Hiatal hernia syndrome
is one of the most common functional GI disorders. Patients manifesting
this condition may present with gastroesophageal reflux symptoms,
and it may also trigger asthmatic bronchoconstrictive episodes.
The patient may already have had an upper GI barium study or endoscopy
(esophagogastroduodenoscopy), which may not reveal organic disease/hiatal
hernia. This does not preclude the possibility that you will detect
this syndrome. I get many referrals for this condition, and the
relief the patients get from the approach described below is often
immediate and dramatic. I teach this technique along with others
in a weekend seminar titled "Functional Gastroenterology Level
I." You can also use this technique to treat a true hiatal
The recognition and management of this syndrome was greatly advanced
by the work of Dr. Ralph Failor, a naturopathic and chiropractic
physician who practiced in Hillsboro, Oregon, during the last half
of the twentieth century. This syndrome is a functional relative
to the true hiatal hernia, a gastric pathology in which the proximal
stomach is herniated into the mediastinum. Hiatal hernia syndrome
is distinguished by the fact that the proximal stomach may only
cause upward pressure against the diaphragmatic hiatus and not actually
protrude into the chest (Figure 1).
A hernia smaller than 2 cm may not be visible on barium films or
Figure 1: Normal Stomach and Hiatal Hernia
The possible symptoms are the same for
both the true hernia and the syndrome. These may include fatigue,
mental dullness, easy satiety, shallow thoracic breathing, relatively
rapid respiratory rates, globus sensation, dysphagia, chest oppression,
reflux, stitching chest pains, regurgitation, aversion to constriction
at the waist, flatulence, a "spare tire" bulge just below
the inferior margin of the ribs, and a tickling, nonproductive cough.
This syndrome may be due to an inherited
wide diaphragmatic hiatus, or may be acquired from trauma or increased
intra-abdominal pressure. Examples of trauma include abdominal surgery,
the impact of jumping from a height, horseback riding, strenuous
abdominal exercise, a blow to the abdomen or a "belly flop"
dive, falling from a height, or merely exertion with breath holding.
An increase in intra-abdominal pressure may also be due to pregnancy
or abdominal obesity or any space-occupying lesion of the abdomen.
Dr. Failor used the following tender
points for detection of the syndrome:
· Left of xiphoid (hiatal hernia
syndrome (HHS) point –
see Figures 2 and 3)
· 4th ICS (intercostal space) midclavicular
· 4th ICS midaxillary
· T10-11 left paravertebral area
I ask the patient to rate these on a 0-4
scale and reassess after treatment.
Figure 2: Hiatal Hernia Point
Figure 3: Hiatal Hernia Reflex Point
Another method that I have found very useful
is an applied kinesiology test:
Step 1. Find any muscle that tests strong (I often use the rectus
Step 2. Retest the strong muscle while having the patient using
both hands to press the upper abdomen inward and cephalad, which
increases the pressure of the proximal stomach against the diaphragm
If the muscle weakens, this is a positive indicator.
Check the spine
with a focus at the occiput, C3,4,5 and T10,11.
Figure 4: Position of Patient's Hands for Muscle
Testing of Hiatal Hernia Syndrome
Table 1: Hiatal Hernia Syndrome -
impact of jumping
|blow to the abdomen
"belly flop" dive
falling from a height
exertion with breath holding
shallow thoracic breathing
stitching chest pains
relatively rapid respiration
aversion to constriction at the waist
"spare tire" bulge just below the rib margin
tickling, nonproductive cough
Left of xyphoid (HHS point)
4th ICS mid clavicular
4th ICS mid axillary
T 10-11 left paravertebral
|Retest a previously strong lower extremity
muscle while having the patient use both hands to press the
upper abdomen inward and cephalad.
If the muscle weakens, this is a positive indicator for the
to the left of the supine patient, use a left hand "claw"
contact. Support the contact hand with your right hand. (Figure
Use continuous traction toward the left ASIS, and wait for the
soft tissue to begin a counterclockwise rotation.
