Diaphragmatic breathing exercises and inspiratory muscle training can measurably strengthen the crural diaphragm, the muscular sling that wraps around the junction between your esophagus and stomach. Research shows these exercises increase the pressure at that junction, reduce acid reflux episodes, and ease symptoms in people with hiatal hernias and gastroesophageal reflux disease (GERD). The approach is not a guaranteed fix for every hiatal hernia, but the evidence is strong enough that it deserves a serious look as part of your management plan.
Why Your Diaphragm Matters for a Hiatal Hernia
A hiatal hernia happens when part of the stomach pushes up through the hiatus, the natural opening in your diaphragm where the esophagus passes through. The diaphragm is not just a breathing muscle. A specific portion of it, called the crural diaphragm, forms a muscular ring around the base of the esophagus. Together with the lower esophageal sphincter, this ring acts as one of the two main barriers preventing stomach acid from washing back up into the esophagus.1PubMed. The lower esophageal sphincter When that muscular ring weakens or stretches, the hiatus gets wider, and the stomach can slide upward more easily.
CT scan studies of people with hiatal hernias show that their hiatal openings are three to four times larger than those of people without hernias, and the muscular border of the opening appears visibly thinner, especially at the front edge.2PubMed Central. Morphology of the Esophageal Hiatus: Is It Different in 3 Types of Hiatus Hernias? The diaphragm is skeletal muscle, meaning it responds to exercise. It thickens and generates more force when you train it, just like a bicep. That principle is what makes diaphragm-strengthening exercises worth trying.
Inspiratory Muscle Training
The most studied method for strengthening the crural diaphragm is inspiratory muscle training, or IMT. You breathe in against resistance using a handheld device (often called a threshold inspiratory trainer), forcing the diaphragm to contract harder than it would during normal breathing. A landmark study measured the effects in GERD patients and found that the average pressure at the esophagogastric junction rose from about 20 mmHg to roughly 30 mmHg after training. During sustained deep-breath maneuvers, junction pressure jumped from about 90 mmHg to around 126 mmHg. The number and duration of transient relaxations of the lower esophageal sphincter, a key trigger for reflux episodes, also dropped.3American Journal of Physiology-Gastrointestinal and Liver Physiology. Inspiratory muscle training improves antireflux barrier in GERD patients In practical terms, the anti-reflux barrier got about 50% stronger, and the muscle stayed contracted more consistently.
These devices are inexpensive and widely available. A typical protocol involves breathing against moderate resistance for 20 to 30 minutes a day, usually split into two sessions. The resistance level is often set at around 30% of your maximum inspiratory pressure, though some protocols ramp up gradually. It feels like sucking air through a narrow straw, and it gets easier as the muscle strengthens.
Diaphragmatic Breathing Exercises
You do not necessarily need a device. Slow, deliberate diaphragmatic breathing, sometimes called belly breathing or abdominal breathing, also trains the crural diaphragm. The technique is straightforward: you lie on your back or sit comfortably, place one hand on your chest and one on your belly, and breathe in slowly through your nose so that your belly rises while your chest stays relatively still. You then exhale slowly, letting your belly fall. The goal is to make the diaphragm do more of the work of breathing rather than relying on your chest and neck muscles.
A systematic review of breathing exercises for GERD confirmed that the crural diaphragm is partially under voluntary control and that its dysfunction can be improved through deliberate breathing practice.4PubMed Central. Breathing Exercises in Gastroesophageal Reflux Disease: A Systematic Review The evidence is not as tightly controlled as the IMT studies, partly because breathing exercise protocols vary widely, but the direction of the findings is consistent: people who practice diaphragmatic breathing regularly report fewer reflux symptoms and less medication use.
One study tracked patients with non-erosive GERD who did abdominal breathing exercises over four months. Their symptom frequency scores dropped from about 27 to under 10. Among those who had been taking antacids every day, daily use fell from 34% of participants to zero by the four-month mark. The proportion of participants classified as good sleepers rose from 24% to 90%.5PubMed Central. Efficacy of abdominal breathing on sleep and quality of life among patients with non-erosive gastroesophageal reflux Those are substantial improvements, even accounting for the fact that an unblinded study like this carries some placebo effect.
Adding Biofeedback
Some clinics take diaphragmatic training a step further with biofeedback, where sensors give you real-time information about how strongly your crural diaphragm is contracting. A randomized pilot trial compared GERD patients who did diaphragm biofeedback training plus a standard acid-suppressing medication against patients who took the medication alone. The biofeedback group showed significant increases in crural diaphragm tension and overall junction pressure, while the medication-only group showed no change in those muscular measures. Over the longer term, the biofeedback group was able to reduce their use of acid-suppressing drugs.6Diseases of the Esophagus. Short-term and long-term effect of diaphragm biofeedback training in gastroesophageal reflux disease: an open-label, pilot, randomized trial
Biofeedback is not widely available and usually requires a specialized gastroenterology or physical therapy center. But the principle behind it is useful even without the technology. The challenge with diaphragmatic breathing is that many people unknowingly compensate with their chest muscles and think they are using the diaphragm when they are not. Any method that helps you feel or confirm the diaphragm is doing the work, whether it is a clinician’s guidance, a sensor, or simply paying close attention to where your breath moves, improves the quality of the exercise.
