Functional Motor Symptoms Research Articles

Functional neurological disorders: Imaging

Functional neurological disorders, also known as conversion disorder, are unexplained neurological symptoms. These symptoms are common and can be associated with significant consequences. This review covers the neuroimaging literature focusing on functional motor symptoms including motor functioning and upstream influences including self-monitoring and internal representations, voluntariness and arousal and trauma.

THE ROLE OF ALEXITHYMIA IN THE DEVELOPMENT OF FUNCTIONAL MOTOR SYMPTOMS (CONVERSION DISORDER)

ObjectiveThe mechanisms leading to the development of functional motor symptoms (FMS) are of pathophysiological and clinical relevance, yet are poorly understood. The aim of the present study was to evaluate...

The role of alexithymia in the development of functional motor symptoms (conversion disorder)

BackgroundThe mechanisms leading to the development of functional motor symptoms (FMS) are of pathophysiological and clinical relevance, yet are poorly understood.AimThe aim of the present study was to evaluate whether...

Effects of robotic treadmill training on functional mobility, walking capacity, motor symptoms and quality of life in ambulatory patients with Parkinson's disease: A preliminary prospective longitudinal study

Decreased mobility and walking capacity occur frequently in Parkinson's disease (PD). Robotic treadmill training is a novel method to improve the walking capacity in rehabilitation. The primary aim of this study was to investigate the effects of robotic treadmill training on functional mobility and walking capacity in PD. Secondly, we aimed to assess the effects of the robotic treadmill training the motor symptoms and quality of life in patients with PD. Seventy patients with idiopathic Parkinson's disease who admitted to the outpatient clinic of the rehabilitation hospital were screened and 12 ambulatory volenteers who met the study criteria were included in this study. Patients were evaluated by Hoehn Yahr (HY) scale clinically. Two sessions robotic treadmill training per week during 5 weeks was planned for every patient. Patients were evaluated by the Timed Up and Go (TUG) test, 10 meter walking test (10 MWT), Unified Parkinson's Disease Rating Scale (UPDRS) motor section and Parkinson's Disease Questionnaire-39 (PDQ-39) at the baseline, at the 5 and 12 weeks. Cognitive and emotional states of the patients were assessed by Mini Mental State Examination (MMSE) test and Hospital Anxiety and Depression Scale (HADS) at the baseline. All patients were under medical treatment for the PD in this study and drug treatment was not changed during the study. Ten patients completed the study. The mean age was 65.6 ± 6.6 years. Five patients (50%) were women. Disease severity was between the HY stage 1-3. Two patients did not continue the robotic treadmill training after 7 sessions. They also did not want to come for control visits. TUG test, 10 MWT and UPDRS motor subscale scores showed statistically significant improvement after robotic treadmill training (p = 0.02, p = 0.001, p = 0.016). PDQ-39 scores improved significantly after robotic treadmill training (p = 0.03), however, the scores turned back to the baseline level at the 12. week control. As a result of this preliminary study, robotic treadmill training was useful to improve the functional mobility, walking capacity and motor symptoms in mild to moderate PD. Robotic treadmill training provided a transient improvement in the quality of life during the treatment.

The prognosis of functional (psychogenic) motor symptoms: a systematic review

BackgroundThe prognosis of functional (or psychogenic) motor symptoms (weakness and movement disorder) has not been systematically reviewed.MethodsWe systematically reviewed PubMed for all studies of eight or more patients with functional...

