Research into the Pathophysiology and Therapy Options of  Mal de Debarquement Syndrome


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Imagine getting off a boat, a plane, a train, a shuttle bus or out of a car or an elevator and feeling like you are still in motion. You may have experienced this unusual sensation before, which typically resolves within a few hours. However, for some people this sensation becomes chronic, and is accompanied by a myriad of relentless symptoms, such as instability, anxiety and brain fog – this is Mal de Debarquement Syndrome (MdDS). MdDS is a complex, poorly understood condition which is life changing and currently has no cure.   

We are closer to finding effective treatments than ever before. Help us conduct cutting-edge research that aims to further our understanding of the pathophysiology of MdDS and find more treatments for this debilitating condition.

The research has three main objectives:

  • This study aims to identify the most effective treatment available for MdDS patients  (considering only motion-triggered patients). Three therapies will be compared; Vestibular Ocular Reflex Readaptation Treatment, Neuromodulation Treatment, and a Therapeutic intervention focused on hormones (antagonistic Calcitonin Gene-Related Peptide (CGRP)). 
  • Patients suffering from motion triggered MdDS and from what is considered to be the “spontaneous – non/motion triggered” form of MdDS or a subform of Persistent postural-perceptual dizziness (PPPD) (1) will be assessed with neuroimaging techniques and their data will be compared against PPPD patients and control patients. This assessment will potentially provide us more insights into any pathophysiological differences among these different types of neurovestibular conditions.
  • Given the recent investigations into gonadal hormones and the female predominance of MdDS, this study aims to assess hormonal influences on neurotransmitter activity (e.g. GABA) in MdDS patients. This will allow us to understand the impact of hormones on this condition and also to observe if/and how MdDS subjects differ from migraineous patients and from healthy controls.

Benefits:

The research into MdDS has come a long way recently yet the underlying pathophysiology of MdDS remains unknown. Due to the lack of understanding many healthcare professionals are not even aware of the condition, let alone the symptoms that an individual with MdDS experiences. This has consequently led to a high rate of misdiagnosis, delayed diagnosis and poor patient management. Patients report negative diagnostic experiences with mental health consequences [11] and high socio-economic burden on patients and healthcare systems around the world [11]. 

Our research group aims to perform two novel studies to further advance our understanding of MdDS pathophysiology as well as providing more treatment options for MdDS patients. 

More information about this condition:

What is MdDS?

Mal de Debarquement (MdD) is French for ‘bad disembarkation’. In simple terms it defines the condition of a person that retains the sensation of motion after disembarking from a boat or other vehicle. This feeling can be described as “feeling like you are on a boat, despite being on land”. This phenomenon is often experienced by healthy individuals, however only transiently (2), with the sensations of phantom motion (e.g. phantom feeling of rocking/bobbing/swaying) lasting from a couple of hours to up to a few days (3) (4). However when symptoms last for more than a month from onset, MdD becomes a pathological condition, named Mal de Debarquement Syndrome (MdDS) (5) (6). 

MdDS was only recognised and described as a medical condition in 1987 (7), therefore it can be considered a relatively new disorder, despite being described much earlier by Erasmus Darwin (5). Given its rarity and lack of thorough investigation, MdDS is often misdiagnosed, with patients often suffering long diagnostic journeys which significantly impacts on their mental health (6). Patients report that the symptoms have a negative impact on their relationships, careers and ability to study.  MdDS symptoms also make it extremely challenging for patients to go about their normal everyday activities such as buying  groceries, hanging the laundry, watching TV, having a shower, etc (8) (6) (9). Thus, MdDS has been described as a debilitating condition with a high level of intrusiveness in the lives of patients (6).

Which symptoms characterize MdDS?

MdDS is characterised by a persistent subjective perception of self-motion (i.e.rocking, bobbing, swaying) (10), which is in some cases is accompanied by other symptoms such as heightened visual sensitivity, unsteadiness, brain fog, cognitive slowing, and co-morbidities such as migraine, anxiety and depression (2). Migraine seems to be dominantly present in MdDS patients (11). 

