Physiotherapy for functional motor disorders: a consensus recommendation, 2015, Nielsen et al

Open access: https://jnnp.bmj.com/content/86/10/1113

Glenn Nielsen, Jon Stone, Audrey Matthews, Melanie Brown, Chris Sparkes, Ross Farmer, Lindsay Masterton, Linsey Duncan, Alisa Winters, Laura Daniell, Carrie Lumsden, Alan Carson, Anthony S David, Mark Edwards

Abstract
Background Patients 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.

Methods A 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.

Results We 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.

Conclusions Physiotherapy 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.

 

It's interesting that they felt that there was not enough data to produce an evidence-based guideline. But they'll present some recommendations anyway, with the Methods section summarised as 'We had a meeting and we decided this seems about right'.

They go on to note that their etiological framework is the BPS model, but yes, although phrases like 'emotional disorder' and 'personality traits' get thrown around freely, they suggest they are moving away from a 'purely psychological model'.

This is the evidence they cite:

1. Jordbru et al
Psychogenic gait disorder: a randomized controlled trial of physical rehabilitation with one-year follow-up. J Rehabil Med 2014
3. Nielsen, Stone, EdwardsPhysiotherapy for functional (psychogenic) motor symptoms: a systematic review. J Psychosom Res 2013


I thought the paragraphs about exercise and management of pain and fatigue were particularly interesting given the issue we are having with the Royal Colleges right now:

You can see how a NICE guideline that specifically says that GET should not be used for chronic fatigue syndrome throws a rather large spanner in the works.

 

I know nothing about functional motor disorders and what sort of treatment people with them find helpful, but I am very wary of assuming fatigue suffered by people with these disorders has anything to do with ME/CFS.

If there were such a big overlap as to warrant the inclusion of ME/CFS in this paper, surely the reverse would be true, and research on ME/CFS would list functional motor disorders as a common co-morbidity. As far as I know that's not the case.

It looks to me more like huge assumptions being made here on the basis that everything the BPS people get involved in ends up with the same theory of false beliefs and phobias and past traumas, and the same GET/CBT being prescribed.