Kitabı oku: «Tics and Their Treatment», sayfa 24
ORTHOPÆDIC TREATMENT
The use which has in some instances been made of various forms of apparatus for temporary fixation or for gymnastic purposes is, as a rule, rather hurtful than otherwise. The patient is disconcerted by their withdrawal, and prone to recommence his inopportune movements. It is preferable to allow him to adopt his own attitudes independently of the physician. An accessory not always at hand must not be allowed to become indispensable to the control of his tic, else he may make its absence a pretext for the discontinuation of his exercises.
Excellent results, it is true, have been obtained in chorea by recourse to apparatus of restraint. According to the recent descriptions of Huyghe218 and of Verlaine,219 after the administration of a few whiffs of chloroform to the patient, the affected limbs are massaged vigorously enough to enable him to have some conception of what is being done. Light anæsthesia is continued while they are immobilised in duly padded splints and covered closely with bandages. At the end of five or six days the dressings are removed, when all choreic twitching will be found, as a general rule, to be gone; should it persist, the treatment must be repeated. In numerous instances the method has been eminently successful.
So favourable an issue is scarcely to be looked for in the case of tics. Rather are these forms of apparatus liable to do harm in the direction of fresh outbursts.
CHAPTER XIX
TREATMENT BY RE-EDUCATION
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's220 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.
Séglas has reported the history of a woman with mental torticollis, who submitted to treatment by Brissaud's method, and a remarkably quick alleviation was the result. At the end of three weeks, however, she allowed her interest to slacken, and ere long the benefits obtained were entirely frustrated.
It cannot be too often repeated that even though the tic disappear, the patient must not be abandoned to himself, but must be persuaded to continue his exercises. This is the price of success. As time goes on, it is true, he encounters fewer difficulties in his way, and once he is conversant with the method, he may be able to work out his own salvation.
In the case of children, the efforts of the medical man may often be seconded by parent or teacher, who has assisted at the first lessons and is in a position to superintend their repetition. On the other hand, treatment may be nullified by deplorable weakness on the part of father or mother. One of the reasons for the existence or at least the persistence of tics in children is that there has been no attempt at their correction when they were still "bad habits." Neglect or indulgence is an etiological factor of the first importance, as we have already seen. Many a time we have had occasion to note this, notwithstanding the protestations of the family. Fear of aggravating the mischief is sometimes advanced as a reason for non-interference. Nothing could be more misleading.
The method which seeks to check the youthful tiqueur by the multiplication of threats and penalties is not to be countenanced; it produces the opposite effect to what is intended. Clearly the educational therapeutic measures we have been advocating demand a patience and an ingenuity on the part of both doctor and patient which we have no desire to minimise, but it is along these lines that success is to be reached.
A noteworthy adjunct to treatment is to sketch out a daily routine for the patient to follow regularly and punctually. His mental disarray is patent not merely from his disorders of motility, but in the unmethodical and changeable habits of his everyday life. To introduce discipline into his manner of living is a most wholesome step. To find something with which to employ his leisure time, to direct his energies into suitable channels, will prove to be eminently beneficial, not merely for the child but also for the adult. Those who tic ought to be able to contract good habits as readily as bad, provided their instructor be sufficiently persevering and inventive.
There is an infinity of occupations for the patient to put his hands to, and this variety suits his unsettled mood and his wavering attention; but longer efforts will be secured from him if his interest in his task can be engaged and stimulated as well. It is a good plan to make him write down each day what he does and how it is done, and to have him rehearse from time to time. Such pedagogical details are far from being superfluous; adults, moreover, are quick to gather their significance and to demonstrate their advantages in practice. That their fickle will must be reinforced they know well; how to achieve this end they are unaware. This fact explains their eager acceptance of the support furnished by these "moral crutches."
Generally speaking, there is no call to interrupt treatment once it is commenced, although occasionally we have found this desirable. The fatigue of the first few days, almost unavoidable as it is, and accompanied by new sensations, need occasion no alarm. We should acquaint our patient of its explanation, and so obviate the mental depression which its existence is apt to engender. Its ephemeral nature will soon become plain, for a rest of a few days suffices for its disappearance.
In some instances resort to procedures reminiscent of antagonistic gestures seems to have been of avail.
