Functional Movement Disorders Assessment Made Simple
Do you remember meeting your first person with a functional movement disorder and saying “what is this”? Maybe even, “did we learn this in PT school”?
[Disclaimer--if you are a person with a functional movement disorder-this blog post is tailored to PT or OT assessment--but there’s loads of good info for you, too! And educate your therapist--bring them this blog post!]
You are not alone! Functional movement disorders (FMD) is often a topic that isn’t even mentioned as part of graduate therapy education. So, when you started to see patients, you likely searched the literature and didn’t find a whole lot. Now, thanks to a growing body of literature (thank you, for the crew out of the UK and MGH in Boston), and a growing number of therapists and movement disorder neurologists, we have a great basis for understanding, assessing and working with people with FMD. We have a real passion to explore and understand FMDs and we have taught courses and done videos and shared a lot of resources to propel the profession forward. But now we wanted to create a go-to guide for you on the most up-to-date and effective assessment and treatment methods for FMD in an easy to use format.
PLEASE NOTE: This information is only a small segment of what we use in our FND course and our Brain Bytes Community. If you want to take your neuro skills to the next level, click here to learn more about our community.
We’ve also gathered all the basics into a helpful Cheat Sheet that you can download for free.
>> Grab Your Free 6 things every clinician should know about FND treatment here
Okay, here we go.
In this post we will cover:
Brief introduction to the pathophysiology of FMD
Our Assessment Pie chart
Focus on the Autonomic nervous system
Questionnaires and assessment tools that are helpful
Why understanding the Pathophysiology of FMD makes all of the difference (Don’t Skip this Part!)
Thanks to my teaching at USC, I am a neuropathology and neurophysiology nerd, and I can’t dive into any discussion of assessment without talking a little bit about the potential pathophysiology of FMD.. I say “potential” because there is still a lot to learn and discover in this field and new things are coming out every month in the field of fMRI (don’t you just love neuro for that!).
Now I’ll keep this simple here—we have a whole section on this in our FND Mini Course
Research has demonstrated that the pathology is not simple (no surprise there!) but it is clear that FMD is not just “in your head” or “faking it”.
From the current literature it appears that FMD is a complex connectivity problem of the nervous system. When we say connectivity problem, we mean a problem with the functional connections between different areas of the brain instead of a structural or pinpoint lesion in one area. There are several key areas that are now implicated in FMD and outlined in a lovely review of the neuroimaging from Sasikumar and Strafella (2021). As indicated in their summary figure below, key connecting brain regions like the right temporal-parietal junction, amygdala and insula have been found to be changed in FMD. These key regions also are associated with functions that underlie FMD such as an altered sense of self agency, impaired top down regulation and abnormal emotional processing.
Why is this important?
First, it tells us that this is a REAL connection problem. Sometimes health care providers struggle to wrap their heads around FMD as an actual connection problem. These studies bring to light the repeatable evidence that this is not “faked” or “made up” and that there are distinct areas where the connections have broken down. Importantly, the pathophysiology guides us to our assessment and treatment. For example, since we know that there is a problem with an altered sense of agency, we can direct intervention at autonomy and restoring self agency.
Now, we have summarized all of the pathophysiology pieces supported in literature in our first pie chart! Each of these areas have research support for underlying pathophysiology: motor control, sensory, psychosocial, lifestyle, autonomic and physical limitations.
FMD Assessment Part 1: listening
If you have heard me teach or talk about FMD (and many other disorders) before, you have heard me talk about our pie charts. The first pie chart that we presented above is based on the literature on pathophysiology in FMD. These main categories remain consistent through assessment and treatment. If you understand and apply the pie chart, you have it made a huge step to helping someone with FMD.
The first step is centered on the person in front of you: the person’s pie chart! Before you start jumping to conclusions about mechanisms and your understanding of FMD, you want to start with the most important step--LISTENING!
What does the person think is going on? What is THEIR personal pie chart? We have a great pie chart in our FMD workbook that we use to have the person describe what they think is happening. I have a screenshot of it here for you. We often send this ahead to people who are participating in our integrated treatment program so we can start to listen to their story and understand their beliefs about what is contributing to their disorder.
Again--this is your most important step of the assessment--listening, understanding and validating their story. As they share with you, they will give you huge clues as to the underlying factors so you can start constructing a pie chart with them together.
Once you have listened thoroughly to the person’s story, you will have a lot of clues as to where to start your assessment. Like in this figure above, you may hear clues that lead you to explore their flexibility, their autonomic nervous system, or the sensory system.
