Treatment of Mal de Debarquement Syndrome in a Deployed Environment

Treatment of Mal de Debarquement Syndrome in a Deployed Environment Abstract We report the case of a 26-year-old Caucasian female with persistent sensations of forward and reverse movement with spontaneous onset. This worsened over 4 wk. The patient reported an episode of these symptoms 5 mo prior, which lasted for 3 mo before improving. Our case details the treatment of Mal de Debarquement syndrome, or Disembarkment Syndrome, in a deployed military environment. Mal de Debarquement was a term originally coined to describe the persistent sensation of rocking back and forth after disembarking a boat and returning to land. This is normal, and usually only lasts for minutes to hours. When it persists, it is called Mal de Debarquement Syndrome. The onset frequently coincides with travel and most commonly by boat, however it can also occur spontaneously as in this case. Currently, there are three different treatment options. The first involves medications that are often sedating. The second uses magnetic resonance imaging at high frequency to stimulate the areas of the brain thought to be involved. The third option is a form of physical therapy termed re-adaptation of the vestibular ocular reflex. As we were in a deployed military environment the first two options were unsafe and unavailable respectively. We employed an improvised version of re-adaptation of the vestibular ocular reflex. The patient demonstrated a 50% reduction in symptoms following 1 wk of treatment and as a result was safely able to complete her deployment. BACKGROUND It is not uncommon for those who have spent time on a boat to feel as if they continue to rock back and forth once returning to land.1,2 This sensation can normally last for several hours to days and is called Mal de Debarquement (MdD), often referred to as “sea legs” in English. In very rare circumstances, the illness can persist for months or remain indefinitely; this is termed Mal de Debarquement Syndrome (MdMS) or Disembarkment Syndrome in English.1,2 Little is known about this condition. It most commonly occurs after sea travel but can also happen after air or land travel. Even less commonly, it can occur spontaneously. In reported cases, it is more common in women who have a history of migraine headaches.1,2 Patients do not describe symptoms of vertigo with spinning, nausea, nor lightheadedness. Instead, this syndrome includes a distinct sensation of continuous to and fro swaying motion at rest. Patients also describe resolution with passive motion, as one would experience when riding a boat or traveling in a car or plane.1,2 Physical examination and neuroimaging will not identify an etiology, and previously studies have used normal physical and neurologic examination and imaging as inclusion criteria.1 Treatment currently focuses on three modalities. The first is pharmacotherapy, primarily benzodiazepines and selective serotonin reuptake inhibitors, as typical nausea and vertigo medications are ineffective.1,2 The second is repetitive transcranial magnetic stimulation.3 The third is re-adaptation of the vestibular ocular reflex (VOR).4 For the purpose of this case we will discuss the third option as it was the most practical and the patient’s preference. CASE A 26-year-old female registered nurse presented to the Role 1-Enhanced Medical Treatment Facility, Camp Bondsteel, Kosovo, Operation Joint Guardian with a continuous sensation of moving forward and reverse as if “on a boat” for 1 mo. She denied typical vertiginous symptoms. She also did not describe the typical side-to-side swaying sensation of MdMS as she sensed forward and backward motion. At the time of presentation, she was 6 mo into deployment, serving as the only registered nurse in the above mentioned Medical Treatment Facility. She had first experienced the same unprovoked symptoms 5 mo earlier that lasted for 3 mo and spontaneously resolved. She remained symptom free for 1 mo before the symptoms returned. Her duties did not change between the two episodes. The patient reported that her symptoms improved when traveling in a vehicle or when running outside, but not while running on a treadmill. She had a history of migraine headaches, but neither migraine treatment nor common vertigo medications improved her current symptoms. Her physical and neurologic examination findings and a magnetic resonance imaging (MRI) of her head and neck, with and without contrast, were unremarkable. The decision was made to pursue re-adaptation of her VOR for several reasons. While an MRI was available for diagnostics at a local national hospital, none were available for repetitive transcranial magnetic stimulation. Additionally, starting sedating or psychotropic medications in a deployed environment would require a medical waiver. While this was an option, the patient preferred to pursue non-pharmacologic options as a first line treatment. A study by Dai et al describing this treatment placed patients in a circular room with vertical black and white stripes projected onto it.4 The stripes would spin in the opposite direction of the impulse of the patient’s