Trick or treat? Showing patients with functional (psychogenic) motor symptoms their physical signs

I read with interest the recent article by Drs. Stone and Edwards.1 Their experience was that if patients with functional motor symptoms were shown their physical signs, they could be persuaded of the accuracy of their diagnosis and the potential reversibility of their symptoms. While this may be true, my personal experience of patients with nonepileptic events has varied. Many patients feel vindicated when shown the nonepileptic event captured on video-EEG. Their complaints finally stand justified in the eyes of their doctor and loved ones. That said, patients rarely if ever completely stop having their typical events after this. In a few patients, the event frequency may exacerbate and new events with previously unreported clinical semiology may be reported.2 These patients are frequently lost to follow-up only to seek medical care in another institution under another physician where invariably diagnostic workup is repeated. This also adds to health care costs to society as a whole. Explicitly telling patients that their events are psychogenic in origin has its own challenges. The discussion is invariably rough for the physician—sometimes heated—and the psychogenic explanation is not readily accepted by most patients. I tell my patients that there is no organic basis to the symptomatology and advise that underlying psychogenic factors need to be aggressively addressed rather than say that the events are real, not imagined, or “all in the mind.”

Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society

Editors’ Note: Dr. Mauskop reviews the literature on the use of butterbur extract for migraine prophylaxis and concludes that it has the potential for serious toxicity. Authors Holland et al. disagree with Dr. Mauskop's interpretation. Dr. Sethi, in response to Drs. Stone and Edwards' “Trick or treat? Showing patients with functional (psychogenic) motor symptoms their physical signs,” airs the difficulty, which most neurologists can relate to, of discussing a psychogenic diagnosis with a patient. Dr. Tfelt-Hansen calls attention to an error in the classification of evidence in the American Academy of Neurology guideline on episodic migraine prevention by Silberstein et al. The authors concur and an …

Failure of explicit movement control in patients with functional motor symptoms

Functional neurological symptoms are one of the most common conditions observed in neurological practice, but understanding of their underlying neurobiology is poor. Historic psychological models, based on the concept of conversion of emotional trauma into physical symptoms, have not been implemented neurobiologically, and are not generally supported by epidemiological studies. In contrast, there are robust clinical procedures that positively distinguish between organic and functional motor signs that rely primarily on distracting attention away from movement or accessing it covertly. We aimed to investigate the neurobiological principles underpinning these techniques and implications for understanding functional symptoms. We assessed 11 patients with functional motor symptoms and 11 healthy controls in three experimental set-ups, where voluntary movements were made either with full explicit control or could additionally be influenced automatically by factors of which participants were much less aware (one-back reaching, visuomotor transformation, and precued reaction time with variable predictive value of the precue). Patients specifically failed in those tasks where preplanning of movement could occur and under conditions of increasing certainty regarding the movement to be performed. However, they implicitly learned to adapt to a visuomotor transformation as well as healthy controls. We propose that when the movement to be performed can be preplanned or is highly predicted, patients with functional motor symptoms shift to an explicit attentive mode of processing that impairs kinematics of movement control, but movement becomes normal when such processes cannot be employed (e.g., during unexpected movement or implicit motor adaptation).

Shell shock at Queen Square: Lewis Yealland 100 years on

This article reviews the treatment of functional neurological symptoms during World War I by Lewis Yealland at the National Hospital for the Paralysed and Epileptic in London. Yealland was among the first doctors in Britain to incorporate electricity in the systematic treatment of shell shock. Our analysis is based on the original case records of his treatment of 196 soldiers with functional motor and sensory symptoms, functional seizures and somatoform disorders. Yealland’s treatment approach integrated peripheral and central electrical stimulation with a variety of other—psychological and physical—interventions. A combination of electrical stimulation of affected muscles with suggestion of imminent improvement was the hallmark of his approach. Although his reported success rates were high, Yealland conducted no formal follow-up. Many of the principles of his treatment, including the emphasis on suggestion, demonstration of preserved function and the communication of a physiological illness model, are encountered in current therapeutic approaches to functional motor and sensory symptoms. Yealland has been attacked for his use of electrical stimulation and harsh disciplinary procedures in popular and scientific literature during and after World War I. This criticism reflects changing views on patient autonomy and the social role of doctors and directly impacts on current debates on ethical justification of suggestive therapies. We argue that knowledge of the historical approaches to diagnosis and management of functional neurological syndromes can inform both aetiological models and treatment concepts for these challenging conditions.

Trick or treat?