FMD Assessment Part 2: The assessment pie chart
Now we get to dive into pie chart part 2: the assessment pie (see below). You can see that visually and categorically it follows the pathophysiology of FMD, which makes sense, right? If we know through research that these areas are important in the mechanism of the disorder, we would want to test them out and create our own pie chart to fully understand the contributing factors.
So where do we begin? If we have done our job of listening, the person has directed us to the areas that are most concerning or haven’t been looked at yet.
The autonomic nervous system (ANS) often gets overlooked and we can understand that they can be a big part of pathophysiology. So, it is important to do ANS testing as part of a thorough assessment.
So—this is where we will start today:
First, there is evidence that autonomic nervous system dysfunction can contribute to FMD symptoms
Decreased parasympathetic activity (not correlated to depression anxiety ) (Maurer et al 2016)
C-reactive protein elevated in FND (Kozlowska et al 2019)
HRV low and resting HR high in FND (Koslowska et al, 2015)
This is why we recommend including the following tests in your assessment of FMD
Measuring heart rate variability (HRV). We love using the LIEF for this because it is a portable ECG, but there are many options available now (like the Polar HR straps)
Pupillometry. We have just started looking at this as an outcome and assessment (because visual sensitivities are so common for people). We have heard good reviews on this Reflex app for this.
Assessing the breathing pattern: is it equal diaphragm and upper chest; is it shallow breaths or long breaths, what is the respiratory rate?
Checking response to breath. For example, do symptoms change with an extended exhale?
PS--we have an awesome “how to” library of all of these tests in our FND mini course and Brain Bytes Community.
FMD Assessment Made Simple
Now, you might be looking at the assessment pie chart and thinking, “That is a lot of stuff for an evaluation, I would never get through it all.” You are absolutely right! The assessment pie chart is not meant to be a checklist of tests for you to perform. It is meant to be a dynamic process of narrowing down and changing the pie slice sizes based on the person in front of you. We have made it comprehensive so that if you find yourself in one piece of the pie, you would have a good idea of what to test. But, we know it can be overwhelming. So, let’s make it simple:
Highlight 1 key area from their story
Identify 1 key area that will respond today
And be ok with not getting it all in one session.
Questionnaires/Tools
Finally, we wanted to provide you with some really great tools and questionnaires that we have found highly valuable in FMD. I have included some key references to the scales as well.
Patient Specific Functional Scale (PSFS) http://www.jospt.org/doi/abs/10.2519/jospt.1998.27.5.331?code=jospt-site
Hospital Anxiety and Depression Scale http://www.sciencedirect.com/science/article/pii/S002239990100296
Patient Global Impression of Change (PGIC) https://s3.amazonaws.com/chirocode-data-files/deskbook/Patient+Global+Imp+of+Change.pdf
Clinician Global Impression of Change (CGIC) http://www.sciencedirect.com/science/article/pii/S0022510X14007953
This 2020 article by Nicholson and colleagues mentions that, “self-report measures may be more clinically meaningful” for people functional neurological disorders. One way that we can make this most meaningful is to use the PSFS. It’s a great way to build rapport, trust, and patient autonomy by allowing your patient to decide which goals are most relevant to them.
Whew - We made it through FMD assessment! When I started working with people with FMD, I wasn’t sure where to start and often felt like I was all over the place before we started to put it together in a more systematic way. Now, our whole team is a part of the evaluation process in an integrated way and we have been able to get to the underlying problems more quickly and see results.
We have boiled down this approach into an easy to use guide Simply sign up here with our cheat sheet that you can use in the clinic with your patients immediately!
Remember, this information is only a small segment of our FND Mini Course. If you want to take your neuro skills to the next level, click here to learn more about this powerful self paced course.
Cheers to your #iloveneuro spirit,
Dr. Julie Hershberg, PT, DPT, NCS and Jake Pham SPT
References (an extended reference list for you!)
Pathophysiology
Aybek S, Vuilleumier P. (2016) Imaging studies of functional neurological disorders. Handbook of Clinical Neurology; 139: 73-84.