symptoms. Simultaneously, an assistant would move the patient’s head laterally to the left, then back to the middle, then laterally to the right, and back to the middle again. The process was repeated for the duration of the treatment.4 In our resource-limited environment, we repurposed a commercially available black garbage can and placed two-inch-wide stripes of medical tape in a vertical orientation around the can, equidistant from each other (Fig. 1). The can was suspended using utility cord. We restricted the patient’s visual field to the spinning stripes using commercially available safety goggles and hospital bed sheets. The speed of the passive head movements performed by an assistant was determined by the frequency of the patient’s to and fro movements. To determine the frequency of her symptoms, she adjusted a metronome until it matched her symptoms. If her swaying motion modeled the arc of a pendulum, the metronome would sound every time the pendulum changed direction, and the position of the patient’s head changed every time the metronome sounded. To determine the leading direction of our patient’s symptoms, we performed the Fukuda stepping test; however, our patient walked forward which did not help determine which direction our stimulus should spin.4 In this test, the patient is asked to close their eyes and march in place for 1 min. If the patient steps to the left or right or rotates clockwise or counterclockwise this it is thought to reveal the direction of the patient’s internal to and fro sensation which then informs the provider which direction to spin the stimulus in re-adaptation of the VOR.4 This test result was consistent with her internal sensation as she described the sensation of rocking forward and backward. FIGURE 1. View largeDownload slide A commercially available garbage can suspend upside down by utility cord and framed by hospital sheets to isolate patient view of distracting surroundings. The patient sat in the chair draped in a sheet in the foreground of the picture. To replicate the therapy described by Dai et al, we wound up the utility cord manually. The can then unwound at a constant speed manually controlled by a provider by applying friction with their hand. FIGURE 1. View largeDownload slide A commercially available garbage can suspend upside down by utility cord and framed by hospital sheets to isolate patient view of distracting surroundings. The patient sat in the chair draped in a sheet in the foreground of the picture. To replicate the therapy described by Dai et al, we wound up the utility cord manually. The can then unwound at a constant speed manually controlled by a provider by applying friction with their hand. We spun the can at a constant speed, for 4-min sessions, three times a day, in accordance with the methods described by Dai et al.4 The speed of rotation was not determined by a measurement but by the patient’s symptomology. Within a certain range her symptoms resolved and with her real time feedback we maintained the speed within that range. As we were unable to determine the direction of her impulses, we started the treatment by spinning the can counterclockwise. However, after 3 d the patient felt her symptoms had not improved and asked to stop the counterclockwise treatment. We stopped treatment and waited until the following Monday to begin spinning clockwise. This was done so the patient would receive 5 d of continuous treatment as described in Dai et al.4 We recorded her symptoms every morning starting the first day of treatment prior to her first treatment session using the Patient-Specific Functional Scale (PSFS).5 The PSFS asked the patient to assess three activities that her symptoms affected the most. The patient recorded concentrating, bending over to shave her legs, and sleeping. We also assessed her symptoms using an eleven-point numeric Likert scale, where zero meant symptom-free, and ten meant the worst symptoms imaginable. We recorded these values each morning and after every treatment session. She also completed the Dizziness Handicap Inventory (DHI) every morning for both trials.6 Score definitions include 16–34 for mild perceived disability, 36–52 for moderate perceived disability, and 54 or more for severe perceived disability. At the completion of the second treatment trial, using clockwise movements, the patient experienced significant improvements. We documented a symptom reduction of greater than 50% in all three PSFS activities at the completion of the treatment (Fig. 2). Follow-up at 1, 3, and 7 d following treatment completion demonstrated continuing improvements. The results of the likert scale revealed that despite improvements at the start of her morning, her symptoms were acutely worse after each treatment, lasting approximately 4 h. Though not measured, the patient noted during treatment she was symptom free for the duration of every 4 min treatment session, including the initial trial of counterclockwise treatments. The patient initiated treatment with a moderate perceived disability of 39/100 on the DHI, and ended the second treatment trial with a mild perceived disability of 20/100. At 1-mo follow-up, her PSFS scores for