Nikki Martin: Speech Pathology, Laryngology & Silent Reflux

Have you ever heard of silent reflux? In this week’s episode, we are going to talk about this and a whole lot of other things.

My guest today is Nikki Martin. Nikki is a skilled Speech Pathologist with 22 years of experience. She has an immense experience in Voice and Swallowing problems, with an exceptionally high client success rate. I had the pleasure of being referred to her for my own issue around silent reflux. And I was just blown away by Nikki’s holistic approach to this.

Join me in this conversation as Nikki and I discuss laryngology, paresis, silent reflux, and so much more.

Nikki Martin: Speech Pathology, Laryngology & Silent Reflux Introduction

Now, today we are going to be exploring speech pathology and something called silent reflux, which is a huge problem which can go on for many, many years and can go untreated and irritate not only the sufferer, but all those around them as people have chronic coughs and are always clearing their throat and may not be enjoying the best of health, even though they could and should. In fact, in order to solve a problem, it always helps to know what that problem is. And so today’s episode will be particularly enlightening for many.

We’re exploring the world of speech pathology. In speech pathology with, as we did earlier last year with Sharon Moore, who wrote the book Sleep-Wrecked Kids, and in that particular episode, we explored speech pathology and myofunctional therapy and the influence that the lip and the tongue and cheek have on swallowing patterns and airway in predisposing people to nasal breathing or mouth breathing. Well, the world of speech pathology encompasses even more than that and Nikki Martin is our guest today.

Podcast Transcript

Dr Ron Ehrlich: [00:00:00] I’d like to acknowledge the traditional custodians of the land on which I’m recording this podcast, the Gadigal people of the Eora Nation and pay my respects to their Elders past, present and emerging.

Hello and welcome to Unstress. My name is Dr Ron Ehrlich. Now, today we are going to be exploring speech pathology and something called silent reflux, which is a huge problem which can go on for many, many years and can go untreated and irritate not only the sufferer, but all those around them as people have chronic coughs and are always clearing their throat and may not be enjoying the best of health, even though they could and should. In fact, in order to solve a problem, it always helps to know what that problem is. And so today’s episode will be particularly enlightening for many.

Dr Ron Ehrlich: [00:01:00] We’re exploring the world of speech pathology. In speech pathology with, as we did earlier last year with Sharon Moore, who wrote the book Sleep-Wrecked Kids, and in that particular episode. 

We explored speech pathology and myofunctional therapy and the influence that the lip and the tongue and cheek have on swallowing patterns and airway in predisposing people to nasal breathing or mouth breathing. Well, the world of speech pathology encompasses even more than that and Nikki Martin is our guest today.

Now, Nikki is someone she’s a speech pathologist with over 20 years of experience in both the public and the private sector, and I had the pleasure of being referred to her for my own issue around silent reflux. And I was just blown away by Nikki’s holistic approach to this and how far-reaching so much of what she taught me had on so many other aspects of health. So I was really keen to share her with you. And so I hope you enjoy this conversation I had with Nikki Martin. Welcome to the show, Nikki.

Nikki Martin: [00:02:13] Thanks, Ron. Thanks for having me.

Dr Ron Ehrlich: [00:02:15] Nikki, you are a speech pathologist and as we’ve learnt on this programme, speech pathology. There’s a lot more to speech pathology than people may imagine. One of the things we explore frequently on this programme are things that we take for granted, and swallowing is another one of those things which people give very little thought to. 

Dr Ron Ehrlich: [00:02:34] Tell us what a good swallowing pattern is.

Nikki Martin: [00:02:37] There is no good and there is no typical because…

Dr Ron Ehrlich: [00:02:41] …ideal.

Nikki Martin: [00:02:42] It’s yet. So the ideal is it goes down the right way and doesn’t go into your lungs. But we are poorly designed in terms of we’ve got one shooter bifurcates into two tubes, one goes into the airway, our lungs, and one goes down into our stomach. So at that bifurcation point, there is obviously a possibility that food, fluid, and saliva can go down the wrong way into the lungs and vice versa air can go into the stomach.

Now we all know what happens when we accidentally, you know, whether we’re eating too quickly or we take too big a mouthful, something goes down the wrong way. We go into a horrendous coughing spell and it’s very uncomfortable. But the cough is designed to protect our airway and to prevent any infection. 

Now, when you have neurological changes so either directly from the brain or from the nerves lower down or you’ve got a direct injury to the throat and those aspiration events start to become more consistent. Or there’s a phenomenon called silent aspiration, where the cough reflexes are dampened to such an extent that there is no cough, so food and fluid and saliva are going into the airway unannounced. All of those situations can cause what’s called aspiration pneumonia, and that can be fatal.

Dr Ron Ehrlich: [00:03:57] Hmm. Well, but also, I mean, I know that’s when we get past the back of the mouth. It’s got to go down that right tube. There’s something about the tongue position which helps ensure that or when you know, people, yeah, talk to us that.

Nikki Martin: [00:04:14] It’s multifactorial. So there are three phases of the swallow. There’s the oral phase, there’s that pharyngeal phase and the oesophageal phase. So in terms of speech pathology, we’re really focussed on the oral and pharyngeal phase in some of the upper oesophageal. So you need adequate mastication. You need adequate tongue movement to form a bolus. 

