Functional Motor Disorders

VIDEO

https://www.youtube.com/watch?v=ZhB3UQLtMtg

THEN

Historically:

-Historically called "Conversion Disorders," "Psychogenic Movement Disorders," or "Somatoform Disorders"

-Movement disorder w/o organic cause

i.e. No damage & No disease process

-Considered psychologic disorder... "they're a little crazy"

-The problem witht the historic approach

Denial of patient's felt & experienced symptoms

"You're doing this to your self" or "This is your fault"

Undermines our education & treatment of the patient

NOW

Now:

-Rebranding in process (from 2013 to 2018)

Edwards, et al. 2013

"From Psychogenic Movement Disorder to Functional Movement Disorder: It’s Time to Change the Name"

Hallet, el al. 2018

"The most promising advances in our understanding and treatment of functional (psychogenic) movement disorders"

-Movement disorder significantly changed by distraction OR placebo maneuvers

EPIDEMIOLOGY

-20% of patients in movement disorder specialty clinics are diagnosed with FMD

-Functional weakness incidence is 3.9/100,000

-Biology + Psychology + Sociology

BIOLOGICAL RISK FACTORS

-Biological or Chemical abnormalities

Either organic disease or abnormal physiology

Sleep deprivation, drug use, anxiety, depression, emotional distress

Possibly abnormal immunologic response

Physical injury leading to chemical imbalance

-Cause: Plasticity in the CNS leading to negative habituation

Hardware intact, Software malfunction

PSYCHOLOGICAL RISK FACTORS

-Predisposition

Emotional disorders, Personality disorders, Traumatic childhood experiences, Abnormal personality traits, Poor coping strategies

-Onset: Acute following negatively perceived life event

-Perpetuation

Perception of symptoms as permanent

Illness beliefs... "I'm disabled" or "I'm damaged"

Fear avoidance... "If I fall I'll get hurt more" or "I'm fragile"

Poor buy-in... "They think I'm crazy" or "They don't know what's wrong with me"

SOCIAL RISK FACTORS

-Predisposition

Life difficulties

Childhood neglect/abuse

Socio-economic hardship

Poor learned coping skills

-Perpetuation

Motivation: due to beliefs about the "sick role" or the "victim role," legal compensation, reliance on pharmaceutical treatment, reinforcment via negative support structures

Poor self-reliance

Poor buy-in to PT

DIAGNOSTIC CRITERIA

DIAGNOSIS METHODS

-PT may be first to identify S/S

-Suspicion: refer & treat

-Neurologist makes diagnosis

Incongruency amongst healthcare team may exacerbate issue

Diagnosis is based on probability not definitive test

-Patient awareness of diagnosis OR dual diagnosis

i.e. a fibromyalgia patient w/ a movement abnormality

SUBJECTIVE CLUES

-Traumatic Stressors (Emotional, Physiological, Mechanical)

-Abrupt Onset

-Static Non-Progressive Limitations

*Deficits may be inconsistent or evolving

-Hx of Spontaneous Remission OR PMH of FMD

-Allied Health Worker

Not frequent, but more correlative than it should be

OBSERVATION

-Resting or essential tremor that is distractible

Cognitive tasks

Bimanual tasks

Contralateral tasks

VIDEO

https://www.youtube.com/watch?v=PiMKtNiVeZY&feature=youtu.be

SPECIAL TESTING

-Functional Weakness has central origins despite absence of pathology

-Hoover Sign... hip ext present only when indirectly tested (pictured)

-Hip abductor sign... hip abd present only when indirectly tested

HOOVER'S SIGN

https://www.youtube.com/watch?v=F4Fk_ZzCX6A&feature=youtu.be

FRAMEWORK

-Clear diagnosis from MD

-Educate

-Demonstrate normal movement can occur

-Divert attention & retrain movement

-Change maladaptive behaviors

BIOPSYCHOSOCIAL

-Earn their trust & build rapport

Your symptoms are real... not imagined

Don't deceive them or cast judgment

Success builds trust

Trust allows for pushing them in the future

-Establish that change is possible

Problem = function of nervous system NOT damage to it

Make improvement an expectation... the future will be better

-Patient's openness to diagnosis + desire for change

BUY-IN

-www.neurosymptoms.org

-Demonstrate that normal movement is possible

Demo functional weakness & distractibility

Get wins early

-Minimize hands on treatment

Build independence & autonomy

-Target functional limitations NOT deficits

Bear weight early & often

Avoid simplistic strengthening

DIVERT ATTENTION

ELLICIT OLD AUTOMATION

FALL RISK?

TECHNIQUES

UNILATERAL FOOT DROP

Conversion Disorder; an Unusual Etiology of Unilateral Foot Drop. Saeed Bin Ayaz, et al. 2015

-L DTRs:

L3/4 Patellar 2+ (WNL)

S1/2 Achilles 2+ (WNL)

-(-)EMG, (-)CT Scan

-E-Stim for 3 weeks failed

-PT + Cognitive-Behavior Therapy initiated

-Full recovery in 6 days

http://www.ant-tnsjournal.com/Mag_Files/24-2/003.pdf

-Acute onset w/ LLE N

-L MMT:

Hip flexion 2/5

Hip extension 2/5

Hip abduction 2/5

Knee flexion 2/5

Knee extension 2/5

DF 0/5

PD 0/5