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Browne CJ, Sheeba SR, Astill T, Baily A, Deblieck C, Mucci V, Cavaleri R. Assessing the synergistic effectiveness of intermittent theta burst stimulation and the vestibular ocular reflex rehabilitation protocol in the treatment of Mal de Debarquement Syndrome: a randomised controlled trial. J Neurol 2024; 271:2615-2630. [PMID: 38345630 PMCID: PMC11055743 DOI: 10.1007/s00415-024-12215-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Mal de Debarquement Syndrome (MdDS) is a rare central vestibular disorder characterised by a constant sensation of motion (rocking, swaying, bobbing), which typically arises after motion experiences (e.g. sea, air, and road travel), though can be triggered by non-motion events. The current standard of care is non-specific medications and interventions that only result in mild-to-moderate improvements. The vestibular ocular reflex (VOR) rehabilitation protocol, a specialised form of rehabilitation, has shown promising results in reducing symptoms amongst people with MdDS. Accumulating evidence suggests that it may be possible to augment the effects of VOR rehabilitation via non-invasive brain stimulation protocols, such as theta burst stimulation (TBS). METHODS The aim of this randomised controlled trial was to evaluate the effectiveness of intermittent TBS (iTBS) over the dorsolateral prefrontal cortex in enhancing the effectiveness of a subsequently delivered VOR rehabilitation protocol in people with MdDS. Participants were allocated randomly to receive either Sham (n = 10) or Active (n = 10) iTBS, followed by the VOR rehabilitation protocol. Subjective outcome measures (symptom ratings and mental health scores) were collected 1 week pre-treatment and for 16 weeks post-treatment. Posturography (objective outcome) was recorded each day of the treatment week. RESULTS Significant improvements in subjective and objective outcomes were reported across both treatment groups over time, but no between-group differences were observed. DISCUSSION These findings support the effectiveness of the VOR rehabilitation protocol in reducing MdDS symptoms. Further research into iTBS is required to elucidate whether the treatment has a role in the management of MdDS. TRN: ACTRN12619001519145 (Date registered: 04 November 2019).
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Affiliation(s)
- Cherylea J Browne
- School of Science, Western Sydney University, Sydney, NSW, Australia.
- Brain Stimulation and Rehabilitation (BrainStAR) Laboratory, Western Sydney University, Sydney, NSW, Australia.
- Translational Neuroscience Facility, School of Medical Sciences, UNSW Sydney, Sydney, NSW, Australia.
- Western Sydney University, Translational Health and Research Institute, Sydney, NSW, Australia.
| | - S R Sheeba
- School of Science, Western Sydney University, Sydney, NSW, Australia
- Brain Stimulation and Rehabilitation (BrainStAR) Laboratory, Western Sydney University, Sydney, NSW, Australia
| | - T Astill
- Brain Stimulation and Rehabilitation (BrainStAR) Laboratory, Western Sydney University, Sydney, NSW, Australia
- School of Health Sciences, Western Sydney University, Sydney, NSW, Australia
| | - A Baily
- School of Health Sciences, Western Sydney University, Sydney, NSW, Australia
| | - C Deblieck
- Laboratory of Equilibrium Investigations and Aerospace (LEIA), University of Antwerp, Antwerp, Belgium
| | - V Mucci
- School of Science, Western Sydney University, Sydney, NSW, Australia
| | - R Cavaleri
- Brain Stimulation and Rehabilitation (BrainStAR) Laboratory, Western Sydney University, Sydney, NSW, Australia
- Western Sydney University, Translational Health and Research Institute, Sydney, NSW, Australia
- School of Health Sciences, Western Sydney University, Sydney, NSW, Australia
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Schoenmaekers C, Jillings S, De Laet C, Zarowski A, Wuyts FL. Guideline for standardized approach in the treatment of the Mal de Debarquement syndrome. Front Neurol 2024; 15:1359116. [PMID: 38566854 PMCID: PMC10985174 DOI: 10.3389/fneur.2024.1359116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/15/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction Mal de Debarquement Syndrome (MdDS) is a debilitating neuro-otological disorder. Patients experience almost continuously a perception of self-motion. This syndrome can be motion-triggered (MT-MdDS), such as on a boat, or occur spontaneously or have other triggers (SO-MdDS) in the absence of such motion. Because the pathophysiological mechanism is unknown, treatment options and symptom management strategies are limited. One available treatment protocol involves a readaptation of the vestibular ocular reflex (VOR). This study assesses the effectiveness of vestibulo-ocular reflex (VOR) readaptation in 131 consecutive patients with a fixed protocol. Methods We administered 131 treatments involving optokinetic stimulation (OKS) paired with a fixed head roll at 0.167 Hz over two to five consecutive days. Each day, four-minute treatment blocks were scheduled twice in the morning and afternoon. Treatment effectiveness was evaluated through questionnaires and posturography. Results We observed significant improvements in the visual analog scale (VAS), MdDS symptom questionnaire, and posturography measures from pre- to post-treatment. No significant differences were found in outcome variables between MT- and SO-MdDS onsets. Conclusion Symptoms improved subjectively and objectively in patients' post-treatment. The overall success rate was 64.1%, with no significant difference between MT (64.2%) and SO (63.3%). This study supports the conclusion that VOR readaptation treatment provides relief for two-thirds of MdDS patients, irrespective of the onset type. Based on consistency in the findings, we propose a standardized method for treatment of MdDS based on the OKS with head roll paradigm.
