Throughout the pandemic, all of us had plans, dreams, and aspects of our lives altered. We found ourselves grieving for lost time, lost opportunities, and lost routines. Our lives were decidedly different. However, for most of us these things were returned following the pandemic. Sure, our routines had evolved and our plans had shifted, but for the most part we all regained control of those lost areas of our lives.
Some were not so lucky. As more people experienced COVID-19 illness and recovered, we realised that some symptoms were long-lasting. Yes, we are talking about Long COVID. ‘Signs and symptoms remaining at least 90 days after acute COVID infection diagnosis’ is the definition used by the authors. As Long COVID is still a relatively new condition to the world of science and research, definitions and manifestations do vary.
Two new case reports appearing in the Asia Pacific Chiropractic Journal have covered the chiropractic care of individuals with long covid. While again, case reports are limited in their capacity to give us big, generalised claims to make, these are pivotal in helping us understand the clinical realities, and day-to-day implications that may occur for people who present for chiropractic care for the reduction of subluxations. Thus, it’s an interesting read indeed.
The First Case.
A 59-year-old photographer responded to a call for research volunteers. Potential participants needed to be experiencing long COVID symptoms and have not received chiropractic care for at least 30 days.
This particular participant presented to the clinic on the 7th of January in 2022, last receiving care in February of 2019. In December of 2019, she found vesicles on both hands, which soon travelled to her abdomen and buttocks. The skin on her fingers became red and sore, resembling what we now know as ‘COVID toes’. Her toes also became red and sore after this. She experiences headaches and fatigue, with a fever and reduced levels of white blood cells.
Her headache lasted 3 months and she lost 15 pounds in that time.
The participant received an MRI in April of 2020, but no abnormalities were apparent. In 2021, she underwent a full course of vaccinations and boosters. Concomitantly, she noted a return of headache, brain fog, fatigue, and arthritic pain. She continued to experience these symptoms when she presented at the clinic.
Examination
- Brain fog rated 2-5/10 (0 = no brain fog, 10 = inability to think or concentrate at all).
- She said she could not hold multiple thoughts in her head at the same time, and trying to do so prompted a headache.
- She found herself unable to complete simple mind games, and wasn’t able to follow recipes she had been following for many years.
- Reading caused her to feel fatigued, so she was relying on audiobooks.
- Interestingly, when monitoring her breathing capacity at home using a peak flow metre, she observed no decline compared to her levels prior to her presumptive diagnosis of COVID-19.
- The chiropractor tested both visual middle and ocular lock, due to the difficulties reading. Both returned negative results.
- Her reverse digit span was 5, and although not a cause for concern in itself, there was a ‘great deal’ of hesitation in answering the test questions, the onset of a headache, and the patient was frustrated to the point of tears.
- The patient also noted an increase in cold intolerance since her illness.
Vertebral subluxations were noted at the occiput, C1, C2, C7, T9, and L1. These were adjusted with Diversified Technique, and modified to use lighter amplitude. (Full details of the adjustments, including neurolymphatic reflex stimulation and stretches to address hypertonicities can be found in the case report referenced below). She received 3 sessions of care over 18 days.
At the follow-up interview, she rated her brain fog as low as 1/10, with rare spikes to 7/10. She reported she was still struggling to follow long recipes, but it was ‘not quite as bad’. Reverse digit span was 6, and caused no headache, frustration, hesitation, or tears. There was a right tingling in her right hand that was coming and going, and she was unable to assess her cold intolerance as the weather had become much colder. The participant reported a 2-day period following the 3rd session where she felt able to multitask, and finished an entire book within a 24-hour period. Overall, she was still experiencing fatigue when reading but reported it was not as bad. She rated her progress at 15-20% improved in comparison to the initial presentation.
Given this was only a short course of care, these findings could be considered both positive and notable.
The Second Case
A 58-year-old real estate agent responded to a call for research volunteers with long COVID in May 2022. Her most recent visits to the practice had been in December 2021 and she made no mention of having had a COVID-19 infection in these sessions. The preceding October in 2021 the patient was diagnosed with COVID-19 and was treated with monoclonal antibody infusion. She had been previously vaccinated and reported she ‘really didn’t feel that sick’. Her symptoms during the acute illness were fatigue and cold-like symptoms, which was followed by a loss of smell.
Examination
- She said that her mouth and eyes probably felt drier than before the illness, which can be suggestive of sympathetic hypertonicity.
- Her sense of smell was not completely absent at the time of presentation, rating it a 1/5 (0 = unable to smell anything, 5 = completely normal sense of smell)
- She noted experiencing a ‘house on fire’ aroma, lasting for at least 1 week when it first appeared. It now only surfaced briefly occasionally, with no apparent trigger or pattern.
