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The Effectiveness of Brief Multidisciplinary Outpatient Treatment for Functional Neurological Disorder: A Pilot Study
Abstract
Background
Functional neurological disorder (FND) is a common, costly, and debilitating condition with a guarded prognosis. Limited evidence supports providers about which treatment approaches to undertake. Evidence-based care for FND is urgently needed to improve patient outcomes. The objective of this study was to evaluate functional and psychological outcomes associated with a novel outpatient multidisciplinary treatment program for adults with FND.
Methods
Participants included 18 sequentially referred adults who attended the five-day FND treatment program, including those who completed ( N = 13) and who were available for follow-up at six months ( N = 9). Intervention included assessment and up to five consecutive days of treatment including two group-administered psychoeducation sessions. Primary measures included the Timed Up and Go (TUG), the EQ-5D-5L index score, and the visual analogue scale (VAS), and the Canadian Occupational Performance Measure (COPM). Secondary outcomes included Battery for Health Improvement-2 (BHI-2) Depression and Anxiety subscales.
Results
Significant improvement observed on COPM performance and COPM satisfaction; EQ-5D-5L index (as well as VAS) and TUG (p = < 0.05) immediately following five-day treatment. Improvement was gained at six months for BHI-2 Depression and Anxiety, and maintained for COPM performance, COPM satisfaction, EQ-5D-5L index, EQ-5D-5L VAS, and TUG.
Conclusions
The findings of this preliminary work suggest that multidisciplinary treatment for FND has a positive impact on psychological and physical outcomes with results sustained up to six months.
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Background:
Functional neurological disorder (FND) is a disabling condition which has poor prognosis without treatment. This study aimed to evaluate the effectiveness of an outpatient integrated multidisciplinary intervention for the condition.
Objectives:
This study aimed to assess the outcomes of a pilot integrated multidisciplinary treatment clinic for FND with motor symptoms.
Methods:
Patients were seen simultaneously by a neurology doctor, a physiotherapist, a clinical psychologist, and sometimes a psychiatrist. The primary endpoint was change in quality of life measured by Short Form-36 (SF-36). Secondary outcomes were change in work and social participation measured by the Work and Social Adjustment Scale (WSAS), ability to participate in full-time or part-time employment, self-rated understanding of FND, and self-rated agreement with the diagnosis of FND. Over the year, 13 patients were recruited to the clinic, and 11 agreed to participate in the outcome study.
Results:
Statistically significant improvements in quality of life were seen across seven out of eight domains of the SF-36, with improvements in individual domains of between 23 and 39 points (of a possible 100). Mean Work and Social Adjustment Scale score halved from 26 to 13 (worst possible is 40). Of the 12 patients treated, one began to work again after complete unemployment, and two who had been working reduced hours due to disability resumed full time work. No patients had worsened occupational status.
Conclusions:
This intervention is associated with substantial improvements in quality of life and function, and may be more amenable to delivery at non-specialist centers than other described interventions for FND.
Functional neurological disorder (FND) represent a common disorder with significant socio-economic impact. In this context and alongside recent new neuroscientific insights, FND attracts a growing interest both in clinical practice and academic activities. New international recommendation and expert opinions suggest that therapy of FND should be a tailored multidisciplinary management involving the neurologist, the physiotherapist, and in most cases the psychotherapist/psychiatrist. A first decisive step is the establishment of a definitive diagnosis, based on the presence of clinical positive signs during neurological assessment together with a clear communication and explanation of the diagnosis by the neurologist. A second important step is based on individual therapeutic sessions, involving different disciplines (neurology and psychotherapy or neurology and physiotherapy). Comorbidities, such as pain or fatigue and psychiatric comorbidities (anxiety, depression, dissociation etc.) should be carefully evaluated, as they need an individualized treatment path. New FND clinics have been created worldwide over the last decades to offer such multidisciplinary settings and this article will present the experience of a first Swiss FND clinic created in 2016. The aim is to highlight in the form of a narrative review the current literature supporting the usefulness and importance of FND clinics, by reviewing the latest evidence on multidisciplinary interventions in FND.
Patients with a functional neurological disorder can be difficult to engage in treatment. The reasons for this are complex and may be related to physician, patient and health care system issues. Providers contribute to difficulties in treatment engagement by giving confusing explanations for the patient symptoms, stigmatizing patients, and not allowing patients time to voice their questions and concerns. Patient factors include a lack of engagement after an explanation of the diagnosis, resistance to treatment, family/work dynamics and prior negative experiences with the health care system. The scarcity of providers skilled in the treatment of functional neurological disorder is yet another hurdle. This article will define these barriers and discuss good clinical practices to help improve outcomes by tackling those challenges and discuss why for many patients an integrated care team approach is needed.
We present a practical overview of functional neurological disorder (FND), its epidemiology, assessment and diagnosis, diagnostic pitfalls, treatment, aetiology and mechanism. We present an update on functional limb weakness, tremor, dystonia and other abnormal movements, dissociative seizures, functional cognitive symptoms and urinary retention, and 'scan-negative' cauda equina syndrome. The diagnosis of FND should rest on clear positive evidence, typically from a combination of physical signs on examination or the nature of seizures. In treatment of FND, clear communication of the diagnosis and the involvement of the multidisciplinary team is beneficial. We recommend that patients with FND are referred to specialists with expertise in neurological diagnosis. FND is a common presentation in emergency and acute medical settings and there are many practical elements to making a positive diagnosis and communication which are useful for all physicians to be familiar with.
Objective
Responsiveness to direct verbal suggestions (suggestibility) has long been hypothesised to represent a predisposing factor for functional neurological disorder (FND) but previous research has yielded conflicting results. The aim of this study was to quantitatively evaluate whether patients with FND display elevated suggestibility relative to controls via meta-analysis.
Methods
Four electronic databases were searched in November 2019, with the search updated in April 2020, for original studies assessing suggestibility using standardised behavioural scales or suggestive symptom induction protocols in patients with FND (including somatisation disorder) and controls. The meta-analysis followed Cochrane, Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analyses Of Observational Studies in Epidemiology (MOOSE) guidelines. Data extraction and study quality coding were performed by two independent reviewers. Standardised suggestibility scores and responsiveness to symptom induction protocols were used to calculate standardised mean differences (SMDs) between groups.
Results
Of 26 643 search results, 19 articles presenting 11 standardised suggestibility data sets (FND: n=316; control: n=360) and 11 symptom suggestibility data sets (FND: n=1285; control: n=1409) were included in random-effect meta-analyses. Meta-analyses revealed that patients with FND displayed greater suggestibility than controls on standardised behavioural scales (SMD, 0.48 (95% C, 0.15 to 0.81)) and greater responsiveness to suggestive symptom induction (SMD, 1.39 (95% CI 0.92 to 1.86)). Moderation analyses presented mixed evidence regarding the extent to which effect sizes covaried with methodological differences across studies. No evidence of publication bias was found.
Conclusions
These results corroborate the hypothesis that FND is characterised by heightened responsiveness to verbal suggestion. Atypical suggestibility may confer risk for FND and be a cognitive marker that can inform diagnosis and treatment of this condition.
