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- psychogenic movement disorders
- functional movement disorders
- conversion disorder
- multidisciplinary clinic
Although labelled a ‘crisis for neurology’ in 2006, little progress has been made towards improved management of patients with functional movement disorders (FMD). FMD is commonly seen in neurological practice, yet the best approach to treatment is ill defined. Prognosis is often poor, and most patients fail to improve without treatment, especially those with symptoms lasting beyond 1 year.1 Collaboration between neurologists and mental health providers is suggested to optimise care for patients with FMD, yet communication between different specialists is often lacking in practice.1–3 Physical therapy and multidisciplinary treatment programmes have shown benefits but are not widely available to patients.4 5 Multidisciplinary clinics have been shown to improve care for patients with complex neurological disorders such as Huntington’s disease and amyotrophic lateral sclerosis and we believe a similar approach should be considered for FMD. We have developed a multidisciplinary clinic to provide comprehensive evaluation and treatment planning for patients with FMD. Here, we report our experience from the first year of the clinic.
Our FMD clinic takes place at Frazier Rehab Institute in Louisville, Kentucky, USA, and is composed of a movement disorder specialist, psychologists, physical therapists and a social worker. The clinic is held once a month for a half-day and accommodates three patients. Patients see each specialist for 1 hour and are asked to complete standardised screening instruments for depression (Beck’s Depression Inventory), anxiety (State-Trait Anxiety Inventory), trauma history (Adverse Childhood Experience Questionnaire) and post-traumatic stress disorder (PTSD) symptoms (primary care PTSD screen). Subsequently, the specialists have a team meeting and afterwards the neurologist conveys treatment recommendations to the patient.
The purpose of the clinic is to confirm the diagnosis of FMD, provide patient education, develop a treatment plan and determine candidacy for our inpatient motor retraining (MoRe) rehabilitation programme. The MoRe programme offers a 1 week long multidisciplinary treatment approach with daily physical, occupational and speech therapy as well as cognitive behavioural therapy-based sessions. Throughout the week, patients are monitored by a physiatrist and a neurologist. We collected data retrospectively from February 2016 to February 2017, using the electronic medical record system to determine referral patterns, clinic attendance rates, patient characteristics, final diagnoses, treatment recommendations and adherence to treatment.
During the study period, 34 patients attended the clinic, referred by neurologists from 12 US states. The attendance rate for appointments was 100%. The majority of patients were female (70.6%) and the mean age was 47.9 (±15.0) years (table 1).
Average symptom duration was 4.9 (±6.8) years and 52.9% of patients were either unemployed or receiving disability benefits. The predominant movement symptoms were gait disorders (41.2%), followed by tremor, dystonia and other hyperkinetic movements (14.7% each). All patients were referred to the clinic with a prior diagnosis of FMD, and the diagnosis was confirmed by the movement disorder specialist (KL) in all cases. Of patients that could recall a precipitating factor for their symptoms (58.8%), 23.5% reported a physical trigger, such as surgery or an accident, and 35.3% reported a psychological trigger. Consistent with prior studies, we found a high lifetime prevalence of depression (82.4%) and anxiety (70.6%), and 51.5% of patients reported a history of sexual and/or physical abuse, which is considered to be a risk factor for FMD. Prior to attending the clinic, 64.7% of patients had participated in physical therapy and did not experience significant symptom improvement. Additionally, 29.4% had received outpatient psychological treatment and 64.7% were currently on antidepressant or anxiolytic medications.
Following the evaluation, 30 out of 34 patients were considered good candidates for the MoRe programme. Three patients with mild symptom severity were recommended to undergo or continue outpatient physical therapy and psychotherapy. One patient was found to suffer from severe depression with suicidality and was referred for psychiatric treatment. Of the 30 patients considered good candidates for inpatient rehabilitation, 25 completed the programme to date. At the end of the week, 22 patients (88.0%) rated their symptoms as improved on a seven-point patient-rated Clinical Global Impression Scale. Of those patients not participating in the programme, two were denied insurance coverage and two decided against participation, and admission was deferred for one patient actively seeking disability benefits, which is frequently considered to interfere with a positive treatment outcome.
We demonstrate a high attendance rate and good adherence to treatment recommendations in patients evaluated in a multidisciplinary FMD clinic. The comprehensive nature of the clinic and expertise from multiple specialists may facilitate patient acceptance of the diagnosis, which is generally considered an important prognostic factor. Evaluations by the psychologist and physical therapist help to uncover psychosocial factors and psychiatric comorbidities, define functional limitations and optimise treatment planning. Formation of a strong therapeutic bond helps patients to feel confident in the treatment process and gives assurance that recovery is possible.
We believe that a multidisciplinary approach meets several needs for this patient population. First, it addresses patients’ symptoms and comorbidities in an integrated manner. The team approach also facilitates communication between specialists, is convenient for patients and promotes a coordinated treatment effort. Additionally, referrals to our clinic from 12 US states highlight the unmet need for specialised care for patients with FMD. Given the high prevalence of FMD in neurological practice and the often chronic, disabling nature of this disorder primarily affecting patients in their most productive years, optimising care for this patient population is of crucial importance.
Our study has several limitations, including a selection bias towards patients willing and able to travel to a referral centre for diagnostic confirmation and treatment of FMD. The study was planned retrospectively; however, all patients seen within the first year of the clinic were included in the analysis.
In conclusion, we believe that multidisciplinary FMD clinics provide valuable care in a time-efficient manner. Further research is needed to study long-term outcomes for patients receiving care at specialised FMD centres.
Contributors AEJ contributed to the collection of data, conducted literature searches and complied and analyzed the data. She also wrote the first draft. CAS, MEJ, ARR, KMP, DLK, DST and KLF contributed to the collection of data, execution of the project, and review and critique of the manuscript. KLF developed the concept for this study.
Competing interests None declared.
Ethics approval Institutional Review Board.
Provenance and peer review Not commissioned; externally peer reviewed.
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