You need soft palate elevation to seal off the nose or pharynx. Otherwise, you can get some nasal regurgitation of food and fluid in saliva. And you need contractions of all the muscles at the back of the throat to then stop the peristaltic movement from the top of this oesophagus down to the stomach. So it’s a highly coordinated movement and process and any issues along any step of that process can cause swallowing problems.

Dr Ron Ehrlich: [00:05:01] Now I know with kids, you know, getting into a good swallowing pattern is very much part of breastfeeding, isn’t it?

Nikki Martin: [00:05:07] Yes.

Dr Ron Ehrlich: [00:05:08] But things can go wrong, even at that early stage, can’t it?

Nikki Martin: [00:05:12] Definitely.

Dr Ron Ehrlich: [00:05:12] Tell us a bit about what can go wrong there.

Nikki Martin: [00:05:15] Look, it’s not so much my area like I haven’t done it for like twenty-one years.

Dr Ron Ehrlich: [00:05:19] Okay.

Nikki Martin: [00:05:20] But so, so essentially the solo mechanism or the swallow reflex gets developed at 30 weeks, just 32 weeks gestation. So any baby that’s born prior to that will not be born with a swallowing defect.

Dr Ron Ehrlich: [00:05:32] Oh wow. Okay.

Nikki Martin: [00:05:32] So you have to stimulate it. And then on top of that, those highly preemie babies have so many tubes in their throat that it again dampens their swallow reflex. So at that stage, you’re looking for tongue thrust and you’re looking for, I mean, the big thing at the moment, and again, I’m not so into this is tongue ties, but they’re looking at the curvature of the tongue and whether they can scrape it and then suck it back. 

But there are so many different conditions there’s like tracheomalacia, where the airway and the upper airway don’t develop properly, and so they’re more likely to aspirate. So there’s a whole lot of things, but that’s not my area.

Dr Ron Ehrlich: [00:06:11] And then as we get older and some of the neurological problems, I mean, you introduce me to this word, which I should have known – paresis.

Nikki Martin: [00:06:20] Paresis. Yes.

Dr Ron Ehrlich: [00:06:20] Yes. Tell us about paresis.

Nikki Martin: [00:06:24] It’s not that familiar in the medical, I think a lot of laryngologists and people doing this sort of work know about it. Everyone is familiar with the term paralysis. Paresis is really something that I’ve been aware of in the last 10 years of my profession. So paralysis is essentially a total loss of function and paresis is a partial loss of function. So the nerve has been damaged. 

You don’t get complete loss of function, but you can get some really strange motor and sensory results from that damage. So and it can cause some quite profound impacts on voice and swallow function.

Dr Ron Ehrlich: [00:07:01] And that can go back a long way. I’m kind of I mean, I know we have this idea in chronic pain muscles have memory, but so do the nerves, and that’s why they have memory. I guess. This is a good example, could you introduce me to, well, you introduce me to something else, and that was the world of laryngology.

Nikki Martin: [00:07:21] Yes.

Dr Ron Ehrlich: [00:07:22] Laryngology. As a speech pathologist, this is your area of speciality. And paresis is an important part of that. Tell us about Laryngology, because a lot of people may not have even heard of that.

Nikki Martin: [00:07:33] So laryngology is essentially a practise that focuses on any disorders of the larynx. So the larynx is the voice box, and the voice box is responsible… Well, the muscles of laryngology are responsible for both voice and swallow production. Can I just backtrack for a second to the paresis? I think the reason why paresis hasn’t been mentioned so much until recently, we essentially didn’t have diagnostics to be able to perceive it. But so especially, you know, in with the vocal folds.

The vocal folds vibrate so quickly that if you’re looking at them with the naked eye, it looks like they’re moving in a horizontal pattern. What they’re actually doing is they’re moving in a wave-like pattern, and it was only when stroboscopy and really high definition stroboscopy, which is a light source that flashes at the same frequency that the vocal folds vibrate that slows it down, and you can visualise that. 

And it’s only when you can say that that you can start to see some slight asymmetry. Some like what’s called glottal incompetence, which is when the vocal folds don’t come together. So there’s essentially an air leak, so you don’t get power behind the voice and there’s an increased space where someone can aspirate through.

Nikki Martin: [00:08:47] So I really think it’s got to do with as medical technology advances. Then we start to pick things up and then I look back on my practise, say, 20 years ago and some of the patients that were potentially diagnosed as being hysterical or it’s, you know, it’s all in their head or it’s a psychiatric condition. I don’t think that that was the case. 

It was because we didn’t have the tools to be able to see what was going on and the symptomatology didn’t align with what we could actually diagnose. And so that’s changed practise dramatically, I would say, in the last decade.

Dr Ron Ehrlich: [00:09:23] And wow. You mean, you know, that’s so common, isn’t it? It’s the practitioners themselves who don’t know what the problem is rather than say, “You know what? I don’t know.” Often it’s, “Ahh! It’s all in your head. You’re fine.” And the other one that’s interesting is you talk about stroboscopy giving you the opportunity to look at things. In dentistry, 3-D X-rays have been a total revelation, even after 40 plus years of practise.