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Affiliation(s)
- Catho Schoenmaekers
- Lab for Equilibrium Investigations and Aerospace, University of Antwerp, Wilrijk, Belgium
| | - Steven Jillings
- Lab for Equilibrium Investigations and Aerospace, University of Antwerp, Wilrijk, Belgium
| | - Chloë De Laet
- Lab for Equilibrium Investigations and Aerospace, University of Antwerp, Wilrijk, Belgium
| | - Andrzej Zarowski
- European Institute for ORL-HNS, Sint-Augustinus Hospital, Wilrijk, Belgium
| | - Floris L. Wuyts
- Lab for Equilibrium Investigations and Aerospace, University of Antwerp, Wilrijk, Belgium
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Maruta J, Cho C, Raphan T, Yakushin SB. Symptom reduction in mal de débarquement syndrome with attenuation of the velocity storage contribution in the central vestibular pathways. FRONTIERS IN REHABILITATION SCIENCES 2024; 5:1331135. [PMID: 38486679 PMCID: PMC10937418 DOI: 10.3389/fresc.2024.1331135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/19/2024] [Indexed: 03/17/2024]
Abstract
Background The velocity storage mechanism of the central vestibular system is closely associated with the vestibulo-ocular reflex (VOR), but also contributes to the sense of orientation in space and the perception of self-motion. We postulate that mal de débarquement syndrome (MdDS) is a consequence of inappropriate sensory adaptation of velocity storage. The premise that a maladapted velocity storage may be corrected by spatial readaptation of the VOR has recently been translated into the development of the first effective treatment for MdDS. However, this treatment's initial impact may be reversed by subsequent re-triggering events. Presently, we hypothesized that MdDS symptoms could alternatively be reduced by attenuating the velocity storage contribution in the central vestibular pathways. Methods Forty-three patients with MdDS (aged 47 ± 14 yo; 36 women) were randomly assigned to two treatment groups and followed for 6 months. The horizontal VOR was tested with chair rotation during laboratory visits, and the strength of velocity storage was quantified with model-based parameters-the time constant (Tc) and the gain of coupling from the vestibular primary afferent signals (g0). To attenuate velocity storage, Group 1 underwent a progressively intensifying series of low-frequency earth-vertical oscillatory rotation coupled to conflicting visual stimuli. Group 2 underwent an established protocol combining head tilts and visual stimulation, designed to correct maladapted spatial orientation but not change the velocity storage strength. The symptom severity was self-rated on an 11-point scale and reported before and up to 6 months after the treatment. Results In Group 1, velocity storage was modified through reduction of g0 (p < 0.001) but not Tc. The symptom rating was at least halved initially in 43% of Group 1 (p = 0.04), the majority of whom retained a similar level of improvement during the 6-month follow-up period. In Group 2, no systematic change was induced in the parameters of velocity storage strength, as expected. The symptom rating was at least halved initially in 80% of Group 2 (p < 0.001), but paralleling previous findings, symptoms often returned subsequently. Conclusion Attenuation of velocity storage shows promise as a lasting remedy for MdDS that can complement the VOR readaptation approach.
