Cervical Manipulation and Koren Specific Technique
Cervical Manipulation and Koren Specific Technique
Cervical Manipulation and Koren Specific Technique
Abstract
This report describes a 42-year-old female patient who presented with an intensive nocturnal dry cough
persisting for over six months. Subsequent to the prolonged cough, she developed shoulder and neck
discomfort, leading her to seek chiropractic care. The patient received cervical chiropractic adjustments
combined with the Koren Specific Technique (KST) emotions protocol. The patient was mainly treated for
her musculoskeletal complaint. However, after two treatment sessions, the patient's chronic cough showed
significant improvement. Two weeks later, the cough had completely ceased, and her shoulder and neck
discomfort had also improved. The cough symptoms did not reappear during the six-month follow-up. The
mechanism of cough improvement remains unclear, whether it is due to spinal adjustments, the KST
emotions protocol, their combined effects, or merely a placebo response. This report discusses the potential
underlying mechanisms of the case improvement, suggesting a non-pharmacological adjunctive therapeutic
approach that could be investigated further in future research.
Introduction
Coughing is one of the primary reasons why patients seek medical attention, with approximately 10% of the
global population experiencing issues with chronic coughing [1]. While chiropractic care primarily addresses
musculoskeletal and nervous system dysfunctions, it is important to recognize the significant pressure
exerted on the shoulders, neck, chest, and intervertebral discs during the Valsalva maneuver that occurs in
the moment of coughing. Treating musculoskeletal issues in patients with persistent coughs is a challenge.
The current evidence and literature supporting the improvement of cough through chiropractic adjustments
are limited. Only one other case report documenting the improvement of cough symptoms after chiropractic
treatment was found in the literature [2]. This case may be one of the first documented instances where
rapid chronic cough improvement was observed after chiropractic adjustment.
A chronic cough is characterized by a persistent cough lasting over two months. After common causes of
coughing are ruled out, such as respiratory infections, chronic obstructive pulmonary disease,
gastroesophageal reflux disease, postnasal drip, side effects of ACE inhibitors, and pathologic causes like
tuberculosis, tumors, or heart failure, patients may receive a diagnosis of chronic neurogenic cough or
somatic cough syndrome. The etiology and mechanisms of chronic cough are not yet fully understood, but
they may be related to neural stimulation or emotional anxiety [3-5].
Chronic coughing has a negative impact on the quality of life and mental health of patients, especially
during daily activities or sleep. Patients often report a sensation of a foreign object in the throat, leading to
frequent coughing without necessarily producing significant phlegm or secretions. This type of cough not
only persists but can also suddenly trigger intense and frequent bouts, causing prolonged, intense
contractions or tension in the associated muscle groups. This can result in discomfort in the shoulders,
neck, chest, and abdomen, and even symptoms like urinary incontinence. The Valsalva maneuver during
coughing moments can also lead to a sudden increase in intervertebral disc pressure, exacerbating
symptoms of spinal or nerve root compression. Frequent coughing can also disrupt sleep quality, leading to
anxiety, social avoidance, and depressive psychological changes. Long-term chronic coughing significantly
impacts patients socially and psychologically. Therefore, it is essential to assess a patient's emotional stress
and screen for depression [4].
In the treatment of chronic cough, commonly employed methods include pharmacotherapy and behavioral
therapy. Pharmacotherapy primarily aims to control the cough reflex, utilizing medications such as
antidepressants, antispasmodics, and sedatives [3,6]. Behavioral therapy encompasses cognitive behavioral
Statistics indicate that only 28% of chronic cough patients are satisfied with conventional antitussive
treatments, and 20% of patients eventually opt to discontinue treatment due to its ineffectiveness [9].
Therefore, exploring new treatment options is crucial. In this report, we present the case of a 42-year-old
female patient who has been experiencing severe nocturnal coughing for six months. Despite a series of
examinations and treatments, her symptoms persisted, accompanied by neck and shoulder pain. Cervical
adjustment and the Koren Specific Technique (KST) emotions protocol were intended to address her
musculoskeletal complaints but inadvertently led to an improvement in her chronic nocturnal cough.
