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Serranová T, Di Vico I, Tinazzi M. Functional Movement Disorder: Assessment and Treatment. Neurol Clin 2023; 41:583-603. [PMID: 37775192 DOI: 10.1016/j.ncl.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
Functional movement disorder (FMD) is a common, potentially reversible source of disability in neurology. Over the last two decades, there have been major advances in our understanding of the clinical picture, diagnosis, and management of this condition. Motor presentation is heterogeneous and several non-motor symptoms (e.g., pain, fatigue) are part of the clinical spectrum. The diagnosis should be made by neurologists or neuropsychiatrists based on the presence of positive signs of inconsistency and incongruence with neurological diseases. Promising evidence has accumulated for the efficacy of physiotherapy, psychotherapy, or both in the management of FMD, for a majority of patients.
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Affiliation(s)
- Tereza Serranová
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Kateřinská 30, 12 800, Prague, Czech Republic.
| | - Ilaria Di Vico
- Movement Disorders Division, Department of Neurosciences, Neurology Unit, Biomedicine and Movement Sciences, University of Verona, Piazzale L. A. Scuro 10, 37124, Verona, VR, Italy
| | - Michele Tinazzi
- Movement Disorders Division, Department of Neurosciences, Neurology Unit, Biomedicine and Movement Sciences, University of Verona, Piazzale L. A. Scuro 10, 37124, Verona, VR, Italy
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2
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Rauline G, Hingray C, Carle-Toulemonde G, Hubsch C, El Hage W, Conejero I, Samalin L, Garcin B, Gharib A. [Validated care programs for patients with functional neurological disorders]. L'ENCEPHALE 2023:S0013-7006(23)00087-8. [PMID: 37400332 DOI: 10.1016/j.encep.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/06/2023] [Indexed: 07/05/2023]
Abstract
Functional neurological disorder (FND) is a common cause of persistent and disabling neurological symptoms. Diagnostic delay may lead to no treatment, inappropriate treatment or even iatrogenic symptoms. Yet, several treatments significantly reduce physical symptoms and improve functioning in FND patients even though not all patients respond to the currently available treatments. This review aims to describe the range of evidence-based rehabilitative and/or psychological therapeutic approaches available for FND patients. The most effective treatments are multidisciplinary and coordinated; using an outpatient or inpatient setting. Building a network of FND-trained healthcare professionals around the patient is an essential aspect of optimal patient management. Indeed, a supportive environment coupled with a collaborative therapeutic relationship improves understanding of FND and appears to help patients engage in appropriate treatments. Patients need to be invested in their own care and have to understand that recovery may depend on their commitment. The conventional treatment combines psychoeducation, physical rehabilitation and psychotherapy (cognitive and behavioral therapy, hypnosis, psychodynamic interpersonal therapy). Early referral of patients to physical therapy is recommended; however, the optimal parameters of treatment, duration and intensity are unknown and seem to vary with the severity and chronicity of symptoms. The goal is to minimize self-awareness by diverting attention or by stimulating automatically generated movements with non-specific and gradual exercises. The use of compensatory technical aids should be avoided as much as possible. Psychotherapeutic management should encourage self-evaluation of cognitive distortions, emotional reactions and maladaptive behaviors while empowering the patient in managing symptoms. Symptom management can use anchoring strategies to fight against dissociation. The aim is to connect to the immediate environment and to enrich one's sensoriality. The psychological interventions should then be adapted to the individual psychopathology, cognitive style and personality functioning of each patient. There is currently no known curative pharmacological treatment for FND. The pharmacological approach rather consists of progressively discontinuing medication that was introduced by default and that could lead to undesirable side effects. Finally, neurostimulation (transcranial magnetic stimulation, transcranial direct current stimulation) can be effective on motor FND.
