Innovation reality, displays and also smart phones.2 Susceptibility

Innovation of transportand industry have led to provocative motion environments, to cars,  trains, funfair rides, aircraft, andsimulators.1 Thus Motion sickness is a common problem in peopletravelling by train, airplane, boat and especially cars. Also people experiencemotion sickness from virtual reality, displays and also smart phones.2Susceptibility to motion sickness is higher in individuals  suffering from spatial disorientation(35.

05%), migraine (26.31%), gastrointestinal disorders (26.82%) and those whomore sensitive to unpleasant odors (24.

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64%). Females (27.3%) are moresusceptible to motion sickness than males(16.8%).6 Initial symptomsis discomfort in stomach, followed by nausea. With rapid worsening of symptomsthere can be salivation changes, dizziness, retching and sopite related symptoms.3,4The primary functionsof the vestibular system are spatial orientation, maintenance of balance, andstabilizing of vision through vestibular–ocular reflexes.15Motion issensed by the brain through three different pathways of nervous system that sendsignals coming from inner ear( sensing motion, acceleration, gravity), theeyes(vision),and the deeper tissues of body surface(proprioceptors).

When thereis an unintentional movement of the body, the brain responds to unfamiliarmotion stimuli which are transmitted to vestibular nuclei. This unfamiliarmotion stimuli is sensed by vestibular labyrinth, the eyes and proprioceptorsand travel to vestibular nuclei, then through cerebellum to vomiting centrelocated in the parvicellular formation of medulla oblongata, this conflictamong the brain and the three pathways lead to motion sickness.16Currently the “neural mismatch theory” states that motion sickness canoriginate from within a single sensory system (e.

g., canal-otolithinteraction), or between two or more sensory systems (e.g. visual-vestibularinteraction).

19,20 As the vestibular system plays a crucial role in the inducement ofmotion sickness, vestibular habituation exercises will help reduced motionsickness. Repetitive vestibular stimulation can therefore cause changes inVestibulo-Ocular Reflex (VOR) and at the same time a reduction in sensitivityto motion sickness.30 Habituation exercisesare based on the mechanism that repeated exposure to a provocative stimulus(e.g. head movements) will lead to a reduction of the motion-provoked symptoms.32These exercises cause a habituation effectcharacterized by decreased sensitivity and duration of symptoms canoccur in as quickly as 2 weeks but can take as long as 6 months.31Effects of breathing strategy have explored by number of experts. Paul Lehrer aleading researcher in area of relaxation training showed that breathingapproach can be quite successful in in reducing physiologic activation of thesympathetic nervous systems.

33A commonly used DiagnosticCriteria for Identifying the Severity of acute motion sickness and theDiagnostic Scale, referred to as Motion Sickness Assessment Questionnaire whichis a reliable method for scoring overall motion sickness with the use of foursubscales is used in this study for rating these symptoms of motion and todifferentiate motion sickness symptoms along four dimensions: gastrointestinal,central, peripheral, and sopite-related.36 Motion sickness affects nearly all people whotravel by land, sea, or air, little documentation exists regarding preventionand management. Repeated recurrence of sickness is not desirable or practicalto daily living.

Limited evidence is available for Controlled breathing andvisual-vestibular habituation training for motion sickness that won’t provokethe undesirable symptoms and can last for upwards of a year. Thus aim of thisstudy was to help determine the effectiveness of visual vestibular habituationand controlled breathing for motion sickness. The research questions were: Isvisual-vestibular habituation and controlled breathing effective for motionsickness? Will there be any difference in severity of motion sickness whentreated with visual vestibular habituation and controlled breathing for motionsickness?METHODDesignThe design was within-inparticipants, experimental study. The study duration was for 2 months (10Sep2017- 27 Nov2017), with intervention of 5 days per week for 2 weeks. Theoutcome measures, Motion Sickness Assessment Questionnaire (MSAQ) andDiagnostic criteria for identifying the severity of acute motion sickness was assessedat Baseline and at the end 2nd week of intervention also a follow upwas taken at the end of 8th week. The study was approved (Ref. No.

PIMS/CPT/IEC/2017/511) from the Institutional Ethical Committee of Dr. A.P.J.Abdul Kalam College of Physiotherapy, Pravara Rural Hospital. Written informedconsent was obtained from all participants.ParticipantsYoung adults of PravaraRural Hospital, Loni susceptible to motion sickness were eligible toparticipate in study if they had visual acuity 6/6 on Snellen chart and thosediagnosed with motion sickness according to criteria for identifying theseverity of acute motion sickness. Participants between age group 18-30 yearsand road travellers were included.