Purpose
Although the EQ-5D has a long history of use in a wide range of populations, the newer five-level version (EQ-5D-5L) has not yet had such extensive experience. This systematic review summarizes the available published scientific evidence on the psychometric properties of the EQ-5D-5L.
Methods
Pre-determined key words and exclusion criteria were used to systematically search publications from 2011 to 2019. Information on study characteristics and psychometric properties were extracted: specifically, EQ-5D-5L distribution (including ceiling and floor), missing values, reliability (test–retest), validity (convergent, known-groups, discriminate) and responsiveness (distribution, anchor-based). EQ-5D-5L index value means, ceiling and correlation coefficients (convergent validity) were pooled across the studies using random-effects models.
Results
Of the 889 identified publications, 99 were included for review, representing 32 countries. Musculoskeletal/orthopedic problems and cancer (n = 8 each) were most often studied. Most papers found missing values (17 of 17 papers) and floor effects (43 of 48 papers) to be unproblematic. While the index was found to be reliable (9 of 9 papers), individual dimensions exhibited instability over time. Index values and dimensions demonstrated moderate to strong correlations with global health measures, other multi-attribute utility instruments, physical/functional health, pain, activities of daily living, and clinical/biological measures. The instrument was not correlated with life satisfaction and cognition/communication measures. Responsiveness was addressed by 15 studies, finding moderate effect sizes when confined to studied subgroups with improvements in health.
Conclusions
The EQ-5D-5L exhibits excellent psychometric properties across a broad range of populations, conditions and settings. Rigorous exploration of its responsiveness is needed.
Objectives:
With few empirically supported treatments, functional movement disorders (FMD) can be challenging to manage. To enable service providers to better support people with FMD, this study sought to understand the lived experience of FMD: to gain insight into how individuals make sense of their experience from symptom onset through medical evaluation and diagnosis to post-diagnostic adaptation.
Design:
An interpretative phenomenological analysis (IPA) of patient accounts of living with FMD.
Methods:
Eight participants were recruited from a UK teaching hospital adult neurology service: seven females, varying in age (20s-70s), FMD symptom type (tremor, dystonia, and tics), and time to diagnosis (10 - 192 months). Semi-structured interviews facilitated participant accounts of key events. Interviews lasted 75-125 minutes and were transcribed verbatim.
Results:
Three super-ordinate themes were apparent. The first covered the experiences of onset ('Something is wrong with me'), including loss of control - with the affected body part often described as a separate entity - threats to identity and disturbance in relationships. 'At last! What now?' outlined the bittersweet experience of diagnosis and of treatments. Third, 'Living my life with it' incorporated ongoing experiences of coping with symptoms. While some continued to struggle with the emotional impact of symptoms, others developed a compassionate relationship with their self and maintained satisfying activities.
Conclusions:
FMD has a significant impact on patients' relationships with themselves and others, which in turn affects well-being. These findings suggest some nuanced additions to interventions (diagnosis, psychotherapy, physiotherapy, public education.).
Background
People with functional neurological disorder (FND) are commonly seen by occupational therapists; however, there are limited descriptions in the literature about the type of interventions that are likely to be helpful. This document aims to address this issue by providing consensus recommendations for occupational therapy assessment and intervention.
Methods
The recommendations were developed in four stages. Stage 1: an invitation was sent to occupational therapists with expertise in FND in different countries to complete two surveys exploring their opinions regarding best practice for assessment and interventions for FND. Stage 2: a face-to-face meeting of multidisciplinary clinical experts in FND discussed and debated the data from stage 1, aiming to achieve consensus on each issue. Stage 3: recommendations based on the meeting were drafted. Stage 4: successive drafts of recommendations were circulated among the multidisciplinary group until consensus was achieved.
Results
We recommend that occupational therapy treatment for FND is based on a biopsychosocial aetiological framework. Education, rehabilitation within functional activity and the use of taught self-management strategies are central to occupational therapy intervention for FND. Several aspects of occupational therapy for FND are distinct from therapy for other neurological conditions. Examples to illustrate the recommendations are included within this document.
Conclusions
Occupational therapists have an integral role in the multidisciplinary management of people with FND. This document forms a starting point for research aiming to develop evidence-based occupational therapy interventions for people with FND.
Comprehensive and repetitive assessments are needed to detect physical changes in an older population to prevent functional decline at the earliest possible stage and to initiate preventive interventions. Established instruments like the Timed “Up & Go” (TUG) Test and the Sit-to-Stand Test (SST) require a trained person (e.g., physiotherapist) to assess physical performance. More often, these tests are only applied to a selected group of persons already functionally impaired and not to those who are at potential risk of functional decline. The article introduces the Unsupervised Screening System (USS) for unsupervised self-assessments by older adults and evaluates its validity for the TUG and SST. The USS included ambient and wearable movement sensors to measure the user’s test performance. Sensor datasets of the USS’s light barriers and Inertial Measurement Units (IMU) were analyzed for 91 users aged 73 to 89 years compared to conventional stopwatch measurement. A significant correlation coefficient of 0.89 for the TUG test and of 0.73 for the SST were confirmed among USS’s light barriers. Correspondingly, for the inertial data-based measures, a high and significant correlation of 0.78 for the TUG test and of 0.87 for SST were also found. The USS was a validated and reliable tool to assess TUG and SST.
AimWe report results from a 5-week MDT treatment programme, with individualised sessions, for a selected group of patients with FNSD, delivered in a neuropsychiatric outpatient setting. Primary aims were to (1) reduce symptoms, (2) improve functional performance and (3) improve health status.Methods
Treatment involved individual sessions of neuropsychiatry, cognitive behavioural therapy, physiotherapy, occupational-therapy, education and family meetings. Outcome measures collected at the beginning and end of treatment and at 6 months, were patient and clinician reported. Aims were assessed by the following: symptom reduction (PHQ15, PHQ9, GAD7, SPIN, Rosenberg); health and social functioning (HONOS, WSAS); functional performance (COPM); health status (EQ-5D-5L) and patient-rated perception of improvement (CGI).ResultsAnalyses of 78 patients completing the programme and attending a 6-month review revealed high-baseline levels of disability compared to EQ-5DL population norms and high rates of disability and psychopathology as indicated by the WSAS and mental health indices (PHQ9, GAD7, SPIN, Rosenberg’s self-esteem). At baseline, 92.3% met the IAPT caseness threshold for depression and 71% met the IAPT caseness threshold for anxiety. A Friedman ANOVA over the three time points and Dunn-Bonferroni post hoc tests indicated statistically significant improvements from admission to discharge and admission to 6-month follow-up. Sustained improvements were seen in somatic symptoms (PHQ15), depression (PHQ9), anxiety (GAD7), health and social functioning (HONOS), functionality (COPM), health status (EQ-5D-5L) and patient-rated clinical global improvement (CGI).Conclusion
An MDT can effectively deliver an outpatient programme for FNSD which can serve as an alternative to costlier inpatient programmes. Early identification and treatment of co-morbidities is advised.
Objective:
Explore trauma, stress, and other predictive factors for treatment outcome in conversion disorder/functional neurological disorder (CD/FND).
