Diagnosis Of Functional Movement Disorders Research Articles

Integrated model of care for functional movement disorder: targeting brain, mind and body

Purpose To describe the therapy approaches and clinical outcomes of an integrated care model for patients with functional movement disorder (FMD). Materials and Methods 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. Results 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. Conclusions These findings support that a time-limited integrated model of care is feasible and effective in treating patients with FMD.

Conclusion instead of exclusion-The clinical diagnosis of functional movement disorders

Functional neurological movement disorders are common in neurological practice and lead to ahigh degree of impairment and chronification. Affected patients usually receive adiagnosis with considerable delay and often do not get disease-specific treatment. The reasons for this delay are related to extensive diagnostic measures to exclude other nonfunctional neurological diseases. As aconsequence, functional movement disorders are typically communicated as diagnoses of exclusion, which makes it difficult for patients to understand and accept the diagnosis. This is particularly unfortunate, because in the majority of patients the diagnosis can be made with confidence based on clinical features, i.e., inconsistency and incongruence. The clarification of the symptoms and the resulting treatment options should be supplemented by patient-friendly explanations of the pathophysiological basis of the disease. In this way, patients are enabled to understand and accept the diagnosis. Moreover, it can put an end to the search for adiagnosis, which can sometimes take decades, and paves the way for treatment. Thus, the diagnosis by exclusion itself becomes the starting point for treatment and can itself have a therapeutic effect.

A Critical Appraisal of the Whack-a-Mole and Swivel Chair Signs in the Diagnosis of Functional Movement Disorders.

The demonstration of positive signs during neurological examination is a cornerstone of the diagnosis of functional movement disorders, however, the available data supporting the diagnostic value of some of these signs is limited. To determine the diagnostic value (sensitivity and specificity) of the "whack-a-mole" (WAM) and "swivel chair" (SC) tests in patients with functional movement disorders (FMD). We enrolled patients with functional and organic movements in the WAM test if they exhibited tremor, dystonia, myoclonus, chorea, or tics. For the SC test, patients with a gait disorder as their primary impairment were recruited. Two blinded movement disorder specialists rated the presence of these signs in edited videos. Inclusion criteria were met by 42 patients with FMD and 65 patients with organic movement disorders. Both tests demonstrated high specificity (means, 78% and 96%), but their sensitivity was low (means, 52% and 37%). Interobserver agreement for the WAM sign was 0.77 in the FMD group, against 0.28 in patients with organic movement disorders, whereas Movement Disorders Clinical Practice for Review Only for the SC sign was 0.69 in both groups. The present study indicates that physicians must be cautious in the application and interpretation of these clinical signs in the diagnosis of functional movement disorders, and they should be carefully considered and used as necessary.

Functional Movement Disorder; Importance of Proper Diagnosis and Treatment: A Case Report

Background: Dystonia is a common movement disorder with a wide range of aetiologies. Delays in the identification and initiation of effective treatments should be minimized to improve patient pain and optimize outcomes. This case report aims to underscore the successful treatment of chronic dystonia with the use of mood-modifying serotonin and norepinephrine reuptake inhibitors (SNRI), and encourage clinicians to consider a diagnosis of functional (psychogenic) movement disorder in patients with dystonia that is refractory to usual treatment.&#x0D; Case Report: This case report describes a 40-year-old woman who presented to a chronic pain clinic for pain related to cervical dystonia with associated head tremor. Her symptoms were refractory to nearly a decade of quarterly botulinum toxin injections. Based on careful evaluation of the patient’s history, a normal neurological examination, increased Generalized Anxiety Disorder Scale (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and Injustice Experiences Questionnaire (IEQ) scores, and unsuccessful symptom management with botulinum toxin A, a diagnosis of functional movement disorder (FMD) was made. Low-dose Cymbalta was initiated. The patient achieved near complete symptom remission and resolution of her chronic pain within 2 months and achieved near complete resolution in 2 years.&#x0D; Conclusion: A diagnosis of FMD should be considered in all patients with dystonia, but especially in patients who respond inadequately to botulinum toxin injections or other rehabilitation therapies. The treatment of comorbid psychiatric conditions can result in substantial benefits and remission from dystonia due to FMD.

Utility of Neurophysiological Evaluation in Movement Disorders Clinical Practice.

