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Article history:
Received 19 July 2011
Received in revised form
5 September 2011
Accepted 14 October 2011
Background: Functional (psychogenic) gait and other movement disorders have proven very difcult to treat.
Objectives: Describe the Mayo Clinic functional movement disorder motor-reprogramming protocol
conducted in the Department of Physical Medicine and Rehabilitation (PMR), and assess short-term and
long-term outcomes.
Design: Historical-cohort-study assessing non-randomized PMR intervention.
Setting: Tertiary care center.
Patients: Interventional group: 60 consecutive patients with a chronic functional movement disorder that
underwent the PMR protocol between January 2005 and December 2008. Control group: age- and sexmatched patients with treatment-as-usual (n 60).
Interventions: An outpatient, one-week intensive rehabilitation program based on the concept of motorreprogramming following a comprehensive diagnostic neurological evaluation, including psychiatric/
psychological assessment.
Main outcome measures: Improvement of the movement disorder by the end of the week-long program
(patient- and physician-rated), plus the long-term outcome (patient-rated).
Results: Patient demographics: median symptom duration, 17 months (range, 1e276); female predominance (76.7%); mean age 45 years (range, 17e79). Physician-rated outcomes after the one-week treatment program documented 73.5% were markedly improved, nearly normal or in remission, similar to the
patient-ratings (68.8%). Long-term treatment outcomes (patient-rated; median follow-up, 25 months)
revealed 60.4% were markedly improved or almost completely normal/in remission, compared to 21.9%
of controls (p < 0.001).
Conclusions: Short-term and long-term successful outcomes were documented in the treatment of
patients with functional movement disorders by a rehabilitative, goal-oriented program with intense
physical and occupational therapy. The rapid benet, which was sustained in most patients, suggests
substantial efcacy that should be further assessed in a prospective, controlled, clinical trial.
2011 Elsevier Ltd. All rights reserved.
Keywords:
Psychogenic movement disorder
Conversion disorder
Functional movement disorder
Physical therapy
1. Introduction
Functional movement disorders (FMD) are characterized by
abnormal motor behaviors that are inconsistent with an organic
etiology. These may resemble organic tremor, dystonia, other
hyperkinetic conditions, gait disorders, paresis or combinations.
These may account for 3% [1] to 15% [2] of patients seen by
* Corresponding author. Tel.: 1 507 284 2511; fax: 1 507 538 6012.
E-mail address: eahlskog@mayo.edu (J.Eric Ahlskog).
1353-8020/$ e see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.parkreldis.2011.10.011
248
Once diagnosed, FMD present an enormous therapeutic challenge. Prognosis is often characterized as poor, with most patients
failing to substantially improve, especially among those with
symptoms persistent beyond one year [4e6]. Even among series
that are more optimistic, substantial numbers of patients have
persistent disability [2].
With the notoriety accorded similar disorders by Freud more
than a century ago [7], therapeutic strategies have focused
especially on psychiatric/psychological interventions. In the
current era, psychotherapy, antidepressant and other psychoactive medications are typically an early treatment approach
[8e10]. Although many publications have attested to the benets
of psychotherapeutic and other psychological/psychiatric strategies, our experience has not been as gratifying, and the pessimistic outcomes from movement clinics are consistent with that
perception [4e6].
Physical therapy has also been advocated for such patients,
although specic strategies have been left to individual
treating therapists [11]. In our experience many of these
patients have already undergone physical therapy, but failed
to substantially benet; thus, generic physical therapy in the
absence of a specic treatment-program has not been
successful.
In fact, there is no consensus about treatment of FMD [12].
Clinicians generally nd this to be a very unsatisfying aspect of their
practice, with frustration among both patients and physicians. This
was our collective experience for many years; we could diagnose,
but not effectively treat.
A number of years ago, we recognized that functional speech/
voice disorders were highly responsive to a behavioral motor reprogramming approach by our Mayo Speech-Language Pathology
colleagues [13,14]. In fact, a parallel approach was being used
successfully, but inconsistently in our Physical Medicine and
Rehabilitation (PMR) Department as treatment for FMD. Encouraged by these outcomes, we developed a more structured motorreprogramming treatment protocol for FMD patients implemented in the PMR Department.
