CSF and Cerebellar Symptoms in Alzheimer's, Parkinson's and MS

The cerebellum is often affected in neurodegenerative diseases such as Alzheimer’s,, Parkinson’s and multiple sclerosis (MS). Cerebellar signs include: problems with posture, balance, gait (walking) and coordination. Muscle coordination problems include disturbances in movements of the eyes such as nystagmus, as well as intention tremors and over shooting movements when attempting to do specific tasks with the arms or legs. Cerebellar signs can also include problems with speech, vertigo, nausea and vomiting. In this regard the cerebellum is often affected in different neurodegenerative diseases due its location in the posterior fossa above the foramen magnum.

The brain floats inside a jacket of water. The jacket of water includes the enlarged spaces, called cisterns (wells) beneath the bottom of the brain and surrounding the brainstem and cerebellum. The cisterns are the blue spaces in the drawing above from a neurology lecture by Dr. Anne Olsen. The cisterns support the brain and protect and cushion it from the hard walls of the cranial vault.

The cisterna magna is the largest of the cisterns and is located inferior to (below the bottom of) the cerebellum. The volume of cerebrospinal fluid (CSF) in the cisterna magna and other cisterns is crititcal to the health and function of the brainstem and cerebellum. An increase or a decrease in the normal volume of CSF in the cisterns can cause problems in the brainstem and cerebellum. For example, an insufficient volume of CSF can cause the brainstem and cerebellum to sink into the foramen magnum. On the other hand, it is my opinion that a  chronic abnormal increase in CSF volume in the cisterns can lead to compression and subsequent degeneration of the brainstem and cerebellum.

Typically, hydrocephalus is associated with an increase in CSF volume in the chambers in the middle of the brain and brainstem, called ventricles, where it is produced. There is debate among experts, however, as to whether to include any abnormal increase in CSF volume inside the cranial vault, which would include those that can occur outside the ventricles in the subarachnoid spaces and cisterns located between the outer and middle layers of the protective membranes, called meninges, that surround the brain and cord. Currently, an increase in CSF volume in the cisterna magna is called a mega cisterna magna or a cystic posterior fossa. At this time, a mega cisterna magna is not considered to be a form of  hydrocephalus but it is sometimes associated with hydrocephalus and enlarged ventricles in a rare condition called Dandy-Walker syndrome.

Dandy-Walker syndrome is a congenital condition associated with a malformed and undersized cerebellum.  The MRI on the right is an example of a Dandy Walker syndrome from a paper published in 2008 in the Internet Journal of Radiology called, Imaging of Congenital Malformations of the Brain by A.B. Shinagare and N.K. Patil from the Department of Radiology in Mumbai. The white arrow points to the cerebellum. The white dart points to the cover over the cerebellum and posterior fossa, which is exceptionally steep. The black dart near the bottom of the posterior fossa points to a dark gray area beneath the cerebellum. The dark gray is CSF in the cisterna magna of the posterior fossa. The black arrow points to the rear side of the pons portion of the brainstem, which is slightly compressed.

A normal healthy cerebellum should nearly fill the posterior fossa. In this case the cerebellum is extremely small. The malformation of the cerebellum is currently believed to be do to underdevelopment (atrophy), or to total lack of development (atresia).  The increase in CSF volume in the cisterna magna is attributed to the decrease in size of the cerebellum. In other words, CSF simply moves in to fill the empy space.

Interestingly, Dandy-Walker syndrome is the complete opposite condition to a Chiari malformation. For example, Chiari malformations are often associated with an undersized posterior fossa. In Dandy-Walker, the posterior fossa is often enlarged. In Chiari malformations, a normal sized cerebellum gets pushed down into the foramen magnum. In Dandy-Walker the cerebellum is underdeveloped and small. Moreover, it often gets pushed up into the posterior fossa of the cranial vault along with the cover over the fossa, called the tentorium cerebelli. In Chiari malformations the cisterna magna is often compressed due to the descent of the cerebellum into the foramen magnum. In Dandy-Walker syndrome the cisterna magna is enlarged. Chiari malformations are also associated with an undersized foramen magnum. Dandy-Walker, on the other hand, is associated with an oversized foramen magnum. Chiari malformations also affect females about three times as often as males. On the other hand, at approximately sixty percent, males make up more than half the cases of Dandy-Walker syndrome. The one characteristic both conditions do share in common is that their cause is often unknown.

In Dandy-Walker the problem is believed to be caused by undersized or absent outlets that normally connect the fourth and lowest ventricle to the cisterns below. The fourth ventricle is located between the front of the cerebellum in the back and the pons of the brainstem in the front. It can be seen in the sketch of the cisterns at the top of the page indicated by the Roman numeral IV in the black space. The third ventricle is above it and is indicated by the Roman numeral III in the black space. The narrow black streak joing them is called the cerebral aqueduct.

