Motion Sickness


 

As I reported earlier, our Group member, SM owner, Circumnavigator in a SM and International Space Station, Astronaut, and Professor of Cardiology, responded with the following advice:

Regarding motion-sickness treatments, I checked with my NASA colleagues, who wrote:
Phenergan (promethazine) is still the treatment of choice for Space Motion Sickness/SAS. As you know I first used it to treat a crewmate on an earlier STS flight and it became the treatment. Questions were raised if ondansetron (ZOFRAN) would be better.  Ondansetron was trialed on ISS (the Space Station); it was not as effective as Phenergan. NASA Flight Medicine thinks that Phenergan will remain the treatment for the foreseeable future because it is effective and that the actual side-effects experienced as opposed to what appears in the package insert have not been an issue.

As you are probably aware, Phenergan can be sedating, but the sedative effect can be countered by amphetamines or ephedrine. Because of the abuse potential of amphetamines, they are not used in the military for treatment of side effects, but the last I heard the military does use ephedrine. Typically they use 25mg of Phenergan and 25 of Ephedrine for embarked Marines on a routine basis.


On Revelation, we've tried Stugeron, but did not find it effective, either personally, or for passengers.


NASA, many years ago, made their own "Scope/Dex". It was a large gel capsule with scopolamine and dexedrine tablets inside.  It worked, but not as well as promethazine (PHENERGAN), so Scope/Dex was discontinued.


Studies were done by NASA with Scopolamine patches.  There was a 10-fold variation in Scopolomine blood levels. with the patch. There are multiple determinants for its absorption.  I still remember one of the volunteers, an engineer in our project, who went from being a quiet, shy person to a "drunken, 'life of the party".  She had to be taken home from work...  Trying the patch, on-shore, would be advisable for anyone contemplating its use at sea, although absorption could still be dramatically different "at sea".


We used Phenergan on Day 1 of our flight.  It was highly effective, and in that setting, didn't seem to cause sedation.  Giving it early, before the person is on the verge of vomiting, works best.  At sea, I take it at the first sign of nausea, as it's better to prevent than "treat".  In space, alertness did not seem to be a problem.  I've taken it as a crewmember, doing studies on the NASA KC-135 (aka "The Vomit Comet").  It does make people sleepy, but they can function better than if they were nauseated and vomiting.


There's no question that being in the cockpit, fresh air, focusing on the horizon,  or even letting the person steer the boat all help.  "Steering" helps even if the boat is actually being steered by the autopilot.

Motion-sickness is thought to be caused by a mismatch between the vestibular and ocular system signals, so moving as though steering the boat reduces the mismatch.  


If someone's nausea has proceeded to vomiting, use a suppository.   When a vomiting person takes Phenergan and then vomits again, there's no way to tell how much of the drug was absorbed.  Too much can be toxic. 
CW Bill Rouse Amel Owners Yacht School
Address: 720 Winnie, Galveston Island, Texas 77550 
View My Training Calendar


Paul Harries
 

On Tue, Jun 15, 2021 at 18:43, CW Bill Rouse
<brouse@...> wrote:
As I reported earlier, our Group member, SM owner, Circumnavigator in a SM and International Space Station, Astronaut, and Professor of Cardiology, responded with the following advice:

Regarding motion-sickness treatments, I checked with my NASA colleagues, who wrote:
Phenergan (promethazine) is still the treatment of choice for Space Motion Sickness/SAS. As you know I first used it to treat a crewmate on an earlier STS flight and it became the treatment. Questions were raised if ondansetron (ZOFRAN) would be better.  Ondansetron was trialed on ISS (the Space Station); it was not as effective as Phenergan. NASA Flight Medicine thinks that Phenergan will remain the treatment for the foreseeable future because it is effective and that the actual side-effects experienced as opposed to what appears in the package insert have not been an issue.

As you are probably aware, Phenergan can be sedating, but the sedative effect can be countered by amphetamines or ephedrine. Because of the abuse potential of amphetamines, they are not used in the military for treatment of side effects, but the last I heard the military does use ephedrine. Typically they use 25mg of Phenergan and 25 of Ephedrine for embarked Marines on a routine basis.


On Revelation, we've tried Stugeron, but did not find it effective, either personally, or for passengers.


