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Behavioral Eructation Retraining Protocol (BERP): A Novel Adjunct Behavioral Therapy for R-CPD.

Andrew Keltz^1,2, Kathryn E Simmons¹, Michael Z Lerner^1,2

¹Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA.

The Laryngoscope

|July 15, 2025

Summary

Behavioral Eructation Retraining Protocol (BERP) therapy shows promise for individuals with retrograde cricopharyngeus dysfunction (R-CPD) who have incomplete symptom relief after botulinum toxin (BTX) injections. This speech-language pathology intervention aids in retraining eructation, offering a new treatment avenue.

Keywords:

behavioral intervention retrograde cricopharyngeal dysfunction (R‐CPD)speech language pathology

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Area of Science:

Otolaryngology
Speech-Language Pathology
Gastroenterology

Background:

Retrograde cricopharyngeus dysfunction (R-CPD) is often treated with botulinum toxin (BTX) injections into the cricopharyngeus (CP) muscle.
Up to 20% of patients experience incomplete symptom relief or recurrence after CP BTX injection, necessitating alternative treatments.

Purpose of the Study:

To explore the efficacy of a behavioral intervention, the Behavioral Eructation Retraining Protocol (BERP), as an adjunct therapy for R-CPD patients with incomplete response to CP BTX injections.

Main Methods:

A retrospective case series involving seven individuals with R-CPD who had suboptimal outcomes with CP BTX injection.
Patients underwent speech-language pathology intervention (BERP) focused on achieving a specific body position to facilitate eructation, including laryngeal lowering, jaw protrusion, head turn and tuck, and torso anchoring.

Main Results:

Six of the seven patients achieved durable R-CPD symptom resolution with the combination of CP BTX and BERP therapy.
Five patients reported significant subjective improvement, with one noting complete resolution.
Six patients successfully demonstrated eructation using BERP positioning during initial therapy sessions.

Conclusions:

The Behavioral Eructation Retraining Protocol (BERP) is a promising adjunct therapy for R-CPD patients with incomplete response to CP BTX injections.
Further prospective research is warranted to validate BERP's efficacy as an adjunct to CP BTX in R-CPD treatment.