This webinar will focus on both the pharmacologic and non-pharmacologic treatment approaches to bothersome tics, including painful tics. This will include an evidence-based review of Comprehensive Behavioral Intervention For Tics (CBIT), medications (Guanfacine, Topamax, dopamine antagonists), and considerations for botulinum toxin injections for specific tics.
Dr. Peter Morrison, DO, received his medical degree from the New York College of Osteopathic Medicine in 2012. He completed his medical internship, neurology residency, and clinical movement disorder fellowship at the University of Rochester. He joined their department of neurology faculty in 2017, specializing in the care of patients with movement disorders including Parkinson’s disease, Essential Tremor, Huntington’s Disease, Dystonia, and Ataxia. Dr. Morrison also has a special interest in the diagnosis and management of children and adults with Tourette Syndrome and other Chronic Tic Disorders, for which he is the Co-Director of the Tourette Association of America (TAA) Center of Excellence at the University of Rochester.
0:04 Hmm, good evening and welcome. 0:07 Thank you so much for joining us tonight for the webinar on Treatment Approaches to Help Manage bothersome TEKS presented by doctor Peter Morrison. 0:17 My name is Katie Delaney. 0:19 I am the Family and Medical Outreach co-ordinator at the New Jersey Center for Tourette Syndrome and Associated Disorders. I will be facilitating. 0:29 I will be your facilitator for this evening. Now, before I introduce doctor Morison, here are the housekeeping notes. 0:37 All participants are muted. 0:39 If you have a question, please type it in the bottom of your question box and click send. 0:44 If you have questions after tonight’s session, you can post your questions on the Wednesday webinar blog, which is accessed from our homepage at WWW dot NJ CTAS dot org. 0:59 Under the heading programs, this blog will be monitored for the next seven days. 1:07 The New Jersey Center for Tourette Syndrome and Associated Disorders, its directors, and employees assume no responsibility for the accuracy, completeness, objectivity, or usefulness of the information presented on our site. 1:27 We do not endorse, or, we do not endorse, any recommendation, or opinion made, by any member, or physician, nor do we advocate any treatment. 1:36 Your you are responsible for your own medical decisions. 1:41 Now, it’s my pleasure to introduce to ours introduce to you our speaker for this evening, doctor Peter Morrison. 1:48 Doctor Morison received his medical degree from the New York College of Osteopathic Medicine in 20 12. 1:56 He completed his medical internship, neurology, residency, and clinical and movement disorder fellers Fellowship at the University of Rochester. 2:06 He joined their Department of Neurology and 2017, specializing. 2:12 The care of patients with movement disorders, including Parkinson’s disease, essential tremors, Huntington’s disease, dystonia, and attacks. Yeah. 2:23 Doctor Morrison has a special interest and the diagnosis and management of children and adults with Tourette syndrome and other chronic disorders as he is the co-director of the Tourette Association of America as Center of Excellence at the University of Rochester. 2:42 Doctor Morrison, we’re so happy to have you here tonight. 2:45 The floor is all yours. 2:47 Thank you very much, Katie. I’m really excited here tonight to be presenting this webinar. Obviously, this is a near and dear topic to me. 2:54 Not only because I’m a movement disorder, neurologist, and specialized in text, but I am also an individual that has Tourette’s syndrome. 3:02 And so I was diagnosed, you know, as a child. And so you know, kind of going through life span, you know, as the patient side of things, and now being on the provider side of things. 3:12 So hopefully I’m able to provide a unique perspective for everyone. I’m really honored to be giving this, and certainly at the end, I’m happy to take any questions. 3:21 So overall, kind of jumping right into it, the primary focus and objective of today’s webinar is going to be looking at the range of effective management and treatment strategies for patients with bothersome texts, including both medication and non medication approaches. 3:37 With that said, it’s always good to have the foundation in understanding of what ticks are different tic disorders. So I will review the phenomenology objects, the different tic disorders that are present. 3:48 Because there probably is various levels of understanding of tic disorders on today’s program. So I just want to make sure we all have a fair kinda playing field, a good background, and then we’ll certainly jump into the crux of the lecture, including the treatment approaches. In addition, it’s always good to look on what’s the horizon. There’s a lot of medications which I’ll be going through that have been present for many years, But it’s good to know what is out there, what is in studies, what could potentially be helpful for patients with ticks going forward. 4:17 So the first thing we need to do is define what is a tick, and basically, the movement disorder aspect is defining phenomenology because there can be different movements that people have. There can be tremor, ataxia, dystonia, vertex. 4:32 So that’s basically describing the phenomenology ticks are not first of all insects tic tacs. contagious are a sign of mental instability. 4:41 Rather, they are repetitive stereotyped, non rhythmic, movements, or sounds. 4:46 Most of the time ticks have what’s called a monetary urge or build a person station before the movement or sound happens. 4:53 Ticks are involuntary the route of the control the individual, but there is this temporary … components, But eventually that urge builds up. They get distracted and the tick occurs. And a lot of times, there’s this relief phenomenon afterwards or frustrated, Or you kinda have to tune into feels just right. 5:09 So overall, again, understanding the definition of what a tick is, being repetitive or stereotyped, non rhythmic movements, or sounds, with a monetary urge temporary suppress ability and a really phenomenal. 5:20 This is important to differentiate from another movement seen in children, which are also repetitive and stereotyped, but are more rhythmic movements. That would be scary out to be, such as hand clapping rocking. So, again, understanding the definition, Upticks is really important to try to differentiate them the neurological you from other movements, WC. 5:41 So now we know what ticks are, But what various ticks are there? So request is both motor in vocaltec. 5:47 So with motor ticks, that contraction of the muscles, it tends to be in the cranial facial distribution, but obviously you can involve the lens and the trunk popup texture, they predict production of a sound. In theory, you actually have to have contraction of muscles to produce the sound. So, it’s more semantics than anything. But, essentially, you have both motor in vocal tics. 6:09 Then, we can characterize further in terms of simple and complex. 6:13 Simple text, or more of the traditional eye blinking, eye rolling, facial grimacing, neck twisting, throat clearing sniffing grunting, But then, you can have more complex co-ordinated research settings where you can have kind of bizarre arcades kicking, jumping, …, and then what people. Unfortunately, think about Richard Syndrome as copper Amelia which is very uncommon in patients with Tourette syndrome but it does occur where we have the inappropriate swearing. 6:39 But, overall, basically, it’s important to know, there’s motor tics, and vocal tics most of the time they’re simple text, but of course, we can have more complex co-ordinated vocalizations. 6:51 So, what are the different type of tic disorders that we have? 6:55 Well, the first is a provisional tik disorder in prior DSM. 6:59 It was known as the transient tick disorder, but it’s been renamed as provisional tick disorder. 7:03 Basically, this is the presence of motor or vocaltec spurred less than a year. 7:08 In general, it is very common for children at some point during development to have tips, Depending upon what research or literature you look at, about 10 to 20% of children. 7:18 At some point we’ll have tips, but overall, the last less than a year, That is known as a provisional tick disorder. 7:26 With that said, there are certain sub amounts, about one to 3%, in which individuals will have checks for more than a year, and that’s where it crosses the threshold of a chronic tick disorder. 7:38 Again, one-year less provisional tick disorder, one year or more chronic disorder, then we get into the subset of the three different types of chronic disorder. 