NASA, many years ago, made their own "Scope/Dex". It was a large gel capsule with scopolamine and dexedrine tablets inside.  It worked, but not as well as promethazine (PHENERGAN), so Scope/Dex was discontinued.


Studies were done by NASA with Scopolamine patches.  There was a 10-fold variation in Scopolomine blood levels. with the patch. There are multiple determinants for its absorption.  I still remember one of the volunteers, an engineer in our project, who went from being a quiet, shy person to a "drunken, 'life of the party".  She had to be taken home from work...  Trying the patch, on-shore, would be advisable for anyone contemplating its use at sea, although absorption could still be dramatically different "at sea".


We used Phenergan on Day 1 of our flight.  It was highly effective, and in that setting, didn't seem to cause sedation.  Giving it early, before the person is on the verge of vomiting, works best.  At sea, I take it at the first sign of nausea, as it's better to prevent than "treat".  In space, alertness did not seem to be a problem.  I've taken it as a crewmember, doing studies on the NASA KC-135 (aka "The Vomit Comet").  It does make people sleepy, but they can function better than if they were nauseated and vomiting.


There's no question that being in the cockpit, fresh air, focusing on the horizon,  or even letting the person steer the boat all help.  "Steering" helps even if the boat is actually being steered by the autopilot.

Motion-sickness is thought to be caused by a mismatch between the vestibular and ocular system signals, so moving as though steering the boat reduces the mismatch.  


If someone's nausea has proceeded to vomiting, use a suppository.   When a vomiting person takes Phenergan and then vomits again, there's no way to tell how much of the drug was absorbed.  Too much can be toxic. 
CW Bill Rouse Amel Owners Yacht School
Address: 720 Winnie, Galveston Island, Texas 77550 
View My Training Calendar

--
Paul Harries
Prospective Amel Buyer


eric freedman
 

This is from one of my crewmembers

 

 

Hi Eric,

   Would love to talk with the astronaut/doctor about his experiences with space motion sickness or SMS. His comments on the etiology of motion sickness in terms of mismatch between vestibular motion detection signals and brain state regarding other detectors of motion is the leading theory among  vestibular scientists.  As I told you, that is what my specialty is, vestibular neuroscientist.  We study not just motion detection, best motion perception, inner ear disfunction, eye movement control during motion, balance, spatial orientation, and navigation. 

 

  I can tell you that as of today’s date, we only have theory about what produces motion sickness in it’s many forms, not a known physiology base that has a pharmacological intervention that works for everyone, certainly not a cure.  We (vestibular scientists) have gained a great deal of information over many decades on the subject but it remains an enigma.  We do know quite a bit about how the brain processes motion information and how multisensory integration signals in the brain and their functional imbalance is the root cause of motion perception dysfunction.  There are priors (effects of vision, proprioception, balance motor command efferent feedback) that are all individualized through experience and developmental variances that lead to differences in one person’s susceptibility over another’s. What I personally am working on for many years is the brain’s multisensory integration capacity and what happens when that integration is disrupted.

 

His comments are correct as I understand it regarding SMS.  Of course, he has personal experience as an astronaut.  I have only worked with the astronaut and cosmonaut core in the past, but not recently.  As I understand it through current scientific literature and discussion with my colleagues who do human spaceflight work at JSC, MIT, and some other places the guided use of promethazine by the astronaut core is under continual flight doc supervision, and as Bill states, it is supplemented by amphetamine to offset the drowsiness side effect of promethazine.  I am familiar with scope/dex and it’s use early in the space program, mostly at the beginning of the space station era, and we have used it in our monkey vestibular studies.  As he states, it was replaced by the current regime of promethazine and amphetamine/ephidrine. As I understand it, use of promethazine for SMS is usually given before a sleep cycle, to diminish the drowsiness side effects for awake mission performance.

 

Currently, in our scientific understanding, we know that SMS is mainly produced by an acute substantial change in the gravito-inertial acceleration (GIA) experienced with the reduction in gravity.  There is still gravity in space, but only at the 0.003g level typical at the ISS level of orbit which is several orders of magnitude less than Earth at 1g.  There is still linear acceleration force experienced in spaceflight from translational motion so the net GIA experienced during spaceflight is vastly different from that experience on Earth and the vestibular inertial detection system is quickly changed upon reaching orbit.  Again the brain has a multisensory informational change that elicits SMS.  However, unlike motion sickness at sea, it is from a loss of signal from the inertial sensing part of the vestibular inner ear, not from a continual motion dynamic like boat motion.