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Affiliation(s)
- Jun Maruta
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Catherine Cho
- Department of Neurology, NYU Langone Medical Center, New York, NY, United States
- Department of Otolaryngology, NYU Langone Medical Center, New York, NY, United States
| | - Theodore Raphan
- Department of Computer and Information Science, Brooklyn College, Institute for Neural and Intelligent Systems, New York, NY, United States
- The Graduate School and University Center of the City University of New York, New York, NY, United States
| | - Sergei B. Yakushin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Maruta J, Yakushin SB, Cho C. Creating Informed Interest in Mal De Débarquement Syndrome. Prim Care Companion CNS Disord 2023; 25:23lr03518. [PMID: 37471494 PMCID: PMC10543159 DOI: 10.4088/pcc.23lr03518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Affiliation(s)
- Jun Maruta
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York
- Corresponding Author: Jun Maruta, PhD, Department of Neurology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029
| | - Sergei B Yakushin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York
| | - Catherine Cho
- Department of Neurology, NYU Langone Medical Center, New York
- Department of Otolaryngology, NYU Langone Medical Center, New York
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Kinkhabwala CM, Yuen E, Brennan E, Cadena A, Rizk HG. Treatment Options in Mal de Débarquement Syndrome: A Scoping Review. Otol Neurotol 2023; 44:e197-e203. [PMID: 36791362 DOI: 10.1097/mao.0000000000003832] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
OBJECTIVE The purpose of this study was to review current treatment options available for mal de debarquement syndrome (MdDS). DATA SOURCES Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review guidelines, we performed systematic search queries for MdDS-related texts. Documents must have been in the English language, and the time frame was all documents up until May 23, 2022. METHODS Studies were selected if they were published in a peer-reviewed journal and if one of the primary objectives was the assessment of treatment for MdDS. The quality and validity of all documents were assessed by two independent co-investigators. Conflicts were resolved by a third investigator. RESULTS One hundred ninety-four unique references were identified and underwent review. Ninety-seven were selected for full-text review, and 32 studies were ultimately included. Data were stratified by treatment methodology for MdDS. The categories used were pharmacologic, physical therapy, and neuromodulating stimulation. CONCLUSIONS Improvement in patient-reported outcomes is reported with several treatment modalities including specific protocols of vestibular rehabilitation, neuromodulating stimulation, and pharmacologic management with several types of neurotropic drugs.
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Affiliation(s)
| | - Erick Yuen
- Department of Otolaryngology-Head and Neck Surgery
| | | | - Angel Cadena
- Department of Neurology, Charleston, Medical University of South Carolina, Charleston, South Carolina
| | - Habib G Rizk
- Department of Otolaryngology-Head and Neck Surgery
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Maruta J. Lasting alteration of spatial orientation induced by passive motion in rabbits and its possible relevance to mal de débarquement syndrome. Front Neurol 2023; 14:1110298. [PMID: 36908625 PMCID: PMC9994528 DOI: 10.3389/fneur.2023.1110298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/30/2023] [Indexed: 02/24/2023] Open
Abstract
Background Mal de débarquement syndrome (MdDS) is a chronic disorder of spatial orientation with a persistent false sensation of self-motion, whose onset typically follows prolonged exposure to passive motion of a transport vehicle. Development of similar but transient after-sensations mimicking the exposed motion and associated postural instability, indicative of central vestibular adaptation, are common. The cause of MdDS is thought to be a subsequent failure to readapt to a stationary environment. However, vestibular plasticity pertinent to this illness has not been studied sufficiently. Because the rabbit's eye movement is sensitive to three-dimensional spatial orientation, characterizing maladaptation of the vestibulo-ocular reflex (VOR) induced in the animal may open an approach to understanding MdDS. Methods Three rabbits underwent a series of 2-h conditioning with an unnatural repetitive motion that involved a complex combination of roll, pitch, and yaw movements in a head-based reference frame, consisting of periodic rolling in darkness in a frame of reference that rotated about an earth-vertical axis. Eye movement in three dimensions was sampled during the conditioning stimulus as well as during test stimuli before and up to several days after conditioning. Results During roll-while-rotating conditioning, the roll component of the VOR was compensatory to the oscillation about the corresponding axis, but the pitch component was not, initially prominently phase-leading the head pitch motion but subsequently becoming patently phase-delayed. Unidirectional yaw nystagmus, weak but directionally compensatory to the earth-vertical axis rotation, was seen throughout the period of conditioning. After conditioning, simple side-to-side rolling induced an abnormal yaw ocular drift in the direction that opposed the nystagmus seen during conditioning, indicating a maladaptive change in spatial orientation. The impact of conditioning appeared to be partially retained even after 1 week and could be partially reversed or cumulated depending on the rotation direction in the subsequent conditioning. Conclusion The observed reversible long-term maladaptation of spatial orientation as well as the depth of knowledge available in relation to the vestibular cerebellar circuits in this species support the potential utility of a rabbit model in MdDS research.