Currently, there is no peer-reviewed scientific literature discussing such an approach, either individually or
simultaneously for chronic cough. The mechanism behind this improvement is unclear but warrants further
exploration and research.
Case Presentation
Chief complaint
The patient, a 42-year-old female, presented to the chiropractic office with a complaint of soreness in the
neck and shoulders due to persistent, severe nocturnal dry coughing for the past six months. The neck and
shoulder pain were rated at 4/10 on the pain scale. She seldom coughed during the day, but the coughing
became notably pronounced at night during deep sleep. At times, the coughing was severe enough that she
had to stop sleeping and sit up for several hours before subsiding. The patient reported that the cough
typically did not occur right away when she began to sleep but started after 3 a.m. and may persist until
around 6 a.m. The patient experienced extremely poor sleep quality and was unable to have uninterrupted
sleep at night due to persistent and intense coughing.
Coughing history
Since November 2022, she has been experiencing nocturnal dry coughing without signs of fever or infection.
After two weeks with no improvement, she sought medical attention for the first time. While primarily
opting for TCM treatment, she also sought Western medical evaluation during this period. Other potential
serious cardiopulmonary lesions were ruled out. Based on her past experiences, she noticed that drugs
tended to alleviate one symptom but often led to the emergence of new symptoms as side effects. Due to
personal treatment preferences, she declined Western pharmaceutical intervention. Her current cough has
never been managed with antitussives, mucokinetics, or mucolytics, and she has no history of taking ACE
inhibitors.
Throughout the treatment period, she consulted three different TCM practitioners, primarily receiving
herbal remedies, acupuncture, and Tuina massage therapy. In mid-May 2023, due to the lack of noticeable
improvement, she discontinued her TCM treatment. Subsequently, she briefly attempted one session of
spiritual and energy-based therapies, as well as Gua Sha (an instrument-assisted soft tissue mobilization
treatment). While she experienced momentary relief physically and mentally, there was no improvement in
her coughing symptoms. She started her chiropractic care for the first time in June 2023.
Social history
The patient primarily engages in sedentary office work and does not have any smoking or alcohol habits. The
long-standing, severe nocturnal coughing significantly disrupts her sleep as well as that of other family
members. Daytime fatigue and lethargy have been causing her additional stress. She experiences feelings of
depression, although she has not undergone a professional assessment or received treatment for it.
(B) Two sides stop at the same level: "NO" in binary biofeedback reaction.
The KST emotions protocol is derived from the concept of NET, based on the close connection between
emotions and the body. Instead of using muscle testing in NET, KST employs the OD method to assess
patients. It posits that emotions and stress can negatively impact the body, leading to pain, tension, and
other issues. For example, merely thinking about a favorite food can lead to salivation, especially when
memory is associated with stress. This physiological reaction is termed "conditioning," and the strength of
the conditioning is determined by the intensity of the emotion. Over time, the conditioned response
typically diminishes and eventually fades away through the natural process of "extinction." However, if the
body is not in a balanced state during conditioning, the extinction process may be hindered. This can result
in an abnormal response to similar stimuli in the future, where a once-appropriate reaction becomes
unnecessary and even excessive. The KST emotions protocol or NET, primarily focuses on adjusting this
mind-body balance rather than providing counseling or therapy for emotions [11].
The KST emotions protocol flow chart is shown in Figure 2. During the KST emotions protocol, the
practitioner first uses the OD and KST emotions charts to identify which emotion is interfering with the
body. Then, use OD to check if it is OK to address and continue to adjust the body-mind balance. If yes, the
patient is asked to recall and immerse themselves in the scene, emotion, and sensation from that time in
The patient has been experiencing a severe nocturnal cough for over six months, leading to discomfort and C0/C1 and
Day
1st soreness in the neck and shoulders. This persistent condition has also resulted in inadequate sleep and KST emotions
1
feelings of depression. protocol
C3/C4 and
Day After the first visit, the intensity and duration of the cough significantly decreased. There were two
2nd KST emotions
3 consecutive nights of good-quality sleep lasting over 6 hours.
protocol
Day After the second visit, the cough has become almost negligible. There was only occasional, light coughing
3rd C7/T1
13 that didn't disrupt sleep. The discomfort in the shoulder and neck areas has also improved.