So the area of learning laryngology that I know we met for and we, you know, we’ve kind of interacted on a professional basis is this issue of silent reflux. And we touched on reflux in several other episodes we did with integrative gastroenterologist Pran Yoganathan and with sleep physician Jim Papadopoulos, but your practise focus is very much on silent reflux. Can you tell us what it is and how common it is?

Nikki Martin: [00:10:19] It’s very, very common. And the reason that I’ve sort of segway-ed into it is that I found that there’s a real gap in the market in terms of a lot of these people will report the symptoms. They’ll go to the GP or the gastroenterologist and they’ll be put on a medication and they’ll just be sent on their way. 

And that’s only like a very small part of reflux management and the reason why I really got into it aside from it, you know, directly affecting my clients is that I experienced, I’ve experienced silent reflux for the last 20 years. And so anything that I have done and has worked is what I roll out to my clients.

Nikki Martin: [00:10:54] And what I found is that silent reflux can have a really profound negative impact on people’s quality of life. So, you know, it can be anything from, you know, consistent throat discomfort, constant voice problems. In extreme conditions, it can cause swallowing problems. It can exacerbate chronic coughs. And, you know, because it is a lifestyle, diet-related and in my perspective, I use medication to treat the reflux when it’s acutely out of control. I tell all my clients that it’s no different to a muscle injury. 

Once you’ve got it, you’re prone to it. So if you get an upper respiratory tract infection again, or if you know your diet and your lifestyle changes significantly, you can get a flare-up so that the times you’re going to be using the medication. But really, long term, it’s going to be diet and lifestyle changes and figuring out the triggers for that individual. And no two people have the same symptoms.

Nikki Martin: [00:11:53] So there is not one fit for everyone. So you really got to spend time with people figuring out what is the triggers for them. How bad is it? Is it? Is it more morning? Is it nighttime? Is it exercise-induced? Is it more diet-induced? You know, and taking the time to go through with them and. As soon as you give people awareness and you educate them, it’s almost like a light bulb goes off. 

You know, I always find it fascinating how disconnected people can be from their bodies. People only stopped paying attention to things when things really go wrong. And, you know, and in some cases and thankfully not so much with reflux, you know, often that’s too late.

Nikki Martin: [00:12:40] So, you know, I kind of try and draw their attention to that your body is a highly intelligent organism and you’re taking it on this journey of your life. So you should treat it with the same respect that you’re essentially treating everyone else. You shouldn’t be dragging it through life. 

So it can create quite a profound change in someone’s existence when all of a sudden they can resume eating without having a negative consequence and eating really other than sustenance to the body is for pleasure and for connection with other people, and also be able to talk and not have to be concerned about what’s going to come out. How am I going to sound? Is it going to hurt me? Am I going to have to suffer for the next three days because I went out for dinner with my friends? 

So, yeah, so it’s great when you get a good result and it’s not that difficult to fix. I mean, obviously, there are some, you know, people that have structural abnormalities, such as impairment in their lower oesophageal sphincter, certain hernias, etc. So some people do need to take medication long term. But I’d say 90% of cases, diet control and medication to reset the system is enough.

Dr Ron Ehrlich: [00:13:51] Hmm. And it’s interesting to hear you say you’ve had you experienced this yourself for 20 years because, as you know, only too well, Nikki, I experienced it for over 35 years, and that manifested itself as a clearing of the throat or a chronic cough. So, so you mentioned you touched on some of those interventions and make the point quite right that it’s personalised. But let’s look at those in a little more detail about what some of those interventions are or triggers.

Nikki Martin: [00:14:22] So probably the primary trigger in Western society, I would say, is caffeine and alcohol, and that’s what most people consume. And, you know, like people think that having six cups of coffee a day because it keeps them alert, you know, the stimulant properties they can focus. It is so bad for you. It is a muscle relaxant. 

It releases the lower oesophageal sphincter and you get a free flow of stomach contents and you can get it all the way to the back of your throat. And because it’s silent and because it’s not giving you pain, you know, people can be throat clearing, have a lump in their throat and the people that will notice that will be their partners or their colleagues.

Dr Ron Ehrlich: [00:15:08] Oh yes. yes. Well, you know, stop at the coffee there. Because I remember one of my habits was to because I do a lot of intermittent fasting. I might not have my first meal until about 11 or 12. And so in the morning, I did have two cups of coffee and you said, “No, no, no, no.” All the things you just said and I eliminated those immediately on your advice and I noticed and my wife particularly noticed a significant improvement. So yeah, I can attest to that coffee. But interesting to hear you talk about it as a stimulant to relaxant of muscle and the flow on effect. And you know, coffee’s a religion to many people. 

Nikki Martin: [00:15:44] Absolutely. And it’s the hardest thing that I have to break in people. You know, two cups of coffee a day, no problem. Or it’s actually two cups of caffeine. And that’s a thing that a lot of people don’t realise. Caffeine comes in many different forms. It’s tea, it’s green tea and green tea is probably the biggest misconception people think because it’s herbal tea, it’s OK. It is still caffeine. It is young black tea. So if you’re having six cups of green tea and you’re clearing your throat and coffee, you’ve got a cause for it. And chocolate as well. And obviously, coke. But you know, like a lot of people are more…

Dr Ron Ehrlich: [00:16:20] As in Coca-Cola?