7:48 Sounds kind of confusing, you know, overall, but it’s actually pretty straightforward. 7:52 There are those individuals who have only motor tips, but no vocal tics for more than that’s known as a chronic motor tic disorders. 7:59 Then you have those who have only vocal tics, but no motor tips, that’s known as a chronic disorder. 8:05 Then there’s Tourette syndrome, which is the combination of at least two motor ticks in one vocal tip. 8:11 So overall, you know, sometimes you get parents to say, oh, you know, really concerned that it’s Tourette’s syndrome, and Swishy was aquatic motor tick disorder. But in the end, it’s more semantics. Because the physiology is the same, regardless of just motor, vehicle, or both. But Tourette syndrome was coined for the combination of both. 8:29 So getting more, specifically into Tourette syndrome, it was named after doctor George … de L’arche right in the late 18 hundreds. And unfortunately, it was initially regarded as a psychological condition. 8:41 But of course, over the years with research and understanding of it, we’ve transformed into understanding that it’s a complex neural development developmental disorder with potentially a genetic component. Again, there’s still a lot of research in terms of that aspect where as another movements orders, for example, Huntington’s disease, we know that it’s specifically related to the Mutation Huntington Gene, having more than 40 CHG repeats will produce the disease resident short syndrome. It’s not as clear. 9:08 There’s been some thoughts in terms of looking at the Citrix one dream, histidine receptor mutation, But, again, it’s not really definitive. So overall, we need a lot more research looking into that. But it’s slightly complex neurodevelopmental disorder with potentially genetic component. 9:23 We talk about overall prevalence, about zero point one to zero point five to 1%. But again, there are more recent studies that are potentially showing that it is a little bit more common. 9:33 The male to female ratio is actually 4 to 1. So predominantly males are more effective than females, but obviously we see it across both sexes. 9:43 So what does Tourette syndrome and the different clinical features? So typically by definition, you have to think about onset of the text less than 18 years old. 9:50 In general, on average, onsen is around 5 to 8 years old. And about 90% less than 10 years old. 9:57 Onset after age 18 to 21 is very unusual, atypical. And as a movement disorder neurologist, you have to think about other causes. 10:04 If you see adult onset of texting, someone that never had a history of tips, in general, again, a lot of what I’m going to be smoking speaking about is generalizations regarding the data that we have. 10:15 Tick severity tends to peak 9, 10, 11, 12, 13. And in the majority of individuals, ticks tend to be pretty stable and or improve with age and about 75% of individuals. But, again, that is not everyone. 10:28 That is what we generally see. But certainly, there are individuals into adulthood, vertex persist and are certainly bothersome. But in terms of education to patients and families when making the diagnosis in general, the trend is that ticks remain stable or improvement. 10:44 In addition, a lot of times, six, or just surface the tip of the iceberg is a lot of people like to say below the surface, we have to look at other Comorbid conditions: ADHD, OCD, inside, depression, just to name a few. Because in most cases, again, not know if those are there. Those are the symptoms that tend to persist into adulthood that are most functioning, Aaron. 11:07 Again, I treat children and adults, people across the lifespan with Tourette syndrome and different disorders. And that is commonly what I see as people get into the adult. Ticks tend to improve in general, but it’s really the OCD, the anxiety, depression that continues to be most functionally impairing, indeed, a function. But again, not always. 11:27 So this is an oldie but goodie. This is a graphic representation of what I was just talking about back from the journal pediatrics in 19 98. Are basically we are individuals’ rate the severity of their ticks at certain ages. Again, as you can see, kinda the answered the development around five years, so they tend to peak 9, 10, 11, 12, 13, and in the majority of individuals ticks, improve with age. But again, it’s a little bit subjective in terms of what constitutes X to be severe. 11:53 Is it one tip that is very large and amplitude and painful? Is that the frequency of tips? Is it the number of tips? 11:59 So again, just because you have 1 or 10, in my opinion, doesn’t necessarily count at or indicates the degree severity. It depends on how it impacts the individual in terms of DVD function. And I think that’s really important to keep in mind. 12:14 This is another graphic representation from the JAMA psychiatry in 20 15. just regarding kind of onset of age and the distribution of symptoms here. 12:23 You see that Trend Senior began earlier on as well as ADHD tend to be pretty similar in terms of timeframe of onset, but then you see the onset of the OCD, the mood disorders, anxiety, depression later on in tend to linger into adulthood. Again, these are generalizations of what we typically see, but certainly there’s patient to patient variability. 12:46 So, now we’ve understood what chicks are, what the different tic disorders are, now we have to consider when do we treat individuals. 12:53 And the most important question, as a provider, and even as a patient or caregiver, or parent, or brother, or sister, is, do we need to treat the mere presence of whether it’s ticks, or other movement disorders of Tremor Correa Dystonia Doesn’t mean that you have to treat if the movements are bothersome to the individual. 13:11 Then we consider treatments, if they’re not, we likely will defer treatment, but again, it comes down to the individual and that word bothersome. As a lot of different meetings, you have to consider the impact on activities, school, social, emotional, self-esteem, or they causing pain, discomfort. There’s a lot of different reasons why it can be bothersome and that’s why you have to individualize it to the patient. 13:35 In most circumstances, when making the diagnosis, just education, in and of itself, can be sufficient bernardo. If you are going to treats, the goal is tolerable suppression in knots elimination of symptoms in mind. 13:50 Again, this goes for all different movements sorters, whether checks, Korea tremor. The goal is to improve frequency and severity that improves quality of life. 13:59 If symptoms eliminate, then that’s great. 14:01 But I think setting up the goals and anticipating what the goals are with the patient is really important because of the position does not set that upfront. Then They’ll fall short. 14:11 You want to be careful not to treat texts to appease the parents. What do I need? So, definitely, you know, we’ve had certain circumstances, the parent comes in with the child and it says, you know, doctor Morrison. My son, Johnny, he took 200 times on the soccer field. 14:25 You know, I really gotta do something about, as Johnny and my Johnny do the text father, you know, they don’t bother me at all, so I wouldn’t treat. Again, it really comes down to the individual patient in terms of asking them, are they bothersome enough? 14:39 How quantifying that in terms of how they affect their day-to-day function? 14:44 You also want to treat the most bothersome symptom first. What do I mean by that? 14:47 Well, as I mentioned, not only could it be text, but there could be Xiety, ADHD, anxiety, depression. A lot of times, there’s gonna be multiple symptoms there. 14:55 You try to triage what is the most bothersome most impactful shrieked at first, and see from there. So again, they could have text, but if the ADHD is off the charts, the significant difficulty concentrating, focusing there’s a lot of impulsivity, maybe focus on treatment of that first and then go from there. 15:13 There are other considerations. It is very common for ticks to wax and wane at the low income they go. 15:20 They change, OK? And certainly, any new life event can be associated with worsening tax. You know, most commonly I hear that ticks are worse than the beginning of the school year, and they get better when during the summer. 15:31 Again, not always they can ebb and flow independently. 15:35 And again, in general six, typically remain stable and or improve with age, but not always. So again, when making the diagnosis, I try to go through these generalizations with the parents in terms of education. A lot of times that’s enough. But certainly, there are going to be indications where we need to treat. 