The obstruction to CSF flow from the fourth ventricle to the cisterns causes the fourth ventricle to enlarge. Chronic enlargement of the fourth ventricle can compress and damage the cerebellum. In Dandy-Walker syndrome, the enlarged fourth ventricle is referred to as a cystic fourth ventricle. Because it involves the ventricles, a cystic fourth ventricle is technically a form of hydrocephalus. On the other hand, the enlarged cisterna magna seen in certain cases of Dandy-Walkers syndrome is not. Instead, the enlarged cistern is attributed to an underdevelopment resulting in an undersized cerebellum. CSF increases in volume in the cisterna magna as a result of the decrease in size of the cerebellum. Since the cisterns are outside the ventricles, technically speaking it is not hydrocephalus.

This is similar to the theory regarding the suspected cause of enlarged ventricles often seen in normal pressure hydrocephalus (NPH), which has been associated with Alzheimer’s disease, dementia  and Parkinson’s disease as well as others. In Alzheimer’s disease the enlarged ventricles are attributed to atrophy; that is, a decrease in size of the brain. In other words, as the brain shrinks in size the ventricles enlarge and CSF volume increases to compensate for the decrease in size of the brain and to fill in the space.

While some cases of Dandy-Walker are clearly associated with undersized, blocked or absent CSF pathways, many are not. The problem is further complicated because the development of the ventricles, as well as the cisterns and CSF pathways start in utero (during preganancy) and continues after birth, which is when problems start to show up. Moreover, the skull is still open at birth, which allows it to accomodate an increase in CSF volume. Consequently, unless it is associated with an oversized head due to hydrocephalus, the problem often  goes unnoticed initially . Whatever the cause, experts all agree that Dandy-Walker syndrome is associated with an imbalance between the rate of production of CSF and its absorption and removal from the brain.

Considering the above, both blood and CSF flow between the brain and cord pass through the foramen magnum and upper cervical spinal canal. Consequently, blockage of blood and CSF flow through the foramen magnum and upper cervical spinal canal can cause inversion flows, turbulance and standing waves to form in the brain, especially in the cisterna magna, which can affect the cerebellum among other things. It can also cause the posterior fossa and foramen magnum to enlarge similar to the affects of hydrocephalus on the upper portion of the cranial vault. This could explain the enlarged posterior fossa and foramen magnum in Dandy-Walker syndrome. Furthermore, it is my contention that chronic obstruction to CSF flow causes local turbulance, inversion flows and standing waves (clapotis) in the brain that can compress and erode the brain.

Other cisterns can similarly be affected in conditions that affect adults. For example, there is a variant of Parkinson’s disease called multi-system atropy (MSA) or olivopontocerebellar atrophy (OPCA) in which the cerebellum and sometimes parts of the brainstem, called the olives and pons, appear small and compressed similar to Dandy-Walker. It is my theory that many cases of Parkinson’s disease and variants of Parkinson’s are due to obstruction to CSF flow oftentimes due to Chiari malformations, which block blood between the brain and cord in the foramen magnum and upper cervical spinal canal. Moreover, obstruction to CSF flow most likely plays a role in multiple sclerosis and Alzheimer’s disease as well. The first place to feel the affect of blockage of CSF flow is the posterior fossa, which contains the brainstem and cerebellum.

In brief, hydrocephalus is associated with children. In contrast to children, adults get normal pressure hydrocephalus. Similarly, Chiari malformations and Dandy-Walker syndromes are associated with children. More recently however, it has been shown that adults can aquire Chiari 1 type malformations, and olivopontocerebellar atrophy (a variant of Parksinson’s) causes similar signs on brain scans to Dandy-Walker syndrome.  In many cases they may share a similar cause, which is blockage of CSF flow that results in an imbalance between its rate of production and removal from the brain. Among other things, an increase in CSF volume in the fourth ventricle or cisterns can affect the cerebellum.

For further information on CSF flow and volume in the cisterns, dysautonomia and heat intolerance, visit my website at www.upright-health.com.

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  • nzer1 says:

    Hi Dr F, is there a way to test the CSF flow that would give an understanding or clues to look for? I am guessing that posture and UPRight MRI will be key factors in checking flow to get an understanding of ‘issues’.
    Regards Nigel

    • Hello Nigel,
      Upright cine MRI is the best way to check for abnormal CSF flow. Although it isn’t good for diagnosis, it can be very helpful in “understanding” many of the complex “issues,” such as the common signs and symptoms seen in MS and other neurodegenerative condtions.

