Nystagmus – Oscillopsia caused by cervical spine instability and neck pain
Ross Hauser, MD
If you have been diagnosed or suspected of having Oscillopsia, you know what Oscillopsia is and you know it took you a long time to get to a diagnosis and understanding of this disorder. For many, Oscillopsia can be one of many diagnoses or comorbidities that you suffer from and a contributing factor for the myriad of symptoms that are causing your health challenges. This article will focus on the problem of a “world in motion,” and other vision problems and how one explanation as to why treatments and therapies have not helped you is because you have unidentified cervical neck/spine instability.
This article is part of a series of articles that include:
Please see my article: Symptoms and conditions of Craniocervical and cervical spine Instability for a more comprehensive review of possible symptoms and conditions related to cervical instability.
Your journey to a diagnosis of Oscillopsia
You have a vision problem where you see things that bounce, jump or appear to be in some type of motion when in fact these objects are not moving at all. In your talking to your doctors, you went through a screening process to see what is causing these problems for you.
You may have been asked about head injuries or trauma, inner ear problems such as Meniere’s disease, a history of seizures, and meningitis. Older patients may be asked about a history of stroke. For other patients, a discussion of nystagmus may be discussed. These are vision problems caused by involuntary or abnormal eye movement.
A 2020 paper (1) gives a good summary of the challenges of diagnosis and the challenges of treating people with dizziness, nystagmus and Oscillopsia.
“Chronic dizziness is defined as a complex of symptoms lasting months or years, including oscillopsia, nystagmus, and postural instability. Diagnostic search includes peripheral vestibulopathy (chronic vertigo, nystagmus with a torsional (rotational) component beating (back and forth movement) toward the unaffected side (unilateral), postural imbalance, unilateral canal paresis (the canals in the inner ear fail to respond to a cold or warm water stimulus, they are in effect paralyzed, this is a cause of chronic dizziness or the offset of vision), and a positive head-impulse test result without other accompanying neurologic or audiological symptoms or signs. (This test commonly referred to as a HiNTs Exam, examines the cause of vertigo from an acute peripheral vestibulopathy – peripheral vestibulopathy is discussed below).
The principles of treatment depend on the diagnosed cause of dizziness and instability and can, to varying degrees, combine pharmacotherapy, vestibular rehabilitation, and psychotherapy, as well as correction of therapy for the underlying disease that caused vestibulopathy.”
A November 2021 paper (2) by doctors at Ludwig Maximilian University offer a good summary of the latest concepts in Nystagmus.
“Nystagmus is defined as rhythmic, most often involuntary eye movements. It normally consists of a slow (pathological) drift of the eyes, followed by a fast central compensatory movement back to the primary position (refixation saccade – often described as small eye movements that help reorient the eye and gaze).”
“The cardinal symptoms are, on the one hand, blurred vision, jumping images (oscillopsia), reduced visual acuity (sharpness) and, sometimes, double vision; many of these symptoms depend on the eye position. On the other hand, depending on the etiology, patients may suffer from the following symptoms:
- permanent dizziness,
- postural imbalance, and
- gait disorder (typical of downbeat and upbeat nystagmus);”
The next sentence is what will be discussed in this article.
If the onset of symptoms is acute, the patient may experience spinning vertigo with a tendency to fall to one side (due to ischemia (the loss of blood flow) in the area of the brainstem or cerebellum with central fixation nystagmus (the problem gets worse as you try to focus or fix on something) or as acute unilateral vestibulopathy (an inner ear disorder that is occurring on one side only) with spontaneous peripheral vestibular nystagmus); or positional vertigo.”
At this point we are going to examine the loss of blood flow caused by cervical spine instability as a possible cause of nystagmus. Let’s hear a real person’s story who came into our office.
A patient describes her symptoms
In this video, one of our patients describes her Oscillopsia journey. A summary transcript is below.
I have a symptom where everything bounces when I move my head up and down. Everything is jumping. I have been told this is called Oscillopsia.