15:50 And that’s what we’re going to jump to. Net. So overall, I just want to make not only the providers here on the webinar but also family aware that the American Academy of Neurology or the recently developed practice guidelines in terms of treating patients with Tourette syndrome and other chronic disorders. This was published at the 2019 meeting, Philadelphia, and so it’s really important for people to be aware that we’re constantly re-assessing the data on these different medications, and non medication approaches to try to provide the best submarine recommendations. 16:23 Alright, so we’ve defined what ticks are, what the diagnosis is. And we’ve discussed with the patient that know what the ticks are very bothersome to me. And again, is that because they’re painful, the social emotional aspect, things like that? So what are our options here? 16:37 Over the years, medications traditionally have been the mainstay of what we’ve really come to know, is that there’s a non medication approach known as comprehensive behavioral intervention for ticks or CIT, which has been shown to be just as effective first line for treatment of bothersome ticks than medications. So, the first part of this treatment program is gonna be focused on CIT and the data behind it because I truly believe and feel that it is can be incredibly helpful for some individuals. But, again, not always. 17:08 If CBI T is ineffective, or in terms of access is an issue then, certainly, we consider medications And the ones that I’m going to go through tonight include the alpha two agonists such as … 17:19 and quantity, topamax arts appear on me. 17:22 The anti dopaminergic, which are also con, commonly known as Neuroleptics dopamine blockers, there’s typical and atypical. one so focused on the typical aircraft rizal, Abilify, risperidone, spread out. 17:35 There’s Tetra benzene, and then Botox or botulinum toxin. So, I will briefly touch on this, because I think in certain specific circumstances, it could potentially be beneficial, but we’ll get into that. 17:47 And, again, you always want to re-assess the presence of comorbidities and the impact of those comorbidities, identity, function, and potentially treating those as well as your address and the tips. 17:58 So, let’s get into CBOT again, CBI, TCM For Comprehensive Behavioral Intervention for Tips. This is a form of CIT or Cognitive Behavioral Therapy for treatment of tips. 18:10 As I mentioned, it’s considered first line for bothersome text. 18:13 If accessible, and if the patient has a monetary or thought about, it’s known as a form of habit reversal Therapy. I don’t like that word habit, because Kickstarted happens. But again, in generalization from a CVT standpoint, that’s what they characterize it. 18:28 So, what’s the methodology? What’s the what’s the idea behind … patients to be aware of that takes? It really utilizes that monitory urge, which I mentioned before as part of the phenomenology of text that kind of build up that urge. 18:40 And they develop what’s called a competing motor response to help with the bothersome Tip. 18:45 Now, if someone doesn’t have a monetary urge, which isn’t always the case with texts, about 80% plus, minus NCBI team may be helpful because if you don’t have that build-up or herbs, then how are you going to develop the motor response? 18:56 But let me describe an example of what is competing motor response. So again, this is kind of more in simplistic terms, I don’t do the therapy itself. 19:05 But the way that I think about is that, let’s say I have a bothersome tick of a rotation. 19:09 I feel the urge of build-up. 19:10 Maybe I’ll just talk mentioned by just wait till the urge passes and then release so you can’t do the neck rotation and the chin tuck at the same time. Therefore, it’s a competing motor response now. 19:21 I have some patients will say, well, doctor Morrison Or are you just treating one to the other? 19:26 The answer is no, because in theory the competing motor response, which is your chin tuck, does not satisfy the urge that neck rotation. 19:34 The next question patients will say, well, doctor Morse. What if I have 20 different tips? How is this going to be helpful? How am I going to develop the motor response for 20 different tips? 19:43 What I tend to tell patients is you focused on the ones that are bothersome. 19:47 But the others got the wayside per se and a lot of times that improves frequency and severity or the quality of life. 19:54 In general, there are different providers that can offer CBOT done by psychologists, neuropsychologists, and even occupational therapists. And we’re really trying to improve access for patients with CBT because to me, that is absolutely the rate limiting step. 20:10 You may not have a provider in your area who’s trained in this. 20:13 So the Trade Association of America has been, you know, developing different training programs to get people certified in terms of trying to increase access to patients. In general, it’s about one visit per week, over eight weeks. So one of the downfalls is you have to be committed, you have to do it once a week, travel, time commitment, things like that. But again, there are going to be certain circumstances where CVI may not be at that. 20:35 You may not have the monitor here or maybe there’s some comorbidities of ADHD or anxiety that are really the more prominent symptom. 20:42 That kind of Buddhism to kind of really focusing on the monitoring, urge you developing the murder response. 20:48 What I would say though during the pandemic is that with the development of telemedicine, similar to what we’re doing today with the webinar, is really increased access for this. 20:57 And so, before, you know, we were really just doing in person CIT visits, but now we’re able to, With insurers get credit for telemedicine. So, we’re able to increase access to those in other parts of at least New York State who don’t have someone locally to do this. 21:12 Now, again, there’s no difficulties with telemedicine and licensing across different states but, you know, with the pandemic, in terms of all the difficulties that it’s really produced, the one kind of silver mining has been the advancement of telemedicine and potentially increase access for those patients with CIT. But, again, we have one leads to that. 21:31 So, obviously, it’s, you know, fine for me to say that CV IT is the number one first line treatment. But we want to look at the evidence, we want, what evidence is there to support what I’m saying. 21:41 So the first was a randomized clinical trial of 126 children, aged 9 to 17 with T S or chronic disorder. 21:49 They basically separated into two groups. one group at eight sessions of CIT over 10 weeks. The other was Control Group of Supportive Therapy and Education. 21:58 What they found was that the behavioral intervention with CIT, but is significantly greater decrease in what’s known as the yield robotics severity scale, or the YIG TSS, compared with the control group. 22:09 Now, overall, you know, not getting into the nitty gritty details of what the …, but overall, in movement disorders, in clinical trials, we have to have motor outcomes. For Parkinson’s disease is a U.p.d. RS Huntington’s disease, …, Soni, Twisters, …, Global Tech severity Scale, or the YIG TSS. And that is one of the major points, at least from an objective scale. 22:32 These common, in addition to the Y G TSS. 22:36 significant different seat down, that they’re significantly more children receiving behavioral intervention, married to those. And the control group were rated as either very much, are much improved. On the clinical. Global impression is improvements scale. 22:49 In the treatment group is 52.5%, versus the control group was only 18.5, in the P value was significant. And again, the P value, just in general, not to go into all by ourselves if everything is less than zero point zero five, is clinically significant. 23:02 Dropout rate was of our 9.5, you know, twelve out of one hundred twenty six. 23:07 The treatment gains for durable, in the sense, that after six months post treatment, they went back, and they found that 87% of the individuals continue to have positive response to the behavioral intervention. 23:20 So then they took it one step further, and they said, all right, so we’ve seen it done in children. Let’s see if this is the same and adults with tic disorders. So, they did a randomized controlled trial, 122 adults, age 16 to 69 with T S or chronic disorder against similar setup of eight sessions as CIT or supportive therapy over 10 weeks. And, again, what they found was that behavioral intervention with CIT resulted in significantly greater decrease on the Y G TSS compared with eight sessions of supportive therapy. 