Transcranial Magnetic Stimulation for Mal de Debarquement Syndrome
Phase: NA
Conditions: Mal de Debarquement Syndrome
Sponsor: University of Minnesota

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Title:   
Transcranial Magnetic Stimulation for Mal de Debarquement Syndrome 
 
Principal Investigator: 
Yoon-Hee Cha, MD 
Associate Investigator, Laureate Institute for Brain Research 
(LIBR), Adjunct Assistant Professor, UCLA School of Medicine 
 
 
Sponsor:  
 
 
 
Laureate Institute for Brain Research, Inc. 
 
Abstract 
Mal de debarquement syndrome (MdDS) is a balance disorder in which patients develop a persistent 
internal sense of movement after a prolonged period of passive motion exposure. This is classically 
described as "land-sickness" occurring after boat rides. Patients describe a hallucination of movement 
such as "rocking" and "bobbing" even though they are not physically moving.  This disorder is thought to 
be due to a primary problem of brain adaptation as testing of inner ear function and structural brain 
imaging is always normal. However, it is unknown which parts of the brain control this adaptation.  Most 
cases of mal de debarquement only last a few hours, but there are many people who experience the 
symptoms for months or years, leading to significant morbidity.  The term MdDS is generally reserved 
for patients who experience symptoms for at least one month.   
 
Our preliminary data on imaging patients with MdDS with FDG PET and functional MRI has shown that 
there is abnormal metabolism in limbic structures that control spatial processing and emotional regulation 
in these individuals and that there are also differences in the functional connectivity between these limbic 
structures and the cortex.  We are now working on modulating the perception of motion in MdDS with 
transcranial magnetic stimulation (TMS), which is a form of external neuromodulation using pulsatile 
magnetic fields on the surface of the head.  Preliminary data shows that TMS can at least temporarily 
suppress the perception of rocking with short-term treatment.  However, long-term studies are needed in 
order to determine whether the short-term suppression can translate into a remission.   
 
A. Specific Aims 
The goal of this study is to determine whether external neurmodulation using rTMS can reduce the 
perception of self-motion that is experienced by patients with MdDS.  We will make correlations between 
functional MRI data, EEG, and specific clinical features to determine whether functional connectivity 
between particular hubs in the brain correlate with clinical improvement.   
 
B. Background and Significance 
Mal de debarquement syndrome (MdDS), the term for persistent feelings of motion occurring after 
exposure to passive motion, was reported over 200 years ago, but there is still no explanation for why 
some people experience such persistent feelings of rocking and swaying after being exposed to prolonged 
but relatively minor amplitudes of motion.  The most common trigger for MdDS is sea travel with the 
quintessential patient being a middle-aged woman who develops sensations of rocking and swaying after 
disembarking from a cruise.  Although brief periods of self-motion perception are common, some people 
experience the chronic rocking sensation for months or years with very few options for symptom relief.  
These patients can become totally disabled, often stopping work, developing strained relationships, and 
experiencing severely reduced quality of life.  The probability of symptoms spontaneously stopping 
decreases dramatically with longer durations of symptoms.  Thus, patients who have had MdDS for more 
than a year have a limited chance for recovery and almost no therapeutic recourse if one or two 
medication trials have failed them.  
MdDS is currently a clinical diagnosis with no available biomarkers.  It is unique among balance 
disorders in that re-exposure to passive motion decreases the internal motion perception rather than 
increasing feelings of motion sickness.  Vestibular function testing, structural brain, and inner ear imaging 

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The EC is part of the default mode network, as are the ventral precuneus and the IPL, specifically in the 
area of connectivity change that we determined (angular gyrus).  The default mode network is a resting 
state network that increases in activity at “rest” and is thus deactivated during the execution of specific 
tasks.  It is associated with resting activities such as daydreaming and introspection.  Thus, it appeared 
that decreases in the posterior portion of the default mode network were associated with decreases in 
MdDS symptoms.  This decrease in resting state functional connectivity in major nodes of the default 
network measured by BOLD was consistent with the decrease in phase coherence between the posterior 
parietal ICA node and other nodes (EEG looks at surface activity so the connectivity with EC itself could 
not be determined).  These analyses are now being extended to a total of 24 participants with MdDS who 
have undergone the same protocol.  
 