When it started
These symptoms started after the birth of my first child when I was 24. I have had about 30 years of treatments and I have just been dealing with this problem. I have not been able to get help. When my symptoms got really bad I would start going into dizzy spells that would last 24 hours. Then I would be fine with the dizziness but then I noticed my field of vision was really bad.
A clue – pain at the C1. Symptoms can be made worse by pressing on the C1 area.
At 1:07 of the video, the patient demonstrates that pressing on the back of her head can make the symptoms appear
- If I press here on my C1 area I can get that same sensation (everything in her vision range is bouncing or vibrating) as if I’m moving my head, it’s a very weird thing. Everything bounces. If I could immobilize my head everything would be okay, but when I start walking, every step I take, everything bounces.
In this screenshot from the video, the patient says: I press here on my C1 area I can get that same sensation as if I’m moving my head, it’s a very weird thing. Everything bounces. If I could immobilize my head everything would be okay, but when I start walking, every step I take, everything bounces.
We will discuss this patient’s treatments below (also see Dynamic Structural Medicine Ross Hauser MD Review of Treatments for Cervical Spine Instability) and the improvements she has seen to date. In this patient, we were able to identify that cervical spine instability was the root cause of her vision problems and oscillopsia. While not every case of oscillopsia may be traced to cervical spine instability, unresponsive cases to conventional treatments may find their answers in the cervical spine.
Oscillopsia caused by cervical spine instability and neck pain. Why patients have many symptoms
This is an email we received. It has been edited for clarity.
“My primary concern is constant neck pain radiates through thoracic area and into base of skull that worsens with activity, ringing in the ears, muscle twitching/spasms, frequent headaches and eye pain, double vision, nystagmus with lateral gaze, frequent nausea, difficulty swallowing, excessive yawning.”
This is an email we received. It has been edited for clarity.
“I am having trouble getting a diagnosis for my serious condition. I’ve been considered for ALS, scleroderma, and a lot more. I exhibit many of these symptoms but have passed an EMG/Nerve Conduction Study. The many doctors are perplexed and I am rapidly deconditioning and suffering with a myriad of symptoms: Swallowing; Respiratory progression [and exercise intolerance]; Intense Eustachian tube pressure discomfort, balance and gait issues, visual disturbances (nystagmus and blur), low/no appetite, feeling full easily, clinically determined tachycardia issues, sharp chest and back pain near heart, chronic fatigue, pulsations in back of neck/head [especially when laying down], peripheral neuropathy, muscle fasciculations all over body (primarily calves and neck), face and jaw muscle tightening w/ fatigue (clinching), muscle tremors w/ activation or strain, noise and light sensitivity, nasopharyngeal constriction (feels closed off), larynx fatigue and hoarse voice, frequent hiccups, ulnar nerve pain and numbness, intense pressure discomfort at base of skull area that builds up and emanates out into head (primarily left side), terrible cognitive issues (very serious ‘brain fog’—memory and focus issues, occasional stuttering, etc), very noticeable dry eyes and dry mouth, difficulty holding up head and posturing back (with associated neck and back pain—very painful), joint rigidity (knees, shoulders, wrists), rapid rumbling in ears, and more. Recently, I’ve had plummeting heart rate and sharp chest pains at night/early morning. It’s very miserable and feels like a heart attack.”
Discussions of acquired nystagmus, diplopia (double vision), and oscillopsia
Above I briefly mentioned nystagmus, I want to go a little further here as a diagnosis of nystagmus and oscillopsia is often confused. As mentioned above, nystagmus is vision problems caused by involuntary or abnormal eye movement. The condition of oscillopsia can be caused by nystagmus.
Let’s allow researchers to help us understand the connection between oscillopsia and nystagmus.
“I suddenly woke up in the middle of the night with vertigo”
This is an email we received. It has been edited for clarity.