23:48 In addition, similar to the pediatric study is that more adults receiving the CIT were rated as being very much improved, or a much improved on the clinical global impression proven skills compare to supportive treatment. 24:01 And again, with the clinically significant dropout rate was a little bit higher, but not too much on, regardless of the treatment group. 24:08 So again, whether they were the CBOT or the support group, and the treatment games were, once again, durable with benefits, sustained six months of street. 24:18 So this is a good graphic representation regarding the CGI or the Clinical Global Improvement in Impression Improvement Scale, were in the child’s study. 52.5% of children found that they were either very much, are much improved. 24:31 Appeared on the 80% of the control group, version, need all study was 38.1% about. They were very much much improved compared to only 6.4% in the control group. 24:44 So, overall, bassa data behind CBOT, obviously, there’s much more that’s been done, but those were really the big studies to show us evidence base that can be very, very effective, not only for children but also for adults. 24:56 So, transitioning them in the sense that let’s say we’ve done CIT and ticks persists in our bothersome or maybe we don’t have access to CBT. What do we do next? 25:05 Well, at that point, it is medication management and there are different groups of medications and I’m gonna go over but, in my opinion, emotion and movement disorders, studied in the alpha two agonists are considered the first line treatment per bothersome text from a medication perspective. 25:20 In addition, the alpha two agonists can also be effective for ADHD symptoms. So if you have the presence of texts and ADHD and potentially you could get a 2 for 1 by using an alpha two, and now they are not as effective from a queer effectiveness standpoint for ADHD compared to the stimulants, but certainly they can be announcing an approach. 25:41 Potentially less potent dopamine blockers, but have less potential side effects. And that’s what I always look at, is what is the side effect profile when we’re looking at these medications? 25:52 In general, most of the common side effects related to the opportune moments are going to be sedation, or the set of hypotension, rated, cartier, dizziness, and constipation. 26:00 Because when we go back and look at the mechanism of action, it actually binds to the alpha two receptors in the CNS, which reduces simpatico memetic outflow. And therefore, in general actually lowers blood pressure and heart rate. That’s its primary mechanism. 26:13 But indirectly, it can be helpful for tips. 26:15 So the two alpha agonistes that are available that most of you may or may not be familiar with or quantity you want to see quantity and also known as … Press. 26:24 Maximum dose is about zero point four to zero point six milligrams, daily, dose, BYOD, can’t be is the extended release form, then there’s one for senior 10 X. Maximum dose is about four milligrams a day In tune is the extended release form. And in general, in my opinion, I tend to go with block to see more than quantity because it gets a little bit less than 80. 26:45 It has a little bit longer half-life and quantity. 26:48 So a lot of times you can get away with dosing daily at night in case of a closet sedation where we’ll continue to work through the day. 26:58 So, let’s say, at that point, you know, we’ve done Alpha two agonists. We’ve done this EBIT, I’m gonna get into another medication that you could consider in the middle before going to the dopamine blockers, but, I think it’s important to go through those nets. Because a lot of you are probably familiar with them. They may not be used as much. 27:15 But it’s really important to understand that The RL in terms of the mechanism, they block dopamine receptors and they have a little bit less search nurture receptor blockade. 27:25 In the past, maybe 15, 20, 25 years ago, most physicians, neurologists, psychiatrists were using them first line, over the years. We’ve really come to understand that they, they shouldn’t be used first line because we have more potential effective medications with the alpha two agonists and have potential less side effects. 27:43 There are two different groups of the anti-psychotics are anti dopaminergic, spurred neurotics. 27:49 There’s the typical and atypical and the difference is that the typical tend to have more dopamine receptor blockade. And that would include …, so in theory, the potential treatment for ticks would be a little bit more with more direct dopamine bucket. 28:03 But with that said, the potential side effects including extra pyramidal side effects, which we’ll go through are a little bit higher. 28:09 Then we have the atypical anti-psychotics, which have a little bit less affinity for dopamine receptors and a little bit more for the … receptors. So therefore, the risk of extra pyramidal side effects are probably a little bit less. there were still possible. 28:24 But with these medications, regardless of typical versus atypical, come with the different suicide effects that you have to be concerned about. 28:31 Sedation, metabolic syndrome, leaking, changes in blood pressure, cholesterol glucose. So, certainly, as a physician, if you’re starting these medications, you want to work with the pediatrician or with the other primary care provider if they’re an adult to make sure that they’re monitoring these things, because certainly, they can meet them. 28:49 You can get … this kind of restlessness ants in your pants. 28:52 Then, of course, the most concerning potential side effects are the extra pyramidal side effects, and that includes tardive syndromes, either as dyskinesia. Oral Buckle Dyskinesia is dystonia there are different tardive phenomenon. Those are the two most common. 29:06 Then, you can have parkinsonism, Maria Tremor, sona Stiffness, but again, a drug induced phenomenon. 29:13 Unfortunately, tardive syndromes can potentially be irreversible. 29:17 So, overall, when we think about using these medications, you want to be thoughtful, you want to be careful. 29:23 In general, if I have to, I will use the atypical … 29:28 such as Risperidone are Abilify compared to the technicals and held on femicide. You still may seem around you all the time that really, I would use held our premises. If somebody comes in on them and they’re stable, then I’ll continue it. 29:40 But again you don’t want to set it and forget it because the risk of the extra pyramidal side effects increase with dose duration in age. 29:49 So the longer you’re on it but the higher the dose, the higher the risk of developing the extra pyramidal side effects. And honestly, as an adult movement, sort of neurologists when I see patients but tic disorders that are on these, I will constantly re-assess the need for them. one in general takes improve with age, but also the risk of these side effects. You want to use lowest dose then improve symptoms to improve. 30:13 So, the next medication is topamax or to pyramid. So, this is actually one that I will potentially goto before escalating to the dopamine blockers. But I’ve already tried it out for two Agnus EBIT. 30:25 Mechanism of Action for those providers out there has likely multiple, including probiotic and hydrates inhibition and potentially potentiality. 30:34 There was 1 phase 3 study done in 29 children and adults, with G: As the mean age was 16 point, by the mean dose during that clinical trial was about 180 milligrams, an overall, based upon the end points that there was improvement in the outcomes were for tips. 30:49 But, what we saw in the study, which is what I see clinically, whether I’m using took them extra text or something else, is the side of apps that can cause cognitive going, sewing. They sometimes … costs, reduced appetite weight, loss, or seizures, which is known as tingling in the hands and feet. 31:06 In an adults. It can propagate kidney stones. So, if anyone has a story, can you stones, then? I won’t use it. 31:12 Again, I think it’s potentially a good option for those that have already tried CIT and or an alpha two Agnus before escalating. 31:23 Now, Tetra benzene, so, this is a medication that’s been around for awhile. I, in my opinion, in my clinical practice, I rarely ever use it, just because of the potential risk of side effects. And there’s other, better available options, but they are still out there. So I think it’s important to know, as well, again, in certain specific cases, could you use a shoe? 31:42 The Mechanism of action, instead, it’s a v-net to inhibitor or a particular … transport to. So basically, what’s happening is that a deeply, it’s pre synaptic formation of dopant, but the dopamine antagonists, newest, post synaptic, here it’s pre synaptic. 