Mal de debarquement syndrome caused by cervical spine instability
Ross Hauser, MD
If you are visiting this page, and you or a loved one have been diagnosed with Mal de debarquement syndrome, you do not need a long explanation of what this treatment is. In its simplest and most life-altering explanation, it is chronic and sustained motion sickness that lasts for years. It is much more likely that you are visiting this page looking for possible answers.
Mal de debarquement syndrome can be caused by health concerns beyond the main culprit of extended sea travel. For people who are not responsive to conventional treatments, I discuss how Mal de debarquement syndrome or non-motion-triggered Mal de debarquement syndrome may be caused by cervical spine instability.
Cervical spine instability is the result of damaged cervical ligaments. These neck ligaments which hold the cervical spine in place can become weakened or damaged by wear and tear motion, poor posture, EDS hypermobility, or accident injury. In this state, damaged cervical spine ligaments can cause a disruption of the normal activity of the proprioceptors, the motion and space sensory receptors that tell the brain about neck motion and the 3D perception of where the head is in space. If bad messages get to the brain as to where the proprioceptors think the head is, the brain will relay head movement commands based on this information and where it thinks the head is in space. Not where it actually is. The end result of this is the problem of chronic or sustained motion sickness that the brain and nerve receptors in the cervical spine create in their conflicting, confused, and sometimes panic messaging.
Later in this article, I will also discuss using Prolotherapy injections to repair these ligaments and how this treatment may alleviate or stop problems of motion sickness. We will also review a Digital Motion X-ray (DMX) of a patient who had constant “motion sickness,” EDS hypermobility, mast cell activation syndrome, and numerous disabling symptoms.
A story of Mal de debarquement syndrome
Mal de Debarquement (literally, bad disembarkment or exiting of a ship) Syndrome is a condition where individuals experience a chronic illusion of self-motion triggered by prolonged exposure to passive motion, such as from sea or air travel. The condition can be very disabling with episodes lasting greater than one month in 51% of patients and 18% lasting more than one year. There were significantly more migraine headache symptoms in patients who had the chronic form of the condition.
The symptoms of Mal de Debarquement are with you constantly; they never leave nor can they be alleviated by anti-motion sickness drugs. Some people say it seems “like trying to constantly walk on a mattress or trampoline.” The symptoms most frequently reported are:
- rocking sensation
- bobbing sensation
- feeling disoriented
- ear pain and/or fullness
- sensitivity to light and/or sound
- difficulty concentrating
Many of these symptoms overlap with other cervical instability syndromes including whiplash-associated disorder, post-concussion syndrome, and craniocervical syndrome, and atlantoaxial subluxation.
Before someone flies into our center, we have them send their records ahead of time to make sure they are a good candidate for our treatments. The screening process can be demanding but we want to make sure that before someone makes the trip to get our care they are a good candidate. Many of these people report dizziness, vertigo, lightheadedness, and disequilibrium, and while all have slightly different meanings, there is some overlap and many have structural causes. We are looking for the clues that the person’s problems are coming from a cervical or upper cervical instability that we can treat.
We saw a patient who had been seen at a dizziness and hearing clinic (balance clinic), where they noted that her symptoms of imbalance and aural fullness had been ongoing. At least six months in duration. Her symptoms also consisted of tilting, nausea upon lying down, double and blurred vision, and lightheadedness. The symptoms appeared in attacks, which usually lasted seconds to minutes and occurred roughly every two to three weeks. They usually came abruptly without warning. Triggers included standing up from sitting, rapid head movements, walking in a dark room, closed eyes and grocery stores, and narrow or wide-open visual spaces. She reported a history of headaches that had increased in the last six months. They occurred once or twice a week and lasted until she took pain medications. She had a history of fibromyalgia scleritis (autoimmune disorders). She had a history of back surgery and epidural injections. She reported an injury to her head (slight concussion), one month prior to her visit to the dizziness and hearing clinic.
