Functional movement disorder (FMD) is a complex neuropsychiatric syndrome, encompassing abnormal movements and weakness, and is a common cause of potentially disabling neurological symptoms. It is ...vital to recognize that FMD is a syndrome, with nonmotor manifestations negatively affecting a patient's quality of life. This review highlights a diagnostic algorithm, where a history suggestive of FMD is combined with the presence of positive signs on examination and appropriate investigations to make the diagnosis. Positive signs indicate internal inconsistency such as variability and distractibility, and clinical findings that are incongruent with other known neurological disease. Importantly, the clinical assessment acts as the first opportunity to allow patients to understand FMD as the cause for their symptoms. Accurate and early diagnosis of FMD is necessary given that it is a treatable and potentially reversible cause of disability, with significant risk of iatrogenic harm associated with misdiagnosis.
To describe the therapy approaches and clinical outcomes of an integrated care model for patients with functional movement disorder (FMD).PURPOSETo describe the therapy approaches and clinical ...outcomes of an integrated care model for patients with functional movement disorder (FMD).A retrospective chart review was conducted for all treated individuals with a primary diagnosis of FMD between January 2020 and July 2022. Patients received time-limited integrated therapy (n = 21) (i.e., simultaneous therapy delivered by psychiatry, neurology and physiotherapy), physiotherapy (n = 18) or virtual physiotherapy alone (n = 9). Primary outcomes included the Simplified-Functional Movement Disorders Rating Scale (S-FMDRS) and Clinical Global Impression-Improvement scale (CGI-I) collected at baseline and post-intervention.MATERIALS AND METHODSA retrospective chart review was conducted for all treated individuals with a primary diagnosis of FMD between January 2020 and July 2022. Patients received time-limited integrated therapy (n = 21) (i.e., simultaneous therapy delivered by psychiatry, neurology and physiotherapy), physiotherapy (n = 18) or virtual physiotherapy alone (n = 9). Primary outcomes included the Simplified-Functional Movement Disorders Rating Scale (S-FMDRS) and Clinical Global Impression-Improvement scale (CGI-I) collected at baseline and post-intervention.Forty-eight patients completed treatment (42% male; mean age, 48.5 ± 16.6 years, median symptom duration 30 months). The most common presentations were gait disorder, tremor and mixed hyperkinetic FMD. Common comorbidities included pain and fatigue. Three-quarters of patients had a comorbid psychiatric diagnosis. There was a significant reduction in S-FMDRS score following therapy (71%, p < 0.0001) and 69% had "much" or "very much" improved on the CGI-I. There was no difference between therapy groups. Attendance rates were high for both in-person (94%) and virtual (97%) visits.RESULTSForty-eight patients completed treatment (42% male; mean age, 48.5 ± 16.6 years, median symptom duration 30 months). The most common presentations were gait disorder, tremor and mixed hyperkinetic FMD. Common comorbidities included pain and fatigue. Three-quarters of patients had a comorbid psychiatric diagnosis. There was a significant reduction in S-FMDRS score following therapy (71%, p < 0.0001) and 69% had "much" or "very much" improved on the CGI-I. There was no difference between therapy groups. Attendance rates were high for both in-person (94%) and virtual (97%) visits.These findings support that a time-limited integrated model of care is feasible and effective in treating patients with FMD.CONCLUSIONSThese findings support that a time-limited integrated model of care is feasible and effective in treating patients with FMD.
Parkinson's Disease (PD) is a chronic and slowly progressive neurodegenerative disease. Team-based care is required to address and manage the diverse array of motor and non-motor symptoms in PD and ...related conditions. As the evidence base for the efficacy of non-pharmacological treatment of PD is expanding, many different centers are implementing interdisciplinary models of care with allied health professionals trained in PD.