How Posture Affects the Hiatus
Strengthening the diaphragm matters more if you understand what works against it. A CT-based study compared people with pronounced thoracic kyphosis (a rounded upper back) against controls and found that the kyphosis group had significantly larger hiatal openings, averaging about 5.1 square centimeters versus 3.6 square centimeters in controls. The degree of spinal curvature independently predicted hiatal size.7PubMed Central. Association Between Thoracic Kyphosis and Hiatal Enlargement: A CT-Based Study Interpreted in Light of GERD-Linked Morphological Markers None of the subjects in that study had an overt hernia, but wider hiatal openings are the structural precondition for one.
This means that the hunched-forward posture many people develop from desk work or aging could be mechanically stretching the hiatus and making the crural diaphragm’s job harder. Strengthening the muscles that pull your thoracic spine into a more upright position, think exercises that open the chest and pull the shoulders back, may complement direct diaphragm training by reducing the mechanical forces that widen the hiatus. The research does not yet show that correcting kyphosis reverses a hiatal hernia, but it suggests that posture is one of the environmental factors worth paying attention to.
Exercises That Could Make Things Worse
Strengthening the diaphragm is different from general core work, and some exercises that seem like they should help can actually increase the risk of worsening a hiatal hernia or causing a recurrence after surgical repair. Any movement that sharply raises pressure inside the abdomen, heavy deadlifts, squats with maximal loads, intense crunches, or forceful Valsalva maneuvers (bearing down hard while holding your breath), pushes the stomach upward against the hiatus.
A study of patients who needed reoperation after laparoscopic hiatal hernia repair found that postoperative heavy lifting was one of the strongest risk factors for hernia recurrence, with odds more than five times higher compared to those who avoided it.8PubMed Central. Patient-related risk factors associated with symptomatic recurrence requiring reoperation in laparoscopic hiatal hernia repair Postoperative vomiting carried even higher risk. While this study looked specifically at the post-surgical period, the underlying mechanism applies more broadly: spikes in intra-abdominal pressure push stomach contents upward through the hiatus and can stretch the opening further.
The practical takeaway is to favor low-pressure, controlled movements when you exercise. Diaphragmatic breathing training is ideal precisely because it strengthens the crural diaphragm without producing the sharp abdominal pressure spikes that come from heavy lifting or high-intensity core exercises. If you do strength train, exhale during the effort phase rather than holding your breath, and avoid loads heavy enough that you need to bear down to complete the repetition.
What Happens to the Diaphragm as You Age
Hiatal hernias become much more common in older adults, and part of the reason is that the diaphragm weakens with age just like other skeletal muscles do. Research on diaphragm aging shows that transdiaphragmatic pressure, the force the diaphragm generates, drops by roughly 20 to 41% in older adults, with an overall decline in diaphragm strength of about 30%.9PubMed Central. Ageing of the Diaphragm Muscle That is a substantial loss, and it means the muscular sling around the hiatus has less reserve strength to hold things in place.
Ultrasound studies have established that a healthy diaphragm at rest is at least 1.3 mm thick in men and 1.1 mm thick in women, and that it should thicken by at least 40% when you take a deep breath.10Frontiers in Medicine. Ultrasound Assessment of Diaphragm Thickness and Thickening: Reference Values and Limits of Normality When in a Seated Position If your diaphragm cannot thicken adequately during breathing, it may not be generating enough force during the moments that matter most, like when you bend over, cough, or strain. The age-related loss of diaphragm strength argues for starting breathing exercises earlier rather than later, even if your hernia symptoms are mild. Preventing further weakening is easier than reversing significant atrophy.
Singing as Diaphragm Exercise
An unexpected finding from a German cohort study is that regular choir singing reduces reflux symptoms. The researchers proposed that the sustained diaphragmatic effort required for singing, especially the controlled exhalation and breath support, strengthens the crural diaphragm in much the same way that formal breathing exercises do.11Thieme Connect / Z Gastroenterol. The “Aachen sings” study (“Aachen choir engagement study into GERD symptoms”): moderate singing and breathing exercises in a choir reduce reflux symptoms – a cohort study in non-specialist choristers The study was small and observational, so it is not definitive. But for people who find isolated breathing drills tedious, singing offers a way to get sustained diaphragmatic work without it feeling like a medical exercise.
A case report similarly found that certain yoga breathing techniques, specifically vigorous abdominal breathing practices called Kapalbhati and Agnisar kriya, combined with standard acid-suppressing medication, improved severe GERD symptoms in a patient with a hiatal hernia who had not responded well to medication alone.12PubMed Central. Can yoga be used to treat gastroesophageal reflux disease? A single case report cannot prove anything on its own, but it aligns with the broader pattern: activities that demand deep, controlled, repetitive diaphragmatic engagement tend to help.
