Tics and Their Treatment

by Henry Meige; E. Feindel

THE author of the article "Tic" in the Dictionary in Sixty Volumes of 1822 urges the necessity of care and perseverance in the correction of the involuntary movements characteristic of the disease. In 1830 Jolly recommended different exercises in the treatment of convulsions, as a means of interrupting the sequence of certain spasmodic phenomena. Blache's[220] adoption, in 1851, of medical gymnastics in cases of "abnormal chorea" was attended with excellent results; and Trousseau, as we have seen, extolled the value of exercises systematically applied to the muscles involved in non-dolorous tic. The principle of the treatment consisted in the regular execution of given movements by the muscular groups affected, to the rhythmical accompaniment of a metronome or the pendulum of a clock.

In these instances we have a forecast of the modern methods of re-education, so successfully employed to combat tic.

Letulle advises an appeal to the intelligence, good sense, and will of the patient in the endeavour to provoke an inverse effort at the moment when the tic begins, or even before. It is the prerogative of the physician to indicate suitable exercises and to encourage and aid the patient in his attempts. Even the most inveterate of tics may thus be controlled and made to disappear. On the other hand, the Traité de médecine ignores the subject, while Lannois' paper in the Traité de thérapeutique contains the statement that in the treatment of myoclonus—under which term various indefinite convulsive movements are comprehended—no method has hitherto been of any avail. Yet in another section of the same book we discover some sound advice anent tics and choreas of hysterical origin, emanating from the pen of Pierre Janet.

It is well to study the influence of the attention on these conditions; some tics are contingent on the direction of the patient's attention to them, others appear solely during times of distraction.... Education of movements by some form of drill may be of the greatest utility.

These general therapeutic indications are applicable to all kinds of tic, independently of their form and localisation. Moreover, they conform to the procedures advocated by Brissaud since 1893.

So long as tic is regarded as a purely external phenomenon, treatment is bound to be insufficient; but recognition of the relations between the convulsion and the mental state of the subject has made possible a rational therapeusis. There can be no doubt, thanks to the laborious work of Bourneville, that systematised mental discipline has sometimes a surprising effect on congenital psychical imperfections; and where the patients have attained a higher level of mental development, re-education has shown itself to be the method par excellence.

The credit of initiating treatment by forced immobility is due to Brissaud, who in the year 1893 first utilised the method in cases of mental torticollis. In the face of the risks of surgical intervention and the unsatisfactory nature of existing therapeutic measures, Brissaud emphasised the value of motor discipline in tic,[221] and it was not long ere rules were formulated and precision introduced into the application of the method.[222] The results were certainly encouraging, so much so that improvement could be promised if treatment was sufficiently protracted; cure, indeed, followed in various instances.

Brissaud's method is a combination of immobilisation of movements with movements of immobilisation. Speaking generally, the patient is directed to perform certain appropriate exercises under given conditions. Some of these exercises are intended to teach him how to preserve immobility, while the object of others is to replace an incorrect movement by a normal one. In the case of the former, immobility is alike the goal in view and the means of attaining it, while by recourse to suitable movements, in the latter instance, the same end is sought.

It is essential to remember that the exercises must be graduated. To begin with, the subject of tic is required to remain absolutely motionless, as for a photograph, for one, two, three seconds—in fact, as long as he can without fatigue. Very gradually the period is increased, for patients have their good and their bad days, and too great a demand on one day is apt to be succeeded by a relapse on the next. One must rest content with even the most insignificant gain at first, and soon the seconds will grow into minutes, and the minutes into hours. It is desirable to specify on each occasion the duration of the expected immobility. Place the patient at the outset in the position in which his tic manifests itself least often, and do not cease to encourage him by affirming that he can and must remain immobile. Once the séance of immobilisation can be maintained for as much as five or six minutes, begin to modify the patient's attitudes. If he has been comfortably seated during the opening performances, try him when he is standing, and as soon as he has accomplished this, vary the position of his head, arms, trunk, and legs, repeating the séance in each case. Eventually he will learn to maintain immobility of certain parts of his body while he is walking, or while he is executing given movements with his arms or legs. In all these performances direction must be specially directed to the patient's tic. The method is obviously simple, so much so that he may be inclined to question its utility and may fail to grasp its import. One must not hesitate, however, to explain its purpose; indeed, the rapid and intelligent appreciation of the method on the part of the patient is a sine qua non for success. Patient and doctor most co-operate in defence and attack; and their union will culminate in triumph. Simultaneously with this discipline of immobilisation the subject must be taught the discipline of movements. The idea is to make him perform slow, regular, and accurate movements to order, addressing oneself to the muscles of the area in which the tic is localised. They must be very simple at first, and the exercises must be very short. The séance should never be prolonged beyond a few minutes, making, with the immobilisation, not more than half an hour. This time will, of course, soon be increased, but it is of prime importance to avoid fatigue. The performances should be gone through three, four, or five times a day, and always at the same hours. One of them at least ought to be under the personal direction of the physician, whose duty it is to modify, instruct, exhort, reprimand, as the case may be. In his absence the supervision of the exercises must be left to some responsible individual, who has an eye for faults as well as for progress. Statements by the patients themselves are to be considered with reserve.

The repetition of the prescribed exercises should take place in front of a looking-glass, whereby the patient may be exactly informed of any mistakes in gesture or attitude. He cannot otherwise judge of the degree of immobility attained, and may deceive himself, although he has the best intentions in the world, as to the real state of affairs. He does not know whether he is holding himself straight or not, as a general rule, but a glance in the mirror will correct his fault. A careful register must be kept of the progress he makes. Little by little the jurisdiction of the physician will be reduced, provided the patient maintains his interest in his own treatment. Indifference and discouragement are fatal, and it must be the physician's aim to prevent their occurrence.