A Fresh Look at GERD

Hi Amy,

Here’s my perspective to pass on to your friend. As you know, I have dealt with GERD on and off for years. I’ve tried all of the standard medical treatments, a bunch of home remedies and “alternative” treatments, and even had an experimental surgery performed on my stomach at one point. None of these things has proven to be effective in the long term. I have only found reliable relief from my GERD symptoms through effective stress management.

In my non-medical but informed opinion, Gastroesophageal reflux disease (GERD) and its voice-disrupting partner laryngopharyngeal reflux (LPR) are caused by:

  • Stress

That’s really it in most cases. When the parasympathetic nervous system (the part of the autonomic nervous system related to “rest and digest,” in opposition to the sympathetic “fight or flight” response) is chronically inhibited, lots of things go subtly wrong in the body. Nervous system pathways related to muscular effort are left in the “on” position, and those related to internal maintenance systems such as digestion are left off. Thus, the abdominal muscles may develop a slight chronic grip as we guard our soft parts from an imagined aggressor, putting upward pressure on the stomach contents and the lower esophageal sphincter (the valve between stomach and esophagus.) Breathing may be affected, causing a subtle holding in the diaphragm, placing further downward pressure on the LES valve. At the same time, the digestive system is hampered– the acids and enzymes that digest food normally may be out of balance and the peristaltic movements of the smooth muscles that propel food along the alimentary canal can be weakened.

Many common treatments aim at the symptoms or mechanism of this problem without addressing the underlying cause– a chronic imbalance in the nervous system. For instance, the most common medical treatment involves proton pump inhibitor (PPI) medications, which shut down acid production in the stomach. We have to remember that the stomach is supposed to be a highly acidic environment– that is what breaks our food down into a digestible form and serves as a first line of defense against food-borne pathogens that can make us ill. PPI meds are a very temporary fix to the problem of GERD. Unfortunately, many people rely on these medications daily, for years. Without getting too political, I’ll point out that PPI meds are an ENORMOUS industry and people don’t seem to be suffering from GERD any less today than they were 20 years ago.

Another common treatment approach is to actually increase the acidity of the stomach, helping the digestive process along. This approach is embraced by many practitioners of alternative/”traditional” medicine. Some people hypothesize that the LES somehow “senses” the pH level of the stomach and closes tightly in response– when the pH level is not acidic enough, it relaxes, allowing the (still fairly caustic) stomach contents to travel upward. Again, treatments based on increasing acid with meals (incorporating coffee, wine, betaine HCl caplets available at health food stores, apple cider vinegar, etc.) can be a good temporary fix for some people, as it helps break down food and move it through the system. Unfortunately, it still doesn’t address the main issue– the digestive system has been thrown out of balance by the stress response in the brain.

Surgical interventions for GERD aim at tightening the LES or altering the angle between the LES and the stomach. Again, these solutions address the mechanism of reflux, but not the cause. I think it goes without saying that surgery should be a last resort.

The hardest solution of all (requiring even more discipline than typically-recommended lifestyle changes such as refraining from certain foods and raising the head of the bed)– but also the most practical solution in the long run– is to examine one’s lifestyle and find ways of introducing more “rest and digest” patterning into the mind on a behavioral and/or cognitive level. Activities that can be good for this might include:

  • Mindful exercise
  • Meditation
  • Various forms of therapy
  • Non-professional hobbies
  • Time off
  • Yoga
  • Prayer
  • Time immersed in nature

…and the list goes on. Anything that gives one some perspective, joy, or serenity is a good starting place.

The breath is a good barometer and also a useful entry point to the psyche– three of the suggestions above deal directly with the breath. The others probably deal with breathing indirectly, and there are countless other examples.

My perspective has broadened slightly since I last visited this topic. I am no longer strongly “anti” any of the standard or non-standard treatments for GERD. They can all be useful stepping stones on the way to good health. But my interest is in a cure, not just treatment, and I’m convinced that real lasting relief from this decidedly modern epidemic can come through the mind in most cases.

Best wishes to you on your journey,

–Jeremy

Addendum: I received this thoughtful response from Joanna Cazden, speech pathologist, voice specialist, Southern California:

Thanks for sending this, Jeremy.

I’m sorry that you had to get as far as surgery, but I generally agree with you that the causal factors — and best treatments/ repairs — are different for each person.  PPI med’s are NOT free of side effects, but for people who are totally out of touch, and unwilling to do anything for themselves except take a pill, often the voice does benefit.

The only thing I’d add to your list of recommendations–for-most-people-to-consider: Probiotics.

In some cases the back ribs are misaligned, tweaking nerves and chem messengers so that gastric system is over-stimulated; I think there are genetic vulnerabilities too.

The general state of Conventional Medicine — and even alternative/complementary/integrative — reminds me of a story about Gandhi.

He was reportedly asked what he thought of western “civilization.” He said “I think it would be a good idea.”

So would reasonable health care — and we’re a long way from that.

 

Response to Belt/High Belt Survey

My response to a NATS survey about belt/high belt singing:

My view is that belt/high belt/chest mix/head mix are not fundamentally different, but differ in their ratio of CT to TA and open/closed quotient– there are grey areas where these registers may overlap depending on the aesthetic of the singer and/or listener, which is one reason there is so much disagreement and controversy on the topic of registration. Throw in resonance variables and the confusion is compounded– how can we verifiably separate, in our ears, components of the sound that are truly due to registration– at the level of the vocal folds– and which are resonance– timbre components added after the phonatory event? The answer, of course, is that we can’t, especially in view of recent findings that suggest that vocal tract configuration affects phonation in complex ways. Nevertheless, I continue to teach from a functional standpoint, under the assumption that training the vocal musculature (strength, flexibility, balance, stamina) is more fundamental (and also more tangible) than endless resonance work. I also find that students respond to athletic analogies of practice and training better when we work with the muscles, and too much resonance work encourages many students’ mistaken idea that it’s possible to forgo rigorous practice in favor of a “magic button” vocal tract shape. That’s not to say that resonance doesn’t have an important place in the studio– simply that it should come after the voice is fairly well balanced in terms of registers.

Addendum: I should probably add that breath work is even more fundamental than phonatory function. So, the order of training follows a logical progression: excitor, vibrator, resonator.