Follow the rotation as it shifts to clockwise – maintaining
When the rotation is finished (usually 2–3 minutes at
the longest), perform three clockwise thrusts (ballooning the
of the syndrome (or an actual sliding hiatal hernia) involves the
Visceral manipulation: Dr. Failor taught us his technique in 1977,
and many doctors still use it.1 It is effective, but can
be a bit forceful. I trained in structural integration in 1996, and
over the last five years I have developed a gentler method. I contact
the epigastric area just inferior to the costosternal angle. I use
a "claw" hand contact and support the contact hand with
my other hand (Figure 5). I traction toward the left anterior superior
iliac spine (ASIS) and wait for the soft tissue to begin a counterclockwise
rotation. I just allow my fingers to follow the movement while continuing
to apply the traction. In most cases, the rotation will shift to clockwise
as I continue the traction. When the rotation is finished (usually
2 to 4 minutes at the longest), I add three additional clockwise thrusts
of my hands. Dr. Failor called this "ballooning the stomach"
and thought that it was important in order for the manipulation to
Figure 5: Visceral Manipulation of the Hiatal Hernia
Any additional techniques that
you already use to free the thoracic vertebrae, ribs, and diaphragm
muscle in general are helpful, should you find these necessary.
Dr. Failor found that the T10 and T11 were especially important,
so I tend to check there. In addition, the occiput is often essential
to check and correct. The basic "cranial base release"
is effective; or use myofascial or other cranial techniques, or
osseous manipulation if you prefer. In addition, check C3, 4, and
5, which "keep the diaphragm alive" (innervate the diaphragm).
After treatment, recheck the tender point or use kinesiology testing.
The change should be immediate.
Post manipulation exercises:
The patient drinks (not sipping) 12 to 16 ounces of warm water on
waking, stands and rises onto the toes, and then drops onto the
heels eleven times in succession. The downward momentum of the water-filled
pendulous stomach supports the benefits of the visceral work.
Lying supine on a flat surface with legs adducted, the patient inhales,
and then while exhaling raises both legs 12 to18 inches, slowly
abducts and adducts the legs, and then lowers them to the resting
position. Gradually increase the number of repetitions over time.
Sitting in a chair, the patient supports the upper body by holding
the arms or seat of the chair. Keeping the knees adducted, the patient
inhales, then exhales as he flexes the legs, bringing the knees
toward the chest (as far as possible). Taking the next breath as
he extend the legs and rest the feet on the floor, he exhales as
he repeats the procedure. Gradually increase repetitions over time.
In general, I find that having patients avoid foods to which they
have sensitivities is important. Simplifying meals (simple combinations)
is also important. Just as important as what they eat is how they
· Avoid overeating and large meals.
· Take time to sit and chew food until it becomes liquid
before swallowing (known as Fletcherizing).
· Avoid stressful discussions or watching television while
· If family-of-origin issues are still affecting eating habits,
consider counseling or energetic psychology interventions.
Treating hypochlorhydria or achlorhydria if present is also essential
for these patients.
Functional breathing and lifting: This is crucial. Teach these patients
functional lifting and exertion. Have them take a slow abdominal
breath before exerting and then exhale as they exert. This prevents
a build-up of intra-abdominal pressure, thus preventing reinjury.
Developing your skills and protocols
for treatment of hiatal hernia technique will gain you many referrals
and the ability to get rapid, lasting results with many cases of
functional esophageal, gastric, and diaphragmatic syndromes.
Sandberg-Lewis, ND, DHANP, is a full professor at NCNM. He has taught
GI physiology, psychophysiology, GI pathology, and gastroenterology
since 1996 and has been in continuous practice since graduating
from NCNM in 1978. He supervises student clinicians at the NCNM
Natural Health Center with a focus on digestive and musculoskeletal
health. The practice emphasis is on diet; myofascial, visceral,
and spinal manipulation; functional analysis; and mind-body clearing
techniques. Dr. Sandberg-Lewis teaches a two-part seminar series
on functional gastroenterology. Level One will be held on February
28 and March 1, 2009. To attend: go to www.ncnm.edu
and click on "Register for CE Classes Here." His new book,
Functional Gastroenterology, will
be available from the NCNM bookstore on May 1, 2009. Go to www.ncnm.edu/bookstore
or e-mail firstname.lastname@example.org.
1. Failor RM. The
New Era Chiropractor, R. Palm
Desert, CA: R.M. Failor; 1979.