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Affiliation(s)
| | - Coraline Hingray
- Pôle universitaire du Grand Nancy, CPN/unité neuropsychiatrique, CHRU de Nancy, Nancy, France
| | - Guilhem Carle-Toulemonde
- Cabinet de psychosomatique et stimulation magnétique transcrânienne, clinique Saint-Exupery, Toulouse, France
| | - Cécile Hubsch
- Parkinson Unit, Department of Neurology, Hospital Foundation Adolphe-de-Rothschild, Paris, France
| | - Wissam El Hage
- CHRU de Tours, clinique psychiatrique universitaire, Tours, France
| | - Ismaël Conejero
- Département de psychiatrie adulte, CHU de Nîmes, Nîmes, France
| | - Ludovic Samalin
- Département de psychiatrie, CHU de Clermont-Ferrand, université de Clermont Auvergne, CNRS, Clermont Auvergne INP, Institut Pascal (UMR 6602), Clermont-Ferrand, France
| | - Béatrice Garcin
- Service de neurologie, hôpital Avicenne, AP-HP, 125, rue de Stalingrad, 93000 Bobigny, France
| | - Axelle Gharib
- Centre bipol-AIR 9, rue Abraham-Bloch, 69007 Lyon, France.
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3
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Functional neurological disorder: new subtypes and shared mechanisms. Lancet Neurol 2022; 21:537-550. [PMID: 35430029 PMCID: PMC9107510 DOI: 10.1016/s1474-4422(21)00422-1] [Citation(s) in RCA: 95] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 10/14/2021] [Accepted: 11/24/2021] [Indexed: 01/12/2023]
Abstract
Functional neurological disorder is common in neurological practice. A new approach to the positive diagnosis of this disorder focuses on recognisable patterns of genuinely experienced symptoms and signs that show variability within the same task and between different tasks over time. Psychological stressors are common risk factors for functional neurological disorder, but are often absent. Four entities-functional seizures, functional movement disorders, persistent perceptual postural dizziness, and functional cognitive disorder-show similarities in aetiology and pathophysiology and are variants of a disorder at the interface between neurology and psychiatry. All four entities have distinctive features and can be diagnosed with the support of clinical neurophysiological studies and other biomarkers. The pathophysiology of functional neurological disorder includes overactivity of the limbic system, the development of an internal symptom model as part of a predictive coding framework, and dysfunction of brain networks that gives movement the sense of voluntariness. Evidence supports tailored multidisciplinary treatment that can involve physical and psychological therapy approaches.
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Diagnosis and Initial Treatment of Functional Movement Disorders in Children. Semin Pediatr Neurol 2022; 41:100953. [PMID: 35450668 DOI: 10.1016/j.spen.2022.100953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 11/20/2022]
Abstract
Functional movement disorders (FMD) are complex neurobehavioral disorders that can be a significant source of disability for both children and their caregivers. While FMD in the adult population is better characterized, the aim of this paper is to review the pertinent clinical and historical features, diagnostic criteria, and multi-disciplinary management of FMD in the pediatric population. We highlight recent trends in pediatric FMD, including the increase in functional tic-like behaviors that has been observed during the COVID-19 pandemic.
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5
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Schwingenschuh P, Espay AJ. Functional tremor. J Neurol Sci 2022; 435:120208. [DOI: 10.1016/j.jns.2022.120208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/02/2021] [Indexed: 10/18/2022]
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6
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Finkelstein SA, Adams C, Tuttle M, Saxena A, Perez DL. Neuropsychiatric Treatment Approaches for Functional Neurological Disorder: A How to Guide. Semin Neurol 2022; 42:204-224. [PMID: 35189644 DOI: 10.1055/s-0042-1742773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
There is a growing body of knowledge regarding management of functional neurological disorder (FND). The aim of this article is to guide the clinician through FND clinical management, from delivery of the diagnosis, to creation of a biopsychosocially-informed treatment plan, to troubleshooting common issues that arise throughout longitudinal care. We review the evidence and core principles of both rehabilitative therapies (physical therapy, occupational therapy, and speech and language therapy) and psychological therapies for the treatment of FND, and discuss the benefits of engaging a multidisciplinary and interdisciplinary team. The optimal timing of specific therapeutic interventions is also discussed, emphasizing a patient-centered perspective. Resources for further reading, for both patients and clinicians, are provided throughout. Additional research is needed to further optimize the therapeutic approach to patients with FND, including the need to develop novel treatments for those that do not positively respond to currently available interventions.
