Readaptation Treatment of Mal de Debarquement Syndrome With a Virtual Reality App: A Pilot Study

Abstract

Mal de Debarquement syndrome (MdDS) is composed of constant phantom sensations of motion, which are frequently accompanied by increased sensitivity to light, inability to walk on a patterned floor, the sensation of ear fullness, head pressure, anxiety, and depression. This disabling condition generally occurs in premenopausal women within 2 days after prolonged passive motion (e.g., travel on a cruise ship, plane, or in a car). It has been previously hypothesized that MdDS is the result of maladaptive changes in the polysynaptic vestibulo-ocular reflex (VOR) pathway called velocity storage. Past research indicates that full-field optokinetic stimulation is an optimal way to activate velocity storage. Unfortunately, such devices are typically bulky and not commonly available. We questioned whether virtual reality (VR) goggles with a restricted visual field could effectively simulate a laboratory environment for MdDS treatment. A stripes program for optokinetic stimulation was implemented using Google Daydream Viewer. Five female patients (42 ± 10 years; range 26-50), whose average MdDS symptom duration was 2 months, participated in this study. Four patients had symptoms triggered by prolonged passive motion, and in one, symptoms spontaneously occurred. Symptom severity was self-scored by patients on a scale of 0-10, where 0 is no symptoms at all and 10 is the strongest symptoms that the patient could imagine. Static posturography was obtained to determine objective changes in body motion. The treatment was considered effective if the patient's subjective score improved by at least 50%. All five patients reported immediate improvement. On 2-month follow-ups, symptoms returned only in one patient. These data provide proof of concept for the limited-visual-field goggles potentially having clinical utility as a substitute for full-field optokinetic stimulation in treating patients with MdDS in clinics or via telemedicine.

Treatment of Gravitational Pulling Sensation in Patients With Mal de Debarquement Syndrome (MdDS): A Model-Based Approach

“…The original studies by Dai et al (2014 , 2017) , as well as replications using this protocol ( Hain, 2018 ; Mucci et al, 2018b ; Schenk et al, 2018 ), demonstrated similar success rates regardless of slight variations in treatment setups and protocols. A subset of cases that initially worsened or did not respond to the treatment, later improved by reversing OKS stimulus, supporting Dai’s hypothesis that countering velocity storage should improve symptoms and that readaptation in the direction of velocity storage should increase MdDS symptoms ( Schenk et al, 2018 ; Yakushin et al, 2020 ). This strengthened the argument that the results of Dai’s studies were not due to placebo and that velocity storage was at the root of the various syndromes associated with MdDS.…”

“…The original treatment of MdDS, was based on the idea that the roll eigenvector of velocity storage had maladapted toward pitch during cross-axis stimulation ( Dai et al, 2009 , Dai et al, 2014 ). Therefore, the protocol developed for treatment was to use a combined OKS and vestibular stimulus, which presumably re-aligned the eigenvectors with the head axes ( Dai et al, 2017 ; Yakushin et al, 2020 ). This protocol, however, could not explain the sensation of pulling experienced by some MdDS patients ( Dai et al, 2017 ; Yakushin et al, 2020 ) and was not effective in treating this symptom.…”

“…These 50 patients are the core of this study. The sensation of gravitational pulling, however, did not seem to improve with the original OKS-VOR readaptation protocol ( Dai et al, 2014 ; Yakushin et al, 2020 ). We, therefore, worked on modifying the original treatment based on the idea that the yaw and pitch eigenvectors could have become maladapted.…”

“…All MdDS patients seeking treatment with the VOR readaptation protocol at MSSM were screened with an intake form and a brief interview. Patient eligibility criteria were the same as for the subjects who were recruited in our previous studies ( Dai et al, 2014 , 2017 ; Yakushin et al, 2020 ). The inclusion criteria were (1) continuous rocking, swaying, bobbing, and/or gravitational pulling, which had persisted for at least 3 weeks, with or without a trigger.…”

“…Non-spinning vertigo persists while sitting, standing, and lying down long after the triggering event. Patients also report a sensation of gravitational pulling in one or several directions ( Dai et al, 2017 ; Yakushin et al, 2020 ). These sensations were commonly accompanied by sensitivity to moving visual stimuli, loud noise, and fluorescent lighting, ear fullness, head pressure, brain fog, fatigue, and sensitivity to head movement.…”