Her diagnostic workup was negative except
Her diagnostic workup was negative except for her MRI of the brain which showed chronic microvascular (sometimes known as small artery disease or small vessel disease) ischemic (no known cause) changes. The radiologist said she correlated clinically for the Tullio phenomenon, a condition in which sounds induce a balance, equilibrium, or dizziness problem. It was clear from the office notes that she was being told everything was related to the brain so nothing could be done to cure the condition, but some balance exercises could help. Well, they didn’t help so she contacted us.
If one looks at this patient’s history, the possible best and obvious explanation of all of her symptoms would be cervical instability and the resultant proprioception (distortion of the sense of space and self-movement) and autonomic nervous system misinformation that is being sent to the brainstem and brain because of it. Her long history of headaches also makes it likely that her cervical instability is pretty significant. Motions of the neck absolutely make her symptoms worse, again pointing to a cervical etiology of her problem. As the patient had a history of neck issues, it is likely the rocking of the boat trip was the straw that broke the proverbial camel’s back in regard to her cervical instability. The body will do whatever it can to accommodate instability in order to reduce symptoms and increase stability, but there are times where no more adaptations can be made. At this point, the person has to get some type of neck stabilization otherwise the symptoms persist. Treatments are discussed below. But first, more on understanding how to get to the correct diagnosis.
The chase for a diagnosis, Mal de debarquement syndrome may be seen as one of many suspects causing your motion sickness.
In our many years of service helping people with cervical spine problems and the symptoms these challenges may cause, we have seen people who have visited with neurologists, audiologists, Ear Nose and Throat specialists, chiropractors, acupuncturists, stress management specialists, physical therapy specialists, and other health care providers seeking the information as to why do they sway or feel dizzy, or, feel like they are on a rocking boat.
Indeed, for some people, a specialist may ask them if they had been on a boat recently or maybe even surfing.
If the answer is no, no type of travel or voyage, then they like you, may have been initially diagnosed with:
- Vestibular neuritis, an inflammation of the vestibular nerve, a nerve in the ear that provides information to your brain to help keep you balanced. This disorder causes dizziness and loss of balance. This is sometimes suspected in people who have overcome a recent viral infection.
- Migraine-associated vertigo is often suspected in people who have a history of headaches and migraines. Please see our article Vestibular migraine and spontaneous vertigo
- Benign paroxysmal positional vertigo. Please see our article Cervical Vertigo and Cervicogenic Dizziness for more information on this disorder.
- Postural-perceptual dizziness (PPPD). This is also a disorder of persistent sensations of rocking or swaying. It can be vertigo, a sensation of movement without dizziness. It is suspected in people who have had or history of concussion or whiplash, some of the disorders listed here: Benign paroxysmal positional vertigo, vestibular neuritis, Meniere’s disease, or Dysautonomia (problems or disease of the autonomic nervous system). Symptoms may worsen by standing or sitting upright.
- Meniere’s disease. Patients with ringing in the ears or hearing loss. Common characteristics include vertigo or a sense of motion when there is no motion.
The initial treatments for this condition are typically some type of medication. For many people, these medications are very helpful in managing these symptoms. These are typically not the people we see. We see people who may have limited or little success with medications and need other answers. Part of the challenge of supplying these answers is finding the right diagnosis. These above disorders share very similar symptom characteristics, while some medications will work for one problem, they may make another problem worse.
“Treatments have expanded beyond medication trials”
For the purpose of this article, we will try to focus on patients who have been diagnosed with Mal de debarquement syndrome and have not responded to treatment. Mal de debarquement syndrome and non-motion-triggered Mal de debarquement syndrome are considered two different entities. Successful treatment of Mal de debarquement syndrome may not be a successful treatment for non-motion-triggered Mal de debarquement syndrome. Often when these treatments fail, doctors may look away from Mal de debarquement syndrome and return to the previous diagnosis list mentioned above.
Is the problem an inner ear disorder? For some yes, not all.
