AU: Phillip ​Ebrall, BAppSc(Chiropr), GC Tert Learn Teach, MPhotog, PhD, DC (Hon), FACCS, FICCS. Director, Chiropractic Education and Research, Chiropractic India. pebrall@me.com

Narrative:  It should not surprise us that over the past 40 years several authors have been notable in the strident condemnation of Chiropractic and its foundational premise. Among these have been Homola, Edzard Ernst, and Joe Keating Jr.

Indexing Terms:  Chiropractic; publication; research; subluxation.

Introduction

Matt McCoy has been reporting the truths uncovered by Senzon through his doctoral work funded by the Foundation for Vertebral Subluxation Research (FVSR). This Journal carried Senzon’s thesis on its web pages but it drew little interest, which is a shame as it is rather erudite, even though its methodology is complex. Senzon pushes the boundaries of the quantitative analysis of selected literature. In his defence I would suggest it is only through  such novel approaches at which Senzon excels that we may finally come to understand why our profession has been behind the 8-ball for far too long.

This complexity is where McCoy comes to the fore, taking Senzon’s core findings and creating digestible truths for us. We are thankful for McCoy’s focus on this important content even though we no longer carry Senzon’s thesis (1) on this site as McCoy is now running with it and frankly, Senzon’s lack of appreciation for our support has finally worn thin.

Indeed, he asked us in the first instance to not make any reference to his work and to not make it available to you. Of course we ignored this given he undertook his research in an Australian university which is generously funded by the Australian taxpayer to facilitate such research. Hence our right and duty to report.

Why does this matter?

It matters because Senzon has provided McCoy with the evidence for the claims he has advanced over some time. We can no longer obfuscate anti-subluxation rhetoric now that we know its origin with precision. And one of Australia’s own is complicit; Keith Charlton being an author on the paper Senzon found to be most discredited of all, yet paradoxically the most influential in damaging all that Chiropractic represents. It disappoints me that one person could actually think it OK to pay forward such damaging drivel.

And in turn this brings us full circle to the core question of ‘who are we’ and of course, ‘why does it matter who we are’? These are the critical questions of our time.

As an educator of Chiropractors I was bound to teach what Charlton and Keating published if only to give it context and limit its intellectual vandalism. I will not cite it here for to do so would only increase its count in some bloody index that suggests it is a more important paper than it is.

I can’t deny it is important because the its citation data shows that it is. But I can dismiss it as a damaging incoming missile from miserable people, one of whom subsequently suicided. 

In the bigger picture Charlton and Keating’s paper is akin to how our profession was attacked through Homola’s rubbish, and in a larger arena how the perpetually dejected Ezard Ernst wrought so much opprobrium on our beloved discipline.

What are you going to do about it?

As Editor of these pages I would like to think you would support us by adding your email at the bottom of our landing page to ensure you receive the notice of each new issue. It costs you nothing but 30 seconds of your time now, yet helps us both. There are no subsequent pleas for money and NO paid subscription levels. Signing up means you get each issue first, before it is publicly on-line. Free.

We are increasing our publication frequency and a simple ‘sign up’ is a good way to make sure to remain current with the most important papers now being published to enrich our profession.

It would also be good if we can start to push back against at those academics wielding power with little responsibility. Here I think of Matt Fernandez (2) who recently promoted an ‘Expert View’ of low back pain which did not mention the role of Chiropractic. Nor did he include Chiropractic in his list of recommended experts to assist. Yet he is the putative head of the Chiropractic program at Central Queensland University. Really?

I’m proud to stand up for the evidence-base role of Chiropractic in managing patients with low back pain, as all Chiropractors should be.

Good things

As a life member of the Australian Chiropractors Association I have a vested interest in what it is is doing and more important, where it is taking us. This month I found President Chow’s most recent report to members highly appropriate if not an inspirational summary of all the good that our profession deserves. Well done Billy. When I see the breadth of activity being undertaken by our peak representative body, I feel both calmed and optimistic for our future.

I would ask you too, please, to be calm and optimistic. As Senzon shows, we can dismiss Charlton and others who have advanced fanciful ideas attacking our foundational premise. One day in the future I shall publish his letter to the Vice Chancellor of Central Queensland University on my appointment as foundation Professor for Chiropractic in that Institution in 2011. Like the VC of the day, and me, you will cringe in embarrassment of the length to which some of our profession will go to in order to advance their own agenda and eat their fellows.

In contrast, here is a short checklist of good things we can celebrate:

• The first university-based program of Chiropractic education to serve India is commencing,
• The Australian Chiropractic Association membership has passed the 3,000 mark
• The Australian Chiropractic College is growing, delivering now from a campus in Adelaide and a new campus in Melbourne,
• The Australian Spinal Research Foundation has again this year attracted many solid research proposals seeking funding,
• This Journal’s new sister-relationship with The United Association for Applied Kinesiology (UAAK) and their journal Applied Kinesiology (Ukrainian),
• RFK Jr being positive for Chiropractic, and
• Discovering that the world’s first case report on subluxation was written in 1676, 350 years ago, thanks to the meticulous research of historian Gary Bovine.

The few remaining deniers of subluxation are intellectually impoverished and incapable of accepting the evidence in front of them. Something to discuss another day.

References

AU: Henry ​Pollard, BSc, Grad Dip Chiro, Grad Dip App Sc, M Sport Sc, PhD, ICSSD, FICC, FAICE. Adjunct Professor, Durban University of Technology. e: drhenrypollard@gmail.com 

Introduction

Musculoskeletal Discomfort (MSD) is a broad group of inflammatory and degenerative conditions affecting muscles, tendons, joints, ligaments, nerves, and other soft tissues that support movement. Work-related musculoskeletal discomfort (WMSD) has emerged as a major concern in both developed and developing countries, often caused by repetitive tasks, awkward postures, forceful exertions, and suboptimal ergonomic environments. This discomfort not only compromises the physical well-being of workers but also leads to reduced productivity, increased absenteeism, and higher compensation and healthcare costs. (1)

In India, the cashew industry is a major export sector, with Kerala alone accounting for 35% of processing units. Cashew processing is a labour-intensive, multistage process involving drying, roasting, shelling, peeling, grading, and packing, most of which are manually performed and physically demanding. Studies have consistently reported low back pain as the most prevalent symptom across various occupations. (2, 3) 

A cross-sectional study among 246 cashew factory workers in Udupi district, Karnataka, found that 28.5% of workers experienced musculoskeletal pain, most frequently in the knees (32.4%), lower back (30.9%), and shoulders (11.8%). Cutting tasks were associated with the highest pain prevalence, and over 70% of affected workers had over five years of experience. (4, 5)

Despite the long-standing operation of cashew factories since the 17^th century in South India, limited research has addressed the ergonomic risks and musculoskeletal implications for workers in this sector. Other regional studies report WMSD prevalence ranging from 28.5% to over 70% among various cashew processing tasks.6 Kerala-specific surveys highlight female gender and lower education levels as significant risk factors for MSD in this workforce. (7) 

While ergonomic assessments and WMSD studies exist in other industrial settings, cashew workers remain underrepresented in the literature. This study aims to address that gap by identifying the intensity of musculoskeletal discomfort and pain among cashew factory workers, examining gender-based and task-specific differences, and highlighting the importance of joint protection, work simplification, and energy conservation techniques as preventive measures. The findings are expected to contribute to occupational health literature and inform ergonomic interventions and policies for this underserved workforce.

Methods

This study used a quantitative cross-sectional design to assess the intensity of work-related musculoskeletal discomfort (WMSD) among cashew workers. It was conducted in villages around Boovikanam, Kasaragod district, Kerala, approximately 10 - 15 km from Kasaragod town. Data collection aimed to provide various postures adopted during cashew work. A total of 40 cashew workers (20 males, 20 females), aged 35 - 55 years, were selected through convenient sampling due to accessibility and willingness to participate, and data were collected over a period of two months, from May to June 2024. This age group was targeted as they are commonly engaged in physically demanding tasks in the cashew industry. 

Inclusion criteria comprised workers involved in post-harvest cashew processing activities. Although cashew processing includes drying, roasting, shelling, peeling, and grading, the present study specifically focused on workers engaged in shelling and peeling tasks, as these activities are predominantly manual and ergonomically demanding. Drying, roasting, and grading processes were not included because these activities were largely mechanised in the selected processing units. Both literate and illiterate individuals were included. 

Exclusion criteria covered those involved in other stages like cultivation or marketing, individuals recently ill, part-time workers, those with major neurological or orthopaedic issues, psychosocial distress, or unwillingness to participate. Data were collected using the standardised tools like Rapid Entire Body Assessment (REBA) and the Visual Analogue Scale (VAS). 

The Rapid Entire Body Assessment (REBA) tool has demonstrated excellent intra-rater reliability (ICC = 0.925) and moderate inter-rater reliability (Fleiss’ κ = 0.54), supporting its use as a reliable ergonomic assessment instrument for evaluating musculoskeletal disorder risk in occupational settings. (8) 

The Visual Analogue Scale (VAS) is a highly reliable and valid instrument for subjective pain assessment, demonstrating excellent test–retest reliability with ICC values commonly reported above 0.90. (9)

REBA, developed by Hignett and McAtamney, is an ergonomic tool used to evaluate posture-related risk without needing specialised training or equipment. (10, 11) Scores were assigned to body regions (neck, trunk, upper limbs, legs), and final risk scores were calculated from task observations.

The REBA scoring system categorises ergonomic risk into negligible (score = 1), low (2 – 3), medium (4 – 7), high (8 – 10), and very high risk levels (11 – 15), with increasing scores indicating greater urgency for corrective action. (10)

VAS, a validated subjective scale, was used to assess pain intensity. It features a 10 – 15 cm line ranging from 0 (no pain) to 10 (worst pain), with visual cues to assist illiterate participants. Pain levels were categorised as no (0 – 1), mild (1 – 3), moderate (4 – 6), or severe. (12)

Descriptive statistics were used to determine WMSD and intensity, and inferential statistics assessed differences across gender and task categories. All methodological details were set before data collection; results are presented separately.

Results

A survey was conducted among 40 cashew workers in Kerala using a convenient sampling method. The data collected underwent extensive analysis using Statistical Product and Service Solutions version 22 (SPSS 22). Work-related musculoskeletal discomfort (WMSD) was assessed using the Rapid Entire Body Assessment (REBA) tool, and pain perception was measured through the Visual Analogue Scale (VAS). A questionnaire, interviews and observational methods were used to gather further information.

Descriptive statistics were used to analyse the frequency and percentage values of REBA and VAS scores. To examine the correlation between REBA and VAS among male and female cashew workers, the Pearson Correlation Coefficient (2-tailed) was applied. Since the data were normally distributed, the Pearson correlation was considered appropriate for analysis. (13)

•     Table 1 shows the mean and standard deviation of demographic data, such as age (43.50 + 5.43), REBA and VAS scores for Cashew workers, such as shelling and peeling workers. 

Table 2 shows the frequency and percentage of risk levels of Work-related Musculoskeletal discomfort through the REBA score for the cashew workers involved in shelling and peeling work. Results denote that the majority of the workers involved in shelling and peeling work had medium risk (i.e., 60% and 40%, respectively). 

Table 3 shows the frequency and percentage of levels of pain through the VAS score for the cashew workers. Both in shelling workers and peeling workers found moderate pain, i.e., 50% and 55% respectively.

Table 4 shows the ergonomic risk factors / WMSD among 40 participants (20 males and 20 females). None of the participants had a negligible risk. Among males, 3 participants had low risk, 8 participants had medium risk, 2 participants had high risk, and 7 participants had very high risk. Among females, 2 participants had low risk, 12 participants had medium risk, 5 participants had high risk, and only one participant had very high risk. In total, 5 participants had low risk, 20 participants had medium risk, 7 participants had high risk, and 8 participants had very high risk.

Table 5 shows the VAS pain level distribution among 40 participants (20 males, 20 females). None of the participants reported no pain (i.e., score: 0). Among males, 4 participants had reported mild pain (score: 1 - 3), 12 participants had reported moderate pain (score: 4 - 6), and 4 participants had reported severe pain (score: 7 - 10). Among females, 8 participants had reported mild pain, 9 participants had reported moderate pain, and 3 participants had reported severe pain. In total, 12 participants had reported mild pain, 21 participants had reported moderate pain, and 7 participants had reported severe pain.