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Affiliation(s)
- Sara A Finkelstein
- Functional Neurological Disorder Unit, Division of Cognitive Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Caitlin Adams
- Functional Neurological Disorder Unit, Division of Cognitive Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Inpatient Psychiatry, Department of Psychiatry, Mass General Brigham Salem Hospital, Salem, Massachusetts
| | - Margaret Tuttle
- Functional Neurological Disorder Unit, Division of Cognitive Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Primary Care Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aneeta Saxena
- Functional Neurological Disorder Unit, Division of Cognitive Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Epilepsy Division, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - David L Perez
- Functional Neurological Disorder Unit, Division of Cognitive Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Neuropsychiatry, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Chastan N, Etard O, Parain D, Gerardin P, Fouldrin G, Derambure P, Tard C, Gillibert A, Nathou C, Delval A, Welter ML, Guillin O. Repetitive transcranial magnetic stimulation for patients with functional paralysis: a randomized controlled study. Eur J Neurol 2022; 29:1293-1302. [PMID: 35098613 DOI: 10.1111/ene.15264] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 01/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (rTMS) has been proposed to treat functional neurological disorders. Here, we aim to assess the efficacy of rTMS to treat functional paralysis in a controlled randomized trial. METHODS Patients received 2 sessions of active or sham 0.25 Hz rTMS (60 stimuli each), with a one-day interval, applied over the motor cortex contralateral to the paralysis. The primary outcome was the number of patients with an increase in motor score between baseline and after the second rTMS session, rated by two investigators blinded to the treatment allocation. Secondary outcomes were changes in global and fine motor scores between groups after rTMS, and occurrence of adverse events. RESULTS Sixty-two patients (46 female; mean [SD] age, 35.2 [13.9] years) were enrolled and randomized. Thirteen out of 32 (41%) and 11/30 (37%) patients had increased motor strength after active or sham rTMS, respectively (p=0.80). Changes in both global and fine motor scores after rTMS relative to baseline were also not significantly different between treatment groups (median difference in the global motor score 0.62 [0.83] and 0.37 [0.61], and fine motor scores 0.12 [0.18] and 0.08 [0.11], in active and sham rTMS groups, respectively, p=0.14). We observed six serious adverse events, consisting of 3 cephalalgia in the active group and 2 cephalalgia and 1 asthenia in the sham group. CONCLUSIONS Two sessions of sham or active low frequency rTMS were effective to improve functional paralysis, suggesting a placebo effect of this non-invasive brain stimulation technique.
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Affiliation(s)
- Nathalie Chastan
- Department of Neurophysiology and Clinical Investigation Center 1404, Rouen University Hospital, Rouen, France.,Normandy University, UNICAEN, INSERM U1075, Caen, France
| | - Olivier Etard
- Université de Normandie, ISTS, EA 7466, GIP Cyceron, Caen, France and CHU de Caen, Service des Explorations Fonctionnelles du Système Nerveux, Caen, France
| | - Dominique Parain
- Department of Neurophysiology and Clinical Investigation Center 1404, Rouen University Hospital, Rouen, France
| | | | - Gaël Fouldrin
- Department of Psychiatry, Rouen University Hospital, Rouen, France
| | - Philippe Derambure
- U1171, Department of Neurophysiology, Lille University Hospital, Lille, France
| | - Céline Tard
- U1171, Department of Neurophysiology, Lille University Hospital, Lille, France
| | - André Gillibert
- Department of Biostatistics, Rouen University Hospital, Rouen, France
| | - Clément Nathou
- CHU de Caen, Service de Psychiatrie adulte, Centre Esquirol, 14000, Caen, France
| | - Arnaud Delval
- U1171, Department of Neurophysiology, Lille University Hospital, Lille, France
| | - Marie-Laure Welter
- Department of Neurophysiology and Clinical Investigation Center 1404, Rouen University Hospital, Rouen, France.,Brain Institute, INSERM U1127, Paris, France
| | - Olivier Guillin
- Department of Psychiatry, Rouen University Hospital, Rouen, France
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Abstract
Functional neurological disorder (FND), previously regarded as a diagnosis of exclusion, is now a rule-in diagnosis with available treatments. This represents a major step toward destigmatizing the disorder, which was often doubted and deemed untreatable. FND is prevalent, generally affecting young and middle aged adults, and can cause severe disability in some individuals. An early diagnosis, with subsequent access to evidence based rehabilitative and/or psychological treatments, can promote recovery-albeit not all patients respond to currently available treatments. This review presents the latest advances in the use of validated rule-in examination signs to guide diagnosis, and the range of therapeutic approaches available to care for patients with FND. The article focuses on the two most frequently identified subtypes of FND: motor (weakness and/or movement disorders) and seizure type symptoms. Twenty two studies on motor and 27 studies on seizure type symptoms report high specificities of clinical signs (64-100%), and individual signs are reviewed. Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms, while psychotherapy is an emerging evidence based treatment across FND subtypes. The literature to date highlights heterogeneity in responses to treatment, underscoring that more research is needed to individualize treatments and develop novel interventions.