31:58 So what are some of the side effects? Parkinsonism? 32:01 Again, is something that you can see Asia, this restlessness bounce difficulty. You can get prolongation, cutesy C, which is part of the Heart Rhythm. 32:10 And, in addition, and unfortunately, has this black box warning of worsening depression, suicidality. 32:15 So, again, in my clinical opinion, I rarely ever use Tetra benzene, given the potential risks and side effects as well as or other available options but certainly in specific scenarios. 32:28 Now, Botox. So, I think this is potentially something that can be used in specific circumstances. It is definitely not the first line. And I’m gonna go through what I think the good scenarios are, potentially use. 32:40 So in terms of its mechanism, it reduces the release of patient advocacy coins, so as a result, it reduces the contraction of muscles. 32:48 In general, benefit is within the first two weeks of injections, it wears off after three months. So the good news is, if Side effects develop, which we’ll talk about, it’s completely reversible goes away. The bad news is that if it works, you gotta come back and get injections every three months. 33:04 Overall one of the good aspects about Botox is that it reduces the risk of systemic side effects. 33:09 What I mean, dizziness, lightheadedness, no balance problems, due to absorption systemically, the medication. 33:16 In the end, the side effects are really going dependent upon where the injections are going. So if it’s around the ice, double vision, blurred vision, if it’s in the neck, swelling of deeds of the wind weakness, it totally depends on where you’re injecting. That determines the site. 33:32 In my opinion, it’s sometimes helpful for simple motor texts that are not responding to typical medications and not an ancient approaches. I have about five PatientsLikeMe Botox sign in general. It’s more towards eye blinking and neck extension. Nodes are the two common scenarios that I’ll use it as their kind of simple texts, where I can go just around the eye muscles or with neck extension. I can focus on the sensors. Now, it becomes a little bit more difficult to move into more complex, where there’s, you know, co-ordinated multiple muscles involved in multiple directions. because then the risk of over weakness, you know, it’s a lot higher. So to me, if they’re more simple, kind of unidirectional movements, then you could potentially use botulinum toxin and actually had pretty good success. And those were, they have a lot of discomfort due to knock extension, or just with a repetitive, I blanking. I’ve had pretty good success with it, but again it’s within specific scenarios. 34:28 So obviously a hot topic in the field of neurology, not just within Tourette syndrome and tic disorders, but in the field of neurology in general, whether that’s Parkinson’s, seizures, or epilepsy is medical marijuana, and obviously I can never get through a pharmacologic lecture here without discussing medical marijuana. 34:45 So I thought I’d ended up on overall. Unfortunately there are just very limited well designed clinical trials with large sample size looking at compounds involving either THC and CBD and treating patients with tips. 34:59 The two that are out there are a little bit older and they were using THC, and I’m going to go through both of those. 35:05 The first was in 2002 in which they did a randomized double blind crossover study of just 12 adults with TS. So essentially what happened was they got a single dose of THC, either of these three milligram doses or placebo. They got one dose and then the rate or rate on that single day only. 35:25 They had a four week washout period and then after four weeks got the other either placebo or the THC. So again, they were just rating scale on one day after one belts, and what they found unfortunately was that there is no significant differences between the treatments in question clinician rated measures, the YIG TSS. 35:44 So then the following year, they did another randomized double blind placebo controlled study with 24 adults, alright so double the amount, again, 12 adults, is not a lot, and this time what they did was that they gave one dose over six weeks so they were giving every day OK, a little bit better study design. 36:00 Unfortunately seven patients dropped out so they ended up only having 17 analyze and again, unfortunately they found no significant difference between the THC in the placebo group on the Y G T S S. 36:11 So in the end from my perspective I don’t have the medical evidence in terms of supporting it but again I think we need more evidence right. That’s the whole point in terms of you know developing clinical trials to obtain the evidence. You know, it’s not that I’m absolutely against, per se. It’s just that, you know, when I make recommendations to patients, you know, we try to use evidence based medicine as much as possible. But, again, everyone is different, but that’s just my perspective. 36:37 So, that, basically, is looking at the different treatments that are available. And, again, a lot of those medications have been around for years, and years, and years. We really haven’t had something that’s been novel that’s developed over the last several years. So, I think it’s also important, exciting to think about, OK, what is on the horizon? Are there other treatment modalities out there that are being studied? And tips? or they have similar mechanism or the novel of different mechanisms. And that’s what I’m going to go through here at the end of the lecture. 37:04 The first set of medications are the newer V-net two inhibitors. 37:07 So, again, I mentioned that Tetra benzene is the beam at two inhibitor and there’s newer versions of it’s called … 37:16 and vau benzene are razor that have been developed and we’ll look at the data with regards to treatment tips. You capa Pam which is a D one Receptor. Antagonist is also being studied as well as ABS 14 31. So, those are the three newer sets of medications that we’re going to look at. 37:34 So, for the newer V-net two inhibitors let’s OK, do Tetra … first or our setup. 37:39 So, essentially, the difference for the providers out there: Tetra Magazine versus do Tetra …. That contains just deuterium atom. It’s a little bit heavier. So, increases the amount of time for metabolism, and therefore, could reduce peak side effects, such as fatigue samoans, get away with twice the dose on dosing instead of potentially …. 38:00 At this point, set or Tetra benzene is approved, for the treatment of Tardive dyskinesia and adults euphoria associated with Huntington’s disease. 38:08 Given that mechanistically or chemically, it’s very, very similar touch event unseen, unfortunately, still carries the same black box warning of worsening potential suicidality and depression. 38:20 Now, in terms of this medication in the clinical trials for texts, there was the artist one, which was a phase 2 and 3 study in the artist to phase three study, that in pediatric patients with moderate to severe ticks, and unfortunately that study was. 38:35 So then the next was looking at it doesn’t Val benzene or embrace: again, pretty similar in structure to Tetra … Senior do Tetra …. It’s approved for tardive dyskinesia, which dose once a day, which is better than 2 or 3 times a day. 38:48 In addition, in those clinical trials of tardive dyskinesia, it did not show worsening of underlying mood disorders, whereas with do Tetra … has a black box one. 38:59 So, they did do a study in texts called T four is a phase two study in both adult and pediatric patients for ticks. But unfortunately, both of those studies were negative. 39:10 So, as of now, with regards to the newer … two inhibitors, unfortunately, both of them were negative treatment. Objects. You will see some providers out there prescribing it. I’ve never done it, You know, for several reasons. one, they were negative, and the trials, and two, they’re pretty expensive. There are about 60 to $70,000 a year out of pocket. 39:31 In addition, there’s a specific treatment for me up to fill out and say the diagnosis. 39:36 And it’s really only for tardive, so I’m not sure how some of the providers get around that, But overall, unfortunately, these newer medications were negative. 39:47 So let’s go to … so this is a novel medication in regards to mechanism of action. And then it has stopped mean one receptor blockade in terms of the neuroleptics, or the anti-psychotics. They were more dopamine two receptor blockade. So this is novel. 40:02 Recently there was a Phase two B study that was multi-center, placebo controlled, double blind, randomized real-world group. Again, this is the type of clinical trial that you want looking at, 149 patients, not too bad pediatric. 