BackgroundPatients with functional motor disorder (FMD) including weakness and paralysis are commonly referred to physiotherapists. There is growing evidence that physiotherapy is an effective treatment, but the existing literature has limited explanations of what physiotherapy should consist of and there are insufficient data to produce evidence-based guidelines. We aim to address this issue by presenting recommendations for physiotherapy treatment.MethodsA meeting was held between physiotherapists, neurologists and neuropsychiatrists, all with extensive experience in treating FMD. A set of consensus recommendations were produced based on existing evidence and experience.ResultsWe recommend that physiotherapy treatment is based on a biopsychosocial aetiological framework. Treatment should address illness beliefs, self-directed attention and abnormal habitual movement patterns through a process of education, movement retraining and self-management strategies within a positive and non-judgemental context. We provide specific examples of these strategies for different symptoms.ConclusionsPhysiotherapy has a key role in the multidisciplinary management of patients with FMD. There appear to be specific physiotherapy techniques which are useful in FMD and which are amenable to and require prospective evaluation. The processes involved in referral, treatment and discharge from physiotherapy should be considered carefully as a part of a treatment package.
Patients with functional gait disorder (FGD) are often referred for physiotherapy, but data on their outcome is limited. The authors present a case series of 35 patients who received targeted physiotherapy for FGD at a regional neuroscience center (mean number of sessions, 11). Significant improvements in the Modified Rivermead Mobility Index (score range, 0-40) were recorded between pretreatment and posttreatment (mean pretreatment vs. posttreatment score, 20 vs. 37, respectively). Improvements also were seen in patients who had chronic symptoms, including those with symptom duration over 6 months (mean pretreatment vs. posttreatment score, 21 vs. 33, respectively) and in patients who had no psychological intervention. These data support the hypothesis that specific physiotherapy for FGD can be surprisingly effective and further encourage the development of larger randomized trials to test efficacy.There is increasing interest and data are accumulating on the outcomes of patients with functional (psychogenic) movement disorder (FMD) who receive physiotherapy. In collaboration with Glenn Nielsen and colleagues in London, we previously described in detail the content of FMD-specific physiotherapy 1 This emphasizes the importance of understanding the reversible nature of the diagnosis and sharing evidence for this, such as Hoover's sign and the entrainment test, with the patient. Physiotherapy for many neurologic diseases, such as stroke, relies on focused attention on the poorly functioning limb. For patients with FMD, attention away from the limb may be more appropriate. The aim is to "train" patients away from habitual abnormal movements back to more normal automatic movements.We describe our experience prospectively evaluating a series of 35 patients treated by 2 of us (A.M. and M.B.) in a regional neuroscience center using these principles to add to the literature in this area. Case SeriesWe carried out a prospective study of patients seen between November 2012 and December 2014 with disabling FGD (predominantly associated with limb weakness) who were referred to A.M. or M.B. for inpatient physiotherapy in an acute neurology ward in the regional neuroscience service in Glasgow. All patients had been diagnosed with FGD by a consultant neurologist, most with extensive supplementary radiologic and neurophysiological testing. Some were admitted acutely because of their symptoms. Most were subacute or chronic presentations who had been admitted for investigation and treatment by their treating neurologist. There was no formal triage process. We recorded demographic data, duration of motor symptoms, and Modified Rivermead Mobility Index (MRMI) scores (before treatment and immediately after the end of treatment). Approval by an ethics committee was not applicable, because the study was carried out as part of routine care.
Introduction Medically Unexplained Neurological Symptoms (MUNS) are the second most common diagnosis in neurology outpatient clinics, accounting for up to 16% of all referrals. 1 Patients with MUNS are frequently admitted for inpatient investigation and management. We reviewed healthcare resource utilisation of patients with MUNS on an acute neurology ward in a tertiary neuroscience centre. Methods A prospective audit of patients admitted to a 19-bedded acute neurology ward, serving a population of approximately 2.2 million people, was performed. We included those with a clinical diagnosis of MUNS and no associated relevant pathology. Patients with MUNS and co-morbid neurological illness (e.g. epilepsy with non-epileptic attack disorder) or individuals assessed electively on the 20-bedded programmed investigation unit (e.g. for video telemetry) were excluded.Clinical and demographic data were collected using paper and electronic records and the national radiology database. Data were collected with respect to healthcare resource utilisation during the single inpatient stay. This included the duration of admission, neuroimaging, electroencephalography (EEG), electromyography (EMG) performed and time with physiotherapists. Results Fourteen patients (11 female, median age 39 years, range 19-56) were admitted to the acute neurology ward over a 9-month period (1st April to 31st December 2012).Eleven out of fourteen (78.6%) were transferred from other hospitals and 3 were admitted form home. Median duration in hospital prior to transfer was 5 days (range 0-15, total 51 hospital days). Patients were taking a mean of 5.4 medications (SD 3.9). Three (21.4%) had prior contact with mental health services and 1 had learning difficulties. Previous attendance at an emergency department had occurred in 6/14 (42.9%) patients (total 84 attendances; range 2-31). Nine patients (64.3%) had prior hospital admissions (total 49 admissions; mean 3.5 [SD 5.6]).A functional motor disorder was diagnosed in 9/14 (64.2%); 3/14 (21.4%) had non-epileptic attack disorder (NEAD), 1/14 (7.1%) had both a functional motor disorder and NEAD and 1 had purely sensory symptoms. Median duration of admission was 8.5 days (range 3-64 days, IQR 5.5-15). Over the 9-month period, patients with MUNS accounted for 231 bed-days, equating to 4.4% of the acute neurology ward bed capacity over this period. CT scans were performed in 9/14 (64.3%, total 12 scans); 10/14 (71.4%) had an MRI (total 22 scans, 1.6 per
A 65-year-old woman presented with a 6-week history of painful ulceration on her thighs and buttocks. Comorbidities included primary hyperparathyroidism, multiple sclerosis, diabetes, chronic kidney disease (stage 3), obesity and atrial fibrillation. She was taking warfarin but not calcium-channel blockers. Physical examination revealed multiple large ulcers with necrotic eschar on skin that was firm to palpation, in keeping with subcutaneous calcification. There were purpuric patches over the buttocks and thighs (Fig. 1a,b). Laboratory investigations gave the following results: corrected calcium 3.4 mmol/L (normal range 2.2-2.6 mmol/L), phosphate 1.51 mmol/L (0.8-1.50 mmol/L), parathyroid hormone 16.5 pmol/L (1.6-7.5 pmol/L) and estimated glomerular filtration rate 48 mL/min (> 60 mL/min). C P Dª
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