Participants diagnosed with posturalinstability, vestibular disorders, migraine with neurological deficit andorthopedic condition, cognitive and perceptual deficit. Also Participants withany respiratory problems and pregnant females were excluded from the study.INTERVENTION   Total 46 subjects were screened outof which 5 did not fit ininclusion criteria. Then written informed consent was obtainedfrom the participants. Pre training baseline scores were obtained for Motion SicknessAssessment Questionnaire (MSAQ) and Criteria for identifying the severity ofacute motion sickness. Instructions were given to fill the questionnaire on thebasis of road travelling experience. Before starting with the training session,few trials were given to the participants for the visual vestibular habituationexercises and controlled breathing technique. Out of the remaining 41participants 4 were notwilling to participate in the intervention programme and 7 discontinued the treatment on 3rdday of 1st week of intervention.

The participants performed the exercises in a well-ventilated, spaciousexercise therapy unit of the physiotherapy department of Pravara RuralHospital.  Instructions to turn off theirmobile phones or keep them on silent mode, to maintain silence, to concentrateon the breathing pattern, and to concentrate on visual vestibular exercisesthroughout the session were given to them prior to each intervention.Participants were told that while doing the exercises they might experiencesymptoms of motion sickness and were also reminded that they could discontinuethe exercise at any time, for any reason (see Table 1 and 2 for Visualvestibular habituation and Controlled breathing Protocol).The total interventional protocol was conducted for 45 min, i.

e. 30 minof Visual vestibular habituation exercises and 15 min for controlled breathingtechniques. Intervention was given for 5days per week for 2 weeks under supervision of researcher.

Also Homeexercise program was taught which will be twice per week for remaining 8 weeks.To rule out the bias participants were requested to avoid travel during 2 weeksof intervention. The participants demonstrated an ability to safelycomplete stage 1 visual vestibular exercises, step 1 through 5 for 10 sec forfirst two days of intervention without any increase in symptoms along withdiaphragmatic breathing.

Then they were asked to continue the same exercisesfor 30 sec for the remaining 3 days if they experience no increase in symptoms.Those who could not continue the exercises for 30 sec or if they felt increasein symptoms were asked to do the exercises for 10 sec until they felt decreasein symptoms or were instructed to stop if the symptoms were alleviated. Theywere instructed to monitor their reactions to exercises (e.g. An increase ordecrease in symptoms) and to note them in a daily log book. They were toproceed to stage 2 activities as instructed for the 2 week of intervention whenthey could complete all stage 1 exercises without symptoms. They were asked toperform the exercises for 30 sec, if they experience any severe reactions theywere told to stop the exercises and contact the therapist.

Exercises were to beperformed dailyAfter the end of 2 week re-assessment using, the MSAQ questionnaire andseverity of acute motion sickness criteria was done. OUTCOME MEASURESØ   Diagnostic Criteria for identifying theseverity of acute motion sickness. Ø  MotionSickness Assessment Questionnaire (MSAQ).    DATA ANALYSISMean Standard deviation and Student paired t test was applied forcomparison of differences in the pre intervention and post intervention scoresof MSAQ and for the Level of severity of Acute Motion Sickness. To find out thedifference from the Baseline and at the end of 2nd week, comparisonwas done between the scores obtained within the same group.

The results wereconcluded to be statistically significant with p value <0.0001.                       Table 1: Difference of Level ofseverity of Acute Motion Sickness at Baseline and week 2 Mean + SD 't' value 'p' value Baseline 8.2 + 4.93 5.

152 p value is <0.001 & significance Result: Significance with pvalue

1           Table 2: Components of Motion Sickness of MSAQ at Baseline and week 2 Components of Motion Sickness Baseline Mean ± SD n= 30 Week 2 Mean ± SD n = 30 ‘t’ value ‘p’ value Gastrointestinal 47.21 ± 17.21 23.11 ± 14.28 8.319 p <0.0001 Central 26.

72 ± 16.49 13.58 ± 6.62 4.65 p <0.0001 Peripheral 22.10 ± 15.63 14.

29 ± 8.85 4.178 p< 0.0002 Sopite Related 41.35 ± 20.84 21.95 ± 12.47 5.

541 p <0.0001 Result: Significance with p value

0001   Week 2 20.28 ± 8.75   Result: Significance with p value

25% 12MIII 8MIII 7MIIA 5 25% 16% 12% 6MIIA 2MI NONE 6 22% 15% 14% 5MIIA 4MIIB NONE 7 43% 21.16% 13.19% 18Frank 3MIIB NONE 8 29.16% 21.

77% 11.11% 4MIIB NONE NONE 9 66% 14% 15.00% 19Frank 2MI 4MIIB 10 53.47% 18.05% 38.19% 12MIII 16Frank 16Frank                  FLOW CHART          RESULTSTo find out the Effectiveness of visual vestibularhabituation and controlled breathing for motion sickness 30 participants wereincluded in this study.  The interventionwas given for 2 weeks and the exercises were performed 5 days per week.

