Symptoms of Dysautonomia

Ross Hauser, MD.

We see many patients with a myriad of horrible symptoms related to cervical instability, some have been diagnosed with Dysautonomia. The symptoms are usually extremely debilitating and the patient is often at the “end of their rope.” Even after numerous physician visits, labs, radiographic tests, and invasive procedures including surgeries, little to no improvement is experienced for one simple reason: the wrong diagnosis was given. For most of these symptoms and conditions, the correct diagnosis is cervical instability.

The symptoms of Dysautonomia are many. Often people will describe these symptoms:

• Joint pain, loss of muscle strength, spasms
• Anxiety
• Vision problems, light sensitivity, eyeball pain, excessive tearing or lacrimation.
• Change in appetite
• Chronic Fatigue
• Cognitive, mood and memory problems
• Depression, loss of interest
• Sleeping difficulties
• Dizziness, vertigo
• Ear pain, ringing in the ears, tinnitus
• Face paresthesia (pins and needles)
• Headaches
• Increased heart rate
• Sinus congestion, runny nose

Is Dysautonomia a disorder of the autonomic nervous system or is it a structural disorder in the neck? Is it actually both?

This is the definition supplied by the NIH National Institute on Neurological Disorders and Stroke. (1) I have added some explanatory notes.

“Dysautonomia refers to a disorder of autonomic nervous system (ANS) function that generally involves failure of the sympathetic (that part of the nervous system that prepares the body for flight-flight response) or parasympathetic components (that part of the nervous system that allows the body to calm down, reduce the heart rate and breathing, digest its food) of the autonomic nervous system, but dysautonomia involving excessive or overactive autonomic nervous system actions also can occur. (Your heart races, you develop POTS, please see my article Postural Orthostatic Tachycardia Syndrome (POTS) caused by cervical instability.)

Dysautonomia can be local, as in reflex sympathetic dystrophy (Complex regional pain syndrome generally appears following a physical injury and is disproportionate to the precipitating event or level of tissue damage, in other words, you have more joint pain than you should and progresses inconsistently over time), or generalized, as in pure autonomic failure (body pain from a disorder of widening and narrowing of blood vessels). It can be acute and reversible, as in Guillain-Barre syndrome (your immune system attacks your nerves), or chronic and progressive. Several common conditions such as diabetes and alcoholism can include dysautonomia. Dysautonomia also can occur as a primary condition or in association with degenerative neurological diseases such as Parkinson’s disease. Other diseases with generalized, primary dysautonomia include multiple system atrophy and familial dysautonomia. Hallmarks of generalized dysautonomia due to sympathetic failure are impotence (in men) and a fall in blood pressure during standing (orthostatic hypotension). Excessive sympathetic activity can present as hypertension or a rapid pulse rate.”

Dysautonomias – Cervical Sympathetic Syndromes

It is well known that cervical instability is associated with a myriad of medical conditions and syndromes. One could even say that a lot of the headache pain from cervical instability is from dysautonomia. The major symptoms in the syndromes and disorders overlap and are from the same etiology. Thus, these symptoms are continuums of the same condition: cervical spinal instability and its effect on the autonomic nervous system. As the cervical instability worsens, the more likely the autonomic nervous system is going to be involved in the complex symptomatology that develops.

As we have discussed, the cervical area is a very important and sensitive section of the body, as it protects parts of the brain stem and spinal cord, provides rotational flexibility, and allows for other body functions to work properly. Damage to the cervical vertebrae and their ligaments can cause many more problems than just pain in the neck. The close proximity of C1 and C2 to the brain stem, spinal cord and autonomic nerve centers can lead to blocked neural signals and cause systematic problems throughout the body.

Cervical sympathetic syndromes, known as dysautonomias, are a common manifestation of cervical instability. I would even say they are the most common. Anyone with symptoms suggestive of dysautonomia should consider getting an evaluation of cervical instability, especially for upper cervical instability, because if it is found, the condition is very treatable. Since, like many cervical syndromes, traditional medicine often considers dysautonomias to be idiopathic, symptom control is the mainstay treatment option versus cure. But it doesn’t have to be.

In this video, Ross Hauser, MD offers an explanation and understanding of autonomic nervous system dysfunction.

Dysautonomias, or dysfunction of the autonomic nervous system, are responsible for many of the usual or bizarre symptoms from cervical instability. For a detailed explanation of this video and summary transcript please see my article: Neurologic, digestive, cardiac, and bladder disorders: Some of the symptoms of Autonomic nervous system dysfunction and treatment options.

