Just ask football legend John Elway, who struggled with gastroesophageal reflux disease (GERD) for more than a decade. “I was totally in the dark about acid reflux,” Elway told the Post. “No one should tough it out like I tried to do.”

Not only does the uncomfortable condition land many people in the hospital, but over time the repeated exposure to stomach acids can irritate and inflame the lining of the esophagus, increasing one’s risk for ulcers and esophageal cancer, a rare but deadly complication of GERD.

That’s the bad news.

There’s good news, too. Gastroenterologists say public awareness of GERD is on the rise. More people are seeking medical help and screenings for complications.
“Today, the public is clearly more aware of the potential importance of heartburn as a symptom of disease and not a trivial item” blamed on overeating, says Dr. Philip Katz of Albert Einstein Medical Center in Philadelphia. And more of us understand that a small percentage of people with chronic reflux symptoms are at risk of serious complications, including cancer, he says.

Just about everyone has an occasional bout of heartburn, or acid indigestion. That awful burning sensation around the breastbone develops when digestive juices—acids—back up in the esophagus, the tube that carries food and liquid to the stomach. When this reflux or regurgitation occurs, food or fluid can sometimes be tasted in the back of the mouth. Gastroesophageal reflux disease is diagnosed when reflux happens more than twice per week for many weeks. Between 25 percent and 35 percent of the U.S. population experiences GERD.

Not just painful, GERD can cause a variety of problems, including swallowing and sleeping difficulties, coughing, sore throat, hoarseness, chest pain, bleeding, and asthma. Over time, if the acid is not controlled, GERD can damage the lining of the esophagus leading to erosive esophagitis, Barrett’s esophagus, and, as noted, esophageal cancer.

The road to relief

Over-the-counter (OTC) antacids, such as Alka-Seltzer, or H2 blockers, such as Pepcid, which decrease acid production, can tame occasional, mild reflux. For more serious, chronic cases, the development of a class of drugs called proton pump inhibitors (PPIs) transformed treatment. Generally taken once per day, these drugs dial down the stomach’s acid pumps and help to heal the irritated lining of the esophagus.

In 2007, patients spent more than $14 billion on heartburn medications, second only to cholesterol-lowering drugs, according to IMS Health, Inc., a company that tracks prescription drug sales.

The popularity of PPIs is understandable, Katz says. “Proton pump inhibitors are such an exceptional class of drugs. They have such an excellent safety profile and are so effective at relieving symptoms due to acid that they have been widely prescribed.”

People with only occasional heartburn do not need the daily pill, but for those with GERD, “daily medication is safe,” he says. “People who take medication every day often feel better, have improved quality of life, and certainly have less symptoms” than those who take medicine intermittently.
People who require a prescription PPI, which can cost $90 to $265 per month depending on brand and dose, may soon have more and cheaper options. More PPIs are expected to become available in generic or over-the-counter forms in 2009 or soon after, joining the two generic PPIs and one OTC currently on the market. Prilosec OTC costs $19 to $26 per month and is a Consumer Reports Best Buy Drug.

“The patients do not have to worry about the expense nearly as much,” says Dr. Kenneth R. DeVault of the Mayo Clinic in Jacksonville, Florida.
Recently, the FDA approved a long-acting PPI for once-daily treatment of GERD. Kapidex (dexlansoprazole) was approved for healing all grades of erosive esophagitis for up to eight weeks, for maintaining healing of erosive esophagitis for up to six months, and for treating heartburn associated with symptomatic nonerosive GERD for four weeks, according to drugmaker Takeda Pharmaceutical.

Not Enough Relief

While PPIs are helpful to many, they are not a magic bullet.

“There’s a substantial group of patients who aren’t satisfied with the relief they get,” DeVault says. “The drugs don’t give you immediate relief. It really takes a few days to build up relief,” he says, adding that he hopes that a PPI containing sodium bicarbonate, an antacid that works quickly, will soon be sold without a prescription.
Another group of PPI users finds that the amount of acid suppression “just isn’t sufficient.” To cope, DeVault says some patients take more than the recommended one pill per day. “Probably 20 percent of people taking PPIs are taking them twice a day or more,” he estimated.