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Affiliation(s)
- Jun Maruta
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Browne CJ, Fahey P, Sheeba SR, Sharpe MH, Rosner M, Feinberg D, Mucci V. Visual disorders and mal de debarquement syndrome: a potential comorbidity questionnaire-based study. Future Sci OA 2022; 8:FSO813. [PMID: 36248065 PMCID: PMC9540399 DOI: 10.2144/fsoa-2022-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/31/2022] [Indexed: 11/23/2022] Open
Abstract
Aim: Mal de debarquement syndrome (MdDS) is a neurological condition characterized by a constant sensation of self-motion; onset may be motion-triggered (MT) or non-motion-triggered/spontaneous (NMT/SO). People with MdDS experience similar symptoms to those with vertical heterophoria, a subset of binocular visual dysfunction. Hence, we aimed to explore potential visual symptom overlaps. Methods: MdDS patients (n = 196) and controls (n = 197) completed a visual health questionnaire. Results: Compared with controls, the MdDS group demonstrated higher visual disorder scores and visual complaints. NMT/SO participants reported unique visual symptoms and a higher prevalence of mild traumatic brain injury. Conclusion: Our findings suggest visual disorders may coexist with MdDS, particularly the NMT/SO subtype. The difference in visual dysfunction frequency and medical histories between subtypes, warrants further investigation into differing pathophysiological mechanisms.
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Affiliation(s)
- Cherylea J Browne
- School of Science, Western Sydney University, Sydney, NSW 2560, Australia
- Translational Neuroscience Facility (TNF), School of Medical Sciences, UNSW Sydney, NSW, 2033, Australia
- Brain Stimulation and Rehabilitation (BrainStAR) Lab, School of Health Sciences, Western Sydney University, Sydney, NSW, 2560, Australia
| | - Paul Fahey
- School of Health Sciences, Western Sydney University, Sydney, NSW, 2560, Australia
| | - Stella R Sheeba
- School of Science, Western Sydney University, Sydney, NSW 2560, Australia
- Brain Stimulation and Rehabilitation (BrainStAR) Lab, School of Health Sciences, Western Sydney University, Sydney, NSW, 2560, Australia
| | - Margie H Sharpe
- Dizziness & Balance Disorders Center, Adelaide, SA, 5000, Australia
| | - Mark Rosner
- NeuroVisual Medicine Institute, Bloomfield Hills, MI 48302, USA
| | - Debby Feinberg
- NeuroVisual Medicine Institute, Bloomfield Hills, MI 48302, USA
| | - Viviana Mucci
- School of Science, Western Sydney University, Sydney, NSW 2560, Australia
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Cha YH. Update on Therapies for Mal de Débarquement Syndrome. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00735-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hojnacki M. Treatment of Mal de Debarquement Syndrome in an Audiology-Vestibular Clinic. J Am Acad Audiol 2022; 33:364-370. [PMID: 36323329 DOI: 10.1055/s-0042-1757769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND Mal de Debarquement Syndrome (MdDS) has a stereotypical presentation of symptoms including continuous rocking/swaying sensations described as feeling like one is "still on the boat," following travel, especially on water vessels. MdDS is even more notorious for the duration of symptoms that can persist months or years, and historically this condition has escaped effective treatments. PURPOSE This case study presents a case of classic MdDS that was effectively treated in an Audiology-Vestibular clinic. Treatment consisted of three, relatively short-lived vestibular rehabilitation sessions using the "Roll Readaptation" technique that has previously been reported in Neurology journals. STUDY SAMPLE The study sample includes a 48-year-old female with a history of MdDS following two separate ocean cruises. She underwent vestibular evaluation and was treated with a treatment paradigm aimed to readapt the central vestibular system and vestibular-ocular reflex. RESULTS This report focuses on a brief review of current symptomology and diagnostic criteria of MdDS, underlying pathophysiology and application of a relatively new treatment technique in an audiology clinic. This patient was shown full-field, omni-directional optokinetic (OPK) stimulus while rolling her head rhythmically for up to 4 minutes at a time. After three treatment sessions, the patient had a significant reduction in subjective symptoms and returned to full-time work. She had previously been off work for nearly 3 months. CONCLUSION Individuals with MdDS suffer large daily and work life disruptions due to the persistent nature of symptoms, and their physical manifestations. In addition, they have historically had minimal treatment options. This case demonstrates that audiologists with proper equipment may have the potential to readily offer treatment for a previously "untreatable" condition.
