Botulinum toxin for motor and phonic tics in Tourette's syndrome

Deep brain stimulation for Tourette's syndrome

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the efficacy and harm of deep brain stimulation for motor symptoms, with psychiatric and behavioural comorbidities, either individually or in combination, in adults and adolescents with Tourette's syndrome compared to placebo, sham intervention, or the best available behavioural and pharmacological treatment.

An Update on the Diagnosis and Management of Tic Disorders

Tic disorders (TDs) are a group of common neuropsychiatric disorders of childhood and adolescence. TDs may impact the physical, emotional, and social well-being of the affected person. In this review, we present an update on the clinical manifestations, pathophysiology, diagnosis, and treatment of TDs. We searched the PubMed database for articles on tics and Tourette syndrome. More than 400 articles were reviewed, of which 141 are included in this review. TDs are more prevalent in children than in adults and in males than in females. It may result from a complex interaction between various genetic, environmental, and immunological factors. Dysregulation in the cortico-striato-pallido-thalamo-cortical network is the most plausible pathophysiology resulting in tics. TD is a clinical diagnosis based on clinical features and findings on neurological examination, especially the identification of tic phenomenology. In addition to tics, TD patients may have sensory features, including premonitory urge; enhanced and persistent sensitivity to non-noxious external or internal stimuli; and behavioral manifestations, including attention deficit hyperactivity disorders, obsessive-compulsive disorders, and autism spectrum disorders. Clinical findings of hyperkinetic movements that usually mimic tics have been compared and contrasted with those of TD. Patients with TD may not require specific treatment if tics are not distressing. Psychoeducation and supportive therapy can help reduce tics when combined with medication. Dispelling myths and promoting acceptance are important to improve patient outcomes. Using European, Canadian, and American guidelines, the treatment of TD, including behavioral therapy, medical therapy, and emerging/experimental therapy, has been discussed.

Atlantoaxial Subluxation Associated With Chronic Motor Tics

Head jerking is one of the most common symptoms of motor tics, and because of this, patients are at an increased risk of cervical spine disorders. However, there have been no reports of atlantoaxial subluxation in the English literature. To the best of our knowledge, this is the first case of atlantoaxial subluxation associated with chronic motor tics. A 41-year-old man with a history of chronic motor tics since childhood was diagnosed with high cervical myelopathy due to atlantoaxial subluxation. The patient underwent posterior fusion surgery using atlantoaxial instrumentation and an autologous bone graft. Although screw breakage occurred as an early postoperative instrumentation failure, the clinical outcome was excellent after surgery without recurrence of subluxation. Other techniques such as atlantoaxial transarticular fixation and occipitocervical fusion followed by long-term external immobilization might be treatment options at the initial surgery, or in case of postoperative recurrent atlantoaxial subluxation.

Tourette Syndrome Treatment Updates: a Review and Discussion of the Current and Upcoming Literature

PURPOSE OF REVIEW

This study aims to examine the treatments currently available for Tourette syndrome (TS) and to discuss evolving therapies, spanning behavioral, pharmacologic, complementary and alternative medicine, and neuromodulation approaches.

RECENT FINDINGS

Behavioral therapies have undergone several modifications to improve accessibility, including transitioning to a virtual format which is particularly important in the current pandemic. There are several recent or ongoing pharmacologic studies that have shown promise including the selective D1 receptor antagonist ecopipam and various cannabinoid compounds. Adaptive DBS may enable the physiologic markers of tics to determine stimulation parameters and improve tic outcomes related to neuromodulation. In recent years, there has been a wealth of research across multiple treatment domains in the TS field. This review highlights exciting and new potential options for the future treatment of patients with TS.

Non-invasive brain stimulation as therapy: systematic review and recommendations with a focus on the treatment of Tourette syndrome

Tourette syndrome (TS) is a neurodevelopmental condition characterised by tics, which are stereotyped movements and/or vocalisations. Tics often cause difficulties in daily life and many with TS express a desire to reduce and/or gain control over them. No singular effective treatment exists for TS, and while pharmacological and behavioural interventions can be effective, the results are variable, and issues relating to access, availability and side effects can be barriers to treatment. Consequently, over the past decade, there has been increasing interest into the potential benefits of non-invasive brain stimulation (NIBS) approaches. This systematic review highlights work exploring NIBS as a potential treatment for TS. On balance, the results tentatively suggest that multiple sessions of stimulation applied over the supplementary motor area (SMA) may help to reduce tics. However, a number of methodological and theoretical issues limit the strength of this conclusion, with the most problematic being the lack of large-scale sham-controlled studies. In this review, methodological and theoretical issues are discussed, unanswered questions highlighted and suggestions for future work put forward.