Can anyone get it?

Unfortunately MdDS can affect anyone, however it seems to be more prominent in adult women (age range 30 and 65 years) (11) (12). In most cases, the onset of MdDS occurs after exposure to passive motion (e.g. being on a boat, travel by car or plane or train etc) (12), these patients are referred to as having motion-triggered (MT) MdDS. However, MdDS can also develop spontaneously or following non-motion triggered events, such as surgeries or childbirth. Anecdotally, MdDS symptoms have been reported after the use of virtual reality experience (6). These patients are referred to as having a spontaneous (SO) MdDS onset or non-motion triggered onset (non-MT) (for facilitating the readers we will refer to non-MT patients in the text) (6). Non-MT patients have identical symptoms to patients with MT MdDS, however the potential differences between these two subtypes are still unclear. Figure from Mucci et al 2018 – Journal of Neurology

Figure from Mucci et al 2018 - Journal of Neurology

Figure from Mucci et al 2018 – Journal of Neurology

What do we know about MdDS pathophysiology and treatments options?

Regarding MdDS pathophysiology, two main theories have been formulated (9) and these theories are associated with two distinct proposed therapeutic approaches. 

Theory 1: According to one theory, MdDS pathophysiology has been considered to originate from a maladaptation of the Vestibular Ocular Reflex (VOR) and velocity storage caused by the exposure to passive motion. Based on this theory, a treatment using optokinetic stimuli (OKN) has been developed. The hypothesis of the maladaptation of the VOR supports the usage of OKN exposure to reduce MdDS symptoms (10) (13). As repetitive OKN exposure is able to adapt the velocity storage and modulate the VOR, this treatment has been proven to have the highest success rate in MdDS patients (14) (15) (16). This treatment will be named in this project as VOR readaptation technique.

Optokinetic Chamber

Optokinetic Chamber

Theory 2: Another theory, following recent neuroimaging and neuromodulation studies (17) (18), describes MdDS as a disorder of abnormal functional connectivity [8, 18]. This theory has led to experimental neuromodulation treatments; such as transcranial Direct Current Stimulation (tDCS) (19) (17) which is based on cathodal transcranial stimulations and low frequency repetitive Transcranial Magnetic Stimulation (rTMS) (16). 

Although neuromodulation treatments have promising results, their success rate remains lower than the use of the VOR re-adaptation technique (18) (16). Further research is needed to explore the benefits of such techniques and also if a combination of neuromodulation and OKN treatment may help easing the myriad of symptoms MdDS patients experience. These two primary theories regarding MdDS pathophysiology, the maladaptive VOR and neuroplasticity disorder, may not be mutually exclusive (9). However to date it remains unclear how they may be interrelated.

tDCS Device

A new line of research – Hormones / Migraine and MdDS: 

In addition to these two main theories, an additional hypothesis has been recently formulated (20). Many questions remain to be addressed considering MdDS pathophysiology. 

Thus, in the past few years our research group has also focused on hormones, especially considering the great female dominance present in MdDS (80% of sufferers are female) (11). Together with my colleagues, we have investigated whether gonadal hormones influence MdDS pathophysiology and/or symptomatology. We presented the data collected through a retrospective online survey on male and female patients from both MT and non-MT onset groups (11). From our findings, we reported a predominance of female patients. Within this group, it was clearly reported that symptoms were aggravated during menstruation and around the mid cycle in female MT patients. This triggered us to propose a new theory where symptoms in female MdDS patients may be aggravated by estrogen withdrawal, similarly to what occurs in migranienous patients.

Fluctuations of estrogen, progesterone and luteinizing hormone during a typical 28-day menstrual cycle. Abbreviations EST- estrogen, PROG- progesterone, LH- luteinizing hormone.

We also ran a novel study specifically designed for pregnant MdDS patients (21). From the data collected, most participants reported an improvement of symptoms during the 9 months of pregnancy (21). We propose that this is due to the absence of estrogen withdrawal and high levels of estrogen and progesterone, which may alleviate MdDS symptoms. Despite being preliminary, we hope that the results will lead to more studies into the gonadal influence on vestibular symptoms.

