Physiotherapy for functional motor disorders: a consensus recommendation, 2015, Nielsen et al

[Hutan]

Open access: https://jnnp.bmj.com/content/86/10/1113

Glenn Nielsen, Jon Stone, Audrey Matthews, Melanie Brown, Chris Sparkes, Ross Farmer, Lindsay Masterton, Linsey Duncan, Alisa Winters, Laura Daniell, Carrie Lumsden, Alan Carson, Anthony S David, Mark Edwards

Abstract
Background 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.

Methods 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.

Results 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.

Conclusions 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.

 

[Hutan]

It's interesting that they felt that there was not enough data to produce an evidence-based guideline. But they'll present some recommendations anyway, with the Methods section summarised as 'We had a meeting and we decided this seems about right'.

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.

They go on to note that their etiological framework is the BPS model, but yes, although phrases like 'emotional disorder' and 'personality traits' get thrown around freely, they suggest they are moving away from a 'purely psychological model'.

In this model, FMD is conceived as an involuntary but learnt habitual movement pattern driven by abnormal self-directed attention. We emphasise that this is commonly triggered by physical or psychophysiological events such as injury, illness, pain and dissociation with panic and is mediated by illness beliefs and expectation. Life events, emotional disorder and personality traits are relevant in understanding and treating some patients with FMD, especially in cases where a clear link exists between mood/anxiety and symptom exacerbation. However, our recommendations, in keeping with revised criteria in the Diagnostic and Statistical Manual of Mental Disorders fifth edition (in DSM-5),12 move away from an assumption that ‘recent stress’ and a purely psychological model are essential to understand and treat patients with FMD.

This is the evidence they cite:

In a recent systematic review of physiotherapy for FMD,3 only 29 studies were identified with a combined total of 373 patients (only seven studies had more than 10 participants). Despite their limitations, these studies show promising results for physiotherapy (and physical rehabilitation), with improvement in 60–70% of patients. In addition, a recently published randomised trial of 60 patients showed highly encouraging results from a 3-week inpatient physical rehabilitation intervention in patients with functional gait disorder (7 point improvement on a 15 point scale).1

1. Jordbru et al
Psychogenic gait disorder: a randomized controlled trial of physical rehabilitation with one-year follow-up. J Rehabil Med 2014
3. Nielsen, Stone, EdwardsPhysiotherapy for functional (psychogenic) motor symptoms: a systematic review. J Psychosom Res 2013


I thought the paragraphs about exercise and management of pain and fatigue were particularly interesting given the issue we are having with the Royal Colleges right now:

Non-specific graded exercise should be considered as part of all general rehabilitation programmes to address reduced exercise tolerance and symptoms of chronic pain and fatigue. There is some evidence for this in FMD.21 Success here is dependent on getting the intensity right to prevent exacerbation of symptoms and promote adherence/compliance with the programme. Graded exercise has been shown in large randomised trials to moderately improve outcomes in patients with chronic fatigue syndrome22—a common accompaniment to FMD (see below)—and is likely to be beneficial to many patients.

You can see how a NICE guideline that specifically says that GET should not be used for chronic fatigue syndrome throws a rather large spanner in the works.

Persistent or chronic pain and fatigue are common in patients with FMD and often have a role in precipitating and maintaining symptoms. Preferably, the patient should have an understanding that these symptoms are all linked together as one problem (with many symptoms) rather than multiple separate illnesses. The core of evidence based treatments for pain and fatigue involve, as suggested for FMD, (1) a change in illness beliefs from perceiving symptoms as due to damage as potentially reversible; (2) recognising that chronic pain is not correlated with harm and (3) changing maladaptive behaviours, such as breaking cycles of over-activity and under-activity with graded exercise. It may be helpful to reformulate pain as another example of the nervous system sending out incorrect signals which, like FMD, can be helped by ‘re-training’ (ie, establishing more normal motor-sensory feedback). A number of good quality evidence based guides to pain management education and helpful patient resources exist.24,25

 

[Peter T]

There was also some discussion of this in the thread

Management of functional communication, swallowing, cough & related disorders: consensus recommendations for speech & language therapy, 2021, Baker
https://www.s4me.info/threads/manag...for-speech-language-therapy-2021-baker.21311/

A considerable edifice is being built on speculation and belief rather than evidence.