Methods:
Prospective observational design. Clinical cohort study among consecutive outpatients with DSM-IV CD/FND in a specialized mental health institution for somatic symptom disorders and related disorders (SSRD), presented between 1 February 2010 and 31 December 2017. Patient files were assessed for early childhood trauma, childhood sexual abuse, current stress, and other predictive factors. Patient-related routine outcome monitoring (PROM) data were evaluated for treatment outcome at physical (Patient Health Questionnaire [PHQ15], Physical Symptoms Questionnaire [PSQ]) level as primary outcome, and depression (Patient Health Questionnaire [PHQ9]), anxiety (General Anxiety Disorder [GAD7]), general functioning (Short Form 36 Health Survey [SF36]), and pain (Brief Pain Inventory [BPI]) as secondary outcome.
Results:
A total of 64 outpatients were included in the study. 70.3% of the sample reported childhood trauma and 64.1% a recent life event. Mean scores of patients proceeding to treatment improved. Sexual abuse in childhood (F(1, 28) = 30.068, β = 0.608 p < .001) was significantly associated with worse physical (PHQ15, PSQ) treatment outcome. 42.2% reported comorbid depression, and this was significantly associated with worse concomitant depressive (PHQ9) (F[1, 39] = 11.526, β = 0.478, p = .002) and anxiety (GAD7) (F[1,34] = 7.950, β = 0.435, p = .008) outcome.
Conclusion:
Childhood sexual abuse is significantly associated with poor treatment outcome in CD/FND. Randomized clinical trials evaluating treatment models addressing childhood sexual abuse in CD are needed.
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Background:
Patients with functional motor disorder (FMD) experience persistent and disabling neurological symptoms such as weakness, tremor, dystonia and disordered gait. Physiotherapy is usually considered an important part of treatment; however, sufficiently-powered controlled studies are lacking. Here we present the protocol of a randomised controlled trial (RCT) that aims to evaluate the clinical and cost effectiveness of a specialist physiotherapy programme for FMD.
Methods/design:
The trial is a pragmatic, multicentre, single blind parallel arm randomised controlled trial (RCT). 264 Adults with a clinically definite diagnosis of FMD will be recruited from neurology clinics and randomised to receive either the trial intervention (a specialist physiotherapy protocol) or treatment as usual control (referral to a community physiotherapy service suitable for people with neurological symptoms). Participants will be followed up at 6 and 12 months. The primary outcome is the Physical Function domain of the Short Form 36 questionnaire at 12 months. Secondary domains of measurement will include participant perception of change, mobility, health-related quality of life, health service utilisation, anxiety and depression. Health economic analysis will evaluate the cost impact of trial and control interventions from a health and social care perspective as well as societal perspective.
Discussion:
This trial will be the first adequately-powered RCT of physical-based rehabilitation for FMD.
Trial registration:
International Standard Randomised Controlled Trials Number ISRCTN56136713 . Registered 27 March 2018.
Psychogenic nonepileptic seizures (PNES) are a highly disabling disorder frequently encountered by neurologists, psychiatrists, and emergency medicine physicians. There is accumulating evidence for the efficacy of psychological therapies, yet the majority of patients do not complete treatment. A range of health care system-based, clinician-based, and patient-based barriers to treatment exists, including stigma, poor clinician-patient communication, and patient ambivalence about the diagnosis and treatment of PNES. These barriers frequently lead to treatment nonadherence. Motivational interviewing (MI) is a patient-centered counseling style targeting ambivalence about behavior change, which has been shown to be effective in improving psychotherapy adherence and outcomes among patients with PNES. The authors review MI processes and techniques that may be useful to health care providers helping patients with PNES and other functional neurological disorders to engage in psychotherapy. The authors examine common challenges arising during MI for patients with PNES, including somatic symptoms distracting from clinician-patient communication, ambivalence about making concrete plans for treatment, and psychiatric comorbidities. Strategies for overcoming these obstacles are reviewed, including the use of complex reflections to enhance patient engagement; the use of an ask-tell-ask format and specific, measurable, achievable, relevant, and time-limited (SMART) goals to facilitate treatment planning; and close collaboration between the neurology and psychotherapy teams.
Reliable data on the prognosis of functional motor disorder are scarce, as existing studies of the prognosis of functional motor disorder are nearly all retrospective, small and uncontrolled. In this study we used a prospectively recruited, controlled cohort design to assess misdiagnosis, mortality and symptomatic and health outcome in patients with functional limb weakness compared to neurological disease and healthy control subjects. We also carried out an exploratory analysis for baseline factors predicting outcome. One hundred and seven patients with functional limb weakness, 46 neurological and 38 healthy control subjects from our previously studied prospective cohort were traced for follow-up after an average of 14 years. Misdiagnosis was determined in a consensus meeting using information from records, patients and their GPs. Numbers and causes of death were collected via death certificates. Outcome of limb weakness, physical and psychiatric symptoms, disability/quality of life and illness perception were recorded with self-rated questionnaires. Outcome measures were compared within and between groups. Seventy-six patients (71%) with functional limb weakness, 31 (67%) neurological and 23 (61%) healthy controls were included in follow-up. Misdiagnosis was found in one patient in the functional limb weakness group (1%) and in one neurological control (2%). Eleven patients with functional limb weakness, eight neurological control subjects and one healthy control subject had died. Weakness had completely remitted in 20% of patients in the functional limb weakness group and in 18% of the neurological controls (P = 0.785) and improved in a larger proportion of functional limb weakness patients (P = 0.011). Outcomes were comparable between patient groups, and worse than the healthy control group. No baseline factors were independent predictors of outcome, although somatization disorder, general health, pain and total symptoms at baseline were univariably correlated to outcome. This study is the largest and longest follow-up study of functional limb weakness. Misdiagnosis in functional limb weakness is rare after long-term follow-up. The disorder is associated with a higher mortality rate than expected, and symptoms are persistent and disabling. It appears difficult to predict outcome based on common baseline variables. These data should help inform clinicians to provide a more realistic outlook of the outcome and emphasize the importance of active and targeted therapy.
At the interface between mind and body, psychiatry and neurology, functional neurological disorder (FND) remains poorly understood. Formerly dominant stress-related aetiological models have been increasingly challenged, in part due to cases without any history of past or recent trauma. In this perspective article, we review current evidence for such models, and how research into the role of traumatic stress in other disorders and the neurobiology of the stress response can inform our mechanistic understanding of FND. First, we discuss the association between stress and the onset or exacerbation of a variety of physical and mental health problems. Second, we review the role of hypothalamic-pituitary-adrenal axis dysfunction in the neurobiology of ill-health, alongside evidence for similar mechanisms in FND. Third, we advocate a stress-diathesis model, in which biological susceptibility interacts with early life adversity, where FND can be precipitated by traumatic events later in life and maintained by psychological responses. We hypothesise that greater biological susceptibility to FND is associated with less severe remote and recent stress, and that FND precipitated by more severe stress is associated with lower biological vulnerability. This would explain clinical experience of variable exposure to historical and recent traumatic stress among people with FND and requires empirical investigation. A testable, evidence-based stress-diathesis model can inform nuanced understanding of how biological and psychological factors interact at the individual level, with potential to inform personalised treatment pathways. Much-needed research to establish the aetiology of FND will enhance clinical care and communication, facilitate effective treatment and inform prevention strategies.