    Table 6 shows the correlation between VAS and REBA scores among 20 male cashew workers. A strong positive correlation (r = 0.725) was found, significant at p = 0.0001, indicating that higher pain levels (VAS) are linked to higher ergonomic risk (REBA) for male cashew workers. 

Table 7 shows the correlation between VAS and REBA scores among 20 female cashew workers. A moderate positive correlation (r = 0.538) was observed, statistically significant at p = 0.014, indicating that higher pain levels (VAS) are moderately linked to greater ergonomic risk (REBA) for female cashew workers. As expected, both VAS and REBA show perfect self-correlation (r = 1).

Discussion

The present study evaluated ergonomic risk factors, work-related musculoskeletal discomfort (WMSD), and pain intensity among cashew workers engaged in shelling and peeling activities. The findings demonstrated a considerable ergonomic risk of WMSD and pain among the workers, with significant correlations between REBA and VAS scores for both male and female participants. These findings indicate that increased ergonomic risk of WMSD is associated with greater pain intensity among cashew workers.

The present findings are consistent with previous studies conducted among cashew-processing workers and other manual labour populations exposed to repetitive movements, awkward postures, and prolonged static work. Girish et al. reported that musculoskeletal pain was highly prevalent among cashew factory workers, particularly affecting the knees, lower back, and shoulders, with repetitive cutting and shelling activities identified as major contributing factors.4 Similarly, Chaitanya et al. observed that female cashew shelling workers experienced substantial musculoskeletal discomfort due to repetitive upper-limb movements and poorly designed workstations. (3) The current study further supports these findings, as most shelling workers demonstrated medium ergonomic risk, while peeling workers exhibited higher proportions of very high-risk REBA scores.

The elevated ergonomic risk of WMSD observed among peeling workers may be attributed to sustained neck flexion, repetitive wrist movements, prolonged sitting posture, and fine motor hand activities performed during peeling tasks. Similar ergonomic concerns were highlighted by Mallampalli et al., who identified awkward postures and repetitive hand-intensive activities as major predictors of WMSD among cashew-processing workers. (2) Another ergonomic intervention study by Mallampalli et al. demonstrated that workstation modification and ergonomic redesign significantly reduced REBA and RULA scores among cashew shellers, emphasising the importance of preventive ergonomic strategies in this sector. (14)

Pain intensity findings from the present study revealed that moderate pain was the most frequently reported category among both shelling and peeling workers. These findings correspond with Satheeshkumar’s study among cashew industry workers in Kerala, which documented a high prevalence of musculoskeletal discomfort associated with repetitive occupational exposure and prolonged working duration. (7) Similar findings have also been reported in manufacturing and agricultural occupations, where repetitive manual tasks and sustained postures contribute significantly to musculoskeletal symptoms and pain development. (15)

Gender-based differences identified in this study are also supported by previous literature. Male workers predominantly reported moderate pain, whereas female workers demonstrated a broader distribution of pain intensity levels. Previous epidemiological studies have consistently shown that women report greater WMSD and severity of musculoskeletal pain than men. Picavet and Schouten found that musculoskeletal pain prevalence was systematically higher among women across multiple body regions. (16) Likewise, Treaster and Burr reported increased susceptibility of women to upper-extremity musculoskeletal disorders due to differences in biomechanics, muscle capacity, task allocation, and occupational exposure patterns. (17) The wider variation in pain intensity among female workers observed in the current study may therefore reflect biological, ergonomic, and psychosocial differences in occupational workload and pain perception.

A significant positive correlation was observed between REBA and VAS scores among both male (r = 0.725, p < 0.001) and female workers (r = 0.538, p = 0.014), indicating that higher ergonomic risk was associated with increased pain intensity. This finding reinforces the clinical relevance of ergonomic assessment tools such as REBA in identifying workers at greater risk of developing WMSDs. Comparable findings have been reported in occupational ergonomic studies where increased postural risk scores were strongly associated with musculoskeletal pain severity and functional limitations. (1, 14)

The present study contributes important evidence to occupational health literature, particularly in the context of the cashew-processing industry, which remains relatively underrepresented in ergonomic research. Unlike many previous studies focusing only on prevalence, the current study combined observational ergonomic assessment with subjective pain evaluation and gender-based comparison, thereby providing a more comprehensive understanding of occupational risk among cashew workers.

Despite these strengths, certain limitations should be considered. The cross-sectional design limits the ability to establish causal relationships between ergonomic exposure and WMSD. The relatively small sample size and convenient sampling technique may also restrict generalisability to larger populations of cashew workers. Additionally, psychosocial and organisational factors such as workload, job stress, rest breaks, and work environment were not assessed and may have influenced pain perception and ergonomic risk.

Overall, the findings emphasise the urgent need for ergonomic interventions within the cashew-processing industry. Strategies such as workstation redesign, posture correction training, scheduled rest breaks, task rotation, and education regarding joint protection and energy conservation techniques may help reduce WMSD risk and improve worker well-being. Gender-sensitive ergonomic approaches may also be beneficial considering the observed differences in pain distribution and ergonomic exposure between male and female workers.

Conclusion

In conclusion, the findings suggest that there is a high risk of WMSD among cashew workers. Also, the study findings indicate a clear trend where higher pain levels are associated with higher ergonomic risk of WMSD for both male and female cashew workers, also emphasising the need for ergonomic interventions, particularly for those experiencing mild to severe pain. This study's findings suggest gender-related variations in pain perception or reporting, with males more frequently reporting moderate levels of pain compared to females, who displayed a broader range of pain experiences.

Limitations 

This study focused solely on physical factors contributing to WMSD risk. Psychosocial aspects (e.g., workplace conditions, autonomy, monotony, work-rest cycle, task demands, social support) and individual factors (e.g., alcohol/tobacco use, stress) were not included. The study was limited to a single industrial worker group, limiting generalizability. Future research should include diverse farm settings to enhance applicability. Additionally, this study assessed only WMSD risk; further studies identifying actual MSD cases are recommended for effective intervention planning.

Ethical consideration 

Informed and written consent was obtained from all participants. Ethical clearance was also obtained from Sri Sri University.

Acknowledgement 

We express our sincere gratitude to the craftsmen who rendered immense cooperation during the completion of this study.

References

1. PunnettL, Wegman DH. Work-related musculoskeletal disorders: The epidemiologic evidence and the debate. J Electromyogr Kinesiol. 2004;14(1):13–23. DOI: 10.1016/j.jelekin.2003.09.015
2. MallampalliKC, Dhar D, PalS. Ergonomic assessment of postures and risk factors associated with work-related musculoskeletal disorders among cashew workers in Eastern India. In: Adv Phys, Social & Occup Ergonomics (AHFE 2020). Berlin, Heidelberg: Springer; 2020:79–86. DOI 10.1007/978-3-030-51549-2_11
3. ChaitanyaK, Dhar D, PalS. Prevalence of musculoskeletal disorders among female cashew nut shelling workers in India. In: Convergence of Ergonomics and Design (ACEDSEANES 2020). Cham: Springer; 2021:281–291. DOI 10.1007/978-3-030-63335-6_29
4. GirishN, Ramachandra K, ArunGM, Asha K. Prevalence of musculoskeletal disorders among cashew factory workers. Arch Environ Occup Health. 2012;67(1):37–42. DOI 10.1080/19338244.2011.573020
5. NarsiaRH, Joseph OR. Participatory ergonomics: Work-related musculoskeletal disorders among cashew nut factory workers in Karkala taluka. Acta Sci Orthop. 2020;3(6):36–40.
6. ChaitanyaK, Dhar D, PalS. Ergonomic assessment and workstation design for women workers in cashew processing. In: Smart Innovation, Systems and Technologies (ICORD 2023). Cham: Springer; 2023:37–47.
7. SatheeshkumarM. Work-related musculoskeletal disorders among cashew industry workers in Kerala. Int J Adv Res Eng Technol. 2018;9(4):162–173.
8. Schwartz, A. H., Albin, T. J., & Gerberich, S. G. (2019). Intra-rater and inter-rater reliability of the Rapid Entire Body Assessment (REBA) tool. International Journal of Industrial Ergonomics, 71, 111–116. https://doi.org/10.1016/j.ergon.2019.02.005
   
9. Bijur, P. E., Silver, W., & Gallagher, E. J. (2001). Reliability of the visual analog scale for measurement of acute pain. Academic Emergency Medicine, 8(12), 1153–1157. https://doi.org/10.1111/j.1553-2712.2001.tb01132.x
   
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11. HignettS, McAtamney L. REBA: a rapid entire body assessment method for investigating work-related musculoskeletal disorders. In: Proc Ergonomics Society Aust, Adelaide 1995:45–51.
12. GouldD, Kelly D, GoldstoneL. Visual Analogue Scale (VAS). J Clin Nurs. 2001;10:697–706.
13. Dancey CP, Reidy J. Statistics Without Maths for Psychology. 7th ed. Harlow (UK): Pearson Education; 2017.
14. MallampalliKC, Dhar D, PalS. Ergonomic assessment of cashew nut sheller reduces REBA and RULA scores. Work J. 2023; Usercentered design study. DOI 10.1007/9783030633356_29  pubmed.ncbi.nlm.nih.gov+4researchgate.net+4researchgate.net+4
    
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Indexing Terms: Chiropractic; India; Case-Mix; Conventional Chiropractic; education; regulation.

This paper presents the first report of the case-mix of conventional subluxation-inclusive Chiropractic in the nation on India. At the time of writing there is no Chiropractic-specific regulation, although common business practices must be adhered to.

There are 12 Chiropractors formally recognised across the nation on India yet evidence exists to show there are some 2,200 imposter clinics claiming to provide chiropractic services without any trained Chiropractor on-site. This is   similar, but vastly larger in scale and potential damage, to the early situation in Australia where individuals could call themselves a ‘chiropractor’ regardless of not having any training. (1) The negative outcome of this was that on the eventual enactment of registration these folk became registered as Chiropractors under grandfathering provisions. 

This must not be allowed to happen in India and the Government is urged to act immediately to protect the public in India.

In contrast, the dominant provider of Chiropractic services with recognised Chiropractors in India is a commercial operation called Dr Spine, and this report is drawn from the clinical data of that group.

Regulation

There is no regulation of Chiropractic in India. The country cannot continue to let untrained and unsupervised hands learn physical techniques on the spines of its citizens. This paper calls for government to do what every serious health system before it has done: set a standard, protect a title, and build a profession in India, for India, by Indian-trained chiropractors.

The education is being built and the evidence is in. What remains is the law and the will to enact it as an urgent matter of public safety the State alone can deliver. This Journal will report updates on the development of the required legal framework in India as it happens. 

The author recognises accredited, university-anchored Chiropractic education as the only legitimate pathway into the profession. To this end, Sri Sri University is starting the Post Graduate Diploma in Chiropractic Sciences & Masters Fellowship programs, to be followed by a 5½ year ‘full’ program of Chiropractic education for school-leavers.

Work is also under way to constitute a Council on Chiropractic in India to set standards, register practitioners, and shield patients from unqualified practice. The NGO Chiropractic India has formulated this to be handed over to the govt to further legitimise and regulate the profession.

About case-mix studies

Case-mix studies are the first approach to understanding the nature of Chiropractic practice in a particular environment and are specifically useful for identifying the variety of clinical presentations. First-level case-mix studies such as this report the broad range of clinical conditions for which patients seek care. At this point it is not known in the evidential sense whether the 12 Chiropractors in India manage patients with low-back pain or headache, for example. Neither anecdotal evidence nor assumptions drawn from Chiropractic practice in other countries constitute sufficient evidence to inform the profession’s development in India. 

Case-mix studies report essential foundational knowledge for informing further studies perhaps of the characteristics of a particular demographic with a particular clinical condition. Case-mix studies are also prime informants of the curriculum for Chiropractic education, ensuing that the real health needs of the nation will be met by Chiropractors specifically trained to identify and manage such conditions within the national health system.

In this manner they differ to demographic studies which report socio-economic information and express it statistically. (2) They also differ to descriptive studies, of which there are several for North America (3, 4, 5) and Europe (6, 7, 8) in that they represent exploratory research with a focus on clinical conditions and are readily undertaken by clinicians. 