From this reasoning, a new theory was created. This theory considers how hormonal changes might influence neurotransmitters, rendering patients more predisposed to developing MdDS, as well as explaining their symptom fluctuation (21).

a) representation of normal distribution of CGRP and b) representation of higher distribution of CGRP (i.e. during migraine attacks)

With regards to this concept it is also important to consider the relationship between MdDS and migraine. Considering recent findings, CGRP has been implicated in the pathophysiology of migraine, mainly after observing that CGRP levels were higher during a migraine attack (22). Additional studies have shown that CGRP can be influenced by hormonal changes (23). CGRP is known to be involved in the “hot flashes”, occurring during perimenopause and menopause (24) by acting centrally on the thermoregulatory centre of the hypothalamus as well as peripherally to cause vasodilation and sweating. Similarly CGRP is also known for being able to influence the trigeminal nociceptive system (20), possibly involved in migraine. Thus, from these recent findings new therapeutic options are emerging by developing antagonistic CGRP drugs (24) (22) to help manage migraine and hormonal changes. By considering the strong link between migraine and MdDS (25), it is possible that CGRP may equally hold some relevance with regards to MdDS pathophysiology. This hypothesis needs further assessment and investigation, hence in qualified patients, this new therapeutic line may be pursued.

What remains to be addressed?

Our research group aims to perform two relevant studies to further advance our understanding of MdDS pathophysiology a well as identifying the most effective treatment options for MdDS patients. 

The first step is to be able to diagnose and distinguish MdDS from other central vestibular disorders such as PPPD. 

It remains unclear how hormonal fluctuations may influence MdDS symptoms as well as if gonadal hormones influence specific neurotransmitters (e.g. GABA). Assessing central changes in MdDS patients and in patients with migraine and comparing them with healthy age matched controls may help us to further understand MdDS pathophysiology. 

Another aspect that remains to be addressed is treatment options. We aim to investigate which one is the most effective treatment for MdDS. This will be done by comparing different types of treatments between each other. Comparisons between the VOR readaptation technique treatment [12, 13] and neuromodulation therapies (such as: transcranial direct current stimulation (tDCS)) [39], as well as additional therapeutic intervention focused on hormones (e.g. antagonistic Calcitonin Gene-Related Peptide (CGRP)), and how effective they are in treating the symptoms of patients and if a combination of those may give better results.

Objectives

This project aims to advance the current understanding of MdDS (and other central vestibular disorders) pathophysiology and subtypes differences between MT, SO, MdDS and PPPD with a particular focus on female patients. 

Further assessing therapeutic options for MdDS will not only provide more information about which treatment is the most effective for the different MdDS subtypes but also explore potential pathophysiological differences present between MT and non-MT/SO MdDS patients.

Why is this research important?

Firstly neuroimaging studying comparing different types of central vestibular disorders may provide us some insights into MdDS neural pathways differences or similarities with other disorders and identify potential biomarkers. This could facilitate the diagnostic process in the future.

 

Currently it is unknown why there is such a great gender predominance of female patients affected by MdDS. This study will be the first of this kind to assess in great detail the hormonal profile of MdDS female patients. Additionally, this study for the first time will try to evaluate further the interaction between the GABAergic system, hormonal fluctuations and neuro-vestibular symptoms in MdDS patients

 

Gaining information about whether hormonal levels correlate with brain alterations found in MdDS patients and, perhaps more practically, whether further treatment should consider these hormonal fluctuations on therapeutic choices may be of great relevance to ease MdDS symptoms and develop successful treatments. 

 

Considering the lack of therapeutic options for MdDS subjects, this project for its second phase aims to implement the VOR readaptation treatment, which is considered the treatment with the highest success rate.  We will simultaneously offer the patients who report aggravation of symptoms during menses to try CGRP antagonist drug therapy. While another independent group will be assessed with tDCS or TMS neuromodulation treatment. 