Refractory Gilles de la Tourette Syndrome-Many Pieces That Define the Puzzle

Gilles de la Tourette syndrome (GTS) is a childhood onset neuropsychiatric disorder characterized by the presence of motor and vocal tics. The clinical spectrum of GTS is heterogeneous and varies from mild cases that do not require any medical attention to cases that are refractory to standard treatments. One of the unresolved issues is the definition of what constitutes treatment-refractory GTS. While for some other neuropsychiatric disorders, such as obsessive-compulsive disorder (OCD), a clear definition has been established, there is still no consensus with regard to GTS. One important issue is that many individuals with GTS also meet criteria for one or more other neurodevelopmental and neuropsychiatric disorders. In many individuals, the severity of these comorbid conditions contributes to the degree to which GTS is treatment refractory. The scope of this paper is to present the current state-of-the-art regarding refractory GTS and indicate possible approaches to define it. In closing, we discuss promising approaches to the treatment of individuals with refractory GTS.

A Review of the Current Treatment of Tourette Syndrome

Tourette syndrome is a hyperkinetic movement disorder that presents before age 18 years and involves motor and phonic tics that may present with a wide range of severity. The severity and presentation of tics in an individual may fluctuate over time. Tourette syndrome may affect social relationships and school attendance, and may result in depression. Comorbidities are common, with attention-deficit/hyperactivity disorder and obsessive-compulsive disorder being most common. The literature supporting optimal treatment is limited but provides a framework for clinical decision-making. The focus of this review is to discuss the symptoms and possible causes of Tourette syndrome and current non-pharmacologic and pharmacologic treatment options, to help practitioners optimize care for pediatric patients with this disease.

Tics and Tourette's syndrome

Tics and Tourette's syndrome are common hyperkinetic movement disorders seen mostly in the pediatric age group. Tics are defined as sudden, rapid, recurrent, nonrhythmic motor movements or vocalization, generally preceded by urge. Tourette's syndrome is defined as the presence of both motor and phonic tics for more than 1 year in patients with onset less than 18 years old. Most of these hyperkinetic movement disorders improve in adulthood. This review emphasizes the clinical pearls in the diagnosis and distinguishing it from other movement disorders. The treatment ranges from behavioral therapies, medical management, and also surgical treatment such as deep brain stimulation that is limited to refractory patients.

Tourette's disorder in children and adolescents

Tourette's disorder (TD) is one of the five American Psychiatric Association's 2013 Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifications of tic disorders. Eponymously linked with the noted 19th century French physician, Gilles de la Tourette [1857-1904], this disorder is identified in 0.3% to 0.7% of the population. It is characterized as a familial neuropsychiatric condition with multiple motor tics and vocal tics (one or more) present for more than 1 year with varying severity. The underlying pathophysiology involves dysfunctional activity of the basal ganglia and circuitry of the frontal cortex as well as dorsolateral striatum deficits. Contributory factors include genetic features interacting with milieu influences. A number of comorbid disorders are seen including obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD). Concepts of management are considered including behavioral therapy and pharmacologic approaches with alpha-adrenoceptor agonists, atypical antipsychotics (AAs), haloperidol, pimozide and others. Other management includes botulinum injections and deep brain stimulation in adults.

Treatment of dystonia and tics

Treatment of dystonia and tics continues to evolve. In dystonia, while oral agents such as benzodiazepines, baclofen and anticholinergics remain in use, botulinum toxin (BoNT) continues to be regarded as the treatment of choice for focal and segmental dystonia, but new preparations are being studied. While deep brain stimulation (DBS) has typically focused on targeting the globus pallidus internus (GPi) when treating dystonia, more recent research has expanded the targets to include subthalamic nucleus (STN) and other targets. In addition to DBS, thalamotomies continue to show therapeutic benefit in focal hand dystonias. Treatment of tics includes a growing armamentarium of options besides the three FDA-approved drugs, all dopamine receptor blockers (haloperidol, pimozide and aripiprazole). Because of lower risk of adverse effects, dopamine depleters (e.g. tetrabebazine, deutetrabenazine, and valbenazine), along with novel D1 receptor antagonists, are currently studied as treatment alternatives in patients with tics. Practice guidelines for the treatment of tics and Tourette syndrome have been recently updated. Data regarding the use of DBS in treatment of tics remains relatively sparse, but international registries have expanded our understanding of the effect of stimulation at several targets.