Case-mix studies also have value in informing public health decisions in developing countries by reporting a related group of patients; an example being a group of patients with tuberculosis. (9) Although common to medicine, case-mix studies are infrequently reported in the Chiropractic literature with the exception of the case-mix in teaching clinics, such as that of an Australian institution by Walsh in 1992. (10) Subsequent reports have been published for teaching clinics (11) in North America (12) and its West Coast region, (13) New Zealand, (14) Mexico (15) and Britain. (16) While not including statistical analysis they typically report a case-mix thought to be representative of private practice in each country. (17) 

This paper also indicates future approaches for scholarly inquiry in India as the profession develops. The generation and publication of peer-reviewed descriptive studies and statistical reports is an important process for an emerging profession. It speaks to transparency in its practices and an accountability to the public.

Methods

This study reports prospective documentation of individual patients Chiropractic care provided by one clinic group in India. Providers included 5 Doctors of Chiropractic, 10 clinical technicians, and 3 physiotherapists.

The 1993 Case-Mix studies (18, 19) of Ebrall formed the seed template for data collection. The database of Dr Spine was interrogated to collate reports on case-mix and demographics of all patients registered over a 45-month-(August 2022 to April 2026)-year period. The top 13 reasons for patient presentation are given in Table 1. The percentage is the frequency of each category of all 13 categories. Categorisation by gender is given in Table 2. 

Table 1: Distribution of presenting complaints

Table 2: Categories of presenting complaints

Results

Distribution of typical Chiropractic presentations

Narrative: Cyst-like formations in various tissues of the body may reflect a common mechanism of their development: uniform pressure of the contents (blood, cerebrospinal fluid, synovial fluid, glandular secretions, etc.) under conditions of connective tissue weakness leads to the formation of spherical structures. The association between these viruses and connective tissue may serve as a unifying factor linking diverse clinical conditions and structural abnormalities.

Cite: Suhorukovs O, Kirdoglo GK. Long-term consequences of Herpesvirus infection and chronic inflammation of connective tissue. Asia-Pac Chiropr J. 2026-7-2. At https://www.apcj.site/SuhorukovsHerpes.pdf

Take-away: 'The clinical diversity of manifestations associated with chronic consequences of exposure to these viruses suggests a profound level of viral impact at the level of fibroblasts and during the formation of different tissues'.

However, insufficient attention has been given to the latent and subclinical consequences of exposure to this group of viruses. Clinically significant lesions and conditions, such as hemangiomas, lipomas, cystic changes, and connective tissue weakness at various anatomical sites, are typically interpreted as degenerative processes. However, in our opinion, they may also have a causal relationship with herpesvirus infection.

Observations of patients with such changes suggest this association, supported both by laboratory findings and by the positive effects of targeted antihomotoxic therapy. Note: Homotoxicology is a branch of biological (regulatory) medicine developed in the 1950s by the German physician Hans-Heinrich Reckeweg. It is based on the concept that disease represents a manifestation of the body's response to homotoxins, endogenous and exogenous toxins, inflammatory mediators, infectious agents, and metabolic byproducts. The primary aim of therapy is not to suppress symptoms, but to support the body’s self-regulatory capacity, enhance detoxification and regenerative mechanisms, and facilitate the restoration of functional equilibrium.

The primary aim of therapy is not to suppress symptoms, but to support the body’s self-regulatory capacity, enhance detoxification and regenerative mechanisms, and facilitate the restoration of functional equilibrium.

Synovial and facet joint cysts of the spine are generally regarded as degenerative formations. In some cases, histological examination reveals pseudocystic degenerative changes of the ligamentum flavum, accompanied by characteristic microcalcifications and a foreign body-type giant cell reaction. According to the literature, these cystic formations are most often not associated with an infectious process and are attributed to degenerative changes and increased segmental mobility of the spine. (4 - 8)

Tarlov cysts

Perineural cysts (Tarlov cysts) are described in clinical and morphological literature as meningeal dilatations of the spinal nerve root sheaths filled with cerebrospinal fluid (CSF). The cyst wall is typically composed of fibrous tissue with elements of the leptomeningeal (arachnoid) membrane, often including nerve fibres within its structure (Fig. 3).

Their origin has been associated with congenital factors, disturbances of cerebrospinal fluid (CSF) dynamics, a valve-like mechanism, or post-traumatic changes. Although their aetiology remains incompletely understood, unlike a number of other pathological processes, perineural cysts do not demonstrate features of infectious or viral involvement. (9 - 13)

A rare complication following microdiscectomy includes discal, annular, and hemorrhagic cysts of the facet joints (Fig. 3, 1), as well as fibrocystic cavities lacking a true synovial lining. (14 - 20) Morphological examination has not revealed specific cytomegalovirus inclusion bodies or viral cytopathic effects.

Synovial cysts are abnormal fluid-filled sacs within the spinal joints and are relatively common in patients with spinal spondylosis. These cysts are benign and resemble cystic formations in other anatomical locations, such as wrist ganglion cysts. They are generally considered to develop as a result of age-related degenerative changes and are most frequently observed in patients over 65 years of age. Although they may occur throughout the spine, they are most commonly found in the lumbar region. For spine surgeons, the presence of a facet joint cyst is indicative of segmental instability at the corresponding spinal level. (41 - 45)

Various conservative treatment approaches for these cysts have been described; however, in cases of chronic pain or neurological deficit, surgical intervention is required. (46, 47)

Clinical manifestations in patients with synovial cysts requiring surgical treatment are typically associated with nerve root compression and spinal instability at the level of the cysts (Figs. 4, 5).

In addition to synovial cysts of the facet joints, patients in this group also presented with hemangiomas (Fig. 6), cystic lesions of internal organs (Figs. 7, 8), cystic formations in other joints (Fig. 9), as well as aneurysms.

Elevated IgG levels against CMV, HSV, and HHV-6 indicate prior infection, i.e., viral carriage. This is typical for the majority of adult patients and does not, in itself, establish a causal relationship with cyst formation or disc herniation.

Demonstration of viral activity requires polymerase chain reaction (PCR) testing (in blood, cerebrospinal fluid, or affected tissue) in conjunction with clinical data; IgG avidity testing is used to determine the timing of CMV infection. (21 - 24) In our opinion, alterations of connective tissue manifested as volumetric, rounded formations, together with elevated IgG titers, may suggest the presence of such an association.

Following primary infection, herpesviruses (including CMV, HHV-6, and HSV) persist in the host for life. Under conditions of stress or immunosuppression, they may undergo reactivation. Even in the absence of detectable viral DNA in the analysed sample, herpesvirus persistence, particularly CMV, may be associated with prolonged immune activation. (25 - 29)

Macrophages normally perform a protective function (M1 phenotype); however, under conditions of chronic viral stimulation, they may shift toward an M2-like phenotype. Such a shift is associated with reduced antiviral immune responses and increased production of profibrotic cytokines. TGF-β, IL-13, IL-17, and IL-10). Resulting in fibroblast activation and collagen accumulation. Note: Cytokines are low-molecular-weight signalling proteins that mediate intercellular communication within the immune system and regulate inflammation, immune responses, and tissue remodelling processes.

A stiffer and less elastic connective tissue is formed, clinically manifested by pain, stiffness, and a tendency toward recurrence following physical нагрузки or surgical interventions; scar tissue may also develop, including in tendons, as an example of a localised fibrotic process (e.g., Dupuytren’s contracture). (30–40) The author observed softening of scar tissue following therapeutic correction with antihomotoxic agents.

Table 2: Key cytokines and their clinical significance

Clinical case 1

Patient B., 56 years old

Complaints of pain in the left thigh, aggravated by movement. The clinical presentation was consistent with left-sided L5 nerve root compression. Instrumental examination revealed a facet joint cyst (Figs. 10, 11). The patient also had a Tarlov cyst. Laboratory testing demonstrated elevated IgG antibodies to CMV and EBV (Fig. 12).

Surgical treatment was performed, consisting of removal of the facet joint cyst. In the postoperative period, resolution of pain in the left leg was observed.

Clinical case 2

Fig. 13. Magnetic resonance imaging (MRI): (1) facet joint cyst before treatment 12/06/2024

Fig. 14.Magnetic resonance imaging (MRI):(1) facet joint cyst after treatment, after 4 months, on 24/10/2024

Figure 16 illustrates how fibroblasts, connective tissue cells, give rise to other specialised cells that form the structures of the body. If impairment of fibroblast function under the influence of herpesviruses is assumed to lead to alterations in multiple tissues, this provides a logical explanation for how CMV and EBV may initiate cystic formations in various anatomical locations.

The clinical diversity of manifestations associated with chronic consequences of exposure to these viruses suggests a profound level of viral impact at the level of fibroblasts and during the formation of different tissues.

Fig. 16. Differentiation of fibroblasts into other cell types of the body.

Cyst-like formations in various tissues of the body may reflect a common mechanism of their development: uniform pressure of the contents (blood, cerebrospinal fluid, synovial fluid, glandular secretions, etc.) under conditions of connective tissue weakness leads to the formation of spherical structures. The association between these viruses and connective tissue may serve as a unifying factor linking diverse clinical conditions and structural abnormalities.

Given the widespread distribution of connective tissue and its derivatives in the body, structural abnormalities potentially associated with herpesvirus infection may be expected to occur almost ubiquitously. The author has not identified references to this in the available literature. Further studies aimed at a more detailed investigation of this phenomenon may allow prediction of cyst development and assessment of connective tissue status, and in many cases may support a shift from surgical treatment toward more conservative and less invasive therapeutic approaches.

Conclusions

1. Morphologically, cysts have a degenerative-fibrotic nature; no direct evidence of herpesvirus cytopathic effects has been identified within them.
2. High seropositivity for herpesviruses (IgG) reflects prior infection and does not constitute evidence of an etiological relationship. This issue requires further investigation.
3. Elevated IgG titers are observed in all patients with cystic formations, indicating the need for further study of the chronic consequences of CMV and EBV infection.
4. Chronic viral burden maintains immune-mediated inflammation, promotes the shift of macrophages from the M1 to the M2 phenotype, and leads to excessive production of profibrotic cytokines. Consequences include chronic pain, stiffness, soft tissue fibrosis, risk of symptom recurrence after interventions, and cystic formations in various tissues.
5. As a rule, patients present with cystic formations in multiple tissues rather than localised involvement.
6. The presence of cystic formations indicates connective tissue weakness, which may be used as a prognostic marker in injury prevention in both athletes and other populations.
7. The use of specific phytotherapeutic, homeopathic, and antihomotoxic preparations (containing information about the nature of the pathogen) may eliminate or, at least, reduce the manifestations of chronic viral impact, thereby suggesting CMV and EBV as factors contributing to significant changes in the body
8. Herpesvirus carriage can only conditionally be considered asymptomatic. The presence of the virus in the body leads to continuous effects on connective tissue, with consequences affecting various structures of the organism.
9. Patients with cysts of various localisations should undergo laboratory diagnostics aimed at detecting herpesvirus infection.
10. The use of manual muscle testing (MMT) allows for diagnosis and individualised selection of antihomotoxic therapy regimens aimed at suppressing herpesvirus infection.
11. The presented data are based on analysis of the literature and clinical observations. The mention of complementary therapeutic approaches does not imply a causal relationship from the perspective of evidence-based medicine and does not replace standard methods of diagnosis and treatment.

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Introduction

Like a physiological phoenix, the neurons of the olfactory nerve can be regenerated after they are destroyed by trauma or infection. This is made possible by stem cells, globose basal cells, closely embedded with the neurons of the olfactory epithelium.

The loss of these stem cells has been implicated as a major culprit in   olfactory dysfunction during acute COVID-19 infection. That the repopulation of the olfactory mucosa with globose basal cells can remain incomplete long after the acute phase is suggested by the fact that as many as ten percent of long COVID victims are afflicted by anosmia, hyposmia, or parosmia according to recent estimates. (Kim et al, 2024)

The responses of patients in a 2023 case series suggest an important role for inflammation in general and rhinitis in particular in this delayed mucosal recovery. Stellate ganglion blocks have been shown to bring about restoration of olfactory function in some long COVID victims. (Kalava et al 2023) The investigators suggest that olfactory dysfunction in these patients was exacerbated by excessive sympathetic stimulation to the nasal mucosa, leading to a hyper-inflammatory state. Stellate ganglion block is hypothesised to reduce this sympathetic stimulation, allowing inflammatory responses to return to normal, with resulting restoration of basal stem cells. 

