Motorist’s Disorientation Syndrome—A Narrative Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the document entitled “Motorist’s Disorientation Syndrome and Its Rehabilitation– A Systematic Review” that was aimed to “extract the symptoms of MDS and rehabilitation suggestions from the literature, and also the differences between MDS and other similar syndromes, such as persistent postural-perceptual dizziness (PPPD). We also aimed to outline the differences between MDS and motion sickness (MS). We discussed the role of the otoliths and semicircular canals, and how patients’ symptoms might be influenced by anxiety.”

The topic is interesting and the information is valuable. However, revision is required to consider publication.

- The document is written as  a Qualitative Evidence Synthesis (instead of a systematic review); since  “The goal … is interpretative in broadening understanding of a particular phenomenon” (Journal of the Medical Library Association 2006; 94: 421–9), which can  lead to development of new theories, overarching “narrative”, generalization or “interpretative translation” (Health Information and Libraries Journal 2009; 26: 91–108)

- The description of the aims of the study is fragmented. The reader may benefit from a more integrative approach to describe the general objective, followed by the detailed explanation.

- Since the topic imply a potentially wide readership, not all familiar with neurotology, the reader may benefit from an appendix to describe the clinical definitions of the main concepts that are discussed In the document; as well as a short introduction paragraph on the main reasons to seek health care.

- The description of the literature search strategy is repetitive, please revise.

- The number of studies included in this review and the flow chart may be included at the beginning of the Results Section. A Table to describe  the general characteristics  of the selected studies would be appreciated, including at least, the study design, the sample size, the  setting, the research group. and the year of publication

- The narrative of each study requires standardization according to the aims of this review, including similar information in a similar order, such as participants number/age//gender, triggers, symptoms/signs, results of vestibular function test (eye movements, VOR, other tests); followed by any additional information.

- To be helpful to examine the clinical findings, Table 1 could be summarized while dissecting them from functional impairment/ treatment in a different Table.

- The qualitative summary of the results should be included in the Results Section.

- Authors may start the Discussion Section with the main findings of the qualitative summary.

- It is highly recommended that the Discussion Section is written according to the specific objectives, preceded by an integrative summary of the related evidence, while avoiding repetition of isolated evidence.

- The Therapeutic strategies could be subdivided into medication and rehabilitation  strategies.    

- A limitation paragraph is required, to include at least the scarcity of studies, the small sample sizes, the few research groups (with bias risk).

- It is highly recommended to describe the Conclusions according to the specific objectives while keeping the same order as in the Discussion Section.   

-Typographical errors (including hyphens out of place) require revision.  

Author Response

Reviewer 1

Comments and Suggestions for Authors

Thank you for the opportunity to review the document entitled “Motorist’s Disorientation Syndrome and Its Rehabilitation– A Systematic Review” that was aimed to “extract the symptoms of MDS and rehabilitation suggestions from the literature, and also the differences between MDS and other similar syndromes, such as persistent postural-perceptual dizziness (PPPD). We also aimed to outline the differences between MDS and motion sickness (MS). We discussed the role of the otoliths and semicircular canals, and how patients’ symptoms might be influenced by anxiety.”

The topic is interesting and the information is valuable. However, revision is required to consider publication.

Answer: we thank the reviewer for having underlined our purpose and for his following constructive remarks.

However, it appears that the version received does not match the last one we submitted, which was, as requested by the Assistant Editor in charge: “Motorist’s Disorientation Syndrome and Its Rehabilitation– A Narrative Review” (and not “-A systematic review”).

The switch to a “Narrative review” in the version actually submitted and subsequent modifications in the method, introduction and discussion of the MS are possibly more corresponding to the remarks.

 

- The document is written as a Qualitative Evidence Synthesis (instead of a systematic review); since “The goal … is interpretative in broadening understanding of a particular phenomenon” (Journal of the Medical Library Association 2006; 94: 421–9), which can  lead to development of new theories, overarching “narrative”, generalization or “interpretative translation” (Health Information and Libraries Journal 2009; 26: 91–108)

Answer: we thank the reviewer for this remark and agree with its contents. However the actually submitted paper was in the title a “Narrative review” paper which corresponds more closely to our intent (strategy of article selection and purpose to discuss pathophysiological orientations and stress on this possibly misidentified or under-diagnosticated pathology) and also to respond to the requests of the other Reviewers.

As mentioned for qualitative evidence synthesis articles, considerable variation exists in search methods for qualitative systematic reviews. While diversity in methods is appropriate during the development of review methodology, major concerns remain about the absence of an accepted standard and so we have oriented our choice toward a “Narrative review” (reference 13).

