Innovation reality, displays and also smart phones.2 Susceptibility

Innovation of transport
and industry have led to provocative motion environments, to cars,  trains, funfair rides, aircraft, and
simulators.1 Thus Motion sickness is a common problem in people
travelling by train, airplane, boat and especially cars. Also people experience
motion sickness from virtual reality, displays and also smart phones.2
Susceptibility to motion sickness is higher in individuals  suffering from spatial disorientation
(35.05%), migraine (26.31%), gastrointestinal disorders (26.82%) and those who
more sensitive to unpleasant odors (24.64%). Females (27.3%) are more
susceptible to motion sickness than males(16.8%).6 Initial symptoms
is discomfort in stomach, followed by nausea. With rapid worsening of symptoms
there can be salivation changes, dizziness, retching and sopite related symptoms.3,4

The primary functions
of the vestibular system are spatial orientation, maintenance of balance, and
stabilizing of vision through vestibular–ocular reflexes.15Motion is
sensed by the brain through three different pathways of nervous system that send
signals coming from inner ear( sensing motion, acceleration, gravity), the
eyes(vision),and the deeper tissues of body surface(proprioceptors). When there
is an unintentional movement of the body, the brain responds to unfamiliar
motion stimuli which are transmitted to vestibular nuclei. This unfamiliar
motion stimuli is sensed by vestibular labyrinth, the eyes and proprioceptors
and travel to vestibular nuclei, then through cerebellum to vomiting centre
located in the parvicellular formation of medulla oblongata, this conflict
among the brain and the three pathways lead to motion sickness.16
Currently the “neural mismatch theory” states that motion sickness can
originate from within a single sensory system (e.g., canal-otolith
interaction), or between two or more sensory systems (e.g. visual-vestibular

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As the vestibular system plays a crucial role in the inducement of
motion sickness, vestibular habituation exercises will help reduced motion
sickness. Repetitive vestibular stimulation can therefore cause changes in
Vestibulo-Ocular Reflex (VOR) and at the same time a reduction in sensitivity
to motion sickness.30 Habituation exercises
are 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.32
These exercises cause a habituation effect
characterized by decreased sensitivity and duration of symptoms can
occur in as quickly as 2 weeks but can take as long as 6 months.31
Effects of breathing strategy have explored by number of experts. Paul Lehrer a
leading researcher in area of relaxation training showed that breathing
approach can be quite successful in in reducing physiologic activation of the
sympathetic nervous systems.33

A commonly used Diagnostic
Criteria for Identifying the Severity of acute motion sickness and the
Diagnostic Scale, referred to as Motion Sickness Assessment Questionnaire which
is a reliable method for scoring overall motion sickness with the use of four
subscales is used in this study for rating these symptoms of motion and to
differentiate motion sickness symptoms along four dimensions: gastrointestinal,
central, peripheral, and sopite-related.36

 Motion sickness affects nearly all people who
travel by land, sea, or air, little documentation exists regarding prevention
and management. Repeated recurrence of sickness is not desirable or practical
to daily living. Limited evidence is available for Controlled breathing and
visual-vestibular habituation training for motion sickness that won’t provoke
the undesirable symptoms and can last for upwards of a year. Thus aim of this
study was to help determine the effectiveness of visual vestibular habituation
and controlled breathing for motion sickness. The research questions were: Is
visual-vestibular habituation and controlled breathing effective for motion
sickness? Will there be any difference in severity of motion sickness when
treated with visual vestibular habituation and controlled breathing for motion



The design was within-in
participants, experimental study. The study duration was for 2 months (10
Sep2017- 27 Nov2017), with intervention of 5 days per week for 2 weeks. The
outcome measures, Motion Sickness Assessment Questionnaire (MSAQ) and
Diagnostic criteria for identifying the severity of acute motion sickness was assessed
at Baseline and at the end 2nd week of intervention also a follow up
was 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 informed
consent was obtained from all participants.


Young adults of Pravara
Rural Hospital, Loni susceptible to motion sickness were eligible to
participate in study if they had visual acuity 6/6 on Snellen chart and those
diagnosed with motion sickness according to criteria for identifying the
severity of acute motion sickness. Participants between age group 18-30 years
and road travellers were included. Participants diagnosed with postural
instability, vestibular disorders, migraine with neurological deficit and
orthopedic condition, cognitive and perceptual deficit. Also Participants with
any respiratory problems and pregnant females were excluded from the study.


  Total 46 subjects were screened out
of which 5 did not fit in
inclusion criteria. Then written informed consent was obtained
from the participants.

Pre training baseline scores were obtained for Motion Sickness
Assessment Questionnaire (MSAQ) and Criteria for identifying the severity of
acute motion sickness. Instructions were given to fill the questionnaire on the
basis of road travelling experience. Before starting with the training session,
few trials were given to the participants for the visual vestibular habituation
exercises and controlled breathing technique. Out of the remaining 41
participants 4 were not
willing to participate in the intervention programme and 7 discontinued the treatment on 3rd
day of 1st week of intervention.

The participants performed the exercises in a well-ventilated, spacious
exercise therapy unit of the physiotherapy department of Pravara Rural
Hospital.  Instructions to turn off their
mobile phones or keep them on silent mode, to maintain silence, to concentrate
on the breathing pattern, and to concentrate on visual vestibular exercises
throughout the session were given to them prior to each intervention.
Participants were told that while doing the exercises they might experience
symptoms of motion sickness and were also reminded that they could discontinue
the exercise at any time, for any reason (see Table 1 and 2 for Visual
vestibular habituation and Controlled breathing Protocol).

The total interventional protocol was conducted for 45 min, i.e. 30 min
of Visual vestibular habituation exercises and 15 min for controlled breathing
techniques. Intervention was given for 5
days per week for 2 weeks under supervision of researcher. Also Home
exercise 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 weeks
of intervention.

The participants demonstrated an ability to safely
complete stage 1 visual vestibular exercises, step 1 through 5 for 10 sec for
first two days of intervention without any increase in symptoms along with
diaphragmatic breathing. Then they were asked to continue the same exercises
for 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 increase
in symptoms were asked to do the exercises for 10 sec until they felt decrease
in symptoms or were instructed to stop if the symptoms were alleviated. They
were instructed to monitor their reactions to exercises (e.g. An increase or
decrease in symptoms) and to note them in a daily log book. They were to
proceed to stage 2 activities as instructed for the 2 week of intervention when
they could complete all stage 1 exercises without symptoms. They were asked to
perform the exercises for 30 sec, if they experience any severe reactions they
were told to stop the exercises and contact the therapist. Exercises were to be
performed daily

After the end of 2 week re-assessment using, the MSAQ questionnaire and
severity of acute motion sickness criteria was done.



Ø   Diagnostic Criteria for identifying the
severity of acute motion sickness.

Ø  Motion
Sickness Assessment Questionnaire (MSAQ).






Mean Standard deviation and Student paired t test was applied for
comparison of differences in the pre intervention and post intervention scores
of MSAQ and for the Level of severity of Acute Motion Sickness. To find out the
difference from the Baseline and at the end of 2nd week, comparison
was done between the scores obtained within the same group. The results were
concluded to be statistically significant with p value <0.0001.                                               Table 1: Difference of Level of severity 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 p value