Summary: This project is extremely relevant to understanding the fundamental pathophysiology MdDS and differentiating the condition from other central vestibular disorders. In addition to this, our research will give insights into novel treatment options and the role of hormones in MdDS symptomatology.

Who are we going to include in the study?

  • Female and Male subjects 
  • Age 18 to 65  yrs old 
  • MdDS patients (with Motion Triggered Onset/Non-motion triggered onset)
  • Patients suffering from PPPD
  • Patients suffering from Vestibular Migraine

What do you think are the potential outcomes of the work?

  • We will gain more information about the hormonal profiles in female MdDS patients We may potentially understand if MdDS patients differ from migraineous and healthy control subjects with regards to GABAergic changes. 
  • We will gain neuroimaging data about the different MdDS subtypes and PPPD 
  • We may potentially identify which treatments is the most effective for patients with MdDS

Budget

In order to perform this study, we need to acquire new equipment, purchase consumables, and – most importantly – allow patients to join the treatment for free.

The budget estimation for the whole project is of: 49,000 Euros = 43,660.30 £ Pounds

This will allow us to assess 80 patients with functional Magnetic Resonance, to include patients for an experimental treatment using tDCS/ TMS and VOR readaptation. The study will be performed in Italy with the support of the Australian lab of Dr.Cherylea Browne. 

What happens if we don’t reach our target? 

If the target is not met we will revise the project, if we have enough money, we will consider running a pilot study; or we may extend the deadline. 

What happens if we raise more money than what is planned? 

If we exceed the target we will be able to allow more patients to partake in the studies and to perform them in the next two years.

Endorsements:

“Since launching this crowdfunding campaign clinicians who do understand the severity of MdDS have offered their support and endorsement including Mr Stephen Darius Rejali who wrote this: “MdDS is a challenging disorder causing significant problems for many patients. Although recent development with Optokinetic treatments are promising more work is required to understand the pathology-physiological mechanisms of this disorder. Further research will eventually lead to better treatments. As an ENT specialist with an interest in this disorder I have supported crowdfunding for MdDS research to help my patients.”

“It will be tremendous if further funding can be secured for MdDS research. Higher centre processing is without doubt the next frontier in balance research.” Professor Peter Rea.”

 

In 2018 an important achievement for the vestibular field and MdDS research was made when a consortium of researchers won The Frontiers in Science Spotlight Award.  In memory of Prof.Cohen, who had a key role in this achievement. We would like to remember him and everyone who worked for the  special issue “Vestibular Contributions to Health and Disease”,  which won the prize last year. https://www.frontiersin.org/research-topics/4868/vestibular-contributions-to-health-and-disease

Team

Dr. Viviana Mucci has dedicated her time over the past years investigating central vestibular disorders and dizziness. Her Ph.D. focussed on researching Mal de Debarquement Syndrome at Antwerp University.  She then moved to Switzerland where she worked in collaboration with the University of Geneva, the University Hospital of Zurich and the Swiss concussion centre on MdDS and central vestibular disorders. She was then invited to take a position in New York at Icahn School of Medicine at Mount Sinai Hospital, for a short time. She then returned to Europe and is now based in Rome at the Foundation Santa Lucia with an Adjunct position at The School of Science at Western Sydney University, Australia. 

In 2018 Dr.Mucci and  Dr.Browne and a team of MdDS researchers launched the largest survey on MdDS, where they performed the first ever study on hormonal influences on MdDS symptoms. In early 2019 Dr.Mucci and Dr.Browne published their work on women who had been pregnant while having MdDS. Dr. Browne is a Senior Lecturer in Human Anatomy at Western Sydney University 
and a Conjoint Lecturer at the School of Medical Sciences, UNSW Sydney. She is also head of the MdDS research lab, Australia. She has an extended knowledge about MdDS and she co-promoted Dr.Mucci’s Ph.D. In addition to this, a new team of experts has been called to join the research on MdDS. In primis Prof Iole Indovina, Associate Professor of Physiology at the University of Messina, Italy, and head of the Vestibular Research laboratory at Santa Lucia Foundation in Rome. She is an expert in persistent postural-perceptual dizziness (PPPD) and Magnetic Resonance Imaging (MRI). Her research in the past years has been focusing on brain mechanisms of perception and cognition through functional MRI. The team also involves Prof. MD Lucio Marinelli, assistant Professor in Neurology at Genoa University in Italy.  Dr.Marinelli is author of 79 peer-reviewed articles published in international PubMed or Scopus indexed journals (25 as first or last author, 51 as co-author, 3 as group collaborator). He has extended clinical experience and will be helping in the diagnostic process and patient management. The team is also supported by Prof. Bruno Burlando from the faculty of Pharmacology at Genoa University. Bruno has recently provided new theoretical models for the development of MdDS. 

