Diagnostic criteria for grading severity of acute motion sicknes

Cramer, D. B.

Graybiel, A.

Miller, E. F., II

Wood, C. D.

English

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DIAGNOSTIC CRITERIA FOR GRADING M E  SEVERITY OF ACUTE 
MOTION SICKNESS* 
Ashton Graybiel, Charles D. Wood, Earl F. Miller 11, and Dewey B. Cramer 
Bureau of Medicine and Surgery 
MR005.04-002 1 .156 
NASA Order R-93 
Released 
Captain J . W. Weaver, MC USN 
Commandi ng Officer 
6 February 1968 
*This research was conducted under the sponsorship of the Office of Advanced Research 
and Technology, National Aeronautics and Space Administration. 
NAVAL AEROSPACE MEDICAL INSTITUTE 
NAVAL AEROSPACE MEDICAL CENTER 
PENSACOLA, FLORIDA 32512 
SUMMARY PAGE 
THE PROBLEM 
A l h u g h  time has endorsed the usefulness of previously presented diagnostic 
criteria defining four levels of severity of motion sickness, it also has revealed cerk in  
limitations. 
FINDINGS 
The new diagnostic criteria that have been developed differ from the old in two 
important respects: 1) "moderate malaise, " previously defined on an exclusion basis, 
. has been divided info two categories and precisely defined, and 2) numerical scoring 
is optional. These criteria a re  more suited fo clinical application as empirical evalu- 
air'onsthan for precise measurement of physiological functions. By holding fast fo the 
definition of endpoints in the "old" criteria with proven reliability and validify, the 
change does not seriously affect the findings in experiments where the old criteria were 
used. 
.. 
I I  
INTRODUCTION 
In earlier reports diagnostic criteria were presented (Table I) defining four levels 
of severity of motion sickness (2,3). This categorization was designed originally to 
evaluate susceptibility to acute motion sickness in a Slow Rotation Room (4), and iis 
use was extended to studies involving other motion sickness producing devices in  the lab- 
oratory and in evaluating air sickness and sea sickness (1,8). An important objecfive 
was to define an endpoint short of vomiting which was at once reliable and "adcepiwble" 
to the subiect. The diagnostic level termed Malaise 111 (severe) met these requirements. 
Reliability and validity were demonstrated by the findings in  connection with evalu- 
ating the effectiveness of antimotion sickness drugs (6,7); by using a double blind 
-experimental technique not only was i t  possible to rank different drugs or combinations 
of drugs in terms of their effectiveness, but, in so doing, the drugs were also found to 
, be grouped according to their principal pharmaceutic action. 
Although time has endorsed the usefulness of  the criteria shown in Table I, i t  also 
has revealed certain limitations. One shortcoming involved Malaise II (moderate) which 
was defined on an exclusion basis, i .e., symptoms more severe than Malaise I cnd less 
severe than Malaise 111. This imprecision not only lessened discrimination from a diag- 
nostic point of  view but also rendered Malaise I I  relatively useless as an endpoint. A 
second limitation was the failure to define ''other symptoms. 'I A third limitation w s  
the lack of numerical scoring which proved to be a handicap in data handling. For 
these and other reasons new diagnostic criteria were defined and put into practice. 
THE NEW CRITERIA 
In making the changes the first step was to give arbitrary point scores to the four 
severity levels of symptoms used in the old criteria which were implied by their valu- 
ation; i .e., two symptoms in  any of the three lower levels equaled one in the next 
higher level. The second step involved the identification of "other" symptoms and 
dividing them into two groups, one double the value of the other. This provided a l i s t  
of "additional qualifying symptoms" (AQS) with a value of 1 point and "minimal" symp- 
toms with a value of  2. In the third step Malaise I I  was divided into two levels of se- 
verity, M IIA and M I I B .  
In brief, the new criteria differ (Table (I) from the old mainly in establishing 
categories M IIA and M IIB and in numerical scoring. One of these, M IIA, has been 
tested and has been found to be reliable (5). To use i t  successfully, however, requires 
more cooperation from the subject and closer attention on the part of the experimenter 
or observer than i s  true for M 111. It has the advantages of  minimal discomfort, quick 
recovery, and reduced tendency to habiiuation as compared with endpoints having 
symptoms of greater severi fy . 
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The use of point scoring increases discrimination by providing "ranges, " especial- 
ly in the case of severe malaise and frank sickness as well as facilitating data handling. 
Grea t  reliance has been placed, as heretofore, on the five cadina l  symptoms of 
motion sickness, and not more than one score for any symptom, e.g., nausea syndrome, 
may be used in any evaluation. The symptomatology of he  "nausea syndrome" has been 
extended to include epigastric discomfort and epigastric awareness. The former is de- 
fined as  a feeling of distress which is more than "awareness" but short of nausea which 
implies a feeling of being ill; epigastric awareness is defined as  a feeling which draws 
attention to the epigastric area but i s  not uncomfortable. Alihough motion sickness 
involves more symptoms than a re  included under the nausea syndmme, they are  rarely 
as prominent o r  distressing. Unless a susceptible person i s  exposed to fairly severe 
stress, the evolutionary development of the nausea syndrome may go through the steps 