Quantitative and objective neurophysiological assessment can help to define the predominant phenomenology and provide diagnoses that have prognostic and therapeutic implications for movement disorders. Evaluate the agreement between initial indications and final diagnoses after neurophysiological evaluations in a specialized movement disorders center. Electrophysiological studies conducted for movement disorders from 2003 to 2021 were reviewed. The indications were classified according to predominant phenomenology and the diagnoses categorized in subgroups of phenomenology. A total of 509 studies were analyzed. 51% (259) of patients were female, with a mean age of 51 years (ranges 5 to 89 years). The most common reasons for referral were evaluation of functional movement disorders (FMD), followed by jerky movements, tremor and postural instability. Regarding FMD referrals, there was a diagnostic change in 13% of the patients after electrophysiological assessment. The patients with jerky movements as indication had a diagnosis other than myoclonus in 27% of them, and tremor was not confirmed in 20% of the cases. In patients with an electrophysiological diagnosis of FMD, it was not suspected in 30% of the referrals. Similarly, tremor was not mentioned in the referral of 17% of the patients with this electrophysiological diagnosis and myoclonus was not suspected in 13% of the cases. Electrophysiological assessment has utility in the evaluation of movement disorders, even in patients evaluated by movement disorders neurologists. More studies are needed to standardize the protocols between centers and to promote the availability and use of these techniques among movement disorders clinics.

Neuropsychiatric phenotypes in functional movement disorder.

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.

Simultaneous Detection and HER2 Profiling of Circulating Breast Cancer Cells in Clinical Patients Using a Rare Cell Sorter.

This study describes a rare cell sorter (RCS) method to detect circulating tumor cells (CTCs) and CTC clusters in whole blood without pretreatment. We collected samples from breast cancer patients at the University of Tsukuba Hospital. A total of 15 whole-blood specimens from patients with breast cancer were collected and analyzed via a microfluidics chip, fluorescence-conjugated antibody staining, and fluorescence microscopy. Of 15 total cases, eight were analyzed by RCS ver3 and seven were analyzed by RCS ver3.5 to reveal potential clinical differences in scanning methods. We then examined the HER2 status on 4 of the 15 patients using our RCS system. RCS efficiently detected all subtypes of CTCs and CTC clusters from the peripheral blood of cancer patients. The concordance rate of HER2 status between tissue and CTCs in 4 tested clinical samples was 100%. RCS is a non-invasive method that allows for simultaneous detection of CTCs, cluster presence, and surface marker (e.g., HER2) status. Frequent sampling is, thus, possible and the large amount of data obtained will be clinically useful to predict response to therapy as well as plan adjunct support therapies in cancer patients.

Hypermobile Ehlers-Danlos Syndrome: A Prodromal Subtype of Functional Movement Disorders?

The phenotypic diversity of functional movement disorders (FMD) is considered a reflection of its many etiological subtypes. Ehlers-Danlos syndrome (EDS), a joint hypermobility syndrome, also has variable phenotypes, which may include functional symptoms. To determine the prevalence of combined diagnoses of FMD and EDS. We searched our Electronic Medical Records for patients carrying diagnostic codes for EDS and FMD. Further data extraction was done through chart review. Of 11,621 patients evaluated from January 1, 2016 to May 1, 2022, 16 carried a diagnosis of EDS, of which 9 (56.3%) were also diagnosed with FMD. Conversely, a diagnosis of FMD was documented in 190 (1.6%), of whom 16 (8.4%) were diagnosed with EDS. In all EDS-FMD cases, the diagnosis of EDS preceded the onset and diagnosis of FMD. The co-occurrence of FMD and EDS is beyond chance, suggesting association. EDS may represent a prodromal subtype of, and share common pathophysiologic features with, FMD.

Movement disorders in COVID-19 times: impact on care in movement disorders and Parkinson disease.

The purpose of this review is to outline the impact of the COVID-19 pandemic on movement disorder holistic care, particularly in the care of people with Parkinson disease (PWP). As the pandemic unfolds, a flurry of literature was published regarding the impact of COVID-19 on people with Parkinson disease including the direct impact of infection, availability of ambulatory care, loss of community-based team care, and acceptability of telemedicine. COVID-19 has impacted the care of PWP in numerous ways. Recognizing infection in PWP poses challenges. Specific long-term complications, including emerging reports of long COVID syndrome is a growing concern. Caregivers and PWP have also been impacted by COVID-19 social isolation restrictions, with radical changes to the structure of social networks and support systems globally. In a matter of weeks, the global community saw an incredible uptake in telemedicine, which brought benefits and pitfalls. As PWP adapted to virtual platforms and the changing architecture of care delivery, the pandemic amplified many preexisting inequities amongst populations and countries, exposing a new 'digital divide'.