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Affiliation(s)
- Selma Aybek
- Neurology Department, Psychosomatic Medicine Unit, Inselspital University Hospital, Bern, and Bern University, Bern, Switzerland
| | - David L Perez
- Divisions of Cognitive Behavioral Neurology and Neuropsychiatry, Functional Neurological Disorder Unit, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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9
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Callister MN, Stonnington CB, Cuc A, Alcott SB, Driver-Dunckley ED, Mehta SH, Hasan S, Marks LA, Wingerchuk DM, O'Carroll CB. In Patients With Functional Movement Disorders, Is Specialized Physical Therapy Effective in Improving Motor Symptoms?: A Critically Appraised Topic. Neurologist 2022; 27:82-88. [PMID: 35051971 DOI: 10.1097/nrl.0000000000000408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Functional movement disorders (FMD, aka psychogenic movement disorders) are very common and frequently chronic and disabling. Despite this, there is a paucity of evidence-based treatment to manage and alleviate these conditions. Specialized physical therapy (PT), involving sequential motor relearning and redirecting attention, has shown promise as a therapeutic intervention for motor symptoms. METHODS The objective of this study was to critically assess current evidence regarding specialized PT compared with usual care in improving motor symptoms among patients with FMD. This was addressed through the development of a structured critically appraised topic. This included a clinical scenario with a clinical question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, and content experts in the fields of physical medicine and rehabilitation, physical and occupational therapy, psychiatry, and psychology. RESULTS A randomized controlled feasibility trial was identified and selected for critical appraisal. This study randomized 60 patients with FMD to a 5-day specialized outpatient PT program or to general outpatient PT referral, and measured patient-reported and clinician-measured outcomes. At 6 months, 72% of patients in the intervention group had a good outcome compared with 18% of control group patients. Patients in the specialized outpatient PT program had significantly better outcomes in 3 Short-Form 36 (SF36) domains (d=0.46 to 0.79) and multiple other scales of physical and social function as well as clinician-measured outcomes. The intervention resulted in 0.08 additional quality-adjusted life years in a cost-effective manner. CONCLUSIONS Current evidence suggests that in patients with FMD, specialized PT improves motor symptoms in a clinically significant, sustained, and cost-effective manner. This promising intervention warrants further investigation and replication.
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Affiliation(s)
| | | | | | | | | | | | | | - Lisa A Marks
- Library Services, Mayo Clinic Arizona, Scottsdale, AZ
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10
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Hess K, Schmitt M, Wabbels B. Periorbital injections of botulinum toxin a: a novel therapeutic option for convergence spasm in neuropsychiatric disorders. J Neurol 2022; 269:243-250. [PMID: 34047854 PMCID: PMC8739525 DOI: 10.1007/s00415-021-10613-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Convergence spasm (CS, spasm of near reflex) is characterized by transient attacks of convergence, miosis and accommodation, often associated with functional neurological disorders. To date, no simple and efficient treatment option is available for CS. This study investigates whether periorbital botulinum toxin injections as used in essential blepharospasm are also a treatment option in these patients. METHODS All patients with convergence spasm having been treated with periorbital BoNTA injections in the department of neuro-ophthalmology were identified. Data were extracted from patient files concerning details and subjective effectiveness of botulinum toxin injections and relation to psychiatric or neurological disorders. Patients reporting with a history of closed-head trauma or organic neurologic pathologies possibly causing CS were excluded. A telephone assessment with a standardized questionnaire was performed to evaluate mental health issues as a trigger, as well as the long-term effect and satisfaction with periorbital injections. RESULTS Of 16 patients treated with periorbital botulinum toxin injections for convergence spasm, 9 patients reported depression and/or anxiety disorders ongoing or in the past. A median number of 3 injections (range 1-13) was administered with a variable effect (relief of symptoms) between no effect and effect of up to more than 12 weeks. A longitudinal follow-up revealed ongoing symptoms in five patients. CONCLUSIONS Periorbital botulinum toxin injections are less invasive than injections in the medial rectus muscle and can be a bridging therapeutic option in patients with CS. Mental health exploration is important due to psychiatric comorbidity.