One of our patients,223 suffering from facial tic, was directed to perform, as far as practicable, the opposite movements to her grimaces. If her mouth was drawn to the right, she forthwith made a corresponding twitch to the left; if her mouth was shut spasmodically, she was instructed to open it widely and quickly. By such simple methods, applied to all her tics, speedy control was regained, and once she had mastered the theory of the process, the practice of regular exercises and the development of antagonistic movements soon effected a complete cure.
Training of the antagonists has also been recommended by Hartenberg,224 in a case of scratching tic. The patient was urged to approximate the hand to the affected cheek very slowly, and almost at the moment of contact the order was given to extend the arm briskly; this gesture of opposition, moreover, was stimulated by faradisation to the extensors of the forearm. The method, of course, is practically identical with that adopted by Frenkel,225 of Heiden, who provoked energetic contractions of antagonistic groups by teaching the patients to overcome increasing resistances. Prudence, however, must be observed in carrying out these ideas, otherwise we run the risk of replacing one tic by another.
After the above general sketch of the essentials of the method, we may give examples of its application to particular instances.
For a tic of the eyelids, in especial for blinking tics, we make the patient open and shut the eyes to order, keep them closed or apart for a space, shut one eye and then the other, and repeat the same sequence in different positions of the head. It is a good plan to enjoin simultaneous action of the oral musculature. The cessation of tonic contractions of the eyelids with opening of the mouth has been remarked several times, and Oppenheim finds an analogy in the observations of Gunn and Helfreich, who have seen ptosis disappear as the mouth is opened.
If the eyeballs are involved in a tic, insist on dissociating the movements of head and eyes; make the patient follow an object slowly with his eyes while the head is stationary; or let the head deviate to right or left, up or down, while the eyes remain fixed on some particular point.
When the lips are the seat of involuntary muscular action, have the patient show his teeth, open and shut his mouth, purse his lips; make him speak and conform his expression to his speech; let him read aloud slowly, and fix his attention on his subject.
As a specimen of treatment for a facial tic, we may cite the subjoined programme:
Every day, and three times a day, at the same hours – nine, one, and six – the patient is to look at himself for two minutes in a mirror, preserving absolute immobility the while; to read aloud for two minutes, to speak in front of the glass for two minutes, to walk backwards and forwards in front of the mirror for two minutes. During the ten minutes of these exercises he will endeavour to keep his facial musculature under control. If the tic assert itself in the course of one of the exercises, he will recommence the latter, if necessary twice; the third time he will leave it till the next séance.
For tics of the head and neck, such as tossing tics and mental torticollis, inclination and rotation movements are indicated, of which an instance may be quoted:
Mademoiselle R. is quick in learning how to correct her muscular faults. Her actions are gradually becoming more complete and ample, and if she performs her allotted task with little animation, at the least there is no question of her indefatigable willingness. In less than a month she has been able to fix her regard, open her eyes widely, turn her head, uninterrupted either by halts or twitches; she can remain motionless in front of a looking-glass for as long as a minute. Equally satisfactory progress hat been made in the art of reading aloud; she breathes more regularly, and articulates more distinctly.
Thus the patient has come to realise that she need but give her attention to the involuntary movements for them to cease, and there has been a synchronous advance in her mental activity and power of concentration. Her nonchalance and timidity have diminished; she is no longer indifferent to her surroundings, nor furtive in her glances; she enters into conversation with zest, and her movements are characterised by decision.
Take another example of treatment, for a case of mental torticollis:
Stand or sit in front of a mirror and endeavour to maintain an absolutely correct position of trunk and shoulders.
Lift the arms vertically and turn the head to the right, then lower the arms while the head remains as it is.
Bend the body forward, and stretch the arms out till they touch the ground, the head meantime being rotated to the right. Then rise up again with the head in the same attitude. After two or three efforts it will be found that the head can be kept straight for a few seconds.
In tics of the limbs, shoulders, hands, feet, innumerable movements will suggest themselves for practice. The young girl with a tic of genuflexion, under the care of Oddo, supplies an excellent proof of the value of Brissaud's method:
The immobilisation of movements was realised by the mother forcing the child to remain motionless in a fixed position for augmented periods. As for movements of immobilisation, the patient made peregrinations of increasing length under the mother's eye, the order being repeatedly given to suppress the genuflexions. At the same time, massage and passive movements to the limbs and joints were prescribed, with a view to diminishing the articular cracks – the exciting cause of the bizarre tic from which the girl suffered.
In the course of ten or twelve days the genuflexions had entirely vanished, and a return of the pain in the coxo-femoral articulation aided materially in consolidating the effects of the treatment.