In people we see, many of them who were suspected of having any of these disorders mentioned above, following extensive testing, perhaps without clear results, were put on medications. As mentioned previously, for many people medications may be very helpful. We typically see patients who did not have success with medication. However, for some of these people, the medications were able to eliminate the belief that they had other disorders like those mentioned above and helped focus their treatment on Mal de debarquement syndrome. Then again for these people, medications did not help their newly diagnosed Mal de debarquement syndrome either.
A January 2020 paper published in Seminars in Neurology (1) from the Department of Neurology, Barrow Neurological Institute, and the University of Minnesota suggests how the treatment of Mal de debarquement syndrome is changing.
“Mal de debarquement syndrome is a disorder of persistent vertigo characterized by a feeling of oscillation such as rocking, bobbing, or swaying. It is triggered by passive motion, typically by exposure to water, air, or land transportation. This syndrome affects middle-aged individuals who are predominantly women. Mal de debarquement syndrome presents as a balance disorder that carries a significant risk of morbidity (health concerns) due to both the direct effects of balance impairment and associated symptoms of fatigue, cognitive slowing, and visual motion intolerance… more insight has been gained into the pathophysiology of morbidity, with current hypotheses pointing to a cerebral and cerebellar basis. Treatments have expanded beyond medication trials, and now include the use of noninvasive brain stimulation and readaptation of the vestibulo-ocular reflex. (The connection between a sense of balance in your inner ear and eye movement.)”
We are going to take a moment to discuss Optokinetic Stimuli. This is considered the first successful treatment for Mal de Debarquement Syndrome. This treatment is focused on people highly suspect of Mal de Debarquement Syndrome because they have had a recent trip, voyage, or activity on the water. The treatment is explained best by statements issued by the Icahn School of Medicine at Mount Sinai and leads research developer Mingjia Dai, Ph.D., Assistant Professor of Neurology.
“Diagnostic tests and early research done at Mount Sinai suggested that Mal de debarquement syndrome was caused by malfunctioning of the vestibule-ocular reflex, a mechanism in the inner ear that maintains balance and stabilizes the eyes during head movements . . . (This) treatment re-adapts the vestibule-ocular reflex by moving the visual surroundings as the head is slowly rolled from side to side at the same frequency as the subject’s symptomatic rocking, swaying or bobbing.”
In this research and treatment, Mal de Debarquement Syndrome cleared because the treatment focused on normalizing where the brain thought the head was in space compared to where the inner ear’s messages to the brain thought the head was. Focusing the eyes and rolling the head in the opposite direction to the sway corrected the problem.
In a case history report, (2) doctors at the U.S. Army Medical Center of Excellence, Army-Baylor University Doctoral Program in Physical Therapy, and the Department of Rehabilitation Medicine at Brooke Army Medical Center, Fort Sam Houston, Texas describe a 39-year-old female reported swaying and rocking after returning from a 7-day cruise. They discussed the treatment program that involves a passive role of the patient’s head while watching optokinetic stripes, resulting in the adaption of the vestibule-ocular reflex and improvement of Mal de debarquement syndrome. The patient was treated with two sessions in a computer-assisted rehabilitation environment and symptoms resolved after two visits.
Is it an estrogen problem in post-menopausal women?
A February 2022 study (6) lead by the School of Science, Campbelltown Campus, Western Sydney University and published in the journal, Current opinion in neurology, researchers note that recent studies have identified a direct link between abnormal hormone levels, specifically estrogen, and vestibular dysfunction. Benign paroxysmal positional vertigo research suggests that the disorder may be linked to the rapid decrease in estrogen, observed in menopausal women, which disrupts otoconial (balance) metabolism within the inner ear. A successful hormonal therapeutic intervention study has advanced our knowledge of hormonal influences in the inner ear in Ménière’s disease. Also, several studies have focused on potential mechanisms involved in the interaction between Vestibular Migraine, Mal de Debarquement Syndrome, and gonadal hormones.
What if sustained motion, as in a sea cruise is not the cause of your Mal de debarquement syndrome? Do you even have Mal de debarquement syndrome? Yes, you can
Above is described situations where the onset of Mal de debarquement syndrome was brought on a sea cruise or other motions, but, what if sustained motion, as in a sea cruise, is not the cause of your Mal de debarquement syndrome? Do you even have Mal de debarquement syndrome?