 

A number of studies from the  Navy and from labs (including our own) has shown that roll motion similar to that experienced on boats in the frequency range of 0.2 Hz or lower is a major effector for producing motion sickness. Pitch motion is not as provocative.  This unusual roll motion is compounded by focal vision (near viewing) high demand tasks such as reading, writing, or cooking where eye coordination to close visual targets is not matched to the boat motion and is very different from the priors stored in your brain memory for types of motion responses one is used too on stable substrates.  That is why people find relief from sea sickness by going on deck, looking at the horizon, or eliminating any form of close visual focal behavior.  That is also why some people find relief in the severity of sea sickness if the boat changes direction (downwind or similar to flatten the boat and reduce the 0.2 Hz roll component).

 

In terms of steering, that is two-fold introduction of motion signal augmentation that can help offset the vestibular mismatch experienced during sea sickness.  First, is the proprioceptive signal from the joints and muscles in your arms, hands, body torso (if seated) and all of those plus ankles/hips (if standing) that provide motion signals about position/movement to feed into the multisensory vestibular brain regions.  These same signals are known to be enhanced when an individual has vestibular ear disease, or loss of vestibular inner ear signals due to trauma or nerve cuts such as occur with certain types of cancer.  When these proprioceptive signals are enhanced with vestibular loss, this leads to an improvement in balance and a reduction in motion sickness in people with vestibular disease.  The same process happens with sea sickness.  That is believed to be the compensation component of the brain that results in many people getting used to sea motion after 48 – 72 hours after at initial sea sickness onset.  The second component of why steering helps some people is a concentration of vision away from focal tasks (near viewing) to distance viewing (horizon, steering targets in the distance, etc).

 

For drugs to be used for propholaxis and sea sickness treatment, there are many studies on the subject.  The modern science points to promethazine, cinnarizine, and hyoscine as the most effective choices.  But all have pluses/minuses, all have different dosages that are effective for different people.  Again, we are talking specifically for sea sickness, not SMS, which has a different defined cause than sea sickness, although the same medications may be efficacious for both. There is no one right answer here!

 

Most vestibular scientists that are also sailors prefer cinnarizine or hyoscine, because of the lower side effect of drowsiness which is high with promethazine.  However, once you are already experiencing sea sickness to the level of emesis, suppository promethazine is preferred.  In addition, one does not have to take an antidrowsiness amphetamine/ephedrine necessarily with cinnarizine or hyoscine.

 

Other than the papers I already sent you from scientific journals last week, here are a couple more abstract.  Hope this is helpful!

 

 

Here is the abstract of a study for cinnarizine from 1994 as an example:

 

Cinnarizine in the prophylaxis of seasickness: laboratory vestibular evaluation and sea study

A Shupak 1I DoweckC R GordonO Spitzer

Affiliations expand

  • PMID: 8004883

 

abstract

Cinnarizine was evaluated for the prevention of seasickness in a laboratory and sea study. The effects of 25 mg cinnarizine on the vestibulo-ocular reflex were investigated in 13 subjects. Significant reduction of the gain in response to sinusoidal oscillations at 0.02, 0.08, and 0.16 Hz (p < 0.05) and increased phase lead at 0.16 Hz (p < 0.01) were observed. The effect of 25 and 50 mg cinnarizine on seasickness severity was examined in 95 subjects during a voyage in rough seas. Seasickness symptoms were improved in 69% of the subjects by 50 mg cinnarizine versus 35% and 31% in the groups receiving 25 mg cinnarizine and placebo (p < 0.05 and p < 0.01, respectively). The percentage of vomiting protection provided by 50 mg cinnarizine was 63% (p < 0.05). We conclude that 50 mg cinnarizine is an effective drug for the prevention of seasickness. The reduction in vestibular sensitivity observed even after administration of 25 mg cinnarizine may explain the potency of cinnarizine in the prevention of seasickness.

 

Here is the abstract from the Royal Naval Medicine journal about cinnarizine use and sea sickness:

INM investigations into drugs for seasickness prophylaxis.

