Researchers Uncover Mechanism Controlling Tourette Syndrome Tics

A mechanism in the brain which controls tics in children with Tourette Syndrome (TS) has been discovered by scientists at The University of Nottingham.

The study, which has been published in the British Psychological Society’s Journal of Neuropsychology, could herald new non-drug therapies to help young people with TS overcome the repetitive physical movements and vocal sounds which characterise their condition.

The work was funded with a £150,000 grant from the James Tudor Foundation and was carried out by PhD student Amelia Draper.

Professor Stephen Jackson, in the University’s School of Psychology, said: “This new study is very important as it indicates that motor and vocal tics in children may be controlled by brain changes that alter the excitability of brain cells ahead of voluntary movements. You can think of this as a bit like turning the volume down on an over-loud motor system. This is important as it suggests a mechanism that might lead to an effective non-pharmacological therapy for Tourette Syndrome.”

Brain re-structuring

The neurological condition TS affects around one child in every 100 and usually starts during early childhood. Scientists believe that the tics that affect children with TS are caused by faulty wiring in the brain that leads to hyper excitability in the brain regions controlling motor function.

In adolescence, there is a period of ‘pruning back’ in which redundant brain connections are removed and other structural and functional brain changes occur.

During this time, around one-third of children with TS will find that their tics disappear and another third are able to more effectively control their tics. Unfortunately, the remaining third of individuals will see little or no change in their tics and are likely to remain troubled by their TS symptoms into adulthood.

This clinical observation suggests that there are mechanisms in the brain that are involved in controlling tics and undergo development or re-organisation during the teenage years.

Amelia Draper added: “The research is based on the general hypothesis that an area in the brain called the striatum is overactive as a result of alterations in the early development of the brain. As a result, the signals that are relayed to the brain’s cortex region lead to hyper-excitability and cause tics to occur.

“We have looked at how that hyperactivity and the resultant tics might be controlled by finding a way to ‘turn down the volume’ on that ‘cortical excitability’. This is potentially extremely important as the parents of children with tics are desperate to find a safe and effective therapy that is an alternative to drug treatments.”

Unwanted movements

In the current study the team used a method called Transcranial Magnetic Stimulation (TMS) in which a magnetic field is passed over the brain to produce a weak electrical current which stimulates motor function to induce a twitch response.

By delivering TMS at different points in time as participants were about to undertake a hand movement, the researchers were able to measure alterations in brain excitability ahead of the movement and chart the differences between each person.

The study showed that subjects with TS, unlike those of a similar age without the condition, were least able to modulate the hyperactivity in the brain.

Professor Jackson said: “If there is a relationship between this cortical excitability or hyperactivity and tics then this is really important as it means that there may be something that we might be able to do to help children with TS to better control these unwanted movements.”

Further research by the team has involved the use of a similar type of brain stimulation called transcranial direct current stimulation (TDCS) to study the brains of children with TS. Early results suggest that TDS can be applied to decrease neuronal excitability and this may be effective in suppressing tics for extended periods. In addition, if another form of TDCS is applied, one that increases neuronal excitability, it may act to improve learning and memory function, particularly in the context of behavioural therapies. Following use of these treatments lasting effects can be applied to the brain.

Effective and longer lasting

If proven to be effective, the technology could be adapted into a TENS machine-style device that would offer a cheap, portable and individualized therapy for children with TS.

Professor Jackson added: “For the one-third of people who aren’t going to get better this could offer them a much needed assistance with controlling their tics, while relying less on other conventional pharmaceutical therapies which can have associated side effects such as weight gain or tiredness.

“It can be applied at home while the child is watching TV or eating their cornflakes so it would reduce the amount of school they would miss and potentially we can use the TDCS to both control the tics and make that control more effective and longer lasting.”

As part of her work Amelia Draper is also using MRI scanning technology to examine the potential relationship between cortical excitability and a brain chemical that appears to be strongly linked to neuronal excitability in TS.

Rod Shaw, Chief Executive of the James Tudor Foundation, said: “We’re glad to see that the funding we have given to this project is producing some interesting and potentially useful results.”

Professor Jackson’s research is a key project within the University’s appeal, Impact: The Nottingham Campaign, which is delivering the University’s vision to change lives, tackle global issues and shape the future

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New Research Shows Promising Results Using Chiropractic Neurology for Tourette’s Syndrome Treatment

Often misunderstood and misrepresented, Tourette’s syndrome is a neurological disorder, not a behavioral disorder that causes sufferers to make sounds and movements they cannot control. These are called tics and there are two kinds: motor and vocal. Some common motor tics include blinking, facial grimacing, jaw movements, head and arm jerking and shoulder shrugging. Some of these motor tics can be more complicated and combined. Common vocal tics include sniffing, throat clearing, grunting and shouting. More complicated vocal tics may include words or phrases that do not sound like they should be part of a normal sentence. In a small percentage of cases, they can also be profane in nature.

