Specialist article on swallowing
Reflux and heartburnWhat role swallowing plays
A burning sensation behind the breastbone, acid rising up, worse at night? Here you will learn how the entrance to the stomach, the diaphragm and swallowing work together to protect the oesophagus, which warning signs mean you should have reflux checked by a doctor, and what studies on breathing training have shown.
Does this sound familiar?
A burning behind the breastbone, and acid is only part of the story
What applies to you?
Tap whatever applies to you.
If several points apply, it is worth taking a closer look. Reflux is a condition that can be diagnosed by a doctor, and some signs should be seen in a practice promptly. You will also learn why swallowing and the diaphragm protect the oesophagus.
Warning signsWhat swallowing has to do with itThe key points at a glance
- Many people know occasional heartburn. Frequent symptoms can be reflux disease, and with warning signs such as difficulty swallowing, weight loss or bleeding, it belongs promptly in medical hands.
- The oesophagus protects itself in two ways. The entrance to the stomach and the diaphragm form a pressure barrier, and swallowing with saliva clears away acid that has flowed back. Acid blockers dampen the acid, but they do not change this double protection.
- The diaphragm is a muscle you can train. Small studies on breathing training show measurable effects on the barrier. In our view, this training belongs in the combined system of breathing, swallowing and head balance.
Video
Reflux and heartburn: causes and what you can do yourself
Das Video lädt erst nach dem Klick. Dann werden Daten an YouTube (Google) übertragen.
Fundamentals
Reflux, heartburn, reflux disease: three terms, one pathway
In everyday language, everything is called heartburn. To put things in context, it helps to keep the terms apart.
The oesophagus is a muscular tube that carries food from the throat to the stomach. If stomach contents flow back, this is called reflux, literally backflow. The sensation it can trigger is heartburn, a burning behind the breastbone, often with acid regurgitation.
of adults in Europe have reflux disease according to a review, defined for example as heartburn or acid regurgitation on at least one day per week1
was the same proportion in North America. Since 1995, the studies have shown an increase1
Whether reflux becomes a disease depends on frequency, severity and the consequences for the mucous membrane. This can be examined, for example with an endoscopy or 24-hour acid measurement. That is why this article begins with the signs for which you should not wait.
Getting it checked
Warning signs: when heartburn belongs in a practice
In its guideline, the American College of Gastroenterology lists alarm signs for which an endoscopy should be carried out as soon as possible. Chest pain is first checked at the heart2.
Difficulty swallowing
Food gets stuck behind the breastbone, or swallowing hurts.
Unintended weight loss
You are losing weight without wanting to.
Bleeding
Blood in vomit, coffee-ground-like vomit or black stools.
Repeated vomiting
You have to vomit repeatedly.
Anaemia
Tiredness and pallor, with a low iron or haemoglobin level in the blood count.
Chest pain
Pressure or pain in the chest can come from the heart and is checked there first.
With chest pain, shortness of breath or pain radiating into the arm, jaw or back, call the emergency number 112. The guideline also recommends an endoscopy if several risk factors for a change in the mucous membrane are present, known as Barrett’s oesophagus2. Whether this applies to you will be clarified by your GP practice or a gastroenterology practice.
Even without warning signs, it is worth having it checked if heartburn occurs several times a week over a period of weeks. Persistent reflux can inflame the mucous membrane, and inflammation detected early is easier to treat. Coughing, hoarseness or asthma can be related to reflux but have many other causes that should also be checked2.
Anatomy
The oesophagus has more than one closure
You often hear that the sphincter at the entrance to the stomach does not close properly. That falls short.
There is no ring muscle at the entrance to the stomach like the one at the anus. The lower sphincter is a zone of thickened muscle in the wall of the oesophagus, and it does not seal on its own. On its way to the stomach, the oesophagus passes through the diaphragm, whose muscular crura encircle it there like a sling. Together, the two form the anti-reflux barrier3.
Top: the entrance
At the transition from the throat to the oesophagus, the upper sphincter opens when you swallow and then closes again. It protects the throat and airways.
Middle: the diaphragmatic sling
Where the oesophagus passes through the diaphragm, its crura wrap around it. When you breathe in, they contract and reinforce the closure.
Bottom: the entrance to the stomach
The lower sphincter maintains a resting tension. When you swallow, it opens for the food and then closes again.