Functional (psychogenic) motor symptoms are diagnosed on the basis of positive signs of inconsistency or incongruity with known neurologic disease. These signs, such as Hoover sign or tremor entrainment, are often regarded by neurologists as 'tricks of the trade,' to 'catch the patient out, ' and certainly not to be shared with them. In this reflective article, the authors suggest that showing the patient with functional motor symptoms their physical signs, if done in the right way, is actually one of the most useful things a neurologist can do for these patients in persuading them of the accuracy of their diagnosis and the potential reversibility of their symptoms.

A Bayesian account of 'hysteria'

This article provides a neurobiological account of symptoms that have been called ‘hysterical’, ‘psychogenic’ or ‘medically unexplained’, which we will call functional motor and sensory symptoms. We use a neurobiologically informed model of hierarchical Bayesian inference in the brain to explain functional motor and sensory symptoms in terms of perception and action arising from inference based on prior beliefs and sensory information. This explanation exploits the key balance between prior beliefs and sensory evidence that is mediated by (body focused) attention, symptom expectations, physical and emotional experiences and beliefs about illness. Crucially, this furnishes an explanation at three different levels: (i) underlying neuromodulatory (synaptic) mechanisms; (ii) cognitive and experiential processes (attention and attribution of agency); and (iii) formal computations that underlie perceptual inference (representation of uncertainty or precision). Our explanation involves primary and secondary failures of inference; the primary failure is the (autonomous) emergence of a percept or belief that is held with undue certainty (precision) following top-down attentional modulation of synaptic gain. This belief can constitute a sensory percept (or its absence) or induce movement (or its absence). The secondary failure of inference is when the ensuing percept (and any somatosensory consequences) is falsely inferred to be a symptom to explain why its content was not predicted by the source of attentional modulation. This account accommodates several fundamental observations about functional motor and sensory symptoms, including: (i) their induction and maintenance by attention; (ii) their modification by expectation, prior experience and cultural beliefs and (iii) their involuntary and symptomatic nature.

Inpatient treatment of functional motor symptoms: a long-term follow-up study

Functional neurological disorders are common, disabling and often difficult to treat. There is little consensus on the best approach to management. Multidisciplinary inpatient approaches are employed in some centres for patients with severe refractory symptoms, but their efficacy and, in particular, long-term outcomes are uncertain. We conducted a study using questionnaires completed retrospectively by patients treated at a specialised multidisciplinary inpatient programme at the National Hospital for Neurology and Neurosurgery. Consecutive patients with functional motor symptoms admitted to this centre between 2006 and 2008 were invited to participate. Questionnaires were sent at least 2 years after discharge. We contacted 32 patients, and 26 responded. The majority had symptoms for at least 3 years prior to admission; 58 % of patients reported benefit from the programme on discharge. This self-reported benefit to symptoms and function was after a 2-year follow-up period in the majority of patients, but return to work or cessation of health-related financial benefits was uncommon even in those who improved. Seventy-four percent of those questioned stated they would recommend the programme to others with similar symptoms. Attribution of symptoms to stress or emotional state was correlated with favourable outcome. Our data suggest that multidisciplinary inpatient treatment for patients with refractory functional motor symptoms provides self-reported benefit in the long-term. Prospective analysis of such interventions and the determinants of benefit need assessment in order to improve the service and target treatment to patients most likely to benefit.

Feasibility of 2 Different Water-Based Exercise Training Programs in Patients With Parkinson's Disease: A Pilot Study

