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 to the myriad of symptoms that are causing your health challenges. This article will focus on the problem of a “world in motion.” We will also look at other vision problems and how one possible explanation, unidentified cervical neck/spine instability, maybe the reason as to why treatments and therapies have not helped you to this point.

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 updated this further with 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:

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

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 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 the thoracic area and into the base of the 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 a vision problem 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 relieve my symptoms. That stopped the nystagmus. I had seen my chiropractor previously thinking an adjustment would help. My chiropractor adjusted my 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

I am going to present here a brief history of 50 years of research in the hopes of giving the reader, or listener of this article, a framework of the challenges their doctors face in understanding their symptoms.

It is a familiar story we hear of confusion that a person has when bouncing from specialist to specialist trying to find the source of their vision problems with seemly no answers.  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 describing and making 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, and 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.

The march 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?

Vision and dizziness are connected as having a common cause, not causing each other. In many, the common cause is a neck issue.

In 1983, noted German researcher Ulrich Reker (4) discussed in his paper the worsening vision symptoms of turning one’s head and the likelihood of a cervical spine origin: “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 proprioceptive (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 extreme positions, the proprioceptive 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 deficiency problem? Is it both?

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:

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.

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.

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.

Potentially all these reflexes are impaired with cervical ligament instability causing symptoms of vertigo, dizziness, Nystagmus, Oscillopsia, visual disturbance, and poor balance.

neck-eye reflexes

The mystery of cerebellar ataxia in Oscillopsia

Cerebellar ataxia is a disorder of balance that affects 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.

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:

Even with all of these possibilities, doctors continue to find isolating the cause of the patient’s problems of hearing loss and oscillopsia.

After Prolotherapy injections – improvements were 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.

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

Focus on C1-C2

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 intra-ocular pressure or elevated intraocular pressure, Limited pupillary constriction, Optic nerve damage

In this image, vision problems caused by cervical spine instability are 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:

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.”

We hope you found this article informative and that 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.

Please visit the Hauser Neck Center Patient Candidate Form

Treating and repairing cervical instability with Prolotherapy: research papers

References.

1 Guseva AL, Pal’chun VT. Clinical diagnosis and treatment of chronic dizziness. Zhurnal Nevrologii i Psikhiatrii Imeni SS Korsakova. 2020 Jan 1;120(12):131-7. [Google Scholar]
2 Strupp ML, Straumann D, Helmchen C. Nystagmus: Diagnosis, Topographic Anatomical Localization and Therapy. Klinische Monatsblätter für Augenheilkunde. 2021 Nov;238(11):1186-95. [Google Scholar]
3
Norré M, Stevens A. Cervical nystagmus and functional disorders of the cervical column. Acta oto-rhino-laryngologica Belgica. 1976 Jan 1;30(5):457-67. [Google Scholar]
4 Reker U. Cervical nystagmus caused by proprioceptors of the neck. Laryngologie, Rhinologie, Otologie. 1983 Jul 1;62(7):312-4. [Google Scholar]
5 Millar JL, Schubert MC. Report of oscillopsia in ataxia patients correlates with activity, not vestibular ocular reflex gain. Journal of Vestibular Research.(Preprint):1-9. [Google Scholar]
6 King S, Priesol AJ, Davidi SE, Merfeld DM, Ehtemam F, Lewis RF. Self-motion perception is sensitized in vestibular migraine: pathophysiologic and clinical implications. Scientific reports. 2019 Oct 4;9(1):1-2. [Google Scholar]
7 Dornhoffer JR, Liu YF, Donaldson L, Rizk HG. Factors implicated in response to treatment/prognosis of vestibular migraine [published online ahead of print, 2020 May 24]. Eur Arch Otorhinolaryngol. 2020;10.1007/s00405-020-06061-0. doi:10.1007/s00405-020-06061-0 [Google Scholar]
8 Petersen JA, Straumann D, Weber KP. Clinical diagnosis of bilateral vestibular loss: three simple bedside tests. Therapeutic advances in neurological disorders. 2013 Jan;6(1):41-5. [Google Scholar]
9 Hauser RA, Steilen 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 Jun 16;3(4):85. [Google Scholar]

This article was updated June 1, 2023

 

 

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