- The description of the aims of the study is fragmented. The reader may benefit from a more integrative approach to describe the general objective, followed by the detailed explanation.

Answer: Accordingly, the aims in the abstract and introduction have been adapted. As suggested the rehabilitation methods which are poorly detailed in literature for this pathology have been only reported but not systematically developed. “Rehabilitation”, which has been secondary added as a request of the Editor, has now been suppressed in the title and in the aims (in order to conciliate your comments with those of the other Reviewers on this point).

 

- Since the topic imply a potentially wide readership, not all familiar with neurotology, the reader may benefit from an appendix to describe the clinical definitions of the main concepts that are discussed In the document; as well as a short introduction paragraph on the main reasons to seek health care.

Answer: We thank the reviewer for this remark. In the modified introduction of the MS, we have tried to justify the reason of a health care in this pathology: this concerns patients who stop driving or have their daily life strongly modified by their symptoms and search for a solution. The current cognitive and behavioral therapies (although very little of scientific literature is addressed to this concern in this topic) seems promising as indicated in the abstract (one aim of our narrative study is to stimulate searchers on this concern).

 

Since the topic imply a potentially wide readership, not all familiar with neurotology, the clinical definitions of the main concepts that are now indicated in the introduction.

The main characteristics of most pathologies previously discussed in the section “Proposed characteristics to separate MDS from other functional pathologies”, are now transferred to the introduction section, corresponding also to a remark of the Reviewer 2.

In this modified introduction, the main characteristics of PPPD, MS, … are now more clearly presented and detailed for a wide readership in this new version of the MS. Otherwise the readers are adressed for these different entities to reference corresponding to the fundamental work for each one: PPPD referring to the ICVD / International Classification of Vestibular Disorders contents published by Staab JP et al. in the JVR in 2017; Motion sickness (MS) is referred to the fundamental works from Golding et al. (MS current opinion 2005); the concept of visual dependancy is refereed to Freyss G 1994 and so on.

 

- The description of the literature search strategy is repetitive, please revise.

Answer: we thank the Reviewer for this remark. However the authors mention that these remarks correspond to a previously submitted version (“systematic review”) but not to the section “Methods” presented in the current and actual version entitled “…-A narrative review”. In this last submitted version, substantial modifications and simplifications in the method section have been performed accordingly to a narrative review.

- The number of studies included in this review and the flow chart may be included at the beginning of the Results Section.

Answer: we thank the reviewer for this remark. However and accordingly to the other Reviewers we prefer to present the flow chart as a method (the legend of the figure has been accordingly modified) and results concerning the eight retained papers are described in the following section in table 1, which we have now divided in two sub-tables following your request mentioned further.

 

- A Table to describe the general characteristics of the selected studies would be appreciated, including at least, the study design, the sample size, the setting, the research group. and the year of publication

Answer: We have now completed table 1 with extra information concerning the study design and setting. In this table 1 the year of publication, the sample size, the setting are mentioned (vestibular explorations etc.) and we have now separated it by creating a new table concerning treatment. This  new table about treatment is now placed as table 5

- The narrative of each study requires standardization according to the aims of this review, including similar information in a similar order, such as participants number/age//gender, triggers, symptoms/signs, results of vestibular function test (eye movements, VOR, other tests); followed by any additional information.

Answer: we thank the reviewer for this contributing remark; this is now modified in the new MS and subsections are individualized in the publications report to follow a similar order. However the different papers do not always broach all the items.

- To be helpful to examine the clinical findings, Table 1 could be summarized while dissecting them from functional impairment/ treatment in a different Table.

Answer: Accordingly, we have now divided table 1 in two different tables. An other table is now dedicated to treatment and named table 5.

- The qualitative summary of the results should be included in the Results Section.

Answer: we thank the reviewer for this comment.

These two tables are now placed in the result section, and can be used to introduce the discussion.

However as underlined by the Reviewer, table 1 which contains the main clinical information and associated pathologies and triggering conditions is important to show the multifactorial character of this entity. It has been completed as required by information on the different research groups, the setting and study design when this last condition is clearly presented in the different related papers. Otherwise as required the new table 2 describes treatment.

 

- Authors may start the Discussion Section with the main findings of the qualitative summary.

Answer: the beginning of the discussion has been accordingly modified. 

 

- It is highly recommended that the Discussion Section is written according to the specific objectives, preceded by an integrative summary of the related evidence, while avoiding repetition of isolated evidence.