Participants were treated with visual-vestibular habituation and controlledbreathing. At the start of 1st week and at end of 2ndweek of intervention participants were reassessed using the Severity criteriafor acute motion sickness and MSAQ scale. The following are the results of thestudy:vTable 1: Shows Comparison of total score in level of severity of acute motion sickness between Baseline and at the end of 2nd Week.  Comparison of total score in level of severity criteria for acute motion sickness between the Baseline and at the end of 2nd Week was found to be statistically extremely significant using the paired t test in which p value is(p<0.001, 95% CI) and t value is(t= 5.152) respectively with 29 degrees of freedom.

That at the baseline of the intervention out of 30 subjects 3 had Frank sickness, 7 had severe malaise (MIII), 13 had Moderate malaise (MIIA), and 6 had Moderate malaise (MIIB) and 1 with slight malaise (MI). That at the end of 2nd week of intervention subjects having Frank sickness at baseline their level of severity for motion sickness was decreased to MIII, MIIA & MIIB & MI. That at the end of 2nd week of intervention subjects having severe malaise at baseline their level of severity for motion sickness was decreased to MIIA, MIIB & MI. That at the end of 2nd week of intervention subjects having Moderate malaise(MIIA ) at baseline their level of severity for motion sickness was decreased to MI or zero( having no motion sickness) or remained the same(moderate) .

That at the end of 2nd week of intervention subjects having slight malaise (MI) at baseline their level of severity for motion sickness was decreased to zero (having no motion sickness at all).  vGraph 1: Shows decrease inMean value of level of severity for acute motion sickness from the Baseline andat the end of 2nd week of intervention was 8.2(SD 4.

93) and 3.83(SD3.71) respectively. vTable 2: shows The comparison of Components of motion sickness at baseline & at the end of 2 week of intervention.

 The most common symptom of motion sickness among the 30 subjects at baseline was the Gastrointestinal (sick, queasy, ill, stomach awareness/discomfort, vomiting). Followed by Sopite related (irritated, drowsy, fatigue, uneasy) then central(faint-like, lightheaded, dizzy, spinning) and Peripheral(sweaty, clammy, hot/warm,). Comparison of MSAQ Sub score of the Baseline and at the end of 2 Week was found to be statistically extremely significant using the students paired t test in which p’ value and t’ value for gastrointestinal was (p<0.0001, 95% CI) and (t= 8.

319), for central was (p<0.0001,95% CI) and (t=4.65), for peripheral was (p<0.0002, 95% CI) and (t=4.178), for sopite related is (p<0.0001, 95% CI) and (t=5.541), respectively with 29 degrees of freedom.

vGraph 2: shows MSAQ sub scores have decreased at the end of 2nd week as compared to baseline scores. The most common symptoms was the gastrointestinal followed by sopite related then central and peripheral from baseline and at the end of 2nd week was improved. The score for Gastrointestinal was at baseline 47.21(SD 17.21) and at end of 2nd week were 23.11(SD 14.28).

The score for central was at baseline 26.72(SD 16.49) and at end of 2nd week were 13.58(SD 6.62). The score for peripheral was at baseline 22.

1(SD 15.63) and at end of 2nd week were 14.29(SD 8.85). The score for sopite related was at baseline 41.

35(SD 20.84) and at end of 2nd week were 21.95(SD 12.47). vTable 3: Shows the differenceof MSAQ total score from Baseline and at 2 week was found to be statistically  extremely significant using the paired t testin which p value is(P<0.0001, 95% CI) and t value is (t=7.149) respectivelywith 29 degrees of freedom.vGraph 3: Shows the decrease inMean value of MSAQ total score from the Baseline and at end of 2nd Week ofintervention was 37.

43(SD 13.52) and 20.28(SD 8.

75) respectively.vAlso the average age is 20.3.vTable 4:Shows Results MSAQ Total score & Result of severity criteria at the end of 8th week Out of 30 participants only 10 subjects travelled and were reassessed after 8th week of intervention.

That for MSAQ total score & severity criteria at the end of 8th week, out of 10 subjects there was increase in score for 2 subjects at the end of 8th week & for 1 participant the score remained the same as per 2nd week, for the remaining 7 participants score of MSAQ decreased. That on comparison from baseline and at the end of 2nd week & 8th week showed that the visual-vestibular habituation exercises and controlled breathing with home exercise programme was effective and helped subjects to decrease their motion sickness. That these exercises caused a habituation effect and decreased their motion sensitivity in quickly as 2 week and was effective as long as till 8 week.   DISCUSSION ‘Much of themotion sickness goes unrecognized’, the point is that unless nausea andvomiting are elicited, decrements in performance may not even be recognized asbeing indicative of motion sickness.39 Peter J. Gianaros, Eric R.Muth suggested that motion sickness may be more appropriately viewed asa multidimensional construct.