Nasal inflammation due to dysautonomia takes on additional significance considering a 2026 paper. In a retrospective study of the medical records of 118 million patients a statistically significant increased risk of allergic rhinitis and chronic rhino-sinusitis was found in COVID-19 survivors with three months of follow up. (Olbrich et al, 2026) Long COVID rhinitis exacerbated by dysautonomia would create what amounts to a perfect storm, plausibly suppressing the replacement of globose basal cells.

Kalava et al mention several possible causes of this and similar forms of dysautonomia, including infection, diabetic neuropathy, obesity, and alcoholism. Absent from this discussion is the possibility of somato-autonomic disturbance due to aberrant vertebral mechanics, the vertebral subluxation complex. With this in mind, the following is offered:

Subluxation and Olfactory Dysautonomia

Within the Chiropractic profession the idea that vertebral subluxation can generate dysautonomia has usually enjoyed broad acceptance. In 1996, the Association of Chiropractic Colleges affirmed the long-standing chiropractic tenet that subluxation can ‘ … compromise neural integrity and may influence organ system function and general health’. (ACC, 1996) By implication, this statement clearly points to the possibility of dysautonomia generated by subluxation. 

Of the multiple mechanisms for subluxation-generated dysautonomia several bear discussion here. Compression or distraction of spinal nerve roots within the intervertebral foramen could disturb the presynaptic fibres of sympathetic pathways. At some spinal levels in some individuals, the vulnerability of spinal nerve roots to this disturbance may be increased by the presence of transforaminal ligaments partially closing the foraminal ‘windows’. (Masarsky, 2025) 

The aberrant motion and/or position of vertebra caused by subluxation would tend to stress the adjacent tissues, including the ligament connecting the anterior surfaces of lamina of adjacent vertebra, the ligamentum flavum. Resultant buckling or swelling of the ligamentum flavum has been shown to result in compression of the dorsal root ganglion. (Giles, 1994) The afferent neurons within this ganglion include those that serve the visceral sensorium. Therefore, disturbance of these neurons could distort autonomic efferent output. 

The formation of osteophytes in response to the aberrant mechanics of a subluxated spinal motion segment could plausibly result in dysautonomia. Interference with spinal nerve roots when osteophytes grow into the intervertebral foramen is one mechanism by which osteophytes can disturb autonomic function. Furthermore, when osteophytes project in an anterolateral direction, they can penetrate the para-vertebral sympathetic chain. (Giles, 1992) 

The existence of connective tissue bridges between cervical extra-spinal structures and the cervical dura mater has been noted since the 1990s. (Hack et al, 1995 and Mitchell et al, 1998) Cervical subluxation would be expected to disturb these myodural bridges with resultant disturbance to the dura mater. The connection between dural disturbance and dysautonomia is widely appreciated. (Henderson, 2015)

Autonomic innervation to the nasal mucosa is primarily via the sympathetic nervous system. Presynaptic sympathetic fibres emerging with the upper four or five thoracic spinal nerves enter the cervical sympathetic chain. They synapse primarily within the superior cervical sympathetic ganglion. Postsynaptic axons innervate the nasal mucosa. Therefore, subluxation-generated dysautonomia affecting the olfactory mucosa would most likely arise from cervical and upper thoracic levels.

Chiropractic adjustments and Long COVID Olfactory Dysfunction

Clinical vignette 1

In the early days of the COVID-19 pandemic (May, 2020) a middle-aged executive presented with a chief complaint of back pain. (Masarsky, 2021) The pain originated when she over-reached to flush the toilet. While Chiropractic intervention focused on lumbar subluxations, adjustments were also indicated and performed at C1 and T2.

Although her chief complaint was not olfactory in nature, she made parenthetical mention of having recently recovered from a COVID-19 infection, which also afflicted other members of her household. Her residual symptoms included loss of her sense of smell, anosmia. 

When she was about to leave, she took a bit of hand sanitiser and was surprised that she could smell its fragrance. On her return visit two days later, she mentioned that she was able to smell garlic at her family’s dinner table the previous evening. This experience prompted a call for subjects to more systematically study the influence of Chiropractic care on long COVID signs and symptoms.

Clinical vignette 2

A 58-year-old real estate agent responded to our call for subjects. (Masarsky and Todres-Masarsky, 2022) Her long COVID manifestations included hyposmia. On a scale of olfactory sensitivity developed by Gupta et al, she rated her sense of smell at ‘1’ where ‘5’ is a completely normal sense of smell. (Gupta et al, 2013) She mentioned that aromas seemed to be less intense when she inspired through the right nostril than the left. On physical examination, Weber test was consistent with a mild conductive hearing loss in the right ear, suggesting the possibility of right sided ear-nose-throat congestion.

In addition to hyposmia, she also suffered from parosmia. This manifested itself as a transient ‘house on fire’ aroma, without any actual fire present. She was unable to identify a pattern or trigger for these parosmia episodes.

Intervention at her first visit included adjustments of C1 and the right first rib. On her second visit three days later, the patient reported the ability to definitively smell the aroma of bread at the dinner table.

After ten Chiropractic visits over a period of six weeks, she rated her sense of smell as 2 - 3 on the previously mentioned Gupta et al scale. Weber test was now negative. Her occasional parosmia episodes continued, but the ‘house on fire’ aroma had evolved into a less disturbing ‘burnt popcorn’ aroma. She reported restoration of her ability to smell several odours, including a litter box, mildew, garlic, tobacco, eucalyptus, and grass. The adjustments during this time included various cervical, thoracic, lumbar, and cranial levels according to the findings of the treating Chiropractor.

Clinical vignette 3

A 66-year-old retired military officer with a history of two COVID-19 infections presented with multiple long COVID manifestations. (Masarsky CS and Todres-Masarsky M, 2025) Regarding his sense of smell, he stated he had some loss after his first infection, which had not completely recovered. Currently he rated his sense of smell as ‘3’ on the previously mentioned Gupta et al scale. He also described one to two parosmia episodes per week, with each episode lasting several hours. During these episodes he perceived a ‘dumpster smell’ unrelated to the presence of garbage in his vicinity. 

Chiropractic adjustments varied from visit to visit based on the treating Chiropractor’s findings. All adjustments included at least one cervical level. After twelve visits over a five-week period, the patient noted his sense of smell was now almost normal, almost ‘5’ out of ‘5’ on the Gupta et al scale. The frequency of his ‘dumpster’ parosmia episodes had been decreasing during this period of care.

Clinical discussion

Chiropractic care for all three cases summarised above included cervical adjustments and often involved upper thoracic adjustments, the vertebral levels most closely associated with sympathetic innervation of the nasal mucosa. 

The asymmetry of olfaction reported by the real estate agent (aromas were less intense in the right nostril than the left) was consistent with the presence of a positive Weber test. The unilateral conductive hearing loss suggested by the positive Weber test could indicate a generalised ear-nose-throat congestion. 

Such congestion could have been aggravated by rhinitis. That the resolution of the Weber test coincided with olfactory improvement further suggests the linkage between auditory and olfactory dysfunction in this patient. It also suggests the aggravation of long COVID auditory and olfactory dysfunction was aggravated by cervical and thoracic vertebral subluxation.  

Testing the hypothesis.

While the findings of the cases published to date plausibly point to aggravation of long COVID olfactory dysfunction by the dysautonomia of vertebral subluxation, robust support for the hypothesis requires more evidence. 

One approach would be to note the presence or absence of outcomes related to dysautonomia that exhibit covariance with olfactory dysfunction. Useful clinical signs would be those closely associated with sympathetic innervation from cervical and/or upper thoracic vertebral levels. 

Such signs could include facial thermography, pupillometry, facial sweat gland activity, and heart rate variability. Symptoms related to these levels of sympathetic innervation could include salivary gland activity (dry mouth or excessive salivation), changes in light sensitivity (aversion to bright light or difficulty seeing in dim light), and changes in tear production (dry eye or excessive tearing). If improvement in these signs/symptoms and olfactory function covary with signs of vertebral subluxation and/or reduction of these signs and symptoms under chiropractic care, such evidence would be supportive of the hypothesis.

Practical implication of the hypothesis

Inter-professional cooperation on behalf of the long COVID patient could be encouraged by wide dissemination of easily applied examination measures that suggest the presence of cervical and/or thoracic subluxation. For example, a medical practitioner examining a patient with long COVID anosmia could notice restriction in cervical flexion/extension or significant asymmetry in cervical rotation/lateral flexion. This could prompt a referral for Chiropractic co-management of this patient. On the other side of the coin, a Chiropractic practitioner caring for a patient with long COVID olfactory dysfunction would be better equipped to explain the rationale for care to others in the patient’s health care team.

Adjuncts to Chiropractic care commonly include measures to counter hyperinflammatory states. Such adjunctive measures are within the common domain health care practice in general Therefore, these interventions can serve as a further arena of inter-professional cooperation.  

Practices to counter hyperinflammatory states take on increased importance for patients with olfactory dysfunction related to vertebrogenic dysautonomia. 

These include yogic and meditation techniques such as alternate nostril breathing, dietary advice to limit animal fat and emphasise fruits/vegetables/whole grains, regular exercise, and laughter. Such measures take on additional significance for a patient with olfactory loss related to a hyperinflammatory state. 

Additional adjuncts to support the Chiropractic adjustment of cervical and thoracic subluxation are also common in chiropractic practice. These would include range of motion exercises for the relevant regions of the spine, postural advice, and consideration of the patient’s bed and pillow, among other factors. Again, these take on additional significance if nasal inflammation is related to vertebrogenic dysautonomia.

About the author

Dr Charles Masarsky has been in the private practice of chiropractic with Dr. Marion Todres-Masarsky since 1983. Marion sadly passed August 2026.
Their office is located in Vienna, Virginia, USA in the suburbs of Washington, DC. He also offers continuing education programs for chiropractic colleges and associations and teaches at George Mason University (Fairfax, Virginia). For information about his practice or his CE programs, please e-mail viennachiropractic@verizon.net.

Citations for Dr Masarsky’s published papers are available at his website under ‘about the doctors’: www.viennachiropractic.com.

Dr Masarsky writes this frequent feature in the Journal called ‘The Wide Angle Lens’ in which he takes a broader than usual perspective on one issue or another, and has contributed much on clinical aspects of COVID. 

Also by this author

• Masarsky CS. The Wide-Angle Lens. Hypothesis: Cranial Suture Complexity is influenced by Sensory Innervation. Asia-Pac Chiropr J. 2026;6.3. www.apcj.net/papers-issue-6-3/#MasarskySutureComplexity  
  
• Masarsky CS. The Wide-Angle Lens: Transforaminal Ligaments, Unanswered questions. Asia-Pac Chiropr J. 2025;6.2. www.apcj.net/papers-issue-6-2/#MasarskyTransforminalLigaments
  
• Masarsky CS. Hypothesis: Chiropractic adjustments reduce the risk of stroke in Long COVID. Asia-Pac Chiropr J. 2025;6.1. www.apcj.net/papers-issue-6-1/#MasarskyLongCOVIDHypothesis
  
• Masarsky CS, Todres-Masarsky M. Long COVID with Obstructive Sleep Apnea: A case report. Asia-Pac Chiropr J. 2025;6.1. www.apcj.net/papers-issue-6-1/#MasarskySleepApnea
  
• Masarsky CS. Respiratory RCTs: What Are We Missing? [The wide-angle lens]. Asia-Pac Chiropr J. 2025;5.3. www.apcj.net/papers-issue-5-3/#MasarskyRespiratoryRCTs
  
• Masarsky CS, Todres-Masarsky M. Long COVID with Parosmia and Exertional Malaise: A case report. Asia-Pac Chiropr J. 2025;5.4. www.apcj.net/papers-issue-5-4/#MasarskyLongCOVID
  
• Masarsky CS, Todres-Masarsky M. Long Haul COVID-19 and Subluxation: A case report. Asia-Pac Chiropr J. 2022;2.6. apcj.net/papers-issue-2-6/#MasarskyLongCovid
  
• Masarsky CS, Todres-Masarsky M. Long COVID Hyposmia/Parosmia and subluxation: A case report. Asia-Pac Chiropr J. 2022;3.2. apcj.net/Papers-Issue-3-2/#MasarskyHyposmia.
  