concentrating, shaving, and sleeping were 1, 1, and 0, respectively. Similarly, her DHI score dropped to a 6/100. Her symptoms remained constant at 2- and 3-mo follow-up, however, the patient noted there were days when she was completely symptom free. FIGURE 2. View largeDownload slide The PSFS was used to assess the patient’s symptoms. The three symptoms most affected were concentrating (symbolized with an x), bent over shaving her legs (symbolized with a square), and sleeping (symbolized with a triangle). Initial treatment during trial one, the stimulus spun in a counterclockwise direction, but after 3 d of this she felt there was no improvement and treatment was halted January 4, 2018. Treatment halted for 4 d until the following Monday January 8, 2018 so the patient could be exposed to 5 full days of clockwise treatment during trial two. Her symptoms were recorded every morning prior to her first treatment and at morning follow-up on days 1, 3, and 7. FIGURE 2. View largeDownload slide The PSFS was used to assess the patient’s symptoms. The three symptoms most affected were concentrating (symbolized with an x), bent over shaving her legs (symbolized with a square), and sleeping (symbolized with a triangle). Initial treatment during trial one, the stimulus spun in a counterclockwise direction, but after 3 d of this she felt there was no improvement and treatment was halted January 4, 2018. Treatment halted for 4 d until the following Monday January 8, 2018 so the patient could be exposed to 5 full days of clockwise treatment during trial two. Her symptoms were recorded every morning prior to her first treatment and at morning follow-up on days 1, 3, and 7. DISCUSSION Disembarkment syndrome can cause disabling symptoms.1 If this patient’s symptoms had not improved, medical evacuation from the deployed military environment due to safety concerns would have been required. This case highlights a non-pharmacologic treatment option for patients with MdMS. In resource-limited environments or settings in which a patient’s employment or preferences may preclude use of medications such as benzodiazepines or selective serotonin reuptake inhibitors, re-adaptation of the VOR may represent a viable treatment option. Conventionally, such treatment requires a dedicated structure and projection equipment. That is what makes this case so novel. We were able to improvise a low-cost treatment option with commonly available supplies. Additionally, we were not able to determine which direction to spin our improvised device based on the Fukuda test. This forced us to attempt a trial and error approach to her treatment. While not ideal, this may be an another approach to adopt in patients that describe their symptoms as forward and backward as opposed to side to side and have unremarkable Fukuda stepping test results. It is important to note that this is only one case and does not include long-term follow-up. However, our patient’s symptoms improved by over 50% after 1 wk of treatment measured by the PSFS and improved from moderate perceived disability to mild perceived disability as measured by DHI. We measured additional benefit at her 1-wk follow-up that was sustained at her 1, 2, and 3 mo follow-up. Additionally, she noted her improvement made it easier for her to complete her activities of daily living and much easier to perform her job. CONCLUSION The discussed case describes the treatment of MdMS in an active duty service member, in an austere environment. We describe a novel treatment option to evoke re-adaptation of the VOR in a resource-limited setting in which traditional pharmaceutical options create occupational hazards and MRI either not available or only available for diagnostics not treatment. REFERENCES 1 Van Ombergen A, Van Rompaey V, Maes LK, Van de Heynig PH, Wuyts FL: Mal de debarquement: a systemic review. J Neurol  2016; 263: 843– 54. Google Scholar CrossRef Search ADS PubMed  2 Cha Y: Mal de Debarquement. Semin Neurol  2009; 29( 5): 520– 7. Google Scholar CrossRef Search ADS PubMed  3 Cha Y, Deblieck C, Wu AD: Double-blind sham-controlled cross-over trial of repetitive transcranial magnetic stimulation for Mal de Debarquement Syndrome. Otol Neurotol  2016; 37( 6): 805– 12. Google Scholar CrossRef Search ADS PubMed  4 Dai M, Cohen B, Smouha E, Cho C: Readaptation of the vestibule-ocular reflex relieves the mal de debarquement syndrome. Front Neurol  2014; 5: 124. Google Scholar CrossRef Search ADS PubMed  5 Stratford P: Assessing disability and change on individual patients: a report of a patient specific measure. Physiother Can  1995; 47( 4): 258– 63. Google Scholar CrossRef Search ADS   6 Jacobson GP, Newman CW: The development of the dizziness handicap inventory. Arch Otolaryngol Head Neck Surg  1990; 116( 4): 424– 7. doi:10.1001/archotol.1990.01870040046011v. Google Scholar CrossRef Search ADS PubMed  Author notes The views expressed herein are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force and Department of Defense, or the U.S. Government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

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Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.