Nikki Martin: [00:16:21] Coca-Cola, yup. Cocaine is a whole other thing. So yeah, so it’s so intermittent fasting has brought a lot of reflux to a lot of people and it’s something that I’ve had to morph my recommendations to satisfy, you know, the eating window and the fasting window. And because a lot of people with intermittent fasting often follow Bullet-Proof, coffee on an empty stomach with the fats and everything, is just a recipe for disaster.

Dr Ron Ehrlich: [00:16:51] Really. From a silent reflux point of view, Bullet-Proof Coffee, which I think has got MCT oil and coconut… 

Nikki Martin: [00:16:59] Well, some people use butter.

Dr Ron Ehrlich: [00:17:01] Butter. Yes.

Nikki Martin: [00:17:03] Yes. So it’s a high-fat source, plus a very high caffeine source, and you’ve been fasting for a period of time. And even though your body gets used to it, so reflux can start from having too many acidic items, but it can also happen if your body is hungry and you’re not feeding it.

Dr Ron Ehrlich: [00:17:21] Mm-Hmm.

Nikki Martin: [00:17:22] What’s happening when you’re intermittent fasting because you’ve and especially the ones that have a bigger fasting window and a shorter eating window by the time you’re eating, your body is craving food. So if the first thing that you’re introducing is caffeine, which is a diuretic, it’s a muscle relaxant and then very high fats, right back up.

Dr Ron Ehrlich: [00:17:44] I wonder whether… This is interesting because let’s stick with this intermittent fasting story because having said that, I wonder whether it’s better to front-load the fast, the eating part in the first part of the day because I know we sleep better if our stomach isn’t that full, so we may have got this little bit… Backwards.

Nikki Martin: [00:18:03] Absolutely. You know, I used to look at my grandparents who immigrated from Europe and their whole eating pattern was essentially, you know, breakfast is the biggest meal of the day, lunch, the second biggest meal of the day and dinner is the smallest. 

And western society over the last few years has flipped that. And I think that they were on to something, you know, and we should definitely be going to bed, you know, for a start, you should be having a two-hour gap before you eat and lie down. And that’s another way that a lot of people get into problems with reflux. A lot of people ate and then go and slouch on the couch to watch TV. Yeah, I agree with you. It should be food, then caffeine and then smaller meals throughout the day.

Dr Ron Ehrlich: [00:18:47] So what do you say to somebody who has got that window later in the day? What’s a good way to start the day if you are intermittent fasting?

Nikki Martin: [00:18:55] I just always say, have something to eat first. So just anything it doesn’t make like cause people to get into very strong patterns. We think so. If they’re so set on having their tea in their coffee first thing and a lot of people do that, I think, to essentially block themselves from feeling hungry for a period of time. 

So don’t drink, drink, drink, drink, drink. They’re cutting down their calories, but they don’t realise they’re creating another problem and then they’ll have one meal a day later. So what you should do is, even if it’s a small handful of nuts, just have something lining your stomach, then have your coffee or your tea.

Dr Ron Ehrlich: [00:19:34] And when you say tea, green tea is high in caffeine. What is some tea, well, I guess herbal tea, some herbal teas?

Nikki Martin: [00:19:40] Well, the hard thing is that with a lot of the herbal peppermint and the mint family is also a muscle relaxant, so also causes reflux. So the problem with a lot of the herbal teas is a lot of the main constituents taste horrific. So what they do is they try to mask it with some of the nicer tasting things and that will be green teas or the mint family. So you’ve got a mixed herbal tea that will cause reflux.

So the ones that are the best ones – are jasmine tea without green tea, rooibos tea, dandelion tea, and chamomile tea. And camomile is probably the best. But the problem with chamomile is most people associate that with having later on in the night to induce sleep. They are more resistant to having that during the day. But any of those and when in doubt, water is your best friend.

Dr Ron Ehrlich: [00:20:30] And you mentioned alcohol. You know, I think to anybody that’s gone alcohol-free for any period of time, you realise how ubiquitous it is. What’s a responsible way of approaching that apart from complete elimination from a silent reflex perspective? 

Nikki Martin: [00:20:50] OK. So all alcohol is acidic. Anything with carbonation, so champagne, beers, ciders. They’re going to be the worst because anything with bubbles that can make you burp, it’s hitting the back of your throat. So then you’ve got a carbonated drink and an alcoholic drink. And then on top of that, alcohol is a muscle relaxant, so it has the same effects as caffeine when it releases a lower oesophageal sphincter.

So alcohol in moderation is definitely the best way to deal with it. Also, alternating alcohol with water to counteract its diuretic effects as well. And if in doubt, if you do start… Oh, the other thing that I tell people is if you find alcohol that works for you, stick to it. So there, so white wine is more acidic than red, rosés in the middle. So is if someone’s a white wine drinker, Pinot Grigio tends to be milder than the white. In terms of the Reds, Pinot Noir and Sangiovese are the lighter ones. And if you have any problems, you cover them with an antacid Gaviscon after. 