- She reported no change in sense of taste
- She stated she felt more forgetful and foggy now, and had more difficulty concentrating.
- She also found herself tiring more easily and taking more naps.
- Her left nostril was more sensitive than her right and Weber’s test result was consistent with a conductive loss on the left. (This was possibly related to a more generalised ear-nose-throat congestion).
- Reverse digit span was 5, which is within the normal range for an adult.
- Subluxations were noted at C1-2, T1-first rib, and the left and right sacroiliac motion segments. Sphenoid cranial fault and active neurovascular reflex at the anterior fontanelle.
- It is important to note that the patient had a history of tachycardia, but this was resolved prior to infection.
The participant attended 10 sessions in total. HVLA adjustments following the Applied Kinesiology protocols were utilised in all sessions. At the 2nd visit she reported being able to smell the aroma of bread at dinner the night before. By the 4th visit her sense of smell was still responding. At the 7th visit she reported having no more trouble with concentration or memory than before COVID, and no longer felt ‘foggy’. Her reverse digit span was 6. She still experienced more fatigue than before the illness and was still taking naps. At the 8th and 9th visit she reported her low back pain feeling much better, fatigue had resolved, and continued improvement in her sense of smell.
There was no official progress examination, as the patient cancelled the appointment and didn’t reschedule. However, anecdotal findings suggest positive responses to care even under a short period of time.
How might Chiropractic have helped?
While we do have to acknowledge spontaneous remission sometimes occurs within Long Covid cases, we also have to acknowledge that many people experience serious and ongoing symptomatology tied up with the condition. Here are some thoughts on the role chiropractic may have played in supporting recovery from Long Covid.
- The authors cite research supporting the role of Dural mechanics underpinning the mutual worsening between subluxation complexes and long COVID symptoms (3-5).
- They also mention the theory previously proposed, that COVID-19 infection may cause lingering cognitive issues by disrupting the normal flow of cerebrospinal fluid (CSF). We also understand that subluxations can alter the flow of CSF and contribute to the cognitive symptoms observed in the above cases.
- Severe COVID-19 infections may also exhibit symptomatic presentations consistent with a cytokine storm and this may be associated with vasoconstriction (reduced blood flow), potentially contributing to the brain fog.
- It is reasonable to say that all measures to support respiration could be useful in alleviating long COVID symptoms. It has been previously published that chiropractic adjustment has shown improved breathing capacity (cited by authors in the studies below).
While there is certainly much left to explore and understand in terms of the mechanisms behind these improvements, and indeed behind the symptomatology of Long COVID, it is encouraging to see these results. It is perhaps especially encouraging given the short courses of care. Imagine what could be achieved in the longer term!
These are the kind of stories that illustrate the importance and value of case reports as a study design. Keeping the descriptive detail and the true effect of symptoms on individuals’ lives. It is the impact on individual’s lives, after all, that get us out of bed at out to our adjusting tables every day.
REFERENCES:
- Case 1: Masarsky CS, Todres-Masarsky M. Long Haul COVID-19 and Subluxation: A case report. Asia-Pac Chiropr J. 2022;2.6. URL: apcj.net/papers-issue-2-6/#MasarskyLongCovid
- Case 2: Masarsky CS, Todres-Masarsky M. Long COVID Hyposmia/Parosmia and subluxation: A case report. Asia-Pac Chiropr J. 2022;3.2. URL: apcj.net/Papers-Issue-3-2/#MasarskyHyposmia
- Hack GD, Koritzer RT, Robinson WL, Hallgren RC, Greenman PE. Anatomic Relations Between the Rectus Capitis Posterior Minor Muscle and the Dura Mater. Spine, 1995; 20(23): 2484-2486. Abstract: http://www.ncbi.nlm.nih.gov/pubmed?term=((Hack%20GD) %20AND%20dura%20mater)%20AND%20rectus%20capitus%20posterior%20minor%20muscle
- Liu P, Li C, Zheng N, Yuan X, Zhou Y, Chun P, Chi Y, Gilmore C, Yu S, Siu H. The myodural bridge’s existence in the sperm whale. PLoS ONE , 2018:13(7): e0200260. Full text: https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0200260&type=printable.
- Mitchell BS, Humphreys BK, O’Sullivan E. Attachments of the Ligamentum Nuchae to Cervical Posterior Dura and the Lateral Part of the Occipital Bone. J Manipulative Physiol Ther, 1998; 21(3): 145-148. Abstract: http://www.ncbi.nlm.nih.gov/pubmed? term=((nucchal%20ligament)%20AND%20dura%20mater)%20AND%20J%20Manipulative%20Physiol%20Ther