Answer: The discussion has been reorganized in order to take into account this remark as well to match with remarks of other reviewers.

- The Therapeutic strategies could be subdivided into medication and rehabilitation  strategies.  

Answer: this is now corrected in the new version of the MS (the subdivision “4.6.2. rehabilitation” has been added).

- A limitation paragraph is required, to include at least the scarcity of studies, the small sample sizes, the few research groups (with bias risk).

Answer: this is now performed in the new version of the MS.

- It is highly recommended to describe the Conclusions according to the specific objectives while keeping the same order as in the Discussion Section.

Answer: The MS conclusion has been accordingly modified.

-Typographical errors (including hyphens out of place) require revision.

Answer: numerous hyphens are automatically generated during the submission process. Most of them are independent from our will and have been already the object of corrections and will be anew revised.

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

Comments for the Authors

This manuscript addresses a clinically relevant and likely underrecognized topic. The subject is interesting and potentially valuable for clinicians working in neurotology, vestibular disorders, and functional dizziness. However, the manuscript would benefit from substantial methodological and structural revision in order to fully support its presentation as a systematic review. The main issues concern the alignment between the title, the review objective, the methodological framework, and the way the evidence is synthesized across the Results and Discussion sections.

1. Title

The current title suggests that the review covers both motorist disorientation syndrome and its rehabilitation. However, based on the manuscript sections reviewed, the rehabilitation component is not yet sufficiently developed or systematically addressed. If rehabilitation is intended to remain part of the title, the review should explicitly define how treatment/rehabilitation studies were identified, what kinds of interventions were considered, and which therapeutic outcomes were extracted and synthesized. Otherwise, the title would benefit from being narrowed so that it more accurately reflects the actual scope of the review.

2. Abstract

The abstract would benefit from clearer methodological framing and a more focused objective. At present, it combines several aims at once, including symptom description, differential diagnosis, pathophysiological interpretation, and rehabilitation. This makes the scope of the review difficult to understand from the outset.

In addition, the abstract tends to merge results with interpretative discussion. Statements regarding visual-vestibular conflict, the role of anxiety, or the velocity storage integrator should be presented more cautiously, especially given the small number of included studies and the likely heterogeneity of the available evidence. The rehabilitation component also appears somewhat overextended in the abstract, as treatment approaches are mentioned but not clearly supported by an explicit synthesis framework. It would strengthen the abstract if it were revised to follow a more conventional systematic review structure: brief background, precise objective, clear methods, main findings, and cautious conclusion.

3. Introduction

The Introduction would benefit from a clearer scientific thread. Several important concepts are introduced, such as MDS/MVDS, PPPD, motion sickness, visual dependence, and related vestibular constructs, but they are not yet presented in a sufficiently hierarchical and structured way. The section moves rather quickly from background information to pathophysiological assumptions and mechanistic interpretation, which gives parts of the Introduction a discussion-like tone.

It would strengthen this section if the authors first defined the key concepts clearly, then highlighted the areas of overlap and disagreement in the literature, and finally identified the specific knowledge gap that justifies the review. The rehabilitation dimension announced in the title should also be better introduced here. At present, the Introduction does not clearly establish why rehabilitation requires systematic review or what therapeutic uncertainty the manuscript seeks to address.

The review objective should also be reformulated more precisely. Rather than listing multiple thematic intentions, the Introduction should end with a clear and reproducible review aim that matches the title, methods, and synthesis strategy.

4. Materials and Methods

The Methods section requires important clarification in order to support the manuscript’s systematic review design.

First, the search strategy is described in a repetitive and incomplete way. The manuscript lists databases and search terms, but it would be helpful to provide a more reproducible account of the search process, including full search strings or search logic, Boolean operators, database-specific adaptations, language restrictions if any, and the exact date of the last search.

Second, the eligibility criteria should be more closely aligned with the stated scope of the review. If the purpose is to describe the clinical profile of a rare syndrome, inclusion of observational studies and case series may be justified. However, it would strengthen the review to avoid treating hypothesis papers or conceptual descriptions as primary evidence within the formal synthesis. Conversely, if rehabilitation is part of the review scope, treatment-oriented studies and therapeutic outcomes should be explicitly defined in the eligibility framework.

Third, no protocol registration is reported, and no formal methodological quality or risk-of-bias assessment appears to have been conducted. Even if the available literature is limited and mainly observational, the review would be methodologically stronger if an appropriate appraisal tool were applied and reported.