• Masarsky CS, Todres-Masarsky M. Long COVID: A Risk Factor for Scoliosis Incidence and Exacerbation? [Hypothesis] Asia-Pac Chiropr J. 2023;3.3. apcj.net/Papers-Issue-3-3/#MasarskyLongCovidScoliosis.
  
• Masarsky CS, Todres-Masarsky M. Long COVID Pharyngitis, Possible Glossopharyngeal Neuralgia, and Subluxation: A case report URL Asia-Pac Chiropr J. 2023;4.1. apcj.net/Papers-Issue-4-1#MasarskyTodreaMasarskyLongCovid 
  
• For others, search ‘Masarsky’ atapcj.net or go to www.viennachiropractic.com.
  

Bibliography

• A third possibility emerges due to the first 12 weeks of the protocol, in which the parents withdrew the patient from all other programs and supports. This was intentional, and the treating chiropractors regard it as a key contributor to the early functional gains (which must be tested through further research). It is equally possible that the removal of demand (i.e. the withdrawal of therapy sessions pitched above the child's functional level, in a child whose presenting complaints centred on resistance to academic tasks and transitions) may have produced substantial behavioural improvement independent of any adjustment delivered. While this may seem separate from Chiropractic ‘treatment’ per se, it is respectful of a nervous system approach in which we give the nervous system what it needs, remove what it does not need, and allow adaptability to emerge accordingly. 

AU2: Ruth Postlethwaite BBiomedSc. Writer, ASRF.

Background: Two male twin infants, aged three months, presented for chiropractic assessment. Twin A presented with severe gastro-oesophageal reflux disease (GERD), laryngomalacia, cow’s milk protein allergy, difficulty latching, and constipation. Twin B presented with excessive irritability, generalised neuromuscular tension, feeding difficulties associated with a residual posterior tongue-tie, positional aversion, and intolerance of tummy time. Both infants were delivered via caesarean section and demonstrated clinical findings consistent with birth-related strain patterns affecting the craniocervical junction, thoracic spine, and shoulder girdle.

Intervention: A multimodal, low-force chiropractic care plan was implemented for both infants over an initial period of eight weeks, comprising instrument-assisted spinal adjustments (Activator), baby drop-piece technique, sustained-pressure contacts, craniosacral therapy, myofascial release, and oral motor stretches. No high-velocity, low-amplitude manipulation was performed.

Outcomes: Both infants demonstrated measurable improvements across objective and subjective outcome measures. Twin A showed significant reduction in reflux frequency, improved postural tone, enhanced coordination, and progression with feeding. Twin B showed resolution of neuromuscular hypertonicity, integration of the exaggerated Moro reflex, improved cervical and shoulder range of motion, and resolution of reflux and eczema, alongside successful attainment of age-appropriate motor milestones including tummy time tolerance and rolling. Parental reports confirmed marked improvements in infant comfort, sleep, feeding, and overall disposition.

Conclusion: This case report demonstrates a role of Chiropractic care for infants presenting with complex birth-related functional and comfort concerns. Addressing underlying subluxation, including spinal, cranial, and oral biomechanical dysfunction may support improvements in neurological regulation, feeding efficiency, postural development, and quality of life. Further research is warranted.

Indexing Terms:Chiropractic; twins; developmental signposts; GERD; infant care.

Introduction

The neurological consequences of a stressful or traumatic pregnancy and birth are rarely, if ever, confined to the delivery suite. For the Chiropractor assessing a distressed, hypersensitive, or poorly-feeding infant, the clinical   question is not whether the birth was difficult, but how the cumulative stressors of gestation and delivery have altered the infant's afferent neurological environment, and what that altered environment is doing to the developing nervous system. This case report presents twin male infants whose complex presentations, including severe reflux, feeding dysfunction, generalised neuromuscular tension, and regulatory dysregulation, are examined through that conceptual lens. 

Multiple gestation pregnancies are recognised as inherently higher-risk pregnancies due to increased rates of maternal stress, prematurity, intrauterine constraint, obstetric intervention, and birth complications. (Alarfaj et al, 2025) Twin pregnancies are associated with elevated rates of caesarean section, assisted delivery, foetal distress, and low birth weight, each of which may contribute mechanical and neurophysiological stress to the neonate during critical stages of neurological development. (Abraham et al, 2023) From a developmental neuroscience perspective, the prenatal and perinatal periods represent times of exceptional neurological plasticity, where excessive nociceptive, inflammatory, mechanical, or emotional stress exposure may influence autonomic regulation, sensory processing, hypothalamic-pituitary-adrenal axis activity, and early neurodevelopmental organisation. (Thomason and Hendrix, 2024)

While these factors may lie largely outside of maternal control, the role of the chiropractor in early life is something that a parent can control. Unfortunately, chiropractic remains beset by challenges communicating these benefits to those who are not yet under care, especially with regard to infant and paediatric care. This case report discusses the chiropractic care of infant twin boys who were presented for care citing concerns with irritability, gastrointestinal reflux, latching, and other individual concerns specific to each twin.

Case details

Two male twin infants, aged three months, presented for Chiropractic assessment accompanied by their parents. Both infants had been delivered via planned caesarean section and shared a history of cow’s milk protein allergy and gastro-oesophageal reflux (GERD). 

Upon presentation, a thorough history and comprehensive infant examination was conducted for each twin. Assessment included spinal and peripheral range of motion, segmental spinal palpation, cranial palpation and measurement (circumference, oblique diameters, fontanelle assessment), cranial nerve assessment, peripheral and central muscle tone assessment, deep tendon and superficial reflex testing, primitive and postural reflex assessment, oral motor assessment, gross motor and developmental milestone assessment, and parental-reported stool and reflux frequency.

Twin A: Clinical findings

Global posture demonstrated a left head tilt with right head rotation. Cranial asymmetry was measured at 5 mm from oblique measurements, indicating right-sided plagiocephaly. Dural tension was minimal, most prominent at the pelvis.

Cervical range of motion demonstrated reduced extension and left lateral flexion with restricted rotation. Mid-thoracic mobility was reduced in rotation. Lumbar range of motion was restricted in extension and right lateral flexion. Right sacroiliac restriction was identified. Bilateral shoulder restriction was present, with involvement of the left sternoclavicular joint.

Peripheral muscle tone was within normal limits. Central tone demonstrated insufficiency in flexion, extension, and shoulder stability. Reflex assessment identified under-responsiveness of the left Achilles reflex; all other deep tendon reflexes were normal. Primitive reflexes were intact. Neck righting reflexes were reduced, with poor cervical stability and a forward head position noted.

Oral assessment revealed reduced lingual function graded at 4 (G4), with buccal tone estimated at 75% bilaterally.

Difficulty was noted with pull-to-sit secondary to reduced anterior cervical activation and with prone extension. Neck extension was adequate; however, shoulder stability required support.

Subluxations were identified at C0 (LAS/RPS), T4, T12, and S2.

Twin B: Clinical findings

Postural assessment demonstrated left head rotation with right head tilt. Cranial asymmetry was measured at 4 mm in oblique comparisons. A pattern of right-sided dural tension and pulling was identified. Significant cranial tension was palpated over the left frontal and right temporal regions.

Cervical range of motion demonstrated moderate to severe restriction, with flexion most significantly affected. Mid-thoracic mobility showed mild to moderate restriction, most prominent in right lateral flexion and rotation. Lumbar restriction was mild to moderate. Left pelvic restriction was identified. Peripherally, right shoulder range of motion was moderately restricted, with right tibiofibular restriction also noted. Neck extension was strained, with compensatory recruitment from the mid-thoracic region.

Cranial nerve assessment identified reduced right-sided tongue lateralisation and a diminished gag reflex, consistent with under-active vagal tone. Deep tendon and peripheral reflexes were otherwise appropriate. Muscle tone was generally good peripherally; however, central stability was reduced, with deficits in deep cervical flexor strength and shoulder girdle stability.

Prior lip and tongue releases had been performed. Residual posterior tongue tension was identified on palpation. An audible click during feeding was consistent with incomplete tongue-tip elevation secondary to residual restriction.

Primitive reflex assessment revealed asymmetry in the placing response. Postural responses demonstrated reduced left neck righting. Pull-to-sit and prone extension were effortful and asymmetrical. The Moro reflex was exaggerated. Subluxations were identified at C0 (LAS), C1, C4, T5, L3, and left sacroiliac joint (LSI).

Clinical impression

The collective findings for both infants were consistent with a significant birth-related strain pattern primarily involving the craniocervical junction, shoulder girdle, and thoracic spine, considered to reflect the cumulative effect of in-utero constraint associated with multiple gestation and the absence of the physiological birth canal transit accompanying caesarean delivery.

The identified subluxation complexes and associated neuromuscular findings were regarded as likely contributors to each twin's presentation, including feeding difficulty, visceral dysregulation, irritability, postural asymmetry, and motor developmental delay, through the mechanisms of aberrant afferent neurological input and sustained autonomic imbalance described in the introduction.

Management of Twin A

The primary aims of care for Twin A were to improve nervous system function through correction of identified subluxations, support postural tone development, and facilitate shoulder girdle strengthening in conjunction with tummy time activities. Longer-term goals included support of oral motor function and optimisation of overall health through ongoing nervous system support.

All care was delivered using low-force methods appropriate for infants under two years of age; no high-velocity, low-amplitude spinal manipulation was performed. Techniques included Activator methods with force delivered over fingertip contact, Touch and Hold sustained-pressure technique, thoracic extension lift, and baby drop-piece and seated drop-piece (speeder board -  a small cushioned platform providing a gentle assisted drop to facilitate spinal correction).

Oral stretches were incorporated, comprising palatal stretch, frenulum mobilisation, buccal stretches, and tongue lateralisation exercises. Gentle cranial adjustments were applied throughout the care plan.

Referral to a specialist for formal tongue-tie assessment and surgical release was recommended, alongside referral to a lactation consultant to optimise feeding mechanics. Home care instruction included pre- and post-release oral exercises to improve tongue lateralisation and sublingual mobility, anterior cervical strengthening exercises, and submental massage to reduce local tension. Daily tummy time was encouraged to support postural development and muscle tone.

Management of Twin B

The primary aims were to optimise nervous system function through correction of identified subluxations and reduction of sympathetic activation, improve postural alignment by reducing subluxation and dural tension, and improve infant comfort and ease through reduction of neurological irritation. Longer-term goals included improved feeding efficiency and attainment of age-appropriate motor milestones.

A multimodal, low-force approach was employed; no high-velocity, low-amplitude spinal manipulation was performed. Instrument-assisted adjustments were delivered using an Activator instrument on a low-force setting, combined with baby drop-piece technique. Craniosacral therapy included sutural releases of the sagittal, coronal, and lambdoid sutures alongside specific sphenoid and palatal techniques. Myofascial release was applied to the suboccipital musculature and shoulder girdle, and sustained-pressure releases addressed residual areas of subluxation or segmental restriction.

Nutritional support included continuation of the amino acid-based formula and introduction of an infant probiotic (Biome Baby) to support gastrointestinal health. Parents were instructed in a home exercise programme comprising cervical and shoulder mobility stretches, pull-to-sit activities to develop anterior cervical flexor strength, and supported prone holds to facilitate postural extension and shoulder girdle activation.

Outcomes

Progress was monitored through objective clinical reassessment and subjective parental report at each visit. Objective measures included reassessment of spinal and peripheral range of motion, segmental palpation, peripheral and central muscle tone, cranial palpation and measurement, deep tendon, primitive, and postural reflex testing, and gross motor milestone progression. Subjective measures included parental-reported stool frequency, reflux frequency and severity, sleep quality, feeding efficiency, and general infant disposition. A formal re-examination was conducted at the twelfth visit for both infants.

Re-examinations made at seven-months were done with expectations in developmental outcomes for that of a seven-month old. So not only were they looking for improvements in their trajectory over that time, but also looking for progression and neuro-maturation expectations aligned with normal development at that age. 