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Abstract

Abstract We report the case of a 26-year-old Caucasian female with persistent sensations of forward and reverse movement with spontaneous onset. This worsened over 4 wk. The patient reported an episode of these symptoms 5 mo prior, which lasted for 3 mo before improving. Our case details the treatment of Mal de Debarquement syndrome, or Disembarkment Syndrome, in a deployed military environment. Mal de Debarquement was a term originally coined to describe the persistent sensation of rocking back and forth after disembarking a boat and returning to land. This is normal, and usually only lasts for minutes to hours. When it persists, it is called Mal de Debarquement Syndrome. The onset frequently coincides with travel and most commonly by boat, however it can also occur spontaneously as in this case. Currently, there are three different treatment options. The first involves medications that are often sedating. The second uses magnetic resonance imaging at high frequency to stimulate the areas of the brain thought to be involved. The third option is a form of physical therapy termed re-adaptation of the vestibular ocular reflex. As we were in a deployed military environment the first two options were unsafe and unavailable respectively. We employed an improvised version of re-adaptation of the vestibular ocular reflex. The patient demonstrated a 50% reduction in symptoms following 1 wk of treatment and as a result was safely able to complete her deployment. BACKGROUND It is not uncommon for those who have spent time on a boat to feel as if they continue to rock back and forth once returning to land.1,2 This sensation can normally last for several hours to days and is called Mal de Debarquement (MdD), often referred to as “sea legs” in English. In very rare circumstances, the illness can persist for months or remain indefinitely; this is termed Mal de Debarquement Syndrome (MdMS) or Disembarkment Syndrome in English.1,2 Little is known about this condition. It most commonly occurs after sea travel but can also happen after air or land travel. Even less commonly, it can occur spontaneously. In reported cases, it is more common in women who have a history of migraine headaches.1,2 Patients do not describe symptoms of vertigo with spinning, nausea, nor lightheadedness. Instead, this syndrome includes a distinct sensation of continuous to and fro swaying motion at rest. Patients also describe resolution with passive motion, as one would experience when riding a boat or traveling in a car or plane.1,2 Physical examination and neuroimaging will not identify an etiology, and previously studies have used normal physical and neurologic examination and imaging as inclusion criteria.1 Treatment currently focuses on three modalities. The first is pharmacotherapy, primarily benzodiazepines and selective serotonin reuptake inhibitors, as typical nausea and vertigo medications are ineffective.1,2 The second is repetitive transcranial magnetic stimulation.3 The third is re-adaptation of the vestibular ocular reflex (VOR).4 For the purpose of this case we will discuss the third option as it was the most practical and the patient’s preference. CASE A 26-year-old female registered nurse presented to the Role 1-Enhanced Medical Treatment Facility, Camp Bondsteel, Kosovo, Operation Joint Guardian with a continuous sensation of moving forward and reverse as if “on a boat” for 1 mo. She denied typical vertiginous symptoms. She also did not describe the typical side-to-side swaying sensation of MdMS as she sensed forward and backward motion. At the time of presentation, she was 6 mo into deployment, serving as the only registered nurse in the above mentioned Medical Treatment Facility. She had first experienced the same unprovoked symptoms 5 mo earlier that lasted for 3 mo and spontaneously resolved. She remained symptom free for 1 mo before the symptoms returned. Her duties did not change between the two episodes. The patient reported that her symptoms improved when traveling in a vehicle or when running outside, but not while running on a treadmill. She had a history of migraine headaches, but neither migraine treatment nor common vertigo medications improved her current symptoms. Her physical and neurologic examination findings and a magnetic resonance imaging (MRI) of her head and neck, with and without contrast, were unremarkable. The decision was made to pursue re-adaptation of her VOR for several reasons. While an MRI was available for diagnostics at a local national hospital, none were available for repetitive transcranial magnetic stimulation. Additionally, starting sedating or psychotropic medications in a deployed environment would require a medical waiver. While this was an option, the patient preferred to pursue non-pharmacologic options as a first line treatment. A study by Dai et al describing this treatment placed patients in a circular room with vertical black and white stripes projected onto it.4 The stripes would spin in the opposite direction of the impulse of the patient’s symptoms. Simultaneously, an assistant would move the patient’s head