The patient reported that both the coughing and discomfort in the shoulders, neck, and chest have been
Day C0/C1 and
4th resolved. There was occasional stiffness in the shoulders and neck. The emotional state has also improved
49 C6/C7
significantly.
C3/C4: The joint between the 3rd and 4th cervical spine.
C7/T1: The joint between the 7th cervical and the 1st thoracic spine.
C6/C7: The joint between the 6th and 7th cervical spine.
After the fourth visit, we discharged the patient from active chiropractic care and continued to see her on an
as-needed basis. We maintained contact and followed up with her for six months. We advised her to seek
further evaluation from a respiratory physician if the cough returned. During this period, she visited twice
for newly onset lower back pain and wellness care. She reported no recurrence of nocturnal coughing in six
months. The detailed timeline of the treatment course is shown in Figure 3.
The patient conducted a self-assessment using the Leicester Cough Questionnaire (LCQ), recognized as an
effective tool for assessing the physical, psychological, and social impact of coughing. Scores range from 1 to
7, with lower scores indicating a more significant impact on quality of life. A 2022 study by Nguyen observed
improvements of 0.8, 0.9, and 0.8 points in the physical, psychological, and social domains, respectively. On
average, there was an increase of 1.3 to 2.3 points in the total LCQ score, signifying clinically meaningful
improvements for the patients [12].
In this case, the patient's self-assessment scores prior to chiropractic treatment were 1.8 (physical), 2.3
(psychological), and 3.5 (social), resulting in an average total of 2.3. Following treatment, the self-
assessment scores improved to 5.9 (physical), 6.7 (psychological), and 6.5 (social), yielding an average total
of 6.3. All metrics exhibited enhancement, with a total score increase of 4 points compared to pre-
treatment. This signifies a notable clinical amelioration in the patient's symptoms (Table 2).
Discussion
In this case, due to the patient's history of heart surgery, it was crucial to prioritize the exclusion of
coughing symptoms caused by cardiac issues when assessing the cough. Coughing symptoms caused by heart
failure may be related to posture (lying down) or exertion. They may also be accompanied by lower-limb
edema. The side effects of blood pressure medications (ACE inhibitors) can also lead to chronic coughing.
Distinguishing between somatic chronic cough and non-somatic chronic cough can be challenging [5], as
patients with chronic cough are more prone to experiencing psychological disorders such as anxiety and
depression, which can, in turn, exacerbate the coughing. While it is commonly believed that somatic chronic
cough tends to occur more frequently when patients are awake and less frequently during sleep, the presence
of accompanying physiological conditions such as gastroesophageal reflux, postnasal drip, bronchitis, etc.
can still result in pronounced nocturnal coughing [5]. The presence or absence of nocturnal cough cannot be
used as the sole basis for diagnosis; somatic cough syndrome can only be diagnosed when a patient meets
the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria [3,5]. In this case,
although it is evident that the cough has persisted for a long time and has caused significant stress, with a
notable impact on the patient's emotions, there are no records of psychiatric assessments before or after the
onset of symptoms. Therefore, it is not possible to diagnose or rule out somatic chronic coughs solely caused
by depressive emotions. Additionally, the nature of the cough, with the patient experiencing almost no
symptoms during the day and only coughing when lying flat in bed during her deep sleep, does not align
with typical somatic cough characteristics. Instead, it resembles conditions previously diagnosed by three
TCM practitioners, such as postnasal drip and gastroesophageal reflux. Although these possibilities have
been explored in treatment, there has been no significant improvement. Therefore, the cough is more likely
to be diagnosed as a chronic neurogenic cough.