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Affiliation(s)
- Kristina Hess
- grid.10388.320000 0001 2240 3300Department of Ophthalmology, University Hospital Bonn, University of Bonn, Ernst-Abbe-Str. 2, 53127 Bonn, Germany
| | - Moritz Schmitt
- grid.10388.320000 0001 2240 3300Department of Ophthalmology, University Hospital Bonn, University of Bonn, Ernst-Abbe-Str. 2, 53127 Bonn, Germany
| | - Bettina Wabbels
- Department of Ophthalmology, University Hospital Bonn, University of Bonn, Ernst-Abbe-Str. 2, 53127, Bonn, Germany.
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11
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Houston KE, McDaniel CE, Greenspan L, Tirandazi P. Case Series: Periodic Accommodative Fluctuations after Concussion. Optom Vis Sci 2021; 98:1387-1393. [PMID: 34905525 DOI: 10.1097/opx.0000000000001810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE This is the first report recording an accommodative disorder after concussion characterized by periodic moderately sized myopic refractive error fluctuations without measurable other features of spasm of the near reflex. PURPOSE Objectively document a class of accommodative dysfunction that may be related to concussion. CASE REPORTS Case 1 involved two sports-related concussions 2 months apart with symptoms of headache and variable blur. Refractive stability was measured 28 months after injury with a binocular open-field refractometer documenting fluctuations from -0.25 to -1.75 D occurring 10 times during 4.2 seconds of recording with no evident miosis or convergent strabismus. The symptoms resolved with 1% atropine × 3 weeks. Case 2 involved a concussive blast injury (improvised explosive device) 7 years prior with symptoms of headache behind the eyes and occasional variable blur and reduced tolerance of electronic displays and other visually intensive tasks. Refractive fluctuations from +0.50 to -2.00 D occurred seven times over 44 seconds of recording with no appreciable miosis or change of interpalpebral fissure. The signs and symptoms were unresponsive to seven occupational therapy sessions involving task modifications and accommodative vision therapy activities. CONCLUSIONS In patients complaining of blurry vision, a careful evaluation of the stability of accommodation is indicated.
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Affiliation(s)
| | | | - Lynn Greenspan
- Pennsylvania College of Optometry, Salus University, Elkins Park, Pennsylvania
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12
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Dreissen YEM, Koelman JHTM, Tijssen MAJ. The auditory startle response in relation to outcome in functional movement disorders. Parkinsonism Relat Disord 2021; 89:113-117. [PMID: 34274620 DOI: 10.1016/j.parkreldis.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The auditory startle reflex (ASR) is enlarged in patients with functional movement disorders (FMD). OBJECTIVES To study whether the ASR relates to symptom reduction in FMD patients, who participated in a placebo controlled double blind treatment trial with Botulinum Neurotoxin (BoNT). METHODS Response to treatment in the BoNT study was assessed using the Clinical Global Impression - Improvement scale (CGI-I). The electromyography (EMG) muscle activity of 7 muscles following 110 dB tones was measured in 14 FMD patients before and after one-year treatment and compared to 11 matched controls. The early and a late (behaviorally affected) component of the ASR and the sympathetic skin response (SSR) were assessed. RESULTS 10 of 14 patients (71.4%) showed symptom improvement, which was believed to be mainly caused by placebo effects. The early total response probability of the ASR at baseline tended to be larger in patients compared to controls (p = 0.08), but normalized at follow-up (p = 0.84). The late total response probability was larger in patients vs. controls at baseline (p < 0.05), a trend that still was present at follow-up (p = 0.08). The SSR was higher in patients vs. controls at baseline (p < 0.01), and normalized at follow-up (p = 0.71). CONCLUSIONS On a group level 71.4% of the patients showed clinical symptom improvement after treatment. The early part of the ASR, most likely reflecting anxiety and hyperarousal, normalized in line with the clinical improvement. Interestingly, the augmented late component of the ASR remained enlarged suggesting persistent altered behavioral processing in functional patients despite motor improvement.
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Affiliation(s)
- Y E M Dreissen
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | - J H T M Koelman
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | - M A J Tijssen
- Department of Neurology, University Medical Centre Groningen, University Groningen, the Netherlands.