Finally, we have recently studied differences in grey matter volume between individuals with MdDS and 
healthy controls using voxel-based morphometry and have found decreases in grey matter volume in the 
anterior cingulate cortex (ACC) even after correcting for concurrent depression scores.  ACC volume 
decreases further as a function of duration of illness (manuscript in review).  Cerebellar volume increases 
in bilateral hemispheric lobules VIII and IX were concurrently observed.  Both the ACC and the 
cerebellar lobule IX are functionally part of the default mode network.  Though lobule VIII is primarily 
functionally connected to the premotor cortex, it is also anti-correlated with every portion of the 
precuneus, suggesting that it may also have some impact on the default mode and other resting state 
networks of which the precuneus is a part.   
 
We are now using the functional connectivity information from our pilot participants to determine 
whether there may be other more optimal rTMS targets in terms of causing this desynchronization.  For 
example, since there is evidence for a role of the default mode network, direct stimulation over one of the 
nodes of the default mode is one of our next plans.  The second is to use a target that is functionally 
connected to the EC in order to more precisely target the region of the DLPFC.  This requires using 
individualized targets that are determined by a functional connectivity map.   
 
D. Research Design and Methods 
Screening: All potential subjects will be screened by the PI to determine whether they meet any 
exclusion criteria (see attached screening script) such as major medical or psychiatric illness or any 
personal or family history of seizures. All screening will occur prior to participation and will be either in 
person or on the phone.  They will complete an MRI safety screen if they qualify for the TMS portion of 
the study.   
 
Consent: The purpose, content, duration, and expected risks and benefits of the study will be reviewed 
with each participant by the PI.  If they pass the screening interview, written consent will also be obtained 
before subjects can participate in either the MRI or TMS portions of the study. Subjects will be 
encouraged to be open with the investigators about any questions or concerns they have either before, 
during, or after the study. 
 
Enrollment: All subjects will undergo a directed interview and a screening neurological exam by one of 
the investigators. A subset of the questionnaires will be completed by the participants depending on the 
participant’s symptoms:  
ABC Scale,Beck Depression Short Form, Cognitive Assessment Questionnaire, Dizziness Handicap 
Inventory, Edinburgh Handedness Scale, Functional Activities Questionnaire, Hospital Depression 
Anxiety Scale, Mal de Debarquement Rating Scale, Multidimensional Fatigue Scale, MIDAS Migraine 
Disability Scale (if applicable), Motion Sensitivity Questionnaire, MSSQ, Memory Questionnaire, SF-36 
(quality of life scale), Tinnitus Handicap Inventory (if applicable), an Empathy Scale (40 point), Body 

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Awareness Questionnaire, a generalized anxiety scale (GAD7), and Overall Anxiety Severity and 
Impairment Scale (OASIS), a Self-Efficacy Scale, and a and a Visual Analogue Scale.   
MRI procedure: 
All MRI scanning in this protocol will be non-invasive (i.e. NO intravenous or other forms of external 
contrast agents will be used) and participants will be provided with earplugs as protection from scanner 
sounds.  Participants will be placed in the magnet with the investigator ensuring that the subject is 
comfortable, able to easily manipulate any required response apparatus and trained to use the scanners 
emergency call button.  The emergency call button is a response apparatus the patient can press to 
indicate that he/she needs immediate attention.  A series of MRI localizer scans will then be obtained in 
order to prescribe the study-relevant anatomical scans.  Before the anatomical scans, participants will be 
instructed as to the type of scan being performed and asked to stay as still as possible by remaining 
relaxed.  These scans typically take 45-90 minutes to complete. 
 
EEG procedure: 
Subjects will undergo EEGs using either the standard electrode-paste leads with between 32 and 128 
leads, or a wireless EEG system with 14 leads that is designed to allow the subject to move.  The EEG 
set-up may take 1-2 hours depending on how much hair the subject has.  These studies will be performed 
before and after the block of TMS or during the TMS sessions.  In each EEG session, they may receive 
either or both the wireless or standard EEG leads.  They will be told beforehand which will be used, or 
both.  The wireless EEG system uses saline soaked sponges which can be applied within about 5-minutes.  
Therefore, these will be applied first then removed before standard EEG leads are placed.   
 