Such motor-reprogramming in the context of physical medicine
has been used for treatment of FMD with limited precedents
[15,16]. The approach involves specically focusing on the aberrant
movements and postures, breaking these down into the individual
motor components and gradually reconstructing more normal
motor patterns. With this strategy, appropriate motor pattens are
reinforced and inappropriate movements are ignored (extinguished). By gradually rebuilding or re-shaping motor movements,
more normal pattens can be achieved. Our initial treatment
protocol arbitrarily conned this to one intensive week of twicedaily physical and occupational therapy, after the physiatrist had
initially designed the therapy program for that patient. Our initial
experience suggested that one week was sufcient. This has been
utilized as the primary therapeutic strategy for the treatment of
FMD patients diagnosed in our movement disorders clinic since
2005.
We now describe our experience with the rst 60 consecutive
patients who were diagnosed with an FMD in our Neurology
Department and subsequently treated with this approach. This was
exclusively designed as a therapeutic PMR protocol for the benet
of our patients, and we had no a-priori plan to formally study/
report the outcomes. The initial follow-up called for reassessment
only at the end of the treatment week. As substantial efcacy
became apparent, we elected to better assess outcomes, which
included adding phone- and letter-follow-up to tabulate longerterm responses. For comparison we also included a control-group
of patients who were similarly diagnosed, but not treated with
this approach.
2.2. Treatment-group
The rst 60 consecutive patients who met the following criteria constituted the
treatment group: (a) given an clinically-established diagnosis of a functional
movement disorder, consistent with criteria of Fahn and Williams [17], and counseled about this; (b) completed whatever diagnostic testing thought appropriate
prior to initiating the treatment protocol; (c) completed at least 3 days of the 5-day
PMR treatment protocol. Excluded from this analysis were cases where the diagnosis
was unclear (n 16), or where there were major departures from the PMR protocol
(n 21).
2.4. Intervention
The patients specic PMR program was initially designed by the physiatrist on
the rst protocol day. We suspected that a crucial component for success was the
initial PMR interaction and counseling before the motor therapy ensued. This
counseling included expressed condence that this approach had a good likelihood
of succeeding, which was important for two reasons: (a) many patients had already
failed physical therapy programs; (b) promoting a positive attitude. The PMR
strategy was described in operational terms, such as the presence of a disconnect
between the patients normal brain motor program and the normal nerves/muscles
used to carry out the movement; thus, the therapy would focus on eliminating that
disconnect. No attempt was made to explain how the disconnect initially
occurred, but rather the emphasis was on re-establishing the normal motor
program.
Following the initial counseling, the PMR treatment plan was implemented with
twice-daily physical/occupational therapy for 5 consecutive days. If a functional
speech disorder was present, consultation and therapy with a speech-language
pathologist was also done during this week (N 7; speech outcomes not included
in current analysis).
An evaluation by a psychiatrist or psychologist was part of the protocol, usually
done after the diagnostic workup was completed and typically early in the treatment
week. This focused on identifying: (a) possible causes or contributory factors, such
as an abuse history; (b) other psychological issues, such as depression or anxiety,
that might interfere with the program and recovery. While most of the patients met
DSM-IV criteria for a conversion or somatoform disorder [18], the psychologist/
psychiatrist reinforced the program model that targeted relearning normal motor
function, rather than focusing on psychological factors that preceded the motor
problem.
The rehabilitation program was aimed at establishing normal movement
patterns, while ignoring abnormal movements, taking a step-by-step strategy,
modied from schemes previously described in the PMR literature [15,16]. Motor
dysfunction was objectied in operational rather than psychological terms. The
motor reprogramming strategy began with establishing very elementary movements in the affected limb or body region, and building on those. Often, distracting
motor tasks were employed to extinguish abnormal movements (such as tapping
the ngers of the unaffected hand in a patient with unilateral tremor, or bouncing
a balloon while working on trunk stability/standing balance). As simple movements were satisfactorily performed, appropriate motor complexity was added,
gradually approximating motor-normality. Positive gains were verbally reinforced.
Abnormal movements were ignored, although major and frequent adventitious
intrusions during the PMR sessions suggested the advisability for rest periods.
Repetition was thought important to lock-in the gains. The necessity of continued/
ongoing practice of these principles beyond completing the PMR week was
emphasized.
3. Results
3.1. Demographics (Table 1)
The mean age of the 60 patients in the treatment cohort was 46
years (range 17e79), with female predominance (76.7%) and
Table 1
Baseline demographic data and characteristics of study patients and controls.
