Effect of the BrainPort™ Balance Device on Patients with Mal de Debarquement Syndrome Robert J. Stanley, MD Kimberly L. Skinner, MPT Yuri Danilov, PhD

Mal de Debarquement Syndrome (MdDS) “Bad Disembarkment” Rare – but more common than reported Misunderstood Life-altering Usually follows a cruise or similar activity

MdDS: Balance Symptoms Key=Persistent sensation of motion Difficulty maintaining balance Ataxia Dizziness Sx’s may abate during auto travel, yet increase afterwords

MdDS: Other Symptoms Fatigue Concentration problems “Heavy head” / Headache Memory loss Anxiety and/or Depression

MdDS: Diagnosis No definitive test to diagnose Clinical diagnosis Patients often include middle-aged women

MdDS: Etiology ? Unknown ? Inappropriate vestibular adaptation after a motion experience ? Migraine variant ? Under reliance on vestibular and visual inputs and increased dependence on somatosensory system for balance

MdDS: Prognosis May last months to years Symptoms often recur secondary to motion challenge or stress

MdDS: Treatment No known cure Physical Therapy – may help Medication (eg. Benzodiazepines, amitriptyline) may help

BrainPort™ Balance Device

Stimulus and Response Accelerometer sends head position information to the electrode array on tongue Patient feels tongue stimulus relative to head position (e.g. head left = signal on left side of array) Patient maintains a centered body position by keeping the signal at center of tongue Patient continues this task for 20 minutes, standing with eyes closed

BrainPort™ Balance Device: Why The Tongue High density of nerve endings Minimal electrical stimulation required Receives and transmits signals to the brain at high resolution and speed Close proximity to vestibular pathways Consistent electrical contact Constant chemical environment Saliva is a good electrolyte Non-invasive

Subject adjusts stimulus to Patient Training Subject stands with eyes closed, using the signal on their tongue to maintain a centered position Subject adjusts stimulus to a comfortable level

Results Improved symptoms Decreased rocking sensation when still and after walking Decreased head pressure Easier to control visual disruptions

Results Improved function Able to turn head and change directions when walking without veering to one side Exhibits confident, normal gait Stable when standing on right and left leg. Able to stand in tandem Romberg position with eyes open and closed

Improved function cont. Results Improved function cont. Improved sleep Improved cognitive awareness Less difficulty with words Feels more stable

Improved function cont. Results Improved function cont. Less difficulty with driving Able to shop in busy environment and fluorescent lighting without being disturbed Able to walk comfortably in a crowd

Results

Results

Results

Results

Theories: Why does it work? ? Biofeedback  Head stabilization ? Head stabilization  affect on tonic neck reflexes ? Activation of vestibular nucleus through direct stimulation of lingual nerve pathway

Scope of Patients Tested Nature of Deficit Etiologies Tested Common Observations Peripheral Ototoxicity Ménière's disease Acoustic Neuroma Perilymphatic Fistulas Endolymphatic Hydrops Vestibular neuritis Improved Decreased Balance Posture Gait DHI ABC DGI Falls Stiffness Rigidity Fatigue Oscillopsia Central Migraine Auto Immune degeneration Mal de Debarquement Idiopathic origin Age-related vestibular loss Non-Vestibular Central Cerebellar lesion Cerebellar ataxia – stroke, brain trauma Parkinson’s Disease

Other Ongoing Studies Bilateral Vestibular Loss Mayo Clinic Washington University University of Wisconsin Unilateral Vestibular Loss HNO Klinik, UKB, Berlin Universitätisklinik der RWTH, Aachen Hôspital Lariboisière, Paris Great Ormond Street Hospital, London Elderly with Balance Dysfunction