Arnold-Chiari Malformation is a structural condition of the craniocervical junction in which the cerebellar tonsils descend below the foramen magnum (the hole at the base of the skull). And it is more common than most people assume. A new case report in the Asia-Pacific Chiropractic Journal describes a 49-year-old woman with Type 1 Arnold-Chiari Malformation and a decompression surgery fifteen years behind her, who reported substantial improvement across a broad range of symptoms during four to six months of subluxation-based upper cervical care.
Chiropractic management of a 49-year-old female with Arnold-Chiari Malformation and associated neurological sequelae: A case report, (Rai, 2026), is the newest entry in a body of chiropractic literature that now stretches back more than three decades. While we don’t have larger studies on the management of patients with an Arnold-Chiari Malformation (ACM), we do now have a trail of chiropractic case reports stretching over years.
Case reports are how clinical observation enters the literature, and they cover a full clinical picture but only for a sample group of one. We can’t make generalisations based on case reports – that’s the role of larger studies. But they do show us what pops up in clinic, and read alongside other case reports, it shows us where those larger studies might be useful.
The condition
Arnold-Chiari Malformation describes a group of structural defects in the relationship between the cerebellum, the skull base and the spinal canal. Type 1 (the form most likely to walk into a chiropractic practice) involves descent of the cerebellar tonsils more than five millimetres below the foramen magnum, with the potential for compression of the brainstem and upper cervical spinal cord.
The underlying problem is usually described as a posterior cranial fossa that is congenitally too small for its contents. The herniation that results can disrupt cerebrospinal fluid flow between the cranial and spinal compartments, creating pressure which may in turn worsen the herniation.
The paper reports estimates of roughly one in a thousand people being symptomatic, with approximately one in a hundred meeting radiological criteria. Prevalence appears higher in adult women than men and many people remain asymptomatic for decades, with symptoms emerging in the third to fifth decade, often after trauma, physical strain, or progressive spinal instability.
Headache is the dominant symptom, reported by the paper as occurring in upwards of 80% of symptomatic patients. Sensory disturbance, nausea, limb weakness, cranial nerve deficits, vertigo, balance disturbance, dysphagia, sleep-disordered breathing and visual disturbance make up the rest of the common symptoms.
Surgery remains the primary intervention for symptomatic patients but it carries real risk and variable outcomes, and (as this paper notes) a proportion of patients continue to experience symptoms afterwards.
The case
The patient in question was a 49-year-old woman, new to chiropractic, who described herself as a housewife with low physical activity levels. She had been diagnosed with ACM Type 1 and had undergone posterior fossa decompression surgery fifteen years before presenting. She reported mild to moderate improvement immediately after surgery, particularly in headache severity and sensory symptoms, and then the return or persistence of a number of symptoms in the years that followed.
When she first came in to see the chiropractor, she reported roughly twenty of severe and episodic migraines. These were usually triggered by bright light and dietary factors, accompanied by visual disturbance and nausea, and managed with injectable treatment and over-the-counter analgesics. Frequency and severity had worsened over the preceding twelve months. Alongside the migraines, she reported neck and shoulder pain that had progressively worsened over the same year, positional dizziness on standing, difficulty taking deep breaths, and poor sleep.
Her stated goals were likely to be relatable to many people: to become more physically active, improve energy, reduce fatigue, and manage pain better. She spoke of difficulty completing household chores and disrupted sleep as her most functionally limiting secondary complaints. While these were the presenting concerns, her chiropractic examination revealed numerous subluxation findings noted in the case report (referenced below).
Care was delivered using the Knee Chest Upper Cervical technique across 36 appointments over four to six months, with re-examination scheduled every twelve appointments or sooner if symptoms changed. The technique positions the practice member in a knee-chest posture on a specialised table, allowing gravity-assisted cervical traction and a precise, low-force toggle-recoil adjustment to the upper cervical spine.
KCUC was chosen in part for its specificity and its gentleness relative to high-velocity rotational cervical manipulation, and the authors specifically stated that extension of the upper cervical spine during adjustment should be avoided in patients with ACM-1, to minimise potential irritation at the foramen magnum. Care proceeded without adverse events.