Aybek, S., Nicholson, T. R., O’Daly, O., Zelaya, F., Kanaan, R. A., & David, A. S. (2015). Emotion-motion interactions in conversion disorder: An fMRI study. PLoS ONE, 10(4), 1–12. https://doi.org/10.1371/journal.pone.0123273
Baizabal-Carvallo, J. F., Hallett, M., & Jankovic, J. (2019). Pathogenesis and pathophysiology of functional (psychogenic) movement disorders. Neurobiology of Disease, 127, 32-44. https://doi.org/10.1016/j.nbd.2019.02.013
Buhrmann, T., & Di Paolo, E. (2017). The sense of agency–a phenomenological consequence of enacting sensorimotor schemes. Phenomenology and the Cognitive Sciences, 16(2), 207-236. https://doi.org/10.1007/s11097-015-9446-7
Centonze, D Stampanoni Bassi, M. (2021) Time for a new deal between neurology and psychoanalysis, Brain, 144(8): 2228–2230,
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Dreissen, Y. E. M., Boeree, T., Koelman, J. H. T. M., & Tijssen, M. A. J. (2017). Startle responses in functional jerky movement disorders are increased but have a normal pattern. Parkinsonism & related disorders, 40, 27-32. https://doi.org/10.1016/j.parkreldis.2017.04.001
Espay, A. J., Maloney, T., Vannest, J., Norris, M. M., Eliassen, J. C., Neefus, E., … Szaflarski, J. P. (2018). Impaired emotion processing in functional (psychogenic) tremor: A functional magnetic resonance imaging study. NeuroImage: Clinical, 17, 179–187. https://doi.org/10.1016/j.nicl.2017.10.020
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Espay, A. J., Maloney, T., Vannest, J., Norris, M. M., Eliassen, J. C., Neefus, E., … Szaflarski, J. P. (2018). Dysfunction in emotion processing underlies functional (psychogenic) dystonia. Movement Disorders, 33(1), 136–145. https://doi.org/10.1002/mds.27217
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Maurer, C. W., LaFaver, K., Ameli, R., Epstein, S. A., Hallett, M., & Horovitz, S. G. (2016). Impaired self-agency in functional movement disorders: a resting-state fMRI study. Neurology, 87(6), 564-570.https://doi.org/10.1212/WNL.0000000000002940.
Maurer CW, Liu VD, LaFaver K, Ameli R, Wu R, Toledo R, Epstein SA, Hallett M. (2016) Impaired resting vagal tone in patients with functional movement disorders. Parkinsonism & Related Disorders, 30, 18-22.
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Pareés, I., Kassavetis, P., Saifee, T. A., Sadnicka, A., Bhatia, K. P., Fotopoulou, A., & Edwards, M. J. (2012). ‘Jumping to conclusions’ bias in functional movement disorders. J Neurol Neurosurg Psychiatry, 83(4), 460-463. http://dx.doi.org/10.1136/jnnp-2011-300982
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Sasikumar, S, Strafella, A.P. (2021)The neuroimaging evidence of brain abnormalities in functional movement disorders, Brain, 144 (8): 2278–2283,
Sojka, P., Lošák, J., Lamoš, M., Bareš, M., Kašpárek, T., & Světlák, M. (2019). Emotion Regulation in Functional Movement Disorder: an exploratory fMRI study. Frontiers in neurology, 10, 861. https://doi.org/10.3389/fneur.2019.00861
Thenganatt, M. A., & Jankovic, J. (2019). Psychogenic (Functional) Movement Disorders. CONTINUUM: Lifelong Learning in Neurology, 25(4), 1121-1140. http://doi.org/10.1212/CON.0000000000000755
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Diagnosis
Finkelstein SA, Cortel-LeBlanc MA, Cortel-LeBlanc A, Stone J. Functional neurological disorder in the emergency department. Academic emergency medicine. Published online 2021. doi:10.1111/acem.14263
Gasca-salas C, Lang A. (2016) Neurologic diagnostic criteria for functional neurologic disorders. Handbook of Clinical Neurology. 2016;139:193-212. doi:10.1016/B978-0-12-801772-2.00017-5
Hallett, M. (2019). Functional movement disorders: Is the crisis resolved?. Movement Disorders. 34(7). 971-974. http://doi.org/10.1002/mds.27713
Hassa, T., Sebastian, A., Liepert, J., Weiller, C., Schmidt, R., & Tüscher, O. (2017). Symptom-specific amygdala hyperactivity modulates motor control network in conversion disorder. NeuroImage: Clinical, 15, 143–150. https://doi.org/10.1016/j.nicl.2017.04.004
Park, J. E., Maurer, C. W., & Hallett, M. (2015). The “Whack‐a‐Mole” Sign in Functional Movement Disorders. Movement disorders clinical practice, 2(3), 286-288. https://doi.org/10.1002/mdc3.12177
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Treatment
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The Other Invisible FND Conditions
Ashar, Y. K., Gordon, A., Schubiner, H., Uipi, C., Knight, K., Anderson, Z., Carlisle, J., Polisky, L., Geuter, S., Flood, T. F., Kragel, P. A., Dimidjian, S., Lumley, M. A., & Wager, T. D. (2021). Effect of pain reprocessing therapy vs placebo and usual care for patients with chronic back pain. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2021.2669
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