Reflux does not only occur when this barrier is constantly too weak. Many episodes of backflow happen in brief moments when the lower sphincter relaxes without a swallow. Added to this are the pressure in the abdomen, gastric emptying and a hiatus hernia. In a hiatus hernia, part of the stomach slides upwards through the gap in the diaphragm, and the two parts of the barrier move apart.
Reflux is not simply too much acid. What matters is whether the barrier holds and whether the oesophagus cleans itself again.Acid belongs in the stomach. It becomes a problem in the wrong place and for too long.
Diaphragm and pressure chamber
The diaphragm: breathing muscle and part of the closure
The diaphragm separates the chest and abdominal cavities. It therefore sits exactly at the point where it is decided whether stomach contents are pushed upwards.
The diaphragm is the most important breathing muscle. When you breathe in, it lowers; when you breathe out, it rises. At the same time, it forms the lid of a pressure chamber whose floor is the pelvic floor.
If the pressure in the abdomen rises, it also presses against the entrance to the stomach. The barrier then has to hold against it. How the diaphragm and pelvic floor work together in breathing is described in our article on pelvic floor training.
How strongly the pressure from below acts is shown by a measurement in 285 people in Chicago. The higher the body mass index and waist circumference, the higher the pressure in the stomach, and the more often the sphincter and diaphragmatic sling moved apart4. Whether this reverses with weight loss remained open.
Like a garden hose in a hand
Imagine a garden hose running through a loosely closed hand. The hand can additionally squeeze the hose when water pressure comes from below. If the hand opens or the hose slips out of it, everything depends on the hose itself. The diaphragmatic sling around the oesophagus works in a similar way.
Unlike the lower sphincter, the diaphragm is a skeletal muscle. You can partly control it voluntarily, and that is why it can be trained. A review from the Czech Republic describes the diaphragmatic crura as one of the main components of the anti-reflux barrier and sees breathing training as an option for selected patients3.
Swallowing
Why swallowing cleans the oesophagus
Even a good barrier lets something through now and then. How long the acid then stays on the mucous membrane is determined by swallowing.
You swallow many hundreds to a thousand times a day, most of them unnoticed. In the process, saliva enters the oesophagus, and a swallow triggers a wave that pushes the contents towards the stomach: peristalsis. How this cleaning takes place was measured in healthy people by a research group in Milwaukee5. More on the phases of swallowing in the article Swallowing and swallowing disorders.
Acid enters the oesophagus
In the experiment, 15 millilitres of dilute hydrochloric acid were introduced into the oesophagus.
The first wave clears the volume
One to two peristaltic waves pushed almost all of the liquid back into the stomach.
An acidic film remains
A small residue kept the pH in the oesophagus low.
Saliva neutralises the residue
With the following swallows, the pH rose step by step until it was normal again. When the saliva was suctioned from the mouth, this cleaning did not take place5.
Swallowing and saliva flow are linked. When healthy people sucked a peppermint lozenge, they produced six times as much saliva and swallowed almost twice as often6. In Tokyo, people with reflux symptoms produced less saliva, which also buffered acid less well, with 33 per group7. Whether this is cause or consequence is not shown by the study.
Saliva is an amplifier of the cleaning, not the cause of reflux.This is how the book “Trust the Triad” classifies it. Swallowing and saliva do not prevent backflow; they shorten the time during which acid acts on the mucous membrane.
Sleep
Heartburn at night: why it gets worse lying down
Many people affected know it: during the day it is fine, at night it burns. There are good physiological reasons for this.
According to a review, reflux events occur less often during sleep than during the day but last considerably longer8. As reasons, the authors cite the sharp decrease in saliva production and swallowing frequency, a weaker perception of the burning and slower gastric emptying. Less saliva and fewer swallows mean a longer contact time for the acid.
When is your heartburn most noticeable?
According to the same review, excess weight and obstructive sleep apnoea favour night-time reflux8. How pauses in breathing arise is described in our article on snoring and sleep apnoea. People who breathe through their mouth at night often wake up with a dry mouth; more on this under dry mouth.
We do not recommend taping the mouth shut at night, not even to switch to nasal breathing. The tape closes the mouth mechanically; the pattern remains. With reflux or vomiting during sleep, a taped mouth can also become dangerous. Background in the article Mouth taping.
Our view
Reflux and the basic functions: what is established and how we see it
Here we draw a clear line between what studies show and the model we work with.
It is established that the diaphragm is part of the barrier and that swallowing and saliva clean the oesophagus. It is not established that a deviating swallowing pattern causes reflux. A search for evidence on this yielded no usable result, as the book “Trust the Triad” also states.