40:14 Patients between 680, They were randomized to copper pan or matching placebo for 12 weeks. Basically, there’s a four week period, tight trading on, getting up on the dose, and then eight weeks of maintenance. 40:26 And what they found was that the … had a significant effect from baseline to week 12, on the Y G T S S total to explore, including both motor and vocal tips for the P value of zero point zero one one, which is less than zero point zero five, So statistically significant. 40:41 In addition, the main change from Baseline Week 12 and that clinical global impression of Tourette’s Syndrome severity score was significant, as well as the global score on the Y G TSS. Again, not to get into the nitty gritty. The total tick score is basically the score of the motor and vocal tics, whereas the global score is the motor vocal. 40:59 And then the impact on day-to-day treatment and related adverse events occurred in 34% of patients. I think of a piano, and 21% in the cboe. 41:08 Most common were headache, insomnia, fatigue, somnolence and restlessness But, again, they didn’t see any evidence of the …. Syndromes are perkinson ISM, which are the concerned with the neuro optics and the … receptor blockade. 41:21 There were no weight gain or other metabolic events. The main study drawbacks are that it was a smaller sample size, but again, 149 is not too bad and the duration of treatment was a little bit short of eight weeks, right? 41:32 It’s always great to potentially have as long of a treatment study as you can to show durability. 41:36 Right now, they’re currently in process for a phase three study in the future, So I think to me, in my opinion, this has potential promise. The U of R may become a site we’ll see on. They reached out to us, whether we’re interested or not. But again, there, that’s a long way, in terms of actually accepting as a site, and then going into the Phase three, but it is in the near future. 41:57 The last is a B X 14, 31. So this was also had a novel mechanism of action, It’s a … inhibitor. 42:05 So essentially, by doing that inhibition, you modulate the endocannabinoid system selectively in areas where circuits are activated. So this is not an exogenous and endogenous. 42:17 So, there’s a phase two study recently, which was neat. We multi-center randomized placebo controlled double blind clinical trial at two doses in 49 adults with moderate to severe … followed by a four week openly. 42:29 And what they found was that the Y G TSS Total Score improved in both the Active and Siebel Group. 42:35 Interestingly, the main treatment difference at Week eight, paper the placebo group. And, therefore, it may be that study endpoints. So overall, conclusion, is that there’s no evidence of DAB X 14, 31 head efficacy in suppressing text. 42:49 So again, that’s why, you know, it’s important, at least from a medical perspective, to do these clinical trials, because we know that the seebeck effect is there, and that patients do improve, But we need to see that it’s a statistically significant difference between them. 43:04 So overall, in terms of summary for tonight, it’s important to understand that Tourette syndrome is a complex neuropsychiatric condition of both not only motor and vocal texts, but also comorbidities of ADHD, Anxiety, depression, OCD. 43:17 In general, ticks tend to remain stable and or improve with age. But certainly, there are those that can continue to have bothersome takes into adulthood, for which I see. 43:27 So you can actually, comorbidities are common in tend to persist with age and in general are most impairing from a day to day life. 43:34 But not always you want to treat the most bothersome symptom first, Whether that is the ticks, whether that’s ADHD, anxiety, or depression. 43:42 Overall, you want to consider both the non pharmacologic in CIT or pharmacological intervention for bothersome tips. And, again, the word bothersome to me Painful? I mean, the social emotional impact on activities you really want to try to find out with the patient. 43:56 You also want to assess and treat the comorbidities. 44:00 So overall, that is the conclusion of my lecture. Here are the references. And before the lecture ends, I always like to give a thanks to my family, my wife, and children, for allowing me, giving me the chance to be able to provide these lectures to everyone. This is actually Austin Barcelona and in April. We went to a soccer game, had a really great. 44:20 And that concludes the lecture and I’m happy to take questions. 44:27 Thank you. so, so much, Kate, you, everything that you said was amazing. I love the picture at the end. Your kiddos are so adorable. We have quite a lot of questions. So, I’m just going to start shooting them out to you. Are you ready? 44:43 Sure. 44:44 OK, So the first question we have is, how do you support an individual with Tourette syndrome in a school setting? 44:52 Yeah. So that’s a really great question. Um, you know, being the provider, you have a really important role. 44:58 And a lot of times, that could be just a letter stating what the diagnoses are or being involved in actually the discussion of educational plans. 45:06 It is not uncommon where I will actually take time out of my schedule to meet with the counselor, the school and the teachers that’s already preset to discuss how the symptoms are an Apple. So, I think, really, as a provider, you have a unique opportunity to advocate for your patients. And, again, I don’t do this essay with every single patient, but they’re certainly those are struggling. 45:25 Whether it is the text of the comorbidities Going the extra effort and supporting them, whether it is part of a school meaning, no education plan can go a long way. 45:37 Thank you so much. So our next question is, my daughter is suffering from pain politics. What to do looking for medical marijuana, do you think this can help her as she’s 21? 45:49 Yeah, Again, so, so great question. So when we talk about bothersome texts, you know, painful ticks is certainly a subset, and you can see that it’s not with everyone, but you can certainly see it would say, is my true. In general, the treatment approach for painful text is pretty similar to not being equal to X in the sense that retreat, you know, the ticks that are bothersome. 46:07 But if they’re painful specifically, EBIT, in my opinion, can be pretty effective. …, you can try to focus on that one specific tick that is very bothersome. It’s causing pain to try to develop a competing motor response. So I had a couple of patients. For example, one was cheap biting. They kept having cheap oil and cheap fighting, and they ended up going to eat multiple, multiple times. Or they had someone that had a lot of abdominal tension is causing pressure, and he was having some five in the eye. And so they actually did pretty well with CIT because we really focus on that one specific tick that was bothersome and uncomfortable to develop the motor response. 46:43 Other times, like with Botox, if there is like a net extension tick that’s bothersome and painful, that can be helpful. But again, really just looking at the different treatment wrote down, these are going to be pretty similar or painful ticks or not. 46:58 Then another question we have is, and this is more towards the beginning of your presentation, they had said, why is having non rhythmic text important to a diagnosis? And does it have to do with having complex versus simple techniques? 47:16 Yeah. So it gets back to phenomenology because not all movements or texts, right? In kids do interesting movement. 47:21 So you really got to define what they are and by definition, ticks are non written, working done whereas more rhythmic movements could be tremors be stereo apiece. 47:31 So again, understanding …, whether it looks like a rhythm versus non rhythmic is important in terms of understanding the phenomenology, which then dictates where the diagnosis is going to be. 47:42 So again, you can have a lot of things that are back to back that are not unwritten. 47:46 Like mindfulness is also about it. 47:48 We have a lot of my phone, is kind of backed up more, written it, but there are discrete, individual movements. So again, that’s how you really help differentiate to define what the movement is first, which then dictates what your diagnosis. 48:03 Perfect. And then, if a child starts showing signs of text at a very young age, does that mean that they are more susceptible to having Tourette syndrome or a tech disorder versus it going away and it just being like one tech for a short period of time in childhood? 