Treatment of functional movement disorders should be patient-centered
Presenter: David L. Perez, MD, of Harvard Medical School, Boston, MA
Diagnosis and treatment of functional movement disorders. Session C64. Presented April 23, 2023.
The challenge of treating functional movement disorders (FMD) in neurology is to understand that focusing only on the signs and disease features does not lead to a patient-centered treatment plan, according to presenter David L. Perez, MD, Harvard Medical School, Boston, MA. Creating and implementing that plan requires a patient-centered care team that includes neurologists, neuropsychiatrists, psychiatrists, physical therapists, occupational therapists, speech and language therapists, social workers and community support, psychologists, clinical neuroscientists and psychologists, cognitive and affective neuroscientists, and genetics/epigenetic specialists.
“Think about holistic-centered treatment and bring in colleagues when appropriate,” he advised.
The biopsychosocial model approach to functional neurological disorders has been shown to aid in the development of a patient-centered treatment plan. “We need to bring the biopsychosocial model to FMD,” he said. “And we need to know the risk factors at play in a specific patient.” He noted that FMD is very common in neurology clinics, and the effects of treatment are similar to other approaches in neurology.
The approach begins with patient communication and learning how receptive the patient is to the diagnosis. “Prior to initiation of first-line treatments, such as physical therapy and psychotherapy, there needs to be at least modest buy-in on the patient’s part,” said Perez. “A common error is to start treatments even though the patient has clearly not been receptive to the diagnosis.” If the patient expresses major doubt about the diagnosis or treatment, it may be appropriate to encourage a review of educational materials from sources such as www.neurosymptoms.org, which includes patient testimonials, along with a planned follow-up. Avoid moving reflexively to other treatment steps.
After providing education on FMD, the initial phase of treatment is three pronged: physical therapy, psychotherapy, and medications. Physical treatment is given for physical symptoms and directed by physical therapists, occupational therapists, and speech and language therapists. Psychotherapy may include cognitive behavioral therapy and alternative psychotherapies, including dialectical behavioral therapy and prolonged exposure therapy; it may be considered if psychiatric comorbidities are prominent. Medications can be given for other psychiatric and neurologic symptoms, such as migraine, insomnia, and major depression.
Physiotherapy for FMD should follow certain general principles: limit hands-on treatment to facilitate rather than support and goal-directed rehabilitation focusing on function and automatic movement. This includes, for example, walking rather than the impairment (weakness) and controlled movement (strengthening exercises).
Physical therapy interventions can utilize neuroscience constructs, such as cognitive or motor dual tasks (subtraction by 7s or leg tapping), sensory dual tasks (manipulate foam in hand), or motor task changes (sliding vs walking). “Encourage an external focus of attention,” said Perez. “Physical therapy for FMDs is different than physical therapy for poststroke recovery.”
A sensory modulation program provides a personalized, balanced, paced schedule of sensory-based activities. The aim is to achieve a “just right” level of arousal appropriate for the task at hand. Some strategies include regularly performed activities that promote self-regulation (use of a weighted blanket at night); activities to keep the body comfortable and focused (chewing gum, using a fidget ball); adaptations to surroundings (reorganizing furniture, lighting a candle); and fun activities (cooking, painting).
Overcoming function neurological symptoms takes a five-areas approach that focuses on symptoms, thoughts, behaviors, emotion, and life experiences. He noted that adding cognitive behavioral therapy-based guided self-help to the usual care improves self-reported general health in patients with functional neurologic symptoms. “As triggers and warning signs for periods of worsening functional movements are identified, this provides an opportunity to use relaxation techniques,” said Perez.
References
Perez DL. Treatment of functional movement disorders. Presented at the 75th Annual Meeting of the American Academy of Neurology, April 23, 2023.
Aybek S, Perez DL. Diagnosis and management of functional neurological disorder. BMJ 2022; 376:o64. doi:10.1136/bmj.o64.
Finkelstein SA, Adams C, Tuttle M, et al. Neuropsychiatric treatment approaches for functional neurological disorder: A how to guide. Semin Neurol 2022; 42(2):204-224. doi:10.1055/s-0042-1742773. Epub 2022 Feb 21.
Saxena A, Paredes-Echeverri S, Michaelis R, et al. Using the Biopsychosocial Model to guide patient-centered neurological treatments. Semin Neurol 2022; 42(2):80-87. doi:10.1055/s-0041-1742145. Epub 2022 Feb 3.
Sharpe M, Walker J, Williams C, et al. Guided self-help for functional (psychogenic) symptoms: A randomized controlled efficacy trial. Neurology 2011; 77(6):564-72. doi:10.1212/WNL.0b013e318228c0c7. Epub 2011 Jul 27.
Disclosures
David Perez has received honoraria from Harvard Medical School for continuing medical education lectures on functional neurological disorders. He serves on the editorial board of Epilepsy and Behavior and Brain and Behavior. He has received honoraria from Cobel Darou, Raymand Rad Medial Group, and Tekaje and has received book royalties from Oxford University Press.