“(A year ago), I suddenly woke up in the middle of the night with vertigo. It was very scary. I went to emergency and had a CAT scan. I was told it was normal. I went to my ENT and he did the Epley maneuver (head tilt) to relive my symptoms. That stopped the nystagmus. I had seen my chiropractor previously thinking an adjustment would help. My chiropractor adjusted neck and head and my ear popped. Then I had an MRA, MRI and still nothing. No nystagmus but constant inner shaking. I feel like my head is filled with something. I have been to a spinal correction for my neck and the curve in my neck. I am still dizzy. I feel like my blood flow is slow to get to my head when I look up. I have headaches every day.”
Fifty years of research trying to suggest that the problems of nystagmus and oscillopsia are coming from the cervical spine
It may be confusing to you that you have bounced from specialist to specialist trying to find the source of your vision problems with seemly no answers. Yet, below I will present selections from fifty years of research trying to show an answer. Let’s take a quick dash through the timeline of nystagmus and oscillopsia
First, let’s put a face on this problem. Here is a sample story:
I’m having a lot of difficulties dealing with the various symptoms, conditions, and diagnoses I have received over the past couple of years. I have bounced from one specialist to the other with no lasting or significant improvement. I know something is wrong with my neck, along with some of my other joints have become significantly looser over the years. I have had difficulties trying to describe and make my doctors aware of this.
When I try to fall asleep I feel my neck move out of position, almost dislocating. When I wake up I have numbness in my hands, numbness in my face, fatigue, concentration difficulties. As the day goes on the symptoms lessen but when I try to sleep at night I know I will repeat this cycle tomorrow.
A neurologist cleared me of any neurological disorders, he also dismissed my own observations that it was in my neck. Also, I have symptoms of mild nystagmus and diplopia.
Almost as an afterthought, nystagmus and diplopia are mentioned. This is a very typical example story. The person intuitively knows what is wrong with them, yet they are routinely dismissed when expressing these concerns.
Let’s take a quick trip through fifty years of research.
In 1976, (3) researchers in Belgium published these observations on neck torsion and nystagmus. These are the summary learning points:
“(The researcher’s test and study) experience concerning the neck torsion-nystagmus has convinced us that this type of nystagmus must be elicited via a proprioceptive (neck movement) mechanism.”
What caused the researchers to be convinced?
- They noticed that the patient’s nystagmus changes its direction every 3-4 seconds, following exactly a stimulating physical movement.
- Their investigations resulted in another very interesting statement. Examining normal subjects, they could state that more than 50% of them presented a neck-torsion-nystagmus.
- Not many of you reading this article may have had a cervical torsion test. The aspect is that if you hold your head still and rotate your trunk, this would indicate cervical dizziness and other cervical spine-related problems.
- This was borne out in a group of patients with vertigo, the researchers could elicit in nearly the same percentage (50%) cervical nystagmus.
- A functional examination of the mobility of the cervical spine showed a significant relationship between a movement restriction of CO-C1 and the presence of neck-torsion-nystagmus.
- The researchers concluded that they believed they had demonstrated and proved nystagmus starts via a proprioceptive (neck movement) mechanism, interfering with the labyrinthine input at the vestibular nuclei (the nerve mechanisms of balance and vision coordination).
Vision and dizziness connected as having a common cause, not causing each other.
In 1983 a German paper (4) wrote:
Pathological nystagmus, occurring during turning of the trunk in relation to the head, which is held stationary in space, clearly points towards a cervical origin of vestibular vertigo. Such cervical nystagmus may have a vascular origin by the compression of the vertebral arteries, or a proprioreceptive (positional movement) origin via the upper neck joints, or it may possibly be due to functional disturbances of the upper cervical spine.
In five patients with isolated bilateral complete vestibular deficiencies (symptoms of dizziness and vision), we found a strong cervico-ocular reflex (This is the stabilization of eyes and field of vision with head movement and neck rotation. Detailed examinations showed that nystagmus occurred during the turning of the body in relation to the head.
On the other hand, when remaining in the extreme positions, the proprioreceptive nystagmus does not persist.