  • Kate says:

    Hello Dr. F,

    I am a young woman with Chiari 1 for which I had decompression surgery (laminectomy only, my surgeon chose not to go through the dura) a year ago. My surgery was not successful, and my symptoms are worse than before my decompression. I believe that I have a problem with the dynamics of my CSF. I can actually feel this pressure change happening in my head. There is an obvious pressure shift when I change positions or bend over, accompanied by a strong throbbing sensation. In addition, I experience pressure that builds through the day, and relieves over night. This process happens every day, and leaves me debilitated from severe pressure by late evening, until such a time that I can be horizontal long enough to “reset” the high pressure.

    My current CINE flow MRI says I have no definite detectable CSF flow in the fourth ventricle or cerebral aqueduct, and that my fourth ventricle is effaced. I also have “minimal flow” to the optic tracts – which is perhaps a cause for the constant pressure in my eyes, and pain with eye movement? Also, I have recently developed several perineural cysts in the cervical spine area, (in addition to the thoracic, lumbar, and sacral perineural cysts I have) and an area of T2 weighted hyperintensity in the C2 vertebrae. Basically, I am a mess in there! I have constant pain and pressure…but even worse, I am starting to have very common MS symptoms, such as eye pain, intentional tremors, fatigue, and muscle spasticity. I am on a mission to find some treatment for my CSF abnormalities before it further damages my central nervous system.

    My neurosurgeon feels that my Chiari decompression was adequate, despite my abnormal CINE flow results. He does not want to do anything except treat me with gabapentin and pain medication. Of course, I do not find that acceptable – I want to solve the problem! I believe very strongly that a complicated relationship between my Chiari, and CSF flow are the root of my body’s issues. Until I found this blog, I have had no validation of that suspicion. I thank you for writing this blog.

    Do you have any advice for me? I am willing to travel to a doctor who is knowledgeable about CSF dynamics and Chiari patients. Thank you so much for your time!

    • neava says:

      decompression is not sucessful if they dont go though the dura and do a proper job of it,
      in other words they didnt cut away enough skull and remove C1 to allow enough room for your brain or fluid, so the CSF is still compressions, (there is a higher sucess rate when they open the dura)
      facebook conquerchiari
      these are some sites you can go on for support and info,
      i am a suffer of chiari and im sorry you are having problems, you need to go back back to your surgeon and get them to relook at it, and correct it,

    • Hello Kate,
      You clearly have aberrant fluid mechanics in your brain and cord. The low flow in the optic tracts, aqueduct and fourth ventricle along with effacement of the fourth ventricle could be due to intracranial hypotension. Intracranial hypotension can cause the brainstem to sink into the foramen mangum. It would also explain why the decompression surgery wasn’t successful. What is your blood pressure and pulse rate? Do you have any x-rays of your spine? Do you have any abnormal curves in the spine such as scoliosis?

  • Kate says:

    Wow, thank you for getting back to me so quickly! I appreciate that very much.

    My blood pressure and pulse are both a smidge low. My pulse is usually 55-60, and my BP is typically about 105/70. This is actually quite surprising to me, as everyone in my family has high BP. I do not think anyone has taken x-rays of my spine. I’ve never been diagnosed with scoliosis. I’ve always been exceedingly healthy until a couple of years ago, when I was pregnant with twins. In my last trimester, I developed severe pitting edema of my body. It was during that time that I noticed my first symptoms – numbness and tingling in the hands, pain in the neck and back, and some areas of numbness on the body. I believe my symptoms were set off by the extreme increase in bodily fluids and the strain on my vascular system. After the pregnancy was over and the edema subsided, I was left with symptomatic Chiari. Initially, I attempted to treat my symptoms with chiropractic care. After a year of unsuccessful chiropractic adjustments, I had a CT scan and was found to have Chiari. My herniation is approximately 15mm and extends to the arch of C2.

    I agree with your assessment that I may have abnormal intracranial pressure. I have asked my neurosurgeon to please check my ICP at the very least – but he has himself convinced that he’s successfully treated my Chiari – even though the CINE flow MRI results do not indicate that my decompression was successful. (I should also add that this is a Cleveland Clinic neurosurgeon who treats many Chiari patients….so it’s not as if I didn’t go to an expert.) I think he basically thinks his work is done, and he is no longer doing anything to treat me. I know I have to find a new doctor, but I am unsure of who to go to. I need someone who is very familiar with my particular issues.