Pingree BJ

Journal of the Royal Naval Medical Service01 Jan 1994, 80(2):76-80
PMID: 7707278 

Review

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Abstract 


A summary is presented of a programme of work investigating the comparative efficacy of the two drugs most commonly used for seasickness prophylaxis in the Royal Navy, hyoscine and cinnarizine. The programme had both laboratory and sea-trial components. It was shown that hyoscine was a more effective drug than cinnarizine, but cinnarizine had less marked side effects. This comparative superior tolerability of cinnarizine decreased as motion sickness increased. Guidance is given as to the optimum indications for each drug, together with prophylactic regimens.

 


Trevor Lusty
 

I have studied every line posted on this subject intently. Thank you to every one who has contributed and as ever, sincere thanks to Bill and Eric for introducing such in depth and informed contributors. I have been a member of the group since 2008/9 and consider this thread the most impressive and in depth review that I have seen.
I sailed my boat Seafever of Cuan SM 425 from La Rochelle to Argentina 2007/08. The only thing that made this possible for me was Scopaderm patches. Unfortunately,  by the time I had reached Brazil, due to overuse, I  had developed contact dermatitis as a reaction to the oil that transmits the drug from the patches.
I was considering giving it all up. The boat was my home and my identity, but without Scopderm, I was beaten physically and mentally with sea sickness.
The definition of seasickness for me without patches was,  incapacity to eat, drink,walk, and  all loss of normal body function, leading to dehydration which at some point was going to lead to a very serious navigation or seamanship error.
In Southern Brazil, I had the good fortune to meet Dr Omar Sanchez, a keen diver and sailor  from Argentina, who kindly accompanied me from Uruguay to Buenos Aires and subsequently far beyond.
Dr Sanchez initially saw me at my worst, (not pretty) and after our trip together reflected on my Mal de mer.
He told me that I  was as an extreme case as he had ever seen. Interestingly, this also was previously mentioned when sailing in France by Michel Charpentier!  When I invited Dr Sanchez to accompany me from Buenos Aires back to the Caribbean he agreed on the following condition.
No alcohol, no pepper, very plain food, no over standing you watch, YOU MUST HAVE SLEEP. You will sleep on the floor ( the passageway between the salon and aft cabin). Drink 7 UP, eat apples, and or, any form of ginger between meals, keep drinking fluids. No reading. No prolonged periods at the chart table. All meals cooked and prepared before departure. Use the generator and microwave to heat the meals, serve them in bowls and eat in the cockpit. Bathroom needs facilitated with a bucket in the cockpit. YOU WILL KEEP WARM.
He prescribed the following ,one Stugeron (cinnariazine) and one Kwells (hyoscine) taken the night before departure, repeat at breakfast. Then one pill of each, taken alternatively every four hours, until the end of the trip.
We experienced some challenging ocean sailing together.
The effects of the medication are, dry mouth and sometimes a taste as if you have a bad cold. The sleepiness effect is negated by the nervousness and adrenaline  we all experience before setting out to sea.
Thirteen years, and tens of thousands of ocean miles later, I have felt badly off colour twice - I had forgotten to take my pill or pills.
I have NEVER been sick since and always been in full control of myself and my vessel and therefore less fearful.
Thanks to Doctor Sanchez and the sagacious elder members of this site for their advice and support on endless subjects, I have continued to sail with more general knowledge  and  a reduced level of fear, but never without the medication.
For the naysayers, please do not criticise  this remedy and warn of possible life debilitating diseases. I am sixty seven, I have been blessed and allowed to experience people, places and experiences previously undreamed off. All I can offer is, that this solution works for me and if it helps someone else, then in some small way, it will  repay my gratitude to  others who have helped me live and sail far beyond my dreams. For me, it has all be worth it, I understand how others  have different values, concerns, and responsibilities and just like the ocean I totally respect that.
 Chantier Amel respect de la mer.

Fair winds  and well rounded  seas to all.
Trevor Lusty
Ireland

 


Alejandro Paquin
 

I agree with Trevor the posts on this subject is one of the best attempt to describe and explain one of the most mysterious maladies that affect sailors in general. Thanks to Bill for bringing the subject up and all that followed. I felt Scopolamine made me feel like a caffeine overdose and didn´t go well with me.I have found that Meclizine HCl works well for me and those in my crew that tend to get sick. I can suddenly become sick in calm nearly no wind situations, and survive rougher sea conditions. Still a mystery.
--
Alex Paquin
S/V " SIMPATICO"
Amel Maramu
Hull #94, 1981