TMS procedure: 
TMS: Determining motor threshold (for MdDS subjects and controls) 
The first step in the procedure is to determine individual subject’s motor threshold in order to select the 
appropriate intensity of stimulation to use in the study. This is done by eliciting motor evoked potentials 
(MEPs) in the first dorsal interosseus muscle of the dominant hand. Surface electrodes will be attached to 
the skin over the muscle using electrode paste and tape. Subjects will wear insert earplugs or earphones to 
attenuate the sound that the magnetic coil makes during stimulation. Ear protection is recommended to 
prevent temporary increases in the auditory threshold during studies involving TMS at frequencies greater 
than 1 Hz. Subjects will sit in a chair. Frameless stereotaxy will be used to position the TMS coil over the 
subject’s head. This procedure uses computer software to co-register the location of the subject’s head in 
real space with his/her head on the MRI scan. Motor threshold is commonly defined as the minimum 
amount of stimulation needed to evoke a MEP in a hand muscle after a single pulse over M1. As such, 
single TMS pulses will be delivered at multiple locations around the motor cortex contralateral to the 
dominant hand. The intensity of the stimulation will be gradually lowered until reaching a level of 
stimulator output at which 5 out of 10 motor evoked potentials (MEP’s) in a hand muscle have an 
amplitude of at least 50 microvolts. This intensity is considered to represent motor threshold. The 
duration of this procedure usually takes about 20 to 30 minutes.  
 
rTMS session (for MdDS subjects only) 
After determination of motor threshold, the TMS coil will be positioned at predetermined locations over 
the cortex using frameless stereotaxy as described above. Surface electrodes will be kept over hand 
muscles on both hands for the purpose of continuous monitoring of the safety of the procedure. We will 
also use theta bursting TMS (TBS) at inhibitory settings (continuous TBS-cTBS). 
Theta burst TMS will be limited to established protocols using 600 pulses per session (40 seconds for 
cTBS).  The first TMS session could last as short as 2 hours and as long as 3 hours with multiple sessions 
of TBS administered with a break of 30-minutes in between sessions. 

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Daily rTMS sessions (for MdDS subjects only) 
Participants with MdDS will receive one sessions each of 3 different targets: occipital cortex, cerebellar 
vermis, lateral cerebellar hemisphere. The order in which these sessions will be administered will be 
randomized between participants. All test sessions will be done on Day 2 (Day 1 will involve baseline 
fMRI and EEG measurements). The treatment choice will depend a combination of the participant’s 
assessment of which target was a the most effective in reducing the vertigo. If they are not sure, then 
balance assessment with the SWAY balance app will be used to determine which protocol improved their 
balance the most.  
We plan an enrollment of 24 participants which would provide 4 groups of each of 6 possible orders of 
stimulation. Participants will be asked to rate the intensity of their rocking vertigo. The goal is to provide 
up to 12 sessions of rTMS over 3 days with 30-minutes of break in between. The end of the final day of 
stimulation will include fMRI and EEG.  
E. Statistical Methods 
This is a pilot study so there are no set power calculations. The goal is to determine which if any of three 
rTMS targets are most effective in reducing oscillating vertigo. Pre-stimulation baseline scores will 
include weekly assessments of the DHI, MBRS, and the HADS divided into the Anxiety and Depression 
subscores. The median of 4 weekly prestimulation scores will be used as the baseline. The participants 
will be making immediate post assessments of each of these scores and weekly thereafter for 6 weeks. 
The differences between these weekly scores and the prestimulation baseline will be calculated. Baseline 
clinical features that determine target selection will be placed in a one-way ANOVA with one factor and 
three levels for response groups (occipital target, vermis target, lateral cerebellar target) with post hoc 
Bonferroni correction to determine which targets showed different responses.  
 
F. Gender/Minority/Pediatric Inclusion for Research 
Women and minorities will be included in the study.  Prior research indicates that MdDS predominantly 
affects females, without any predilection for any racial or ethnic groups.  It is a disorder of adults, 
however, as the average age of a first episode is near 40 years old.  
 
G.  Human Participants 
We plan to enroll 24 subjects with MdDS and 20 healthy controls over a span of 5 years.   
 
Inclusion criteria for controls: 
1. Age ≥18 years old 
2. Willing and capable of interacting with the informed consent process 
3. No history of dizziness or balance disorder.   
 
Inclusion criteria for MdDS subjects: 
1. Age ≥18 years old 
2. Willing and capable of interacting with the informed consent process 
3. Primary disorder being a persistent perception of motion with no other cause determined after a careful 
interview. 
 