Fourth, the description of data extraction is too general. The manuscript would benefit from explicitly stating which variables were extracted from each study, for example: patient demographics, clinical manifestations, triggering situations, vestibular findings, associated conditions, and treatment/rehabilitation approaches.

Finally, the PRISMA flow diagram should be revised for clarity and alignment with standard reporting conventions, particularly with respect to duplicate removal and the distinction between screening stages.

5. Results

The Results section would benefit from substantial reorganization. At present, it is presented mainly as a chronological narrative of individual studies, which makes it difficult to identify the main patterns emerging from the literature. A more thematic structure would considerably improve clarity and would better reflect the expectations for a systematic review.

For example, the Results could be organized into subsections such as: study characteristics, symptoms and triggering circumstances, vestibular and visual findings, associated conditions/comorbidities, and reported treatment or rehabilitation approaches. This would allow the manuscript to move from description to synthesis more effectively.

 

The relationship between the text and the tables should also be strengthened. The narrative should guide the reader through the principal messages emerging from the tabulated data rather than reproducing details study by study. Table 1 is currently overloaded and would benefit from redesign. Its title should be concise and descriptive, while abbreviations and explanatory notes should be moved to footnotes. More broadly, the tables should function as synthesis tools and align directly with the structure of the Results text.

6. Discussion

The Discussion contains several potentially useful observations, particularly regarding symptom triggers, overlap with related vestibular syndromes, and possible pathophysiological mechanisms. However, it currently appears to take on part of the synthesis function that should already have occurred in the Results section.

In particular, the introduction of Tables 2–4 in the Discussion weakens the overall structure of the manuscript. If these tables summarize empirical findings, they should first be presented in the Results section and then interpreted in the Discussion. If, on the other hand, a table such as Table 4 is intended as a conceptual summary of pathophysiological hypotheses, this should be made explicit, and its interpretative nature should be clearly distinguished from the empirical synthesis.

The Discussion would also benefit from a more consistent separation between what is directly supported by the included studies and what remains hypothetical or interpretative. This is especially important for mechanistic explanations and rehabilitation implications, which should be framed cautiously given the limited and heterogeneous evidence base.

Overall recommendation

Overall, the manuscript addresses an interesting and clinically relevant topic, but in its current form it would require major methodological and structural revision to function convincingly as a systematic review. In particular, the review objective remains too broad, the rehabilitation component is not yet systematically supported, the eligibility framework is insufficiently aligned with the stated scope, and the synthesis of findings is more narrative and interpretative than methodologically systematic. For this reason, the authors may wish to consider whether the manuscript would be more appropriately framed as a narrative review, or possibly as a scoping review, rather than as a formal systematic review. Such a repositioning may better match the nature of the available literature, which appears sparse, heterogeneous, and partly conceptual. If the authors wish to retain the systematic review format, substantial revision of the methodology, evidence selection, and results synthesis will be necessary.

Comments on the Quality of English Language

Even though English is not my first language, I find that the manuscript is generally understandable, but it has recurrent problems with syntax, phrasing, redundancy, articles, hyphenation, and scientific style. In places, the language leads to conceptual ambiguity and weakens the distinction among results, interpretation, and hypotheses. So I would not rate the English as fully satisfactory.

Author Response

REVIEWER 2

Comments for the Authors

This manuscript addresses a clinically relevant and likely underrecognized topic. The subject is interesting and potentially valuable for clinicians working in neurotology, vestibular disorders, and functional dizziness. However, the manuscript would benefit from substantial methodological and structural revision in order to fully support its presentation as a systematic review. The main issues concern the alignment between the title, the review objective, the methodological framework, and the way the evidence is synthesized across the Results and Discussion sections.

Answer: The authors thank the reviewer for his encouraging and constructive remarks and to have underlined our purpose. However it appears that the version received does not match the last one we submitted, which was, as requested by the Editor in charge: “Motorist’s Disorientation Syndrome and Its Rehabilitation– A Narrative Review” and not “-A systematic review”.

The switch to a “Narrative review” in the version actually submitted and subsequent modifications in the method, introduction and discussion of the MS provided are possibly more in accordance with the Reviewer remarks.

 

1. Title

The current title suggests that the review covers both motorist disorientation syndrome and its rehabilitation. However, based on the manuscript sections reviewed, the rehabilitation component is not yet sufficiently developed or systematically addressed. If rehabilitation is intended to remain part of the title, the review should explicitly define how treatment/rehabilitation studies were identified, what kinds of interventions were considered, and which therapeutic outcomes were extracted and synthesized. Otherwise, the title would benefit from being narrowed so that it more accurately reflects the actual scope of the review.