Dr Ron Ehrlich: [00:21:58] Now you did mention that I know that medication is part of the at least short term approach. You’re not advocating it for long term use. Talk to us a little bit about these, these antacid, well, you know, protein pump, Gaviscon, and all that. Tell us a bit about that.

Nikki Martin: [00:22:16] So the reason why LPR or silent reflux is really hard to treat is like I said before, they’re often given a class of medication called a PPI or there’s another class of medication called H2 antagonist. OK, and both of them are acid suppression medications working with different pathways. So in severe cases, you can put people on both of those medications. You can layer them.

Because there are two types of reflux, there’s gastroesophageal reflux disease (GERD) which is more heartburn and you feel it and that stomach contents going up the oesophagus. And then there’s the LPR, so the stomach contents are going to the throat to laryngopharyngeal reflux. 

Nikki Martin: [00:22:58] With GERD, if you put them on a PPI or an H2 antagonist. That alone is often enough to treat it. Now because with LPR, you’ve got stomach contents hitting the back of the throat, the lining of the vocal folds is mucosal tissue, which is the same as the tissue inside of our mouth, and it only takes one or two reflux events before they become tissue change and inflammation.

Now there are lots and lots of studies that show in even in extreme conditions, when you look at medication and diet control, certain people take six months to respond to treatment. OK, so GERD and LPR are two very different animals and very different treatments. So the reason why a lot of people get put on these PPIs or H2 antagonists and get told to go and then as still not symptom-free is because when we reflux, we reflux everything in our stomach and in our stomach acid and enzymes. 

So if you’re only taking a medication that treats acid, only doing 50% of the job at the level of the throat, the enzymes are just as damaging as the acid. So you need an antacid like Gaviscon. So you need the two in combination. So either a PPI and Gaviscon or a PPI and an H2 antagonist and the Gaviscon.

Dr Ron Ehrlich: [00:24:16] So the Gaviscon focuses on the enzyme.

Nikki Martin: [00:24:19] Yes.

Dr Ron Ehrlich: [00:24:19] Okay, okay. It’s disgusting. I know that.

Nikki Martin: [00:24:23] It is disgusting but the mixed berry flavour is so much better than the other two than the peppermint and the…

Dr Ron Ehrlich: [00:24:29] Yes, it’s less disgusting. It is less disgusting, but okay. So coming back to paresis, the thing that surprised me as well because as I said the long history of it was this idea that nerves can be damaged by an old respiratory, viral or bacterial infection, which is a huge issue for so many people when they’re younger or when any time, really, we’re just living through a pretty big respiratory issue at the moment. But that kind of thing can damage a nerve and affect you for years and years and years later

Nikki Martin: [00:25:06] Yes, I think they don’t know why it happens in certain people and why it doesn’t, and why one particular infection is enough to tip someone over the edge. The theory is that in some people that the nerves can lie closer to the edge of the surface. And then the bacteria or the virus gets in temporarily stops the nerve working and then when it starts refiring it’s misfiring, essentially.

So the thing is that with someone who has a very old injury, the infection at the time can be completely innocuous. It can be a very mild cold so you don’t pay attention, and it can take some period of time for the symptoms from that nerve injury to really amp up. And if you’re in that kind of mild category where you’ve just got like a throat clear or a cough, but it’s not really affecting your voice or it’s not really affecting your swallow, you don’t pay attention to it until something compounds it and it forces you to…

Dr Ron Ehrlich: [00:26:09] I know that in my own case, whenever I would get a cold or flu, it would usually take me weeks and sometimes months to get over the chesty coughy type thing. And I guess that would be a perfect set-up for full paresis, for damaging nerve and muscle function.

Nikki Martin: [00:26:27] Definitely. And you know what? I always ask people, you know, people seem to have like a predisposition to have specific types of infection, and in my experience, it’s either it’s like everyone gets a sinus infection, it’s a right infection or a chest infection. And so people have like a weakness in one of those three systems. And it’s definitely the people, like you just said, that are prone to these kind of upper respiratory tract infections and cough that are more likely to to get these types of injuries.

Dr Ron Ehrlich: [00:26:57] Mm-Hmm. The other thing is, I think what I’ve observed is the relationship with water consumption and eating, you know, and I know that I go, you go to, for example, the worst thing. The worst thing that can happen is you go to a restaurant, someone walks up to you, go, will that be still or sparkling? And you go all that sparkling and they start pouring. And because they want to be good waiters, they keep pouring and keep pouring through your meal. So you are adding this into diluting and fizzing up, you’re setting up. It’s a perfect storm, really, isn’t it?

Nikki Martin: [00:27:34] Totally. And also, you know, the big SodaStream has gone. It has exploded in the last five years and people have a real aversion to drinking water. It’s something in how where we’re brought up that we must have flavour it with everything that we eat. And when it has no flavour. So I’m just not going to touch it. If he doesn’t, if I add bubbles, at least it makes it more interesting. 

So, yeah, so the bubbles and carbonated drinks are in moderation. Everything in moderation is fine. It’s when we start doing things, you know, when we start tipping the scale to more 60 to 80%, that’s when you start having problems. So, yeah, so my advice is to cut anything with bubbles down and you’re already on your way to improving your gastric health.