Oversensitivity of the vagus nerve is considered one of the main factors in chronic neurogenic cough [3,13].
The Arnold nerve reflex induces a cough reflex by stimulating a branch of the vagus nerve in the ear. This
branch runs from the vagus nerve to the external auditory canal, making it the only area where the vagus
nerve is superficially distributed [3,13]. Testing primarily involves inserting a cotton swab into the external
auditory canal for 3-5 mm and gently rotating it for two to three seconds. If coughing occurs within 10
seconds, it is considered a positive response. Studies have found that in adults with chronic cough, the
prevalence of the Arnold nerve reflex is over 11 times higher compared to healthy individuals, especially in
females. However, the prevalence of this reflex in pediatric patients with chronic cough did not show a
similar increase, suggesting that vagus nerve hypersensitivity may be acquired later in life [13]. The authors
of this study suggest that the mechanisms of chronic cough in adults and children may differ. The
hypersensitivity of the vagal response in adults might be related to acquired infections or other
environmental factors later in their lives, although there is currently no supporting research confirming
infections as the main cause. In light of these findings, further research is needed to investigate whether
adult chronic cough, possibly induced by cervical dysfunction, which is more commonly seen in adults, could
be linked to an overactive vagus nerve. A case report published in 2020 identified three patients with chronic
neurogenic cough, in whom coughing was triggered by hair stimulation of the vagus nerve within the ear
canal. Significant improvement in coughing was observed after the removal of the hair, indicating that the
over-activation of the vagus nerve plays a significant role in unexplained chronic cough [14].
The improved chronic cough in this case may be related to adjusting the upper cervical spine to affect the
balance of the autonomic nervous system and/or regulating emotional stress. The vagus ganglia consist of
the superior ganglion, the jugular ganglia, and the inferior ganglion, the vagal nodose ganglion, which
primarily innervates the trachea and lungs, responding to mechanical stimuli. Both ganglia are closely
interconnected and situated between the occiput (C0) and the first cervical vertebra (C1). In guinea pig
studies using selective stimulation of C-fiber subtypes of the vagus nerve, it was shown that activation
originating from the vagal nodose ganglion can acutely inhibit coughing, while activation from the jugular
ganglia makes coughing more sensitive or triggers coughing [15]. In other words, C fibers originating from
different ganglia may play opposite roles in cough regulation, and it is possible that humans have similar
opposing regulatory mechanisms [15]. The joint dysfunction between the occiput and the first cervical
vertebra may disrupt the normal functioning of the nerve ganglia. In this case, the first adjustment focused
on correcting C0/C1, and after the first adjustment, a noticeable improvement in nocturnal coughing and
restored C0/C1 joint play were observed. It is hypothesized that this change in the relative position or
restored joint play of the cervical vertebrae may have an impact on the vagus nerve.
Some studies have also found that relative head posture can impact vagal tone, thereby influencing
respiratory and cardiac functions. The study suggests that lying flat increases vagal activity, potentially
triggering bronchoconstriction mechanisms in asthma patients. Tilted at 60 degrees, vagal activity
decreases, aligning with Mossberg's 1990 hypothesis that vagal nerve activation in the supine position may
be associated with nocturnal respiratory symptoms in asthma patients [16]. Another study assessed the
impact of head positioning on the proportion of atrial fibrillation episodes in patients with atrial fibrillation.
The results showed that tilting the head down increased vagal tone, leading to a decrease in fibrillation rate,
while tilting the head up increased sympathetic activity, resulting in a higher fibrillation rate [17]. In a study
published by Moustafa et al. in 2020, participants with a forward head posture demonstrated abnormal
sensory-motor control and dysfunction in the autonomic nervous system compared to those with a normal
head alignment [18]. These indirect pieces of evidence imply that in cases of cervical dysfunction, changes
in the relative position of the head and neck by the patient may interfere with the vagus nerve and impact
the automatic nervous system. This may explain the absence of coughing symptoms when the patient is in
The vagus nerve, in addition to controlling the cough reflex, is also a crucial component of the autonomic
nervous system and is closely associated with the body's response to emotional stress [3,8,19]. Apart from
physical/mechanical stimuli, the vagus nerve can also be influenced by chemical/hormonal stimulation.