Together this team will be capable of successfully continuing to research MdDS and developing innovative approaches to this complex and debilitating disorder. 

A picture of the Barany Conference 2018 with Dr.Dai (Assistant Professor Icahn School of Medicine, Mount Sinai, NYC, USA), who we honour and remember after he sadly passed away last February. Dr.Dai has dedicated his life to research Motion Sickness and MdDS. It is because of his work that patients can access OKN treatment. On the right side of the picture are Dr. Mucci and Dr.Yakushin.

More about each team member:

Dr. Viviana Mucci

Dr. Viviana Mucci (Ph.D) is a postdoc researcher from Western Sydney University, Sydney Australia and the Foundation of Santa Lucia Rome, Italy. She previously worked at the university of Zurich University of Geneva,the Swiss Concussion Centre, Schulthess Klinik in Switzerland. Viviana won the Future Science Early Career Research Award in 2018, following her work on Mal de Debarquement Syndrome performed during her Ph.D. She completed her Ph.D. program in the field of Neurotology in July 2018 from Antwerp University, Faculty of Medical Science. Her background involves a BSc in Medical Physiology (University of East London, UK), which she completed with distinction in 2012 and a MSc in Space Physiology and Health from King’s College London (UK), where she graduated in 2013. Since her Ph.D. Viviana’s work has been focused  on continuing to investigate Mal de Debarquement Syndrome.  She is currently focusing on central vestibular disorders on a broader aspect including PPPD and post concussion dizziness in addition to MdDS. Although the neuro-vestibular knowledge has grown over the last few decades there are still many pieces of this remarkable system that remain to be addressed. This lack of knowledge is a strong drive for Viviana to continue pursuing research in this particular field.

 Viviana and the other team members have worked together in previous projects.

Dr. Iole Indovina

Dr. Iole Indovina is Associate Professor of Physiology at the University of Messina, Italy, and head of the Vestibular Research laboratory of Neuromotor Physiology at Santa Lucia Foundation in Rome. She is also affiliated to the Centre of Space BioMedicine at the University of Tor Vergata Rome, Italy. She is an expert in persistent postural-perceptual dizziness (PPPD) and Magnetic Resonance Imaging (MRI). Her research in the past years has been focusing on brain mechanisms of perception and cognition through functional MRI. She researched the visual-vestibular perception and encoding of motion in the gravitational field, from object motion to self-motion, to neural coding of navigation in the three-dimensional space. She developed functional-MRI protocol of visual and vestibular stimulation and applied specific analysis.

Dr.Lucio Marinelli

Dr. Lucio Marinelli is assistant professor of Neurology at the University of Genoa since 2011. He graduated as MD in 1999 and specialized in Neurology in 2004. He obtained his Ph.D. in Neurophysiology and Neuropharmacology in 2008. His research interests focus on the pathophysiological mechanisms of alterations in muscle tone in stroke survivors, patients with movement disorders, multiple sclerosis and cognitive impairment, using neurophysiological methods that are therefore able to explore the nervous system from a functional point of view. He is author of several publications and clinically conducts electromyography, nerve conduction studies, evoked potentials, EEG interpretation, intraoperative monitoring, botulinum toxin treatment and nerve blocks at the Neurophysiology Unit – San Martino Hospital, Genova. He serves as ad-hoc reviewer for many international journals and is editor for the European Journal of Molecular & Clinical Medicine and Frontiers in Neurology – Movement Disorders. This is his Orcid ID. More information is available on his home page and Publons profile.