In this review, the authors outline these various models and review the evidence for multidisciplinary approaches to care in PD. They begin by defining the terms used to describe the spectrum of multidisciplinary and integrated care models, followed by synthesizing the evidence for these models in PD. The authors then highlight some representative models to illustrate the variety of multidisciplinary care interventions: a community network-based model, a day-hospital model, an academic clinic-based model, and an intensive inpatient rehabilitation model. The authors synthesize these results and suggest directions for team-based PD care for the future.
The future of medicine is team-based care that is decentralized and integrated vertically and horizontally across health systems. Building an evidence base for these complex interventions will require alternative models of evaluation other than randomized controlled trials.
Neuroimaging studies have provided a major contribution to our understanding of the mechanisms of the placebo effect in neurological and psychiatric disorders. Expectation of symptom improvement has ...long been believed to play a critical role in the placebo effect, and is associated with increased endogenous striatal dopamine release in Parkinson's disease and increased endogenous opioid transmission in placebo analgesia. Evidence from positron emission tomography and functional magnetic resonance imaging studies suggests that expectations of symptom improvement are driven by frontal cortical areas, particularly the dorsolateral prefrontal, orbitofrontal, and anterior cingulate cortices. The ventral striatum is involved in the expectation of rewarding stimuli and, together with the prefrontal cortex, has also been shown to play an important role in the placebo-induced expectation of therapeutic benefit. Understanding the mechanisms of the placebo effect has important implications for treatment of several medical conditions, including depression, pain, and Parkinson's disease.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Functional movement disorder (FMD), the motor-dominant subtype of functional neurological disorder, is a complex neuropsychiatric condition. Patients with FMD also manifest non-motor symptoms. Given ...that patients with FMD are diagnosed based on motor phenotype, the contribution of non-motor features to the neuropsychiatric syndrome is not well characterized. The objective of this hypothesis-generating study was to explore potential novel, neuropsychiatric FMD phenotypes by combining movement disorder presentations with non-motor comorbidities including somatic symptoms, psychiatric diagnoses, and psychological traits.
This retrospective chart review evaluated 158 consecutive patients with a diagnosis of FMD who underwent deep phenotyping across neurological and psychiatric domains. Demographic, clinical, and self-report features were analyzed. A data-driven approach using cluster analysis was performed to detect patterns when combining the movement disorder presentation with somatic symptoms, psychiatric diagnoses, and psychological factors. These new neuropsychiatric FMD phenotypes were then tested using logistic regression models.
Distinct neuropsychiatric FMD phenotypes emerged when stratifying by episodic vs. constant motor symptoms. Episodic FMD was associated with hyperkinetic movements, hyperarousal, anxiety, and history of trauma. In contrast, constant FMD was associated with weakness, gait disorders, fixed dystonia, activity avoidance, and low self-agency. Pain, fatigue, somatic preoccupation, and health anxiety were common across all phenotypes.
This study found patterns spanning the neurological-psychiatric interface that indicate that FMD is part of a broader neuropsychiatric syndrome. Adopting a transdisciplinary view of illness reveals readily identifiable clinical factors that are relevant for the development and maintenance of FMD.
Objective:A growing interest in functional neurological disorders (FND) has led to the development of specialized clinics. This study aimed to better understand the structure and role of such ...clinics.Methods:Data were retrospectively collected from clinical records at three national referral centers, two specifically for motor FND and one for FND in general. Data were for 492 consecutive patients referred over a 9- to 15-month period: 100 from the United Kingdom clinic, 302 from the Swiss clinic, and 90 from the Canadian clinic. Data included symptom subtype and duration, comorbid pain and fatigue, disability, and treatment recommendations.Results:The mean age of the 492 patients was 44 years, and most (73%) were female. Most had a prolonged motor FND (mean symptom duration of 6 years); 35% were not working because of ill health, 26% received disability benefits, and up to 38% required a care giver for personal care. In the Swiss cohort, 39% were given a diagnosis of another somatic symptom disorder rather than an FND diagnosis. Pain was common in the United Kingdom (79%) and Canada (56%), as was fatigue (48% and 47%, respectively). Most patients (61%) were offered physiotherapy; referral to neuropsychiatry or psychology differed across centers (32%−100%).Conclusions:FND specialty clinics have an important role in ensuring correct diagnosis and appropriate treatment. Most patients with motor FND require specialized neurophysiotherapy. Patients readily accepted an integrated neuropsychiatric approach. Close collaboration between FND clinics and acute neurology facilities might improve early detection of FND and could improve outcomes.