Let’s stop here, the paper points out that at extreme neck turned positions, the nystagmus goes away. This is something we do see as well when we examine patients using digital motion x-ray images. The symptomology of patients is, in many cases, dependent on head position. It does not mean that the greater you turn your head the worse your symptoms are.
Contrary to this, cervical nystagmus due to vascular causes shows a latency period (no symptoms) after torsion of the neck and increases if the head remains in the extreme position.
Let’s stop again, the paper points out that extreme neck turned positions continues or worsens as a matter of arterial or venous compression. This can be one of the great challenges that people with these symptoms have. Is it a neurological problem? Is it a vestibular deficiencies problem? Is it both?
The mystery of cerebellar ataxia in oscillopsia
Cerebellar ataxia is a disorder of balance that effects the cerebellum. It can be caused by many medical problems including whiplash and cervical spine instability. In December 2021, doctors at Johns Hopkins University reported (5) on patients with cerebellar ataxia who complained of oscillopsia, “bouncy vision” during activity. What the doctors were looking for was to quantify the magnitude (severity of symptoms) of oscillopsia and investigate its relation to vestibulo-ocular reflex function and daily activity in cerebellar ataxia.
- What the researchers found was “Patients with cerebellar ataxia and oscillopsia have impaired vestibulo-ocular reflex gains (the amount of eye rotation relative to the amount of head rotation), yet severity of oscillopsia and vestibulo-ocular reflex gains are not correlated. Patients with cerebellar ataxia have abnormal oculomotor (eye movement) behavior during passive head rotation that is correlated with gait velocity, but not magnitude of oscillopsia.”
Vestibular Migraine and Oscillopsia. A clue that cervical spine instability is at the root of the problem?
In my article: Vestibular migraine and spontaneous vertigo – Migraine Associated Vertigo, I note: “Poorly understood” is a recurrent theme when it comes to patients with Vestibular migraine and spontaneous vertigo. A study published in October 2019, led by researchers at Massachusetts Eye and Ear Infirmary, Harvard Medical School, and Ohio State University examined Vestibular migraine as one of the most common causes of spontaneous vertigo and why this problem remains poorly understood. The study was published in Scientific Reports (6).
The study’s learning points suggest:
- Vestibular migraine patients were abnormally sensitive to roll tilt (a misalignment of the eyes disrupting the sense of gravity and space), which co-modulates semicircular canal and otolith organ activity (this is an ability to sense gravity and sense motion), but not to motions that activate the canals or otolith organs in isolation (where fluid in the ears stabilizers balance), implying sensitization of canal-otolith integration. (Something is off but it is not a Meniere’s Disease type problem.)
- The researchers suggest a pathogenic model where vestibular symptoms emanate from the vestibular nuclei, (the cranial center point for the vestibular nerve) which are sensitized by migraine-related brainstem regions and simultaneously suppressed by inhibitory feedback from the cerebellar nodulus and uvula, the site of canal-otolith integration.
The suggestion is simply, something is happening to the vestibular nerve which is overly sensitized to pain by the reaction of something happening to the brainstem, and the process is further sent into panic by a dysregulation of the function of the balance mechanism in the ear.
Why certain patients were not benefiting from certain treatments for their Vestibular Migraines and Oscillopsia. No one was looking at their neck.
Now let’s look at a May 2020 paper (7) from the Department of Otolaryngology-Head and Neck Surgery, the Medical University of South Carolina wanted to see why certain patients were not benefiting from certain treatments for their vestibular migraines. Here are the summary learning points.
- 47 patients evaluated for treatment of definite vestibular migraine.
- Treatments included antidepressants, antiepileptics, beta-blockers, and vestibular rehabilitation (physical therapy). Patients failing initial therapy received botulinum toxin per the PREEMPT (a treatment guideline to prevent recurrence of migraine) protocol and vestibular rehabilitation for motion desensitization in case of known vestibular dysfunction.
This was an effective treatment for many. But not all. Let’s see who these treatments did not help. The success of the treatment was based on the reduction of dizziness.
