to a surgical operation.

#### *5.1.4 Existing treatments for dysphagia*

As discussed, patients with a dysfunctional swallow sometimes after stroke are often treated with compensatory treatments [5, 6]. These care pathways allow patients to live within the limitations of their conditions. Direct and successful treatment of the dysfunctional swallowing chain is to be preferred and is presented in this chapter.

#### *5.1.5 Treating the muscles*

If the cause of both dysphagia and reflux is known to be neuromuscular, why are the most common treatments medication or surgical intervention? It is easy to grasp the idea that rebuilding muscle strength will improve swallowing, and allow the muscles in the Hiatal canal to regain their ability to grip around the esophagus.

If a patient presented with an arm that had atrophied because it had been in a plaster cast for some weeks, we might expect a rehab program based on weights and exercises. However, the atrophied-arm parallel has an important disconnect. As we have explained earlier, there are key differences between the arm muscles and many of the muscles that are needed to ensure an effective swallow and to prevent LES intrusion through the diaphragm allowing reflux. 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 most of the muscles in the swallowing chain cannot, they are controlled and commanded through other nerve types and command systems. The paradox then is how to exercise muscles that cannot be commanded to flex.

## **6. IQoro**

#### **6.1 What is IQoro?**

IQoro (**Figure 1**) is a simple hand-held plastic device that is inserted predentally (inside the lips and in front of the teeth) by a patient and pulled forward against lip pressure to exercise the swallow. At the time of writing, July 2021, it has been used by more than 50,000 individuals and is used by healthcare professionals to treat patients in hospitals and other settings across several countries. It is a CE-marked Class 1 Medical device, internationally patented and costing around USD 150.