Functional neurological disorders (FND) are common and associated with significant morbidity and healthcare costs. Patients with FND often present acutely, particularly with dissociative seizures (resembling epilepsy) or persistent weakness resembling a stroke. History and careful observation and examination are critical to diagnosis, as investigations will often be normal or non-contributory. The nature of convulsive movements in dissociative seizures often differs from that in epilepsy, and long duration of individual events, waxing and waning, closed eyes and high reported frequency in an apparently well individual are all suggestive. In those with stroke-like episodes, demonstration of normal power even briefly (eg Hoover's sign, 'give way' weakness) together with distractability are positive physical features indicating a functional disorder. A positive diagnosis and clear non-judgemental explanation, backed up by reliable information sources associated with prompt onward referral to a neurologist can greatly reduce distress and ultimately improve outcomes.
There is widespread agreement that the way health professionals communicate the diagnosis of functional neurologic disorders (FND) has a central role in treatment, as it does arguably for most conditions. In this chapter we discuss barriers to effective diagnosis, different models of explanation and evidence regarding the importance of effective communication of the diagnosis in FND, especially movement disorders, and dissociative (nonepileptic) seizures. Debates and disagreements about how to go about this task often reflect different theoretic models held by health professionals rather than evidence. More evidence is required to know whether an initial emphasis on one model is more or less effective than another (e.g., a functional model vs. a psychologic model). We conclude, however, that there are a number of generic components to effective explanation shared by most authors on the topic that form the basis of a consensus. These include taking the patient seriously, giving the problem a diagnostic label, explaining the rationale for the diagnosis, some discussion of how the symptoms arise, emphasis on the potential for reversibility (rather than damage), and effective triage and referral for other treatment where appropriate. Although explanation can sometimes be therapeutic on its own, its role is probably more important as a facilitator to other therapy, including self-help, physical treatments, and psychotherapy.
A multidisciplinary expert review of key issues and future directions from the conference “Controversial labels and clinical uncertainties: psychogenic disorders, conversion disorder, and functional symptoms.”
On October 9 and 10, 2015, a conference entitled “Controversial labels and clinical uncertainties: psychogenic disorders, conversion disorder, and functional symptoms” was held at the Center for Ethics, Emory University, Atlanta, GA, USA. This conference brought together a select group of 30 distinguished thought leaders and practitioners, including ethicists, researchers, clinicians, humanities scholars, and advocates to discuss the unique challenges and controversies related to the diagnosis, treatment, and stigma for patients with what is currently recognized as functional (“psychogenic”) neurological disorders. Our group of experts explored the conflicts and ethical tensions within health care that must be addressed in order to advance care for these disorders. What follows is a reflection on the conversations between conference attendees outlining key challenges and value conflicts in the diagnosis and treatment of patients with functional disorders. With this report, we aim to provide a roadmap for reducing stigma and improving care for functional neurological disorders (FND). A path forward would involve (1) setting a multifactorial research agenda that equally prioritized access to effective psychotherapy as well as identification of novel biomarkers; (2) empowering patients with FND to be heard and to drive changes in care; and (3) reducing isolation for clinicians by providing formal training and setting up multidisciplinary care teams and support networks.
Background: Behavioral Shaping Therapy (BeST) is a program that uses a multidisciplinary approach to treat
patients diagnosed with functional movement disorder (FMD). While this diagnosis is classified as a
psychological disorder by the Diagnostic and Statistical Manual of Mental Disorders, the BeST program
focuses on treating the physical manifestations of FMD. Occupational therapists are an integral part of the
multidisciplinary team, employing a variety of cognitive behavioral and motor reprogramming techniques to
normalize movement patterns.
Method: Patients 18 years of age or older with a confirmed diagnosis of FMD participated in this study. This
retrospective chart review used the Canadian Occupation Performance Measure to examine the patients’
satisfaction and perceived change in task performance on discharge from the program.
Results: Results from the dependent t-test indicated a positive outcome after participating in the BeST
program, with a mean change in performance of 3.4 and a mean change in satisfaction of 4.7.
Discussion: This study shows that occupational therapy can have a positive effect on patients diagnosed with
FMD.
Purpose To examine the criterion validity, responsiveness, and minimal clinically important difference (MCID) of the EuroQoL 5-Dimensions Questionnaire (EQ-5D-5L) and visual analog scale (EQ-VAS) in people receiving rehabilitation after stroke.
Methods The EQ-5D-5L, along with four criterion measures—the Medical Research Council scales for muscle strength, the Fugl-Meyer Assessment, the Functional Independence Measure, and the Stroke Impact Scale—were administered to 65 patients with stroke before and after 3 to 4 weeks therapy. Criterion validity was estimated using the Spearman correlation coefficient. Responsiveness was analyzed by the effect size (ES), standardized response mean (SRM), and criterion responsiveness. The MCID was determined by anchor-based and distribution-based approaches. The percentage of patients exceeding the MCID was also reported.
Results Concurrent validity of the EQ-Index was better compared with the EQ-VAS. The EQ-Index has better power for predicting the rehabilitation outcome in the activities of daily living than other motor-related outcome measures. The EQ-Index was moderately responsive to change (SRM = 0.63), whereas the EQ-VAS was only mildly responsive to change. The MCID estimation of the EQ-Index (the percentage of patients exceeding the MCID) was 0.10 (33.8%) and 0.10 (33.8%) based on the anchor-based and distribution-based approaches, respectively, and the estimation of EQ-VAS was 8.61 (41.5%) and 10.82 (32.3%).
Conclusions The EQ-Index has shown reasonable concurrent validity, limited predictive validity, and acceptable responsiveness for detecting the health-related quality of life in stroke patients undergoing rehabilitation, but not for EQ-VAS. Future research considering different recovery stages after stroke is warranted to validate these estimations.
The objective was to explore patient characteristics and 10-year outcome of sick leave and work disability for patients with recent-onset multiple medically unexplained symptoms (MUS) and persistent somatoform disorders (SD).
Consecutive patients consulting their family physician (FP) completed a preconsultation questionnaire on symptoms and mental illness (n=1785). The main problem was categorized by the FP after the consultation, and a stratified subsample was examined using a standardized diagnostic interview (n=701). Patients were grouped into three cohorts: recent onset of multiple MUS (n=84); Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, persistent SD (n=183); and reference group with well-defined physical disease according to FP (n=833). Register data on sick leave and disability pension were obtained.
At index consultation, disability pension was received by 8.3% (n=7) in the recent-onset multiple MUS group, 19.1% (n=35) in the SD group and 3.5% (n=29) in the reference group. Both the recent-onset multiple MUS group [hazard ratio (HR)=2.28, 95% confidence interval (CI): 1.14-4.55] and the SD group (HR=3.26, 95% CI:1.93-5.51) had increased risk of new disability pension awards. Furthermore, the SD group had increased risk of sick leave.
Both recent-onset and persistent MUS have significant long-term impact on patient functioning in regard to working life; this calls for early recognition and adequate management of MUS in primary care.
Copyright © 2014. Published by Elsevier Inc.