Dr Ron Ehrlich: [00:28:25] I can definitely attest to that. And I was a huge bubbles person because I tried, you know, reducing alcohol intake is good and I thought I’d treat myself with a few bubbles. But you alerted me to the folly of that way.

Another thing that you’ve done, now, so we kind of talk about the whole coffee, alcohol, fluid intake, antacid intake only for and we’re talking about for about four to six month period, really, aren’t we? We’re not talking about long term use.

Nikki Martin: [00:28:56] No, no, no, no, no. So, you know, so in my clinical experience, I can count on one hand how many people have required six months of medication use prior to achieving partial or complete resolution. So they’re definitely in the minority. I’d say the majority of my clients are on these medications for six to 10 weeks and then I’m tapering them off. 

Dr Ron Ehrlich: [00:29:20] Oh, great. So it’s even less, even less than that. Yes. Yes. 

Nikki Martin: [00:29:24] So great rule of thumb is that the longer the person’s had the problem, the longer it takes to remediate the issue. So if someone catches it really quickly, so I think. So at the moment if someone has COVID and has been coughing their guts out for the last two months, it’s generated reflux. I can fix that in four to six weeks in most cases.

If someone has a 30-year history of reflux, it can take longer. But probably the difficult part was that I had people complying with the recommendations. So people are either not great at taking the medication or they’re non-compliant with the diet part, or they’ll do some of the diet parts, but not all. And so if you completely commit to the process and do it for four to six weeks, you’ll get the results.

Dr Ron Ehrlich: [00:30:14] Hmm. I can attest to that. And I remember after a week, the first week or two of you know, you were helping me through this and I came back to see you and you said, “How’s it going?” “Well, you know, it’s funny. I wasn’t sure there was much improvement.” But when I told my wife I was coming to see you professionally, she said, “Wow, there’s been such an improvement.” And I go, “Oh, wow, okay.” So best to ask your partner, well people around you.

So, Nikki, another thing that you introduced me to was This Breather Fit. So I thought, I think it’s fantastic and I’m kind of really excited about it for my own practise, but tell us a little bit about Breather Fit. About what it is or how you got into it.

Nikki Martin: [00:30:56] Sure. So the breather in The Breather Fit two devices that come under the umbrella of what’s called RMST, which is called Respiratory Muscle Strength Training and both of the devices, both inspiratory and expiratory muscle strength trainers. And so it’s a resistive device. And so you breathe in and out of the device. And because you’ve got a load against the internal muscles, it develops strength and changes muscle patterns. And the other thing that it does as well is it works on neuroplasticity.

So if you’ve got impaired neural connections that are responsible for either voice or swallowing, you can set up new neural pathways to overcome and so it creates better muscle contraction. So in terms of my practise, it’s kind of catapulted all of my clients’ outcomes.

Nikki Martin: [00:31:47] So traditionally, speech pathology has been centred on voice exercises. A lot of the voice exercises are focussed on what’s called semi occluded vocal tract exercises. So it can range from lip trilling humming and what I found was doing those exercises will change the muscle patterns while you’re doing them, but it doesn’t have such longevity with changing the muscle pattern.

What I find with RMST is, and I tend to combine traditional speech pathology practises in combination with RMST. You get long term, permanent muscle change. And the beauty of it is it’s a device. People can see it. People are motivated to do it because they can see changes from the device really quickly in probably about 90% of cases. 

People can see changes within 24 to 48 hours. It strengthens coughs, it improves voice projection. It reduces vocal effort. It improves lung function. There was a study out of, I think it was Colorado last year that shows that the inspiratory side reduces blood pressure and reduces heart… 

So it’s targeted towards not just voice and swallow clients, in my personal experience and my personal recommendation, everyone can find a benefit to it regardless of whether it’s, you know, voice swallow, fitness, breathing. It helps, it reduces snoring. So it’s got wide-ranging applications and it’s easy to use. People are motivated to use it. It takes four minutes a day.

Dr Ron Ehrlich: [00:33:20] Yeah, no, no. Look, I’m in here. Here is my Breather Fit, which is just actually nothing more than it looks like a pipe, except instead of a little something to hold the tobacco. It’s a bowl with too little resistance, once for the inhale and once for the exhale, and by twisting the resistance you up the exercise. And it’s literally I think I’ll demonstrate it. (demonstrates)

Nikki Martin: [00:33:48] Slow it down, Ron.

Dr Ron Ehrlich: [00:33:50] Slow it down. I was just demonstrating that. Yes, I know, but that’s interesting. So slow it down. So it actually is. I’ll do it again because I do think it’s worth it. This is so because we talk about breathing and sleeping and snoring. And here you are talking to me about solid reflux and laryngeal muscles that are, you know, affected by paresis. This is what I love about this, the simplicity of it. So an ideal way of doing it would be…

Nikki Martin: [00:34:20] I always get people to inhale first. I find you get more traction and the way that I try to explain it is that the slower you do it, you’re getting more expansion and contraction so better muscle recruitment and then… with what you just said before in terms of paresis. So if you’ve got a paresis. 

So once the nerve gets impacted, you can have impaired movement, but you can have impaired sensation as well. And once you get impaired movement, there’s a possibility that you get wasting of the muscle. And so then you get glottal incompetent. So you don’t get the vocal folds coming together. So the device gives you more kind of stake awareness of what the muscles are doing.

