Chinese research suggests that singing for 15 minutes each day can reduce the severity of supragastric belching.
Belching can be problematic at the best of times. But for the roughly 3% of patients with upper gastrointestinal symptoms, supragastric belching can be a real problem.
SGB refers to a behavioural disorder where involuntary diaphragmatic contractions cause air to rapidly move in and out of the oesophagus, leading to one or more burps.
“It is still not fully clear [what causes the involuntary diaphragmatic contractions in SGB], but current research suggests these involuntary contractions in SGB are likely tied to a learned, gradually automated behavioural pattern, with possible links to psychological factors,” lead author Assistant Professor Haitao Shang, from Qingdao Municipal Hospital in China, told Gut Republic.
Now, new Chinese research has explored whether a structured singing therapy can be used as a treatment for SGB. The findings were published in Clinical Gastroenterology and Hepatology.
Seventy-two Chinese adults aged 18-75 years with a diagnosis of SGB (defined as persistent belching occurring at least three days per week for six or more months) and accompanying “observable vertical laryngeal movement (distinct from swallowing) with characteristic pre-belching mouth closure and facial muscle contraction, and/or abrupt inspiratory arrest following deep thoracic inspiration due to glottal closure” were included in the trial.
Individuals with gastric and duodenal ulcers, gastric cancer, metabolic disorders (including poorly controlled diabetes and chronic kidney disease), a history of fundoplication surgery, or severe mental illness were excluded, as were people who were currently pregnant or lactating.
Participants were randomised to either singing therapy or diaphragmatic breathing (DB), with both interventions lasting one week.
The singing therapy intervention involved singing one of four standardised Chinese folk songs (with each song being around five minutes long, using visual and tactile cues to ensure they were sufficiently activating their diaphragm and a smartphone app to ensure the sung at the target vocal intensity of 80dB) three times per day, and were also instructed to sing for a further five minutes when symptoms appeared.
The DB group received specialised training to follow a standardised protocol that included education on the pathophysiology of belching, how to properly control their breathing, and how to progress from performing the breathing exercises while seated to doing them while standing.
Like the active intervention, the control group performed DB in three five-minute sessions each day, with an additional five minutes of DB when they felt symptomatic.
Belching severity was measured by a composite score of four different visual analogue scales ranging from 0 (asymptomatic) to 100 (maximum severity): symptom severity intensity, impairment of daily activities, perceived controllability, and functional interference in social contexts. While each item was scored individually, overall severity was the sum of each scale.
The primary outcome for the trial was the treatment response rate, or the proportion of patients who achieved at least a 50% reduction in their belching severity score between baseline and each of the follow-up time points. Secondary outcome measures included changes in self-reported quality of life, gastrointestinal symptoms, and anxiety and depression.
The one-week singing therapy resulted in significantly higher response rates than the equally long DB intervention at one week (72.2% versus 38.9%) and at one month (50.0% versus 30.6%).
Older age and baseline belching severity were identified as predictors of being a responder, after adjusting for factors including group allocation, sex, age, and BMI: each additional year of age increased the odds of being a responder by 10% (adjusted odds ratio and 95% confidence interval 1.10, 1.03-1.18) while each additional point on the baseline belching score increased the odds of being a responder by 2% (aOR 1.02, 1.01-1.04).
“Patients with more severe symptoms showed better responses, reflecting a hallmark of effective treatment,” the researchers wrote.
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“Older age [also] emerged as a significant positive predictor, potentially owing to age-related respiratory changes that increases susceptibility to diaphragmatic dysfunction.
“Importantly, singing may improve respiratory efficiency in older adults by enhancing diaphragm function and lung capacity. Furthermore, advanced age is associated with better emotion regulation, which may contribute to improved treatment outcomes.”
The researchers did not assess the singing habits of participants, with Professor Shang suggesting that prior singing (professionally, recreationally, or for treatment purposes) would not have impacted the results.
“The benefit came from rhythmic exhalation during daily vocalization, not pitch or skill; anyone who hummed or sang regularly – even off-key – disrupted the air-swallowing reflex, and consistent practice likely prevents recurrence by reinforcing that breathing pattern,” they said.
In comparison to DB, singing therapy also led to greater improvements in self-reported health-related quality of life (as measured via the EuroQol visual analogue scale) at the end of treatment. However, there was no significant difference between groups at the one-month follow-up.
In addition, singing therapy did not lead to improvements in gastrointestinal symptoms such as diarrhoea, indigestion, and reflux (as measured by the Gastrointestinal Symptom Rating Scale), anxiety (via the Generalised Anxiety Disorder scale), depression (via the Patient Health Questionnaire) when compared to DB.
Participants in the singing therapy group reported greater treatment acceptability scores than participants in the DB group (raw values not reported). Participants who responded to their randomised treatment rated their treatment as more acceptable than participants who did not display a response. The larger the improvement in belching scores, the more acceptable the treatment was deemed to be.
“Singing therapy may ameliorate belching through mechanisms potentially shared with DB,” wrote the researchers.
“First, both interventions likely reduce belching by attentional diversion, as distraction-based attentional modulation has been shown to alleviate belching.”
“Second, although existing literature indicates that both singing therapy and DB possess anxiolytic effects, our analysis revealed no statistically significant difference in anxiety reduction between the interventions. Consequently, we were unable to determine whether improvements in belching were mediated via anxiety-reduction pathways.”
One potential limitation of the study was that it was not possible to determine how much of the observed effect on belching severity came from the singing compared to the educational part of the intervention.
“Since SGB is fundamentally a behavioural disorder, all participants first received identical, standardised education on its pathophysiology to build shared treatment confidence across both groups,” the researchers said.
“While we cannot precisely quantify the exact proportional contribution, the nearly twofold gap in one-week symptom response rates between the two arms strongly confirms that the vast majority of the observed efficacy directly comes from the structured singing therapy and diaphragmatic breathing interventions themselves.”
Professor Shang told GR that a study testing a singing therapy intervention of longer duration (four weeks) in SGB was currently underway.