Tics of speech should be handled in the same way as stammering. "We do not treat stammerers, we educate them," says Moutard-Martin. There can be no gainsaying the convincing results obtained by Chervin's technique.
For years there has been unanimity of opinion on the value of respiratory gymnastics in the treatment of stammering. The plan is to make the patient inspire deeply and quickly, and follow this with a prolonged expiration. Difficulties of articulation and phonation may be overcome by recitation, by declaiming, by scanning utterance, by dwelling on the vowels, etc. Various authors have laid stress on the advisability of concomitant therapeutic treatment.
In cases of stammering (says Olivier), all surgical interference is to be deprecated. Operations on the nose or throat are directed toward the removal of obstructions in the air-ways, but they are merely a preparatory step to the adoption of the education method. No one of the vaunted "cures" for stammering is infallible, since all depend in the last resort on the will power of the patient, nor is there anything mysterious about them. Isolation is not always indicated; what is indispensable is reinforcement of the will.
The intimate relation between tics of speech and various kinds of stammering has led to the application to both of the same re-education methods. Pitres,226 in particular, bases his line of treatment for tics in general on regulation of respiratory activity, as he has observed that tics diminish or die away with a deep and regular respiratory rhythm. His plan is as follows:
Supported against a wall, with shoulders braced back, the patient is instructed to take slow and deep inspirations, raising his arms the while, and letting them fall with expiration. This performance is repeated three times a day, for ten minutes at a time.
The method has been elaborated by Tissié, and Cruchet also has thereby obtained excellent results, which he has put on record in his thesis.
The patient is placed upright against some support, his heels together and his arms by his side. For the first three minutes he recites aloud, drawing a slow deep breath at frequent and regular intervals. Then he proceeds to make similar long inspirations and expirations, elevating his arms synchronously with the former, and depressing them with the latter. The exercises may advantageously be repeated every three hours to begin with, then their duration may be increased and the intervals lengthened, until the séances are extended to fifteen minutes three times a day. Their continuance will vary with the individual, but the ultimate aim is to reduce the period and to spin out the interval still more, until eventually their object has been attained and they may cease.
A concrete example may be given:
A young man had suffered for eleven years from generalised tics of peculiar intensity. Every few seconds violent twitches of an electric-like rapidity seized the muscles of his head, trunk, and limbs, to the accompaniment of abrupt cries and inarticulate growls. A sojourn of a few weeks in hospital, and the acquisition of the most elementary technique in athmotherapy, resulted in a complete cure ere many months had passed.
Tissié explains the action of this method on tics by a special action of regular respiration on psychomotor centres. Raymond and Janet incline to the opinion that attention depends on respiratory activity, but Tissié227 argues there is antagonism between deep respiration and maintenance of attention, and Cruchet supports this hypothesis.
If we prescribe respiratory exercises, we are temporarily suppressing the attention, and reducing psychical activity to a minimum. Thus tic, which is a reflex of thought, does not occur, and if the exercises are renewed often enough, the habit will gradually be lost.
In our opinion, it is precisely the bestowal of the attention on the allotted task that has such a salutary effect. Whatever be the movements, they demand of the patient a momentary halt, a momentary interruption of those ill-timed motor reactions that make concerted action impossible. Observation shows that the degree of successful control is in proportion to the degree of concentration of the attention. The novelty of the exercise in itself acts as a stimulus, but when this novelty wears off, faults are prone to reappear. Hence the necessity of varying the procedures, and of rendering them always interesting; in the end the habit of supervision is contracted, and the patient feels increasing satisfaction in watching his physical infirmities daily diminish and the resources of his will daily widen.
Respiratory drill is an admirable method of procuring this result; it acts in the same way as any of the other exercises. Its use is not confined to tics of speech or of respiration, for thoracic muscles are involved in tic much more frequently than is commonly supposed. By resort to this technique Madet cured an expiratory hiccough228 in a man of forty-six, who was afflicted in addition with twitches of head, trunk, and hands.
Systematized exercises have of course the advantages of exercise in general; motor, sensory, and psychical functions alike are stimulated and regulated, and tend to become normal. In particular, muscular exercise is a striking way of disciplining volition. Accordingly, we never fail to prescribe such pastimes as gymnastics, in any of its forms, rowing, fencing, cycling, lawn tennis, etc.; games which demand attention, skill, and decision are useful auxiliaries, and manual occupations of a more delicate nature ought not to be forgotten, provided they require of the patient a certain amount of immobility. Every case, needless to say, must be treated on its merits, but the general indications we have supplied can easily be modified to suit the individual.