indicated in Table I I ,  but as everyone with experience knows, there are  exceptions. 
Only two symptoms have been added to the big five, dizziness and headache, 
Dizziness is  bmadly defined to include giddiness and, in common parlance, vertigo; 
the mle  of vision is taken into account by requiring that "severe dizziness'' be apparent 
with eyes open to qualify. Headache is a more frequent symptom in subacute o r  chronic 
motion sickness but may appear early. 
As much attention was given to rejection as  to inclusion of symptoms. Symptoms 
not included fell into three categories: 1) those reliable but difficult to measure or 
estimate, e.g., respiratory irregularity; 2) those reliable but having a similar diag- 
nostic significance fo a symptom already present, e.g., anorexia; and 3) hose  with 
lack of reliability, e.g., blurred vision. 
The criteria put forward in this report f i t  many siiuations in which symptoms of 
motion sickness appear in a short period of time. Modifications in scoring may b e  re- 
quired to increase accuracy in situations where the force envimnment cannot be  manip- 
ulated and the stress is either very mild or  very severe. Mild stress over long periods 
tends to evoke symptoms characteristic of subacute o r  chronic motion sickness, e.g., 
general discomfort, fatigue, headache, anorexia, etc. Severe stress may result in over- 
shooting the endpoint because of the lag beiween stimulus and response. A small per- 
centage of persons do not manifest the uwal clinical picfure of acute motion sickness, 
and in these instances the proposed diagnostic criteria may prove to be inadequate. The 
experienced investigator will improvise and should have little difficulty. Symptoms s f  
anxiety and fear may be indistinguishable from symptsms of motion sickness; both the 
individual and the circumstances need fr, be taken into account. Persons who minimize 
o r  exaggerate their subjective symptoms may provoke emrs in estimations; this should 
be suspected when there is lack of concordance beween objective signs and subjective 
complaints. Serial determinations a re  usually needed b establish a baseline; in doing 
this habituation must be taken into account. The criteria are of limited usefulness in 
chronic motion sickness. 
4 
REFERENCES 
1. Deane, F. R., Wood, C. D., and Graybiel, A., The effect o f  drugs in altering 
susceptibility to motion sickness in aerobatics and the Slow Rotation Room. 
Aerospace Med. , 38:842-845, 1967. - -  
2. Graybiel, A. , Vestibular.sickness and some of i ts  implications for space flight. 
- In: Fields, W. S., and Alford, B. R .  (Eds.), Neurological Aspects of Auditory 
- and Vestibular Disorden. Springfield, 111 .: Charles C Thomas, 19647- 
3. Graybiel, A,, The labyrinth and space flight. In: Bedwell, T. C., Jr., and 
Strughold, H. (Eds.), Bioastronautics -- and thExploration of Space. Brooks 
Air Force Base, Texas: Aerospace Medical Division, Air FGce Systems Command, 
1966. 
4. Graybiel, A., Clark, B., and Zarriello, J. J., Observationson human subjects 
living in a "Slow Rotation Room" for periods of two days. - Arch. Neurol. , - 3: 
55-73, 1960. 
5. Miller, E. F. 1 1 ,  and Graybiel, A., Unpublished data. 
6. Wood, C. D. , Graybiel, A. , and McDonough, R. C. , Human centrifuge studies on 
the relative effectiveness of some antimotion sickness drugs. Aerospace - Med , 
37: 187- 190, 1966. 
7. Wood, C. D. , Graybiel, A. , and Kennedy, R. S, , A comparison of  effectiveness 
of some antimotion sickness drugs using recommended and larger than recom- 
mended doses as tested in the Slow Rotation Room. Aerospace - -  Med., 37:259- 
262, 1966. 
8. Wood, C. D., Graybiel, A,, Cramer, D. B., and Molina, E. A., Comparisonof 
antimotion sickness drug evaluations a t  sea and on the Slow Rotation Room, 
NAMI-1013. NASA R-93. Pensacola, Fla.: Naval Aerospace Medical 
Institute, 1967. 
5 
Unclassified 
Ashbn Graybiel, Charles D. Wood, Earl F. Miller I I ,  and Dewey B. Cmmer 
6 February 1968 6 8 
8a. C O N T R A C T  OR G R A N T  N O  98. ORIGINATOR'S R E P O R T  NUMBERISJ 
NAMI-1030 NASA R-93 
b. P R O J E C T  N O  
96. O T H E R  R E P O R T  NO(SI (Any othernumbers the tmay  be assigned 
C. d  MR005,04-002 1 ~ this report) 
10 D I S T R I B U T I O N  S T A T E M E N T  
This document has been appmved for public release and sale; its distribution is  unlimited. 
I 1  S U P P L E M E N T A R Y  N O T E S  1 2  SPONSORING M I L I T A R Y  A C T I V I T Y  
13 A B S T R A C T  
New diagnostic criteria are presented for grading the severity of acute motion sickness. 
They are more suited io clinical application as empirical evaluations than for precise meusure- 
ment of physiological functions. The new criteria differ fmm the old in two important respects: 
1) "moderate malaise, " previously defined on an exclusion basis, has been divided into two cate- 
gories and precisely defined, and 2) numerical scoring i s  optional, By holding fast to the defini- 
tion of endpoints in the "old" criteria with proven reliability and validity, the change does not 
seriously affect the findings i n  experiments where the old criteria were used. 
I 
Unclassified 
Securitr Classification 
DD lF2Y651 473 ( P A G E  
S/N 0101-807-6801  
Unclassified 
Security Classification 
Acute motion sickness severity 
Diagnostic criteria with clinical applications 
Moderate malaise levels 
Numerical scoring 
FORM DD I NOV..1473 ( B A C K )  
LINK A -
R O L E  -
LINK a -
R O L E  
I_ 
Unclassified 
(PAGE 2) Security Classification 


Diagnostic criteria for grading the severity of acute motion sickness

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