In early 2008, the American Gastroenterological Association Institute surveyed 1,064 people who used PPIs and found that nearly 40 percent still experienced GERD symptoms, such as acid reflux. Half of those surveyed used over-the-counter remedies, such as antacids, to ease breakthrough symptoms.
DeVault notes several studies have suggested that taking acid suppressants for an extended period of time could have side effects, including a higher risk of hip fractures, pneumonia, and an infection with a bacterium called C. difficile. “Those studies probably are legitimate, although the absolute risk is very, very low. If patients need acid-suppressing drugs, they should take them,” he says, adding that the patients at higher risk of side effects seem to be those taking PPIs more than once a day.

Within several years, DeVault expects to see new drugs that improve the function of the lower esophageal sphincter, the valve between the stomach and esophagus. “To me, those (drugs) are some of the more exciting things out there. They’ll probably be given to patients along with one of the acid blockers, but they’ll take care of the symptom of regurgitation, or the feeling of food coming back up.”

GERD and Asthma

Scientists are also making progress in understanding the link between GERD and asthma and other lung issues.
Physicians have observed that treating one condition sometimes leads to relief of the other. “We see patients frequently who have asthma exacerbated by reflux, and conversely, we see patients with reflux that can be exacerbated by asthma,” Katz says. “There is a relationship. It’s not clear whether it’s cause and effect.”

Reflux should be considered when a patient has difficult-to-manage, nighttime, nonallergic, or late-onset asthma. Reflux is also a consideration in patients with chronic laryngitis, hoarseness, other voice disturbances, or chronic sinus problems.

“It’s very hard to make that connection sometimes, so it requires careful thought and a careful approach,” Katz says, noting that a patient can be monitored to determine if reflux and other symptoms occur simultaneously or independently.

Chest pain is another symptom that should inspire a visit to a physician, DeVault says. Reflux and chest pain can go together, he says, but “don’t assume chest pain is indigestion.” The problem might be heart disease. A couple of times a year, he says, he sees a patient who is worried about reflux but actually has angina, which is chest pain caused by an insufficient flow of blood to the heart.

Barrett’s Esophagus and Cancer

In a small percentage of cases, GERD is a precursor to Barrett’s esophagus, a precancerous condition in which the cells lining the lower esophagus change in color, texture, and composition because of repeated exposure to acidic stomach contents. A small number of people with Barrett’s develop esophageal cancer.
Considerable debate remains over who should undergo expensive screening tests, in which an endoscope is used to view the lining of the esophagus.

“While Barrett’s tends to be most common in white men older than 50, the disease occurs in both genders, as well as all ages and races,” Katz says.

GERD and Babies

It’s normal for babies to spit up once in a while. But some infants get irritable and uncomfortable after nursing. Some scream for hours. Some refuse to eat. Instead of assuming the child has colic, some doctors are diagnosing GERD and prescribing drugs called proton pump inhibitors.

Children with GERD may have symptoms, including: repeated regurgitation, nausea, laryngitis, coughing, or wheezing. The National Digestive Diseases Information Clearinghouse suggests consulting a health care provider if your child frequently has reflux-related symptoms that cause discomfort.

Frequent reflux can cause complications, including: heartburn; esophagitis, which can develop into swallowing problems; poor growth due to poor nutrition; and respiratory problems from stomach contents entering the nose or lungs, according to the Pediatric/Adolescent Gastroesophageal Reflux Association.

Pain and stiffness stopped Lynn Sygiel whenever she tried to brush her hair, open a door, or reach into her back pocket. Any time she moved her left arm, it hurt. Getting dressed became an ordeal. “Even pulling up tights was painful,” says Sygiel, 58.

She didn’t know what the trouble was and couldn’t remember straining her arm or shoulder. “It was kind of out of the blue,” she says. The pain was so bad that she could hardly sleep at night. Then, her left shoulder got so stiff, she could barely lift her arm from her side.

Her doctor gave her anti-inflammatory medicine, which eased the pain but not the stiffness. “I had no strength whatsoever” to lift or carry anything, says Sygiel, director of Y-Press, an Indianapolis-based youth journalism program.

A month later, Sygiel met an orthopedic specialist, who quickly diagnosed her condition—frozen shoulder. Officially known as adhesive capsulitis, the term refers to the way the capsule, or lining, of the joint thickens and gets sticky. Irritated and inflamed, the shoulder capsule contracts so much that the top of the arm can’t move; it freezes in the joint.