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13
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Marapin RS, Gelauff JM, Marsman JBC, de Jong BM, Dreissen YEM, Koelman JHTM, van der Horn HJ, Tijssen MAJ. Altered Posterior Midline Activity in Patients with Jerky and Tremulous Functional Movement Disorders. Brain Connect 2021; 11:584-593. [PMID: 33724053 DOI: 10.1089/brain.2020.0779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: To explore changes in resting-state networks in patients with jerky and tremulous functional movement disorders (JT-FMD). Methods: Resting-state functional magnetic resonance imaging data from seventeen patients with JT-FMD and seventeen age-, sex-, and education-matched healthy controls (HC) were investigated. Independent component analysis was used to examine the central executive network (CEN), salience network, and default mode network (DMN). Frequency distribution of network signal fluctuations and intra- and internetwork functional connectivity were investigated. Symptom severity was measured using the Clinical Global Impression-Severity scale. Beck Depression Inventory and Beck Anxiety Inventory scores were collected to measure depression and anxiety in FMD, respectively. Results: Compared with HC, patients with JT-FMD had significantly decreased power of lower range (0.01-0.10 Hz) frequency fluctuations in a precuneus and posterior cingulate cortex component of the DMN and in the dorsal attention network (DAN) component of the CEN (false discovery rate-corrected p < 0.05). No significant group differences were found for intra- and internetwork functional connectivity. In patients with JT-FMD, symptom severity was not significantly correlated with network measures. Depression scores were weakly correlated with intranetwork functional connectivity in the medial prefrontal cortex, while anxiety was not found to be related to network connectivity. Conclusions: Given the changes in the posterodorsal components of the DMN and DAN, we postulate that the JT-FMD-related functional alterations found in these regions could provide support for the concept that particularly attentional dysregulation is a fundamental disturbance in these patients.
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Affiliation(s)
- Ramesh S Marapin
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jeannette M Gelauff
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan B C Marsman
- Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, Groningen, The Netherlands
| | - Bauke M de Jong
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - Harm J van der Horn
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Marina A J Tijssen
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
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14
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Perez DL, Edwards MJ, Nielsen G, Kozlowska K, Hallett M, LaFrance WC. Decade of progress in motor functional neurological disorder: continuing the momentum. J Neurol Neurosurg Psychiatry 2021; 92:jnnp-2020-323953. [PMID: 33722822 PMCID: PMC8440656 DOI: 10.1136/jnnp-2020-323953] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/08/2021] [Accepted: 02/23/2021] [Indexed: 12/29/2022]
Abstract
Functional neurological disorder (FND) is a prevalent, disabling and costly condition at the neurology-psychiatry intersection. After being marginalised in the late 20th century, there has been renewed interest in this field. In this article, we review advances that have occurred over the past decade (2011-2020) across diagnosis, mechanisms, aetiologies, treatments and stigma in patients with motor FND (mFND, that is, functional movement disorder and functional limb weakness). In each content area, we also discuss the implications of recent advances and suggest future directions that will help continue the momentum of the past decade. In diagnosis, a major advance has been the emphasis on rule-in physical signs that are specific for hyperkinetic and hypokinetic functional motor symptoms. Mechanistically, greater importance has been given to determining 'how' functional neurological symptoms develop, highlighting roles for misdirected attention, expectation and self-agency, as well as abnormal influences of emotion/threat processing brain areas on motor control circuits. Aetiologically, while roles for adverse life experiences remain of interest in mFND, there is recognition of other aetiologic contributors, and efforts are needed to investigate links between aetiological factors and mechanisms. This decade has seen the first randomised controlled trials for physiotherapy, multidisciplinary rehabilitation and psychotherapy performed in the field, with consensus recommendations for physiotherapy, occupational therapy and outcome measures also published. Across patients, clinicians, healthcare systems and society, stigma remains a major concern. While challenges persist, a patient-centred integrated clinical neuroscience approach is primed to carry forward the momentum of the past decade into the future.