In our view, the control nevertheless plays a role. The oesophagus and the entrance to the stomach are controlled via the vagus nerve, and the same brainstem coordinates breathing and swallowing. More on this in the article on the vagus nerve.
According to Dr. Berndsen’s model, reflux often also arises from a compensatory swallowing pattern. If the swallow runs without tooth contact and without a strong tongue thrust, the nerve stimuli that trigger the reflex sequence via the vagus nerve and oesophagus down to the entrance of the stomach remain weak. The closure there is not a simple ring muscle, but a reflexively controlled interplay with the diaphragm. This chain has not been studied; it is his explanation based on function.
The pattern deviates
Mouth breathing, shallow chest breathing, a low-lying tongue or a head that has drifted forward.
The body compensates
The diaphragm works less, other muscles step in, and the nervous system stores the substitute.
The environment changes
The rib cage sinks, and the pressure in the abdomen is distributed differently.
Symptoms can follow
In our view, in many people affected this can contribute to the barrier holding less well. When and to what extent depends on duration, severity and age.
Breathing, swallowing and head balance work as a combined system. If the head is balanced above the body, the rib cage moves freely and the diaphragm works through its full range. If the tongue rests in the tongue reference position and the lips are closed, breathing runs through the nose and swallowing takes place with negative pressure and tooth contact.
Muscles that are not involved in their function are not used and lose tension. In our view, this also applies to the diaphragm. Whether training that brings breathing and swallowing back into their function leads to an improvement in reflux has not been studied for our training.
Research
Breathing training for reflux: what studies show
There are now several small studies on training the diaphragm for reflux. None of them examined the FaceFormer.
was the drop in Graz in the proportion of the day during which the oesophagus was acidic, after four weeks of abdominal breathing training. 19 people, randomly allocated; no change in the comparison group9
was the rise in Fortaleza in mean pressure at the entrance to the stomach in 12 people with reflux after training the inspiratory muscles10
was the rise in the Czech Republic in lower sphincter pressure in 53 people after at least three months of diaphragmatic breathing11
In Graz, eleven of the nineteen participants continued the training. After nine months, their quality of life was better and on average they took fewer acid blockers as needed. Among those who did not continue training, no long-term effect was found9. In Fortaleza, the number of brief relaxations of the sphincter also decreased after the training, whereas acid exposure in the lower part of the oesophagus did not change10.
In the Czech study, the values of the same people were compared before and after the training. The waves of the oesophagus also became stronger. The training had no influence on the size of an existing hiatus hernia11. That is an important limitation.
The absence of a study does not mean that the connection does not exist. It means that it has not been tested.The studies are small. They show that the barrier can be influenced by active training. For training breathing, swallowing and head balance as a combined system, this test is still pending. You can find our own studies under Studies and science.
Putting treatment in context
Acid blockers, surgery, training: how they fit together
People with reflux are often prescribed proton pump inhibitors, such as pantoprazole or omeprazole. They have their place.
Proton pump inhibitors reduce the production of stomach acid and, according to the guideline, are the drug treatment of choice, including to allow inflammation of the oesophagus to heal. They do not change the barrier at the entrance to the stomach or the cleaning of the oesophagus. The same guideline describes the growing concern about side effects with long-term use and, after a response to an eight-week treatment, recommends an attempt to discontinue2.
of 120 healthy people had acid-related complaints in a randomised study after eight weeks of esomeprazole and subsequent discontinuation, compared with 15 % on placebo. People with reflux disease were not studied there13
So discontinuation is not harmless; the body reacts to the constant suppression, even in healthy people. In our view, practising the function therefore belongs alongside it, because the barrier and cleaning depend on it.
Dampening acid
- Reduces how acidic the backflow is
- Protects the mucous membrane and treats inflammation
- Works as long as you take the medication
- After discontinuation, acid-related complaints can occur
- Does not change the barrier or cleaning
Training the barrier and cleaning
- Addresses the diaphragm, breathing and swallowing
- Needs weeks to months of regular practice
- Does not replace a diagnosis or treatment of inflammation
- Can be combined with medical treatment
The two sides are not mutually exclusive. One protects the mucous membrane, the other addresses the function.
Do not stop prescribed medication on your own. Inflammation of the oesophagus needs its treatment, and an attempt to discontinue belongs under medical supervision, not in your own hands. You can read how we classify FaceFormer therapy alongside other treatments under FaceFormer and other treatments.