Although Sygiel never heard of frozen shoulder, she soon discovered that other female friends and acquaintances experienced the painful condition, too.

“It is extremely common, especially in perimenopausal women,” says Dr. Jennifer L. Solomon, a specialist in physical medicine and rehabilitation at the Hospital for Special Surgery in New York.

The disorder strikes about two percent of the population, according to the American Academy of Orthopaedic Surgeons (AAOS). But that estimate is “probably low, based on the fact that a lot of people are misdiagnosed or not diagnosed at all,” says Dr. Peter Sallay, a shoulder expert with Methodist Sports Medicine/The Orthopedic Specialists in Indianapolis. Sallay and his partner see between 300 and 400 patients with frozen shoulder a year.

And most of those patients are between the ages of 40 and 65, at least two thirds of them women.

The risk of frozen shoulder is higher in people who have diabetes, thyroid problems, Parkinson’s disease or cardiac disease, according to the AAOS. In rare cases, frozen shoulder occurs when an arm is immobilized after an injury or surgery. Many cases of frozen shoulder occur like Sygiel’s—seemingly out of the blue. She woke up one morning wondering why her shoulder hurt.

While there are several theories about the cause of idiopathic (arising spontaneously or from an obscure or unknown cause) frozen shoulder, no definitive explanation has yet emerged, Solomon says. Because the condition occurs most commonly among middle-aged women, some experts feel hormonal changes are at work.

“Hormonal imbalances may cause a systemic reaction, which causes inflammation of the capsule,” she says. “It’s like Saran wrap. The Saran wrap tightens up.” The persistent inflammation results in fibrosis, or scarring, in the shoulder, causing the capsule to stiffen and shrink.

“We don’t know what causes it and we don’t know why it goes away,” Sallay says of the bizarre condition. Oddly, it never recurs in the same shoulder.

While researchers have studied the capsular material looking for biochemical markers in frozen shoulders, nobody has really found a common triggering cause.

“The fact of the matter is that patients for no good reason typically wake up and have pain,” Sallay explains. “And then the pain gets worse, and then they start to lose range of motion.”

After a period of stiffness, the pain ebbs, and patients start to recover range of motion. More than 90 percent of people with idiopathic adhesive capsulitis will eventually resolve their condition. “The length of time it takes to resolve varies,” says the orthopedic surgeon. “It can range anywhere from one to three years. Most people resolve within 18 months, in my experience. Frozen shoulder is one of those things that really test a patient’s psychological stamina.”

The Road to Diagnosis

Frozen shoulder is typically diagnosed by analyzing a patient’s medical history and through a physical examination to assess range of motion. With some shoulder problems, the doctor is able to move the affected arm, but with frozen shoulder, neither the patient nor the doctor can move the arm beyond a certain point.

Unfortunately, the condition is frequently misdiagnosed.

“The most common scenario is that a patient sees a family doc who says, ‘You have bursitis, an inflammation of the cushion between bone and tendon, or tendonitis,’ ” says Sallay.

Many people suffer through the painful disorder—and eventually recover—but never get an accurate diagnosis.

To rule out other possible reasons for shoulder pain and immobility, such as a rotator cuff tear, the doctor usually will order an x-ray, MRI, or other type of imaging test.

To Treat or Not to Treat

There are several schools of thought on how and when frozen shoulder should be treated. “There is a debate about it,” Solomon says. “It’s a controversial subject.”

Solomon and her colleagues say early diagnosis and immediate treatment with a cortisone injection and physical therapy is vital. She likes to start treating people in what is known as Stage 1 of the condition—the freezing stage—when the pain is increasing and the shoulder is losing mobility.

“If people are diagnosed very early and treated appropriately, the course of recovery is much quicker, sometimes by several months,” Solomon says. And she does not agree with the notion that a frozen shoulder will thaw in a year or two, no matter what you do or don’t do.

Generally, Solomon recommends a corticosteroid injection into the shoulder. Steroids can reduce inflammation and pain, and increase range of motion. “You can see that very quickly,” she says.

She also prescribes gentle physical therapy, giving the therapist a detailed protocol. “If too aggressive with physical therapy, you can cause a flare-up,” she says.