Answer: we thank the Reviewer for his contributing suggestion and we have now suppressed “rehabilitation” from the title of the new MS. The paucity of papers dedicated specifically to MDS cannot allow a large discussion and is mainly dedicated to visuo-visual rehabilitation in general which is not the scope of this paper.

1. Abstract

The abstract would benefit from clearer methodological framing and a more focused objective. At present, it combines several aims at once, including symptom description, differential diagnosis, pathophysiological interpretation, and rehabilitation. This makes the scope of the review difficult to understand from the outset.

Answer: we thank the reviewer for this suggestion and contributive proposals. In the last version of the MS (this one the Reviewer has apparently not received) we underlined that 3 main goals are now mentioned to clarify the individuality of this under-recognized and under diagnosed entity by describing more precisely its symptoms and summarize them through the current although sparse dedicated literature, to differentiate it from other close entity and to try to merge from current literature data a conceptual summary for pathophysiological hypotheses. This necessary clarification is in line with the fact that de motorist’s syndrome is not so far described in the International Classification of Vestibular Disorders (ICVD).

 

However these remarks are different and not in accordance with those of the other Reviewers who approved the need for this emerging and under-recognized entity to be clarified by presenting the important points i.e. the symptoms, the triggering conditions, the difficulties to distinct (differentiate) it from other close pathologies (PPPD and MS) which makes it a still underdiagnosed pathology.

In addition, the abstract tends to merge results with interpretative discussion. Statements regarding visual-vestibular conflict, the role of anxiety, or the velocity storage integrator should be presented more cautiously, especially given the small number of included studies and the likely heterogeneity of the available evidence.

Answer: it is a narrative review which so include “interpretative discussion” and this section is introduced as a conceptual summary of pathophysiological hypotheses in accordance with the other reviewers

 

The rehabilitation component also appears somewhat overextended in the abstract, as treatment approaches are mentioned but not clearly supported by an explicit synthesis framework. It would strengthen the abstract if it were revised to follow a more conventional systematic review structure: brief background, precise objective, clear methods, main findings, and cautious conclusion.

Authors answer: We thank the reviewer for this remark and the intend about rehabilitation is now suppressed from the abstract (as suggested by other Reviewer) but will be more simply presented in the discussion. The paucity of papers dedicated specifically to MDS rehabilitation is actually limitating.

 

1. Introduction

The Introduction would benefit from a clearer scientific thread. Several important concepts are introduced, such as MDS/MVDS, PPPD, motion sickness, visual dependence, and related vestibular constructs, but they are not yet presented in a sufficiently hierarchical and structured way. The section moves rather quickly from background information to pathophysiological assumptions and mechanistic interpretation, which gives parts of the Introduction a discussion-like tone.

Answer: we thank the reviewer for this remark. The different pathologies and their concepts PPPD, MS etc… cited are detailed in the section “Proposed characteristics to separate MDS from other functional pathologies” concerning the differential diagnosis.

However, accordingly, these entities are more characterized in the introduction. Moreover, the term and concept of visual dependency is now more detailed.

The naming “MVDS” (Motorist vestibular disorientation syndrome) vs “MDS” (Motorist Disorientation syndrome is a question of historical wording as presented in the introduction and explained in the results section as It designs the same pathology.

According to your remark, the introduction has been revised to improve its clarity and the thread of its presentation.

 

It would strengthen this section if the authors first defined the key concepts clearly, then highlighted the areas of overlap and disagreement in the literature, and finally identified the specific knowledge gap that justifies the review. The rehabilitation dimension announced in the title should also be better introduced here.

Answer: We thank the reviewer for this remark and his constructive suggestions; we have accordingly modified the introduction.

At present, the Introduction does not clearly establish why rehabilitation requires systematic review or what therapeutic uncertainty the manuscript seeks to address.

Answer: In this narrative review we have accordingly modified the introduction. This paper which now does not stress about rehabilitation current techniques which are specifically poorly described or developed in literature (except in papers from Bronstein) but suggest an improvement and further development.

The review objective should also be reformulated more precisely. Rather than listing multiple thematic intentions, the Introduction should end with a clear and reproducible review aim that matches the title, methods, and synthesis strategy.

Answer: we thank the reviewer for his proposals to improve our paper. We have accordingly modified the introduction and précised or hierarchized our goals.

