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Schoenmaekers C, De Smet D, Deblieck C, Van Riel J, Zarowski A, Wuyts FL. Virtual reality application matches the most established treatment for Mal de Debarquement Syndrome: A non-inferiority, randomized, open clinical trial. Neurotherapeutics 2024:e00390. [PMID: 38942708 DOI: 10.1016/j.neurot.2024.e00390] [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: 04/19/2024] [Revised: 05/29/2024] [Accepted: 06/18/2024] [Indexed: 06/30/2024] Open
Abstract
Mal de Debarquement Syndrome (MdDS) is a debilitating neuro-otological disorder where individuals consistently feel self-motion, often triggered by motion like being on a boat (MT-MdDS). Due to the unknown pathophysiological mechanism, available treatment options for managing symptoms are limited. Our objective was to develop a virtual reality application (VRA) to simulate the full field optokinetic stimulation (OKS) booth and evaluate its efficacy compared to the standard treatment. In our randomized, open, non-inferiority clinical trial with 30 MT-MdDS patients, 15 received the OKS booth and 15 the new VRA over four consecutive days. Two 4-min treatment blocks were scheduled in the morning and afternoon, with a total of four blocks. Treatment effectiveness was evaluated through questionnaires and posturography. Our findings suggest that the choice of modality does not significantly differ in achieving an overall improvement in symptoms. We advocate that the VRA can be used as an accessible alternative to the booth method worldwide, effectively mitigating MdDS symptoms and enhancing the QoL of numerous MdDS patients.
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Affiliation(s)
- Catho Schoenmaekers
- Lab for Equilibrium Investigations and Aerospace, University of Antwerp, Antwerp, Belgium.
| | - Dario De Smet
- Lab for Equilibrium Investigations and Aerospace, University of Antwerp, Antwerp, Belgium
| | - Choi Deblieck
- Lab for Equilibrium Investigations and Aerospace, University of Antwerp, Antwerp, Belgium
| | - Jan Van Riel
- Telmio BV, Luchthavenlaan 27, Vilvoorde, Belgium
| | - Andrzej Zarowski
- Telmio BV, Luchthavenlaan 27, Vilvoorde, Belgium; European Institute for ORL-HNS, Sint-Augustinus Hospital, Wilrijk, Belgium
| | - Floris L Wuyts
- Lab for Equilibrium Investigations and Aerospace, University of Antwerp, Antwerp, Belgium; Telmio BV, Luchthavenlaan 27, Vilvoorde, Belgium; European Institute for ORL-HNS, Sint-Augustinus Hospital, Wilrijk, Belgium
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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] [Grants] [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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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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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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