What was reported
Improvements were reported early and across a wide front. Along with improvement in objective measures, her functional health improved significantly. Migraine frequency and intensity reduced to less than one per month with reduced reliance on injectable and analgesic management. Neck and shoulder pain improved significantly, dizziness on standing became less frequent and less severe, and breathing comfort improved. The practice member also reported reduced stress and anxiety, improved memory and clarity, better sleep, better balance, and greater capacity for household tasks.
The Bournemouth questionnaire score moved from 43 at baseline to 7 at final re-examination. Because she made no other lifestyle changes and did not significantly increase her physical activity, the gains are more likely attributable to the chiropractic care than to lifestyle modification.
What the wider chiropractic literature says
The case report isn’t an isolated one either. The breadcrumbs on this condition began back in 1993. The Asia-Pacific Chiropractic Journal has carried related work. Jesse and Keila Nichols reported a 42-year-old woman with Chiari Type 1 and cystic syringomyelia of the cervical cord from C3 to T2, with cerebellar tonsillar displacement of 7–8mm, managed with Sacro-Occipital Technique category one procedures, cervical stairstep technique and cranial work over approximately three years. Their report is unusual in the literature for tracking an anatomical measure over time: tonsillar displacement reduced from 7–8mm in December 2019 to 7mm in December 2020 and 6–7mm in November 2022, while the syringomyelia itself remained unchanged. The patient reported significant improvement in upper extremity weakness, neuralgias, cranial torsion and cervicothoracic pain, though visual disturbances persisted.
Joseph Ierano published a case series and review of 15 patients in this journal in 2024, drawn from two Atlas Orthogonal practitioners, one Australian and one American, presenting with Chiari malformations, cerebellar tonsillar ectopia, cranio-cervical syndrome and cranio-cervical instability. The paper is as much a warning as a report. Ierano writes that the cases “in no way reflect the suggestion that Atlas Orthogonal chiropractic care is an adequately researched cure for brainstem pathologies,” and is explicit that outcome measures were purely descriptive, with no controls and no standardised instruments. The paper offered a structured approach to assessing this population, and a discussion of where the limitations of surgery and the contraindications to manual therapy actually fall, which is the question chiropractors (and their patients) most need answered. Charles Blum and Scott Cuthbert, in the Journal of Manipulative and Physiological Therapeutics in 2005, reported a young woman with complex optic nerve neuritis exacerbated by Type I ACM, treated with applied kinesiology chiropractic approaches, who showed improvement in her ability to see, read and perform smooth eye tracking.
Other case reports have appeared in the Annals of Vertebral Subluxation Research, Journal of Upper Cervical Chiropractic Research and the Journal of Pediatric, Maternal and Family Health, showing that this is not an isolated incident: it’s just one we haven’t studied at a grand scale.
The necessary caution
Two papers in the same search complicate the picture, and reporting this literature without them would be dishonest.
A paper in the Journal of the Canadian Chiropractic Association (back in 1994) presented two adult cases of Type I ACM, both initially managed conservatively before MRI established the diagnosis. Neither patient improved. McArthur’s point was that chiropractors need to be aware of the varied presentations of ACM in adults because it can masquerade as something more ordinary. That paper is thirty years old, but it remains the only chiropractic report we found of Chiari patients who did not do well, and which advises gentle adjusting and a lower threshold for referral if something is off.
On safety, the news is better but still requires care. Donald Murphy and colleagues, in JMPT in 1993, reported two patients with Type I ACM who received multiple cervical adjustments for unrelated conditions, with no ill effects or complications attributable to the anomaly, concluding that asymptomatic Type I ACM is “not necessarily a contraindication to skilled adjustments to the cervical spine.” Still, the protocol seems clear: imaging first, gentle and specific technique, no upper cervical extension, and a low threshold for referral if anything changes.
What this means for chiropractic
For patients, these case reports create a picture of whole-of-person care, and a little hope. For chiropractors, it’s a little more detailed: A practice member with a known craniocervical anomaly, imaged before care, managed with a low-force specific technique chosen deliberately over rotational manipulation, with an explicit contraindication observed, reassessed on a schedule, using both objective indicators and a validated questionnaire. That is what a defensible approach to a complex presentation looks like, and it is reproducible whatever technique system you work within.