Opinions and clinical practice of functional movement disorders: a nationwide survey of clinicians in China

BackgroundThere is rare reports about opinions and clinical practice of functional movement disorders (FMD) in China. The present survey aimed to investigate the views of FMD in Chinese clinicians.MethodsThe Chinese version survey of FMD were conducted in nationwide practitioners by means of an online questionnaire.ResultsFour hundred and thirty-four Chinese clinicians completed a 21-item questionnaire probing diagnostic and management issues in FMD. More than 80% of respondents considered that atypical movement disorder, multiple somatizations, and emotional disturbance were essential or absolutely necessary for clinically definite diagnosis of FMD. About three quarters of respondents requested standard neurological investigations to rule out organic causes. Over half believed that prior diagnosis of an organic disorder (59.9%), lack of associated non-physiologic deficits (51.8%), and evidence of physical injury (50.0%) were ‘very influential’ or ‘extremely influential’ for a non-FMD diagnosis. The majority (77.4%) of the respondents may refer patients to a neuropsychiatrist or psychiatrist experienced in FMD, followed by psychologist or psychotherapist experienced in FMD (53.2%). However, lack of guidelines, physician knowledge, and training often limited clinicians’ ability in managing patients with FMD. Early diagnosis of FMD, identification and management of concurrent psychiatric disorder, and acceptance of the diagnosis by the patient were considered most important for predicting a favorable prognosis.ConclusionsOpinions and clinical practice of Chinese practitioners not only varied among Chinese neurologists, but also differed from international peers. Combined efforts are needed to promote related research and establish practice guidelines in China in the future.

Corticolimbic Modulation via Intermittent Theta Burst Stimulation as a Novel Treatment for Functional Movement Disorder: A Proof-of-Concept Study.

Neuroimaging studies suggest that corticolimbic dysfunctions, including increased amygdala reactivity to emotional stimuli and heightened fronto-amygdala coupling, play a central role in the pathophysiology of functional movement disorders (FMD). Transcranial magnetic stimulation (TMS) has the potential to probe and modulate brain networks implicated in neuropsychiatric disorders, including FMD. Therefore, the objective of this proof-of-concept study was to investigate the safety, tolerability and preliminary efficacy of fronto-amygdala neuromodulation via targeted left prefrontal intermittent theta burst stimulation (iTBS) on brain and behavioral manifestations of FMD. Six subjects with a clinically defined diagnosis of FMD received three open-label iTBS sessions per day for two consecutive study visits. Safety and tolerability were assessed throughout the trial. Amygdala reactivity to emotionally valenced stimuli presented during an fMRI task and fronto-amygdala connectivity at rest were evaluated at baseline and after each stimulation visit, together with subjective levels of arousal and valence in response to affective stimuli. The FMD symptom severity was assessed at baseline, during treatment and 24 h after the last iTBS session. Multiple doses of iTBS were well-tolerated by all participants. Intermittent TBS significantly decreased fronto-amygdala connectivity and influenced amygdala reactivity to emotional stimuli. These neurocircuitry changes were associated to a marked reduction in FMD symptom severity. Corticolimbic modulation via iTBS represents a promising treatment for FMD that warrants additional research.

Psychiatric Comorbidities in Functional Movement Disorders: A Retrospective Cohort Study

Functional movement disorders (FMD) are characterized by abnormal movements and motor symptoms incongruent with a known structural neurologic cause. While psychological stressors have long been considered an important risk factor for developing FMD, little is known about the impact of psychiatric comorbidities on disease manifestations or complexity. To compare characteristics of FMD patients with co-occurring mood and trauma-related psychiatric conditions to FMD patients without psychiatric conditions. We performed a retrospective cohort study of patients seen in the University of Colorado Health system between January 1, 2015 and December 31, 2019. Patients were included if they had a diagnosis of FMD, determined by ICD-10 coding and ≥1 phenomenology-related diagnostic code (tremor, gait disturbances, ataxia, spasms, and weakness), and at least one encounter with a neurology specialist. Fisher's exact and unpaired t-tests were used to compare demographics, healthcare utilization, and phenomenologies of patients with psychiatric conditions to those with none. Our review identified 551 patients with a diagnosis of FMD who met inclusion criteria. Patients with psychiatric conditions (N=417, 75.7%) had increased five-year healthcare utilization (mean emergency room encounters 9.9 vs. 3.5, P=0.0001) and more prevalent non-epileptic seizures (18.2% vs. 7.5%, P=0.001). Suicidal ideation (8.4%) and self-harm (4.1%) were only observed amongst patients with comorbid psychiatric conditions. Patients with FMD and comorbid psychiatric conditions require more healthcare resources and have greater disease complexity than patients without psychiatric illness. This may have implications for treatment of patients without comorbid psychiatric conditions who may benefit from targeted physiotherapy alone.