Nikki Martin: [00:34:58] What tends to happen with the paresis is you get a compensatory muscle pattern called muscle tension dysphonia, where you’ve got the ventricular folds, which are next to the vocal folds and they start to tighten to slam those vocal folds together. So by doing the device, you get retraction of those ventricular folds so you don’t get this really tight muscle pattern, you get better project projection in terms of the silent reflux as well. 

It’s got a tonal effect on the oesophagus and they’re looking at studies. And there has been some studies on RMST that show that you can have a tunnel effect on the lower oesophageal sphincter as well. So there are a lot of positive reports in terms of its effect on silent reflux as well.

Dr Ron Ehrlich: [00:35:37] And what I’ve noticed is because of the focus on diaphragmatic breathing while I’m doing this, you know, it’s toning up my diaphragm. And interestingly, an integrative gastroenterologist have mentioned that he felt that reflux gastro – GERD, gastroesophageal reflux is more a function of diaphragmatic sarcopenia, which means underdeveloped diaphragm. So when he said that, from a gastroenterologist, and you give me this, which also apart from toning up my laryngeal and pharyngeal muscles..

Nikki Martin: [00:36:16] it essentially has a tunnel effect from other muscle groups, from your perineum up to your nasopharnynx. 

Dr Ron Ehrlich: [00:36:22] Which is another aspect of that. That was the other thing. Perineal tone is, you know, something we all need to improve as we get older. I mean, certainly for women after they’ve had children not to go to and for all of us as we get older, toning up the pelvic floor muscles. And this is what I love about this. It’s kind of taking this more, looking at the whole body effect of what’s going on here and probably improving digestion in the process as well. 

Nikki Martin: [00:36:51] Absolutely, absolutely. So like I said, you know, it’s got so many applications and you know, like it doesn’t make a difference. What I find really interesting about it is, you know, like I’ve had some clients that like I can have a marathon runner. And what is a marathon is at 52…

Dr Ron Ehrlich: [00:37:07] I think at 42.

Nikki Martin: [00:37:09] It’s at 42. Okay.

Dr Ron Ehrlich: [00:37:10] Last time I did it. I can’t, you know, I went through the wall at around two or three and the rest is a blur.

Nikki Martin: [00:37:16] OK? No, no, not, no. I don’t understand you, people. So you would think that someone who would be able to who’s got the capacity to run those distances would be good at breathing. No, you know, I can have a marathon runner who’s got an impaired breathing pattern and then I can have an 80-year-old woman with Parkinson’s who’s better than the marathon runner.

Dr Ron Ehrlich: [00:37:39] Wow.

Nikki Martin: [00:37:39] So, so you know, there’s a lot of discussion about breathing. And you know, we get into we can get into funny breathing patterns from illness, from infection. Trauma often makes people hold on to things and stop breathing in a really shallow range. So there are so many reasons why we get into non-beneficial breathing patterns. 

And you know, I at one stage was looking at becoming a yoga teacher and the theory behind it that yogis believe is that we are born with a finite set of breaths and that once you expend them all, that’s when you pass away. So if you and I don’t know whether that’s true or not, but I thought that was like, it’s a nice idea. That’s a cute idea.

Dr Ron Ehrlich: [00:38:21] Yeah. Yeah. No. I like it.

Nikki Martin: [00:38:23] But it’s really interesting when you look at it like that. And it’s like if you do have those finite breaths and you’re expelling them in a really quick non-productive way, don’t you want to change that? And don’t you want to improve your quality of life and also extend your life? Yeah.

Dr Ron Ehrlich: [00:38:41] And as we’ve covered in many episodes, the breath has a tremendous impact on every system in your body, both physical and mental. So the idea of breathing slower and gentler, extending your life, whether it’s a numerical thing about saving up your breaths. But it certainly impacts in a positive way on your body and mind. That’s what I like to say.

Nikki Martin: [00:39:05] Can I say something about that, right? Yeah, that’s one of the feedback that I, that’s sort of the feedback that I get from a lot of the clients that they actually perceived, like going through the exercises with the breather of The Breath Fit effect as meditative. 

Dr Ron Ehrlich: [00:39:18] Hmm. Yes. And interestingly, you mentioned humming or other exercises, I know didgeridoos a very good for toning those muscles, but what I love about this is you could literally put it in your top pocket and it’s very accessible and achievable. 

Gee, Nikki. You know, the more I mean, we’ve spoken, you know, professionally one on one many times, and this has been so good to bring it all together into one conversation. I wonder if we, as we come to an end, I wanted to just take a step back from your role as a speech therapist, as a health worker, because we are all on a health journey through life in this modern world. What do you think the biggest challenge is for a person with this?

The Biggest Health Challenge

Nikki Martin: [00:40:01] I think with modern-day life, I think we’re so distracted and I think it’s more pronounced now with social media and access to information. You know, I look back on growing up and everything and life are a lot simpler and less complicated. You know, 20 years ago, I think, I think being grateful for the body that you’ve got, taking good care of it before, there’s a problem, and enjoying, you know, like being present and, you know, and enjoying everything and being grateful, I think gratitude is probably the biggest key to life. 

