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Downloaded from https://academic.oup.com/milmed/article/183/11-12/e775/4999175 by DeepDyve user on 19 July 2022 MILITARY MEDICINE, 183, 11/12:e775, 2018 Treatment of Mal de Debarquement Syndrome in a Deployed Environment CPT Stephanie M. Schenk, NC, USA, BSN, RN-BC*¶; 1LT Jacklyn M. Wagner, SP, USA, PT, DPT, ATC†¶; CPT Jarrod A. Miller, VC, USA, DVM‡¶; CPT Tracey M. Lyons-White, SP, USA MPAS, PA-C§¶; MAJ Emilee C. Venn, VC, USA, DVM, MS, DACVECC‡¶; MAJ Michael D. April, MC, USA, MD, DPhil, MSc║; CPT Brit Long, MC, USAF, MD║; MAJ Steven G. Schauer, MC, USA, MD║; CPT Joshua J. Oliver, MC, USA, MD║¶ 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 nor- mal, 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 impro- vised 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 sea travel but can also happen after air or land travel. Even It is not uncommon for those who have spent time on a boat less commonly, it can occur spontaneously. In reported to feel as if they continue to rock back and forth once return- cases, it is more common in women who have a history of 1,2 1,2 ing to land. This sensation can normally last for several migraine headaches. Patients do not describe symptoms of hours to days and is called Mal de Debarquement (MdD), vertigo with spinning, nausea, nor lightheadedness. Instead, often referred to as “sea legs” in English. In very rare cir- this syndrome includes a distinct sensation of continuous to cumstances, the illness can persist for months or remain and fro swaying motion at rest. Patients also describe resolu- indeﬁnitely; this is termed Mal de Debarquement Syndrome tion with passive motion, as one would experience when rid- 1,2 1,2 (MdMS) or Disembarkment Syndrome in English. Little is ing a boat or traveling in a car or plane. Physical known about this condition. It most commonly occurs after examination and neuroimaging will not identify an etiology, and previously studies have used normal physical and neuro- *21st Combat Support Hospital, BLDG 89013 Quartermaster Ln, Fort logic examination and imaging as inclusion criteria. Hood, TX 76544. Treatment currently focuses on three modalities. The ﬁrst is †Department of Physical Therapy, Carl R. Darnall Army Medical pharmacotherapy, primarily benzodiazepines and selective Center, 36065 Santa Fe Ave, Fort Hood, TX 76544. serotonin reuptake inhibitors, as typical nausea and vertigo ‡43rd Medical Detachment Veterinary Services, BLDG 89013, 1,2 medications are ineffective. The second is repetitive tran- Quartermaster Ln, Fort Hood, TX 76544. §Raymond W. Bliss Army Health Center, 2240 Winrow Ave, Fort scranial magnetic stimulation. The third is re-adaptation of Huachuca, AZ 85613. the vestibular ocular reﬂex (VOR). For the purpose of this ║Emergency Department, Brooke Army Medical Center, 3551 Roger case we will discuss the third option as it was the most prac- Brooke Dr, Fort Sam Houston, TX 78234. tical and the patient’s preference. ¶Multinational Battlegroup-East, Task Force Medical, KFOR 23, APO, AE 09340. The views expressed herein are those of the authors and do not reﬂect CASE 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, A 26-year-old female registered nurse presented to the Role the Department of the Army, the Department of the Air Force and 1-Enhanced Medical Treatment Facility, Camp Bondsteel, Department of Defense, or the U.S. Government. Kosovo, Operation Joint Guardian with a continuous sensa- doi: 10.1093/milmed/usy108 tion of moving forward and reverse as if “on a boat” for 1 Published by Oxford University Press on behalf of the Association of mo. She denied typical vertiginous symptoms. She also did 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. not describe the typical side-to-side swaying sensation of MILITARY MEDICINE, Vol. 183, November/December 2018 e775 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e775/4999175 by DeepDyve user on 19 July 2022 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 unremark- able. 