 

[Peter T]

There is also a parallel piece on for Occupational Therapists

Nicholson C, Edwards MJ, Carson AJ, et al. Occupational therapy consensus
recommendations for functional neurological disorder. J Neurol Neurosurg Psychiatry
2020;91:1037–45.
https://jnnp.bmj.com/content/jnnp/91/10/1037.full.pdf

 

[Daisybell]

*********

 

[MSEsperanza]

It's interesting that they felt that there was not enough data to produce an evidence-based guideline. But they'll present some recommendations anyway, with the Methods section summarised as 'We had a meeting and we decided this seems about right'.

Yes, interesting and concerning. At least the article is in the rubric "Viewpoint".

Whereas... -- not sure if this RCP journal's "practical review" from January 2021 has been posted already elsewhere on the forum:

A practical review of functional neurological disorder (FND) for the general physician
Karina Bennett, Clare Diamond, Ingrid Hoeritzauer, Paula Gardiner, Laura McWhirter, Alan Carson, Jon Stone
Clinical Medicine Jan 2021, 21 (1) 28-36; DOI: 10.7861/clinmed.2020-0987

 

[Peter T]

Yes, interesting and concerning. At least the article is in the rubric "Viewpoint".

Whereas... -- not sure if this RCP journal's "practical review" from January 2021 has been posted already elsewhere on the forum:

A practical review of functional neurological disorder (FND) for the general physician
Karina Bennett, Clare Diamond, Ingrid Hoeritzauer, Paula Gardiner, Laura McWhirter, Alan Carson, Jon Stone
Clinical Medicine Jan 2021, 21 (1) 28-36; DOI: 10.7861/clinmed.2020-0987

The links to this article cited above

A practical review of functional neurological disorder (FND) for the general physician
https://www.rcpjournals.org/content/clinmedicine/21/1/28/tab-article-info

and the full text as a pdf
https://www.rcpjournals.org/content/clinmedicine/21/1/28.full.pdf?download=true

 

[Trish]

I know nothing about functional motor disorders and what sort of treatment people with them find helpful, but I am very wary of assuming fatigue suffered by people with these disorders has anything to do with ME/CFS.

If there were such a big overlap as to warrant the inclusion of ME/CFS in this paper, surely the reverse would be true, and research on ME/CFS would list functional motor disorders as a common co-morbidity. As far as I know that's not the case.

It looks to me more like huge assumptions being made here on the basis that everything the BPS people get involved in ends up with the same theory of false beliefs and phobias and past traumas, and the same GET/CBT being prescribed.

 

[Jonathan Edwards]

We recommend that physiotherapy treatment is based on a biopsychosocial aetiological framework.

This is just bad medicine. In modern medicine we do not base treatment on theoretical frameworks.
We base it on evidence of safety and efficacy.

It is salutary to compare this statement with what is in the draft NICE guideline. The latter says nothing about basing treatment on theoretical frameworks and specifically recommends against frameworks such as deconditioning.

 

[MSEsperanza]

Whereas... -- not sure if this RCP journal's "practical review" from January 2021 has been posted already elsewhere on the forum:

A practical review of functional neurological disorder (FND) for the general physician
Karina Bennett, Clare Diamond, Ingrid Hoeritzauer, Paula Gardiner, Laura McWhirter, Alan Carson, Jon Stone
Clinical Medicine Jan 2021, 21 (1) 28-36; DOI: 10.7861/clinmed.2020-0987

Forum thread here.

Thread on the related editorial here.

 

[MSEsperanza]

If there were such a big overlap as to warrant the inclusion of ME/CFS in this paper, surely the reverse would be true, and research on ME/CFS would list functional motor disorders as a common co-morbidity. As far as I know that's not the case.

Unless they think motor fatigue belongs to the same type of disorder ... -- but maybe they do?

 

[chrisb]

It is salutary to compare this statement with what is in the draft NICE guideline

Ah, but is that in the pre-publication draft? He asks, innocently.

 

[rvallee]

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

This is completely self-contradictory.

High school essays have higher requirements of not being self-contradictory.

 

[Jonathan Edwards]

Ah, but is that in the pre-publication draft? He asks, innocently.

It's in what counts, he said innocently.