    I have become very interested in neurology since developing Chiari. I view this as a puzzle that can be solved, and I intend to persevere until I find a way to treat this successfully. I am unwilling to accept lifelong CSF abnormalities that will probably cause further damage to my brain and CNS. I am only 31 years old, with two small children. It’s imperative that I figure this out. I’m sure if someone can restore balance in my body, I can return to being my old self. I still feel the potential in my body. Two years ago I was training for a triathalon! Now I can barely go to the store because of the pain and pressure in my head. It’s pretty disheartening.

    One question I had… what process causes the fourth ventricle to efface? Can you explain what is going on with my CSF flow? This is from my CINE report:

    “CSF flow study shows biphasic flow ventral and dorsal to the brainstem at the level the foramen Monroe. There is biphasic flow in the prepontine cistern. The fourth ventricle or outflow tracts are effaced and a small amount of biphasic flow is identified on the axial images. No definite
    biphasic flow is identified in the circle aqueduct or fourth ventricle.”

    and (final result summary):

    What exactly does that mean? That’s pretty abnormal, right? And probably the cause of my pain, pressure, and eye pain?

    Thanks so much…

    • Hi Kate,
      The fourth verntricle can be effaced by an increae in external pressure or a decrease in internal pressure. You have low flow and most likely low pressure in your ventricles and aqueduct, as well as your optic tract. Over shunting CSF in hydrocephalus cases can similarly cause effacment of the lateral ventricles called slit ventricles. Biphasic flow is normal. When the heart contracts during systole blood volume and pressure in the head increase. Excess venous blood and CSF are vented through the foramen magnum according to prevailing pressure gradients in the brain and cord. During relaxation of the heart blood volume and pressure decrease and CSF flows up the cord and back into the brain to be delivered to the dural sinuses for removal. It should be noted however that biphasic flow is abnormal when it occurs simultaneously in the brain. In other words CSF backjets into the brain during cardiac contraction (systole are abnormal). They can also cause turbulence and standing waves in the brain. I will be covering battered bones and brains from aberrant CSF flow in my next post.

      In light of your Chiari condition, your low blood pressure, low pulse rate and your symptoms of swelling during pregancy you should get a complete systems review. Getting around upright while pregnant takes it toll on the body and circulation. As every mother knows, it effects the colon and bladder and it can cause hiatal and other hernias. It also compresses blood vessels to your legs.

      You may not be producing enough CSF due to sluggish blood flow or you may have a decrease in the CSF pressure gradient due to back pressure in the cervical spine for example. X-rays of your spine would be helpful. Specific upper cervical correction is an option but you have additional post surgical complications that have significantly weakened the upper cervical spine. You should only be seen by the most highly trained, experienced and competent professional using low force methods. You have an unusal and complicated case. I will contact you privately for more confidential information.

  • sara says:

    Hello Dr.
    My father is 70 years old. He was suffering extreme fatigue, depression and memory problems.
    Years later it became clear he has hydrocephalus so he underwent an operation to drain the liquid and he recovered and returned to himself. His health and his memory became normal. But one year later, he began weakening again. We thought it was that the hydrocephalus returned but the doctor told us that my father is suffering from Alzheimer’s and that the brain scans showed atrophy.
    Is there a solution to help my parents?
    Thank you very much .

    • Hello Sara,
      Doctors don’t yet see the connetion between chronic NPH and AD. It’s the NPH that is causing your father’s problem. Draining CSF temporarily took pressure off of the brain but it didn’t solve the chronic drainage problem causing the NPH. The drainage system can get backed up by several factors such as structural problems in the aging, injured and degenerated cervical spine. I also suspect however, that aging and circulatory decline can cause a decrease in CSF produciton. This can cause the brain to sink inside the cranial vault into the foramen magnum and block blood and CSF drainage outlets. I think that there are some solutions currently available and some that are on the near horizon. The key is getting doctors to understand the cause.

      • sara says:

        Thank you so much Dr. F,
          What are the solutions currently available?
        Who is the right doctor for my father case?
        Is it a neurologist ,or orthopedic specialist , or vessels specialist?

        • Hi Sara,
          It may be worth trying a well trained upper cervical doctor with years of experience. Getting the upper cervical spine corrected can decrease resistance to blood and CSF flow through the foramen magnum and upper cervical spinal canal. There are good craniosacral methods that are useful as well. The problem is finding good craniosacral doctors who understand neurodegenerative diseases and how to properly apply their techniques. In addition to upper cervical and craniosacral there are special tables used by chiropractors to move blood and CSF in the brain and cord that may be helpful. Lastly, there are herbs used in Traditional Chinese Medicine that are currently under investigation for neurodegenerative diseases that can slow down the process and alleviate some of the symptoms. They have low toxicity, are easily tolerated and most don’t interfere with medications. Again the problem is finding professionals who are knowledgeable about neurodegenerative diseases and the latest research. Surgical solutions are on the horizon.