1. Materials and Methods

The Methods section requires important clarification in order to support the manuscript’s systematic review design.

Authors answer: it is a narrative review (and not a PRISMA review). Otherwise this question remains difficult to answer since in particular one other Reviewer supports a different point of view, this Reviewer indicating: ”The method of reviewing is clear. Conclusions, including suggested pathophysiological background (visual-visual conflict and visual-vestibular mismatch) for MDS look well-supported by literature”.

First, the search strategy is described in a repetitive and incomplete way. The manuscript lists databases and search terms, but it would be helpful to provide a more reproducible account of the search process, including full search strings or search logic, Boolean operators, database-specific adaptations, language restrictions if any, and the exact date of the last search.

Answer: This is a narrative review and accordingly to the reviewers the research strategy has been simplified and repetitive mentions suppressed. However, we have reintroduced the Boolean operators.

Second, the eligibility criteria should be more closely aligned with the stated scope of the review. If the purpose is to describe the clinical profile of a rare syndrome, inclusion of observational studies and case series may be justified.

Answer: thank you for this remark. As a fact, our initial intent and primary objective was to describe this rare syndrome by presenting its historical delineation based on eight selected observations and case studies.

However, it would strengthen the review to avoid treating hypothesis papers or conceptual descriptions as primary evidence within the formal synthesis. Conversely, if rehabilitation is part of the review scope, treatment-oriented studies and therapeutic outcomes should be explicitly defined in the eligibility framework.

Answer: accordingly with your remark and those of other Reviewers, we have now suppressed the rehabilitation from the scope of this review (this rehabilitation concern was previously requested by the Assistant Editor).

Third, no protocol registration is reported, and no formal methodological quality or risk-of-bias assessment appears to have been conducted. Even if the available literature is limited and mainly observational, the review would be methodologically stronger if an appropriate appraisal tool were applied and reported.

Answer: it is now a narrative review corresponding to the guidelines (Ref.: Sukhera)(13).

 

Fourth, the description of data extraction is too general. The manuscript would benefit from explicitly stating which variables were extracted from each study, for example: patient demographics, clinical manifestations, triggering situations, vestibular findings, associated conditions, and treatment/rehabilitation approaches.

Finally, the PRISMA flow diagram should be revised for clarity and alignment with standard reporting conventions, particularly with respect to duplicate removal and the distinction between screening stages.

Answer: this paper has been submitted as a narrative study and not a systematic review. We regret that the Reviewer has not had access to the version submitted requested by the Assistant Editor.

 

1. Results

The Results section would benefit from substantial reorganization. At present, it is presented mainly as a chronological narrative of individual studies, which makes it difficult to identify the main patterns emerging from the literature. A more thematic structure would considerably improve clarity and would better reflect the expectations for a systematic review.

Answer: We thank the reviewer for these constructive advices. However our intend was to illustrate the difficulty to identify clear specific symptoms in this rare and recent pathology which is not still integrated in the ICVD and so we prefer to follow a chronological presentation of the few articles which have contributed in its progressive historical individualization. This first part is presented as an historical individualization of this recent entity as mentioned in the new MS.

For example, the Results could be organized into subsections such as: study characteristics, symptoms and triggering circumstances, vestibular and visual findings, associated conditions/comorbidities, and reported treatment or rehabilitation approaches. This would allow the manuscript to move from description to synthesis more effectively.

Answer: this synthesis is presented at the beginning of the discussion in the section “Triggering circumstances and symptoms.

 

The relationship between the text and the tables should also be strengthened. The narrative should guide the reader through the principal messages emerging from the tabulated data rather than reproducing details study by study. Table 1 is currently overloaded and would benefit from redesign. Its title should be concise and descriptive, while abbreviations and explanatory notes should be moved to footnotes. More broadly, the tables should function as synthesis tools and align directly with the structure of the Results text.

Answer: table 1 has been now divided into 2 sub tables. A new separated table deals with the treatment. Otherwise, synthesis tools are described in table 2 entitled Symptoms and precipitating conditions.

1. Discussion

The Discussion contains several potentially useful observations, particularly regarding symptom triggers, overlap with related vestibular syndromes, and possible pathophysiological mechanisms. However, it currently appears to take on part of the synthesis function that should already have occurred in the Results section.

Answer: we thank the Reviewer for this remark. However other Reviewer asks to introduce the discussion by summarizing the main points extracted from the section results and put them into tables to be discussed. Then we prefer to introduce the discussion with the main common points extracted from the presentation of the chronological results presented in this recent and still rare pathology.