Variables
Patients
(n 60)
Controls
(n 60)
Gender F, n (%)
Age, mean (range)
Second neurological opinion, n (%)
Referral diagnosis, n (%)
Neurologic disorder
Conversion disorder
Indeterminate
Categories of movement disorders, n (%)
Gait disorders
Hyperkinetic disorders
Paresis
Paroxysmal disorders
Symptom duration in months,
median (range)
Onset less than 12 months, n (%)
Acute onset, n (%)
Trigger factor, n (%)
Acute depression, n (%)
Lifetime history of depression, n (%)
Other psychiatric diagnosis (e.g. anxiety,
personality disorder, PTSD), n (%)
Current treatment with antidepressive
medication, n (%)
Diagnosis of chronic pain disorder, n (%)
Employment status, n (%)
Employed
Unemployed
Work disabled
Other (e.g. retired, student)
History of sexual abuse, n (%)
Family history of alcohol abuse in
parents or siblings, n (%)
46 (76.7)
45 (17e79)
57 (95.0)
46 (76.7)
47 (21e85)
58 (96.7)
24 (42.1)
14 (24.6)
19 (33.3)
24 (41.4)
3 (5.2)
31 (53.4)
24
26
6
4
17
(40.0)
(43.3)
(10.0)
(6.7)
(1e276)
31
17
6
6
18
(51.7)
(28.3)
(10.0)
(10.0)
(1e252)
24
21
18
18
26
25
(40.0)
(35.5)
(30.0)
(30.0)
(43.3)
(41.7)
25
22
12
11
44
13
(41.7)
(36.7)
(20.0)
(18.3)
(73.3)
(21.7)
p-value
1.0
0.38
0.65
0.001
249
0.37
0.89
0.85
0.84
0.21
0.14
<0.001
0.02
34 (56.7)
30 (50.0)
0.46
19 (31.7)
17 (28.3)
0.69
0.21
20
9
18
13
17
19
18
3
26
13
13
20
(33.3)
(15.0)
(30.0)
(21.7)
(28.3)
(31.7)
(30.0)
(5.0)
(43.3)
(21.7)
(21.7)
(33.3)
0.48
0.85
250
Fig. 1. Short & long-term outcomes after completion of PMR protocol. 1A. Initial
outcomes (after completion of PMR program; values in percent). 1B. Self-rated longterm outcomes (questionnaire, phone followup; values in percent).
Table 3
Predictors of successful outcome with the PMR protocol.
3A. acute outcome (end of treatment week; n 60)
Table 2
Long-term follow up of patients and controls.
Variable
Patients
(n 48)
25 (10e64) 33 (11e57)
43 (89.6)
e
42 (87.5)
28 (87.5)
Controls
(n 32)
(8.3)
(16.7)
(14.6)
(22.9)
(37.5)
29 (60.4)
3
15
15
15
21
(6.3)
(31.2)
(31.2)
(31.2)
(43.8)
15 (31.3)
3 (6.3)
14
6
5
3
4
0.002
1.0
(43.8)
(18.7)
(15.6)
(9.4)
(12.5)
7 (21.9)
11
7
8
6
26
(34.3)
(21.9)
(25.0)
(18.8)
(81.3)
16 (50.0)
4 (12.5)
Female gender
Age under 60
Symptom onset < 1 year
Acute onset
Trigger factor
Absence of acute depression
Absence of depression history
Absence of chronic pain
Sexual abuse history
78.3
73.5
83.3
81.0
83.3
78.6
82.4
78.1
76.5
p-value
<0.001
4
8
7
11
18
Variable
2.7
1.0
2.5
1.9
2.2
2.3
2.9
2.1
1.3
(0.8e9.6)
(0.2e4.5)
(0.7e8.9)
(0.5e6.8)
(0.6e9.1)
(0.7e7.7)
(0.9e9.5)
(0.6e6.8)
(0.3e4.6)
0.12
0.96
0.15
0.33
0.25
0.16
0.07
0.23
0.73
<0.001
0.019
<0.001
0.09
0.33
Variable
Good outcomea
in %
Odds ratio
p-value
Female gender
Age under 60
Symptom onset < 1 year
Acute onset
Trigger factor
Absence of acute depression
Absence of depression history
Absence of chronic pain
Sexual abuse history
68.4
67.6
70.0
66.7
76.9
61.1
62.9
61.8
71.4
5.1
3.6
2.0
1.5
2.8
1.1
1.3
1.2
1.9
0.03
0.06
0.25
0.49
0.15
0.86
0.68
0.76
0.32
(1.1e23.0)
(0.9e14.9)
(0.6e6.7)
(0.5e5.1)
(0.7e11.9)
(0.3e4.2)
(0.4e4.1)
(0.3e4.3)
(0.5e7.6)
a
Good outcome markedly improved, almost completely normal or in
remission.
251