The stories of people

We often receive emails with the medical journeys people have taken. They go like this:

My MRI shows c1 & c2 degeneration. I am severely sick with dysautonomia, pots, my bowels have stopped moving, Small intestinal bacterial overgrowth, I’ve been treated for Lyme Disease, mold allergy and sensitivity, I am still sick, I have neck pain and excruciating headaches and ringing in my ears. I am a mess, I have adrenal insufficiency, severe food, and environmental allergies. No doctors I have seen can figure out what it is all coming from. I believe it is the cervical cranial nerve and have considered cervical fusion.  

The symptoms of dysautonomias are numerous and sometimes bizarre. The arms or legs can be characterized by feelings of pins and needles, tingling, numbness, and pinching that can affect all fingers or toes or be localized to only some of them. These symptoms are called acroparesthesias and can be felt on one side of the body or on both sides. All of an extremity or only part of an arm, hand, the shoulder can feel cold or cool and when actually felt compared to the non-symptomatic side it actually does feel colder because it is.

Dysautonomia can also cause the skin to become extremely sensitive to touch. A physical examination technique called pinch rolling can cause pain. The skin, subcutaneous fat, and fascia are held between the thumb and index finger and pinched and rolled. When this causes pain it is called cellulalgia. Some people with dysautonomia will get itchy or red skin for no apparent reason.

For more information on these problems see my companion articles: Tactile hallucinations and Formication: Strange skin sensations including insects crawling on your skin, and,
Skin Pain, Hot and Cold Skin: Are fixing upper cervical neck instability problems the missing treatment?

Another symptom of dysautonomia includes exercise intolerance due to an inability to alter heart rate and regulate the cardiovascular system. Excessive or insufficient sweating is a problem due to problems regulating temperature. Slow digestion causes nausea, loss of appetite, bloating, diarrhea or constipation, gastroparesis, other digestive problems, and difficulty swallowing. Urinary problems can include difficulty starting urination, incontinence, and incomplete emptying of the bladder. Problems with vision include blurry vision or the failure of the pupils to react quickly enough to changes in light.

A very common problem is the person feels “off.” Upon further examination, it is clear that their position sense and balance are off. Sometimes they say, “It feels like my head is too heavy for my neck.” Lying down feels the best but as activity increases from sitting up to walking to moving the head too quickly, then dizziness or even vertigo can occur. It is important to know that most of the receptors that control head and neck balance, position, and motion sense are in the neck.

Almost any symptom possible in human disease or for that matter, any human disease itself can be caused by an abnormality of the autonomic nervous system, and the most common structural cause of dysautonomia is cervical instability, especially upper cervical instability.

Fatigue, abnormal breathing patterns, dyspnea, vertigo, syncope, gait problems, hypoglycemia, anxiety, insomnia/non-restorative sleep, and peripheral paresthesias—any or all of these symptoms may be present in varying degrees of severity with dysautonomias. Likewise, symptoms such as dizziness, heart palpitations, speech and swallowing difficulties, changes in vision, runny nose and eyes, breathing, and digestive problems can also occur for no obvious reason. Immunodeficiency or immune system problems can even occur because the autonomic nervous system is involved with every tissue and cell of the human body. When you combine these types of symptoms with a person who has cracking in the joint(s) with movement, tenderness where ligaments and tendons attach, and other signs and symptoms of joint instability, it should be assumed that many or all of the symptoms the person has is from the joint instability causing dysautonomia.

Dysautonomia and long-COVID syndrome?

We are contacted by people, diagnosed with long-COVID symptoms, previously treated for neck instability problems, who have some degree of confusion about their symptoms of Long-haul COVID neck injuries. Is it long-COVID? Was the infection a cause of their worsening symptoms?

A September 2022 study from the Department of Neurology, State University of New York, Upstate Medical University, Syracuse writes: “The association between dysautonomia and long-COVID syndrome has gained considerable interest.” This study examined the findings of autonomic reflex screen (ARS) in long-COVID patients presenting with orthostatic intolerance.