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 FIGURE 1. A commercially available garbage can suspend upside down an option, the patient preferred to pursue non-pharmacologic by utility cord and framed by hospital sheets to isolate patient view of dis- options as a ﬁrst line treatment. tracting 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, A study by Dai et al describing this treatment placed we wound up the utility cord manually. The can then unwound at a constant patients in a circular room with vertical black and white speed manually controlled by a provider by applying friction with their stripes projected onto it. The stripes would spin in the oppo- hand. site 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 test result was consistent with her internal sensation as she the right, and back to the middle again. The process was described the sensation of rocking forward and backward. repeated for the duration of the treatment. We spun the can at a constant speed, for 4-min sessions, In our resource-limited environment, we repurposed a three times a day, in accordance with the methods described commercially available black garbage can and placed two- by Dai et al. The speed of rotation was not determined by a inch-wide stripes of medical tape in a vertical orientation measurement but by the patient’s symptomology. Within a around the can, equidistant from each other (Fig. 1). The can certain range her symptoms resolved and with her real time was suspended using utility cord. We restricted the patient’s feedback we maintained the speed within that range. As we visual ﬁeld to the spinning stripes using commercially avail- were unable to determine the direction of her impulses, we able safety goggles and hospital bed sheets. The speed of the started the treatment by spinning the can counterclockwise. passive head movements performed by an assistant was However, after 3 d the patient felt her symptoms had not determined by the frequency of the patient’s to and fro move- improved and asked to stop the counterclockwise treatment. ments. To determine the frequency of her symptoms, she We stopped treatment and waited until the following Monday adjusted a metronome until it matched her symptoms. If her to begin spinning clockwise. This was done so the patient swaying motion modeled the arc of a pendulum, the metro- would receive 5 d of continuous treatment as described in nome would sound every time the pendulum changed direc- Dai et al. tion, and the position of the patient’s head changed every We recorded her symptoms every morning starting the time the metronome sounded. To determine the leading ﬁrst day of treatment prior to her ﬁrst treatment session using direction of our patient’s symptoms, we performed the the Patient-Speciﬁc Functional Scale (PSFS). The PSFS Fukuda stepping test; however, our patient walked forward asked the patient to assess three activities that her symptoms which did not help determine which direction our stimulus affected the most. The patient recorded concentrating, bend- should spin. In this test, the patient is asked to close their ing over to shave her legs, and sleeping. We also assessed eyes and march in place for 1 min. If the patient steps to the her symptoms using an eleven-point numeric Likert scale, left or right or rotates clockwise or counterclockwise this it is where zero meant symptom-free, and ten meant the worst thought to reveal the direction of the patient’s internal to and symptoms imaginable. We recorded these values each morn- fro sensation which then informs the provider which direc- ing and after every treatment session. She also completed the tion to spin the stimulus in re-adaptation of the VOR. This Dizziness Handicap Inventory (DHI) every morning for both e776 MILITARY MEDICINE, Vol. 183, November/December 2018 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e775/4999175 by DeepDyve user on 19 July 2022 PATIENT-SPECIFIC FUNCTIONAL SCALE Concentrating Shaving Sleeping FIGURE 2. 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 counter- clockwise 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 fol- lowing 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. trials. Score deﬁnitions include 16–34 for mild perceived may preclude use of medications such as benzodiazepines or disability, 36–52 for moderate perceived disability, and 54 selective serotonin reuptake inhibitors, re-adaptation of the or more for severe perceived disability. VOR may represent a viable treatment option. Conventionally, At the completion of the second treatment trial, using such treatment requires a dedicated structure and projection clockwise movements, the patient experienced signiﬁcant equipment. That is what makes this case so novel. We