“Recognizing the similarities and differences between motion-triggered and non-motion triggered Mal de Debarquement Syndrome can prevent unnecessary diagnostic testing and lead to earlier and more effective treatments.”
A May 2018 study (3) lead by the Laureate Institute for Brain Research and the University of Tulsa, questioned whether Mal de Debarquement Syndrome and non-motion triggered Mal de Debarquement Syndrome are actually two different disorders.
“There has been increasing awareness that post-motion triggered rocking self-vertigo can last for months or years, a disorder known as Mal de Debarquement Syndrome. A similar feeling of oscillating self-motion can occur without a motion trigger in some individuals, leading to controversy about whether motion-triggered and non-motion-triggered Mal de debarquement syndrome symptoms ultimately represent the same disorder. Recognizing the similarities and differences between motion-triggered and non-motion triggered can prevent unnecessary diagnostic testing and lead to earlier and more effective treatments.”
In this study, researchers offered questionnaires to 80 individuals with persistent motion-triggered Mal de debarquement syndrome and non-motion triggered Mal de debarquement syndrome
- 81% of patients were female with an average age of about 43
- The average duration of illness was significantly longer in the non-motion-triggered Mal de debarquement syndrome (82.8 to 35.4 months).
- Improvement with re-exposure to motion (driving) was typical for both (Mal de Debarquement Syndrome = 89%, non-motion triggered Mal de debarquement syndrome = 64%), but non-motion triggered Mal de debarquement syndrome individuals more frequently had symptoms exacerbated with motion.
- Peri-menstrual and menstrual worsening of symptoms were typical in both Mal de debarquement syndromes (each 71%).
- Both Mal de debarquement syndromes exhibited a higher population baseline prevalence of migraine (23% (motion group) and 38%, (non-motion group) respectively).
- Benzodiazepines and SSRI/SNRIs (Selective Serotonin Reuptake Inhibitors) were helpful in both subtypes. (>50% individuals with a positive response).
- Physical therapy was modestly helpful in the motion type (56%) subtype but not in non-motion-triggered Mal de debarquement syndrome (15%).
- Vestibular therapy made as many individuals worse as better in the motion group and none improved in the non-motion-triggered Mal de debarquement syndrome group.
Why Vestibular therapy did not work and other clues that point to Mal de debarquement syndrome as being caused by cervical spine instability in some patients
Above we discussed the research on medications, treating the problems of inner ear disorders to include Vestibular therapy, of which Optokinetic Stimuli is one, and therapy to move to head in opposite rotation to the sway people suffer from. What if all these treatments and therapies do not work and the patient still suffers symptoms? Failure of these treatments is our clue that the patient’s Mal de debarquement syndrome is a problem in the neck.
A case history presentation – a patient who has hypermobility Ehlers Danlos Syndrome (hEDS) and Mal de debarquement syndrome
Summary learning points and explanatory notes of this video
- Patients with hEDS suffer from loose connective tissue that makes recurrent joint dislocations and spinal and cervical instability common disabling symptoms. This case is an illustration of what weakened and damaged cervical spine ligaments can cause whether from hypermobility Ehlers Danlos Syndrome or degenerative wear and tear in the cervical spine.
- In 2014 our staff at Caring Medical published our paper “Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability,” in The Open Orthopaedics Journal. (4). In this peer-reviewed research, which is cited by 113 other research publications, we offered the following points:
- “When the cervical spine capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae. In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to, nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches.” What we found in patients was the common characteristic symptoms of sense of motion without motion, dizziness, and disorientation could be helped if we non-surgically repaired their cervical spine ligaments, restored cervical spine stability, and eventually helped restore the natural curve of the neck. This would extend from treating C0 – C5). This is all explained below.
Dr. Hauser narrates the video below, a summary transcript is included.