Bruno Burlando

Bruno Burlando is professor of Physiology at the University of Genova, Italy. He is an expert in cellular physiology, notably intracellular calcium dynamics and its cross-talking signal transduction mechanisms. He is author of more than 120 peer-review papers and book articles, 1 scientific book, 2 WO patents, and several contributions to scientific meetings (H index: 31-Scopus, 28-WOS, 34-Google Scholar). In 2017, he formulated a theoretical framework aimed at yielding a synthetic, comprehensive view of the functioning of living beings, named Loopomics. This entails a completely new way of looking at living beings, which are essentially seen as control systems that realize arrays of dynamic feedback loops. A determinant feature in the behavior of loop dynamics is the existence of candidate oscillators (homeostasis, pacemakers) and multistationary systems (cell growth, differentiation, development). In multistationary systems, an external perturbation can induce the transition from an equilibrium point to another equilibrium point. A corollary of Loopomics is that the pathogenesis of any disease, including MdDS, must involve at least one endogenous positive loop. According to this view, detecting the loop(s) that drive the transition from healthy to pathological conditions is fundamental for an understanding of the pathogenic mechanism, allowing to identify critical pharmacological targets for the development of clinical treatments.

Dr. Cherylea Browne

Dr.Cherylea Browne is a Senior Lecturer in Human Anatomy at Western Sydney University 
and a Conjoint Lecturer at the School of Medical Sciences, UNSW Sydney. She completed a Bachelor of Medical Science with honours at The University of Sydney in 2007 majoring in Cell Pathology, Anatomy and Neuropathology, and completed her PhD in Auditory Neuroscience in 2013 at Western Sydney University. She is an anatomist with ~9 years’ experience teaching a broad range of units to medical, clinical health science and 
postgraduate students, across various educational and training institutions 
She has also a broad background in neuroscience researcher with ~12 years’ experience – currently focusing on investigating the underlying 
mechanisms of Mal de Debarquement Syndrome specifically focussing on the hormonal influences and sympathetic nerve activity.  She is also involved with the Translational Neuroscience Facility at UNSW Sydney working on the use of pulsed electric 
fields for gene delivery to stimulate neural regeneration. She is the head of the Mal de Debarquement Syndrome Research Group, in Australia. She is also a member of the Mal de Debarquement Syndrome Australia Medical Advisory Board. She is actively involved in community outreach programs and events promoting science and higher education 
as well as promoting Mal de Debarquement Syndrome research.

Thank you note

Thanks to Enea Ferrari (www.eneaferrari.ch , Instagram: eneaphotography) who has contributed to the creation of the video content.

References: 

References: 