  • nzer1N says:

    Hi Dr F.
    From what I have seen in recent months are the advances made by technology, the Upright Fonar imaging is now supporting your understanding.
    Is there more to come from imaging that you are experiencing that will turn the Medical worlds view point.
    From what I understand the problems lie in the snapshot imaging and assumptions that were made about CSF flow. The cord requires flow that surrounds it if I understand what I am reading, and the CSF flow around the brain has to be checked in regions rather than at a convenient place for the image method.
    The changes in symptoms that occur from shunts or surgery to decompress the skull contacting the brain stem in many examples change over time and the medical world guesses why there are symptom changes rather than image the flow changes and consider the reason for the symptom change. The examples of rapid change in Chiari cases has amazed me how the blood and CSF can change the position of the brain within the skull, in fact push the brain stem out of the skull.
    When there is contact with the cord from disc bulges is another example of the missing knowledge by the Medical World, it seems that there is an assumption that contact of the cord with disc or vertebra is the only possible reason Dr’s use to explain symptoms they see on snapshot imaging, they don’t consider the flow of CSF or the Vertebral Veins as a possible cause of symptoms.
    Maybe they should live inside closed plastic bags when they make their assumptions, they may learn something from the experience.
    Biggest flood ever outside home at the river, 12 hr down pour over night, great photos taken at the peak when the rain stopped.

    • Hello Nigel,
      You have learned a great deal and grasp the subject better than most professionals. That’s why I wrote my book for patients and lay people so that they could be part of the discussion and drive the debate and the research. Seeing inteligent comments from patients like you make me realize my work was worthwhile. Stay dry mate.
      Dr. F

  • sara says:

    Hi Dr F.
    My father was suffering from fistula
    and had an operation to remove the fistula several years ago
    is there a link between the fistula and CSF and veins ?

    • Hi Sara,
      A fistula is an abnomal passageway. It can effect blood vessels and CSF pathways resulting in abnormal connections, pathways and flow of fluids.

      • sara says:

        Hi Dr F.
        I notice that my father gets tired a lot of car
        What’s your explanation ؟

        • Hi Sara,
          It’s hard to say. There are many things about riding in a car that can aggravate a patient with Alzheimer’s, especially your father who has signs of weak circulation. Sitting motionless makes matters worse. While it can be relaxing for some it can cause fatigue or be challenging and disconcerting for others. Ridiing in traffic can also be uninteresting and boring. Riding in a car can make normal people sleepy.

  • Alfiya Johnson says:

    Hi, Uprightdoctor! I have a hopefully easy question about a long-lasting problem.
    About 9 months ago I came down with very strange and scary symptoms after painting ceilings in my new house over a period of a couple of months (that’s in addition to a few sports injuries and a couple of car accidents throughout my younger yrs.) One day I took myself to ER with a sudden onset of tachycardia, loss of normal proprioception, bilat. upper and lower extremities numbness/tingling, abnormal visual/spacial perception, inability to sit or drive d/t ataxia. Two trips to ER, CTs and initial neurologist consult brought no answers. They attributed my super-dilated pupils to anxiety or drug use, neither of which I have or do. After suffering with this for a couple of months with no help from anyone, I did some googling of symptoms and realized I am dealing with something quite serious and directed myself to Phoenix Barrow’s neurological center and asked for an MRI and cervical spine X-Ray. The tests revealed Chiari I with 6 mm cerebellar tonsils herniation and C3-C5 subluxations. Of course, the neurologist immediately recommended for me to see a neurosurgeon, stating that the only treatment for Chiari is surgery. While feeling too scared to see the neurosurgeon right away, I continued to read about these conditions, and came across several articles about C1 and C2 subluxations that can cause or potentiate Chiari formation (my neck discomfort started pointing by then to upper cervical area). I wondered if these subluxations caused Chiari, and could fixing these subluxations make Chiari go away? So, I found an orthogonal treatment chiropractor and had 4 sessions so far with temporary alleviation of symptoms (I can’t see him often enough, but I am still hopeful.) This Monday I had a cine-MRI done that was ordered by the neurosurgeon. The MRI ‘clearly shows NO CHIARI’, with “normal CSF flow ventrally around the cerebellar tonsils in the region of the foramen magnum, however there is absent flow dorsally.” I have to wait a month before seeing the neurologist and neurosurgeon again. I have always felt that I am more of an orthopedic problem with neuro symptoms, but this MRI finding bothers me. So, here are the questions:
    1. What S&S would pts have with no CSF flow dorsally?
    2. Is there anything else I can do to make things better and expedite healing? I am obviously trying to avoid neurosurgery. I am tired of being tired. Body-building used to be my hobby, and now I can barely drag my feet.

