Table 3

Examples of intervention strategies for functional movement symptoms

SymptomIntervention strategy
Functional tremor
  • Superimpose alternative, voluntary, ‘rhythms’ on top of the existing tremor and gradually slowing all movement to a complete rest.

  • Unilateral tremor: use the unaffected limb to dictate a new rhythm (eg, tapping/opening and closing the hand), that is entrain the tremor to stillness. Music can be introduced to dictate a rhythm to follow.

  • Assist the person to relax the muscles in the limb to prevent cocontraction.

  • Try to control a tremor with the person at rest, before moving on to activity.

  • Use of gross rather than fine movements (which take more concentration), for example, handwriting retraining; using a marker and large piece of paper or white board with big lettering or patterns/shapes rather than trying to focus on ‘normal’ handwriting.

  • Discourage cocontraction or tensing of muscles as a method to suppress a tremor, as this is unlikely to be a helpful long-term strategy.

Functional jerks
  • Addressing unhelpful prejerk cognitions and movement (eg, signs of anxiety, frustration or effort, such as breath-holding).

  • General relaxation techniques;: diaphragmatic breathing or progressive muscular relaxation.

  • Sensory grounding; a strategy that can be used to bring oneself into the present moment40 (eg, noticing details in the environment (sounds, sights and smells), feeling a textured item, cognitive distractors such as counting backwards and singing).

  • Encourage learning of ‘slow’ movement activities such as yoga or tai chi as a way of regaining movement control and redirecting attention away from the symptom.

  • Encouraging optimal postural alignment at rest and within function, considering a 24-hour management approach.

  • Encourage even distribution of weight in sitting, transfers, standing and walking to normalise movement patterns and muscle activity.

  • Grade activity to increase the time that the affected limb is used (using normal movement techniques) within functional activities.

  • Avoid postures that promote prolonged positioning of joints at the end of range (eg, full hip, knee or ankle flexion while sitting).

  • Discourage nursing of the affected limb but demonstrate and promote therapeutic resting postures and limb use.

  • Strategies that reduce muscle overactivity, pain and fatigue, for example, muscle relaxation strategies, supporting the affected limb when at rest, using pillows or furniture to take the weight of a limb when sitting or lying down.

  • Address associated problems of pain and hypersensitivity.

Functional limb weakness
  • Engage the person in tasks that promote normal movement, good alignment and even weight-bearing. Task examples may include: transfers, sit to stand, standing, perch sitting in personal care or kitchen tasks, using the hand to stabilise objects (so as to avoid learnt non-use) and placing the hand on the kitchen bench while standing to prepare food (rather than letting it hang by the side).

  • Bilateral functional lower limb weakness; joint sessions with PT colleagues to complete tasks using the upper limbs while standing with the aid of a standing frame.

  • With all symptom types, employing anxiety management and distraction techniques when undertaking a task can be helpful. Video recording interventions (with consent) can be useful to play back to the person to identify changes in symptoms (eg, in tremor amplitude or extinction). It can demonstrate changeability, highlight successes (and build confidence) and act as a reference point for replication of strategies outside of therapy.