Nielsen, Glenn; (2017) A feasibility study of physiotherapy for functional motor symptoms. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Functional motor disorder (FMD) is a common cause of disability and distress amongst patients seen by neurologists and physiotherapists. Patients present with combinations of weakness, tremor, jerks, dystonia and gait disorder. The long term prognosis is poor. Historically, psychological explanations for FMD have dominated, correspondingly, psychological therapy has been considered the treatment modality of choice, although evidence for its effectiveness is limited. A more recent understanding of FMD, considers symptoms within a broader biopsychosocial framework. This is backed by research into biological mechanisms that suggest FMD is associated with abnormalities in motor planning and agency, related to illness beliefs/expectations and abnormal self-directed attention. This broader conceptual model of FMD provides a rationale for physiotherapy treatment. A systematic review of the literature found that, while promising, the evidence for physical rehabilitation is limited, with a lack of randomised controlled trials. This thesis describes a specific 5-day physiotherapy intervention that is based on a mechanistic understanding of how functional motor symptoms are generated. The intervention was tested in a randomised feasibility study with an embedded longitudinal qualitative study. Sixty patients were randomised to either the intervention or treatment as usual control. At six months follow up, feasibility was demonstrated by high rates of recruitment, retention and intervention acceptability. The intervention was associated with a significant improvement across a range of physical and quality of life outcome measures, with a moderate to large effect size. A health economic analysis showed evidence of likely cost-benefit. Findings from the qualitative study suggest that helping the patient develop a biopsychosocial understanding of their problem was an important ingredient of the intervention. The findings from these studies add to the growing evidence for specialist physiotherapy for FMD and support the need for a multicentre randomised controlled trial.

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