Twin A: Outcomes

At seven months of age, parents reported clinically meaningful improvements across multiple domains. There was a significant reduction in the frequency and severity of reflux episodes, with decreased regurgitation volume and reduced associated distress. Postural tone demonstrated progressive improvement, with enhanced coordination and balance in age-appropriate gross motor activities. Parents noted increased active movement, greater upper limb strength, and improved resilience manifest as faster recovery from fatigue and intercurrent illness. General infant behaviour was described as improved, with a calmer and more settled demeanour. Feeding and reflux progression remained ongoing at the time of reporting.

Twin B: Outcomes

At the formal re-examination, objective clinical findings demonstrated marked improvement. Cervical and shoulder range of motion had substantially increased, and palpable neuromuscular hypertonicity had resolved throughout the assessed regions. The exaggerated Moro reflex had integrated. The infant’s overall disposition had changed from persistently irritable and hypertonic to calm and content. Developmentally, tummy time was tolerated and ultimately mastered, facilitating the achievement of rolling as an age-appropriate milestone.

Parental report confirmed the infant was described as ‘doing really well’, ‘less agitated’, and a ‘happy baby’. Significant improvements in sleep duration and quality were noted alongside a marked reduction in crying episodes. Both reflux and eczema had resolved. The parents expressed that they were ‘very happy with the changes in a short period of time’.

Discussion 

While maternal stress in a multiple gestation pregnancy, during a concurrent time of heightened life stress may have been unavoidable, bringing the infants in for Chiropractic care early on in their lives created an opportunity to interrupt these early patterns of restriction and autonomic dysregulation. How this difference may impact their development across the first year of life is largely speculative. However, given the outcomes, it is likely significant.

Both infants demonstrated examination findings consistent with birth-related strain patterns characterised by craniocervical restriction, thoracic and lumbar segmental dysfunction, cranial asymmetry, and altered neuromuscular tone, which may have contributed to their respective presentations. They also demonstrated significant improvements concurrent with Chiropractic care. 

There were multiple issues at play in this case, and it should be considered that in this scenario, the Chiropractor played a role as a quasi care-coordinator who was able to bring together multiple factors in order to support the babies, and by virtue of that, the family, as a whole.

The resolution of craniocervical and thoracic subluxation findings in both infants, concurrent with improvements across feeding, sleep, visceral regulation, and motor development, is consistent with the proposed mechanism of Chiropractic: restoration of normal mechanoreceptive afferent input to the brainstem and cerebellum, with consequent reduction in central sensitisation and sympathetic facilitation, and a shift toward improved parasympathetic tone. 

The crux of this case is that, when we adjust the subluxation and restore optimal neurological function, an infant’s ability to rest, digest, grow and thrive may be profoundly impacted, though larger-scale research would be required in order for us to confidently claim the size and cause of this impact. 

As seen in this case, Twin B’s cranial nerve findings (reduced vagal tone on presentation with subsequent clinical resolution) provide a particularly illustrative example. The integration of the exaggerated Moro reflex, resolution of postural hypertonicity, and progressive attainment of motor milestones are each consistent with a nervous system moving from a state of heightened alerting into one of greater regulatory capacity and developmental readiness.

For Twin A, the relationship between subluxation correction and gastrointestinal function, including severe GERD and laryngomalacia, may have been significant and the concurrent dietary interventions may have contributed to the improvements seen alongside Chiropractic care. With this said, Chiropractic is about caring for the whole person, and that often means recommending alternative dietary approaches (within the scope of the Chiropractor’s knowledge). Chiropractic care of the whole child recognises that physical, chemical and emotional stressors can have an impact on symptoms and nervous system states. Thus, our approach needs to remain holistic and serve to reduce stressors across all three categories.

The observed reduction in reflux frequency concurrent with chiropractic management is consistent with improved vagal efferent output to the lower oesophageal sphincter and gut, mediated by reduction in the craniocervical afferent load that was sustaining sympathetic dominance. The resolution of constipation similarly suggests improved parasympathetic regulation of large bowel motility.

It is important to note that, in this case, ‘chiropractic management’ extended beyond checking and adjusting, and it provided a rationale for multimodal care in some cases. The outcomes observed in both infants are almost certainly attributable to a combination of contributing factors, and illustrate why it is so important for Chiropractors to be able to work with other allied health professionals when the case calls for it. 

For Twin A, it is likely that the lactation consultation, specialist referral for tethered oral tissue assessment, and formula optimisation each independently contributed gastrointestinal improvements. For Twin B, dietary transition to an amino acid-based formula, probiotic supplementation, and the parents’ consistent engagement with the home exercise program reinforced gains in postural strength and mobility between clinic visits were all likely contributors to the improvements. 

The natural process of infant neurological maturation between three and seven months of age is also to be expected, and spontaneous resolution of some functional concerns including reflux may occur in this period independently of intervention. However the associated body tension, asymmetry and immaturity that was present, is less likely to resolve without support. What we saw with this case report is not just the resolution of symptoms, but the infants catching up with age-related expectations for their development.

These cases reinforce the clinical importance of comprehensive spinal, cranial, and neurological assessment in infants presenting with functional concerns following difficult or multiple-gestation pregnancies. A Chiropractor is well positioned to identify the substrates of infant dysregulation and to offer conservative, age-appropriate intervention during a period of maximal neuroplasticity.

Conclusion

The cases also illustrate the value of integrated collaborative care: Chiropractic correction of the neurological substrate, combined with targeted co-management of dietary, oral, and postural factors, creates the conditions in which the infant's own regulatory capacity can re-emerge. 

For the infant wellbeing literature more broadly, these cases highlight that the improvements most valued by parents (reduced distress, improved sleep, better feeding, a calmer temperament) may result from a neurologically grounded model of Chiropractic care that addresses underlying autonomic dysregulation. 

As is the case with paediatric Chiropractic, further research is needed to better understand the mechanisms behind changes like these, as case reports are limited. Future research incorporating objective physiological measures such as heart rate variability as an index of vagal tone, alongside neurodevelopmental or blinded assessor outcome measures, would substantially strengthen the evidence base for these observations.

References

Abraham, M., Ali, N., Shivani Garapati, S. S. L., Pandey, P., Nair, S., Swarna, S., Chowdary, D. V., Aladeniyi, F., Daing, A., & Abbas, K. (2023). Delivery Methods in Twin Gestations: Evaluating Outcomes, Risk Factors, and the Paradigm Shift Towards Elective Cesarean Deliveries. Cureus, 15(10), e46514.

Alarfaj, R. K., Alwahhabi, A., Alshalan, R., Alabdulkareem, Y., Alabdulkareem, D., & Alkharouf, F. (2025). Comparing Outcomes and Risks of Multiple Gestations: Assisted versus Spontaneous Conceptions. International journal of women's health, 17, 4347–4357. https://doi.org/10.2147/IJWH.S544868 

Thomason, M. E., & Hendrix, C. L. (2024). Prenatal Stress and Maternal Role in Neurodevelopment. Annual review of developmental psychology, 6, 87–107. https://doi.org/10.1146/annurev-devpsych-120321-011905 

About the Case Report project

This Case Report is a part of the ASRF Case Report Project, a project designed to gather client studies from chiropractors and transform them into much-needed case reports, focused on the effects of chiropractic care on clinical presentations highly relevant to chiropractic, such as stress, immunity and adaptability. This project was made possible by the generous fundraising and contributions of ASRF supporters.

AU2: Ruth Postlethwaite BBiomedSc. Writer, ASRF.

Cite: Rai S, Postlethwaite R, McIvor C. Chiropractic management of a 49-year-old female with Arnold-Chiari Malformation and associated neurological sequelae: A case report. Asia-Pac Chiropr J. 2026;7.2 https://www.apcj.site/RaiACMalformation.pdf   

Introduction

Arnold-Chiari Malformation (ACM), also referred to simply as Chiari Malformation (CM), describes a group of structural defects of the cerebellum and its relationship to the skull base and spinal canal. (1) The condition was originally described by Hans Chiari in 1891 and subsequently classified into four subtypes (Types I - IV) based on the extent and nature of the herniation and associated anomalies. Type 1, the most likely form encountered in a Chiropractic practice, is characterised by caudal descent of the   cerebellar tonsils by more than 5 millimetres below the foramen magnum, causing compression of the brainstem and upper cervical spinal cord. (2)

Type 2, often associated with myelomeningocele, wherein parts of the brain and spinal cord are pushed down into the spinal canal, involves more extensive posterior fossa structures and typically presents perinatally. Types 3 and 4 are considerably more rare and carry a more severe prognosis. This report concerns ACM-1, the variant most likely to be encountered in adult Chiropractic practice.

The true prevalence of ACM-1 has historically been difficult to establish due to the variable clinical presentation and the high proportion of asymptomatic individuals. Contemporary estimates suggest that 1/1000 people are symptomatic and approximately 1/100 meet the radiological criteria. (3) ACM-1 exhibits a higher prevalence in adult females than males, a pattern consistent with several autoimmune and connective tissue conditions that may co-exist or predispose individuals to posterior fossa crowding. (4) 

A significant proportion of patients with ACM-1 remain asymptomatic for years or decades, with symptoms often emerging in the third to fifth decade of life following a precipitating event such as trauma, physical strain, or progressive spinal instability. This delayed presentation underscores the importance of thorough case history and imaging in chiropractic practice when evaluating patients with suboccipital pain, unexplained dizziness, or progressive neurological symptoms.

The primary anatomical abnormality is a congenitally small or underdeveloped posterior cranial fossa, which fails to accommodate the normal volume of posterior fossa contents, resulting in herniation of the cerebellar tonsils through the foramen magnum. (5) This herniation disrupts the normal flow of cerebrospinal fluid (CSF) between the cranial and spinal compartments, creating a craniospinal pressure gradient that may further propagate or exacerbate the herniation. Brainstem and upper cervical cord compression resulting from tonsillar herniation produces a wide and often non-specific constellation of symptoms that complicates timely diagnosis.

ACM-1 often presents with variable symptomatology. The most commonly reported symptom is headache, particularly suboccipital or ‘Valsalva-type’ headache precipitated by coughing, straining, or physical exertion, reported in the majority (upwards of 80%) of symptomatic patients.(2) Other frequently observed presentations include severe pain, sensory disturbances such as paraesthesia and dysaesthesia, nausea and vomiting, limb weakness, and cranial nerve deficits. Vertigo, balance disturbance, dysphagia, sleep-disordered breathing, and visual disturbances are also reported.(1, 2)

It is important to note that, in this case, cranial nerve involvement presenting as facial palsy is not a primary ACM-1 symptom. However, it can occur secondary to brainstem compression, elevated intracranial pressure, or cerebellar compression. Facial nerve (cranial nerve VII) palsy, whether presenting as focal facial weakness or more complete hemifacial drooping, may occur in isolation or in combination with abducens (VI) and other lower cranial nerve palsies. (6, 7)

Published case reports document bilateral abducens palsies and facial weakness as presenting manifestationsof ACM-1, seven and more complex cranial nerve syndromes, including the rare 'Eight Syndrome' (conjugate gaze palsy with ipsilateral facial nerve palsy), have been described in the context of ACM-associated syringomyelia. (7) These observations are clinically relevant when examining a patient such as the one presented in this report, in whom pre-existing facial palsy formed part of the complex neurological picture.

For symptomatic patients seeking relief, surgery remains the most obvious option. However, this is complicated by the risks of surgery and reports of variable results. The existence of a subset of patients who undergo surgery yet retain residual neurological and musculoskeletal symptoms creates a patient population for whom complementary conservative management may be of interest. However, the paucity of literature on the topic likely makes this option almost invisible to them. The available evidence consists primarily of case reports, and no controlled trials or prospective cohort studies examining chiropractic management of ACM-1 have been identified at the time of writing.

A notable Chiropractic case report was published in the Journal of Chiropractic Medicine in 2014, describing chiropractic care for a 34-year-old woman previously diagnosed with ACM-1 presenting with headaches and dizziness. The patient responded positively to a course of low-velocity, low-amplitude upper cervical mobilisation followed by high-velocity, low-amplitude adjustments. (8) The authors appropriately cautioned that spontaneous resolution of some ACM symptoms is possible, and therefore a direct causal relationship between chiropractic care and structural or clinical improvement could not be definitively established.