Video: By the time the patient sought care with us she had pain in almost every body part. She was also previously diagnosed with mast cell activation syndrome, (immunological condition of repeated episodes of the symptoms of anaphylaxis (allergic reactions)). She had dizziness, tinnitus, and a list of other symptoms that clearly indicated that her nervous system was not working correctly.
Signals to the brain convey the wrong information of motion to the brain. Possible cause: Cervical spine ligament damage
- At 1:45 of this video: This particular patient is very sensitive to any type of motion. The nerves, or more commonly proprioceptors, motion and space sensory receptors that tell the brain about neck motion and the 3D perception of where the head is in space, are embedded within the ligaments of the cervical spine. So when there is cervical spine instability caused by cervical spine ligament damage, the proprioceptors themselves become confused and disoriented and cannot give the right information to the brain. This misinformation results in the rocking, swaying, bobbing disorientation common in Mal de debarquement syndrome.
Loss of natural cervical spine curve
- At 2:29 of this video: a Digital Motion X-Ray (DMX) image of her lateral cervical spine reveals that she has a loss or total disruption of the natural cervical spine curve. The cervical spine curve is supposed to be lordotic like the letter C and we see in the DMX image that the patient’s curve, does not look like a C but looks more like an S. This is a typical indication that this patient has suffered from ligament laxity and ligament damage.
Offset disconnect between cervical vertebrae
- At 2:52 of this video: This ligament laxity in the cervical spine has led to an offset between C4 and C5. This indicates that the vertebrae are not together or floating away from each other and this will lead to cervical spine instability.
Digital Motion X-ray (DMX) demonstrates the patient’s neck problems
- At 3:09 the DMX now shows an x-ray of the patient’s neck in real-time motion. As the patient moves her neck in flexion, C4-C5 instability is apparent. The more she moves her neck in flexion, the worse the instability becomes. (Neck flexion– lowering your chin down to your chest.)
The loss of natural curvature of the cervical spine
- 3:22. With neck extension, the patient’s “George’s Line” (or the Posterior Body Line) the patient’s neck curve falls into proper alignment. This is the benefit of using DMX motion x-ray. During the patient’s natural neck movements we can see which movements cause problems and which movements do not cause extensive problems. (Neck extension– raising your chin skyward.)
- 3:45 the DMX demonstrates that when the patient raises her chin skyward or looks forward, her natural curve returns.
- 3:53 – problems detected:
- In the DMX open mouth view, we see the C2 spinous process is not in line with the dens, the bony protrusion of the C2 vertebrae. This misalignment has been implicated in many of the problems of dizziness, fainting, loss of balance among other problems. The main symptom in this patient is the terrible motion sickness that she has all the time.
- When the ligament strength in her neck is restored with Prolotherapy injections, and the proper lordosis in her neck is restored, which we do with various exercises, making her work area ergonomically correct. Using traction, weights to help restore the curve, we feel the prognosis is excellent.
Treating and repairing damaged cervical ligaments with Prolotherapy
In this image, we see a CT venogram in a patient with horrible dizziness. Both the sagittal and coronal planes show compression of the internal jugular vein by the lateral mass of the atlas (C1).
The cervical ligaments are strong bands of tissues that attach one cervical vertebra to another. In this role, the cervical ligaments become the primary stabilizers of the neck. When the cervical ligaments are healthy, your head movement is healthy, pain-free, and non-damaging. When the ligaments are suffering from degenerative wear and tear or excessive looseness or laxity that prevents the ligaments from holding the vertebrae together, the ligaments lose their ability to control the proper motion of your head. The head begins to move in a destructive, degenerative manner on top of your neck. When this occurs you can develop the symptoms of cervical vertigo, motion disorders, and dizziness.
Actual Prolotherapy treatment
Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult to treat musculoskeletal disorders. We are going to refer to our 2014 study mentioned earlier in this article, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments.
