Using Interactive Metronome® to Improve Symptoms of Tourette

MATTHEW MCNATT, DIRECTOR OF MCNATT LEARNING CENTER, INC.

Clinical Symptoms of Tourette

�  Motor tics: More than one physical movement that a person (a) initiates but (b) doesn’t want to make. ¡  A tic is not a spasm. ¡  A tic is not a stretch.

�  Vocal tic(s): One or more sounds of the same criteria.

Clinical Symptoms of Tourette

�  These movements and sounds must be observed over the course of one year.

�  These movements and sounds cannot be absent for more than three consecutive months during that year.

�  These movements and sounds cannot result from another known illness.

Experiential Symptoms of Tourette

�  Sensory tics: Premonitory sensations that one “has to” move or speak.

¡  Examples (Sneeze, Sore shoulder, Yawn) �  Sensory tics precede most motor and vocal tics. �  In general, awareness of sensory tics increases

with age and decreases with medication for Tourette symptoms.

¡  Young children with Tourette frequently do not report experiencing sensory tics.

¡  Highly medicated persons with Tourette frequently report minimal sensory tics.

�  Some people with Tourette are more bothered by sensory tics than by motor or vocal tics; others are more bothered by motor or vocal tics. This highly individual.

Cognitive Load & Tourette

�  People with Tourette often expend tremendous “mental energy” managing their tics.

�  When spent managing tics, this “mental energy” is not available for other tasks.

�  Some medicines that can help manage tics have “cognitive dulling” as a side effect.

�  Whether cognitive capacity has been reduced by medicines or is spent managing tics, the loss of function is undesirable — and the people experiencing it represent a market for any service demonstrated to help.

Habituation & Tourette

�  Initially, a sensory tic may have a purpose. ¡  If a person hasn’t moved in a while, an

impulse to move can be a good thing. ¡  If a person’s structure is “off” (e.g.,

one shoulder is lower than the other, or one hip is lower than the other), an impulse to restore balance can be a good thing.

¡  If a person feels misunderstood or mistreated, speaking out can be a good thing.

Habituation & Tourette

�  Motor or vocal tics are rarely, if ever, the most efficient way to respond to a real problem.

�  Sufficiently intense motor or vocal tics can displace subtle but irritating awareness of a problem.

�  This reward reinforces particular tics. As they are rewarded, they readily develop into habits.

Recruitment & Tourette

�  To move with enough intensity to temporarily displace subtle but irritating awareness of a problem— to “do something” about a sensory tic — often involves moving more than the area in which one initially feels a problem. ¡  Recruitment of muscles not

essential to an intended movement increases the neurological “noise” that can drown out sensory tics.

¡  Repeated recruitment of muscles not essential to intended movements, however, eventually skews awareness of what muscles are essential to achieve a desired goal.

Recruitment & Tourette

�  As muscles are needlessly recruited, more force is needed to execute “simple,” goal-directed movements.

�  As more force is needed, the likelihood of injuries — including the slight injuries that effect an awareness that something is “off” (i.e., sensory tics) — increases.

�  In the presence of sensory tics, recruitment carries its own reward. Recruitment, however, in turn increases sensory tics.

Recruitment & IM

�  IM training involves thousands of repetitions of movement sequences that: ¡  Are sufficiently dissimilar from everyday movement sequences that

they are rarely already habituated, and ¡  Are sufficiently similar to everyday movements that, as IM movement

sequences become easier, everyday movement sequences become easier, too… if and only if the movement sequences practiced during IM are efficient.

Habituation & IM

�  When, due to habituated recruitment, a client moves many parts of his or her body without being aware that he is doing so, learning through successive approximation becomes more problematic. ¡  However, because clients become aware of what

body parts are moving, IM training can use successive approximation for improvement (refined movement through practice).

¡  A client needs an opportunity to slowly differentiate movements (e.g., Feldenkrais training), or

¡  A client needs to be given sufficient instruction in efficient movement sequences and ongoing feedback in maintaining them. IM training provides a perfect opportunity.

Cognitive Load, IM & Maximum Capacity

�  The following three challenges require immense attention for clients: ¡  Maintaining rhythm, ¡  Matching beat, and ¡  Minimizing recruitment.

�  During IM training, you can expect clients with Tourette to become unable to maintain the cognitive control over their bodies that many have grown accustomed to maintaining.

�  However, IM’s emphasis on efficient movement offers people an opportunity to develop efficient movement patterns without the interference of their sensory tics and trying to “fix” motor & vocal tics. They may notice: ¡  More fluid, less robotic movement; ¡  Greater ease; and ¡  Less pain.

Cognitive Load, IM & Efficiency

�  Because the cognitive load of IM training is high, and can be kept high by adding simple mental tasks, the efficient movement patterns developed during Interactive Metronome® are less prone to regression from stress.

�  IM offers an opportunity for persons with Tourette to develop a repertoire of more efficient movement patterns that they can expect to carry with them into everyday life.

�  The more practice, the less prone someone is to recruit muscles they don’t need to help them reach their goals. If efficient movements become automatic in the context of IM training, further refinement can continue after IM training concludes.

�  As fewer muscles are needlessly recruited, less force is needed for movement.

Teaching Rhythm Correcting Recruitment

�  Some people have difficulty maintaining a steady cadence.

�  These clients clap, step, or move to their own beat (or lack thereof) irrespective of the steady beat of the IM reference tone.

�  It is important to recognize what muscles are necessary to execute a movement and what muscles are not necessary to execute a movement.

�  Hand-over-hand assistance can help keep the Both Hands activity smooth and circular until the movement becomes easier to maintain.

IM and Tourette

Remember

�  A primary goal of IM training for clients with Tourette is efficient, fluid movement. ¡  Sensory tics generally wane as movement becomes more fluid and efficient. ¡  Motor and vocal tics may wane, too—but reduction in motor or vocal tics is not

generally a primary goal of IM training.

�  Emphasizing efficient, fluid movement is important for two reasons: ¡  IM training for Tourette is still in its infancy. More rigorous, scientific studies are

needed before making claims as to Interactive Metronome’s effectiveness in reducing motor and vocal tics. If practitioner reports are any indication, however, this will be a very promising direction for research to take.

¡  A client who focuses on reducing tics may focus on controlling his or her tics, as (s)he has grown accustomed to doing, and this focus is likely to hinder progress. For clients with Tourette, we want movement fluid, even if not precise.

And so much more…

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The End

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