Is vestibular rehabilitation (excluding the Dai protocol) advisable for managing motion-triggered symptoms in patients with Mal de Debarquement Syndrome (MdDS)?

Vestibular Rehabilitation for Motion-Triggered Mal de Debarquement Syndrome (MdDS)

Vestibular rehabilitation therapy (VRT) is not recommended as a primary treatment for motion-triggered MdDS symptoms, as there is insufficient evidence supporting its effectiveness for this specific condition. 1

Understanding MdDS and Treatment Options

• MdDS is characterized by persistent sensations of rocking, swaying, or bobbing that typically occur after motion experiences (e.g., sea, air, or road travel), though it can also occur spontaneously 2, 3
• MdDS differs from Ménière's disease, for which specific vestibular rehabilitation guidelines exist 4
• Traditional vestibular rehabilitation has shown limited effectiveness for MdDS patients, with one study questioning its efficacy as the frequency content of postural sway was not modified by VRT and patient symptoms as measured by Dizziness Handicap Inventory showed no improvement 1

Evidence-Based Treatment Approaches for MdDS

Recommended First-Line Treatment

• The Dai protocol (optokinetic stimulation with head roll) has demonstrated significant effectiveness specifically for MdDS with a 64.1% success rate across both motion-triggered and spontaneous onset types 2
• This specialized VOR readaptation protocol involves optokinetic stimulation paired with head movements at specific frequencies and has shown objective improvements in posturography measures 2, 5

Alternative Treatment Options

• Benzodiazepines and antidepressants have been reported by patients as being most beneficial in reducing MdDS symptoms in both motion-triggered and spontaneous onset groups 6
• These medications are likely effective due to their stress-reducing capacities, as stress is a known trigger for symptom exacerbation 6

Important Clinical Considerations

• Traditional vestibular rehabilitation therapy that is typically effective for peripheral vestibular disorders may not address the underlying pathophysiology of MdDS 1
• A study comparing VRT to healthy controls found that while MdDS patients demonstrated a reduction in sway velocity after VRT, the frequency content of their postural sway remained unchanged, suggesting that VRT does not target the core mechanisms of MdDS 1
• In contrast, studies of the Dai protocol (optokinetic stimulation with head roll) have shown no placebo effect and significant improvements in 48% of patients, with 70% of responders being from the motion-triggered subtype 5

Treatment Algorithm for Motion-Triggered MdDS

1. First-line approach: Refer for specialized VOR readaptation treatment (Dai protocol) which has shown effectiveness in approximately two-thirds of MdDS patients 2, 5
2. Medication management: Consider benzodiazepines or antidepressants for symptom management if specialized treatment is not available or unsuccessful 6
3. Adjunctive therapies: While traditional vestibular rehabilitation alone is not recommended, it may be considered as an adjunct to other treatments, though with limited expectations for symptom improvement 1

Common Pitfalls to Avoid

• Misdiagnosing MdDS as another vestibular disorder like BPPV or Ménière's disease, which have different treatment approaches 4, 7
• Applying standard vestibular rehabilitation protocols designed for peripheral vestibular disorders to MdDS patients without modification 1
• Continuing with traditional vestibular rehabilitation despite lack of improvement, rather than transitioning to specialized protocols designed specifically for MdDS 2, 5

Monitoring and Follow-up

• Regular assessment of symptom severity using validated tools such as the visual analog scale (VAS) and posturography measurements can help evaluate treatment effectiveness 2, 5
• Treatment protocols may need to be adjusted based on individual response, with the greatest postural changes typically occurring within the first 3 days of specialized treatment 5