Stress can stimulate the hypothalamus-pituitary-adrenal axis or act through the sympathetic-adrenal-
medullary system, involving the sympathetic nervous system, adrenal glands, and medullary system, to
produce stress hormones. Under prolonged stress, the body releases large amounts of adrenaline and other
stress hormones, altering the immune system and making the body more susceptible to inflammation and
heightened sensitivity to pain stimuli [20]. The exact mechanisms behind this process are not fully
understood, but it appears to contribute to an increased sensitivity of the cough reflex. Over time, coughing
may become a habit, even evolving into a physiological and psychologically conditioned reflex state.
Therefore, resetting this mind-body response through cognitive-behavioral therapy can be an effective
therapeutic approach [3,7]. Spinal adjustments have also been found to regulate the autonomic nervous
system. In healthy subjects, receiving adjustments in the upper cervical spine (C1/2) activates the
parasympathetic nervous system [21], while adjustments in the lower cervical spine (C6/7) activate the
sympathetic nervous system. For patients with neck pain, adjustments in either the upper or lower cervical
spine activate the parasympathetic nervous system [21]. Balancing the autonomic nervous system and
regulating stress can be a viable direction for treating chronic cough.
Furthermore, chronic cough patients have a higher prevalence of symptoms related to autonomic nervous
system dysfunction and depressive symptoms [4,22]. It remains unclear whether these are caused by
coughing or if chronic coughing and depression are actually part of a broader pathological manifestation of
vagus nerve dysfunction. In recent years, vagus nerve stimulation has been increasingly used to treat severe
depression and has shown considerable effectiveness [23]. In addition to implanting electrode chips into the
vagus nerve in the neck, research has found that electrical stimulation of the Arnold nerve, a branch of the
vagus nerve in the ear, can improve depressive symptoms [24]. This is believed to be related to the vagus
nerve's regulation of and reduction in the body's inflammatory response. In animal experiments with rats,
continuous vagus nerve stimulation was found to increase the secretion of serotonin and norepinephrine in
rats [25]. Serotonin has been found to have inhibitory effects on cough reflexes in the peripheral or central
nervous system [6]. This is one of the mechanisms underlying the improvement in neurogenic chronic cough
patients when given antidepressant medications. Once again, it suggests that vagal nerve dysfunction may
be associated with chronic coughing and depressive symptoms to some extent.
People with self-harming thoughts may not necessarily disclose their true feelings to others, especially
when chiropractors are not specifically trained to address such issues. The identification of these thoughts
was actually made through the OD method. Subsequently, using OD to assess the appropriateness of
addressing and adjusting these mind-body connections was undertaken. If OD indicates adjustability, the
process continues; however, if OD shows an inability to adjust, the process will not continue, and an urgent
referral to a psychiatrist is necessary (Figure 2). This is indeed a serious matter. With the patient's consent,
communication was established with both the patient and her family, elucidating the severity of the
situation and seeking family support in consulting with a mental health professional. Documenting the
findings and reactions is crucial. Research has shown that individuals with a history of depression are more
likely to experience a resurgence of depressive symptoms in the context of chronic cough [4]. This
phenomenon was also observed in this case and significantly impacted her subsequent recovery. According
to the biopsychosocial model, especially for individuals with chronic health issues, a multidisciplinary
professional intervention is necessary [26]. Approaching the chronic situation solely from a physiological
perspective often yields limited results. Some chiropractic techniques incorporate psychological aspects, but
their primary objective remains to alleviate musculoskeletal discomfort. It is not intended as a direct
treatment for the patient's mental health issues. When encountering such cases, it is essential to refer the
patient for further assessment and treatment by mental health professionals.
Conclusions
Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.
Critical review of the manuscript for important intellectual content: Hsuan Pin Chang
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial
relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.
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