Saturday, June 14, 2014

Reflux Disease? Maybe It's a Pressure-Overload-Induced Sliding of the Hiatal Hernia? Injury is Common in Power Athletes & Bodybuilders - 7/8 Lifters Affected

If you don't want to have your phrenoesophageal ligament (see Figure 1) go baggy or rupture, you better watch your breath, when you're deadlifting and squatting or doing any other form of strenuous whole body lifting exercise.
I know that the increasing naturopath followership will tell you that everyone suffering from reflux disease would just have to pound tons of betaine HCL (stomach acid) to cure this nasty condition... obviously, this is just like 99% of the common Internet wisdom only partially true. Yes, there are people who suffer from (non-acidic!) reflux due to insufficient stomach acid, but based on personal experience I would estimate that this is by no means the most frequent reason gymrats regurgitate their food involuntarily.

Rather than a lack of stomach acid, the combination of a per se healthy, but hard to digest diet, the negative impact of exercise on the digestion process and last but not least the risk of developing a pressure-overload sliding of the hiatial hernia during deadlifts, squats & co are the most frequent contributers to "reflux disorders" in physical culturists.
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I guess the first two factors, i.e. a ton of high fiber foods, veggies and protein, as well as the role of exercise as digestion "off-switch" are pretty self-explanatory and eventually nothing you could not deal with by appropriately timing your food intake.

Figure 1: Wrong breathing patters promote the rupture / bagging out of the phrenicoesophageal ligament and will thus allow the parts of the stomach including the the lower esophageal sphincter, which keeps the stomach shut, to pass through.
The occurrence of sliding hiatal hernias, on the other hand, is something that's commonly associated with increasing age and the accompanying degenerative processes that impair the structural integrity of all tissues, including the phrenoesophageal ligament (see Figure 1) which will then allow parts of the stomach, including the lower esophageal sphincter that's supposed to keep the stomach shut, into the thorax.

The incidence of sliding hiatal hernias in the general population is 0.5%. In fact, the prevalence in the Western world is thought to be significantly higher, with approximately 60% of geriatric patients in North America having a hiatal hernia on radiologic studies.

Most hiatal hernias occurring in young adults are idiopathic or associated with hardly noticeable reflux problems after large meals.

There has been speculation of a stress-induced hiatal hernia from repeated episodes of elevated intra-abdominal pressure, and there is plenty of evidence that "injuries" like these are pretty common among elite body builders and, as a 1999 study by Smith et al. shows, young male power athletes, as well.
Warning - Belts don't protect you! Aside from the fact that weightlifting belts increase the already high pressure that's at the heart of the weightlifting induced sliding hiatus hernia, the contemporary evidence suggests, that they don't protect those of you who have nor previous back issues against injury, increase the risk of severe over less severe injuries, tend to give people the unwarranted perception that they were "protected", tend to increase both intra-abdominal pressure and blood pressure, and appear to change the lifting styles of some people to either decrease the loads on the spine or increase the loads on the spine, so that their use is, as Stuart M. McGill from the University of Waterloo points out in an invited review for the National Strength and Conditioning Association  (NSCA Hot Topics Series) not recommended for healthy individuals either in routine work or exercise participation (McGill. 2005).
The data in Figure 1 was collected in a sample of eight male elite power athletes and seven male non-weightlifters who were matched for age. The subjects underwent a fluoroscopy with barium which allowed Smith and his colleagues to test their hypothesis that "pressure overload can induce hiatal hernias in young adults." (Smith. 1999).
Figure 2: Occurrence of sliding hiatial hernia in power-lifters and non-weight training subjects (left; Smith. 1999); normal and pathologically altered esphagus and stomach (right).
Although it cannot be be repeated often enough that statistical significance and "significance" in absolute terms are two pairs of shoes, I don't think that it's necessary to point out that a difference between 7 out of 8 and 0 out of 7 is both real-world and statistically signifcant.


It should likewise not be necessary for me to point out that the occurrence of this injury is a consequence of wrong breathing patterns and will usually happen, when lifters are still working on their form and breathing technique - in other words, it happens to exactly those rookies who are particularly prone to use way more weight than they can handle.
The good news, however, is that for most those wannabe-weight lifters the hernia is without consequences of the 7 power-lifting subjects in the Smith study, for example, only one admitted to having reflux symptoms outside of weight lifting - that was also the one with one of the moderate-sized hiatal hernias.

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Unless you're overdoing it and trying to protect your back with one of those belts that actually caused the stomach to protrude into the thorax in one of the otherwise unsymptomatic powerlifters in the Smith study, it's thus unlikely you'll be turning into a ruminant from weight lifting. And in case it's already to late, there are currently a handful of effective minimally invasive treatment techniques available that can help those of you who suffer from an unbearable reflux due to a professionally diagnosed sliding hiatal hernia eat and digest normal again (Bello. 2012).
References:
  • Bello, Brian, et al. "Impact of minimally invasive surgery on the treatment of benign esophageal disorders." World journal of gastroenterology: WJG 18.46 (2012): 6764. 
  • McGill, Stuart M. "On The Use Weight Belts." NSCA Hot Topics Series. www.nsca-lift.org (2005).
  • Smith, A. B., et al. "Pressure-overload-induced sliding hiatal hernia in power athletes." Journal of clinical gastroenterology 28.4 (1999): 352-354.