In particular, the introduction of Tables 2–4 in the Discussion weakens the overall structure of the manuscript. If these tables summarize empirical findings, they should first be presented in the Results section and then interpreted in the Discussion. If, on the other hand, a table such as Table 4 is intended as a conceptual summary of pathophysiological hypotheses, this should be made explicit, and its interpretative nature should be clearly distinguished from the empirical synthesis.

Answer : We thank the reviewer for these remarks. However this table 4  is part of the usual intents, purpose  or insights allowed in a narrative review whose aim is to orientate readers toward further research or solicit controversies and conceptual pathophysiological hypothesis.

The tables 2 to 3 show a synthesis of the historical individualization of this entity concerning successively its symptoms and triggering conditions ( table 2) and a synthesis of vestibular explorations ( table 3) which are otherwise discussed.

The Discussion would also benefit from a more consistent separation between what is directly supported by the included studies and what remains hypothetical or interpretative. This is especially important for mechanistic explanations and rehabilitation implications, which should be framed cautiously given the limited and heterogeneous evidence base.

Answer: we agree with these remarks and accordingly modifications haver been brought.

Overall recommendation

Overall, the manuscript addresses an interesting and clinically relevant topic, but in its current form it would require major methodological and structural revision to function convincingly as a systematic review. In particular, the review objective remains too broad, the rehabilitation component is not yet systematically supported, the eligibility framework is insufficiently aligned with the stated scope, and the synthesis of findings is more narrative and interpretative than methodologically systematic. For this reason, the authors may wish to consider whether the manuscript would be more appropriately framed as a narrative review, or possibly as a scoping review, rather than as a formal systematic review. Such a repositioning may better match the nature of the available literature, which appears sparse, heterogeneous, and partly conceptual. If the authors wish to retain the systematic review format, substantial revision of the methodology, evidence selection, and results synthesis will be necessary.

Answer: The authors thank the reviewer for this remark and have already sent a revision to the Editorial board as it is a narrative review . The new resubmission is entitled “Motorist’s Disorientation Syndrome and Its Rehabilitation– A Narrative Review.

Our intent was more to stress on the possible poor identification and acknowledgment of this entity which is underdiagnosed because very few papers on this topic are published. Our second main intend was to prospectively give possible new insights and support recent pathophysiological hypothesis. These objectives correspond more closely to a narrative review than a systematic review.

 

 

Comments on the Quality of English Language

Even though English is not my first language, I find that the manuscript is generally understandable, but it has recurrent problems with syntax, phrasing, redundancy, articles, hyphenation, and scientific style. In places, the language leads to conceptual ambiguity and weakens the distinction among results, interpretation, and hypotheses. So I would not rate the English as fully satisfactory.

Authors answer: We thank the reviewer for this remark. However the MS has been verified by an English native speaker (PhD, coauthor). The iphens which we also regret are in many places independent from our will since a number of them reappear after corrections and new transfer.

 

Submission Date

17 March 2026

Date of this review

06 Apr 2026 12:07:02

 

Reviewer 3 Report

Comments and Suggestions for Authors

A study by Dumas et al. “Motorist disorientation syndrome and its rehabilitation – a systematic review” is devoted to an extremely important emerging problem - motorist disorientation syndrome (MDS). It seems that this problem is still underestimated by the professional community.  The method of reviewing is clear. Conclusions, including suggested pathophysiological background (visual–visual conflict and visual-vestibular mismatch) for MDS look well-supported by available literature. However, I have a few minor comments:

Table 3 (lines 417 – 418): It would be helpful to see translation of numerous abbreviations (CaT, SVV, VV, VHIT, VEMPs, SVINT, OKAN, OKN) in this Table (like it is done in Tables 1 and 4).

Figure 1 (line 151, the right bottom panel) presents “Insufficient number (patients series ≤4)”. It means “equal to or less than 4”? However, “… Bronstein et al. 2013 (10) reported a series of 4 MDS patients…” (line 217). Should it be “Insufficient number (patients series ≤3)”?

In that study patients with the diagnosis of MDS were mostly within the age range 40 to 50 years (middle age). However, according to Feller et al. (2019), relying  on visual (and proprioceptive) sensory cues is the characteristic of older people (including people with Parkinson’s disease). Feller KJ, Peterka RJ, Horak FB. Sensory Re-weighting for Postural Control in Parkinson's disease. Front Hum Neurosci. 2019;13:126. doi: 10.3389/fnhum.2019.00126.