Exclusion criteria for both: 
1. Subjects who cannot comply with study conditions. 
2. Active psychiatric condition such as mania or psychosis 
3. Unstable medical condition 
4. Implanted metal anywhere in the body (infusion pumps, pacemakers, metal or shrapnel in the body, 
deep brain stimulators, aneurysm clips, metal prostheses, joints, rods or plates). Dental fillings are 
acceptable. 

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5. Personal history of seizures or a first-degree relative with uncontrolled epilepsy 
6. Medications known to lower seizure threshold: typical (high-potency) neuroleptics and tricyclic 
antidepressants: Subjects who take one or a combination of the following drugs will be excluded: 
imipramine, amitriptyline, doxepine, nortriptyline, maprotiline, chlorpromazine. clozapine, foscarnet, 
ganciclovir, ritonavir, amphetamines, cocaine (including MDMA, ecstasy), phencyclidine (PCP, angel’s 
dust), ketamine, gamma-hydroxybutyrate (GHB), theophylline, haloperidol, fluphenazine, bupropion.  
7. Pregnancy  
 
Eligibility will be determined by the PIs through history and neurological examination. Dr. Cha is a 
Board certified neurologist who has expertise in the evaluation of patients with motion perception 
disorders, auditory symptoms, movement disorders, pain, and stroke.  Control subjects who are recruited 
by advertisement will undergo a screening interview to determine whether they have had any problems 
with motion perception in the past. This includes various kinds of motion sickness or vertigo and a history 
of migraine.  
 
H. Recruitment and Consent Procedure 
Subjects will be recruited from advertisements Flyers/Information Sheet/Internet Postings. 
 
Screening will be conducted by study personnel in person or over the phone. A screening script will be 
used to ensure uniformity in the screening process. We will need to obtain their name and contact 
information should they pass the phone screening and still remain interested. If the subject is qualified by 
the initial phone screen, they will be invited to the first visit with the PI in order go through the consent 
process and undergo a neurological exam. They will be mailed the consent form prior to the first visit in 
order for them to have adequate time to review and think of questions. 
 
The informed consent process will include interactive assurances that participation in this study is 
voluntary, that there is no consequence to refusing to participate, that participating or not will not affect 
any ongoing or future care, and that the subject is free to withdraw at any time with no consequence to 
their ongoing or future care. 
 
I. Subject Risks 
MRI: Risks and general protection against risk 
 
Possible mild side effects include mild muscle stiffness or discomfort from prolonged immobility in the 
MRI scanner.  This side effect will be monitored and logged on the investigators scanning log.  
Participants are at risk for injury from the MRI magnet if they have pacemakers or other implanted 
electrical devices, brain stimulators, dental implants, aneurysm clips (metal clips on the wall of a large 
artery), metallic prostheses (including metal pins and rods, heart valves, and cochlear implants), 
permanent eyeliner, implanted delivery pump, or shrapnel fragments. Participants will be screened for 
these conditions prior to the study, and if they have any, they will not receive an MRI scan. Women who 
are pregnant may not undergo a research MRI. Therefore, all women of childbearing potential will be 
excluded if they are unsure of their pregnancy status. Individuals with fear of confined spaces may 
become anxious during an MRI.  
 
Side effects that occur during MRI could include temporary contractions or twitching of muscles during 
the MRI scan. It is described as a creeping sensation along the back, twitching of the nose, or electric 
shocks, which may be almost imperceptible or mildly painful. Some individuals experience nausea and/or 
dizziness during the MRI scan. 
 
Participants that are taking medications during the screening process will not be discontinued from their 
current treatment for the MRI procedures. 

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EEG: Risks and general protection against risk 
An EEG is minimal risk procedure that is performed widely for clinical purposes.  In this study, there are 
potentially more leads being placed than a standard EEG, which will increase the set-up time.  We will 
initially start with only 32-leads, similar to a standard clinical EEG, but over time we may need up to 128 
leads in order to attain better localization.  The placement of the leads themselves is not uncomfortable, 
but the subject may find cleaning the scalp with alcohol pads to be irritating.  The conductive gel used in 
the studies will require that the subject wash their hair afterwards, which may be a hassle.  It is possible, 
though highly unlikely that the subject would be allergic to the conductive gel.  There are no limitations 
on who can receive an EEG since it is a non-invasive procedure that only involves recording.  The subject 
may discontinue the set-up at any time if they are uncomfortable.   
  