Symptoms of Tourette’s syndrome are If a child shows at least two motor and one vocal tic and they persist for a period of at least one year. Generally beginning before the age of 18, and becoming worse when the child is excited or agitated, some children can control the tics for a period of time but cannot stop them altogether. Other problems can be associated with Tourette’s syndrome including overactivity, trouble concentrating in school, anxiety and learning difficulties. However, it is important to understand that children and adults living with Tourette’s syndrome are just as smart and live just as long as anyone else.

While it is complicated to determine the exact cause for Tourette’s syndrome, scientists believe that it is caused by problems in one of more parts of the brain, many times likely inherited, but also possibly linked to other triggers such as strep infections have been examined, although the findings are subjective.

Until the 1970’s, it was thought that Tourette’s was very rare, however today more patients experiencing milder symptoms are being diagnosed; the current estimate is 3-6 children out of 1000 are likely to be affected. Treatment for Tourette’s typically includes pharmacology and combined drug therapies, as well as behavioral intervention and even deep brain stimulation for patients who have not responded to other therapies.

However, there are new studies showing promise for Tourette’s treatment through non-invasive and drug-free treatments like Chiropractic Neurology. In a study published by the Journal of Pediatric, Maternal & Family Health, research shows support for chiropractic care in the case of Tourette’s and other disorders that share their origin with Tourette’s syndrome as well. This research shows that as the brain develops, it relies on normal structural movement and joint movement, and also that complex communication and pathways in the brain are tied to spinal biomechanics and their neurological pathways.

Dr. Kim Muhlenkamp, one of the co-authors of the study explains, “It makes perfect sendse when you think about it. Neurological disorders may be related to how the entire body communicates with the brain and the most critical area for this is the spine.”

Our nervous systems need constant stimulation in order to develop properly. Abnormal positioning can lead to nerve interference, or vertebral subluxations, which chiropractors correct. The added benefits of a care plan developed with a Chiropractic Neurologist for neurological conditions like Tourette’s syndrome makes a perfect fit as this specialized area of chiropractic treatment focuses on the brain and spine connection to the entire body. As research continues, and more and more information and real world studies become available, the results continue to be promising.

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Habit Reversal: A Treatment Approach for Tics, Tourette's Disorder and Other Repetitive Behavior Disorders

Habit reversal (HR) is a type of behavioral treatment that is used to reduce repetitive behaviors which may be bothersome and serve no adaptive function, such as tics, hair-pulling, and nervous habits. HR was first developed in the 1970s, and has since been used in the treatment of several repetitive behavior disorders, particularly tic disorders. 

How does Habit Reversal work?

HR is based on the premise that people are often not aware each time a tic or other repetitive behavior occurs, and that repetitive behaviors often follow an urge or feeling of discomfort which is only relieved by engaging in the behavior itself. HR works to increase awareness of one's behaviors and to provide relief with strategies that replace the unwanted behavior with a less bothersome behavior.

After the initial evaluation and before the start of treatment, the plan and rationale are presented to the child and family. The history and occurrence of the behavior are identified and described, including the estimated frequency of each occurrence of the behavior and its precipitating factors such as bedtime, homework, social situations, etc. Clear instructions are given about self-monitoring, which involves keeping a log or record of each time the behavior occurs. The log should include not only frequency of the behavior, but also places and times of day when it occurs, so that the child can recognize those situations in which the behavior is more likely to happen. To benefit most from the program, it is helpful to enlist a partner, such as a parent, to help with maintaining awareness of the behavior and to ease record-keeping. If the behavior is frequent, it may be helpful to begin monitoring a specified amount of time each day, such as 30 minutes. As the process becomes more comfortable, the child may then log each occurrence of the behavior throughout the day. It is also useful to discuss challenges to self-monitoring and to problem-solve around those difficulties before they occur.

The next step in Habit Reversal is developing a competing response. A competing response is another behavior that the child may do in place of the repetitive behavior. A competing response often uses the same muscles used in the initial behavior, so that the child is unable to do the behavior while performing the competing response. For example, a child who has a shoulder shrug tic might use the competing response of lengthening the neck and pushing the shoulders downward. The competing response should be held for at least one minute, be inconspicuous, and strengthen the muscles opposite to the repetitive behavior.

It may be helpful for the child to practice his competing response in front of a mirror to show that it is not noticeable to others and to help him become more comfortable with this new behavior. The child should be encouraged to use the competing response whenever he notices himself doing the repetitive behavior or even feels the urge to do so. Parents should praise their child's correct use of the competing response and remind the child to use it when he is engaged in the repetitive behavior. Praise should also be used whenever the behavior is reduced in frequency.

What other strategies may be used to decrease repetitive behaviors?

