Movement disorders describe a group of neurological conditions characterized by abnormalities in the quality and quantity of spontaneous movement. The clinical presentation ranges from an almost inability to move to severe constant and excessive movement. These patients are usually divided into two groups: those with excessive movements, called hyperkinetic movement disorders, and those with diminished movements, called bradykinetic movement disorders. These disorders affect the speed, quality and ease of movement. Most pediatric movement disorders are felt to result from abnormalities in the basal ganglia, which are groups of neurons deep in the brain linked in circuits and responsible for the planning and execution of movement.
Three of the most common movement disorders in children are tic disorders, Tourette’s syndrome, and cerebral palsy. Children’s Hospital of Orange County is a leader in diagnosing and managing these and other pediatric movement disorders. The multidisciplinary team at The CHOC Neuroscience Institute takes an innovative approach to these conditions, offering patients access to the latest treatment alternatives in a compassionate, patient-centered environment.
Tics are movements or sounds that are repeated over and over that a child cannot control. Throat clearing and eye squinting are common tics. Tics usually last less than a year, and often become worse when a person is stressed, tired or anxious. Tic disorders are substantially more frequent in boys than in girls, and a family history of tics is common. There are two categories of tics – simple and complex:
- Simple tics – Simple tics are sudden, brief movements that involve a limited number of muscle groups. They occur in a single or isolated fashion, and are often repetitive. Some of the more common examples of simple tics include eye blinking, shoulder shrugging, facial grimacing, head jerking, yelping and sniffing.
- Complex tics – Complex tics are distinct, coordinated patterns of successive movements involving several muscle groups. Complex tics may include jumping, smelling objects, touching the nose, touching other people, shouting obscenities, echoing the words of other people, or self-harming behaviors.
Tourette’s syndrome, which is an inherited neurological disorder, is one form of tic disorder. Symptoms generally appear before the individual is 18 years old. It is estimated that 100,000 individuals have true Tourette’s syndrome, and as many as 1 in 200 demonstrate a partial expression of the disorder, such as chronic multiple tics or transient childhood tics. Tourette’s syndrome affects people of all ethnic groups, and males are affected 3 to 4 times more often than females.
Although Tourette’s syndrome symptoms range from very mild to quite severe, the majority of cases fall in the mild category. The first symptoms of Tourette’s syndrome are usually facial tics, most commonly eye blinking. However, facial tics can also include nose twitching or grimaces. With time, other motor tics may appear such as head jerking, neck stretching, foot stamping or body twisting or bending. These individuals may utter strange sounds, words or phrases. They may also continuously clear their throat, cough, sniff, grunt, yelp, bark or shout.
Some individuals may involuntarily shout obscenities or constantly repeat the words of other people. They may touch other people excessively or repeat actions obsessively and unnecessarily. Tics associated with Tourette’s syndrome tend to worsen in stressful situations. However, they improve when the person is relaxed or absorbed in an activity. In most cases, tics decrease markedly during sleep. Symptoms may subside for weeks or months at a time, and recur later.
Other problems associated with Tourette’s syndrome include:
- Obsessive-compulsive behaviors – The person is compelled to perform certain tasks repeatedly (e.g., washing hands or checking that a door is locked).
- Attention deficit disorder – The individual has difficulty concentrating and is easily distracted.
- Learning disabilities– This includes problems with reading, writing, math and perceptual difficulties.
- Problems with impulse control – This can result in overly aggressive behaviors or socially inappropriate acts.
- Sleep disorders – These include frequent awakenings or talking in one’s sleep.
Cerebral palsy is a broad term used to describe a group of chronic disorders impairing control of movement. “Cerebral” refers to the brain and “palsy” refers to a disorder of movement or posture. These disorders appear in the first few years of life and generally do not worsen over time. They are caused by faulty development of or damage to motor areas in the brain that disrupts the brain’s ability to control movement and posture. Between 500,000 and 700,000 Americans have some degree of cerebral palsy. About 3,000 babies are born with the disorder each year, and another 500 or so acquire it in the early years of life.
Symptoms of cerebral palsy include difficulty with fine motor tasks, difficulty maintaining balance or walking, and involuntary movements. Early signs of cerebral palsy usually appear before 3 years of age. Infants with cerebral palsy are frequently slow to reach developmental milestones such as learning to roll over, sit, crawl, smile or walk.
Cerebral palsy may be congenital or acquired during or after the birth process. The causes of cerebral palsy include illness during pregnancy, premature delivery, or lack of oxygen supply to the baby. Chief among the causes is an insufficient amount of oxygen or poor flow of blood reaching the fetal or newborn brain. This can be caused by premature separation of the placenta, an awkward birth position, labor that goes on too long or is too abrupt, or interference with the umbilical cord.
When diagnosing tics, the major features that distinguish tics from other movement disorders are the sudden, rapid and transient nature of the movement, together with the lack of an underlying neurological disorder; their repetitiveness; their disappearance during sleep; and the ease with which they may be voluntarily reproduced or suppressed.
Diagnosing Movement DisordersTourette’s Syndrome
There are no blood tests or other laboratory tests that definitively diagnose Tourette’s syndrome. Instead, the physician diagnoses the disorder by observing the symptoms and evaluating family history. Neuroimaging studies such as magnetic resonance imaging (MRI), computerized tomography (CT), electroencephalography (EEG), or certain blood tests may be used to rule out other conditions that could mimic Tourette’s syndrome.
Although the symptoms of cerebral palsy may change over time, the disorder by definition is not progressive. So if an individual shows increased impairment, the problem may be something other than cerebral palsy.
Treating Movement DisordersTic Disorders
Medications are the most widely used treatment for tic disorders. They attempt to balance the alleviation (not cure) of symptoms with the inevitable side effects of currently known medications. The severity, type and location of symptoms change frequently, and spontaneous remissions are possible. A combination of medication and behavioral treatment has also been found to be effective. Children at The CHOC Neuroscience Institute have access to the latest clinical trials to treat tic disorders.
Although medications are available to reduce specific symptoms, there is no one medication that is helpful to all patients with Tourette’s syndrome. Additionally, since all medications have side effects, their usefulness must be weighed against problems they may cause. Other types of therapy may also be helpful. For example, psychotherapy may help the person better cope with the disorder and deal with the secondary and emotional problems that sometimes occur. Relaxation techniques and biofeedback may be useful in alleviating stress, which can exacerbate the symptoms of Tourette’s syndrome. Patients at The CHOC Neuroscience Institute have access to the latest pharmaceutical clinical trials and other advanced approaches to treat Tourette’s syndrome.
Early identification of cerebral palsy can lessen developmental problems and lead to appropriate intervention when it helps the most. Drugs can be used to control seizures and muscle spasms, and special braces can compensate for muscle imbalance. Other treatment approaches include surgery, mechanical aids to help overcome impairments, counseling for emotional and psychological needs, and physical, occupational, speech and behavioral therapy.
Surgical TreatmentThe CHOC Neuroscience Institute has one of the largest intrathecal baclofen programs in the United States for treatment of spasticity and dystonia of cerebral origin. These pumps deliver a constant, low dose of baclofen -- a medication to reduce muscle spasticity -- via catheter to the patient’s spinal cord and brain, allowing muscles to relax. Results of this treatment have shown dramatic success in reducing spasticity, offering patients greater mobility and independence. And, intrathecal baclofen avoids the side effects of oral baclofen treatment.