TMS: Risks and general protections against risk 
One person who is certified to administer TMS will be present at every TMS session. In general, this will 
either be one of the PIs or a technician. In addition, all rTMS studies will be performed with a physician 
skilled in seizure management present on-site.  
 
Subjects will be fully informed about the foreseeable risks and discomforts associated with participation 
in this study. The consent forms describe these risks and discomforts clearly. Patients must know that 
they have the option to withdraw from TMS studies at any time. Withdrawal from this study can be done 
without consequence. The investigators may also choose to terminate a participant from this study, if they 
suffer a severe adverse event, do not follow study requirements, or feel that continued participation will 
put the person at a greater risk than indicated. 
 
Specific protections against risk 
1. Headaches or neck aches. Headaches and neck aches routinely respond to acetaminophen ibuprofen. 
Headaches are no different that usual headaches that patients may get. Efforts to minimize TMS intensity 
to avoid sensitive areas of scalp muscles or nerves will be done. 
 
2. Use of earplugs. In order to prevent transient hearing threshold shifts due to TMS, subjects and 
investigators will be offered earplugs during TMS.  
 
3. Fainting. All investigators must know and will be trained on how to manage fainting in the laboratory. 
 
4. Inadvertent seizure. Screening and enrollment procedures will exclude subjects for whom rTMS is 
contraindicated or who are at increased risk of seizure or for whom the potential consequences of a 
seizure are increased. The informed consent process will note the potential risk of seizures with rTMS and 
should mention possible medical and social consequences. There is no evidence that a rTMS induced 
seizure increases the risk of having a second seizure in an otherwise healthy individual. 
 
There have been no seizures reported after theta burst TMS to date. Both medical and psychological 
support will be provided to patients and normal subjects who have TMS-induced seizures. Subjects who 
experience a TMS-induced seizure will be informed of the fact that an induced seizure does not place 
them at greater risk for further seizures than before. The seizure event does become documented in the 
subject’s medical record. None of the subjects who have been described as having TMS-induced seizures 
has suffered lasting physical sequelae. Electroencephalographic and neuropsychological measures had 
returned to normal within 1-2 days. Furthermore, there is no evidence to suggest that a TMS induced 
seizure makes another seizure more likely in an otherwise healthy individual. Documentary support of a 
healthy subject’s claim that a provoked seizure carries no adverse prognosis will be provided in cases 
where the report of the seizure in the subject’s medical record could be misinterpreted or deliberately used 

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as a pretext for the denial of employment or medical insurance. Prospective subjects will be informed of 
this potential consequence. 
 
5. Neuropsychological and motor effects. rTMS can disrupt cognition during the period of stimulation. 
Monitoring for adverse events should be done with tasks based on regions stimulated, e.g. verbal fluency 
task after left prefrontal stimulation, perceptual task after right parietal stimulation.  
 
6. Potential for unforeseeable adverse events. All subjects will be informed of this point. 
 
J. Benefits versus Risks 
In accordance to the principle of beneficence, research should maintain a favorable balance of benefit to 
risk. The proposed rTMS parameters in MdDS patients in this protocol fall within a Class II classification 
of benefit-risk ratio. That is, rTMS as used here is of potential, but unproven benefit. In comparison, use 
of TMS in normal subjects is a Class III classification of benefit-to-risk: providing no expected benefit, 
but will advance general understanding. As such, all TMS studies on normal subjects are done with a 
higher ethical guideline than studies on patients with neurological disorders as there may be a potential 
for benefit to those with a neurological disorder that does not exist in neurologically normal subjects. 
Given our experience, the recent FDA approval at more intense parameters, and experience of other TMS 
laboratories, to date, the rTMS parameters used in this protocol are safe and constitute a ‘minimal risk’ 
application. 
 
K. Data and Safety Monitoring Plan 
The risk for adverse events is minimal. No medication, therapeutic decision or investigational device is 
made based on the results of these studies. Participants may experience some discomfort upon discussing 
their symptoms with staff and receiving unanticipated information about diagnosis.  Participants may find 
it difficult to participate in detailed ratings. Any reportable adverse events will be reported to the IRB of 
record and Laureate Institute for Brain Research Human Protection Administrator at (918) 502-5155 or 
via email at hpa@laureateinstitute.org.  
 