Patients with functional motor disorder (FMD) including weakness and paralysis are commonly referred to physiotherapists. There is growing evidence that physiotherapy is an effective treatment, but the existing literature has limited explanations of what physiotherapy should consist of and there are insufficient data to produce evidence-based guidelines. We aim to address this issue by presenting recommendations for physiotherapy treatment.
A meeting was held between physiotherapists, neurologists and neuropsychiatrists, all with extensive experience in treating FMD. A set of consensus recommendations were produced based on existing evidence and experience.
We recommend that physiotherapy treatment is based on a biopsychosocial aetiological framework. Treatment should address illness beliefs, self-directed attention and abnormal habitual movement patterns through a process of education, movement retraining and self-management strategies within a positive and non-judgemental context. We provide specific examples of these strategies for different symptoms.
Physiotherapy has a key role in the multidisciplinary management of patients with FMD. There appear to be specific physiotherapy techniques which are useful in FMD and which are amenable to and require prospective evaluation. The processes involved in referral, treatment and discharge from physiotherapy should be considered carefully as a part of a treatment package.
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Although functional neurological symptoms are often very disabling there is limited information on outcome after treatment. Here we prospectively assessed the short- and long-term efficacy of an inpatient multidisciplinary programme for patients with FNS. We also sought to determine predictors of good outcome by assessing the responsiveness of different scales administered at admission, discharge and follow-up. Sixty-six consecutive patients were included. Assessments at admission, discharge and at 1 year follow-up (55 %) included: the Health of the Nation Outcome Scale, the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire-15, the Revised Illness Perception Questionnaire, the Common Neurological Symptom Questionnaire, the Fear Questionnaire and the Canadian Occupational Performance Measure. At discharge and at 1 year follow-up patients were also asked to complete five-point self-rated scales of improvement. There were significant improvements in clinician-rated mental health and functional ability. In addition, patients reported that their levels of mood and anxiety had improved and that they were less bothered by somatic symptoms in general and neurological symptoms in particular. Two-thirds of patients rated their general health such as "better" or "much better" at discharge and this improvement was maintained over the following year. Change in HoNOS score was the only measure that successfully predicted patient-rated improvement. Our data suggest that a specialized multidisciplinary inpatient programme for FNS can provide long-lasting benefits in the majority of patients. Good outcome at discharge was exclusively predicted by improvement in the HoNOS which continued to improve over the 1 year following discharge.
Objective: Psychogenic gait disorder, defined as loss of ability to walk without neurological aetiologies, has poor rehabilitation options that are well documented. Left untreated these patients have substantial and long-lasting dysfunction. The present study examined the effect of a 3-week inpatient rehabilitation programme compared with a waiting list control condition, and whether eventual gains were maintained at 1-month and 1-year follow-up. Design: A cross-over design evaluated the effect of treatment, and a carry-over effect was considered as a long-lasting treatment effect. Treatment consisted of adapted physical activity within a cognitive behavioural framework, and focused on offering an alternative explanation of symptoms, positively reinforcing normal gait and not reinforcing dysfunction. Patients: A total of 60 patients were recruited from neurological departments and were randomly assigned to immediate treatment (intervention) or treatment after 4 weeks (controls). Results: Cross-over design revealed that the mean difference between treatment vs no treatment was 8.4 Functional Independence Measure units (p < 0.001, 95% confidence interval 5.2-11.7), and 6.9 Functional Mobility Scale units (p < 0.001, 95% confidence interval 5.5-8.3). Patients significantly improved their ability to walk and their quality of life after inpatient rehabilitation compared with the untreated control group. The improvements in gait were sustained at 1-month and 1-year follow-up. Conclusion: Substantial and lasting improvement can be achieved by inpatient rehabilitation of patients with psychogenic gait, and the gains are maintained during follow-up.
Functional neurological disorder (FND) is a condition at the intersection of neurology and psychiatry, with some patients experiencing sensory hypersensitivities and other sensory processing difficulties. It has been postulated that poor integration and modulation of sensory information with cognitive, affective and behavioral processes may play a role in the pathophysiology of FND. In this article, we first succinctly review the role for occupational therapy (OT) in the multidisciplinary therapeutic approach to managing patients with FND. After highlighting previously published data identifying sensory processing difficulties in patients with FND, we subsequently outline the components of the sensory-based outpatient OT program for FND at the Massachusetts General Hospital. Here, we detail how occupational therapists assess and treat sensory modulation difficulties with the aid of resources like the Adolescent/Adult Sensory Profile (AASP), The Canadian Occupational Performance Measure (COPM), and the Sensory-Motor Preference Checklist. We then report on two clinical cases representative of the sensory modulation difficulties endorsed by some patients with FND, illustrating how developing an individualized, sensory-based treatment plan can help improve functional neurological symptoms and overall participation in activities of daily living. Prospective, controlled research is needed to further operationalize OT-based sensory modulation interventions, as well as define the tolerability and efficacy of this intervention for pediatric and adult populations with FND.
Introduction
To establish the responsiveness of the Danish version of the Canadian Occupational Performance Measure (COPM-DK).
Method
A cross-sectional study was performed in three Danish settings, including 88 clients, 40 men, aged 16–90 years, with a variety of diagnoses. To determine construct responsiveness, the mean changes of the COPM performance and satisfaction score (COPM-P/S) were compared and correlated with the mean changes in the five-item World Health Organization (WHO) Well-Being Index (WHO-5) and the EuroQol–five domains–five levels questionnaire (EQ-5D-5L). To determine the responsiveness, data were analysed with ROC curves to establish the optimal cut-point values for the COPM-DK scores. Minimal important change (MIC) was assessed in relation to anchor-based questions.
Results
The mean change for COPM-P/S was 3.1 and 3.0, respectively. Small positive correlations were found between the COPM-DK scores and the WHO-5 and EQ-5D-5L scores. The AUC were 0.76 and 0.75, respectively. The optimal cut-point values for the COPM-P/S-scores based on either all positive answers or to the two highest, were 1.2 or 4.20 (COPM-P) and 1.67 or 5.80 (COPM-S), respectively
Conclusions
The capability of the COPM to detect changes in perceived occupational performance issues is supported. We recommend an MIC on 3.5 points on both scales.
Communication problems (eg, dysphonia, dysfluency and language and articulation disorders), swallowing disorders (dysphagia and globus), cough and upper airway symptoms, resulting from functional neurological disorder (FND), are commonly encountered by speech and language professionals. However, there are few descriptions in the literature of the most effective practical management approaches. This consensus document aims to provide recommendations for assessment and intervention that are relevant to both adults and young people. An international panel of speech and language professionals with expertise in FND were approached to take part. Participants responded individually by email to a set of key questions regarding best practice for assessment and interventions. Next, a video conference was held in which participants discussed and debated the answers to these key questions, aiming to achieve consensus on each issue. Drafts of the collated consensus recommendations were circulated until consensus was achieved. FND should be diagnosed on the basis of positive clinical features. Speech and language therapy for FND should address illness beliefs, self-directed attention and abnormal movement patterns through a process of education, symptomatic treatment and cognitive behavioural therapy within a supportive therapeutic environment. We provide specific examples of these strategies for different symptoms. Speech and language professionals have a key role in the management of people with communication and related symptoms of FND. It is intended that these expert recommendations serve as both a practical toolkit and a starting point for further research into evidence-based treatments.