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Affiliation(s)
- Mike Hojnacki
- Spectrum Health Balance Center, Grand Rapids, Michigan
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Yakushin SB, Raphan T, Cho C. Treatment of Gravitational Pulling Sensation in Patients With Mal de Debarquement Syndrome (MdDS): A Model-Based Approach. Front Integr Neurosci 2022; 16:801817. [PMID: 35676926 PMCID: PMC9168314 DOI: 10.3389/fnint.2022.801817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 04/06/2022] [Indexed: 11/13/2022] Open
Abstract
Perception of the spatial vertical is important for maintaining and stabilizing vertical posture during body motion. The velocity storage pathway of vestibulo-ocular reflex (VOR), which integrates vestibular, optokinetic, and proprioception in the vestibular nuclei vestibular-only (VO) neurons, has spatio-temporal properties that are defined by eigenvalues and eigenvectors of its system matrix. The yaw, pitch and roll eigenvectors are normally aligned with the spatial vertical and corresponding head axes. Misalignment of the roll eigenvector with the head axes was hypothesized to be an important contributor to the oscillating vertigo during MdDS. Based on this, a treatment protocol was developed using simultaneous horizontal opto-kinetic stimulation and head roll (OKS-VOR). This protocol was not effective in alleviating the MdDS pulling sensations. A model was developed, which shows how maladaptation of the yaw eigenvector relative to the head yaw, either forward, back, or side down, could be responsible for the pulling sensation that subjects experience. The model predicted the sometimes counter-intuitive OKS directions that would be most effective in re-adapting the yaw eigenvector to alleviate the pulling sensation in MdDS. Model predictions were consistent with the treatment of 50 patients with a gravitational pulling sensation as the dominant feature. Overall, pulling symptoms in 72% of patients were immediately alleviated after the treatment and lasted for 3 years after the treatment in 58% of patients. The treatment also alleviated the pulling sensation in patients where pulling was not the dominant feature. Thus, the OKS method has a long-lasting effect comparable to that of OKS-VOR readaptation. The study elucidates how the spatio-temporal organization of velocity storage stabilizes upright posture and how maladaptation of the yaw eigenvector generates MdDS pulling sensations. Thus, this study introduces a new way to treat gravitational pull which could be used alone or in combination with previously proposed VOR readaptation techniques.
