Functional Neurological Disorder Responds Favorably to Interdisciplinary Rehabilitation Models, 2019, Jimenez et al

Andy

Andy

Retired committee member
Not a recommendation.
Background
Functional neurological disorder (FND) is difficult to treat and costly. Interdisciplinary chronic pain rehabilitation programs (iCPRPs) are multidimensional functional restoration interventions for pain; their impact on FND specifically has not been assessed.

Objective
The purpose of this study was to assess iCPRP's impact on functioning in FND.

Methods
Data were examined retrospectively from an Institutional Review Board-approved registry capturing admission and discharge data from patients participating in an outpatient iCPRP. Subjective measures included pain-related disability, depression, anxiety, and stress scores, whereas objective measures included physical functioning measures (timed up and go, stair climbing test, and 6-min walk test). Pre-iCPRP and post-iCPRP measures were compared using a paired t-test approach.

Results
Forty-nine FND patients completed care and showed pre-measures and postmeasures. Statistically significant reductions in subjective measures of pain-related disability (46.40–20.91; P < 0.001, d = 1.92), depression (20.38–4.81; P < 0.001, d = 1.53), anxiety (15.09–6.29; P < 0.001, d = 1.18), and stress (21.96–9.70; P < 0.001, d = 1.21) scores were observed. Statistically significant changes in objective measures of mean timed up and go scores (decreased from 15.96 to 8.87 s), stair climbing test scores (increased from 40.98 to 71.93 steps), and mean 6-minute walk test scores (increased from 0.21 to 0.30 miles) were also observed across the group.

Conclusions
While preliminary and based on a small patient sample, these findings support the use of interdisciplinary care models for FND treatment. Clinical and investigational implications are explored.
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Paywall, https://www.sciencedirect.com/science/article/abs/pii/S0033318219301203
Sci hub, https://sci-hub.se/10.1016/j.psym.2019.07.002
 
63 patients with FND who participated in the iCPRP were identified between the years 2013 and 2017. Of these, 49 (78%) completed treatment (14 were either discharged early or left voluntarily).

I wonder why people were discharged early or why some left voluntarily. Failures they didn't want to mention in the final results perhaps?

As someone who was told they had a functional disorder 20 years ago this paper just reeks of sadism. I was diagnosed with IBS, but the word "functional" got bandied about as well and I had it explained to me that my symptoms were all in my head and my brain was making them up because I was depressed. The cause of my IBS was found and fixed with surgery in 2003, and the surgery wasn't performed on my head!
 
Trish said:
So where's the control group. Maybe doing nothing would be even better for these patients.
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Why bother? PACE normalize non-controlled research and it's basically hailed as the very peak of mount science, the very notion that it may be flawed in any way is surefire evidence of paranoid delusion. "We prefer this outcome" is now peer-reviewed valid justification for massive deviation from protocol so why even bother having one?
 
  • Yeah, small sample size - tick.
  • Selective recruitment - tick.
  • Large % of dropouts - tick.
  • Heterogeneous sample - tick.
  • Poor rigour and lack of consistent approach to diagnosis - tick.
  • No controls - patients not given alternative treatment without the magic ingredient - tick.
  • No controls - no data on expected improvement in objective measures from factors not related to real improvement e.g. improvement due to familiarity with the specific exercise - tick
  • Results of subjective outcomes from non-blinded treatment assumed to show real benefit - tick.
  • Objective outcomes irrelevant to patient's illness - tick
    This study also lacked specific FND measures assessing clinical intervention effects on FND-specific symptoms or signs.
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  • Uncritically quotes waffling pseudoscience about brain imaging - tick.
  • Unwarranted negative labelling of people - tick
    This model conceptualizes PNES episodes as brief dysregulation moments involving an unstable cognitive-emotional attention system resulting in phenotypic expressions of dissociation, excessive emotionality, cognitive inflexibility, limited volitional control, hypervigilance, and other deficits.
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  • Unwarranted conclusion - tick
Interdisciplinary functional restoration programs such as iCPRPs make significant impacts on many functional neurological conditions.
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Study not worth the paper it's written on - tick.
 