Fourteen patients were identified. All patients had normal cardiovagal function and 2 patients had abnormal sudomotor function. (abnormal control of sweat gland activity). “The head-up tilt table (HUTT) was significantly abnormal in 3 patients showing postural orthostatic tachycardia syndrome (POTS).  . . The most common clinical scenario was symptoms of orthostatic intolerance (the inability to stand upright without symptoms) without demonstrable head-up tilt table (HUTT) orthostatic tachycardia or orthostatic hypotension. The researchers showed this was a symptom of long-COVID. It is also a symptom of cervical spine instability.

What we hear from some people are the challenges they face with this combined diagnosis: These emails have been edited for clarity.

“Chronic neck pain and stiffness, migraine headaches, muscle spasms in neck and back, acid reflux, vision issues, tinnitus, light and sound sensitivity. Suffered neck injury more than 30 years ago. Treated over the years with just about everything possible short of surgery. Imaging early on showed some minor disc bulging and reversal of normal lordosis in cervical spine. Surgeons have said surgery has a 50/50 chance of making it better or making it worse.

I had Covid-19 a few months ago and my neck/headache pain and stiffness issues have spiked over the past month. I am not sure if that is related or not. I’ve been doing acupuncture which has helped with mobility. But the headaches and neck pain have been severe again.”

Two years since COVID infection

“I have had multiple head injuries in the past while playing professional sport. I have suspected vagus nerve damage as I have been diagnosed with an overactive bladder, hyperventilation and anxiety. I am now suffering with long COVID, severe fatigue, some brain fog and tinnitus.”

Cervical instability causing dysautonomia

The autonomic nervous system (ANS) is made up of nerves that control the automatic functions throughout the body. It is the master regulator, controlling heart rate, blood pressure, temperature, respiration, sweating, digestion, and other vital functions. These systems operate without consciously thinking about them because the ANS provides the connection between them and the brain. The autonomic nervous system is a complex neural network that maintains internal physiologic homeostasis. This network controls everything in the body that happens automatically and includes cardiovascular, thermoregulatory, gastrointestinal, genitourinary, and ophthalmological functions.

As discussed previously, the autonomic nervous system has two branches, the sympathetic and parasympathetic nervous systems, which are responsible for the control of vital signs including blood pressure, pulse, and respiration; control of body temperature; control of immune function; digestion; swallowing; vision; and everything else in the body that happens automatically.

The autonomic nervous system handles basically everything in the body to keep us at homeostasis or health. For instance, when it is cold outside, your body automatically constricts blood vessels in your periphery to direct blood flow to your core body, so your body temperature stays up. You may start to shiver to achieve the same effect. When it is sunny outside and you start to overheat, the autonomic nervous system is activated and dilates the blood vessels in the periphery to activate sweating to cool the body off.

Under normal circumstances, the cervical sympathetic trunk, which is intricately involved in everything related to the head, neck, face, and homeostasis of the human condition, contains 3-4 ganglia including the superior, middle (sometimes two of them), and inferior cervical/cervicothoracic ganglia. All of these are connected and lie right next to the anterior cervical vertebrae.

Even more intriguing is the fact that the nerve that controls basically all parasympathetic nervous system function is also right near the anterior cervical vertebrae: the vagus nerve. The vagus nerve is most important nerve in the body for helping the body enjoy homeostasis, health, and harmony. The two parts of the ANS, sympathetic and parasympathetic, have to work in unison, if one takes control of the body over the other, disease, disorder, and degeneration will occur.

What are we seeing in this image?

The caption of the illustration reads:

The cervical sympathetic and the continuation of autonomic fibers to effectors in the head. Simply, In the autonomic nervous system, nerve fibers or preganglionic fibers, connect the central nervous system to the nerve ganglia. It is a communication highway from brain to body.

In the illustration, we ask you to note the relationship of the superior cervical ganglion to the Vagus and glossopharyngeal cranial nerves and the internal carotid artery. This is because of the various communications between these structures. We also asked you to pay attention to the Gray (not white) rami communicates course from the cervical chain to the cervical spinal nerves. Understanding Dysautonomia may lie in an understanding of nerve impulses. The grey and white rami communicantes are as they are described. They communicate nerve impulses. They are colorized by the amount of myelinated nerve fibers. Myelinated (simply insulated with fat) nerve fibers contain myelin insulation. There are more myelinated than unmyelinated fibres in the white rami communicantes while the opposite is true for the grey rami communicantes. What does that mean? White impulses move faster than the gray impulses because of the myelinated (better communication insulated by the fatty sheath). Why were you built this way? The Gray rami simply move up and down the spine conveying messages. Once the spine wants to send a message to the brain the impulse moves over from gray to white rami. It is at this point because the brain needs messages to be delivered as fast as possible, that the impulse will then travel the white faster route. The problem is the messages coming from the gray rami communicate. Since it does not have insulation, these messages can be distorted or corrupted. The problems of Dysautonomia begin.