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Affiliation(s)
- Sergei B. Yakushin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- *Correspondence: Theodore Raphan,
| | - Theodore Raphan
- Institute for Neural and Intelligent Systems, Department of Computer and Information Science, Brooklyn College of the City University of New York, Brooklyn, NY, United States
- Department of Computer Science, Graduate Center of CUNY, New York, NY, United States
- Ph.D Program in Psychology and Neuroscience, Graduate Center of CUNY, New York, NY, United States
- Sergei B. Yakushin,
| | - Catherine Cho
- Department Neurology and Otolaryngology, NYU Robert I. Grossman School of Medicine, New York, NY, United States
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Hoppes CW, Vernon M, Morrell RL, Whitney SL. Treatment of Mal de Debarquement Syndrome in a Computer-Assisted Rehabilitation Environment. Mil Med 2021; 187:e1011-e1015. [PMID: 33604663 DOI: 10.1093/milmed/usab077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/29/2021] [Accepted: 02/09/2021] [Indexed: 11/13/2022] Open
Abstract
Individuals with mal de debarquement syndrome (MdDS) describe symptoms of swaying, rocking, and/or bobbing after sea or air travel. These symptoms may be because of maladaptation of the vestibulo-ocular reflex (VOR) to roll of the head during rotation. Dai and colleagues have developed a treatment paradigm that involves passive roll of the patient's head while watching optokinetic stripes, resulting in adaption of the VOR and improvement of MdDS. The purpose of this case report is to describe replication of this treatment paradigm in a virtual reality environment with successful resolution of symptoms in two visits. A 39-year-old female reported swaying and rocking after returning from a 7-day cruise. The patient was treated with two sessions in a computer-assisted rehabilitation environment (CAREN). The patient canceled her third visit because of complete resolution of her symptoms. Her Global Rating of Change was +7 (on a 15-point scale of -7 to +7). She had returned to her prior level of function. This case report is the first to describe use of the CAREN for effective treatment of MdDS by replicating the treatment paradigm developed by Dai and colleagues.
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Affiliation(s)
- Carrie W Hoppes
- U.S. Army Medical Center of Excellence, Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, TX 78234, USA
| | - Michael Vernon
- Center for the Intrepid, Department of Rehabilitation Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Rebecca L Morrell
- Physical Therapy Services, Department of Rehabilitation Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Susan L Whitney
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA 15219, USA
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Mucci V, Indovina I, Browne CJ, Blanchini F, Giordano G, Marinelli L, Burlando B. Mal de Debarquement Syndrome: A Matter of Loops? Front Neurol 2020; 11:576860. [PMID: 33244308 PMCID: PMC7683778 DOI: 10.3389/fneur.2020.576860] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 10/05/2020] [Indexed: 12/30/2022] Open
Abstract
Introduction: Mal de Debarquement Syndrome (MdDS) is a poorly understood neurological disorder affecting mostly perimenopausal women. MdDS has been hypothesized to be a maladaptation of the vestibulo-ocular reflex, a neuroplasticity disorder, and a consequence of neurochemical imbalances and hormonal changes. Our hypothesis considers elements from these theories, but presents a novel approach based on the analysis of functional loops, according to Systems and Control Theory. Hypothesis: MdDS is characterized by a persistent sensation of self-motion, usually occurring after sea travels. We assume the existence of a neuronal mechanism acting as an oscillator, i.e., an adaptive internal model, that may be able to cancel a sinusoidal disturbance of posture experienced aboard, due to wave motion. Thereafter, we identify this mechanism as a multi-loop neural network that spans between vestibular nuclei and the flocculonodular lobe of the cerebellum. We demonstrate that this loop system has a tendency to oscillate, which increases with increasing strength of neuronal connections. Therefore, we hypothesize that synaptic plasticity, specifically long-term potentiation, may play a role in making these oscillations poorly damped. Finally, we assume that the neuromodulator Calcitonin Gene-Related Peptide, which is modulated in perimenopausal women, exacerbates this process thus rendering the transition irreversible and consequently leading to MdDS. Conclusion and Validation: The concept of an oscillator that becomes noxiously permanent can be used as a model for MdDS, given a high correlation between patients with MdDS and sea travels involving undulating passive motion, and an alleviation of symptoms when patients are re-exposed to similar passive motion. The mechanism could be further investigated utilizing posturography tests to evaluate if subjective perception of motion matches with objective postural instability. Neurochemical imbalances that would render individuals more susceptible to developing MdDS could be investigated through hormonal profile screening. Alterations in the connections between vestibular nuclei and cerebellum, notably GABAergic fibers, could be explored by neuroimaging techniques as well as transcranial magnetic stimulation. If our hypothesis were tested and verified, optimal targets for MdDS treatment could be found within both the neural networks and biochemical factors that are deemed to play a fundamental role in loop functioning and synaptic plasticity.