laterally to the left, then back to the middle, then laterally to the right, and back to the middle again. The process was repeated for the duration of the treatment.4 In our resource-limited environment, we repurposed a commercially available black garbage can and placed two-inch-wide stripes of medical tape in a vertical orientation around the can, equidistant from each other (Fig. 1). The can was suspended using utility cord. We restricted the patient’s visual field to the spinning stripes using commercially available safety goggles and hospital bed sheets. The speed of the passive head movements performed by an assistant was determined by the frequency of the patient’s to and fro movements. To determine the frequency of her symptoms, she adjusted a metronome until it matched her symptoms. If her swaying motion modeled the arc of a pendulum, the metronome would sound every time the pendulum changed direction, and the position of the patient’s head changed every time the metronome sounded. To determine the leading direction of our patient’s symptoms, we performed the Fukuda stepping test; however, our patient walked forward which did not help determine which direction our stimulus should spin.4 In this test, the patient is asked to close their eyes and march in place for 1 min. If the patient steps to the left or right or rotates clockwise or counterclockwise this it is thought to reveal the direction of the patient’s internal to and fro sensation which then informs the provider which direction to spin the stimulus in re-adaptation of the VOR.4 This test result was consistent with her internal sensation as she described the sensation of rocking forward and backward. FIGURE 1. View largeDownload slide A commercially available garbage can suspend upside down by utility cord and framed by hospital sheets to isolate patient view of distracting surroundings. The patient sat in the chair draped in a sheet in the foreground of the picture. To replicate the therapy described by Dai et al, we wound up the utility cord manually. The can then unwound at a constant speed manually controlled by a provider by applying friction with their hand. FIGURE 1. View largeDownload slide A commercially available garbage can suspend upside down by utility cord and framed by hospital sheets to isolate patient view of distracting surroundings. The patient sat in the chair draped in a sheet in the foreground of the picture. To replicate the therapy described by Dai et al, we wound up the utility cord manually. The can then unwound at a constant speed manually controlled by a provider by applying friction with their hand. We spun the can at a constant speed, for 4-min sessions, three times a day, in accordance with the methods described by Dai et al.4 The speed of rotation was not determined by a measurement but by the patient’s symptomology. Within a certain range her symptoms resolved and with her real time feedback we maintained the speed within that range. As we were unable to determine the direction of her impulses, we started the treatment by spinning the can counterclockwise. However, after 3 d the patient felt her symptoms had not improved and asked to stop the counterclockwise treatment. We stopped treatment and waited until the following Monday to begin spinning clockwise. This was done so the patient would receive 5 d of continuous treatment as described in Dai et al.4 We recorded her symptoms every morning starting the first day of treatment prior to her first treatment session using the Patient-Specific Functional Scale (PSFS).5 The PSFS asked the patient to assess three activities that her symptoms affected the most. The patient recorded concentrating, bending over to shave her legs, and sleeping. We also assessed her symptoms using an eleven-point numeric Likert scale, where zero meant symptom-free, and ten meant the worst symptoms imaginable. We recorded these values each morning and after every treatment session. She also completed the Dizziness Handicap Inventory (DHI) every morning for both trials.6 Score definitions include 16–34 for mild perceived disability, 36–52 for moderate perceived disability, and 54 or more for severe perceived disability. At the completion of the second treatment trial, using clockwise movements, the patient experienced significant improvements. We documented a symptom reduction of greater than 50% in all three PSFS activities at the completion of the treatment (Fig. 2). Follow-up at 1, 3, and 7 d following treatment completion demonstrated continuing improvements. The results of the likert scale revealed that despite improvements at the start of her morning, her symptoms were acutely worse after each treatment, lasting approximately 4 h. Though not measured, the patient noted during treatment she was symptom free for the duration of every 4 min treatment session, including the initial trial of counterclockwise treatments. The patient initiated treatment with a moderate perceived disability of 39/100 on the DHI, and ended the second treatment trial with a mild perceived disability of 20/100. At 1-mo follow-up, her PSFS scores for concentrating, shaving, and sleeping were 