Can chiropractic manipulation cause reactivation of herpes zoster in patients with a history of zoster?

Chiropractic Manipulation and Zoster Reactivation

There is no evidence that chiropractic manipulation causes reactivation of herpes zoster in patients with a history of zoster. The established risk factors for varicella-zoster virus (VZV) reactivation are well-defined and do not include physical manipulation or chiropractic interventions.

Established Risk Factors for Zoster Reactivation

The primary driver of VZV reactivation is impaired cellular immunity, not mechanical trauma or manipulation 1. Specific risk factors include:

• Advanced age - the most significant risk factor, with approximately one in three persons developing zoster during their lifetime 2, 3
• Immunosuppressive conditions including hematologic malignancies, HIV/AIDS, and transplant recipients 1
• Immunosuppressive medications such as:
  • High-dose corticosteroids (≥7.5 mg/day prednisone) 1, 4
  • T-cell depleting agents (alemtuzumab, fludarabine) 1
  • JAK inhibitors (3-9 per 100 patient-years) 1, 4
  • Chemotherapy agents like bortezomib and carfilzomib 1
• Female gender 1, 4
• Psychological stress and elevated glucocorticoid levels 5

Why Mechanical Trauma Is Not a Recognized Trigger

While mechanical trauma has been proposed as a potential trigger in older literature 6, current evidence-based guidelines from major societies (NCCN, EULAR, CDC) do not identify physical manipulation or mechanical trauma as risk factors for VZV reactivation 1, 2. The virus reactivates from latency in sensory ganglia through immunologic mechanisms, not mechanical disruption 5, 3.

Clinical Implications

Patients with a history of zoster can safely receive chiropractic manipulation without concern for viral reactivation. The focus should instead be on:

• Identifying true risk factors such as immunosuppression, age >60 years, or concurrent immunosuppressive therapy 1, 4
• Considering vaccination with the recombinant zoster vaccine (RZV), which reduces herpes zoster risk by approximately 81% in immunocompromised populations 4, 7
• Monitoring for prodromal symptoms (itching, burning, paresthesia 12-24 hours before lesions) in high-risk patients 5

Important Caveat

If a patient develops zoster coincidentally after chiropractic manipulation, this represents temporal association, not causation. The reactivation was driven by underlying immunologic factors, not the manipulation itself. Treatment should focus on prompt antiviral therapy (acyclovir, valacyclovir, or famciclovir) within 72 hours of rash onset 1, 2, 8.