If complaints persist despite medication, an operation in which the stomach is wrapped around the oesophagus may be considered. It reinforces the closure mechanically and can have consequences, such as difficulty swallowing and bloating, which according to a surgical article occur relatively frequently14. It does not change how you breathe and swallow. In our view, such an operation should therefore be preceded by a look at the function.
There are clear data on lifestyle. In two randomised studies, acid exposure of the oesophagus decreased after weight loss. Late evening meals prolonged it while lying down; raising the head end of the bed reduced it from 21 to 15 per cent of lying time12. The guideline advises not eating anything for two to three hours before sleeping2.
Training
Training the diaphragm and swallowing: the breathing exercise
In FaceFormer training, breathing, swallowing and head balance are practised together. For the diaphragm, the breathing exercise is the core.
The foundation is the basic exercise. The FaceFormer sits in the oral vestibule, the tip of the tongue rests on the small ridge behind the upper front teeth, and the head is balanced upright. You press the lip wedge together, bite down briefly and swallow.
From about week 6, the breathing exercise is added. One hand rests on the abdomen just below the breastbone. You feel the abdomen rise as you breathe in, because the diaphragm lowers.
The breathing exercise links the diaphragm and the swallow in a single sequence. You breathe in through the nose for about six seconds while pressing your lips against the lip wedge. Then you hold your breath, bite down and swallow. After that, you breathe out for six seconds.
You extend the pause afterwards in small steps, as far as it remains comfortable. The pelvic floor exercise brings in the pressure space from below.
- From day 1
Basic exercise
Three times a day for a few minutes with the FaceFormer ZERO, guided by the free app.
- From around week 3
Pull exercise and night
The pull exercise is added. At night you wear the FaceFormer ZERO as soon as you have mastered the basic exercise.
- After a few weeks
Switching to the ONE
During the day you train with the FaceFormer ONE, the same size as the ZERO, just made of a firmer material.
- From around week 6
Breathing exercise
Breathe in, hold while biting down and swallowing, breathe out. The pause afterwards becomes longer over time.
- Over months
The pattern runs by itself
We expect six to twelve months until the new patterns run without thinking.
If your nose has been blocked for a long time, have this checked before doing the breathing exercise. If there are warning signs, a medical examination comes before training. You can find all modules on the exercise pages.
Everyday life
What you can do in everyday life for heartburn
Eat dinner earlier
There should be two to three hours between your last meal and lying down.
Raise the head end of the bed
If it burns at night, raise the head end of the bed instead of bending your head forward with pillows.
Upright after eating
Stay upright after eating. When the head is balanced over the body, the diaphragm has room.
Eat and swallow calmly
Chew thoroughly and swallow consciously instead of hastily washing food down. People who eat quickly often swallow air as well.
Breathe through your nose
Lips gently closed, the tongue in the reference position. This keeps the mouth moist, and saliva is ready for swallowing.
Weight and smoking
Excess weight increases the pressure in the abdomen. The guideline and the review explicitly recommend weight loss and giving up tobacco.
Observe triggers
Fatty or rich food, alcohol, coffee or spicy food make the burning worse in some people. A short diary shows what matters for you.
Questions
Frequently asked
What is the difference between reflux and heartburn?
Reflux is the backflow of stomach contents into the oesophagus. Heartburn is the burning sensation behind the breastbone that it can trigger. Reflux can also show up as throat clearing, coughing or acid regurgitation.
When should I see a doctor about heartburn?
Promptly if there are warning signs: difficulty swallowing, unintentional weight loss, blood in vomit or black stools, repeated vomiting or anaemia. With chest pain, the heart is checked first; with shortness of breath, call the emergency number 112. Heartburn that occurs several times a week over a period of weeks should also be assessed by a doctor.
What role does swallowing play in reflux?
Swallowing cleans the oesophagus. The first wave pushes almost the entire amount back into the stomach, and the remaining film of acid is neutralised by the saliva that follows with the subsequent swallows. During sleep you swallow less often, which is why acid remains longer at night. That a deviating swallowing pattern causes reflux has not been demonstrated. According to his model, Dr. Berndsen nevertheless sees a connection via the control system; it has not been studied.
What does the diaphragm have to do with heartburn?
The oesophagus passes through the diaphragm, whose crura wrap around it like a sling. Together with the lower sphincter, they form the barrier against backflow. In a hiatus hernia, the two move apart.
Can the diaphragm be trained against reflux?