Functional neurological disorder (FND) is a prevalent, disabling and costly condition at the neurology–psychiatry intersection. After being marginalised in the late 20th century, there has been renewed interest in this field. In this article, we review advances that have occurred over the past decade (2011–2020) across diagnosis, mechanisms, aetiologies, treatments and stigma in patients with motor FND (mFND, that is, functional movement disorder and functional limb weakness). In each content area, we also discuss the implications of recent advances and suggest future directions that will help continue the momentum of the past decade. In diagnosis, a major advance has been the emphasis on rule-in physical signs that are specific for hyperkinetic and hypokinetic functional motor symptoms. Mechanistically, greater importance has been given to determining ‘how’ functional neurological symptoms develop, highlighting roles for misdirected attention, expectation and self-agency, as well as abnormal influences of emotion/threat processing brain areas on motor control circuits. Aetiologically, while roles for adverse life experiences remain of interest in mFND, there is recognition of other aetiologic contributors, and efforts are needed to investigate links between aetiological factors and mechanisms. This decade has seen the first randomised controlled trials for physiotherapy, multidisciplinary rehabilitation and psychotherapy performed in the field, with consensus recommendations for physiotherapy, occupational therapy and outcome measures also published. Across patients, clinicians, healthcare systems and society, stigma remains a major concern. While challenges persist, a patient-centred integrated clinical neuroscience approach is primed to carry forward the momentum of the past decade into the future.
Importance
There is limited information about health care use and costs in patients with functional neurological disorders (FNDs).
Objective
To assess US emergency department (ED) and inpatient use and charges for FNDs.
Design, Setting, and Participants
This economic evaluation used Healthcare Cost and Utilization Project data to assess all-payer (1) adult (age, ≥18 years) hospitalizations (2008-2017), (2) pediatric (age, 5-17 years) hospitalizations (2003, 2006, 2009, 2012, and 2016), and (3) adult and pediatric ED evaluations (2008-2017). International Classification of Diseases, Ninth Revision, Clinical Modification code 300.11 (conversion disorder) or 306.0 (musculoskeletal malfunction arising from mental factors) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification codes for conversion disorder/functional neurological symptom disorder (F44.4 to F44.7) were used to conservatively define FNDs and to compare them with other neurological disorders that are associated with high levels of health care use. Analysis was performed between January 2019 and July 2020.
Main Outcomes and Measures
Admission traits (eg, demographic characteristics of patients, length of stay, and discharge disposition) and hospital charges.
Results
Compared with other neurological disorders in 2017, emergency FND evaluations of 36 359 adults (25 807 women [71.0%] and 3800 children (2733 girls [71.9%]) more frequently resulted in inpatient admissions (22 895 adult admissions [69.2% female] and 1264 pediatric admissions [73.4% ]). These FND admissions had a shorter mean (SEM) hospital length of stay (5.21 [0.15] days vs 6.03 [0.03] days, P < .001) but higher workup rates than admissions for comparable neurological diagnoses. Admissions for FNDs had low rates of inpatient physical therapy, occupational therapy, speech and language pathology, and psychiatric consultation. The total annual costs (a proxy for total costs in 2017 US dollars) were 971-1241 million (95% CI, 1351 million) for anterior horn cell disease; 57-86 million (95% CI, 108 million) for demyelinating diseases; and 144-135 million (95% CI 159 million) for refractory epilepsy. Total charges per admission for ED care of FNDs were higher than the other comparison groups in adults. Total costs and costs per admission for FNDs increased from 2008 to 2017 at a higher rate than that of other neurological disorders.
Conclusions and Relevance
This economic evaluation found that the more than $1.2 billion and increasing annual costs for ED and inpatient care of FNDs were similar to other investigation-intensive and pharmacologically demanding neurological disorders. Unnecessary investigations and iatrogenic harm inflate costs at the expense of necessary but neglected psychiatric and rehabilitative treatments.
Objective
To determine if self-rated health of patients with motor Functional Neurological Disorder can be improved by unguided internet-based self-help and education.
Methods
In this non-blinded randomised controlled trial, patients were 1:1 allocated unbiased to an unguided education and self-help website in addition to usual care, or usual care only. Patients over 17 years of age with a functional motor symptom which caused distress or disability were included. The primary outcome was self-rated health on the Clinical Global Improvement (CGI) scale, at three and six months. Secondary outcomes were severity of motor symptoms, other physical and psychiatric symptoms, physical functioning, quality of life, work and social adjustment, illness beliefs and satisfaction with care.
Results
186 patients were randomised, with a follow-up rate of 87% at 6 months. There was no difference in improvement of self-rated health at three months (44% vs 40%, p=0.899) or six months (42% vs 43%, p=0.435). Secondary outcomes did not differ between groups with a threshold of p<0.01. Satisfaction was high, with 86% of patients recommending the website to other patients.
Conclusion
We found no significant effect of the intervention added to usual care on self-rated health or secondary outcome measures, despite high patient satisfaction with the intervention. These results suggest online education and non-guided self-help could be valuable additions to stepped care for motor FND, but are not effective treatments as interventions in their own right.
Classification of Evidence
This study provides Class III evidence that for patients with motor Functional Neurological Disorder, an online education and self-help intervention does not significantly improve self-rated health. Trial registry: NCT02589886
Background:
There is large variability in the diagnostic approach and clinical management in functional movement disorders (FMD). This study aimed to examine whether opinions and clinical practices related to FMD have changed over the past decade.
Methods:
A survey to members of the International Parkinson and Movement Disorder Society (MDS).
Results:
We received 864/7689 responses (denominator includes non-neurologists) from 92 countries. Respondents were more often male (55%), younger than 45 (65%), and from academic practices (85%). Although the likelihood of ordering neurological investigations prior to delivering a diagnosis of FMD was nearly as high as in 2008 (47% versus 51%), the percentage of respondents communicating the diagnosis without requesting additional tests increased (27% versus 19%; p=0.003), with most envisioning their role as providing a diagnosis and coordinating management (57% versus 40%; p<0.001). Compared to patients with other disorders, 64% of respondents were more concerned about missing a diagnosis of another neurological disorder. Avoiding iatrogenic harm (58%) and educating patients about the diagnosis (53%) were again rated as the most effective therapeutic options. Frequent treatment barriers included lack of physician knowledge and training (32%), lack of treatment guidelines (39%), limited availability of referral services (48%), and cultural beliefs about psychological illnesses (50%). The preferred term for communication favored "functional" over "psychogenic" (p<0.001).
Conclusions:
Attitudes and management of FMD have changed over the past decade. Important gaps remain in the education of neurologists about the inclusionary approach to FMD diagnosis, and improving access to treatment.
Functional movement disorders (FMD) are commonly seen in neurologic practice and frequent sources of disability. Patients may present with tremor, weakness, dystonia, jerking movements, abnormal gait and speech, often combining several movement phenomenologies. Associated symptoms include chronic pain, depression, and anxiety. Treatment of FMD begins with an explanation of the diagnosis and needs to be tailored to patients' symptoms and comorbidities. There may be benefit from multidisciplinary treatment, including physical, occupational, and speech therapy, as well as psychotherapeutic interventions, especially cognitive behavior therapy. The role for neuromodulation such as transmagnetic stimulation in FMD treatment requires further research.
