Rehabilitation Program Improves Symptoms of Functional Movement Disorders

Data indicate that rehabilitation, combined with cognitive behavioral therapy, yields sustained functional gains.

Neurology Reviews. 2017 April;25(4):23

March 24, 2017|Neurology Reviews

RIVIERA BEACH, FL—A comprehensive, interdisciplinary rehabilitation program for functional movement disorders (FMD) is providing high rates of sustained improvement in patients with this challenging clinical problem, according to an initial analysis. In this program, which is administered during a one-week in-hospital stay, the emphasis is on relearning normal movement through physical therapy, but attention is also paid to the psychological component of the disorder.

“I do not think that just any physical therapist can work with these patients. You have to know about these disorders. You have to have some experience in how to talk to the patients and how to integrate the treatments,” said Kathrin LaFaver, MD, Director of the Parkinson’s Disease and Movement Disorders Clinic at the University of Louisville. Speaking at the 44th Annual Meeting of the Southern Clinical Neurological Society, Dr. LaFaver reported that the one-week Motor Retraining (MoRe) Program at her center produced substantial clinical improvements in 87% of patients. The improvement was sustained at six months in 74% of patients.

What Is FMD?

FMD includes movement abnormalities such as tremor, gait disturbances, or dystonia that are not explained by organic lesions or diseases. FMD is common and occurs in 3% to 5% of patients presenting at movement disorder clinics, according to Dr. LaFaver. Although FMD has an important psychogenic component, Dr. LaFaver said that the symptoms can be as persistent and debilitating as those associated with organic disorders. As with organic diseases, the consequences of FMD include chronic disability.

This last point was emphasized in the demographics of a series of 32 patients with FMD presented by Dr. LaFaver. The mean duration of symptoms was seven years, and 56% of patients were on disability at the time of enrollment into the MoRe program. Consistent with other series of patients with FMD, the population was predominantly female (75%), and a substantial proportion reported posttraumatic stress disorder (53%), sexual abuse (48%), and physical abuse (41%). Mean scores on the Beck Depression Inventory (16.59) and the State-Trait Anxiety Index (40.79) indicated that mood disorders were common. This result also has been previously reported in patients with FMD.

The MoRe Program

Over the course of the inpatient MoRe program, patients begin with simple, repetitive, and structured exercises relevant to their FMD, progressing to more complex motor tasks as they improve. Positive gains with physical therapy, which is provided for five consecutive days, are reinforced with structured cognitive behavioral therapy (CBT). The motor reprogramming provided is analogous to that offered for various neurologic symptoms associated with organic diseases, such as paraplegia or hemiparesis. Importantly, participants in the MoRe program are encouraged to think of their disorder as definable and treatable, even if the psychogenic component is not concealed.

“We do set the expectation that they will be normal by the end of the week,” said Dr. LaFaver, who explains to patients that neurologic abnormalities are likely to be involved, even if they cannot be objectively demonstrated.

MoRe is run as an inpatient program to permit an adequate intensity of physical therapy and to allow patients to develop trust in their physical and psychological therapists, Dr. LaFaver said. She also suggested that the emphasis on physical therapy in the MoRe program allows patients to frame the goals of treatment in a useful way. The psychological support is essentially adjunctive.

“It can be helpful to use analogies, such as describing the movement disorder as a software [problem] rather than a hardware problem,” Dr. LaFaver explained. The emphasis is on engaging patients to participate in treatment that will reverse adverse changes in the neurologic circuitry that is driving the symptoms. Citing recent functional MRI (fMRI) studies that have shown changes in right temporoparietal junction connectivity in patients with FMD, Dr. LaFaver suggested that the premise of a change in brain function with FMD has evidential support.

Rehabilitation Yields Improvements

In the series of 32 patients treated during a two-year period starting in 2014, the predominant symptoms were abnormal gait in 31%, dystonia in 31%, tremor in 13%, chorea in 13%, myoclonus in 6%, and weakness in 6%. On video rating performed by a movement disorder specialist to compare symptom severity at baseline with that following treatment, movement symptoms improved by 59% on average from day 1 to day 5 of treatment.

The improvement in video ratings was supported by patient self-assessment. On a descending scale of 7 to 1, with 1 signifying the greatest symptom control, the mean patient-assessment score was 2.07 immediately after completing the MoRe program and 2.78 at the six-month follow-up, according to Dr. LaFaver.

Patient satisfaction with the program was high. On an ascending scale of 0 to 10, with 10 providing the best rating, patients gave physical therapy an average rating of 9.23 and psychological skills training an average rating of 8.87. For mental practice training, another aspect of the MoRe program used to reinforce motor reprogramming, the average patient rating was 8.62. Ninety-six percent of patients reported that they would participate in the program again.