The dynamic ANS testing at The Hauser Neck Center attempts to solve the following mysteries concerning why your nervous system is not working properly:

1. Is it truly a sympathetic dominance/parasympathetic (vagal tone) deficiency?
2. What is the major cause of it?
3. How much of the problem is due to neck instability?  Reversal of the cervical curve? Emotional baggage/negative self-talk/toxic relationships? Harmful visual stimuli? Other harmful/destructive stimuli?
4. Are there actions you can take to help restore ANS homeostasis and improve vagal tone?

The major causes of dysautonomia, vagopathy and autonomic nervous system imbalances can be broken down into two camps:  structural and/or systemic causes.  As I have asked patients who have a complex medical history of 10+ different disorders, Do you really think it’s these numerous individual disorders causing your dizziness, light and sound sensitivity, change in voice quality, irritable bowel, nausea, dizziness, ringing in your ears, ear fullness, blurry vision, itching, poor body temperature control, brain fog, choking sensations, depression, anxiety, inability to focus and other symptoms or just one.

Once the body’s nerve supply to the vital organs and brain is off, the body’s homeostatic mechanisms for survival start to fail. This ultimately leads to a breakdown of pulse and blood pressure control, digestion, endocrine gland secretion, circulation, temperature regulation, immune function and as well as proper balance, hearing, vision, taste, speech and ultimately brain function. Once brain function starts plummeting, any symptomatology is possible, including headaches, head pressure, poor vision, inability to concentrate, overwhelming fatigue, brain fog, depression, anxiety, panic disorder and a myriad of other horrible consequences.

In our office, we can take a baseline ANS function in a relaxed position, then a person is put through a variety of physical maneuvers starting with various neck positions to see the effect neck position and thus stressors on neck ligaments and nerve centers in the neck has on ANS function. We do a lot of work with heart rate variability (HRV) which is an excellent ANS marker. The person is put through a variety of stressors depending on the persons history to assess each stressor and its effect on their ANS. The amount of change from baseline is then calculated.  This change from baseline and the time it takes for a person to get back to baseline is an indicator of the magnitude of the effects those stressors had on the ANS. Ultimately, the person is given “homework” to use what they have learned to improve their vagal tone and ANS functioning.

Summary

The hallmark feature of dysautonomia is dysfunction of the vagus nerve. The most common symptoms of vagus nerve dysfunction include chronic pain, fatigue, dizziness, lightheadedness, spinning or pulling sensation (in a particular direction), weight loss, poor focusing, exercise intolerance, emotional lability, inflammation, heartburn, bloating, diarrhea, tinnitus, headache, anxiety, depression, brain fog, swallowing difficulty, vision changes, and inability to handle stress well.

One clue that there is a neck cause to a person’s dysautonomia is when turning of the head or facial movements such as laughing, chewing or speaking cause what we term ‘episymptoms’, which are symptoms that are manifested by activities that don’t normally cause those symptoms, such as flushing, sweating, temperature dysregulation, headaches, vision changes, electric shocks, palpitations, tachycardia or other autonomic symptoms. Signs include changes in blood pressure, impaired thermoregulation, fatigue, changes in mental state (such as increase in stress or lightheadedness), dilated pupils, uvula deviation to one side, an inability of the palate to raise normally, decreased gag reflex, and dilated pupils. Many of these are signs of vagopathy.

The primary reason patients are seen at our Neck Center is to receive Comprehensive Prolotherapy and curve correction in order to restore function of the brain and vagus nerves. As we say, 50% is us, and 50% is you. Therefore, doing everything possible to better understand what is working against your healing, and how to mediate those things, is paramount to see significant long-term improvement.

Injections and Cervical Spine Curve Correction

At our center, we offer non-surgical options for the treatment of the various disorders described above.

When instability is the primary structural issue, Prolotherapy injections to tighten the ligaments are started. Digital motion x-ray is then utilized to measure the amount of stabilization obtained.

Published research papers from our doctors at Caring Medical on Cervical Spine Instability and related symptoms

• 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]

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

References

1 Dysautonomia Information Page and the National Institutes of Health.

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• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.