Individualized Physiotherapy of Upper Body Functional Movement Disorder – Two Illustrative Cases

Introduction

Functional neurological disorders are common and multiple neurological professions are engaged in their management [1]. One of the largest subgroups of functional neurological disorders are motor/movement disorders. Despite their great heterogeneity, they are all characterized by inconsistency in severity and phenomenology under attentional refocusing. As a second diagnostic pillar incongruency to other non-functional movement disorders and neuroanatomical rules has been proposed. However, there is an intensive discussion whether this term should be avoided, as it might just be another way of making a diagnose of exclusion and requires omniscience in clinical neurology [2]. Unfortunately, many patients are undiagnosed or have long diagnostic delays and thus receive no or delayed therapy, which is mostly unspecific [1]. Based on the biopsychosocial model, functional movement disorders are multifactorial in origin, which makes it essential for the specific physiotherapy to identify individual factors. Predisposing vulnerabilities, e.g. in the biological context of an “organic” disease, in the sense of an emotional disorder on a psychological level, or in the social context of a specific life event or difficulty. Precipitation mechanisms, e.g. in the biological context of a physical injury/pain or e.g. in the psychological context of a life event perceived as negative and unexpected. Perpetuating factors are described in the biological context as plasticity in the motor and sensory pathways of the CNS leading to habitual abnormal movements and deconditioning, or in the psychological context as abnormal perceptions of illness [3]. These factors influence the development and progression of the disorder and their processing helps to design a comprehensive and individualized therapy together with the patient. Therefore, specific physiotherapy follows a cognitive behavioral approach and differs from conventional neurological therapy concepts [3]. Of note, specifically targeted physiotherapy is considered a first-line treatment [4, 3, 5] and greatly differs from conventional physiotherapy concepts for neurological diseases [1]. However, only a few studies [3, 6, 7, 8] provided information on specific symptoms, e.g., functional tremor [7], but detailed descriptions and practical or real-world applications for the physiotherapeutic treatment of functional movement/motor disorders that go beyond functional gait disorders or affect the upper body are mostly missing.

For this reason, we here describe two illustrative cases demonstrating the applicability of previous findings and their adaptation to functional disorders other than gait disorders.

Case Settings

Based on two illustrative cases, we demonstrate how specific physiotherapy can be practically applied in an outpatient setting for patients with functional movement disorders of the face and upper body. Patients received between 10 and 20 treatment sessions, each lasting approximately 60 minutes. Core elements of the specific physiotherapy were adapted from consensus recommendations [3] and included 1) psychoeducation about the clinical picture to promote its acceptance and understanding, 2) redirecting attention to foster movement (re)learning by promoting automated movements and 3) establishing awareness of self-efficacy of symptom reduction. A detailed summary of the clinical and therapeutic characteristics of both patients is given in Table 1.

Case 1 «Eyes on the juggle»

Case 2 «Back to society with touch and hearing»

Discussion

Our case series demonstrate that disease-specific physiotherapy in an outpatient setting is feasible and effective in patients with various functional movement disorders of the face and upper body. Such treatment differs from conventional physiotherapy applied for non-functional neurological disorders, with its core element being not to focus on dysfunction/ affected limbs. Thus, manual therapy or strength training, focussing on movement execution and control of the affected body region, are inefficient and can instead maintain and even worsen symptoms [3]. In contrast, physiotherapy for functional movement disorders educates patients to control and redirect attention away from the symptomatic body part, thus reducing excessive pathological extrinsic control and fostering more automatic, intrinsic movements [3, 5, 4]. For this purpose, at the beginning of our training, we analysed which stimulus quality, e.g., acoustic, tactile, or visual, helped the individual patient best to redirect her attention easily and effectively away from the symptomatic body region.

Moreover, our treatment comprised psychoeducation. We enabled the patients to realize that there are certain mechanisms in their daily life that alleviated their symptoms (e.g., hobbies) and included them in our treatment. Therefore, interests and personal preferences should be integrated into treatment sessions when designing individual therapeutic strategies. With the help of visual feedback (e.g., mirror, video), patients experienced their agency, which increased their self-confidence and encouraged them to increase their training level, i.e., trying out new motor tasks. Patients reported key moments resembling turning points in coping with the disease. Importantly, patients described that our training not only reduced motor symptoms but also had, albeit less so, positive effects on fatigue, mood, concentration, and pain.

It is important to keep in mind that in our experience patients with functional movement disorders tend to over-perform once they notice symptom reduction. Newly gained control of action can lead to increased expectations, pressure, and stress, which in turn can result in relapses. In such situations focussing on psychoeducation is very helpful. Thus, the physiotherapist can enable the patient to identify disease mechanisms that might have contributed to the current symptom exacerbation and ensure that the patient fully understood the disease and its perpetuating factors. Moreover, including pacing, graded exercise, and relaxation strategies can help to better cope with psychological stressors [3, 5, 6, 9].

Another aspect for relapse of symptoms could be that stimuli and training techniques became too trivial to effectively capture attention and require adaptation to keep the attention span high enough. Thus, a gradual increase of performance difficulty is recommended.

Our case series resemble two different responses to specialized physiotherapeutic treatment. The first patient totally recovered from symptoms whereas the second one used the treatment to temporarily suppress her symptoms. Thus, the latter patient continued to have symptoms especially when confronted with disease-triggering factors during her daily life. It emphasizes that a central understanding and acceptance of the illness and its therapy are key mechanisms to achieve consistent symptom relief. Therefore, it is crucial to facilitate interdisciplinary exchanges with other disciplines involved in the treatment of the same patient. It is highly recommended to ensure a uniform treatment according to the same guidelines. A broad range of information and training for therapists and other healthcare professionals is needed to raise awareness of functional neurological disorders and to establish nationwide therapeutic services.

Financial Disclosures for the previous 12 month

Christof Degen-Plöger

Annemarie Reincke

Christina Bolte

Carl Alexander Gless

Kerstin Lüdtke

Alexander Münchau

Kirsten E. Zeuner

Anne Weissbach

Ethics and Consent

Approval of the local ethic committee of the University of Lübeck, Germany was obtained for the study (22-008). Informed consent of all patients was obtained prior to inclusion of the study. We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this work is consistent with those guidelines.

Funding Information

This work was support by the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG, WE5919/4-1).

Competing Interests

The authors have no competing interests to declare.

Author Contributions

1. Research project: A) Conception, B) Organization, C) Execution.

2. Manuscript Preparation: A) Writing of the first draft, B) Review and Critique.

Author 1 Christof Degen-Plöger: 1A, 1B, 1C, 2A

Author 2 Annemarie Reincke: 1A, 1B, 2B

Author 3 Christina Bolte: 1A, 1B, 1C, 2B

Author 4 Carl Alexander Gless: 1A, 2B

Author 5 Kerstin Lüdtke: 1A, 2B

Author 6 Alexander Münchau: 2B

Author 7 Kirsten E. Zeuner: 1A, 2B

Author 8 Anne Weissbach: 1A; 1B, 1C, 2B