The neuroimaging evidence of brain abnormalities in functional movement disorders.

Neuroimaging has been pivotal in identifying and reframing our understanding of functional movement disorders. If accessible, it compensates for the limitations of the clinical exam and is especially useful where there is overlap of functional symptoms with classical presentations of disease. Imaging in functional movement disorders has increasingly identified structural and functional abnormalities that implicate hypoactivation of the cortical and subcortical motor pathways and increased modulation by the limbic system. Neurobiological theories suggest an impaired sense of agency, faulty top-down regulation of motor movement and abnormal emotional processing in these individuals. This framework challenges our traditional understanding of functional movement disorders as distinct from the deceptive term of 'organic' diseases and proposes that these conditions are not considered as mutually exclusive. This update summarizes the literature to date and explores the role of imaging in the diagnosis of functional movement disorders and in detecting its underlying molecular network.

Pediatric Functional Movement Disorders: Experience from a Tertiary Care Centre

Functional movement disorders (FMDs) pose significant diagnostic and management challenges. We aimed to study the socioeconomic and cultural factors, underlying psychopathology and the phenomenology of FMDs in children. The study is a retrospective chart review of 39 children (16 girls and 23 boys) who attended our neurology OPD and the movement disorders clinic at the National Institute of Mental Health and Neurosciences (NIMHANS) between January 2011 and May 2020. The diagnosis of FMD was based on Fahn and Williams criteria and the patients were either diagnosed as "documented" or "clinically established". All the relevant demographic data including the ethnicity, socioeconomic and cultural background, examination findings, electrophysiological, and other investigations were retrieved from the medical records. The mean age at onset was 12.69 ± 3.13 years. Majority of the children were from urban regions (56.41%) and belonging to low socioeconomic status (46.15%). Thirty (76.92%) were found to have a precipitating factor. Myoclonus was the most common phenomenology observed in these patients (30.76%), followed by tremor (20.51%), dystonia (17.94%), and gait abnormality (7.69%). Chorea (5.12%) and tics (2.56%) were uncommon. Tremor (37.5%) and dystonia (18.75%) were more common in girls, whereas myoclonus (39.13%) was more common in boys. The symptoms of FMD have great impact on the mental health, social, and academic functioning of children. It is important to identify the precipitating factors and associated psychiatric comorbidities in these children as prompt alleviation of these factors by engaging parents and the child psychiatrist will yield better outcomes.

Testing a Potential Marker for the Diagnosis of Functional Movement Disorders (1221)

Testing a Potential Marker for the Diagnosis of Functional Movement Disorders (1221)

Opinions and clinical practices related to diagnosing and managing functional (psychogenic) movement disorders: changes in the last decade.

There is large variability in the diagnostic approach and clinical management in functional movement disorders (FMD). This study aimed to examine whether opinions and clinical practices related to FMD have changed over the past decade. Adapted from a 2008 version, we repeated the survey to members of the International Parkinson and Movement Disorder Society (MDS). In all, 864/7689 responses (denominator includes non-neurologists) were received from 92 countries. Respondents were more often male (55%), younger than 45 (65%) and from academic practices (85%). Although the likelihood of ordering neurological investigations prior to delivering a diagnosis of FMD was nearly as high as in 2008 (47% vs. 51%), the percentage of respondents communicating the diagnosis without requesting additional tests increased (27% vs. 19%; P=0.003), with most envisioning their role as providing a diagnosis and coordinating management (57% vs. 40%; P<0.001). Compared to patients with other disorders, 64% of respondents were more concerned about missing a diagnosis of another neurological disorder. Avoiding iatrogenic harm (58%) and educating patients about the diagnosis (53%) were again rated as the most effective therapeutic options. Frequent treatment barriers included lack of physician knowledge and training (32%), lack of treatment guidelines (39%), limited availability of referral services (48%) and cultural beliefs about psychological illnesses (50%). The preferred term for communication favored 'functional' over 'psychogenic' (P<0.001). Attitudes and management of FMDs have changed over the past decade. Important gaps remain in access to treatment and in the education of neurologists about the inclusionary approach to FMD diagnosis.