The diaphragm is a skeletal muscle and can be trained. Small studies from Austria, Brazil and the Czech Republic found higher pressure at the entrance to the stomach or less acid in the oesophagus after breathing training. The training had no influence on a hiatus hernia. It does not replace diagnosis and treatment.
Why is heartburn worse at night?
During sleep, saliva production and swallowing frequency decrease sharply, and the stomach empties more slowly. Reflux episodes are less frequent at night but last longer. Late meals make this worse; a raised head end of the bed can reduce it.
Can I simply stop taking my acid blockers if I train?
Not on your own. Acid blockers protect the mucous membrane and treat inflammation. Whether and how you reduce the dose is something to discuss with your practice. The training can be combined with the treatment.
Does the FaceFormer help with reflux?
The FaceFormer is the training device for the basic functions of breathing, swallowing and head balance. In the breathing exercise, you train diaphragmatic breathing and swallowing in one sequence. Whether this leads to an improvement in reflux has not been studied for the FaceFormer.
More articles from the knowledge section
Where to go next
Sources
- El-Serag HB, Sweet S, Winchester CC, Dent J (2014). Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut 63(6):871-880. PMID 23853213. Source
- Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ (2022). ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. American Journal of Gastroenterology 117(1):27-56. PMID 34807007. Source
- Zdrhova L, Bitnar P, Balihar K, Kolar P, Madle K, Martinek M, Pandolfino JE, Martinek J (2023). Breathing Exercises in Gastroesophageal Reflux Disease: A Systematic Review. Dysphagia 38(2):609-621. PMID 35842548. Source
- Pandolfino JE, El-Serag HB, Zhang Q, Shah N, Ghosh SK, Kahrilas PJ (2006). Obesity: a challenge to esophagogastric junction integrity. Gastroenterology 130(3):639-649. PMID 16530504. Source
- Helm JF, Dodds WJ, Pelc LR, Palmer DW, Hogan WJ, Teeter BC (1984). Effect of esophageal emptying and saliva on clearance of acid from the esophagus. New England Journal of Medicine 310(5):284-288. PMID 6690951. Source
- Kapila YV, Dodds WJ, Helm JF, Hogan WJ (1984). Relationship between swallow rate and salivary flow. Digestive Diseases and Sciences 29(6):528-533. PMID 6723485. Source
- Koeda M, Momma E, Tanabe T, Kitasako Y, Hoshikawa Y, Hoshino S, Kawami N, Iwakiri K (2023). Differences in salivary secretion and epidermal growth factor concentrations in mild reflux esophagitis and non-erosive reflux disease. Esophagus 20(2):317-324. PMID 36344779. Source
- Orr WC, Heading R, Johnson LF, Kryger M (2004). Review article: sleep and its relationship to gastro-oesophageal reflux. Alimentary Pharmacology and Therapeutics 20 Suppl 9:39-46. PMID 15527463. Source
- Eherer AJ, Netolitzky F, Högenauer C, Puschnig G, Hinterleitner TA, Scheidl S, Kraxner W, Krejs GJ, Hoffmann KM (2012). Positive effect of abdominal breathing exercise on gastroesophageal reflux disease: a randomized, controlled study. American Journal of Gastroenterology 107(3):372-378. PMID 22146488. Source
- Nobre e Souza MÂ, Lima MJ, Martins GB, Nobre RA, Souza MH, de Oliveira RB, dos Santos AA (2013). Inspiratory muscle training improves antireflux barrier in GERD patients. American Journal of Physiology, Gastrointestinal and Liver Physiology 305(11):G862-G867. PMID 24113771. Source
- Zdrhova L, Bitnar P, Friedl L, Mares J, Madle K, Balihar K, Kolar P, Kozeluhova J, Fox M, Martinek J (2025). Effect of Diaphragmatic Breathing Training on the Esophagogastric Junction and Esophageal Motility in Patients With Reflux Symptoms. Neurogastroenterology and Motility 37(12):e70172. PMID 40984704. Source
- Ness-Jensen E, Hveem K, El-Serag H, Lagergren J (2016). Lifestyle Intervention in Gastroesophageal Reflux Disease. Clinical Gastroenterology and Hepatology 14(2):175-182. PMID 25956834. Source
- Reimer C, Søndergaard B, Hilsted L, Bytzer P (2009). Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy. Gastroenterology 137(1):80-87. PMID 19362552. Source
- Bramhall SR, Mourad MM (2019). Wrap choice during fundoplication. World Journal of Gastroenterology 25(48):6876-6879. PMID 31908391. Source
Get started
Ready for the training?
The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