48:21 So yeah, let me so is the question at the age of onset of ticks? Does that help differentiate whether it’s going to be a provisional tick disorder versus more of a chronic disorder? Again, I don’t know if the person can respond, but that’s, I think, what they’re asking, I believe so. Yeah, I don’t know if we have data in terms of saying the age of onset of the tick determines whether or not it will be President for less than a year or more per year. No, again, so, I don’t know if we have the data on that. In general, tends to be 5 to 8. But I certainly have kids have age of onset at three. And, again, age of onset, per se, doesn’t necessarily dictate severity down the road, right, if they’re there for more than a year, regardless of tic disorders. 48:59 But it doesn’t necessarily dictate severity, per se. 49:03 At least, in, at least, in the COCs that we have in my clinical experience, because certainly, you could have the development of ticks at 9 10, And they can still be pretty significant. 49:12 Had the development at three, but not necessarily be senior. 49:16 And then, our next question is, when you were talking about frequently changing techs, did you mean different, having different motor and vocal techs? 49:29 Yes, yes. So again, you can start with an eye blinking, and then it goes to zero. And then it goes to nose rank, rank on the neck. And then you throw clearing, and later on it can be sniffing. So a lot of times they come and go, they may be out there at one point. But sun come to the forefront, then the receipt. others come to the forefront and then proceed. So it is very common for motor and vocal tics to change. You know, first, again, patients or parents really goes. nine blinky lights a couple of months. He started doing this weird sound, and then it started being head nods, so it is very calm, that is classic cortex to change and more over time. 50:05 Oh, and then. 50:11 So, Tourette diagnoses commonly include ADHD, medications such as Adderall help ADHD seem to flare up tech activity. 50:21 Are stimulant medications like Adderall Clinically proven to be problematic for tech control? 50:28 That is an excellent question. I’m glad that brought it up because that is another one of the common questions that I get and I think it’s helpful that I help try to clarify based upon the data. 50:36 Unfortunately, over the years there has been a misnomer that stimulants such as Adderall Methylphenidate whatever may worsen or produce the onset of texts. We actually have clinical data in a meta analysis from 20 15 in the Journal of Psychiatry that showed that wasn’t the case. And actually, there was one specific trial that we had. 50:56 Where we had one with takes an ADHD where they got one for our quantity stimulants quantity. Want the senior placebo OK. All three of those treatment groups. 51:08 Whether it was quantity stimulant are both all improved So, overall, based upon our meta analysis from 20 15. It did not show that ticks were Smith stimulant use with. 51:20 That said, Again, there are certainly individuals that come to me after starting esteem and say, their chicks worse. Again, you know. Because we’re talking about generalizations based on what the studies show it to say. Absolutely. 51:33 I guess my point is based upon what the data is available, if someone has text and pretty significant ADHD. And the ADHD is very, very I will not be afraid to try stimulant to see if we can improve the ADHD if it happens to … for their perspective, insurable rethink. 51:50 But I don’t be afraid to use a stimulant with the presence of tips. 51:54 OK, that’s a great. That really was a great question and answer. Thank you so much. And addition, which we have more and more questions, Island, and I love it. 52:07 I do my best. 52:09 Oh, no, you’re doing great. 52:10 No worries So another person asked, I’m aware of two CBOT online programs. Do you think they’re worth having my child go to? 52:20 Yes, I do. And again, it comes down to access. You notice, again, in theory, having an in person provider is always the best, but you don’t have access to that at times. So, there are several online modules, one being …. I’m not sure The other one that they may be referring to, but there are certainly are several that. I would definitely recommend that, because at least it’s something better than not providing, You know. The thing with the online is that they’re modules. They’re tape, they’re not live, but again, I definitely even before the pandemic, that’s actually what I was recommending to people that didn’t have access to in person CIT now that telemedicine become a little bit better. But I still definitely recommended. But, again, it actually cost money financially. So, you have to consider those options, but I think they are helpful. Yes. 53:04 OK, that’s great to know. Thank you. So another question we have is, are there any treatment success’s using mindfulness practice? 53:13 Yeah, I think, so, you know, certainly not everything’s medication. That’s also what I want to be cleared ready in, that, you know, we have different tools to treat text. But certainly outside of CVI team, mindfulness, things like that can certainly be helpful. Because a lot of times in general, he takes increase when anxious nervous very tense. And vice versa, right? If you’re having a lot of text, you’re going to be pretty anxious. If you have an audit anxiousness, you’re going to have a lot of text. So I think using mindfulness and other things like that certainly could be an added benefit for patients. 53:42 OK, and then someone mentioned, what are your views on? New pulse is a wearable technology in which the you wear device around your wrist and it applies a mild electrical stimulation, and rhythmic patterns to help reduce the frequency intensity and the urge to tick. 54:03 I don’t know, actually, I’m not as familiar with that. Just being honest and transparent, I’m not as familiar with that. So I don’t really have a comment that I’m happy. You know I’ll get I can certainly look into that. Yeah, leasing a mood disorder society is not something that’s truly wearing at everyone’s doing. I just, I don’t know much about it, so don’t have a lot of common, unfortunately, But I can certainly look into it. 54:23 Yeah, no, No worries whatsoever. 54:25 It’s on us, said, do you see a relationship between Strep throat, and Tourette onset? 54:34 I know, right? 54:36 Yeah, I guess I can never avoid that question, Right? Yeah, so, you know, a little bit outside the scope anything of today, but listen, so, you know, certainly, I think people are referring to pandas pans and … syndrome and neuropsychiatric development and so you know, I just want to acknowledge that you know, it’s, it’s controversial topic. It’s very emotional topic. 54:54 And so least from my perspective, since the question was asked for my medical opinion, you know, I don’t see any evidence relating the, you know, development abstract. And then the onset of ticks are in our psychiatric condition, OK? That’s just my opinion. in general, there was a recent meta analysis that was done in the journal Pediatrics by John Me harvesting here, and then when I can’t remember the third author, that looked through all the data and didn’t show clear. 55:22 So, I guess, in my opinion, you know, certainly if they’re strap causing Strep throat can eat, right? Tree. but if it’s the presence of strep and text only. 55:31 I don’t recommend to treat with antibiotics or defending their feet again. It’s controversial, it’s very emotional topic I totally understand. 55:38 And we’ll kind of leave it at that, because, again, we could have a whole lecture on that for sure. That’s my thing. 55:44 Well, thank you so much for that for answering that question. I appreciate it. 55:48 So, with a few more minutes, another question that just came in is, is there any research being done with … as a comorbidity to Tourette syndrome, this individuals’ child, their tax increase significantly with certain a sound triggers or things having to do with … and … 56:09 EBIT did not help in those situations. Yeah. So I don’t I’m not aware of any current active research that is looking at …, specifically in the relationship or worsening of tick assessment. So not that I’m aware of, specifically in terms of ongoing. Then again, there’s a lot of different research. Both medication out right then in these correlation Not just looking at treatment approach but comorbidities, association, epidemiology, prevalence. so not that I’m aware of. 56:37 OK, gotcha. 56:38 And then what are your thoughts related to I’m totally going a bunch of this so bear with me. 56:48 Blue, fin, bluefin. I’ve seen, yeah. Yeah, so that is the yet. But then as an end, or lyrica, being used for Tourette Treatment. 