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Affiliation(s)
- Viviana Mucci
- School of Science, Western Sydney University, Penrith, NSW, Australia.,Laboratory of Neuromotor Physiology, Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Santa Lucia, Rome, Italy
| | - Iole Indovina
- Laboratory of Neuromotor Physiology, Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Santa Lucia, Rome, Italy.,Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Cherylea J Browne
- School of Science, Western Sydney University, Penrith, NSW, Australia.,Translational Neuroscience Facility, School of Medical Sciences, UNSW Sydney, Sydney, NSW, Australia
| | - Franco Blanchini
- Department of Mathematics, Computer Science and Physics, University of Udine, Udine, Italy
| | - Giulia Giordano
- Department of Industrial Engineering, University of Trento, Trento, Italy
| | - Lucio Marinelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Genova, Italy.,Division of Clinical Neurophysiology, Department of Neurosciences, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, Genova, Italy
| | - Bruno Burlando
- Department of Pharmacy, University of Genova, Genova, Italy
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Cohen B. Dedication to Mingjia Dai, Ph.D. for Discovery of the First Successful Treatment of the Mal de Debarquement Syndrome. Front Neurol 2019; 10:1196. [PMID: 31920903 PMCID: PMC6923218 DOI: 10.3389/fneur.2019.01196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/28/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Bernard Cohen
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Mucci V, Meier C, Bizzini M, Romano F, Agostino D, Ventura A, Bertolini G, Feddermann-Demont N. Combined Optokinetic Treatment and Vestibular Rehabilitation to Reduce Visually Induced Dizziness in a Professional Ice Hockey Player After Concussion: A Clinical Case. Front Neurol 2019; 10:1200. [PMID: 31849804 PMCID: PMC6896248 DOI: 10.3389/fneur.2019.01200] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 10/28/2019] [Indexed: 11/13/2022] Open
Abstract
Background: The appropriate detection and therapy of concussion symptoms are of great importance to avoid long-term impairment and absence from pre-concussive activities, such as sport, school or work. Post-traumatic headache and dizziness are known as risk factors of persistent symptoms after a concussion. Dizziness has even been classified as a predictor for symptom persistence. One type of dizziness, which has never been considered is visually induced dizziness (VID) often develops as a consequence of vestibular impairment. This manuscript presents the clinical case of a 25-year-old male, professional ice hockey player, whereby a therapeutic approach to VID after concussion is demonstrated. Case: A detailed interdisciplinary clinical and laboratory-assisted neurological, neurovestibular and ocular-motor examination was performed 20 days post-concussion, which indicated VID symptoms. Thus, the player qualified for a 5-day combined vestibular, balance and optokinetic therapy, which aimed to reduce the player's increased sensitivity to visual information. Each treatment day consisted of two sessions: vestibular/ocular-motor training and exposure to optokinetic stimuli combined with postural control exercises. The optokinetic stimulus was delivered in the form of a rotating disk. VID symptoms were recorded daily via posturography and a visual analog scale prior to the optokinetic sessions. The player improved over the course of each treatment day and was able to return to ice hockey 15 days after the final treatment session. Three months later the player reported no symptoms in the follow up questionnaire. Conclusion: The combination of vestibular, balance and optokinetic therapy led to remission of VID symptoms in a professional ice hockey player after multiple concussions, within a short time frame after his last concussion. Thus, this case study highlights the significant benefit of treating post-concussive VID symptoms utilizing a multi-modal approach.