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Affiliation(s)
- David L Perez
- Neurology and Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mark J Edwards
- Neuroscience Research Centre, St George's University of London, London, UK
| | - Glenn Nielsen
- Neuroscience Research Centre, St George's University of London, London, UK
| | - Kasia Kozlowska
- Westmead Institute of Medical Research, The Children's Hospital at Westmead, Sydney Medical School, Westmead, New South Wales, Australia
| | | | - W Curt LaFrance
- Psychiatry and Neurology, Rhode Island Hospital, Providence, Rhode Island, USA
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Frucht L, Perez DL, Callahan J, MacLean J, Song PC, Sharma N, Stephen CD. Functional Dystonia: Differentiation From Primary Dystonia and Multidisciplinary Treatments. Front Neurol 2021; 11:605262. [PMID: 33613415 PMCID: PMC7894256 DOI: 10.3389/fneur.2020.605262] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/31/2020] [Indexed: 12/12/2022] Open
Abstract
Dystonia is a common movement disorder, involving sustained muscle contractions, often resulting in twisting and repetitive movements and abnormal postures. Dystonia may be primary, as the sole feature (isolated) or in combination with other movement disorders (combined dystonia), or as one feature of another neurological process (secondary dystonia). The current hypothesis is that dystonia is a disorder of distributed brain networks, including the basal ganglia, cerebellum, thalamus and the cortex resulting in abnormal neural motor programs. In comparison, functional dystonia (FD) may resemble other forms of dystonia (OD) but has a different pathophysiology, as a subtype of functional movement disorders (FMD). FD is the second most common FMD and amongst the most diagnostically challenging FMD subtypes. Therefore, distinguishing between FD and OD is important, as the management of these disorders is distinct. There are also different pathophysiological underpinnings in FD, with for example evidence of involvement of the right temporoparietal junction in functional movement disorders that is believed to serve as a general comparator of internal predictions/motor intentions with actual motor events resulting in disturbances in self-agency. In this article, we present a comprehensive review across the spectrum of FD, including oromandibular and vocal forms and discuss the history, clinical clues, evidence for adjunctive "laboratory-based" testing, pathophysiological research and prognosis data. We also provide the approach used at the Massachusetts General Hospital Dystonia Center toward the diagnosis, management and treatment of FD. A multidisciplinary approach, including neurology, psychiatry, physical, occupational therapy and speech therapy, and cognitive behavioral psychotherapy approaches are frequently required; pharmacological approaches, including possible targeted use of botulinum toxin injections and inpatient programs are considerations in some patients. Early diagnosis and treatment may help prevent unnecessary investigations and procedures, while facilitating the appropriate management of these highly complex patients, which may help to mitigate frequently poor clinical outcomes.
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Affiliation(s)
- Lucy Frucht
- Faculty of Arts and Sciences, Harvard University, Boston, MA, United States
| | - David L. Perez
- Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Functional Neurological Disorder Research Program, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Neuropsychiatry Division, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Janet Callahan
- MGH Institute of Healthcare Professionals, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Julie MacLean
- Occupational Therapy Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Phillip C. Song
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States
| | - Nutan Sharma
- Functional Neurological Disorder Research Program, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Dystonia Center and Movement Disorders Unit, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Christopher D. Stephen
- Functional Neurological Disorder Research Program, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Dystonia Center and Movement Disorders Unit, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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16
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Dreissen YE, Lambert F, Dijk JM, Koelman JH, Tijssen MA. Botulinum neurotoxin (BoNT) treatment in functional movement disorders: long-term follow-up. J Neurol Neurosurg Psychiatry 2020; 91:1120-1121. [PMID: 32661081 PMCID: PMC7509513 DOI: 10.1136/jnnp-2020-323684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/04/2020] [Accepted: 06/17/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Yasmine Em Dreissen
- Neurology, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands.,Clinical Neurophysiology, Amsterdam University Medical Center (AMC), University of Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - Franka Lambert
- Neurology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Joke M Dijk
- Clinical Neurophysiology, Amsterdam University Medical Center (AMC), University of Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - Johannes Htm Koelman
- Neurology, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands.,Clinical Neurophysiology, Amsterdam University Medical Center (AMC), University of Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - Marina Aj Tijssen
- Neurology, University Medical Centre Groningen, Groningen, The Netherlands
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17
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Marapin RS, van der Stouwe AMM, de Jong BM, Gelauff JM, Vergara VM, Calhoun VD, Dalenberg JR, Dreissen YEM, Koelman JHTM, Tijssen MAJ, van der Horn HJ. The chronnectome as a model for Charcot's 'dynamic lesion' in functional movement disorders. Neuroimage Clin 2020; 28:102381. [PMID: 32927233 PMCID: PMC7495110 DOI: 10.1016/j.nicl.2020.102381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/07/2020] [Accepted: 08/09/2020] [Indexed: 01/14/2023]
Abstract
This exploratory study set out to investigate dynamic functional connectivity (dFC) in patients with jerky and tremulous functional movement disorders (JT-FMD). The focus in this work is on dynamic brain states, which represent distinct dFC patterns that reoccur in time and across subjects. Resting-state fMRI data were collected from 17 patients with JT-FMD and 17 healthy controls (HC). Symptom severity was measured using the Clinical Global Impression-Severity scale. Depression and anxiety were measured using the Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI), respectively. Independent component analysis was used to extract functional brain components. After computing dFC, dynamic brain states were determined for every subject using k-means clustering. Compared to HC, patients with JT-FMD spent more time in a state that was characterized predominantly by increasing medial prefrontal, and decreasing posterior midline connectivity over time. They also tended to visit this state more frequently. In addition, patients with JT-FMD transitioned significantly more often between different states compared to HC, and incorporated a state with decreasing medial prefrontal, and increasing posterior midline connectivity in their attractor, i.e., the cyclic patterns of state transitions. Altogether, this is the first study that demonstrates altered functional brain network dynamics in JT-FMD that may support concepts of increased self-reflective processes and impaired sense of agency as driving factors in FMD.