A second case report published in the American Journal of Case Reports described a 62-year-old woman with residual syringomyelia following foramen magnum decompression who presented to a chiropractor with progressive neck pain and headaches. Multimodal chiropractic and rehabilitative therapies resulted in clinical improvement, though the authors noted that given the limited evidence base, these interventions could not be broadly recommended but warranted consideration on a case-by-case basis. (9)

As further 6 case reports have been published in this pages, and this present report is offered as a contribution to this limited literature, with the hope of stimulating larger-scale inquiry into Chiropractic care for this population.

Case details

A 49-year-old female presented for Chiropractic care with a chief complaint of chronic migraines and facial palsy. She was novice to Chiropractic, and reported a low level of physical activity. At the time of presentation, she described herself as a housewife and disclosed a diagnosis of Arnold-Chiari Malformation. 

History and examination included a discussion of the patient’s goals. She was diagnosed with Arnold-Chiari Malformation Type 1 and had undergone posterior fossa decompression surgery fifteen years prior to presentation. She reported mild to moderate improvement in symptoms following surgery, with a reduction in the severity of headaches and sensory symptoms in the immediate post-operative period. However, a number of symptoms persisted or re-emerged in the years following surgery.

The patient reported having experienced chronic migraines for approximately twenty years. These were described as severe, episodic headaches exacerbated by bright lights and the ingestion of dietary triggers, particularly chocolate. Associated symptoms included visual disturbances and nausea. The patient managed migraines with injectable treatment  and over-the-counter analgesics. She reported that migraine frequency and severity had worsened in the 12 months before her presentation at the clinic.

Facial drooping was also a concern, with the patient describing intermittent unilateral facial shifts. The precise aetiology and onset of the facial palsy in the context of ACM were not further specified in the patient history; however, the association between cranial nerve VII dysfunction and ACM is documented in the literature, and this was considered a potentially related neurological sequela of her underlying condition.

Neck and shoulder pain had progressively worsened over the year preceding presentation. During this time, the patient had sought assessment from her general practitioner and a neurosurgeon, but had not initiated any new intervention. Positional dizziness upon transitioning from sitting to standing was reported. She also noted difficulty taking deep breaths, with a background history of rhinitis contributing to upper respiratory limitations that may co-occur with ACM-1. The patient also reported poor sleep.

Aims of care, for the patient, included a desire to become more physically active, to improve her energy levels, reduce fatigue, and manage her pain more effectively. She identified difficulty completing household chores and disrupted sleep as her most functionally limiting secondary complaints, and wished to regain her functional capacity here. She also described sensitivity to bright lights as an ongoing quality-of-life concern. 

Clinical findings

Postural assessment revealed an antalgic posture with observable compensatory patterns. A functionally short leg was identified on static assessment, where it was noted that the patient had a right short leg (approximately 1cm) which was corrected by rotating the head right. Cervical range of motion was restricted. 

Cervical radiographs were also taken, confirming the diagnoses of ACM, and also revealing straightening of the cervical spine, sever narrowing of disc spaces C5/6 and C6/7, background cervical spondylosis and mild osteophytosis of vertebral bodies

Use of the Balance Scales indicated asymmetrical weight distribution.

Radiographic analysis in conjunction with thermographic findings identified the site and nature of subluxation for the purpose of directing the Knee-chest upper cervical adjustment technique. Integrating findings from thermography, leg length analysis, postural assessment, and radiographic evaluation, subluxations were identified at the craniocervical junction, with primary involvement of the atlas (C1) and axis (C2). Secondary findings consistent with subluxation were noted at C5-6 and C6-7. 

Management

The primary Chiropractic technique employed was Knee Chest Upper Cervical (KCUC), a subluxation-based approach focused on analysis and correction of craniocervical subluxations at the atlas and axis. The technique involves positioning the patient in a knee-chest posture on a specialised adjusting table, allowing gravity-assisted cervical traction and facilitating a precise, low-force toggle-recoil adjustment to the upper cervical spine.

A care plan of 36 appointments over four to six months was recommended. Formal reexaminations were scheduled at every 12 appointments, or sooner if new or worsening symptoms were reported. The reexamination protocol included reassessment of all baseline objective measures (thermography, cervical range of motion, leg length, cervical distraction, and Bournemouth questionnaire), as well as a structured review of subjective symptom changes as reported by the patient.

In addition to segment-specific Chiropractic care, the patient was provided with general information and guidance regarding lifestyle factors known to support musculoskeletal and neurological health. These included education on sleep hygiene, dietary considerations, and the importance of graduated physical activity appropriate to her current functional capacity. 

Outcomes

As laid out in the original care plan, reviews were undertaken every twelve weeks. However, early on in the care plan, the patient began reporting improved stress levels, memory, breathing and balance alongside reduced pain, numbness, anxiety and dizziness. This co-occurred alongside improved findings across all objective measures. 

Paraspinal thermography demonstrated a reduction in bilateral asymmetry at the upper cervical region, indicating improved neurological balance. Cervical range of motion improved across multiple planes: flexion, extension, left lateral flexion, right lateral flexion, left rotation, and right rotation. Functional leg length inequality reduced. Postural analysis demonstrated improved spinal alignment.

The patient reported meaningful subjective improvement across all primary complaints. Migraine frequency and intensity were reduced to less than one visit per month, with the patient requiring less reliance on injectable and analgesic management. Neck and shoulder pain improved significantly. Episodes of dizziness upon sitting to standing became less frequent and less severe. The patient noted improvement in breathing comfort, which she attributed in part to reduced upper cervical tension.

Broader health improvements were reported at reexamination, including reduced perceived stress, improved memory and cognitive clarity, reduced anxiety, and improved sleep quality. The patient reported improved capacity for household tasks and greater functional independence. Balance was subjectively improved. The BQN score at final reexamination was now down  to seven, where the original score was 43, representing significant improvement from the baseline.

The patient expressed satisfaction with the outcomes of care and noted a meaningful improvement in her overall quality of life. She reported feeling more ‘in control’ and independently began re-engaging in limited household activities.

Discussion

The breadth of self-reported improvements, encompassing stress, pain, numbness, memory, anxiety, breathing, dizziness, and balance, reflects the systemic influence of craniocervical subluxation on neurological function and the potential for meaningful change following its correction. While this is likely to be true in any case, the involvement of ACM-1 in this case adds gravitas to the results. 

The patient's improved sleep and greater capacity for activities of daily living may reflect a combination of Chiropractic care and the general wellness guidance provided. However, it is notable that the patient made relatively limited lifestyle changes during the care period and did not significantly increase her physical activity level, suggesting that the objective and functional gains observed are more likely attributable to the Chiropractic intervention than to lifestyle modification alone.

The management of patients with known ACM-1 and craniocervical instability requires careful clinical reasoning and technique selection. The KCUC technique, with its low-force toggle-recoil adjustment and thermography-guided approach, was selected in part for its specificity and relatively gentle nature compared with high-velocity rotational cervical manipulation. As noted in the broader Chiropractic literature on this condition, extension of the upper cervical spine during adjustment should be avoided in patients with ACM-1 to minimise potential irritation at the foramen magnum. The clinical management of this patient proceeded without adverse events throughout the care period.

Conclusion

As a single case report, the findings cannot be generalised to the broader ACM-1 population. Patient consistency with appointments represented a logistical limitation during the care plan, with some interruptions to the intended schedule. With this considered, the patient made significant improvements and this is of note, especially if it assists her in avoiding surgery. However given the paucity of chiropractic literature on the topic, the prevalence of the condition and the proportion of patients who continue to experience post-surgical residual symptoms, further research is required in order to give chiropractors the ability to make confident claims as to Chiropractic’s effect on ACM.

This report adds to the limited body of chiropractic literature on this condition and highlights the potential value of subluxation-based upper cervical care as a conservative management option for patients with ACM-1 and associated sequelae. 

1. National Institute of Neurological Disorders and Stroke (NINDS). Chiari Malformations. Bethesda, MD: National Institutes of Health. Available at: https://www.ninds.nih.gov/health-information/disorders/chiari-malformations
   
2. Lena JR, Bhimani AD, Tuchman A, et al. Chiari Malformation Type 1 — StatPearls. Treasure Island (FL): StatPearls Publishing; 2024. Available at: https://www.ncbi.nlm.nih.gov/books/NBK554609/  
   
3. Sadler, B., Kuensting, T., Strahle, J., Park, T. S., Smyth, M., Limbrick, D. D., Dobbs, M. B., Haller, G., & Gurnett, C. A. (2020). Prevalence and Impact of Underlying Diagnosis and Comorbidities on Chiari 1 Malformation. Pediatric neurology, 106, 32–37. https://doi.org/10.1016/j.pediatrneurol.2019.12.005 
   
4. Alvarado-Villanueva R, Maqueda-Blanco MA, Ibarra-Ríos D, et al. Chiari Syndrome: Advances in Epidemiology and Pathogenesis: A Systematic Review. J Clin Med. 2023;12(20):6694. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10607306/ 
   
5. Visocchi, M., Benato, A., Palombi, D., & Signorelli, F. (2024). Chiari Formation or Malformation? Trends in the Pathophysiology and Surgical Treatment of an Ever-Elusive Entity. Brain sciences, 14(10), 1006. https://doi.org/10.3390/brainsci14101006 
   
6. Keane JR. Bilateral abducens palsies and facial weakness as initial manifestations of a Chiari 1 malformation. PubMed. 2007. PMID:18049357. Available at: https://pubmed.ncbi.nlm.nih.gov/18049357/ 
   
7.  Pereira W, et al. A Rare Case Report of Eight Syndrome Secondary to Syringomyelia Associated with Type I Chiari Malformation. PubMed. 2023. PMID:37345329. Available at: https://pubmed.ncbi.nlm.nih.gov/37345329/ 
   
8. Hospers LA, Ecklund CJ. Chiropractic care for headaches and dizziness of a 34-year-old woman previously diagnosed with Arnold-Chiari malformation type 1. J Chiropr Med. 2014;13(3):200–207. PMC4161710. Available at: https://www.sciencedirect.com/science/article/abs/pii/S155637071400090X 
   
9. Chu, E. C., Trager, R. J., Ng, G. S. N., & Shum, J. S. F. (2022). Neck pain and Headache Complicated by Persistent Syringomyelia After Foramen Magnum Decompression for Chiari I Malformation: Improvement with Multimodal Chiropractic Therapies. The American Journal of case reports, 23, e937826. https://doi.org/10.12659/AJCR.937826 
   

Objective: Lumbar disc herniation (LDH) is a major contributor to chronic low back pain and lower extremity radiculopathy, posing significant disability burden globally. Nonsurgical spinal decompression (NSD) therapy has demonstrated efficacy in reducing disc herniation size in prior research; however, the minimum time required to achieve measurable MRI-confirmed disc reduction following an intensive NSD protocol has not been previously reported. This case report presents MRI-confirmed disc herniation reduction at the L5-S1 level following only 18 days of accelerated NSD therapy in a young female patient with a two-year history of failed conservative and interventional treatment, highlighting a potentially accelerated pathway to structural disc improvement.

Clinical Features: An 18-year-old female presented with a greater than two-year history of low back pain, left leg numbness, and sciatica radiating to the left calf, rated 8/10 on the Visual Analog Scale (VAS). She had failed epidural steroid injection and was scheduled for spinal surgery. Pre-treatment MRI taken 4 months prior to her appointment confirmed a disc protrusion at L5-S1. The patient’s condition progressively worsened including functional limitations such as the inability to walk more than five minutes.

Intervention and Outcome: The patient underwent an accelerated NSD protocol of decompression sessions combined with cold laser therapy, electrical muscle stimulation (EMS), and cryotherapy over an 18-day period. Post-treatment MRI, obtained 18 days after the initiation of treatment, demonstrated a 26.5% reduction in the Herniation Index at L5-S1. The patient reported complete resolution of pain (0/10 VAS) and was walking greater than 20,000 steps per day at discharge.

Conclusion: This case documents structural disc reduction and alleviation of symptoms after 18 days of an accelerated NSD protocol. The findings suggest that high-frequency NSD therapy may substantially accelerate disc size reduction, even in cases of prolonged chronicity and failed prior intervention. Further controlled investigation is warranted to evaluate the disc resorption timeline in NSD management of low back pain. 