The various procedures directed, under different names, to the suppression of tic by re-education, are all modelled on the same plan. Köster attributes the disease to exhaustion of higher co-ordinating centres, and counsels their reinforcement by appropriate exercise. Oppenheim, in his Lehrbuch der Nervenkrankheiten, adduces evidence of the value of what he calls Hemmungstherapie, which is merely an application of the principles and therapeutic rules laid down by Brissaud in 1893, and described by one of us in 1897, apropos of mental torticollis. The same may be said of the line of treatment pursued by Dubois, which appears to be based on the pathogenic interpretation given by Oettinger,229 according to whom the brain of tic patients is incapable of conserving the image of sustained immobility, and thereby loses the habit of voluntary immobilisation. The essence of treatment, therefore, consists in habituating the subject to rest motionless like a statue in a position conducive to repose, and for a given time.
As has been already remarked, the polymorphism of tics is such that the plan of treatment selected must be necessarily elastic if it is to be altered to suit individual cases. What is the point in enjoining absolute immobility on a patient whose blepharotic is never in evidence unless he is walking about?
We may now proceed to narrate the details of various cases of tic treated by the combined method of disciplinary movements and immobility, taking the history of O. as our first example.
October 15, 1901.– Séance of absolute immobility in the upright position, with the head straight, for five seconds; to be repeated in front of a mirror for five minutes, with intervals for rest of fifteen seconds. Movements of rotation of the head to left and right, with progressively lengthening pauses in each of the extreme positions. Respiratory exercises with elevation and depression of the arms eight times a minute, decreasing steadily to four a minute. These exercises are to occupy a quarter of an hour morning and evening. Explain to the patient the action of the sternomastoids and how they combine to fix the head. Make the patient lie on his back and move his head antero-posteriorly.
October 19.– O. has still his tics, but he can already remain motionless on command, and is conscious of satisfaction in so doing. Just as his exercises come to an end there is always a momentary recrudescence of the tics, but a very appreciable calm follows.
October 21.– Immobility is maintained well for half a minute. The patient is to resume his cycling and fencing, physical exercises which he has abandoned for more than a year.
October 25.– O. considers himself greatly improved. He has gained insight into the way of combating his tics, and his self-confidence is on the up grade. For several days he has devoted his attention to his tic of blinking, with the result that he can open his eyes longer and more easily.
October 28.– He evinces a preference for certain of the exercises: if they please him, he performs them accurately; if they do not, they are neglected.
November 20.– The head tics are still rather violent at times. A period of intellectual and bodily fatigue has supervened, but he tries his fencing again, and to his profound satisfaction he has managed to keep free of tics during the bouts. He is recommended to avoid all possible causes of cerebral and physical exhaustion.
December 3.– He continues to make satisfactory progress. His habit of supporting his chin on his cane is abandoned, though an attempt to dispense with the latter entirely, when he is out in the street, has ended disastrously. He is content to hold it in his hand and strike his leg with it from time to time.
December 13.– Whenever O. is tempted to tic again, he stands in front of a mirror and commences to sing, and while the song lasts his tics remain in abeyance. His trick of sitting crossways on a chair and rubbing his chin against the back is also discarded, with the result that the callosities have vanished. As far as his walking is concerned, he has adopted the plan of endeavouring to get from one point to another without allowing his tics to assert themselves, and his efforts have been crowned with success.
February 3.– The patient has recovered his self-confidence, and the compliments of his friends prove an additional restorative. It is true the tics still recur, but their number is less, their duration shorter, their severity considerably diminished. What O. is best able to appreciate is the disappearance of the state of mal obsédant that accompanied them.
Take another example in the person of young J.:
In his case our object was to discipline him by successive modifications of his caprices. The first important result achieved was the suppression of his precious mattress – a result not obtained without difficulty, for the mere mention of it sufficed to provoke floods of tears and ebullitions of anger. He was then sent into the country for a few days to forget his heart's desire, but the labour was lost. No sooner had he arrived than he discovered another mattress in a barn, and transferred his affections to it.
Eventually the day came when he was finally convinced of the absurdity and inconvenience of his practice, and when the tender yet firm remonstrances of his parents prevailed. The prospect of congratulations awaiting him, and his own keenness to get better, stimulated him to fresh efforts, and the reward was success.
