THE RESPONSE OF AN ADULT
TOURETTE PATIENT TO LIFE UPPER
CERVICAL ADJUSTMENTS
Nicolina Trotta, B.S., M.S., DC
Assistant Professor,
Division of Clinical Science, Life College
INTRODUCTION
Tourette's Syndrome is a chronic familial neuropsychiatric
disorder of unknown etiology accompanied
by chemical imbalances in the brain. It is characterized
by motor tics and uncontrolled vocalizations that
wax and wane in severity. Although there have been
anecdotal reports of total remission of symptoms in
these patients while under chiropractic care, there are no
known documented controlled studies existing
in the current literature. The present study covers three
months of care for a single patient ; the results
suggest that chiropractic care may be useful in the
management of this disorder. However, since no
long-term follow-up data exist, the results must be
considered preliminary.
BACKGROUND
Tourette's Syndrome was named for French physician, Gilles
De La Tourette who first described the
disorder in 1885. Although definitive epidemiologic
studies are lacking, estimates of the lifetime
prevalence of Tourette's Syndrome are about 0.1 to 1.0 pe
r 1000 persons; as many as 200,000 may
be affected in the United States alone (1,2). It is a
neurological disorder characterized by rapid body
movements, called "tics" and by involuntary, often
inappropriate, vocalizations. Tics may include rapid
eye mo vement, blinking, shoulder shrugging, head jerking,
facial twitches or other repetitive movements
of the torso or the limbs (3). Tics normally start at the
age of six and regress as the child matures. They
may at first be voluntarily controlled, buy per sistent
tics eventually become automatic. Vocalizations
may include repeated sniffing , throat clearing, coughing,
grunting, barking or shrieking. Some patients
may experience echolalia, palilalia (stuttering) or
coprolalia(4). These symptoms are often misconstrued
as a sign of behavioral abnormality. For example, in
children, they are referred to as "attention deficit
disorders", or nervous habits (5).
In 70-80% of cases, the symptoms are severe enough to
warrant treatment. Most families seek
neurologic consultation and as many as 55% of these
patients are treated solely by neurologists (6).
Haloperidol (Haldol, Orap) has been the drug of choice in
the treatment of these patients, but 20% of
them have not been responsive to the drug. Of the
remaining 80%, patient compliance drops to about
33% over the long term (7). The probable cause for t his
non-compliance is the inability on the part of
the patient to cope with the many deleterious
extrapyramidal symptoms which they experience from the
drug. These "side-effects" include excessive fatigue,
weight gain, dysphoriphobic reactions, parkinson
ism, intellectual dulling, personality changes, "feeling
like a zombie", and akathisia. The risk of tardive
dyskinesia becomes very real over long term administration
of Haldol. The fact that tardive dyskinesia
symptomatology is irreversible warrants fu rther
exploration into alternative methods of treatment for
Tourette's Syndrome.
PATIENT HISTORY
The patient, a thirty-one year old single male, presented
himself at our clinic after hearing our
presentation on chiropractic at a local meeting of the
Tourette's Syndrome Association (TSA). Aside
from the chief complaint, the patient also had suffered
from allergies for the past several years. he
reported being diagnosed as having Tourette's Syndrome at
age four. At that time, he was mildly
symptomatic. There was no further development of problems
until he reached middle school. In the six
years pr eceding presentation, his symptoms have worsened,
at times causing him embarrassment and
social stress. He suffered from psychomotor "tics" and
since 1981 has also suffered from uncontrolled
vocalizations. He reports grunting and sniffing behaviors
whic h worsen at night and with stress. He has
been prescribed a number of medications that have been
unsuccessful in relieving his symptoms. His
most recent prescription was for Orap 1 mg QD. However,
after ten months of unsuccessful attempts at
relief, he stopped taking this medication.
Sleep and diet patterns were reported as being normal. The
only chemicals that the patient reports
ingesting were coffee - three cups per day, and alcohol -
beer, two twelve ounce bottles per week.
Physical findings were unremarkable; blood pressure and
other vital signs were within normal limits.
Neurological findings included hypo-responsive deep tendon
reflexes bilaterally in muscles innervated by
the C5-C7 cord levels: biceps brachii, triceps and
brachioradialis. Foraminal compression was the only
positive orthopedic finding. Cervical range of motion was
within normal limits.
His cervical radiographs indicated a hypolordosis of the
cervical spine. Chiropractic x-ray analysis
revealed listings of atlas (ASLP) and C2 (body right); a
right head tilt was also noted.
The patient was, and still is under medical care, but was
not on any medication while under chiropractic
care.
METHODS
Treatment consisted of C1 adjustments delivered by an
instrument along a specific vector, as
determined using the Life Cervical analysis. Leg length
discrepancy found in the supine position was
used as the primary indicator of the need for adjustment.
T his type of care extended over three months
with the patient being seen on a weekly basis.
Symptoms associated with Tourette's were monitored during
the course of the study by a self-scoring
instrument, the TSA symptom survey, developed and provided
by TSA (Appendix 1). Using the
instrument, the patient rates each of 30 symptoms on a
daily bas is. To monitor stress, Stress Audit
Profiles (8) were administered at the beginning of care
and after three months.