Background
Functional neurological disorder (FND), previously known as conversion disorder, is common and often results in substantial distress and disability. Previous research lacks large sample sizes and clinical surveys are most commonly derived from neurological settings, limiting our understanding of the disorder and its associations in other contexts. We sought to address this by analysing a large anonymised electronic psychiatric health record dataset.
Methods
Data were obtained from 322 patients in the South London and Maudsley NHS Foundation Trust (SLaM) who had an ICD-10 diagnosis of motor FND (mFND) (limb weakness or disorders of movement or gait) between 1 January 2006 and 31 December 2016. Data were collected on a range of socio-demographic and clinical factors and compared to 644 psychiatric control patients from the same register.
Results
Weakness was the most commonly occurring functional symptom. mFND patients were more likely to be female, British, married, employed pre-morbidly, to have a carer and a physical health condition, but less likely to have had an inpatient psychiatric admission or to receive benefits. No differences in self-reported sexual or physical abuse rates were observed between groups, although mFND patients were more likely to experience life events linked to inter-personal difficulties.
Conclusions
mFND patients have distinct demographic characteristics compared with psychiatric controls. Experiences of abuse appear to be equally prevalent across psychiatric patient groups. This study establishes the socio-demographic and life experience profile of this understudied patient group and may be used to guide future therapeutic interventions designed specifically for mFND.
Background: Patients with functional motor disorder are perceived as difficult by health care professionals, but we know very little about the patients’ perspective. Understanding the experiences and perceptions of patients could help to improve clinical services and patient outcomes.
Purpose: To explore the experiences and perspectives of patients with functional motor disorder using qualitative research methods.
Methods: This qualitative study was embedded within a feasibility study of specialist physiotherapy. Eleven patients with functional motor disorder participated in semi-structured qualitative interviews prior to receiving treatment. The interview transcripts were subjected to an inductive thematic analysis.
Results: The data were arranged into six themes: (1) the burden of living with functional motor disorder; (2) nobody knew what was wrong; (3) dissatisfaction with psychological explanations; (4) patients feel abandoned; (5) iatrogenic harm; and (6) powerlessness.
Discussion and Conclusion: The study participants experienced substantial physical and emotional burdens associated with functional motor disorder. They were generally dissatisfied with psychological explanations for their symptoms and commonly felt misunderstood and abandoned by health care professionals, which appeared to leave them vulnerable to iatrogenic harm. A lack of understanding of functional motor disorder left participants feeling unable to help themselves. This research highlights a number of inadequacies within current clinical services for patients with functional motor disorder.
• Implications for rehabilitation
• Careful communication is required to help patients understand and accept the diagnosis of functional motor disorder.
• It is important to listen to the patient’s narrative in order to help them make sense of their illness experience.
• A nuanced biopsychosocial explanatory model is needed to help patients understand how psychological factors can be relevant to physical symptoms and symptoms that are often perceived to be precipitated by a physical event.
• A lack of understanding and acceptance of the diagnosis may leave patients vulnerable to iatrogenic harm and powerless to help themselves.
Functional neurological disorder (FND) is a common and highly disabling disorder, but its aetiology remains enigmatic. Conceptually, there has been reduced emphasis on the role of psychosocial stressors in recent years, with a corresponding increase in neurobiological explanations. However, a wealth of evidence supports the role of psychosocial adversities (eg, stressful life events, interpersonal difficulties) as important risk factors for FND. Therefore, there is a need to integrate psychosocial (environmental) and neurobiological factors (eg, sensorimotor and cognitive functions) in contemporary models of FND. Altered emotional processing may represent a key link between psychosocial risk factors and core features of FND. Here, we summarise and critically appraise experimental studies of emotional processing in FND using behavioural, psychophysiological and/or neuroimaging measures in conjunction with affective processing tasks. We propose that enhanced preconscious (implicit) processing of emotionally salient stimuli, associated with elevated limbic reactivity (eg, amygdala), may contribute to the initiation of basic affective/defensive responses via hypothalamic and brainstem pathways (eg, periaqueductal grey). In parallel, affect-related brain areas may simultaneously exert a disruptive influence on neurocircuits involved in voluntary motor control, awareness and emotional regulation (eg, sensorimotor, salience, central executive networks). Limbic-paralimbic disturbances in patients with FND may represent one of several neurobiological adaptations linked to early, severe and/or prolonged psychosocial adversity. This perspective integrates neurobiological and psychosocial factors in FND and proposes a research agenda, highlighting the need for replication of existing findings, multimodal sampling across emotional response domains and further examination of emotional influences on sensorimotor and cognitive functions in FND populations.
Background:
Stressful life events and maltreatment have traditionally been considered crucial in the development of conversion (functional neurological) disorder, but the evidence underpinning this association is not clear. We aimed to assess the association between stressors and functional neurological disorder.
Methods:
We systematically reviewed controlled studies reporting stressors occurring in childhood or adulthood, such as stressful life events and maltreatment (including sexual, physical abuse, and emotional neglect) and functional neurological disorder. We did a meta-analysis, with assessments of methodology, sources of bias, and sensitivity analyses.
Findings:
34 case-control studies, with 1405 patients, were eligible. Studies were of moderate-to-low quality. The frequency of childhood and adulthood stressors was increased in cases compared with controls. Odds ratios (OR) were higher for emotional neglect in childhood (49% for cases vs 20% for controls; OR 5·6, 95% CI 2·4-13·1) compared with sexual abuse (24% vs 10%; 3·3, 2·2-4·8) or physical abuse (30% vs 12%; 3·9, 2·2-7·2). An association with stressful life events preceding onset (OR 2·8, 95% CI 1·4-6·0) was stronger in studies with better methods (interviews; 4·3, 1·4-13·2). Heterogeneity was significant between studies (I221·1-90·7%). 13 studies that specifically ascertained that the participants had not had either severe life events or any subtype of maltreatment all found a proportion of patients with functional neurological disorder reporting no stressor.
Interpretation:
Stressful life events and maltreatment are substantially more common in people with functional neurological disorder than in healthy controls and patient controls. Emotional neglect had a higher risk than traditionally emphasised sexual and physical abuse, but many cases report no stressors. This outcome supports changes to diagnostic criteria in DSM-5; stressors, although relevant to the cause in many patients, are not a core diagnostic feature. This result has implications for ICD-11.
Funding:
None.
In this chapter we review key psychologic theories that have been mooted as possible explanations for the etiology of functional neurologic symptoms, conversion disorder, and hysteria. We cover Freudian psychoanalysis and later object relations and attachment theories, social theories, illness behavior, classic and operant conditioning, social learning theory, self-regulation theory, cognitive-behavioral theories, and mindfulness. Dissociation and modern cognitive neuroscience theories are covered in other chapters in this series and, although of central importance, are omitted from this chapter. Our aim is an overview with the emphasis on breadth of coverage rather than depth.
In this chapter we define important concepts related to affect regulation including emotion, mood, feelings, stress, and affect. Then, we review the most significant findings on the relationships between emotion regulation and various mental disorders.