- Results: 47 patients underwent therapy for vestibular migraine.
- This population had a significant dizziness reduction with therapy.
- BUT, if you had neck pain and oscillopsia, these treatments did not help your migraine as much as those patients without neck pain and oscillopsia.
In the image below the neck-eye reflexes are described.
These reflexes keep the head balanced while a person is watching moving objects or the body or head is in motion.
- The reflex vestibulo-ocular (VOR) causes eye gaze stabilization during head motion
- The reflex cervico-ocular (COR) helps the eyes to move in relation to neck rotation, (because of cervical ligament and facet joint proprioceptors – neurons that sense motion.)
- The reflex vestibulocollic (VCR) helps to stabilize head in space when the body moves.
- The reflex cervicalcollic (CCR) muscles tightened to stabilize head (because of cervical ligament and facet joint proprioceptors – neurons that sense motion.)
Potentially all these reflexes are impaired with ligament cervical instability causing symptoms of vertigo, dizziness, Nystagmus, Oscillopsia, visual disturbance and poor balance.
Unilateral, Bilateral Vestibular Loss and Oscillopsia. A clue that cervical spine instability is at the root of the problem?
Loss of hearing and oscillopsia symptoms.
We see many patients who have a problem with hearing and oscillopsia symptoms. Unilateral and bilateral vestibular loss, hearing loss in one or both ears can be caused by many things. Finding out which one of these many things is the cause has proved to be very challenging to doctors.
A paper in the journal Therapeutic advances in neurological disorders (8) describes some of the symptoms:
- Patients with bilateral vestibular loss may present with or without vertigo and hearing loss.
- They usually complain about oscillopsia during head movements and about unsteadiness, especially while walking in the dark.
- Common causes of bilateral vestibular loss are side-effects of vestibulotoxic antibiotics (or ototoxic antibiotics) (especially gentamicin), even after short periods of administration. Symptoms of ototoxicity are hearing loss, vertigo, and tinnitus
- Autoimmune ear diseases such as Cogan’s syndrome, Menière’s disease, and meningitis
- Bilateral vestibular loss, may also be associated with hereditary diseases
Even with all of these possibilities, doctors continue to find isolating on the cause of the patient’s problems of hearing loss and oscillopsia.
- It should be noted that in this study, patients with instability of the cervical spine and abnormal brainstem or cerebellum on MRI were not included.
- When a patient has hearing loss and oscillopsia and cervical spine instability is noted, the testing and provocation needed to confirm study results may be considered dangerous for patients, or because of the instability, the study results may be skewed. Either way, as we have seen in our clinical work, it is these people, who we can trace to having cervical spine instability, that we can help with their oscillopsia.
After Prolotherapy injections – improvements seen.
Our patient above described her symptoms over the course of 30 years of unsuccessful treatment. She presented a very complicated case.
Prolotherapy treatments are simple injections that are explained and demonstrated below. These improvements were seen after 8 treatments.
- Improvements with the optic nerve.
- I went to go see my doctor last summer and he told me both of my eyes (vision) got better at the same time which is very unusual supposedly because of my age (mid-50s).
- Discontinued Adderall
- I got off my Adderall which was another huge thing for me. Because the treatments here have helped me get more blood flow to the brain, my vision has improved enough. (Not seeing too many things at once).
- TMJ pain improvement
- I’ve had TMJ pain since I was in my twenties. I could never figure out where my bite was and now I know where my bite
The impact on symptoms including vision problems when treating cervical neck instability
We are going to start with an introductory video by Ross Hauser, MD. Below the video is a summary of the video with explanatory notes to help further and explain some of the concepts that Dr. Hauser is putting forth in explaining vision problems as they relate to neck pain.
Summary learning points
- Dr. Hauser emphasizes that to understand the impact on symptoms of cervical neck instability causes, including ultimately vision problems, you have to understand that the nerves that travel the spine are so intertwined with each other and through the cervical vertebrae that any compression to the nerves will cause far-reaching problems.