This multidimensional syndrome consists ofvarious symptoms which affect the travellers which further affects theirjourney. They are ·      The nausea syndrome  comprised of at least three dimensions: Ø  gastrointestinaldistress (sick, queasy, ill, stomach awareness/discomfort, vomiting),Ø  somaticdistress (shaky, lightheaded, sweaty, tired/fatigued, weak, warmth), andØ  emotionaldistress (upset, worried, hopeless, panicked, nervous, scared/afraid).§  Sopite-relatedsymptoms include drowsiness, yawning, and disengagement from the environmentThe presentstudy was designed to investigate whether the visual vestibular habituationexercises and controlled breathing can improve motion sickness as the bestmethods for preventing motion sickness without the use of medication that hasundesired side effects. 30 participants of 18-30 years of age were given theintervention. In this study outcome measure was assessed by using the severitycriteria of acute motion sickness and Motion Sickness Assessment Questionnaire(MSAQ).

Data was analysed using mean, standard deviation and student paired ttest which showed positive effect of habituation exercises and controlledbreathing on decreasing the symptoms and their motion sickness. The results ofMotion Sickness Assessment Questionnaire & the severity criteria of acutemotion sickness depict that the motion sickness improved significantly after 2weeks of intervention as indicated by decrease in mean values. Also a homeexercise programme was given for 8th weeks, results at the end of 8thweek showed that those who followed the home exercise programme, the visualvestibular habituation exercises caused habituation effect in them and haddecreased their motion sensitivity. Although subjects were not completely freeof symptoms, but their ability to function while travelling was no longerlimited and their symptoms were mild. Furthermore, the study suggests thatduring the time the patient reduce the amount of exercise, the progress was minimal.This leads to conclusion that with an increase in amount of exercise and levelof difficulty, improvement is increased.

The sensoryconflict hypothesis by Reason and Brand et al implies that, ‘how’ of motion sicknessis based on some form of sensory conflict or sensory mismatch. The sensoryconflict or sensory mismatch is between actual versus expected invariantpatterns of vestibular, visual and kinesthetic inputs. These also includeintra-vestibular conflicts between rotational accelerations sensed by thesemi-circular canals and linear-translational accelerations (includinggravitational) sensed by the otolith.

40Habituation is superior to anti-motion sickness drugs, and it isfree of side effects. The most extensive habituation programmes, often denoted”motion sickness desensitisation,” are run by the military, where anti-motionsickness medication is contraindicated for pilots because of side-effectsincluding drowsiness and blurred vision. Neural structures such as the amygdalaas well as such areas as the nucleus tractus solitarius are thought to beimportant in processes of induction of and habituation to motion sickness.Habituation programmes have success rates exceeding 85% but can be extremelytime consuming, lasting many weeks. Critical features include:(a)    the massing of stimuli (exposures at intervals greater than a weekalmost prevents habituation),(b)   use of graded stimuli toenable faster recoveries and more sessions to be scheduled, which may helpavoid theopposite process of sensitization, and(c)   maintenance of apositive psychological attitude to therapy.

51 Miles andBraitman examined activity in cranial nerve VIII and reported that the changesare not due to adaptation at the peripheral level, but rather to habituationthat involves central nervous system changes.53In summary, aconflict between visual and vestibular information regarding spatialorientation has been identified as the primary causal factor for motionsickness, and visual stimuli alone have been shown to induce motion sicknesssymptoms.13 The intervention presented in this study was developed based onthese reports and implemented for a patient with vision-induced motionsickness.The results ofthis study showed that their symptoms of motion sickness were reduced at theend of 2nd week. After the end of 8th week again data wascollected from 10 participants who travelled. The MSAQ total score and subscores from Baseline and at the end 2nd week & 8thweek was found to be decreased as indicated by decrease in mean values. Thisconcluded that subjects having most common symptoms of Gastrointestinal (sick,queasy, ill, stomach awareness/discomfort, vomiting) followed by Sopite related (irritated, drowsy,fatigue, uneasy) , central(faint-like, lightheaded, dizzy, spinning) andPeripheral(sweaty, clammy, hot/warm,) were reduced and experienced only slightmotion sickness ( mild light-headedness, clammy but no nausea, dizziness orsweating) respectively.

On comparison of total score in level of severitycriteria for acute motion sickness between the Baseline and at the end of 2ndWeek & 8th week was found to be improved, as those having Frank,severe or moderate malaise was decreased to moderate to mild. For few thesymptoms of motion sickness were completely resolved.   Although timealone may have resulted in reduction of symptoms, this study indicatesworsening of the symptoms while travelling which did not stabilize or reduceuntil the exercise regimen began. Thus the study can be generalized to allindividuals with motion sickness; it describes a non-pharmacological treatmentoption for this syndrome.