Outpatient Physical Therapy for [FND]: A Preliminary Feasibility and Naturalistic Outcome Study in a U.S. Cohort, 2019, Maggio et al

[Andy]

Abstract

Objective:
Despite promising research and consensus recommendations on the important therapeutic role of physical therapy for motor functional neurological disorder (FND), little is known about the feasibility and potential efficacy of implementing physical therapy for this population in a U.S.-based outpatient program. Given health care system differences internationally, this is an important gap in the literature.

Methods:
In this retrospective cohort study, the authors investigated the relationship between treatment adherence and clinical outcome in a hospital-based outpatient physical therapy clinical program. Medical records of 50 consecutive patients with motor FND referred from an FND clinical program were reviewed. The physical therapy intervention included a 1-hour initial assessment and the development of individualized treatment plans guided by published consensus recommendations. Statistical analyses included nonparametric, univariate screening tests followed by multivariate regression analyses.

Results:
In univariate analyses, there was a statistically significant positive correlation between the number of sessions attended and clinical improvement. This relationship held when adjusting for demographic variables, concurrent psychogenic nonepileptic seizures, and other major neurological comorbidities. In a post hoc analysis of the subset of individuals with available gait speed data, posttreatment 10-meter gait speed times improved compared with baseline measurements. Baseline neuropsychiatric factors did not correlate with clinical improvement.

Conclusions:
This preliminary, retrospective cohort study demonstrated that treatment adherence to a U.S.-based outpatient physical therapy program was associated with clinical improvement. Prospective observational and randomized controlled trials are needed to further optimize physical therapy for patients with functional motor symptoms in the outpatient setting.

Paywall, https://neuro.psychiatryonline.org/doi/10.1176/appi.neuropsych.19030068
Sci hub, https://sci-hub.se/10.1176/appi.neuropsych.19030068

 

[rvallee]

Data were analyzed over a 4-month period. The primary outcome was clinical improvement, defined as the ability to tolerate a final session asymptomatically or demonstration of “marked improvement” in the final session. Marked improvement was defined as substantially enhanced ability to manage motor-based activities of daily living or near complete symptom resolution at the final session. In addition, gait speed using a 10-meter walk test was collected for a subset of patients at the start and end of treatment.

I tried and can't find how they actually assessed "being asymptomatic". It mentions somewhere that among limitations are lack of self-reported outcomes, but then I have no idea how "being asymptomatic" is otherwise measured.

The other "marked improvement" is not particularly helpful, a 10-meter walking test only means that it's possible to practice and improve for that very short test. It's possible to train paraplegics to climb a few stairs on their ass. Being able to demonstrate that is very far from that being a reasonable solution in real life or that it actually means an improvement to the paralysis itself.

It is noteworthy that 11 patients in the not-improved group and two patients in the improved group discontinued treatment before discharge

Drop-outs were 13/50, so 26%. That's very high for a short trial and it's not clear how impaired they were. Selection was based on DSM criteria for psychogenic motor problems, which are untestable so it's not really clear who those participants actually are. "Improvement" rates are 17/50, or 24%, though there is no objective outcome of what improvement means.

This approach likely had low sensitivity, limiting our ability to identify those patients who made improvements while remaining symptomatic, which may have also limited our ability to appreciate relationships between baseline clinical factors and clinical improvement.

The authors do note how unreliable assessment of "improvement" is, which does not prevent the usual conclusions of an "association" with short-term improvement.

So it's hard to define improvement, but it may have occurred in some. As always. Literally, this is always the same damn recipe. The same trials done over and over again. The same conclusion despite the same lack of specific reliable data supporting the conclusion.

 

[Mithriel]

Like all these trials they have found that people who were able to finish the course were not so ill as people who were not. The more of the sessions you could do the less sick you were at the end, though as usual the set up is so ill defined that in reality it is difficult to say if they fond anything at all.

Taking their results at face value the patients were all keen to do something that might help them get better so motivation to get well is high in FND (the same could be said about ME patients in things like PACE). However a quarter were physically unable to complete the course despite their motivation.

At the end of the trial, exercise classes had helped a little bit but not enough to make a real world difference so, basically, the most you can say is that some patients with the diagnosis of FND can gain some fitness by physical therapy if they can mange to do it.