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Affiliation(s)
- Ramesh S Marapin
- Department of Neurology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; Expertise Center Movement Disorders Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands.
| | - A M Madelein van der Stouwe
- Department of Neurology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; Expertise Center Movement Disorders Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands.
| | - Bauke M de Jong
- Department of Neurology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - Jeannette M Gelauff
- Department of Neurology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Victor M Vergara
- Tri-institutional Center for Translational Research in Neuroimaging and Data Science (TReNDS), Georgia State, Georgia Tech, Emory, 55 Park Pl NE, Atlanta, GA 30303, United States
| | - Vince D Calhoun
- Tri-institutional Center for Translational Research in Neuroimaging and Data Science (TReNDS), Georgia State, Georgia Tech, Emory, 55 Park Pl NE, Atlanta, GA 30303, United States.
| | - Jelle R Dalenberg
- Department of Neurology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; Expertise Center Movement Disorders Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands.
| | - Yasmine E M Dreissen
- Neurology and Clinical Neurophysiology, Amsterdam University Medical Center, location AMC, Amsterdam, The Netherlands.
| | - Johannes H T M Koelman
- Neurology and Clinical Neurophysiology, Amsterdam University Medical Center, location AMC, Amsterdam, The Netherlands.
| | - Marina A J Tijssen
- Department of Neurology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; Expertise Center Movement Disorders Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands.
| | - Harm J van der Horn
- Department of Neurology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
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19
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Briand MM, Boudier-Réveret M, Rodrigue X, Sirois G, Chang MC. A Moving Residual Limb: Botulinum Toxin to the Rescue. Transl Neurosci 2020; 11:34-37. [PMID: 32161684 PMCID: PMC7053396 DOI: 10.1515/tnsci-2020-0006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/10/2020] [Indexed: 12/23/2022] Open
Abstract
Movement disorders post-amputation are a rare complication and can manifest as the jumping stump phenomenon, a form of peripheral myoclonus. The pathophysiology remains unknown and there is currently no standardized treatment. We describe the case of a 57-year-old male with unremitting stump myoclonus, starting one month after transtibial amputation, in his residual limb without associated phantom or neurological pain. The consequence of the myoclonus was a reduction in prosthetic wearing time. Failure to respond to oral medication led us to attempt the use of botulinum neurotoxin Type A injections in the involved muscles of the residual limb. Injection trials, over a two-year period, resulted in an improvement of movement disorder, an increased prosthetic wearing time and a higher satisfaction level of the patient. Injection of botulinum toxin type A should be considered as an alternative treatment for stump myoclonus to improve prosthetic wearing time and comfort.
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Affiliation(s)
| | - Mathieu Boudier-Réveret
- Department of Physical Medicine and Rehabilitation, Centre hospitalier de l'Université de Montréal, Montreal, Canada
| | - Xavier Rodrigue
- Institut de réadaptation en déficience physique de Québec, Québec, Canada
| | - Geneviève Sirois
- Institut de réadaptation en déficience physique de Québec, Québec, Canada
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University 317-1, Daemyungdong, Namku, Taegu 705-717, Republic of Korea
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