- This is what we wrote: “To date, there is no consensus on the diagnosis of cervical spine instability or on traditional treatments that relieve chronic neck instability issues like those mentioned above. In such cases, patients often seek out alternative treatments for pain and symptom relief. Prolotherapy is one such treatment that is intended for acute and chronic musculoskeletal injuries, including those causing chronic neck pain related to underlying joint instability and ligament laxity. While these symptom classifications should be obvious signs of a patient in distress, the cause of the problems is not so obvious. Further and unfortunately, there is often no correlation between the hypermobility or subluxation of the vertebrae, clinical signs or symptoms, or neurological signs or symptoms.”
What we demonstrated in this study is that the cervical neck ligaments are the main stabilizing structures of the cervical facet joints in the cervical spine and have been implicated as a major source of chronic neck pain and in the case of Mal de debarquement syndrome type symptoms, cervical instability.
Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative/reparative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.
This video jumps to 1:05 where the actual treatment begins.
This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.
- The patient was experiencing vertigo, tinnitus, severe neck pain, migraines, and other problems based on C1-C2 instability.
In 2015 our research team published our finding in our paper “The biology of prolotherapy and its application in clinical cervical spine instability and chronic neck pain: a retrospective study.” This peer-review research was published in the European Journal of Preventive Medicine. (5)
Here we wrote: “In an effort to facilitate the diagnosis and treatment of clinical cervical spine instability and chronic neck pain, we investigated the role of proliferative injection Prolotherapy in the reduction of pain and recovery of constitutional and neurological symptoms associated with increased intervertebral motion, structural deformity and irritation of nerve roots. . . 95 percent of patients reported that Prolotherapy met their expectations in regards to pain relief and functionality.”
Caring Cervical Realignment Therapy (CCRT)
Caring Cervical Realignment Therapy (CCRT) was developed by Ross Hauser, M.D. after decades of treating patients with neck disorders, including cervical instability and degenerative disc disease.
Through extensive research and patient data analysis, it became clear that in order for patients to obtain long-term cures (approximately 90% relief of symptoms) the re-establishment of some lordosis, (the natural cervical spinal curve) in their cervical spine is necessary. Once spinal stabilization was achieved with Prolotherapy and the normalization of cervical forces by restoring some lordosis, lasting relief of symptoms was highly probable.
In this video Ross Hauser, MD explains Caring Cervical Realignment Therapy
- Caring Cervical Realignment Therapy is one of the therapies we use to correct abnormal cervical spine
- The cervical spine should have lordotic curvature, it should be shaped like a C. The C shape keeps stress forces on the cervical spine at a minimum.
- When you have a cervical spine ligament injury, the ligaments cannot hold the C shape. The neck can progress to a Military curve, it is straight up and down. Eventually, the natural curve of the neck distorts and twists into a letter S. (See illustrations below).
- At 1:07 of the video: How do we reverse this?
- We treat the injured ligaments with Prolotherapy injections, which will cause the ligaments to strengthen and tighten and provide cervical spine stability.
- At 1:24: Once the cervical spine is stabilized, then the neck can handle the weight forces of the Caring Cervical Realignment Therapy. Dr. Hauser explains.
- 1:46 images of post-treatment correcting cervical spine curvature.
There are complex cases that can benefit from the individualized Dynamic Structural Medicine techniques that are unique to the Hauser Neck Center at Caring Medical Florida. Thus, our patients travel here from all over the world. Dr. Hauser is widely regarded as one of the most experienced Prolotherapists for complex upper cervical cases, and the upper cervical spine is an area that most Prolotherapists are not able to treat. If you have been looking for better answers to your medical questions, been dismissed by other facilities, and feel that your symptoms haven’t been taken seriously or properly diagnosed, we are available to review your case and see if we can help! We do have a multi-step process to assess if a patient is a good fit for our testing and treatment center. Please understand that we cannot accept every patient who inquires about care here. Dr. Hauser and his neck team review neck cases ahead of time to ensure they are coming to the ideal Caring Medical location for their case, as well as give you an idea of what to expect at your first visit to the neck center. Please reach out to us and we will direct you to which provider will be the optimal fit for your case.
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This page was last updated September 16, 2021