Ayán C, Cancela J. Feasibility of 2 different water-based exercise training programs in patients with Parkinson's disease: a pilot study. ObjectiveTo compare the effects of 2 different water-based exercise training programs on functional mobility, motor symptoms, and quality of life (QOL) on patients with mild to moderate Parkinson's disease (PD). DesignMatched, controlled, pilot study. SettingOutpatient Parkinson's disease center. ParticipantsPatients (N=21) with PD (Hoehn and Yahr stage range, 1–3). InterventionsParticipants were assigned to a low-intensity water exercise program (group 1) or a muscular resistance water exercise intervention (group 2). Group sessions were held for 12 weeks, twice a week for 60 minutes per session. Main Outcome MeasuresFunctional mobility was measured by means of the Five Times Sit-to-Stand Test, while the motor part of the Unified Parkinson's Disease Rating Scale was used to assess motor impairment. Patients' QOL was rated by means of the 39-item Parkinson's Disease Questionnaire. ResultsOnce the intervention ended, the participants' QOL improved significantly, regardless of the program undertaken (P=.02 for group 1; P=.005 for group 2). Only participants in group 2 showed a significant change in functional mobility (P=.001) and Parkinsonian motor symptoms (P=.012). ConclusionsWater-based exercise training programs are a helpful therapy in PD. Muscular resistance programs of this kind seem to be of value in improving functional mobility, motor symptoms, and QOL in patients with PD. Some of the methodologic aspects detailed here can be used to design larger controlled trials.

The quality of life of lumbar radiculopathy patients under conservative treatment

The quality of life of lumbar radiculopathy patients conditioned by their health status is a result of both their subjective perception of the disease and their objective health status. The aim of this study was to evaluate the quality of life of lumbar radiculopathy patients under conservative treatment by means of generic and another lumbar syndrome specific questionnaires. A total of 50 patients (33 males, 17 females average age 46.1 years,) under conservative treatment in a hospital over four weeks were included in the study. They were interviewed using two questionnaires: the SF36 (Short form (36) Health Survey) generic questionnaire measuring eight domains of their quality of life summarized into two main ones (i.e. overall physical and overall mental health), and the lumbar syndrome specific North American Spine Society--Low Back Pain Outcome Instrument (NASS LBP), a questionnaire measuring four domains (functional limitations, motor and sensitive neurological symptoms, expectations from the treatment and satisfaction with it). The values of physical health domain was low as 31.1 at the beginning of the treatment, were rising over the following six months and dropped insignificantly after four years (42.1/48.7 /47.0) The mental health values (47.2) did not alter as compared to that of the general population. A values of the quality of life stabilized within six months. The neurological symptoms domain did not correlate with other value scales and domains. The quality of life of lumbar radiculopathy patients was impaired only from its physical aspect, but after conservative treatment it improved over the following six months. After four years there is an insignificant drop of all quality of life values, indicating a need for a longer term monitoring of their patients.

Can Private Placement Life Insurance Still Be Used as a Tax Efficient Vehicle to Invest in Tax Inefficient Hedge Funds?

Functional neurological disorder and somatic symptom disorder are complex neuropsychiatric conditions that have been linked to circuit-based dysfunction of brain networks. Neuromodulation is a novel therapeutic strategy capable of modulating relevant brain networks, making it a promising potential candidate for the treatment of these patient populations. We conducted a systematic review of Medline, Embase and PsycINFO up to 4 March 2021. Trials investigating neuromodulation devices for the treatment of functional neurological disorder or somatic symptom disorder were selected. Extracted variables included study design, demographic and clinical characteristics, psychiatric comorbidity, neurostimulation protocols, clinical outcome measures and results. 404 studies were identified with 12 meeting inclusion criteria. 221 patients were treated in the included studies with mean study sample size of 18 (4–70). Five studies were randomised clinical trials. Functional motor symptoms (six weakness, four movement disorders) were the most studied subpopulations. Transcranial magnetic stimulation (TMS) was the most frequently used device (10 studies), followed by electroconvulsive therapy (one study) and direct-current stimulation (one study). Treatment protocols varied in intended therapeutic mechanism(s): eight studies aimed to modulate underlying network dysfunction, five aimed to demonstrate movement (one also leveraged the former) and three boosted their primary mechanism with enhanced suggestion/expectation. All but one study reported positive results; however, methodological/outcome heterogeneity, mixed study quality and small sample sizes precluded quantitative meta-analysis. Neuromodulation, particularly TMS for the treatment of functional motor symptoms, shows preliminary promise in a growing line of research. Larger, sham-controlled studies are needed to further establish efficacy and better understand therapeutic mechanisms.