Abstract Background Functional dystonia (FD) is a common subtype of functional movement disorder. FD can be readily diagnosed based on positive signs and is potentially treatable with rehabilitation. ...Despite this, clinical outcomes remain variable and a gold standard approach to treatment is lacking. Cases Here we present four cases of axial and limb functional dystonia who were treated with integrated rehabilitation and improved. The therapy approach and clinical outcomes are described, including videos. Literature review A literature review evaluated the published treatment strategies for the treatment of functional dystonia. Out of 338 articles, 25 were eligible for review and included mainly case reports and case series. Most patients received more than one treatment modality. Non‐invasive therapies, commonly physiotherapy and psychological approaches were mostly associated with positive outcomes. Multiple treatments commonly used in dystonia were used, including botulinum toxin injections, pharmacotherapy and surgery, leading to variable outcomes. Conclusion Therapy should be personalized to the clinical presentation. In challenging cases, initiation of a multidisciplinary approach may provide benefit regardless of etiology. Pharmacotherapy should be used judiciously, and surgical therapy should be avoided.
Full text
Available for:
FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
With continuing improvements in spatial resolution of positron emission tomography (PET) scanners, small patient movements during PET imaging become a significant source of resolution degradation. ...This work develops and investigates a comprehensive formalism for accurate motion-compensated reconstruction which at the same time is very feasible in the context of high-resolution PET. In particular, this paper proposes an effective method to incorporate presence of scattered and random coincidences in the context of motion (which is similarly applicable to various other motion correction schemes). The overall reconstruction framework takes into consideration missing projection data which are not detected due to motion, and additionally, incorporates information from all detected events, including those which fall outside the field-of-view following motion correction. The proposed approach has been extensively validated using phantom experiments as well as realistic simulations of a new mathematical brain phantom developed in this work, and the results for a dynamic patient study are also presented.
ABSTRACT
Background
Treatment of functional movement disorder (FMD) should be individualized, yet factors determining rehabilitation engagement have not been evaluated. Subspecialty FMD clinics are ...uniquely poised to explore factors influencing treatment suitability and triage.
Objectives
To describe our approach and explore factors associated with triage to FMD rehabilitation.
Methods
We conducted a retrospective chart review of 158 consecutive patients with FMD seen for integrated assessment by movement disorders neurology and psychiatry, with the purpose of triage to rehabilitation. Demographic and clinical variables were compared between patients triaged to therapy versus no therapy, and logistic regression was used to explore factors predictive of triage outcome. Change in primary outcome scores were analyzed.
Results
Sixty‐six patients (42%) were triaged to FMD therapy from July 2019 to December 2021. Patients triaged to therapy were more likely to have a constant movement disorder, gait disorder and/or tremor, hyperarousal, readiness for change, and people pleasing traits. Patients triaged to no therapy demonstrated persistent diagnostic disagreement, an inability to appreciate motor symptom inconsistency, low self‐agency, a propensity to dissociate, and cluster B traits. 90% of patients triaged to rehabilitation had improved outcomes.
Conclusions
The ability to “opt‐in” to FMD rehabilitation relies on different factors than those relevant to establishing a diagnosis. Unlike many other neurological disorders, a triage and treatment planning step is recommended to identify those likely to meaningfully engage at that time. Holistic assessment through a transdisciplinary lens, and working collaboratively with the patient is essential to prioritize symptoms, determine engagement, and identify treatment targets.
Full text
Available for:
FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
PDF