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Affiliation(s)
- Viviana Mucci
- Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland.,Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Cornelia Meier
- Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland
| | - Mario Bizzini
- Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland.,Human Performance Lab, Schulthess Clinic, Zurich, Switzerland
| | - Fausto Romano
- Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland.,Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Daniel Agostino
- Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland
| | | | - Giovanni Bertolini
- Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland.,Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Nina Feddermann-Demont
- Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland.,Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
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15
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Schepermann A, Bardins S, Penkava J, Brandt T, Huppert D, Wuehr M. Approach to an experimental model of Mal de Debarquement Syndrome. J Neurol 2019; 266:74-79. [DOI: 10.1007/s00415-019-09345-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 11/29/2022]
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Abstract
Although motion of the head and body has been suspected or known as the provocative cause for the production of motion sickness for centuries, it is only within the last 20 yr that the source of the signal generating motion sickness and its neural basis has been firmly established. Here, we briefly review the source of the conflicts that cause the body to generate the autonomic signs and symptoms that constitute motion sickness and provide a summary of the experimental data that have led to an understanding of how motion sickness is generated and can be controlled. Activity and structures that produce motion sickness include vestibular input through the semicircular canals, the otolith organs, and the velocity storage integrator in the vestibular nuclei. Velocity storage is produced through activity of vestibular-only (VO) neurons under control of neural structures in the nodulus of the vestibulo-cerebellum. Separate groups of nodular neurons sense orientation to gravity, roll/tilt, and translation, which provide strong inhibitory control of the VO neurons. Additionally, there are acetylcholinergic projections from the nodulus to the stomach, which along with other serotonergic inputs from the vestibular nuclei, could induce nausea and vomiting. Major inhibition is produced by the GABAB receptors, which modulate and suppress activity in the velocity storage integrator. Ingestion of the GABAB agonist baclofen causes suppression of motion sickness. Hopefully, a better understanding of the source of sensory conflict will lead to better ways to avoid and treat the autonomic signs and symptoms that constitute the syndrome.
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Affiliation(s)
- Bernard Cohen
- Department of Neurology, Icahn School of Medicine at Mount Sinai , New York, New York.,Department of Neurology, New York University, New York
| | - Mingjia Dai
- Department of Neurology, Icahn School of Medicine at Mount Sinai , New York, New York.,Department of Neurology, New York University, New York
| | - Sergei B Yakushin
- Department of Neurology, Icahn School of Medicine at Mount Sinai , New York, New York.,Department of Neurology, New York University, New York
| | - Catherine Cho
- Department of Neurology, Icahn School of Medicine at Mount Sinai , New York, New York.,Department of Neurology, New York University, New York
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Canceri JM, Brown R, Watson SR, Browne CJ. Examination of Current Treatments and Symptom Management Strategies Used by Patients With Mal De Debarquement Syndrome. Front Neurol 2018; 9:943. [PMID: 30483208 PMCID: PMC6240763 DOI: 10.3389/fneur.2018.00943] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 10/22/2018] [Indexed: 12/15/2022] Open
Abstract
Introduction: Mal de Debarquement Syndrome (MdDS) is a neurological disorder which affects the vestibular system pathways, manifesting as a constant sensation of movement in the form of rocking, bobbing, or swaying. The mechanism of MdDS is poorly understood and there is a lack of awareness amongst medical professionals about the condition. This study aimed to examine treatments and symptom management strategies used by MdDS patients and evaluate their self-reported effectiveness. Method: Motion-Triggered and Spontaneous/Other onset MdDS patients responded to a set of comprehensive questions as a retrospective survey regarding epidemiological details, diagnostic procedures, onset, and symptom triggers, hormonal influences as well as treatments and symptom management strategies used to reduce symptoms. The Motion-Triggered questionnaire was made available through Survey Monkey and the Spontaneous/Other Onset questionnaire through Qualtrics. The link for each questionnaire was made available on online MdDS support groups and on various research websites. Descriptive statistics were used for epidemiological data and Pearson's Chi Square tests were used for comparisons between and within both subtype groups. Results: A total of 370 patients participated in the surveys, with 287 valid responses collected for the section regarding treatment and symptom management strategies. The success of the treatments and symptom management strategies did not vary between subtypes Benzodiazepines/Antidepressants were reported as being most beneficial in reducing symptoms in both groups. Conclusion: This was the first attempt to evaluate the reported success of treatments and symptom management strategies in MdDS patients by assessing the patients' perceived helpfulness. The treatments and symptom management strategies reported to be the most helpful in managing and/or reducing symptoms are proposed to be effective due to their stress-reducing capacities. We hope this study will broaden MdDS awareness and that this study will increase patient knowledge regarding treatments and symptom management strategies that other patients found helpful.
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Affiliation(s)
- Josephine M Canceri
- School of Science and Health, Western Sydney University, Sydney, NSW, Australia
| | - Rachael Brown
- School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Shaun R Watson
- Prince of Wales Private Hospital, Sydney, NSW, Australia
| | - Cherylea J Browne
- School of Science and Health, Western Sydney University, Sydney, NSW, Australia.,Translational Neuroscience Facility, School of Medical Sciences, UNSW Sydney, Sydney, NSW, Australia
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