Functional movement disorders: Successful treatment with a physical therapy rehabilitation protocol

Abstract

Background

Functional (“psychogenic”) gait and other movement disorders have proven very difficult to treat.

Objectives

Describe the Mayo Clinic functional movement disorder motor-reprogramming protocol conducted in the Department of Physical Medicine and Rehabilitation (PMR), and assess short-term and long-term outcomes.

Design

Historical-cohort-study assessing non-randomized PMR intervention.

Setting

Tertiary care center.

Patients

Interventional group: 60 consecutive patients with a chronic functional movement disorder that underwent the PMR protocol between January 2005 and December 2008. Control group: age- and sex-matched patients with treatment-as-usual (n = 60).

Interventions

An outpatient, one-week intensive rehabilitation program based on the concept of motor-reprogramming following a comprehensive diagnostic neurological evaluation, including psychiatric/psychological assessment.

Main outcome measures

Improvement of the movement disorder by the end of the week-long program (patient- and physician-rated), plus the long-term outcome (patient-rated).

Results

Patient demographics: median symptom duration, 17 months (range, 1–276); female predominance (76.7%); mean age 45 years (range, 17–79). Physician-rated outcomes after the one-week treatment program documented 73.5% were markedly improved, nearly normal or in remission, similar to the patient-ratings (68.8%). Long-term treatment outcomes (patient-rated; median follow-up, 25 months) revealed 60.4% were markedly improved or almost completely normal/in remission, compared to 21.9% of controls (p < 0.001).

Conclusions

Short-term and long-term successful outcomes were documented in the treatment of patients with functional movement disorders by a rehabilitative, goal-oriented program with intense physical and occupational therapy. The rapid benefit, which was sustained in most patients, suggests substantial efficacy that should be further assessed in a prospective, controlled, clinical trial.

Introduction

Functional movement disorders (FMD) are characterized by abnormal motor behaviors that are inconsistent with an organic etiology. These may resemble organic tremor, dystonia, other hyperkinetic conditions, gait disorders, paresis or combinations. These may account for 3% [1] to 15% [2] of patients seen by neurology movement disorder specialists but are also common in general neurology clinics.

These conditions are often categorized as “psychogenic”, and this term is sometimes used interchangeably with “functional”. The lay-dictionary defines “psychogenic” as, “originating in the mind or in mental or emotional conflict.” [3]. This obviously implies a primary psychological cause and this may not be strictly applicable to many patients. Moreover, telling patients their life-altering disorder is “psychogenic,” with all the implications, may sabotage the working relationship with the clinician. In this manuscript, we will avoid that term, preferring “functional”.

Once diagnosed, FMD present an enormous therapeutic challenge. Prognosis is often characterized as poor, with most patients failing to substantially improve, especially among those with symptoms persistent beyond one year [4], [5], [6]. Even among series that are more optimistic, substantial numbers of patients have persistent disability [2].

With the notoriety accorded similar disorders by Freud more than a century ago [7], therapeutic strategies have focused especially on psychiatric/psychological interventions. In the current era, psychotherapy, antidepressant and other psychoactive medications are typically an early treatment approach [8], [9], [10]. Although many publications have attested to the benefits of psychotherapeutic and other psychological/psychiatric strategies, our experience has not been as gratifying, and the pessimistic outcomes from movement clinics are consistent with that perception [4], [5], [6].

Physical therapy has also been advocated for such patients, although specific strategies have been left to individual treating therapists [11]. In our experience many of these patients have already undergone physical therapy, but failed to substantially benefit; thus, generic physical therapy in the absence of a specific treatment-program has not been successful.

In fact, there is no consensus about treatment of FMD [12]. Clinicians generally find this to be a very unsatisfying aspect of their practice, with frustration among both patients and physicians. This was our collective experience for many years; we could diagnose, but not effectively treat.

A number of years ago, we recognized that functional speech/voice disorders were highly responsive to a behavioral motor re-programming approach by our Mayo Speech-Language Pathology colleagues [13], [14]. In fact, a parallel approach was being used successfully, but inconsistently in our Physical Medicine and Rehabilitation (PMR) Department as treatment for FMD. Encouraged by these outcomes, we developed a more structured motor-reprogramming treatment protocol for FMD patients implemented in the PMR Department.

Such motor-reprogramming in the context of physical medicine has been used for treatment of FMD with limited precedents [15], [16]. The approach involves specifically focusing on the aberrant movements and postures, breaking these down into the individual motor components and gradually reconstructing more normal motor patterns. With this strategy, appropriate motor pattens are reinforced and inappropriate movements are ignored (extinguished). By gradually rebuilding or re-shaping motor movements, more normal pattens can be achieved. Our initial treatment protocol arbitrarily confined this to one intensive week of twice-daily physical and occupational therapy, after the physiatrist had initially designed the therapy program for that patient. Our initial experience suggested that one week was sufficient. This has been utilized as the primary therapeutic strategy for the treatment of FMD patients diagnosed in our movement disorders clinic since 2005.

We now describe our experience with the first 60 consecutive patients who were diagnosed with an FMD in our Neurology Department and subsequently treated with this approach. This was exclusively designed as a therapeutic PMR protocol for the benefit of our patients, and we had no a-priori plan to formally study/report the outcomes. The initial follow-up called for reassessment only at the end of the treatment week. As substantial efficacy became apparent, we elected to better assess outcomes, which included adding phone- and letter-follow-up to tabulate longer-term responses. For comparison we also included a control-group of patients who were similarly diagnosed, but not treated with this approach.