Real world use of a neurophysiology service for the differential diagnosis of hyperkinetic movement disorders

IntroductionClinical neurophysiology constitutes a potentially useful aid in differentiating hyperkinetic movement disorders (HMD). Parameters including presence of a Bereitschaftspotential on back-averaged electroencephalography (EEG) have been demonstrated to help distinguish between these disorders. In 2008, a Movement Disorder neurophysiology service was established in Greater Manchester to aid in the diagnostic process. MethodsWe retrospectively reviewed records of patients with HMD who underwent EEG back-averaging through this service from January 2009 until January 2018. The aim was (i) to characterise the clinical features of our patient cohort and (ii) to determine how frequently neurophysiological testing altered the final diagnosis. ResultsA total of 39 patients (23 females, 16 males), with a mean age at onset of 42.6 years and mean disease duration of 2.0 years underwent neurophysiological examination. The clinical diagnosis was changed in 16 cases (41%) and refined in a further seven. Distractibility (P = 0.001), variability (P = 0.002), the presence of a Bereitschaftspotential (P < 0.0001), and electromyography burst duration > 300 ms (P = 0.012) were more frequent in those with an eventual diagnosis of functional movement disorder (n = 24) compared to other HMDs (n = 15). ConclusionNeurophysiology is an invaluable adjunct in complex HMD, altering the diagnosis and treatment options for a significant proportion of patients. Our data also demonstrate, consistent with previous studies, that the majority of patients referred for jerky HMDs to a tertiary movement disorder service have a functional movement disorder.

Testing a Potential Marker of Attention for the Diagnosis of Functional Movement Disorders

Background: The diagnosis of Functional Movement Disorders (FMD) mostly relies on clinical expertise, with a paucity of confirmatory tests available. More objective markers are needed. We determine whether an in-clinic attention task can aid in diagnosis. Methods: A single-site study comparing subjects with FMD, essential tremor (ET), and healthy controls (HC). Subjects completed a modified Stroop Interference task and standardized questionnaires assessing mood symptoms. Level of disability was estimated by modified Rankin Score (mRS). The primary endpoint was the difference in error rate and response time on the Stroop between groups. Data was analyzed using Wilcoxon test or Fisher’s exact test. Results: 50 subjects were screened and 35 recruited (12 FMD, 11 ET, and 12 HC). No significant differences were seen in task performance between groups, although the FMD group made the most errors and had the longest median response time. Significant between-group differences were found in reported symptom severity and health concerns, despite a similar mRS between FMD and ET groups. Discussion: A modified Stroop task was not able to distinguish with significance between FMD, ET, and HC. Self-reported questionnaire responses showed significant differences with higher prevalence of depression and anxiety and greater perceived disability in patients with FMD despite similar mRS.

How Do I Explain the Diagnosis of Functional Movement Disorder to a Patient?

Functional movement disorders (FMDs) are common in neurological practice and a source of significant distress and disability. There is consensus that successful explanation which helps the patient feel confident that the diagnosis is correct is an essential platform for further treatment. Many doctors find delivering the diagnosis difficult. In these two short films, we explore why certain ways of approaching the explanation of an FMD can cause difficulties, especially failure to give an explicit diagnostic label, and a tendency to jump to a speculative etiological discussion about possible psychological factors instead of helping the patient understand the nature and mechanism of the movement disorder itself. Demonstrating the physical signs to the patient is often of key importance in helping the patient to understand that, first, the diagnosis is made positively and not just because the tests are normal. Crucially, it also shows the potential for symptom reversibility, which can then feed in to an understanding of how physiotherapy promotes automatic movement and "retrains the brain." Seeing the patient again is important in assessing the patient's confidence and readiness for therapy as well as calibrating your own communication skills.

Functional movement disorders: positive diagnostic criteria

Functional movement disorders (FMDs) are a complex medical problem requiring a set of different diagnostic and treatment approaches: neurological, psychiatric, psychotherapeutic, and neurophysiological. With the advent of positive criteria for the diagnosis of FMDs, the latter are no longer just a diagnosis of exclusion, which is difficult for clinical interpretation. The review considers positive clinical and instrumental diagnostic criteria and presents the neurophysiological characteristics of functional tremor and functional myoclonus, which allow one to suspect this diagnosis. Their timely recognition is extremely important, as this permits patients to reduce the cost of unnecessary examinations and ineffective drugs and increases the chances for successful treatment, since the best prognosis is noted with the shortest duration of the disease.