A similar treatment plan worked well for Sygiel. The same day she was diagnosed with frozen shoulder, she received a steroid injection, and the pain eased over a couple of days. Then she went to a physical therapist. Twice a week for six weeks, the therapist carefully guided her arm and shoulder in a series of gentle exercises designed to increase range of motion. She also applied heat, to literally thaw the joint. The physical therapist also provided Sygiel with daily exercises to do at home.

Six months after her shoulder pain began, Sygiel recovered 90 percent of her normal range of motion. “I can’t reach all the way behind me,” she admits, but she is grateful to have most of her strength and mobility back.

Not all doctors believe a patient needs to rush into treatment. There’s no way to shorten the course of the disease, Sallay says. “Once it starts, it’s like a locomotive going downhill.”

Patients tend to be referred to him after weeks or months of debilitating pain and stiffness. Many have already tried physical therapy and found their pain is getting worse, not better. “They’re typically very apprehensive,” and desperate for sleep and pain relief, he says.

“The first thing I tell them is, don’t go to the therapist. Stop. And within a week, they’re better in terms of pain,” he says. “I tell people, this is like a campfire that’s burning; the embers are still there. But if you go and stoke those embers, it’s going to take a whole lot longer to settle this down.”

During the early stages of adhesive capsulitis, he recommends ice, pain medication, and anti-inflammatories. Steroids, either oral or injected, are effective in many people.

Sallay says the time for physical therapy is when the inflammatory phase is over. “You can accelerate the thawing phase with physical therapy,” he says.

When All Else Fails—Last Resort

Only a small percentage of frozen-shoulder cases do not improve with medical treatment, therapy, and time. For these people, doctors may do a procedure called shoulder manipulation or mobilization—forcing the arm to move—under anesthesia. Others require arthroscopic surgery.

That’s what happened to Natalie Heck, 45.

Heck’s right shoulder started hurting in January 2007. “I had trouble sleeping, had a lot of pain, and was losing a lot of strength,” says Heck, a married mother of two teens. “Grocery bags were difficult; a 12-pack of soda was painful.”

Her family doctor suggested a cortisone injection, thinking she might have bursitis. “The shot didn’t alleviate any pain,” she says. Physical therapy, in fact, exacerbated the condition.

“I started feeling pain in my wrist, numbness and tingling all the way down my arm,” she recalls. Because she worked all day on a computer keyboard, she struggled to do her job.

An orthopedic surgeon ordered an MRI, diagnosed a rotator cuff tear and impingement, and recommended immediate surgery. A second specialist diagnosed frozen shoulder. Looking for a tie-breaker, Heck consulted Dr. Sallay, who agreed with the frozen shoulder diagnosis. Because Heck wanted to avoid surgery, she followed Sallay’s suggestion of a ”wait and see” period to see if her pain and stiffness gradually disappeared.

It didn’t. “I lasted until the end of October and asked to have the surgery scheduled,” Heck says.

Heck underwent a short outpatient procedure called “arthroscopic capsular release.” Using an arthroscope, the surgeon loosened the contracted ligaments and removed scar tissue. Taking medication for the considerable pain and swelling, Heck began physical therapy “the very next day.”

After three weeks, “I could tell there was some improvement” in range of motion, she says. Eight months after the surgery, Heck’s shoulder was almost normal. “I don’t experience the pain or the weakness.”

For the thousands of people suffering from the debilitating shoulder condition, Heck hopes researchers soon determine the cause of frozen shoulder and develop better diagnosis and treatment methods. She would also like to know why the condition seems to run in her family—her mother suffered through frozen shoulder 20 years ago.

“I’d like them to find out,” Heck says, “because now my 13-year-old daughter is wondering if she’s going to get it.”

A Series Of Stages

Frozen shoulder typically has three stages, according to the American Academy of Orthopaedic Surgeons:

Stage 1: The freezing stage may last six weeks to nine months. Pain develops. As it worsens, the shoulder loses motion.

Stage 2: The frozen stage may last four to nine months. Pain fades but the stiffness remains.

Stage 3: The thawing stage may last five to 26 months. Shoulder motion gradually returns toward normal.

When a shoulder “freezes” up, stretching and range-of-motion exercise can help restore function and reduce stiffness: more than 90 percent of patients improve with simple treatments, according to the American Academy of Orthopaedic Surgeons.