  1. Staab JP, Eckhardt-henn A, Horii A, Jacob R, Strupp M. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. J Vestib Res. 2017;27(4):191–208. 
  2. Cha Y, Cui YY, Baloh RW. Comprehensive Clinical Profile of Mal De Debarquement Syndrome. Front Neurol. 2018;9(May):1–10. 
  3. Cha Y-H, Baloh R., Cho C, Magnusson M, Song J-J, Strupp M, et al. Mal de Débarquement Syndrome: Diagnostic Criteria Consensus document of the Classification Committee of the Bárány Society. Consens Pap Barany Soc [Internet]. 2017;53(9):1689–99. Available from: file:///C:/Users/User/Downloads/fvm939e.pdf
  4. Cha Y-H. Mal de debarquement. Semin Neurol [Internet]. 2009;29(5):520–7. Available from: http://archotol.jamanetwork.com/article.aspx?articleid=509503
  5. Van Ombergen A, Van Rompaey V, Meas LK, Van de Heyning PH, Wuyts FL. Mal de debarquement syndrome : a systematic review . J Neurol. 2016;263(5):843–854. 
  6. Mucci V, Canceri JM, Brown R, Dai M, Yakushin S, Watson S, et al. Mal de Debarquement Syndrome: a survey on subtypes, misdiagnoses, onset and associated psychological features. J Neurol [Internet]. 2018;265(3):486–99. Available from: http://link.springer.com/10.1007/s00415-017-8725-3
  7. Brown J, Baloh R. Persistent mal de debarquement syndrome: a motion-induced subjective disorder of balance. Otol Neurotol. 1987;8(4):219–22. 
  8. Hain TC, Cherchi M. Mal de d ebarquement syndrome. Handb Clin Neurol. 2016;137:391–5. 
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  10. Dai M, Cohen B, Smouha E, Cho C. Readaptation of the Vestibulo-Ocular Reflex Relieves the Mal De Debarquement Syndrome. Front Neurol [Internet]. 2014;5(July):1–6. Available from: http://journal.frontiersin.org/article/10.3389/fneur.2014.00124/abstract
  11. Mucci V, Canceri JM, Brown R, Dai M, Yakushin SB, Van Ombergen A, et al. Mal de Debarquement syndrome : a retrospective Online Questionnaire on the influences of gonadal hormones in relation to Onset and symptom Fluctuation. Front Neurol. 2018;9(May):1–16. 
  12. Hain TC, Cherchi M, Dizziness C, Sciences HM. Mal de d ebarquement syndrome. Handb. 2016;137. 
  13. Cohen B, Yakushin SB, Cho C. Hypothesis : The Vestibular and Cerebellar Basis of the Mal de Debarquement Syndrome. Front Neurol. 2018;9(February):28. 
  14. Mucci V, Perkisas T, Jillings SD, Van Rompaey V, Van Ombergen A, Fransen E, et al. Sham-Controlled Study of Optokinetic Stimuli as Treatment for Mal de Debarquement Syndrome. Front Neurol [Internet]. 2018;9(October):1–13. Available from: https://www.frontiersin.org/article/10.3389/fneur.2018.00887/full
  15. Dai M, Cohen B, Cho C, Shin S, Yakushin SB, Yakushin SB. Treatment of the Mal de Debarquement syndrome : a 1-Year Follow-up. Front Neurol. 2017;8(May):1–10. 
  16. Canceri J., Brown R, Watson SR, Browne C. An Examination of Current Treatments and Symptom Management Strategies Utilized by Mal de Debarquement Syndrome Patients. Front Neurol. 2018;9(November):1–13. 
  17. Cha YH, Urbano D, Pariseau N. Randomized Single Blind Sham Controlled Trial of Adjunctive Home-Based tDCS after rTMS for Mal De Debarquement Syndrome: Safety, Efficacy, and Participant Satisfaction Assessment. Brain Stimul [Internet]. 2016;9(4):537–44. Available from: http://dx.doi.org/10.1016/j.brs.2016.03.016
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  19. Shou G, Member I, Yuan H, Member I, Urbano D, Cha Y, et al. Changes of Symptom and EEG in Mal de Debarquement Syndrome Patients after Repetitive Transcranial Magnetic Stimulation over Bilateral Prefrontal Cortex : A Pilot Study. In: Conf Proc IEEE Eng Med Biol Soc. 2014. p. 4294–7. 
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    Corporate Sponsor: This crowdfunding campaign is now open to corporate sponsorship. Any companies donating £1,000 or more (or the equivalent in any currency) will have the option to have their logos displayed here and have their names mentioned on the public MdDS pages. If you would like to participate, please contact Dr Viviana Mucci via Viviana.mucci@gmail.comfor further information

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    Thank you for your generous support! In addition to the monthly Research Update email (and yes you can unsubscribe at any time!), all manuscript PDFs, we will include your name (if you wish) on any manuscript in the acknowledgements as a generous donor! The first 2 backers contributing at this level will receive a ‘thank you’ artwork made by a Artist from the Accademia delle belle Arti of Brera, Milan, Italy.