Indexing Terms: Chiropractic; Low Back Pain; MRI; Lumbar Disc Herniation; Spinal Decompression; Radiculopathy; Herniation Index; Sciatica.

Introduction

Low back pain (LBP) remains the leading cause of disability worldwide, affecting more than half a billion people globally and projected to exceed 800 million by 2050. (1) The economic and societal burden is substantial, with direct spine-related healthcare costs in the United States estimated at US$315 billion annually, with surgical procedures accounting for most expenditures. (2) Lumbar disc herniation (LDH) is among the most common structural aetiologies of LBP and lower extremity radiculopathy, and it disproportionately affects younger populations whose functional demands and long-term disability risk are greatest.

Standard management of LDH includes pharmacological therapy, physical rehabilitation, epidural steroid injections, and surgical discectomy. While surgery provides short-term relief in severe cases, 5 to 40% of patients develop failed back surgery syndrome in the years following lumbar surgery, with estimated annual treatment costs ranging from US$18,195 to US$21,402 per patient. (3, 4) Given this risk, identifying effective nonsurgical alternatives capable of producing measurable structural disc improvement is a high clinical priority.

Nonsurgical spinal decompression (NSD) therapy is a computer-controlled motorised traction system designed to apply segmental distraction forces to the lumbar spine, creating negative intradiscal pressure (-100 to -600 mmHg) within the nucleus pulposus. (9) This negative pressure gradient is theorised to facilitate retraction of herniated disc material, reduce nerve root compression, and promote disc rehydration through improved nutrient diffusion. (9, 10) 

Several randomised controlled trials and case series have demonstrated the effectiveness of NSD therapy in reducing pain, improving function, and producing MRI-confirmed reductions in disc herniation size. (11 - 14)

Our prior published case series documented MRI-confirmed herniation index reductions ranging from 9.4% to 78% following eight weeks of NSD therapy combined with Chiropractic care in four patients with LBP and radiculopathy. (14) A critical unanswered question is the minimum treatment duration required to achieve measurable structural disc reduction, and whether an accelerated, high-frequency NSD protocol can compress the resorption timeline beyond what is observed with standard conservative management.

This case report describes an 18-year-old female with a greater than two-year history of chronic LBP, left leg numbness, and sciatica who had failed epidural steroid injection and was scheduled for surgical intervention.

The patient

An 18-year-old female presented with a chief complaint of low back pain, left leg numbness, and sciatica radiating to the left calf. The patient had experienced these symptoms for greater than two years with progressive functional decline and no sustained relief from prior interventions. The patient’s clinical condition progressively worsened. Pain intensity increased, and ambulation tolerance declined further. She rated her pain intensity at 8/10 on the Visual Analog Scale (VAS) at initial presentation. Her quality of life was severely compromised, with functional limitations including the inability to walk more than five minutes continuously. The patient was unable to participate in normal daily activities commensurate with her age.

Prior treatment history included an epidural steroid injection at the L5-S1 level, which provided no sustained improvement. Given the failure of conservative and interventional management, the patient had been recommended for lumbar spinal surgery. 

Pre-treatment MRI of the lumbar spine confirmed a disc protrusion at the L5-S1 intervertebral level. The pre-treatment AP dimension measured 11.3 mm, yielding a pre-treatment Herniation Index of 471.5. The patient consented to participation in this case report; all identifying information has been de-identified in accordance with patient privacy standards.

The patient underwent the accelerated NSD protocol, consisting of twice-daily decompression sessions combined with cold laser therapy, EMS, and cryotherapy over 18 consecutive days. This technique is discussed in the section on ‘NSD Treatment Protocol’. Compliance with the protocol was complete for the full treatment course.

Follow-up MRI of the lumbar spine was obtained 18 days following the initiation of treatment. Radiological review confirmed a measurable reduction in disc herniation size at L5-S1. The post-treatment AP dimension measured of 10.97 mm, indicating a post-treatment Herniation Index of 346.44, representing a 26.5% reduction from baseline. 

Figure 1: Pre-treatment axial MRI image at the L5-S1 intervertebral disc level demonstrating the disc protrusion. Posterior disc protrusion with encroachment on the spinal canal is noted, consistent with the patient’s clinical presentation of low back pain, left leg numbness, and sciatica radiating to the left calf.

Clinically, the patient reported complete resolution of pain at discharge, rating pain intensity 0/10 on the VAS, a reduction of 8 points from baseline.

Figure 2: Post-treatment axial MRI image at the L5-S1 intervertebral disc level demonstrating reduction in disc protrusion size following 18 days of accelerated nonsurgical spinal decompression therapy. Reduced posterior disc protrusion and improved visualisation of the spinal canal are noted compared to Figure 1.

Imaging protocol

To evaluate the change in the herniated disc following NSD therapy, magnetic resonance imaging (MRI) was performed 4 months prior to the initiation of treatment and repeated 18 days following the commencement of therapy. MRI of the lumbar spine was performed utilising a 1.5 T magnet. Standard imaging with sagittal T1, T2, and STIR sequences along with an axial T2 sequence were obtained. The type of herniation was categorised as a protrusion.

Disc herniation size was quantified using the herniation index methodology (HI) described in our previously published research. (14) The HI was calculated utilising the axial image demonstrating the greatest degree of distortion of the posterior intervertebral disc margin. The calculation involved multiplying the maximal anteroposterior (AP) dimension of the intervertebral disc herniation by the width of the herniated disc material and then dividing this value by the product of the sagittal diameter of the spinal canal and the width of the spinal canal at the same axial level, multiplied by 1,000.

HI Formula: (AP distance × Width distance)/ (AP sagittal canal distance× Width sagittal canal distance) × 1000 = Herniation Index (HI)

All MRI measurements and HI calculations were performed by a spinal radiologist. The measurements were obtained 3 times and averaged to obtain a final value. See Table 1 for the values obtained in this patient.

NSD treatment protocol

The accelerated NSD treatment protocol in this case consisted of twice-daily decompression sessions administered in 13 sessions delivered over an 18-day period. Two (2) to 3 sessions were clustered on treatment days, spaced 30 minutes to 3 hours apart, based on patient scheduling. Each session included 20 to 30 minutes of active spinal decompression on a computerised motorised traction table. At the initiation of each session, the patient was positioned supine on the decompression table and fitted with adjustable body harnesses. The computerised algorithm gently applied distraction force to the lumbar spine; as paraspinal musculature resisted the applied tension, sensors detected resistance and modulated tension until relaxation occurred before reapplying the decompression force.

The ratio of hold to rest time was 1:1, with oscillation ranging from 10 - 50% decrease between hold and rest phases. Each session was supplemented with adjunctive therapies including cold laser therapy, electrical muscle stimulation (EMS), and cryotherapy (ice application). No Chiropractic spinal manipulation was performed during the acute treatment phase. The treating clinician supervised all sessions.

Discussion

The primary finding of this case report is MRI-confirmed structural disc herniation reduction at L5-S1 after 18 days of an accelerated NSD protocol. The patient had experienced disc herniation related symptoms for greater than two years with progressive functional decline and no sustained relief from prior interventions. This change in the disc herniation and patient symptoms has important implications for the understanding of how NSD therapy may mechanistically influence the disc resorption process, and for the clinical management of young patients with chronic LDH who have failed conventional and interventional treatment.

Several biomechanical mechanisms may explain why an intensive, twice-daily NSD protocol could accelerate disc size reduction beyond what is achievable with standard conservative care. NSD therapy generates significant negative intradiscal pressure (-100 to -600 mmHg) within the nucleus pulposus, a magnitude of decompressive force that exceeds conventional traction and that cannot be replicated by rest, physical therapy, or injection alone. (9)

This negative pressure gradient is theorised to facilitate mechanical retraction of herniated disc material, restoration of disc height, and enhanced diffusion of oxygen and nutrients into avascular disc tissue, thereby promoting biological remodelling. (9, 10) The twice-daily administration of these decompressive forces in this case doubled the mechanical stimulus compared to standard once-daily protocols, potentially amplifying both mechanical retraction and biological rehydration effects.

The biological mechanisms underlying disc resorption, including macrophage-mediated phagocytosis, neovascularisation, inflammatory cascade activation, and matrix protease activity,  are relevant to the accelerated response observed in this case. (5, 6) It is well established in the resorption literature that protrusion-type herniations, in which the annulus fibrosus remains intact, demonstrate lower spontaneous resorption rates compared to extrusion and sequestration types, as intact annular containment limits contact between disc material and the epidural venous plexus necessary to trigger immune-mediated degradation. (8) 

The change in the disc protrusion in this patient suggests that the mechanical decompressive forces generated by the twice-daily NSD protocol, rather than immune-mediated biological resorption alone, may be the primary driver of the observed structural change, potentially through direct mechanical retraction of contained disc material and restoration of negative intradiscal pressure gradients. This proposed mechanism warrants direct investigation in future controlled studies.

The chronicity of this patient’s presentation adds additional significance to the rapidity of the observed response. The patient had been symptomatic for greater than two years. a duration associated with structural disc changes, neurological sensitisation, and reduced likelihood of spontaneous resorption in the epidemiological literature. (5) The patients symptoms were progressively becoming worse prior to NSD intervention. Despite this unfavourable chronicity profile, and despite prior failure of epidural steroid injection, the patient achieved complete pain resolution and dramatic functional restoration within 18 days of the commencing treatment.

This outcome challenges the clinical assumption that prolonged symptom duration predicts resistance to conservative disc intervention and suggests that the intensity of the NSD protocol may be a more important determinant of outcome than chronicity alone.

The results are consistent with and extend the findings of our previously published case series, in which four patients with LBP and radiculopathy achieved herniation index reductions ranging from 9.4% to 78% following eight weeks of standard-frequency NSD therapy combined with chiropractic care, with all four patients achieving complete pain resolution. (14) The present case demonstrates that comparable or superior structural and clinical outcomes may be achievable in a fraction of the treatment duration when a high-frequency protocol is employed, at least in select patients. The 26.5% reduction in HI at 18 days compares favourably with the eight-week outcomes reported in our prior series and with findings from other published NSD studies demonstrating disc reduction following standard protocols. (11 - 14)

Additional published NSD research is consistent with the clinical improvements observed here. Amjad et al. demonstrated that NSD combined with routine physical therapy produced superior reductions in pain intensity and functional disability compared to physical therapy alone in patients with lumbar radiculopathy. (11) Gaowgzeh et al. found NSD combined with core stabilisation significantly outperformed core stabilisation alone in patients with lumbar disc prolapse. (12) The present case extends this literature by documenting the potential of an accelerated NSD protocol to produce rapid structural disc change in a clinically complex, previously treatment-resistant patient.

Several limitations of this case report merit acknowledgment. As a single case, the findings cannot be generalised, and the absence of a control condition precludes attribution of disc reduction solely to the NSD protocol. The possibility that some degree of spontaneous regression contributed to the observed structural change is unlikely, since the patient presented with greater than two years of chronicity. The MRI measurements are subject to the inherent limitations of HI calculation methodology, including inter-reader variability, and the use of different magnets and the imaging protocols of different facilities. 

Prospective controlled trials comparing accelerated versus standard-frequency NSD protocols with serial MRI monitoring are needed to confirm these preliminary findings.

Conclusion

This case report documents MRI-confirmed 26.5% reduction in lumbar disc herniation at L5-S1 following 18 days of accelerated nonsurgical spinal decompression therapy in an 18-year-old female with greater than two years of chronic LBP, sciatica, and radiculopathy who had failed epidural steroid injection and was facing spinal surgery.

As of the initiation of the NSD treatment, the patient’s condition was progressively becoming worse. The 18-day treatment period for measurable disc reduction is significant when considering the timeline reported in the spontaneous resorption literature.

This study extends our prior published case series by suggesting that high-frequency NSD protocols may substantially accelerate the disc reduction process. The patient achieved complete pain resolution and returned to full functional activity, avoiding surgery. 

These findings support the continued investigation of accelerated NSD protocols as a time-efficient, nonsurgical intervention for LDH, particularly in younger patients with chronic, treatment-resistant disc pathology. Prospective controlled trials with serial MRI assessment are warranted to confirm whether intensive NSD frequency is a determinant of the rate of structural disc improvement.

References