    Sincerely and respectfully,

    Alfiya J.

    • Hello Alfiya,
      Although I haven’t seen your brain scans or x-rays, you obviouly have problems in the cervical spine in that you had a 6 mm descent of the cerebellar tonsils into the foramen magnum, as well as subluxation of C3-5. It was wise that you saw an Atlas Orthogonal doctor to get your upper cervical spine corrected. It appears to have corrected the tonsilar ectopia (Chiari). However, you still have subluxations in the lower cervical spine most likely due to spondylosis (degeneration), which can limit the complete correction of the Chiari.

      There are no particular signs and symptoms associated with dorsal obstruction to CSF flow. Instead, you should monitor your previous and current signs and symptoms such as POTS, numbness and tingling, abnormal spatial orientation, ataxia and neck pain. I would definitely continue with the Atlas Orthogonal as you have had temporary relief so far after only four sessions. You should give it more time for the correction to take hold and for the brain to recover and heal. You will also need lifetime care to maintain your condition and to keep the Chiari from returning. Keep me posted about your progress.

  • Alfiya Johnson says:

    Thank you very much for your response. Realizing that this condition is a result of multiple injuries accumulated since childhood, I have signed up to see this chiropractor once a week for a whole year. All the symptoms you have listed above have become much milder since the very first treatment, so I am more optimistic. When I feel the onset of symptoms, I take 2.5 mg of Valium and it does the trick. Today I did not need it at all. Last week, it was 2 x day. Prior to the chiropractor, I had to take this dose 5-6 x day to keep the symptoms, especially tachycardia, under control. I don’t quite understand the mechanism of how Valium is helping here, but it does. My PCP prescribed it to me to help with muscle spasms. It does not help with spasms, but keeps the rest of the symptoms controlled somehow. Does it help with CSF flow? Does it decrease intracranial pressure? I can’t wait to follow up with my neurologist and neurosurgeon, who were so animate about “Chiari only being fixed surgically!” I will keep you posted.
    Meanwhile, I am worried about the lower subluxations. They are d/t badly degenerating discs. This condition affects my ability to look up and down; I just roll my eyes up to look up or bend at the waist to keep my back and neck aligned. I hear and feel popping and grinding when I do any movement with my neck. I have been told that there is no good treatment for this instability, but surgery. Is it true?


    • nzer1N says:

      Great to hear that there are positives from adjustments.
      Dr F I have had in the back of my mind a question that hasn’t really found an easy way to verbalise.

      Is the body positions that we achieve to make an improvement in symptoms with Atlas alignment issues a clue to out of alignment issues?.

      eg does having our head rotated give relief to C1 misalignments?

      Could left or right turn be an indication of CSF flow issues?

      I notice that I have a posture that tells me I am compensating for alignment problems. The Lady who magically does my house work’s Partner has just injured his back and chest and the body positions he is in tells a story of pain and compensation which we talked about today as she was heading away for his second adjustment.

      I kind of know the answer, I am just putting it out there that if we are mind full of our being we can work towards wellness.


      • Hi Nigel,
        Although non-specific, certain positions that cause improvement in signs and symptoms do provide clues about the type of misalignment. For example, certain positions of the arm can cause thoracic outlet syndromes to manifest. Similarly, turning and tilting the head and neck can stretch, compress and irritate nerves and blood vessels while the opposite direction relieves the strain. I know you knew the answer.

    • Your welcome. Valium causes the muscles to relax which can improve blood and CSF flow. I would give the AO upper cervical corrections some time to take full effect. Aligning the upper cervical spine can significantly reduce the compression loads acting on the lower cervical segments, as well as alignment and motion. Spondylosis (degeneration) isn’t necessarily associated with joint instability. It is more often associated with loss of motion. There are many manual methods for effectively treating spondylosis in the lower segments of the spine. In addition to manual methods I also used physiotherapy such as traction, electrical muscles stimulation, combination ultrasound, hot packs, diathermy, infrared etc, Rehabilitative exercise is also important. In brief there are many things you can do to repair and maintain the health of your spine.

      • Alfiya says:

        Thank you, again.

        My flexion X-Ray shows instability/motion of C3-C4 (or C4-C5, I don’t have it in front of me.) I have been going to physical therapy 3 x wk for 5 months already, and they use all of the above modalities, except traction of upper neck, only mild manual traction of lower neck/upper back. I even just got a Ceragem bed, just would be afraid to use it in the neck area for now. But my lower back is going out now. So, I will try it on my mid and lower back.