were improvements. We documented a symptom reduction of able to improvise a low-cost treatment option with commonly greater than 50% in all three PSFS activities at the comple- available supplies. tion of the treatment (Fig. 2). Follow-up at 1, 3, and 7 d fol- Additionally, we were not able to determine which direc- lowing treatment completion demonstrated continuing tion to spin our improvised device based on the Fukuda test. improvements. The results of the likert scale revealed that This forced us to attempt a trial and error approach to her despite improvements at the start of her morning, her symp- treatment. While not ideal, this may be an another approach toms were acutely worse after each treatment, lasting to adopt in patients that describe their symptoms as forward approximately 4 h. Though not measured, the patient noted and backward as opposed to side to side and have unremark- during treatment she was symptom free for the duration of able Fukuda stepping test results. every 4 min treatment session, including the initial trial of It is important to note that this is only one case and does counterclockwise treatments. The patient initiated treatment not include long-term follow-up. However, our patient’s with a moderate perceived disability of 39/100 on the DHI, symptoms improved by over 50% after 1 wk of treatment and ended the second treatment trial with a mild perceived measured by the PSFS and improved from moderate per- disability of 20/100. At 1-mo follow-up, her PSFS scores for ceived disability to mild perceived disability as measured by concentrating, shaving, and sleeping were 1, 1, and 0, DHI. We measured additional beneﬁt at her 1-wk follow-up respectively. Similarly, her DHI score dropped to a 6/100. that was sustained at her 1, 2, and 3 mo follow-up. Her symptoms remained constant at 2- and 3-mo follow-up, Additionally, she noted her improvement made it easier for however, the patient noted there were days when she was her to complete her activities of daily living and much easier completely symptom free. to perform her job. DISCUSSION CONCLUSION Disembarkment syndrome can cause disabling symptoms. The discussed case describes the treatment of MdMS in an If this patient’s symptoms had not improved, medical evacu- active duty service member, in an austere environment. We ation from the deployed military environment due to safety describe a novel treatment option to evoke re-adaptation of concerns would have been required. the VOR in a resource-limited setting in which traditional This case highlights a non-pharmacologic treatment option pharmaceutical options create occupational hazards and MRI for patients with MdMS. In resource-limited environments either not available or only available for diagnostics not or settings in which a patient’s employment or preferences treatment. MILITARY MEDICINE, Vol. 183, November/December 2018 e777 2-JAN-18 3-JAN-18 4-JAN-18 5-JAN-18 6-JAN-18 7-JAN-18 8-JAN-18 9-JAN-18 10-JAN-18 11-JAN-18 12-JAN-18 13-JAN-18 14-JAN-18 15-JAN-18 16-JAN-18 17-JAN-18 18-JAN-18 19-JAN-18 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e775/4999175 by DeepDyve user on 19 July 2022 4. Dai M, Cohen B, Smouha E, Cho C: Readaptation of the vestibule- REFERENCES ocular reﬂex relieves the mal de debarquement syndrome. Front Neurol 1. Van Ombergen A, Van Rompaey V, Maes LK, Van de Heynig PH, 2014; 5: 124. Wuyts FL: Mal de debarquement: a systemic review. J Neurol 2016; 5. Stratford P: Assessing disability and change on individual patients: a 263: 843–54. report of a patient speciﬁc measure. Physiother Can 1995; 47(4): 258–63. 2. Cha Y: Mal de Debarquement. Semin Neurol 2009; 29(5): 520–7. 6. Jacobson GP, Newman CW: The development of the dizziness handicap 3. Cha Y, Deblieck C, Wu AD: Double-blind sham-controlled cross-over inventory. Arch Otolaryngol Head Neck Surg 1990; 116(4): 424–7. trial of repetitive transcranial magnetic stimulation for Mal de doi:10.1001/archotol.1990.01870040046011v. Debarquement Syndrome. Otol Neurotol 2016; 37(6): 805–12. e778 MILITARY MEDICINE, Vol. 183, November/December 2018
Military Medicine – Oxford University Press
Published: Nov 5, 2018
Keywords: magnetic resonance imaging; military personnel; travel; european continental ancestry group; brain; reflex; sensory perception; persistence; body rocking; military deployment
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