Thermographic readings were taken prior to each adjustment
using a non-contact computerized infra-
red thermographic instrument (Stillwagon Visitherm) as a
means of monitoring autonomic lability.
RESULTS
The TSA symptoms survey results in ratings for each of 30
symptoms on a scale from 0 to 5 as shown
in Appendix 1. For analysis, the symptoms are grouped into
three classifications:moto tics, phonic
symptoms and behavioral prob lems. The average rated value
for each of these classifications was
calculated for each day from the patient's rating sheets.
These data were plotted with respect to time as
shown in Figure 1. The days on which the patient was
adjusted or examined are represented along the
horizontal axis of the same figure.
As can be seen, there is an alternating pattern in the
frequency and severity of symptoms. In most cases,
a reduction in symptoms was noted immediately following
adjustment, with a subsequent increase
occurring prior to the next visit. The patient was s een a
total of 12 times; he was found to be in
alignment on 4 of those visits and did not require
adjustment.
Significant reduction in stress was indicated by the
Psychological Stress Audit Test, from the start to the
end of the 3 month study interval. The stress audit
produces ratings of severity of stress in 16 different
components. A rated value of 50 or abo ve on any component
is considered a sign of significant stress
(8). Figure 2 is a plot of the stress profiles before and
after the treatment period. Prior to treatment,
there was significant stress in 9 of the 16 component
factors. The post- adjustment profile registers
significant stress in only 1 component.
Thermographic reading showed a consistent left sided
temperature elevation in the cervical and thoracic
areas. Follow-up x-ray studies suggest that the atlas
misalignment has not been completely corrected.
DISCUSSION
Tics are considered to be neurological disorders, some of
which are extrapyramidal in nature. They
often involve multisynaptic upper motor neurons that
connect with basal ganglia, reticular formation, the
cerebellum and the cerebrum. Irritation to the l ower
brain stem and the upper cervical cord may
therefore play a role in the genesis of tics. However, the
exact mechanism of tic production is still
lacking in the literature.
It is hypothesized that upper cervical subluxations could
irritate either sensory or extrapyramidal tracts
by distorting the spinal cord at the level of C1-C2(9).
One of the effects of that irritation could be tic
production. Correcting these structural misalignments
should enable the nervous system to again
integrate and respond appropriately to the demands placed
on it. Better integration should lead to
proper muscle action and also to normal phonic function.
It is thus hypothesized that the frequen cy and
severity of Tourette's Syndrome episodes should decrease
as a result of correcting or reducing the
cervical structural misalignments; this should, in turn
lead to improved integration of the motor activity
initiated by the cerebral cortex.
In the present case, the fact that the patient remains
somewhat symptomatic, suggests that the care plan
may need revision. In particular, the frequency of
adjustment may need to be increased. The patient was
reluctant to come in more that once-a-week d ue to the
distance that he lived from the campus and
because of his work schedule. Whether this situation can
be improved is questionable. Further, the
residual misalignment noted on the three-month x-ray
suggest that a modification of the adjustment ve
ctors may be necessary.
Since we know that symptoms can wax and wane, long-term
care of this patient is almost a necessity if
we wish to determine whether chiropractic care is indeed
the reason for the decrease in
symptomatology that we observed in our preliminary
findings.
About the author : Nicolina Trotta, D.C. a 1989 Life
College graduate, is an assistant in the Division
of Clinical Sciences at Life College. She has earned a
B.S. degree in psychology and a double master's
degree in rehabilition counseling and edu cation from the
University of Pittsburgh. She was employed as
a clinical psycologist in western Pennsylvania for many
years and directed her own clinic. She has
assisted in publishing articles for psychiatric journals
on both drug and alcohol addiction research.
ACKNOWLEDGEMENTS
The author wishes to thank the patient for his
participation,as well as students Kent Johnson, who
assisted in the liaison with the Tourette's Syndrome
Association, and Manola Tejada who assisted in the
care.
REFERENCES
? 1. Shapiro, A.K., Shapiro, E. The Psychopathology of
Gilles De la Tourette Syndrome,
American Journal of Psychiatry 1972 129:
(427-437).
? 2. Shapiro, A.K., Shapiro E., Wayne, H.L., Tourette's
Syndrome: Summary of data on
Patients, Psychosom. Medicine 1973 35:(419-435).
? 3. Beard, C.M., Experiments with "Jumpers" of Maine.
Paper presented to the American
Neurological Assoc., June 1880.
? 4. Nuwer, M.R., Coprolalia as an Organic Symptom,
Psychiatry; Q., 34: (600-622).
? 5. Nomura, Y., Sagawa, M., Tourette Syndrome in Oriental
Children, Advances in Neurology,
Vol. 35:(277-280).
? 6. Shapiro, A.K., Shapiro, E., The Gilles De la Tourette
Syndrome. 1972 Raven Press, New
York.
? 7. Bonnet, K.S. Neurobiological Dissection of Tourette
Syndrome: A Neurochemical Focus on
a Human Neuroanatomical Model, Advances in Neurology, 1986
35:(77-83).
? 8. Miller, L.H., and Smith, A.D. (1987) Stress Audit
(Behavioral Associates Inc.).
? 9. Grostic, J.D., Dentate Ligament - Cord Distortion
Hypothesis, Chiropractic Research
Journal, 1988 1(1):(47-55).
