Streamlining MdDS Treatment: The Art of Clinical Judgment and VOR Re-adaptation (Time Under Tension & Individualized Care)
Brian Werner, your National Director of Vestibular Education & Training at FYZICAL, is a fellow PT passionate about vestibular.
Today, I want to discuss a significant study on Mal de Debarquement Syndrome (MdDS) treatment: "Guideline for standardized approach in the treatment of the Mal de Debarquement syndrome" by Schoenmaekers et al. (2024). This research offers valuable insights into VOR readaptation, emphasizing efficiency, the critical role of clinical judgment, and the practical application of key clinical tools. However, it also raises important questions about treatment duration and the necessary time under tension for neurological adaptation.
MdDS, as many of you know, is a challenging condition with persistent self-motion sensations. Traditionally, treatment varied widely, often involving lengthy daily sessions. This new study aimed to standardize and streamline the process while acknowledging the importance of individualization.
Schoenmaekers and their team conducted a study with 131 treatments across 101 patients, focusing on a standardized optokinetic stimulation (OKS) protocol combined with controlled head rolls. The core protocol, as a guideline, involves:
Optokinetic Stimulation (OKS): A moving stripe pattern with 10 degrees per second velocity.
The direction of the stripes is determined using the Fukuda Stepping Test, a crucial tool in our arsenal, and patient subjective reports. If a patient rotates left during the Fukuda test, the OKS moves right, and vice versa. Forward deviations indicate downward OKS. When the Fukuda Stepping test does not produce a clear direction of rotation, the patient's subjective reports are even more critical.
Head Roll: Manual oscillation in the frontal plane, with a range of ±20 degrees, at a frequency of 0.167 Hz (approximately 10 BPM). An auditory cue is used to maintain rhythm.
Treatment Schedule: Typically, three consecutive days, two sessions daily (morning and afternoon), and two 4-minute blocks per session. Patients are encouraged to remain active between sessions.
Crucially, this protocol is a guideline, not a rigid prescription. While the study demonstrated positive results with 8 minutes of daily treatment (4 minutes, twice a day), I am unsure whether this is sufficient time under tension for the central nervous system to adapt, especially in more severe cases of MdDS.
This is where your clinical judgment becomes paramount. While the study shows results with this protocol, it is your clinical decision to adjust the number of daily sessions and treatment duration based on individual patient needs and responses. Monitoring for symptom exacerbation is essential, and session frequency and duration should be adjusted accordingly.
The severity of the MdDS disorder will significantly influence the required treatment time. More severe cases require longer and more frequent treatment sessions to drive meaningful neurological change. Eight minutes a day may not be enough for substantial adaptation in these cases.
Compared to older protocols, this approach reduces treatment time, enhancing practicality and adherence. The study demonstrated significant improvements in patient outcomes, both subjectively (VAS scores, symptom questionnaires) and objectively (posturography), with no significant difference between motion-triggered (MT-MdDS) and spontaneous-onset (SO-MdDS) MdDS.
The Fukuda Stepping Test is vital in determining OKS direction, counteracting the patient's rotational drift. Maintaining a 10 BPM rhythm during head rolls is also essential for effective treatment.
Why does this matter to us as PTs? This study provides robust evidence for an efficient OKS protocol but underscores the importance of clinical judgment, particularly regarding treatment duration. We must adapt the protocol to each patient, prioritizing their safety, well-being, and the necessary time for neurological adaptation.
Key Takeaways:
MdDS treatment is evolving toward efficiency, but clinical judgment remains paramount, especially regarding treatment duration.
VOR readaptation is effective when tailored to the individual, considering the severity of their condition.
The Fukuda Stepping Test and precise 10 BPM rhythm are crucial.
Clinical decision-making will always be essential to treatment, including determining the appropriate time under tension for neurological adaptation.
Further research is needed to explore long-term outcomes and optimize individualized approaches. I encourage you to read the complete study and join us on this journey of discovery.
As always, I'm here to share the latest research and insights to help you provide the best possible care for your patients.
Stay tuned for more updates, and let's continue advancing the vestibular rehabilitation field together.
Until next time,
Brian K. Werner, PT, MPT National Director of Vestibular Education & Training at FYZICAL
Reference
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 Mar 19;15:1359116. doi: 10.3389/fneur.2024.1359116. PMID: 38566854; PMCID: PMC10985174.