1, 1, and 0, respectively. Similarly, her DHI score dropped to a 6/100. Her symptoms remained constant at 2- and 3-mo follow-up, however, the patient noted there were days when she was completely symptom free. FIGURE 2. View largeDownload slide The PSFS was used to assess the patient’s symptoms. The three symptoms most affected were concentrating (symbolized with an x), bent over shaving her legs (symbolized with a square), and sleeping (symbolized with a triangle). Initial treatment during trial one, the stimulus spun in a counterclockwise direction, but after 3 d of this she felt there was no improvement and treatment was halted January 4, 2018. Treatment halted for 4 d until the following Monday January 8, 2018 so the patient could be exposed to 5 full days of clockwise treatment during trial two. Her symptoms were recorded every morning prior to her first treatment and at morning follow-up on days 1, 3, and 7. FIGURE 2. View largeDownload slide The PSFS was used to assess the patient’s symptoms. The three symptoms most affected were concentrating (symbolized with an x), bent over shaving her legs (symbolized with a square), and sleeping (symbolized with a triangle). Initial treatment during trial one, the stimulus spun in a counterclockwise direction, but after 3 d of this she felt there was no improvement and treatment was halted January 4, 2018. Treatment halted for 4 d until the following Monday January 8, 2018 so the patient could be exposed to 5 full days of clockwise treatment during trial two. Her symptoms were recorded every morning prior to her first treatment and at morning follow-up on days 1, 3, and 7. DISCUSSION Disembarkment syndrome can cause disabling symptoms.1 If this patient’s symptoms had not improved, medical evacuation from the deployed military environment due to safety concerns would have been required. This case highlights a non-pharmacologic treatment option for patients with MdMS. In resource-limited environments or settings in which a patient’s employment or preferences may preclude use of medications such as benzodiazepines or selective serotonin reuptake inhibitors, re-adaptation of the VOR may represent a viable treatment option. Conventionally, such treatment requires a dedicated structure and projection equipment. That is what makes this case so novel. We were able to improvise a low-cost treatment option with commonly available supplies. Additionally, we were not able to determine which direction to spin our improvised device based on the Fukuda test. This forced us to attempt a trial and error approach to her treatment. While not ideal, this may be an another approach to adopt in patients that describe their symptoms as forward and backward as opposed to side to side and have unremarkable Fukuda stepping test results. It is important to note that this is only one case and does not include long-term follow-up. However, our patient’s symptoms improved by over 50% after 1 wk of treatment measured by the PSFS and improved from moderate perceived disability to mild perceived disability as measured by DHI. We measured additional benefit at her 1-wk follow-up that was sustained at her 1, 2, and 3 mo follow-up. Additionally, she noted her improvement made it easier for her to complete her activities of daily living and much easier to perform her job. CONCLUSION The discussed case describes the treatment of MdMS in an active duty service member, in an austere environment. We describe a novel treatment option to evoke re-adaptation of the VOR in a resource-limited setting in which traditional pharmaceutical options create occupational hazards and MRI either not available or only available for diagnostics not treatment. REFERENCES 1 Van Ombergen A, Van Rompaey V, Maes LK, Van de Heynig PH, Wuyts FL: Mal de debarquement: a systemic review. J Neurol  2016; 263: 843– 54. Google Scholar CrossRef Search ADS PubMed  2 Cha Y: Mal de Debarquement. Semin Neurol  2009; 29( 5): 520– 7. Google Scholar CrossRef Search ADS PubMed  3 Cha Y, Deblieck C, Wu AD: Double-blind sham-controlled cross-over trial of repetitive transcranial magnetic stimulation for Mal de Debarquement Syndrome. Otol Neurotol  2016; 37( 6): 805– 12. Google Scholar CrossRef Search ADS PubMed  4 Dai M, Cohen B, Smouha E, Cho C: Readaptation of the vestibule-ocular reflex relieves the mal de debarquement syndrome. Front Neurol  2014; 5: 124. Google Scholar CrossRef Search ADS PubMed  5 Stratford P: Assessing disability and change on individual patients: a report of a patient specific measure. Physiother Can  1995; 47( 4): 258– 63. Google Scholar CrossRef Search ADS   6 Jacobson GP, Newman CW: The development of the dizziness handicap inventory. Arch Otolaryngol Head Neck Surg  1990; 116( 4): 424– 7. doi:10.1001/archotol.1990.01870040046011v. Google Scholar CrossRef Search ADS PubMed  Author notes The views expressed herein are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force and Department of Defense, or the U.S. Government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Journal

Military MedicineOxford University Press

Published: May 18, 2018

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