57:00 OK, so with regards the flu vaccine, that actually is one of the typical anti-psychotics. I didn’t put it up there. You know, held on femicide are the two most common but the vanishing had been commonly use over the years. You know, in terms of my opinion, again as part of that, typical anti-psychotic Regiment in terms of potential risks and side effects Extra pyramidal side effects start, I’ve syndromes. Parkinson is, um, you know, I really stay away, in my opinion from the Tacoma anti-psychotics. I feel like there’s a lot of other better options in terms of CIT of two agonists topamax potentially help if we have to I personally choose the atypical in terms of risperidone and develop I first. So I actually have never used to Tennessee. I have 1 or 2 people that are on or app, which are again, part of that, typical anti-psychotic, Those patients have been on it and they came to me on it, and they’re very stable. So I kept it, but I have not had a patient with … MC, but I know certainly in the past, it had been used before the development of these other medications. 57:57 OK, that’s good to know. Another question we have is do you have any patients that have ticks that have gotten worse in adulthood? 58:06 Yeah, for sure. 58:08 For sure. Again, you know what I talked about is just, you know, generalizations regarding what we have. 58:13 It doesn’t encompass everything, right? I absolutely have a subset of individuals for ticks, you know, maybe for awhile over well controlled. And then something happened in the tick’s kind of our master. You guys see that. 58:24 You know, and I, in the treatment approach, is pretty similar, you know, in terms of, you know, trying to cebit, try to do medications, but I definitely have those individuals, for whatever reason, where the … works in adulthood. For sure. 58:39 I know that for me, my texts have gotten worse and adulthood in Indiana and I definitely see that, and I am actively treating them, and then what I would say is I’ve had success in those individuals who had had re-emergence worsening of text and adulthood. Nobody that said there are some that have instances of text, no matter what I’ve done. 58:58 Again, that’s a small percentage, but it does happen. 59:02 Perfect, well, thank you. And then I’m just gonna have a whole bunch more questions, but I’m gonna ask one more X, I know we’re running out of time, So, I have. 59:14 While it feels extreme, I’ve heard that there has been more talk about deep brain stimulation, What are your thoughts? Yeah, Yeah, so, again, another very, very excellent question. So, DDS, or deep brain stimulation, is used in different movement disorders, are already that are approved for Parkinson’s Disease, Essential Tremor, dystonia, tardive Dyskinesia. 59:33 In terms of Tourette Syndrome, they are certainly individuals that have gotten on a very, very case by case, circumstance, OK. And at the end, in 20 19, you know, really, they have provided some degree of guidance about that, You know, really, you’ve had to exhaust. All the different mitigation options. Ticks are very impairing quality of life. 59:55 And also, very importantly, the treatment. The comorbidities are well controlled the anxiety, depression. Oh, so you can, certainly. There’s a lot of overlap there. 1:00:02 I mean, certainly on case by case circumstance DBS has been done we haven’t ever done at U of R. But there are different institutions around the country and in the world that have done it. And there’s a DBS registry in, for patients with Tourette syndrome. 1:00:16 What I would say is, you want to be a little careful as well because in general, especially in the younger age, you know where, like I said in general just kind of creep up in severity and then in general, improve with age. So you want to be careful about doing a major neurosurgical intervention at a younger child. 1:00:33 When in general, ticks improve with age. 1:00:36 So, again, that’s just my, my point is just, you want to be very, very careful that you don’t want to do a major intervention when, in general, symptoms will improve on their own, but not always, but it is case by case, and it is done. We have never done went too far. 1:00:51 OK, thank you so much, so, I know it’s 8 31 right now. If you guys need to hop off, feel free, we are going to stay on. If that’s OK with you, doctor Morrison, to go through the remainder of questions I do have a few more. for those that do need to log off. Our next presentation will be on What does it mean to have ADHD by doctor Eric … on Wednesday, December seventh at 7 30 PM, E S T The webinar. Blog is now open and available for the next seven days. 1:01:25 On the … website, for any additional questions that were not covered tonight, that website is WWW dot N J C T S dot org. Also, a archived recording of tonight’s webinar will be posted to the website for those that need to log off. I hope you have a wonderful evening and thank you so, so much for attending. For those that are still with us, I’m going to go through the other questions And Pete, thank you so much for staying on a little bit longer with us. How many more are there? 1:01:56 Just from, I believe there’s like 5 or 6 me. 1:02:01 Finally, I won’t get through as much as we can just in time, You know, Of course. Of course, and if you need to hop off, just let me know. 1:02:09 I don’t want to Yeah, I can answer. Certainly, what other ones are left? 1:02:12 Sure, OK, thank you so much, so all we have. 1:02:21 OK, bear with me. 1:02:24 What are your thoughts on lyrica being used as a troll’s? Yes, I’m sorry, I didn’t. So I apologize because I was there to medication is there. 1:02:34 So from a clinical standpoint, I don’t think there’s a lot of data using their car for the treatment of ticks. 1:02:42 A lot of times there is used for your different pain, you know, different syndromes, as well as can be helpful with anti-depressant, things like that. 1:02:49 So, again, sometimes, if there’s an overlying pain, discomfort, mood, it can be helpful. But I’ve never use it specifically to target ticks in my opinion. And I don’t think there’s a lot of literature per se out there. 1:03:03 OK, and then I have another one that says, Do you see patients for a console or a second opinion by telehealth? 1:03:12 Yeah, so great question. So obviously, I do see many second opinion, but typically not. by Telehealth, you know, to me, when news a new patient second opinion in person is the way to go. 1:03:22 Because I can do a full neurologic exam, you know, testing tone, strength valence, skate. you know, certainly there are roles for telemedicine, especially follow ups, and a lot of times the exams are normal, in general, in patients with texts, But no, I really see your way from new patient consults via telemedicine because I really feel there’s value to the in person exam initially. 1:03:44 The second aspect of that is that being licensed in New York State, I can only do telehealth in patients that are in New York State at the time of the visit. 1:03:52 So, if the person’s in Pennsylvania, Florida, whatever, I can’t do across the lines. So, there are regulation of licensing issues. 1:04:01 OK, and thank you so much, I know that we’ve talked about that as well, and then I’m just going to ask one more. The rest of these won’t be on the website. 1:04:12 So the last one will be, What would be the perfect dose of … for a 10 year old child? This person’s child is on one milligram and it’s stopped working. 1:04:29 Yep. So, I’ve been going to be finding and it’s based fun, you know, what, what their blood pressure and heart rate is. You know, you want to be a little bit careful not to drop it too much, but I say maximum dose is for in general. But I think if they’re tolerating well in the ticks, you have persisted or maybe those initial improvement. they continued on. And she’s going to 1.5, or even to be the next step, and I always do a stage wise. 1:04:53 OK, so, I know that we had so many questions. Thank you. So, so, so much, doctor Morrison and everybody for joining our webinar tonight on Treatment Approaches to Help Manage bothersome Techs. There is an Exit survey. Please take a moment to complete. The webinar blog is now open and available for the next seven days on the … website. For any additional questions that were not covered tonight, that website is WWW dot … JS dot org. Also, once again, an archived recording of tonight’s webinar will be posted to our website. Like I said before, our next presentation will be on What Does it mean to have ADHD by doctor Eric Dabbler on Wednesday, December seventh at 7 30 PM, Eastern Standard Time. This ends tonight’s webinar. Thank you once again so, so much, Doctor Morris, and for your presentation. And thank you, everyone, for attending. We hope that you have a wonderful night.