This model conceptualizes PNES episodes as brief dysregulation moments involving an unstable cognitive-emotional attention system resulting in phenotypic expressions of dissociation, excessive emotionality, cognitive inflexibility, limited volitional control, hypervigilance, and other deficits.
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One thing you can't fault the authors, their bullshitspeak game is on point. It takes years of thinking nonsense in order to come up with stuff like that. This is pro-level gibberish.

One proposed change: replace ", and other deficits" with ", or whatever". Same effect.

Alternatively, scrap the whole thing and just replace it with a good old plumbus infomercial, no one could tell the difference:
First they take the dinglebop, then smooth it out with a bunch of shleem. The shleem is then repurposed for later batches. They take the dinglebop and push it through the grumbo. Where the fleeb is then rubbed against it. Its important that the fleeb is rubbed, because the fleeb has all the fleeb juice. Then a shlammie shows up and he rubs it and spits on it. They cut the fleeb. There are several hizzards in the way. The blamfs run against the trumbles and the ploobis and grumbo are shaved away. That leaves you with a regular old plumbus.
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Just to express my amazement at the rubbish that gets published a bit more:

Imagine there's a study on the impact of a 3 week 'inter-disciplinary functional restoration program' course for blind people. The outcome measure is a 6 minute walk without a cane, because the researchers have noted that blind people tend to walk slowly and hesitantly without a cane. At the end of the course, the blind people are managing to walk the corridor faster; they know when to turn. Some may even have got a bit fitter.

The study write-up notes that blind people are excessively timid in new situations and that the intervention was a success. They conclude
Interdisciplinary functional restoration programs make significant impacts on blindness
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Makes as much sense as this FND study.
 
Hutan said:
  • Yeah, small sample size - tick.
  • Selective recruitment - tick.
  • Large % of dropouts - tick.
  • Heterogeneous sample - tick.
  • Poor rigour and lack of consistent approach to diagnosis - tick.
  • No controls - patients not given alternative treatment without the magic ingredient - tick.
  • No controls - no data on expected improvement in objective measures from factors not related to real improvement e.g. improvement due to familiarity with the specific exercise - tick
  • Results of subjective outcomes from non-blinded treatment assumed to show real benefit - tick.
  • Objective outcomes irrelevant to patient's illness - tick
  • Uncritically quotes waffling pseudoscience about brain imaging - tick.
  • Unwarranted negative labelling of people - tick
  • Unwarranted conclusion - tick
​
Study not worth the paper it's written on - tick.
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You need to turn this checklist into a paper for EBM live or send it to F Godlee!
 
"Subjective measures included pain-related disability, depression, anxiety, and stress scores, whereas objective measures included physical functioning measures (timed up and go, stair climbing test, and 6-min walk test). Pre-iCPRP and post-iCPRP measures were compared using a paired t-test approach"

The PACE trial was looking at chronic fatigue so outcomes like the 6 minute walking test were appropriate, even the questionnaires had a dubious relevance but these seem irrelevant to FND and just highlight that they are making a single category of diverse biological problems.

As was said, the difference in the physical tests were probably the result of practice and we all know that CBT primes for answering questions. If IBS and interstitial cystitis are included the number of trips to the toilet is the only useful outcome measure. If there was someone with a deformed foot then the angle of the ankle would be useful and so on.

Again it is impossible to guess their logic. FND is caused by anxiety, so a questionnaire showing less anxiety is a positive result even if the patient still has the original problem.
 
Data were examined retrospectively from an existing IRB-approved registry capturing admission and discharge data from all patients participating in the iCPRP.
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I guess we'll have to assume that IRB had granted ethics approval?

Terms used to identify FND patients in this database included: “functional neurological,” “conversion,” “functional movement,” “functional gait/tremor,” “psychogenic movement,” “pseudoneurological,” “pseudoseizures,” “psychogenic nonepileptic seizures,” and “paroxysmal nonepileptic events.”
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I'm not sure how the stair climbing test and six minute walking test are relevant to those groups of patients.
 
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