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    Thank you for your generous support! In addition to the monthly Research Update email (and yes you can unsubscribe at any time!), all manuscript PDFs, we will include your name (if you wish) on any manuscript in the acknowledgements as a generous donor! The first 2 backers contributing at this level will receive a ‘thank you’ artwork made by a Artist from the Accademia delle belle Arti of Brera, Milan, Italy.

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    Thank you for your generous support! In addition to the monthly Research Update email (and yes you can unsubscribe at any time!), and manuscript PDFs, we will include your name (if you wish) on any manuscript in the acknowledgements as a generous donor! The first 2 backers contributing at this level will receive a ‘thank you’ artwork made by a Artist from the Accademia delle belle Arti of Brera, Milan, Italy.

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    Thank you for your generous support! In addition to the monthly Research Update email (and yes you can unsubscribe at any time!), and manuscript PDFs, we will include your name (if you wish) on any manuscript in the acknowledgements as a generous donor! The first 2 backers contributing at this level will receive a ‘thank you’ artwork made by a Artist from the Accademia delle belle Arti of Brera, Milan, Italy.

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CONTINUE
  • 25 Backers

    Thank you for your generous support! We will keep you updated on our experiments via a monthly Research Update email (and yes you can unsubscribe at any time!).

  • 5 Backers

    Thank you for your generous support! We will keep you updated on our experiments via a monthly Research Update email (and yes you can unsubscribe at any time!).

  • 2 Backers

    Thank you for your generous support! We will keep you updated on our experiments via a monthly Research Update email (and yes you can unsubscribe at any time!).

  • 23 Backers

    Thank you for your generous support! In addition to the monthly Research Update email (and yes you can unsubscribe at any time!), we will send you a PDF of any manuscript that arises from this project!

  • 1 Backer

    Thank you for your generous support! In addition to the monthly Research Update email (and yes you can unsubscribe at any time!), we will send you a PDF of any manuscript that arises from this project!

  • 2 Backers

    Corporate Sponsor: This crowdfunding campaign is now open to corporate sponsorship. Any companies donating £1,000 or more (or the equivalent in any currency) will have the option to have their logos displayed here and have their names mentioned on the public MdDS pages. If you would like to participate, please contact Dr Viviana Mucci via Viviana.mucci@gmail.comfor further information

  • 1 Backer

    Thank you for your generous support! In addition to the monthly Research Update email (and yes you can unsubscribe at any time!), we will send you a PDF of any manuscript that arises from this project! The first 2 backers contributing at this level will receive a ‘thank you’ artwork made by a Artist from the Accademia delle belle Arti of Brera, Milan, Italy.

  • Backers

    Thank you for your generous support! In addition to the monthly Research Update email (and yes you can unsubscribe at any time!), all manuscript PDFs, we will include your name (if you wish) on any manuscript in the acknowledgements as a generous donor! The first 2 backers contributing at this level will receive a ‘thank you’ artwork made by a Artist from the Accademia delle belle Arti of Brera, Milan, Italy.

  • Backers

    Thank you for your generous support! In addition to the monthly Research Update email (and yes you can unsubscribe at any time!), all manuscript PDFs, we will include your name (if you wish) on any manuscript in the acknowledgements as a generous donor! The first 2 backers contributing at this level will receive a ‘thank you’ artwork made by a Artist from the Accademia delle belle Arti of Brera, Milan, Italy.

  • Backers

    Thank you for your generous support! In addition to the monthly Research Update email (and yes you can unsubscribe at any time!), and manuscript PDFs, we will include your name (if you wish) on any manuscript in the acknowledgements as a generous donor! The first 2 backers contributing at this level will receive a ‘thank you’ artwork made by a Artist from the Accademia delle belle Arti of Brera, Milan, Italy.

  • Backers

    Thank you for your generous support! In addition to the monthly Research Update email (and yes you can unsubscribe at any time!), and manuscript PDFs, we will include your name (if you wish) on any manuscript in the acknowledgements as a generous donor! The first 2 backers contributing at this level will receive a ‘thank you’ artwork made by a Artist from the Accademia delle belle Arti of Brera, Milan, Italy.