The vertebral subluxation is understood at this Foundation as a diminished state of being, comprising a state of reduced coherence, altered biomechanical function, altered neurological function and altered adaptability. A presentation in which pain, balance, breathing, sleep, cognition and mood appear to shift together — as reported here, and as reported in several of the older cases — is a fair clinical description of that idea. Whether correcting craniocervical subluxation is what produced the change is the question the literature cannot yet answer.
There are currently no controlled trials and no prospective cohort studies of chiropractic care in this population. There is, however, a defined population that is easy to identify, a clear unmet need in post-surgical patients with residual symptoms, and now several decades of case reports pointing in the same direction. The next step is not another single case. It is a prospective case series with validated instruments, standardised imaging intervals, and follow-up long enough to say whether change holds.
For practice members with a Chiari diagnosis, the summary is this: chiropractors have reported helping people with this condition for more than thirty years. If you are considering chiropractic care, make sure you mention your ACM to your chiropractor, get some imaging done, and go with a gentle technique.
The literature has been saying the same thing for three decades: this is worth studying properly. It is well past time someone did.
References
- 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-Pacific Chiropractic Journal. 2026;7.2. Available at: https://www.apcj.site/RaiACMalformation.pdf
- Nichols J, Nichols K. The effect of sacro occipital technique (SOT) category one procedures on Chiari type 1 and cystic syringomyelia: A case report [conference abstract]. Asia-Pac Chiropr J. 2023;4(1).
- Ierano J. Atlas orthogonal chiropractic practitioner presentations of craniocervical junction and brainstem disorders: A case series and review of 15 patients. Asia-Pac Chiropr J. 2024;5(2):37.
- Drury R, O’Keefe C. Resolution of symptoms from Arnold-Chiari malformation in a 6-year-old male following reduction of vertebral subluxation with Knee-Chest upper cervical care: Case report & selective review of the literature. J Upper Cervical Chiropr Res. 2017;2017(2):12–21.
- Smith JL. Effects of upper cervical subluxation concomitant with a mild Arnold-Chiari malformation: A case study. CRJ. 1997;4(2):77–81.
- Hock S, Kelly A. Reduction of headaches in a patient with type I Chiari Malformation and Ehlers-Danlos following chiropractic care to correct vertebral subluxation: A case study. Ann Vert Sublux Res. 2021;2021:18–23.
- Burcon MT. Resolution of vertigo, restored hearing and improved quality of life in a patient with Meniere’s disease and failed craniectomy: A case report and review of the literature. J Upper Cervical Chiropr Res. 2021;2021:10–19.
- Willemin A. Improvement in ataxia, dizziness, & visual disturbance, in a child with vertebral subluxations undergoing chiropractic care: A case study. J Pediatr Matern & Fam Health – Chiropr. 2010;2010(3):89–94.
- Bowler B, Conlen K. An interdisciplinary approach to juvenile idiopathic scoliosis, craniosynostosis, and Chiari I malformation. J Pediatr Matern & Fam Health – Chiropr. 2012;2012(2):54–60.
- Sergent AW, Cofano GP. 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):192–195.
- Chu EC, Trager RJ, Ng GSN, Shum JSF. Neck pain and headache complicated by persistent syringomyelia after foramen magnum decompression for Chiari I malformation: Improvement with multimodal chiropractic therapies. Am J Case Rep. 2022;23:e937826.
- Blum C, Cuthbert S. Symptomatic Arnold-Chiari malformation and cranial nerve dysfunction: A case study of applied kinesiology cranial evaluation and treatment. J Manipulative Physiol Ther. 2005;28(4).
- McArthur RA. Arnold-Chiari Type I malformation: A look at two cases in the adult. J Can Chiropr Assoc.1994;38(4):203–210.
- Murphy DR, Goldstein D, Katz M. Chiropractic adjustment to the cervical spine and the Arnold-Chiari malformation. J Manipulative Physiol Ther. 1993;16(8):550–555.
- Murphy DR. Post-traumatic syringomyelia: Absolute contraindication to manipulation? A report of two cases. J Neuromusculoskelet Syst. 2000;8(2):54–58.