Osteopathic Manipulation and Manual Therapy
Some practitioners offer manual therapies aimed at reducing a hiatal hernia physically, by pulling the stomach back down below the diaphragm through external pressure and positioning. A published case report documented a hiatal hernia, confirmed by endoscopy, that was successfully reduced using osteopathic manipulative treatment. The patient’s reflux symptoms resolved without surgery.13PubMed Central. Reduction and Resolution of a Hiatal Hernia Using Osteopathic Manipulative Treatment: A Case Report The authors noted it was the first such documented case.
A single case report is the lowest level of clinical evidence, so this should be taken as a proof-of-concept, not a treatment recommendation. Manual techniques do not strengthen the diaphragm. What they may do is physically reposition the herniated portion of the stomach, potentially allowing the crural diaphragm to resume its normal function without the mechanical disadvantage of having a stomach pushing through it. Whether the effect lasts without ongoing treatment or concurrent diaphragm strengthening is unknown. If you are interested in this approach, seek a trained osteopathic physician rather than attempting self-manipulation, which could cause injury.
When Exercise Is Not Enough
Diaphragm-strengthening exercises work best for small sliding hiatal hernias, the type where the junction between the stomach and esophagus slides upward through the hiatus. These are by far the most common type and the ones most closely linked to reflux symptoms. Larger paraesophageal hernias, where a portion of the stomach rolls up alongside the esophagus, are a different clinical problem. They can cause obstruction, and in severe cases, the stomach can twist on itself, a surgical emergency called gastric volvulus.
A literature review of hiatal hernia management found that the indications for surgery remain clear: patients with paraesophageal hernias causing obstructive symptoms or volvulus need urgent surgical repair. For sliding hernias, surgery is typically considered when reflux symptoms persist despite medication, especially when regurgitation (not just heartburn) is the dominant complaint.14PubMed Central. The management of hiatal hernia: an update on diagnosis and treatment
Breathing exercises are not a substitute for surgery when surgery is indicated. But for the large majority of people with small to moderate sliding hiatal hernias managed with lifestyle changes and occasional medication, diaphragm training is a reasonable addition. The goal is not to close the hiatus entirely, which no exercise can do once the opening has stretched significantly. The goal is to make the crural diaphragm strong enough to generate better squeeze pressure around the esophagogastric junction, reducing how much acid escapes upward.
Putting a Routine Together
If you want to start strengthening your diaphragm, the evidence points toward a few practical guidelines:
- Start with belly breathing: Lie on your back with your knees bent, one hand on your chest and one on your abdomen. Breathe in slowly through your nose for four to six seconds, feeling your belly rise. Exhale slowly through pursed lips for six to eight seconds. Do this for 10 to 15 minutes twice a day.
- Consider an IMT device: A threshold inspiratory trainer set at about 30% of your maximum inspiratory pressure adds resistance to your inhale. Aim for two sessions of 15 minutes daily. The devices typically cost between $20 and $50.
- Avoid pressure spikes: While training, do not hold your breath or bear down. The point is to strengthen the diaphragm through controlled, sustained contractions, not explosive effort.
- Work on posture: Exercises that counteract a rounded upper back, like thoracic extensions over a foam roller, wall angels, and rows, may help reduce mechanical strain on the hiatus.
- Be patient: The studies showing improvement in junction pressure and symptom scores ran for at least several weeks, and the best results came at three to four months. This is a slow adaptation, like any muscle-building process.
You can do these exercises alongside acid-suppressing medication without any conflict. The biofeedback study specifically demonstrated that combining diaphragm training with medication produced better outcomes than medication alone, and that patients who trained their diaphragm were eventually able to reduce their drug use.6Diseases of the Esophagus. Short-term and long-term effect of diaphragm biofeedback training in gastroesophageal reflux disease: an open-label, pilot, randomized trial No study has shown that breathing exercises alone are enough to replace medication in moderate to severe GERD, but the consistent finding is that they reduce the amount of medication needed and improve quality of life on top of whatever treatment you are already doing.
Sleep, Timing, and When to Practice
Reflux tends to worsen at night, when you are lying flat and gravity is no longer helping keep stomach acid in place. This is also when a weak crural diaphragm becomes most consequential, because the barrier pressure needs to compensate for the lost gravitational advantage. The abdominal breathing study that tracked participants over four months found that sleep quality was one of the most dramatically improved outcomes, with the proportion of good sleepers nearly quadrupling.5PubMed Central. Efficacy of abdominal breathing on sleep and quality of life among patients with non-erosive gastroesophageal reflux
Doing a short diaphragmatic breathing session before bed may help for two reasons. First, it gives the crural diaphragm a final training stimulus. Second, slow deep breathing activates the parasympathetic nervous system, which naturally reduces gastric acid secretion and promotes relaxation. Some people also find it helpful to practice a brief session after meals, when reflux risk is highest, though you should stay upright while doing so. Lying down immediately after eating to practice belly breathing would defeat the purpose, since the horizontal position encourages reflux regardless of how well you are breathing.