Objective:
A considerable amount of patients with somatoform disorders do not benefit from psychotherapy as much as expected. Our aim was to explore whether readiness to change moderates the relationship between the intensity of symptoms and therapy outcome in the early stages of psychotherapy.
Method:
144 patients with somatoform disorders received an outpatient cognitive-behavioural intervention. Symptom intensity was measured with the Screening for Somatoform Disorders (SOMS-7). For readiness to change, a German modification of the Pain Stages of Change Questionnaire (PSOCQ) was used, which comprises four subscales (FF-STABS). Regression analyses were carried out, with baseline symptoms and the readiness to change subscales as predictors and symptom reduction as the outcome variable.
Results:
Moderation analyses revealed significant interaction effects between baseline symptoms and the precontemplation subscale, as well as between baseline symptoms and the action subscale. For preparation and maintenance, no significant interaction effects were found.
Conclusions:
The results suggest that readiness to change is a variable that can be used to differentiate between patients, with low precontemplation and action scores indicating a better chance for positive outcome, even with high initial impairment. Rather than using readiness to change sum scores, the sub-aspects of this construct should be the subject of future research.
Objective
To determine the feasibility of conducting a randomised controlled trial of a specialist physiotherapy intervention for functional motor symptoms (FMS).
Methods
A randomised feasibility study was conducted recruiting patients with a clinically established diagnosis of FMS from a tertiary neurology clinic in London, UK. Participants were randomised to the intervention or a treatment as usual control. Measures of feasibility and clinical outcome were collected and assessed at 6 months.
Results
60 individuals were recruited over a 9-month period. Three withdrew, leaving 29 intervention and 28 controls participants in the final analysis. 32% of patients with FMS met the inclusion criteria, of which 90% enrolled. Acceptability of the intervention was high and there were no adverse events. At 6 months, 72% of the intervention group rated their symptoms as improved, compared to 18% in the control group. There was a moderate to large treatment effect across a range of outcomes, including three of eight Short Form 36 (SF36) domains (d=0.46–0.79). The SF36 Physical function was found to be a suitable primary outcome measure for a future trial; adjusted mean difference 19.8 (95% CI 10.2 to 29.5). The additional quality adjusted life years (QALY) with intervention was 0.08 (95% CI 0.03 to 0.13), the mean incremental cost per QALY gained was £12 087.
Conclusions
This feasibility study demonstrated high rates of recruitment, retention and acceptability. Clinical effect size was moderate to large with high probability of being cost-effective. A randomised controlled trial is needed.
Trial registration number
NCT02275000; Results.
Some patients admitted to acute stroke units are diagnosed as stroke mimics. A minority have a functional neurological disorder ('functional mimics').
To determine the incidence of functional stroke mimics admitted to a hyperacute stroke unit (HASU); to compare their clinical characteristics with medical mimics and stroke cases and obtain information about outcomes.
Patients admitted to the King's College Hospital HASU between 2011 and 2012 were analysed. Data were obtained from the Stroke Improvement National Audit Programme (SINAP) database. Expert consensus diagnosis was used to classify functional mimics. Follow-up information was obtained from a retrospective case series in primary care over the year following discharge.
1165 patients were admitted to the HASU; 904 patients with stroke (77.6%), 163 medical mimics (14%) and 98 functional mimics (8.4%). Functional mimics were significantly more likely to be female (63.3%) versus 49.7% medical mimics and 45.5% stroke, and younger (mean age (SD)) 49.1 (18.8) than medical mimic (63.5 years (16.7)) and stroke cases (71 years (15.5)). Weakness and slurred speech were the commonest presentations of functional mimics and diagnostic MRI was used more often. Clinician recorded visual and speech symptoms and neglect were significantly more frequent in patients with stroke than either mimic group. Of the 68 functional mimics on whom follow-up information was obtained, 40 (59%) were referred to another service most often for a psychologically-based intervention.
Functional stroke mimics are an important subgroup admitted to acute stroke services and have a distinct demographic and clinical profile. Their outcomes are poorly monitored. Services should be developed to better diagnose and manage these patients.
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The objective was to compare a brief interdisciplinary psychotherapeutic intervention to standard care as treatments for patients recently diagnosed with severe motor conversion disorder or nonepileptic attacks.
This randomized controlled trial of 23 consecutive patients compared (a) an interdisciplinary psychotherapeutic intervention group receiving four to six sessions by a consultation liaison psychiatrist, the first and last sessions adding a neurological consultation and a joint psychiatric and neurological consultation, and (b) a standard care group. After intervention, patients were assessed at 2, 6 and 12 months with the Somatoform Dissociation Questionnaire (SDQ-20), Clinical Global Impression scale, Rankin scale, use of medical care, global mental health [Montgomery and Asberg Depression Rating Scale, Beck Depression Inventory, mental health component of Short Form (SF)-36] and quality of life (SF-36). We calculated linear mixed models.
Our intervention brought a statistically significant improvement of physical symptoms [as measured by the SDQ-20 (P<.02) and the Clinical Global Impression scale (P=.02)] and psychological symptoms [better scores on the mental health component of the SF-36 (P<.05) and on the Beck Depression Inventory (P<.05)] and a reduction in new hospital stays after intervention (P<.05).
A brief psychotherapeutic intervention taking advantage of a close collaboration with neurology consultants in the setting of consultation liaison psychiatry appears effective.
Copyright © 2015. Published by Elsevier Inc.
Patients with functional motor disorder (FMD) are commonly seen by physiotherapists and there is growing evidence to support a physical rehabilitation approach. There are, however, few descriptions in the literature of the content of successful physiotherapy treatment. This prospective cohort study reports the practicalities and outcomes of a pilot 5-day physiotherapy programme. Patients were referred from a specialist movement disorders clinic. The treatment consisted of education and movement retraining, with a long-term self-management focus. Education and movement retraining was based on a pathophysiological model for FMD that stresses the importance of self-focussed attention and illness belief. Patients were assessed at baseline, end of treatment and 3-month follow-up. 47 patients completed the programme, mean symptom duration was 5.5 years, 64 % were unemployed due to ill health. At the end of treatment, 65 % rated their symptoms as “very much improved” or “much improved”, this reduced to 55 % at 3 months. At follow-up, there was a significant improvement in physical domains of the SF-36, Berg Balance Scale and 10 Metre Timed Walk. Measures of mental health did not change. This prospective cohort study adds to the growing evidence that supports the use of specialist physiotherapy treatment for FMD. Improvements here were made despite the cohort having characteristics associated with poor prognosis. We argue that specific treatment techniques are important and have the potential to improve physical function, quality of life and may prove to be a cost-effective treatment for selected patients with FMD.
Functional ("psychogenic") gait and other movement disorders have proven very difficult to treat.
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.
Historical-cohort-study assessing non-randomized PMR intervention.
Tertiary care center.
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).
An outpatient, one-week intensive rehabilitation program based on the concept of motor-reprogramming following a comprehensive diagnostic neurological evaluation, including psychiatric/psychological assessment.
Improvement of the movement disorder by the end of the week-long program (patient- and physician-rated), plus the long-term outcome (patient-rated).
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).
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.