Focus on C1-C2
- At 1:30 of the video: Dr. Hauser talks about C1-C2 instability and its impact on the Vagus Nerve (Cranial Nerve X)
- When the Vagus nerve is injured by compression caused by instability at C1-C2, this can cause vasospasms (narrowing of the arteries and reduction of blood flow). If these vasospasms impact the ophthalmic artery, the artery that supplies blood to the eye and eye area including the orbit – this can lead to some of the symptoms are patients describe to us such as darkening, black spots, or grayness in the vision of one eye.
At 2:00 Minutes of the video, Dr. Hauser refers to this slide:
In this image, vision problems caused by cervical spine instability is connected to Diminished ocular blood flow, Exaggerated pupillary hippus dilating, Hampered accommodation or human ocular accommodation mechanism or accommodation reflex, Increased intraocular pressure or elevated intraocular pressure, Limited pupillary constriction, Optic nerve damage. Here are brief explanatory notes:
- Diminished ocular blood flow can cause symptoms, usually in one eye, or blurred vision, or partial or complete loss of vision
- Exaggerated pupillary hippus dilating and constricting can cause problems with light sensitivity and the pupil fails to respond correctly to light sources.
- Hampered accommodation or human ocular accommodation mechanism or accommodation reflex. This is the function of the eye that maintains a clear focus on objects whether close by or far away.
- Increased intraocular pressure or elevated intraocular pressure. This is high pressure inside the eye is caused by an imbalance of production and drainage of the inner eye fluids. The symptoms here include various vision disturbances. Researchers speculate a connection to the development of glaucoma.
- Limited pupillary constriction. This is also a problem with the dilation of the pupil. Your eye may not respond properly or at all to light stimulus.
- Optic nerve damage caused by blood flow restriction.
Demonstration of Prolotherapy treatment
Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult to treat musculoskeletal disorders.
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.
In 2015, our research team published our findings 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.(8)
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.”
Summary and contact us. Can we help you? How do I know if I’m a good candidate?
We hope you found this article informative and it helped answer many of the questions you may have surrounding Nystagmus – Oscillopsia diagnosis. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.
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Treating and repairing cervical instability with Prolotherapy: research papers
- Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability
- This paper was published in the European Journal of Preventive Medicine
- Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The Open Orthopaedics Journal. 2014;8:326-345. [Google Scholar]
- The Biology of Prolotherapy and Its Application in Clinical Cervical Spine Instability and Chronic Neck Pain: A Retrospective Study
- This paper was published in the European Journal of Preventive Medicine
- Ross Hauser, MD, Steilen-Matias D, Gordin K. The biology of prolotherapy and its application in clinical cervical spine instability and chronic neck pain: a retrospective study. European Journal of Preventive Medicine. 2015;3(4):85-102. [Google Scholar]
- Non-Operative Treatment of Cervical Radiculopathy: A Three-Part Article from the Approach of a Physiatrist, Chiropractor, and Physical Therapists
- This paper was published in the Journal of Prolotherapy
- Ross Hauser, MD, Batson G, Ferrigno C. Non-operative treatment of cervical radiculopathy: a three-part article from the approach of a physiatrist, chiropractor, and physical therapists. Journal of Prolotherapy. 2009;1(4):217-231.
- Dextrose Prolotherapy for Unresolved Neck Pain
- This paper was published in Practical Pain Management
- Hauser R, Hauser M, Blakemore K. Dextrose Prolotherapy for unresolved neck pain. Practical Pain Management. 2007;7(8):58-69.
- Cervical Instability as a Cause of Barré-Liéou Syndrome and Definitive Treatment with Prolotherapy: A Case Series
- This paper was published in the European Journal of Preventive Medicine
- Hauser R, Steilen-Matias D, Sprague IS. Cervical instability as a cause of Barré-Liéou syndrome and definitive treatment with prolotherapy: a case series. European Journal of Preventive Medicine. 2015;3(5):155-166. [Google Scholar]
This article was updated February 13, 2021