Probably, such  early onset of visual dependence in people with MDS has individual background (e.g. the level on anxiety, agency as was actually mentioned in the paper). In addition, the concept of peripersonial space (the space around the body) could contribute to correct percieving the surrounding space (for example, Holmes et al., 2004; G'Angelo et al., 2018).

Holmes, N. P., Spence, C. (2004) The body schema and the multisensory representation(s) of peripersonal space. Cognitive Processing, vol. 5, no. 2, pp. 94–105. https://doi.org/10.1007/s10339-004-0013-3

D’Angelo, M., di Pellegrino, G., Seriani, S. et al. (2018) The sense of agency shapes body schema and peripersonal space. Scientific Reports, vol. 8, no. 1, article 13847. https://doi.org/10.1038/s41598-018-32238-z

Author Response

REVIEWER 3.

 

Comments and Suggestions for Authors

A study by Dumas et al. “Motorist disorientation syndrome and its rehabilitation – a systematic review” is devoted to an extremely important emerging problem - motorist disorientation syndrome (MDS). It seems that this problem is still underestimated by the professional community.  The method of reviewing is clear. Conclusions, including suggested pathophysiological background (visual–visual conflict and visual-vestibular mismatch) for MDS look well-supported by available literature.

Authors Answer:

Authors thank the reviewer for these remarks and agree with the important fact MDS is an underestimated pathology. However the last submitted version in agreement with the academic Editors was modified as a Narrative review.

However, it appears that the version received does not match the last one we submitted, which was, as requested by the editor-in-chief in charge: “Motorist’s Disorientation Syndrome and Its Rehabilitation– A Narrative Review” and not “-A systematic review”

However, I have a few minor comments:

Table 3 (lines 417 – 418): It would be helpful to see translation of numerous abbreviations (CaT, SVV, VV, VHIT, VEMPs, SVINT, OKAN, OKN) in this Table (like it is done in Tables 1 and 4).

Authors answer: these data are now mentioned and detailed in the new version of the MS in the legend of table 3 (lines 416 – 419).

Figure 1 (line 151, the right bottom panel) presents “Insufficient number (patients series ≤4)”. It means “equal to or less than 4”? However, “… Bronstein et al. 2013 (10) reported a series of 4 MDS patients…” (line 217). Should it be “Insufficient number (patients series ≤3)”?

Authors answer: this indication is meaning for series of patients lower than 4. The minimal number of patients included in the retained series was 4 (as in the series from Bronstein in 2013). For more clarity it is now written in the new version (fig 1): “number of patients < 4”.

In that study patients with the diagnosis of MDS were mostly within the age range 40 to 50 years (middle age). However, according to Feller et al. (2019), relying on visual (and proprioceptive) sensory cues is the characteristic of older people (including people with Parkinson’s disease). Feller KJ, Peterka RJ, Horak FB. Sensory Re-weighting for Postural Control in Parkinson's disease. Front Hum Neurosci. 2019;13:126. doi: 10.3389/fnhum.2019.00126.

Answer: We thank the reviewer for this remark. The reference of Feller et al. has been added (visual dependence was already mentioned in the introduction and referenced with Freyss G. (ref 11).

Probably, such early onset of visual dependence in people with MDS has individual background (e.g. the level on anxiety, agency as was actually mentioned in the paper). In addition, the concept of peripersonial space (the space around the body) could contribute to correct percieving the surrounding space (for example, Holmes et al., 2004; G'Angelo et al., 2018).

Holmes, N. P., Spence, C. (2004) The body schema and the multisensory representation(s) of peripersonal space. Cognitive Processing, vol. 5, no. 2, pp. 94–105. https://doi.org/10.1007/s10339-004-0013-3

Answer: accordingly and following this interesting remark and contribution from the Reviewer to improve our paper we have added this indication and references in our discussion about anxiety, peripersonal space and early visual dependency. The following references have been added.

D’Angelo, M., di Pellegrino, G., Seriani, S. et al. (2018) The sense of agency shapes body schema and peripersonal space. Scientific Reports, vol. 8, no. 1, article 13847. https://doi.org/10.1038/s41598-018-32238-z

Holmes, N. P., Spence, C. (2004) The body schema and the multisensory representation(s) of peripersonal space. Cognitive Processing, vol. 5, no. 2, pp. 94–105. https://doi.org/10.1007/s10339-004-0013-3

Submission Date

17 March 2026

Date of this review

06 Apr 2026 08:38:27

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

This verson of the manusrcipt is greatly improved and more comprehensive.