Each subject is given a unique identifier with a code that depends on their primary vestibular disorder.  
For example, patients with mal de debarquement have a code starting with “MdDS” followed by their 
initials or a number code if initials overlap.  Controls are labeled as “CTRL.”  The code key that links the 
unique identifier to the subjects’ names is kept in a separate file.  All psychophysics and imaging data are 
linked to this unique identifier.  All data analysis is performed on de-identified data.    
 
De-identified imaging, EEG, and TMS outcome data may be shared with other investigators at the 
Laureate or with collaborators outside of the Laureate.  Other than the principal investigator, there is no 
need for personally identifying information to be known to other investigators.   
 
Data will be coded on two levels.  Each subject will be given a unique code according to their primary 
assignment.  When data is entered, it is entered in numerical form, eg (Yes=1, No=2).  The data code is 
kept separate from the data, which would make the raw data uninterpretable otherwise.  
 
Data that is entered through the online diaries through either SurveyMonkey or REDCap will be entered 
with the subject’s code, not their real name.  No personally identifying information will be ascertained on 
the questionnaires.  SurveyMonkey procedures allow for creation of a study specific research.net URL 
that only subjects within the study can ascertain.  REDCap is an online electronic data capture program 
(project-redcap.org) used by over 600 institutions for anonymous data capture.  As the study grows in 
scope, either one of these sites may be used.  No personally identifying information is stored on either of 
these sites.  The link to access the sites are, however, sent to the subject via their email address.  If the 

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subject does not consent to use of electronic datacapture, they will always be give the option of entering 
all data on a paper document.   
 
The link to the patient identifications as well as to the encoded data is stored on a password-protected 
computer on a separate spreadsheet in a locked room.  Only Dr. Cha will have access to the link.  
Anonymized data can be requested in writing to the PI.  However, there would be no need for any 
personally identifying information to be revealed to other investigators.   
 
If Dr. Cha leaves LIBR, and agreement will be made between LIBR and Dr. Cha’s new institution to 
transfer the data so that the study can continue.  If another investigator at LIBR becomes a co-investigator 
of the study, their name will be added to the list of investigators and they will become responsible for 
maintaining data security at LIBR.   
 
Study information will be made available to the subjects when there has been sufficient recruitment to 
make reasonable aggregate assessments.  We can share general study characteristics (how many people 
were recruited, age, primary disorder etc.) early in the process but we do not share study results with 
subjects until the quality of the data is close to publication level.   
 
L. Confidentiality 
Records of the participant’s participation in this study will be held confidential except as disclosure is 
required by law or as described in the informed consent document (under "Confidentiality").  The study 
doctor, the sponsor or persons working on behalf of the sponsor, and under certain circumstances, the 
United States Food and Drug Administration (FDA) and the Institutional Review Board (IRB) will be 
able to inspect and copy confidential study-related records which identify the subject by name.  
Therefore, absolute confidentiality cannot be guaranteed.  If the results of this study are published or 
presented at meetings, the subject will not be identified. 
 
Paper copies of consents, other forms, testing results or papers containing Personally Identifiable 
Information (PII) will be stored in a secured medical records room with access granted only to authorized 
personnel. 
 Online datacapture will only not include any personally identifying information.  These data will only be 
captured by the subjects research code.   
 
 
M: References 
 
General MdDS 
1. Cha YH.  Mal de Debarquement.  Semin Neurol. 2009;29 (5):520-7 
2. Cha YH, Brodsky J, Ishiyama G, Sabatti C, Baloh RW. Clinical features and associated syndromes of 
mal de debarquement. J Neurol 2008;255:1038-1044. 
3. Hain TC, Hanna PA, Rheinberger MA. Mal de Debarquement. Arch Otolaryngol Head Neck Surg 
1999;125:615-620. 
4. Gordon CR, Spitzer O, Doweck I, Melamed Y, Shupak A. Clinical features of Mal de Debarquement:  
adaptation and habituation to sea conditions. J Vest Res 1995;5:363-369. 
5. Brown JJ, Baloh RW. Persistent mal de debarquement: a motion induced subjective disorder of 
balance. Am J Otolaryngol 1987;8:219-222. 
6. Cha, Yoon-Hee.  Mal de Debarquement Syndrome: New insights. Ann N Y Acad Sci (Epub date Feb 
27, 2015) 
7. Cha YH, Chakrapani S, Voxel based morphometry alterations in mal de debarquement syndrome, in 
press PLoSOne, 2015 
 
General TMS Safety 

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REDCap: 
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