***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Background & Aims In patients with gastroesophageal reflux disease ( GERD ) and excessive belching , most belches are supragastric , and can induce reflux episodes and worsen GERD . Supragastric belching ( SGB ) might be reduced with diaphragmatic breathing exercises . We investigated whether diaphragmatic breathing therapy is effective in reducing belching and proton pump inhibitor (PPI)‐refractory gastroesophageal reflux symptoms . Methods We performed a prospect i ve study of 36 consecutive patients with GERD refractory to PPI therapy and a belching visual analogue scale ( VAS ) score of 6 or more , seen at a gastroenterology clinic at a tertiary hospital in Singapore from April 2015 through October 2016 . Patients underwent high‐resolution manometry and 24‐hour pH‐impedance studies while they were off PPIs .  Fifteen patients were placed on a st and ardized diaphragmatic breathing exercise protocol ( treatment group ) and completed question naires at baseline , after diaphragmatic breathing therapy , and 4 months after the therapy ended . Twenty‐one patients were placed on a waitlist ( control subjects ) , completed the same question naires with an additional question naire after their waitlist period , and eventually received diaphragmatic breathing therapy . The primary outcome was reduction in belching VAS by 50 % or more after treatment . Secondary outcomes included GERD symptoms ( evaluated using the reflux disease question naire ) and quality of life ( QoL ) scores , determined from the Reflux‐Qual Short Form and EuroQoL‐VAS . Results Nine of the 15 patients in the treatment group ( 60 % ) and none of the 21 control subjects achieved the primary outcome ( P < .001 ) . In the treatment group , the mean belching VAS score decreased from 7.1 ± 1.5 at baseline to 3.5 ± 2.0 after diaphragmatic breathing therapy ; in the control group , the mean VAS score was 7.6 ± 1.1 at baseline and 7.4 ± 1.3 after the waitlist period . Eighty percent of patients in the treatment group significantly reduced belching frequency compared with 19 % in control subjects ( P = .001 ) . Treatment significantly reduced symptoms of GERD ( the mean reflux disease question naire score decreased by 12.2 in the treatment group and 3.1 in the control group ; P = .01 ) . The treatment significantly increased QoL scores ( the mean Reflux‐Qual Short Form score increased by 15.4 in the treatment group and 5.2 in the control group ; P = .04 ) and mean EuroQoL‐VAS scores ( 15.7 increase in treatment group and 2.4 decrease in the control group ) . These changes were sustained at 4 months after treatment . In the end , 20 of the 36 patients who received diaphragmatic breathing therapy ( 55.6 % ) , all with excessive SGB , achieved the primary outcome . Conclusions In a prospect i ve study , we found a st and ardized protocol for diaphragmatic breathing to reduce belching and PPI‐refractory gastroesophageal reflux symptoms , and increase QoL in patients with PPI‐refractory GERD with belching — especially those with excessive SGB OBJECTIVES : The lower esophageal sphincter ( LES ) , surrounded by diaphragmatic muscle , prevents gastroesophageal reflux . When these structures become incompetent , gastric contents may cause gastroesophageal reflux disease ( GERD ) . For treatment , lifestyle interventions are always recommended . We hypothesized that by actively training the crura of the diaphragm as part of the LES using breathing training exercises , GERD can be positively influenced . METHODS : A prospect i ve r and omized controlled study was performed . Patients with non-erosive GERD or healed esophagitis without large hernia and /or previous surgery were included . Patients were r and omized and allocated either to active breathing training program or to a control group .  