I think most people look at what they don’t have. Rather than taking stock of what, what’s, what’s working for them and trying to build on that. So, yeah, I mean, I think life is to have fun. So and if you’re not having fun, you’re doing something wrong. So, yeah.

Dr Ron Ehrlich: [00:40:51] Well, Nikki, what a great note to finish on, and I’m extremely grateful to you for joining us today and for everything you’ve done for me professionally and I wanted to share you with our listeners. So thank you so much.

Nikki Martin: [00:41:02] Oh, thank you for having me. I’m really grateful as well. It’s been a lot of fun.


Dr Ron Ehrlich: [00:41:06] Thanks. So there it is, a whole branch of speech pathology that is called Laryngology. And focussing on a common problem, a really common problem, and I can attest to it. And Nikki attested to it herself that silent reflux is something that affects many people and it’s manifest, as we said, with the throat-clearing and coughing, etc.

And in my experience, and that’s what I loved about Nikki’s approach and the more I talked to her, the more holistic the approach is really because here she is talking about how to consume fluids to minimise the chance of reflux, but in the process by consuming them in the way that she’s recommending, you improve digestion.

 I mean, at the end of the day, stomach acid, and it’s very acidic. I mean, it’s got a PH or something like two or three, which on a PH scale, it’s amazing that it doesn’t burn a hole right through our body because if you dropped acid onto a PH of 2 onto your skin, it would most certainly burn a hole right through your skin.

So think about that. The PH in our stomach is there for a reason, and it’s there for two I think main reasons. One is to break down nutrients into their components, which can be then absorbed and used to rebuild parts of our body. That’s what nutrition news is all about. 

That’s why we focus on a nutrient-dense diet because we want those nutrients to be broken down and for them to be available for us to rebuild our body optimally. So particularly, I mean, that’s what stomach acidity is all about. And of course, breaking down meat, you do need good stomach acid for them.

So that is one thing, but it’s also anti-microbial as well. You forget that actually the outside world is really the inside world with a tube running through the middle overs and that starts in the mouth and it ends in our anus. And that is an external opening to the world. So this is why the stomach acid is also so important because it’s anti-microbial, and that’s why I actually have a real problem with the long term, it’s one of the problems I have, with long term use of antacids, which is very common.

 I mean, many of you. Some of you may know somebody or maybe yourself on a proton pump inhibitor like Nexium or So Mac. They are called blockbuster drugs because they generate over a billion dollars worth of sales every year. And the reason they do is because reflux, heartburn and indigestion are such common problems.

So of course, it’s very easy, you know, 10, 5, 10 or 15-minute consultation for someone to, for a doctor to prescribe you with a proton pump inhibitor. And that is a symptom-based approach to health care, which is very common in our society. 

The problem with that on a long term basis is that you do not break down and therefore absorb your nutrients as well as you might, and you are more susceptible to things like osteoporosis, which of course, there is another medication for, you could be on bisphosphonates. Isn’t the pharmaceutical world of medicine so wonderful for each breach ill as a pill. And it’s a great economic model. It’s just not a very good health model.

The other problem is that it makes you more susceptible to infection. Well, yes, you could take antibiotics as well. The other problem is that long term use of these kinds of protein pump inhibitors may also affect your ability to sleep well. But, okay, guess what? There’s another medication there. So it’s far better to explore how you are consuming your foods, number one. 

And that is particularly in relationship to the fluids that you’re consuming and how you’re consuming them. And I think that’s a good rule, as is not to drink while you eat. And probably not to drink for about 10 15 minutes before you eat and not to drink while you are eating and perhaps to wait another 10 or 15 minutes before you continue to drink. So that’s another thing. 

So when you picture yourself in a restaurant with a very attentive waiter filling up water all the time or even worse, filling up carbonated water all the time, that may not be the best move. So it’s not just how, but it’s also what we eat. There may be foods that you are sensitive to, and this is another issue. We’ve raised several times on this programme that there’s a difference between food allergies and food sensitivities.

Food allergies are when you eat something and you break out in hives or start sneezing immediately, and that’s an immediate allergic reaction, but sometimes allergic reactions are delayed and may take several hours or a day or two to manifest themselves, so you might not realise that you are sensitive to those foods.

I also love The Breathe Fit, and here it is. Breather Fit with an exhale gauge and an inhale gauge. It’s about the size of a pipe with a little ball on the end and different resistance levels. And I love the way it’s not only toning up muscles in the pharynx, which as we get older, become looser and make us more susceptible to snoring. But it also helps us tone up our diaphragm and our pelvic floor.

And you know, the more I learn about the diaphragm and the pelvic floor muscles, the more important it is. So this simple little device helps all of that look. We’ll have links to Nikki’s site and then she’s a wealth of information and she’s a terrific professional. I can certainly attest to that. And another page in our discovery of what speech pathology is all about. I had this find you well. Until next time. This is Dr Ron Ehrlich. Be well.



This podcast provides general information and discussion about medicine, health, and related subjects. The content is not intended and should not be construed as medical advice or as a substitute for care by a qualified medical practitioner. If you or any other person has a medical concern, he or she should consult with an appropriately qualified medical practitioner. Guests who speak in this podcast express their own opinions, experiences, and conclusions.