GERD, Breathing & the Diaphragm
GERD and the diaphragm are more connected than they look.
Gastroesophageal reflux disease is usually discussed in terms of stomach acid and the lower esophageal sphincter. But the antireflux barrier is not created by the esophagus alone. Part of your diaphragm surrounds the esophagus and contributes directly to the barrier between the stomach and the chest.
The esophagus passes through the diaphragm before reaching the stomach. That anatomical relationship matters to the mechanics of reflux.
The Anatomy
Your diaphragm is part of the antireflux barrier.
The lower esophageal sphincter is often described as the valve that helps prevent stomach contents from moving back into the esophagus. That is only part of the story. Where the esophagus passes through the diaphragm, fibers of the crural diaphragm surround it and contribute an additional external sphincter-like effect.
The lower esophageal sphincter and the surrounding crural diaphragm contribute together to the gastroesophageal antireflux barrier.
The esophagus passes through the diaphragm.
Before joining the stomach, the esophagus travels through an opening in the diaphragm called the esophageal hiatus.
The lower esophageal sphincter is only part of the barrier.
The intrinsic lower esophageal sphincter helps resist reflux, while the surrounding crural diaphragm provides an additional external component of that pressure barrier.
Breathing and reflux mechanics meet in the same structure.
The diaphragm must participate in breathing while also contributing to trunk pressure and the mechanics of the gastroesophageal junction. Researchers have therefore begun asking whether training diaphragm function can influence reflux.
More Than a Breathing Muscle
The diaphragm has several jobs happening at once.
It drives respiration. It contributes to pressure regulation and trunk stabilization. And at the esophageal hiatus, it participates in the mechanical barrier that helps keep stomach contents where they belong.
That doesn't mean every case of GERD is a diaphragm problem. Reflux is multifactorial, and appropriate medical evaluation still matters. But it does mean diaphragm function is a legitimate part of the physiology rather than an unrelated rehabilitation theory.
Training the Diaphragm
So what happens when diaphragm function is trained?
This question has moved beyond anatomy and theory. Researchers have used esophageal manometry, pH monitoring and clinical outcomes to investigate whether diaphragmatic breathing and respiratory training can influence the antireflux barrier and symptoms of gastroesophageal reflux.
The pressure barrier can change.
Studies of diaphragmatic and inspiratory muscle training have reported increases in pressure generated around the lower esophageal sphincter and esophagogastric junction.
Esophageal function can change too.
More recent work has found changes not only in sphincter pressure, but also in the strength and effectiveness of esophageal contractions after diaphragmatic breathing training.
Some patients report less reflux.
Clinical trials and systematic reviews suggest that diaphragmatic breathing can reduce GERD symptoms in some patients, although the evidence is not yet strong enough to say who will respond or how large the benefit should be expected to be.
A Closer Look · 2025
Researchers measured what changed inside the esophagus.
In a 2025 study, researchers including Petr Bitnar and Pavel Kolář analyzed 53 adults with persistent reflux symptoms who underwent high-resolution esophageal manometry before and after at least three months of diaphragmatic breathing training.
Because this was a prospective before-and-after study rather than a randomized controlled trial, it cannot by itself prove that breathing training caused every observed change. But the physiological findings are notable.
The Prague Research
This question has been studied within the same Prague rehabilitation tradition that developed DNS.
Petr Bitnar has been particularly involved in the study of viscero-somatic relationships: the ways in which internal-organ function, breathing, posture and the musculoskeletal system can interact.
In 2023, Bitnar and Kolář were among the authors of a systematic review examining breathing exercises for GERD. The review describes the crural diaphragm as an important component of the esophagogastric junction and the antireflux barrier, while also emphasizing that GERD is multifactorial and that patient selection for respiratory physiotherapy remains an open question.
This is an important distinction. The research does not show that every case of reflux is caused by dysfunctional breathing, or that every DNS exercise is a treatment for GERD. It does show that the relationship between diaphragm function and reflux is a legitimate subject of gastroenterology and rehabilitation research.
What the Evidence Says
Promising does not mean proven for everyone.
The research base has grown considerably. A 2026 systematic review and meta-analysis identified 10 randomized controlled trials involving 476 patients and found an overall improvement in GERD symptom scores favoring diaphragmatic breathing.