Quality of life ( QoL ) , pH-metry , and on-dem and proton pump inhibitor ( PPI ) usage were assessed at baseline and after 4 weeks of training . For long-term follow-up , all patients were invited to continue active breathing training and were further assessed regarding QoL and PPI usage after 9 months . Paired and unpaired t-test was used for statistical analysis . RESULTS : Nineteen patients with non-erosive GERD or healed esophagitis were r and omized into two groups ( 10 training group and 9 control group ) . There was no difference in baseline patient characteristics between the groups and all patients finished the study . There was a significant decrease in time with a pH<4.0 in the training group ( 9.1±1.3 vs. 4.7±0.9 % ; P<0.05 ) , but there was no change in the control group . QoL scores improved significantly in the training group ( 13.4±1.98 before and 10.8±1.86 after training ; P<0.01 ) , but no changes in QoL were seen in the control group . At long-term follow-up at 9 months , patients who continued breathing exercise ( 11/19 ) showed a significant decrease in QoL scores and PPI usage ( 15.1±2.2 vs. 9.7±1.6 ; 98±34 vs. 25±12 mg/week , respectively ; P<0.05 ) , whereas patients who did not train had no long-term effect . CONCLUSIONS : We show that actively training the diaphragm by breathing exercise can improve GERD as assessed by pH-metry , QoL scores and PPI usage . This non-pharmacological lifestyle intervention could help to reduce the disease burden of GERD The crural diaphragm ( CD ) is an essential component of the esophagogastric junction ( EGJ ) , and inspiratory exercises may modify its function . This study 's goal is to verify if inspiratory muscle training ( IMT ) improves EGJ motility and gastroesophageal reflux ( GER ) .  Twelve GER disease [ GERD ; 7 males , 20 - 47 yr , 9 esophagitis , and 3 nonerosive reflex disease ( NERD ) ] and 7 healthy volunteers ( 3 males , 20 - 41 yr ) performed esophageal pH monitoring , manometry , and heart rate variability ( HRV ) studies . A 6-cm sleeve catheter measured average EGJ pressure during resting , peak inspiratory EGJ pressures during  sinus arrhythmia maneuver ( SAM ) and inhalations under 17- , 35- , and 70-cmH2O loads ( TH maneuvers ) , and along 1 h after a meal . GERD patients entered a 5-days-a-week IMT program . One author scored heartburn and regurgitation before and after IMT . IMT increased average EGJ pressure ( 19.7 ± 2.4 vs. 29.5 ± 2.1 mmHg ; P < 0.001 ) and inspiratory EGJ pressure during SAM ( 89.6 ± 7.6 vs. 125.6 ± 13.3 mmHg ; P = 0.001 ) and during TH maneuvers . The EGJ-pressure gain across 35- and 70-cmH2O loads was lower for GERD volunteers . The number and cumulative duration of the transient lower esophageal sphincter relaxations decreased after IMT . Proximal progression of GER decreased after IMT but not the distal acid exposure . Low-frequency power increased after IMT and the higher its increment the lower the increment of supine acid exposure . IMT decreased heartburn and regurgitation scores . In conclusion , IMT  improved EGJ pressure , reduced GER proximal progression , and reduced GERD symptoms . Some GERD patients have a CD failure , and IMT may prove beneficial as a GERD add-on treatment The treatment of gastroesophageal reflux disease may be clinical or surgical . The clinical consists basically of the use of drugs ; however , there are new techniques to complement this treatment , osteopathic intervention in the diaphragmatic muscle is one these . The objective of the study is to compare pressure values in the examination of esophageal manometry of the lower esophageal sphincter ( LES ) before and immediately after osteopathic intervention in the diaphragm muscle . Thirty-eight patients with gastroesophageal reflux disease - 16 su bmi tted to sham technique and 22 su bmi tted osteopathic technique - were r and omly selected . The average respiratory pressure ( ARP ) and the maximum expiratory pressure ( MEP ) of the LES were measured by manometry before and after osteopathic technique at the point of highest pressure . Statistical analysis was performed using the Student 's t-test and Mann-Whitney , and magnitude of the technique proposed was measured using the Cohen 's index . Statistically significant difference in the osteopathic technique was found in three out of four in relation to the group of patients who performed the sham technique for the following measures of LES pressure : ARP with P= 0.027 . The MEP had no statistical difference ( P= 0.146 ) . The values of Cohen d for the same measures were : ARP with d= 0.80 and MEP d= 0.52 . Osteopathic manipulative technique produces a positive increment in the LES region soon after its performance 
    Output:
    
The results of meta- analysis indicate that breathing exercises can improve pressure generated by the lower oesophageal sphincter ( LES ) , and a statistically significant difference was observed .
The possible mechanism behind this is the enhancement of the anti-regurgitation barrier [ especially crural diaphragm ( CD ) tension ] .
CONCLUSIONS To some extent , breathing exercises can relieve the symptoms of patients with GERD