  • sara says:

    Hi Dr F.
    I notice that my father gets tired form riding the car
    What’s your explanation ؟

    • I answered your question on the other other page you posted your comment on.

      • sara says:

        Thank you very much for your response ,
        my father rides the car only one time a week for 30 min!
        when he gets home he feels tired that he can’t sit, he just lay on his bed.
        now he never rides the car except for the hospital, then he gets sick after that for a while.
        forgive me for too much questions, i’m just trying to help my father to get better.
        thank you very much.

  • Stacey says:

    Hi Upright Doctor,
    I am 43 years old and 3 years ago they diagnosed me with Parkinson’s. I do have some of the classic symptoms such as rigidity, gait issues, (my left leg wants to drag a little) and a very slight tremor but only when I am using my left hand, not at rest. All my symptoms are affecting my left side. The diagnosis of Parkinson’s has never set right with me. My intuition has never been comfortable accepting that diagnosis, so I have continually been looking for different explanations to my symptoms. Just recently I had a practitioner suggest that my bones in my skull were out of alignment and they felt like that could be causing the protective sheath (can’t remember the technical name) to be restricting the flow of my CSF and therefore causing Parkinson like symptoms. What is your opinion on this?

    • Hello Stacey.
      My theory is that there is a dissociation of CSF flow between the cranial vault and spinal canal that results in faulty hydraulics. The faulty hydraulics increase pressure waves acting on the brain and cord. Chronic increases in pressure waves can be destructive. The dissociation of CSF flow can be caused by different factors that affect blood and CSF flow in the brain and cord. I suspect that design variations in the skull and spine can predispose people to Parkinson’s. Inherited malformations and acquired injuries and misalignments of the upper cervical spine and base of the skull can also play a role in Parkinson’s by obstructing CSF flow between the cranial vault and spinal canal. Vacular Parkinson’s can be caused by decreased blood flow to the brain. Upper cervical malformations and misalignments can also affect arterial blood flow to the brain.

      My next post will be on atrophy of the midbrain, which is seen in a variant of Parkinson’s disease called progressive supranuclear palsy. It is also seen in vascular Parkinson’s, vascular dementia and dementia with Lewy-body disease. Dementia with Lewy-body disease is a variant of Alzheimer’s and Parkinson’s diseases.

      • Stacey says:

        Upright Doctor,
        Thank you for your response. I have had two accidents which resulted in blows to my head. Do you think pursuing cranial alignment therapy would be beneficial? Is there any other treatments for the dissociation of the CSF flow?
        Thank you for your time.

        • Stacey,
          It is certainly worth pursuing evaluation and treatment for potential head and neck injuries. The challenge is finding the right doctor or therapist. You need to find someone with expertise in structural misalignments and connective tissue injuries of the craniocervical junction and lower spine. The treatment should be based on objective clinical evidence from a thorough physical exam, x-rays and MRI scans of the brain and cervical spine. There are good craniosacral doctors and other professionals who treat the bones of the skull but most of them base their treatment on highly subjective findings. Specific upper cervical chiropractors use a much more objective analytical approach based on three dimensional analysis of the strain of the craniocervical junction (base of the skull) taken from specific x-rays. Many upper cervical doctors, however, do little if any rehabilitation of soft tissues such as deep tissue massage, connective tissue release, traction and electrotherapies. Take your time and look for someone familiar with neurodegenerative conditions.

          • Stacey says:

            Thank you for your advice! Do you think I should look into a upright MRI? Do you know of anywhere near Denver or Northern Colorado that does type of imaging?

          • Stacey,
            An upright MRI and cine CSF flow study would be helpful but make sure you find a neuroradiologist who has training and experience with adult acquired Chiari (CTE), connective tissue tears, joint instabilities etc. Upright flexion and extension views would also be helpful Contact FONAR Corporation at the link below for the closest Upright MRI facility.

  • MNOURHAJ says:


  • Amanda Caddy says:

    Hi upright doc, I am hoping you are still around, I am trying to get hold of a copy of your book, I ordered a copy from QBD a month ago, and have just been told it is now out of print, and their supplier can’t get any. Your website does not ship to Australia, so was trying to get it another way, Amazon have a couple, but are charging nearly $150 for it, and that’s before postage, don’t know why there is such a discrepancy in price between Amazon and your site and QBD who had it for $40. So was just wondering if you know, if more will be printed soon, so I can wait for QBD to have it in stock again?
    I have Ehlers Danlos Syndrome, and was recently diagnosed with papilledema, but my brain MRI came back normal, so my doctor is sceptical that I have high intracranial pressure, especially since my symptoms are worse later in the day rather than first thing in the morning, like pseudo tumour cerebri is. I don’t actually think my MRI is normal though, I have a long and slightly retro flexed odontoid, and my cerebellum is protruding below the foremen magnum on both sides of the spinal cord, just not in the midline view, radiologists are always saying that you have to look at a scan 3 dimensionally, so I don’t get why a 2 dimensional view of the middle of your brain is all that gets mentioned. Plus there was a lot of fluid in the subarachnoid space above my brain, which was not mentioned, and according to other books I have read, this can put pressure on the cranial nerves, which would explain the vagus nerve symptoms I have. I also have a severe thoracic kyphosis, and I suspect an occult tethered cord, due to a tight filuum, which is common in EDS. My uncle has also been diagnosed with dementia in his 50’s, which I am suspecting is maybe due to untreated high intracranial pressure, so I want to try an avoid getting that, by convincing my doctor, that there are many reasons for HII, especially in people with EDS, and then I can also help my family members with EDS, that are having symptoms of HII, so am trying to gather as much info and resources I can.

    • Hello Amanda,

      It’s been months since you posted your comment but I was never notified. I hope your recieve this reply.

      Regarding your question of whether more copies of my book would be printed soon, we won’t be publishing any more copies of the paperback but have considered doing a second edition as an e-book to make it more easily accessible to people outside the USA and Canada. At the moment, however, I am up against a deadline for my next book, which is written mainly for professionals but laypeople can also get through most of it as well. The title of the book is “The Role of Craniospinal Hydrodynamics in Disorders of the Brain and Cord.” The book should be out late this year.

      Regarding your condition, while it is possible that you have high intracranial pressure, such as Idiopathic Intracranial Hyperteniso (pseudo tumor cerebri), considering that you have EDS, a retroflexed odontoid and kyphosis and possible tethered cord it is quite likely that you have a pseudo Chiari malformation. Pseudo Chiari malformations can be caused by CSF leaks resulting in intracranial hypotenison/hypovolemia (decreased CSF volume and pressure). EDS is associated with CSF leaks. On the other hand, a retroflexed odontoid and abnormal clivoaxial (upper cervical) angles can compresses the epidural space of the canal and subarachnoid space of the cord and therby obstruct blood and CSF flow. It is my opinion that obstruction to return flow of CSF from the canal to the cranial vault may play a role in certain cases of intracranial hypovolemia. I cover CSF leaks and intracranial hypovolemia in my next book. Abnormal curvatures of the spine, such as scoliosis and kyphosis can also cause downward displacement (ectopia) of the brain in the cranial vault due to abnormal tension on the dura mater, which is attached to the craniocervical junction (upper cervical spine).

      • Amanda Caddy says:

        Thanks for the reply, ebooks are great, I get lots of my books that way, as most of the ones I want are not sold in book stores, plus it is usually cheaper, so I can get more of them, does not really replace the feel of a book in your hands, but I am trying to get used to it, as it is really the information you want. I will look out for your new book at the end of the year, I don’t mind that it is written for professionals, I find them more informative, I can always look up anything I don’t understand anyway.

        Turns out that I had pseudo papillodema, due to small optic nerves entering at an angle, took 4 doctors to figure it out. I had come to the conclusion that I did not have a true Chiari, and was thinking along the lines of a CSF leak, as I had fluid leaking from my ears, and they were often painful, but it seems to have resolved itself now, I think having a pulmonary embolism, and being on warfarin may have triggered it, as for several months after stopping warfarin, the really bad headaches, leaky sore ears and pulsitile tinitus, gradually got better, and I no longer have them now. But at least I will know what direction to point doctors in if it happens again. Thanks for putting so much effort into your books, great for those of us who love to research everything.

  • Your welcome Amanda. My new book will be hardcover you can hold in your hands. I am sure your will be able to get through it with no problems. It’s written in a lighter tone. The real challenge for anyone, including professionals, myself included, is the sheer volume of information it involves regarding anatomy, physiology and pathology of the skull, spine, brain and cord.

    A CSF leak makes sense in your case. I suspect, however, that in addition to leaks there are other causes of pseudo Chiari malformations and intracranial hypovolemia as well. My theory is that some people have low pressure conditions and decreased CSF production that predispose them to the brainstem sinking in the vault. Others have obstruction to CSF flow that affects return flow to the cranial vault resulting in intracranial hypovolemia and pseudo Chiari malformations. Lastly, strain of the craniocervical junction, scoliosis and tethered cords can cause tension strains on the dura mater that can lead to pseudo Chiari malformations. I cover intracranial hypotenison, intracranial hypovolemia and pseudo Chiari malformations in more detail in my book.

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