But the studies used different breathing protocols, different patient populations and different outcome measures. Statistical heterogeneity was substantial. The authors therefore concluded that the evidence is not yet sufficient for definitive clinical recommendations.
That's a more interesting conclusion than either extreme. Diaphragmatic training is not merely a theoretical idea, but neither should it be presented as a universal replacement for established GERD care.
What can we reasonably say?
The crural diaphragm is an established component of the antireflux barrier.
Diaphragmatic breathing can measurably influence esophageal and gastroesophageal-junction physiology.
Some clinical studies show improvement in GERD symptoms with diaphragmatic breathing or respiratory training.
GERD has multiple potential mechanisms, so diaphragm-focused treatment will not necessarily be appropriate or sufficient for every patient.
Why This Interested Me
I first encountered this connection through DNS training in Prague.
My interest in the relationship between the diaphragm and reflux did not begin as an internet theory. It grew out of advanced clinical training in Dynamic Neuromuscular Stabilization and exposure to the work being done by the rehabilitation group in Prague.
During my DNS Practitioner training in Prague, I trained alongside Professor Pavel Kolář and the DNS team within their hospital system. One area of their work that particularly caught my attention was the relationship between diaphragm function and the gastrointestinal system.
Petr Bitnar has been one of the Prague clinicians and researchers most closely associated with this area. His work examines viscero-somatic relationships, including how breathing, stabilization, posture and internal-organ function may interact.
During my training, I was shown endoscopic imaging in which the appearance of a hiatal hernia changed immediately as the patient shifted from an upper-chest breathing strategy to a more abdominal, diaphragmatic one. It was a striking demonstration of how dynamic the relationship between breathing mechanics and the gastroesophageal junction can be.
That observation should not be confused with evidence that breathing training permanently reduces a hiatal hernia. In fact, the 2025 study discussed above found no change in measured hiatal hernia size after diaphragmatic breathing training. But seeing the anatomy change in real time helped make the underlying mechanical relationship difficult to ignore.
A Project That Almost Happened
Before COVID, this was moving from an idea toward a clinical pilot.
Before the COVID-19 pandemic, I had begun planning a pilot collaboration with an ENT physician at Northwestern who was interested in referring patients with reflux for diaphragm-focused conservative treatment rather than relying exclusively on medication.
The project never got far enough to generate data. COVID disrupted the plan before the pilot could actually be carried out. I include it here not as evidence that the treatment works, but because it reflects why this subject has remained clinically interesting to me.
The idea was simple: if the diaphragm is an active component of the antireflux barrier, could improving the way it functions meaningfully change symptoms in appropriately selected patients?
Putting It in Context
GERD is not one problem with one solution.
The diaphragm is part of the story, but it is not the entire story. Gastroesophageal reflux can involve several mechanisms, and symptoms that feel like reflux do not always have the same cause. That is why the research question is increasingly about patient selection rather than whether everyone with heartburn should simply practice diaphragmatic breathing.
The mechanics matter.
The relationship among the lower esophageal sphincter, crural diaphragm, esophageal hiatus and stomach contributes to the antireflux barrier. Hiatal hernia can alter that relationship.
Function can be trained.
Research shows that diaphragmatic breathing and respiratory training can influence measurable esophageal physiology and may improve symptoms in some people.
Not everyone has the same reflux.
GERD is multifactorial. Understanding who is likely to benefit from diaphragm-focused rehabilitation remains an important unanswered clinical question.
New or persistent reflux symptoms, difficulty or pain with swallowing, gastrointestinal bleeding, unexplained weight loss, persistent vomiting, anemia, or other concerning symptoms should be medically evaluated. Diaphragmatic training should not be used to delay appropriate diagnosis or necessary medical treatment.
The Bigger Movement Picture
Why does DNS pay so much attention to the diaphragm?
DNS looks at the diaphragm not only as a respiratory muscle, but as part of a coordinated system involving breathing, pressure regulation, stabilization and movement. The GERD research is one particularly interesting example of how the diaphragm's role can extend beyond the way we usually think about breathing.
Research & Further Reading
Selected research behind this article.
This page is intended as educational material. These sources provide a starting point for readers interested in the physiology and clinical research discussed above.
Originally published as a brief NeuroActive GERD resource. Substantially revised and updated in 2026.