Because many repetitive behaviors are often increased during times of stress or tension, it may be helpful to implement strategies that lead to an overall decrease in tension. For example, children may be taught to breathe in slowly through the nose and to exhale through the mouth. They can also learn to recognize the way their diaphragm expands with each inhale and contracts with each exhale. This tends to have a calming effect, and it is another strategy that may be used inconspicuously in any situation.

What about research?

HR has been found to be effective, with results lasting over time, in treatment of chronic tics, other repetitive behaviors, and Tourette's Disorder. Despite numerous studies, only a few controlled studies have been conducted. In these studies, HR was found to be effective when compared to wait list strategies, and when compared to supportive psychotherapy. When compared to exposure and response prevention treatment, no differences were found, and both treatments were found to be effective. Overall, a large body of evidence supports the effectiveness of Habit Reversal. However, additional research is needed using controlled studies with larger sample sizes and comparing behavioral interventions with medication.

Who should consider trying habit reversal?

Habit Reversal should be considered as an addition or alternative to medication therapy. It is now recommended as the first approach to treatment of children and adolescents with mild to moderate tics. This may be particularly helpful for those who refuse or discontinue medication due to side effects or other problems. As with other approaches, please discuss habit reversal with your treating physician before beginning any new type of treatment.

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New Tourette's Treatment Quiets Tics

Blinking and grunting are just some of the uncontrollable twitches and sounds kids with Tourette’s make. The involuntary movements and sounds impact a child's ability to learn and socialize at school.

Now, an investigational drug is helping them live with their disease.

Henry D'Alessio got his first guitar four years ago. It was the same year he was diagnosed with Tourette’s.

"My neck kept going back and forth," said Henry.

"And these movements were so intense and there were so many of them, if you were stopped at a stop light, the car would actually move," explains Henry’s Mom Daeinka D’Alessio.

Henry takes medication to help control it, but it has also caused him to gain 60 pounds in two years. It is a common side effect of current meds.

"A lot of weight gain and sometimes the emergence of other involuntary movements, sometimes cardiac problems, sleepiness and fatigue," explains Katie Kompoliti an Associate Professor of Neurological Sciences at Rush University Medical Center.

Now, a new investigational drug used to treat schizophrenia and depression could treat the disorder with fewer side effects.

"It is going to work for tics because it blocks dopamine," says Kompoliti.

It's the first Tourette’s drug available in pill form. And Henry has to remember to take his meds twice a day.

"It would make life a lot easier because I would not have to keep track of that all the time," says Henry.

Instead he would have more time to make music.

As of now, there is no cure for Tourette’s. The phase three trial of this new pill is currently recruiting kids with Tourette’s in 100 centers around the world.

MEDICAL BREAKTHROUGHS
RESEARCH SUMMARY

TOPIC: New Tourette's Treatment Quiets Tics
REPORT: MB # 3688

BACKGROUND: Tourette's syndrome (TS) is caused by a malfunction in the brain and can be linked to genetics. Adults and children who are affected by this syndrome experience "tics" which are uncontrollable movements and sounds. It is common for Tourette's patients to have other issues such as OCD, ADHD, anxiety, emotion and behavior control problems and learning difficulties. TS is measured by the severity of the patient's tics; sometimes a patient's tics will go away by the time they have reached adulthood. (Source: http://tsa-usa.org/imaganw/What_is_TS_English.pdf) 

SYMPTOMS: If a person is under the age of 18 and is noticing constant tics for more than a year, then there may be a chance that the individual has Tourette's syndrome. There are two kinds of motor tics and two kinds of vocal tics; simple and complex tics. Simple motor tics include: head jerking, eye darting and blinking, finger flexing and shoulder shrugging. Complex motor tics consist of flapping the arms, hopping around and crude gesturing. As for vocal tics, some simple symptoms are yelling, hiccupping and throat clearing, while complex vocal tics incorporate the repetition of another's own words, the use of different tones of voice and the use of swear words. (Source: http://www.mayoclinic.com/health/tourette-syndrome/DS00541/DSECTION=symptoms) 

TREATMENT: As of now, there is no cure for Tourette's syndrome, but there are medications offered to those who have tics that interfere with daily functioning. Most patients do not need treatment but behavioral treatments such as habit reversal and comprehensive behavioral intervention for tics (CBIT) are offered to those who suffer from severe tics. (Source: http://www.cdc.gov/ncbddd/tourette/treatments.html) 

NEW TREATMENT: A new drug is being studied to decrease the amount of tics a patient with Tourette's experiences. Typical medication is injected into a muscle several times a day to relieve the tic, while this new pill only requires one dose a week. Side effects from older medication include weight gain, fatigue and dulling of the mind. This new medication is still being studied but will be preferred for patients so they do not have to constantly remember to take their medicine. (Source: http://www.mayoclinic.com/health/tourette-syndrome/DS00541/DSECTION=treatments-and-drugs)
FOR MORE INFORMATION, PLEASE CONTACT:

Lucy Blasucci, RN,
Research Coordinator
Rush University Medical Center
312-563-2900

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