Physiotherapy for functional (psychogenic) motor symptoms: A systematic review

Abstract

Objective

Functional (psychogenic) motor symptoms (FMS), also called motor conversion disorder or non-organic motor symptoms are a common cause of disability and distress among patients attending neurology and neurorehabilitation services. Patients with FMS are often referred for physiotherapy but it is not clear whether this is effective. Here we aim to systematically review the literature regarding physiotherapy interventions for patients with functional motor symptoms.

Methods

Systematic review of databases with reference search for period 1950 to September 2012.

Results

There was only one controlled intervention study with a historical control group and 28 case series or reports describing interventions. The total number of patients in all studies was 373. Physiotherapy most commonly occurred in the context of multidisciplinary treatment and involved a motor learning approach. Novel approaches included the use of distraction techniques and transcutaneous electrical nerve stimulation (TENS) machine. Deceptive behavioural techniques have also been described. Most studies reported benefit from physical treatment, including some studies with long-term follow up.

Conclusions

Patients with FMS are commonly encountered in neurological practice and are often referred for physiotherapy. The existing data to guide physiotherapy treatment for FMS is of low quality and limited in scope. However, it suggests potential positive effects and provides a useful resource for developing and testing physiotherapy interventions in future studies.

Introduction

Patients frequently present with neurological symptoms that are unexplained by neurological disease [1]. These symptoms, once called hysterical, are now referred to as psychogenic, functional, non-organic, dissociative or as conversion symptoms. The diagnosis of “functional neurological symptoms” is one of the commonest made in neurological practice, and patients with functional motor symptoms (e.g. hemiparesis, gait disturbance, tremors) are at least as common as those with multiple sclerosis [2], [3]. Such patients have levels of disability, distress and health care usage that equals and in some cases surpasses patients with neurodegenerative disease [4].

Physiotherapy is considered an important component of treatment by most clinicians. In a survey of 526 neurologists 79% considered physiotherapy to be at least somewhat effective and at least as effective as psychotherapy alone [5]. In another survey of 702 neurophysiotherapists in the UK most (77%) said they saw patients with FMS and a quarter said they spent more than 10% of their time on this patient group [6]. They had generally positive attitudes to these patients with 82% responding that they felt that physiotherapy was an appropriate treatment. However, many reported a lack of evidence to support treatment as well as a lack of support from neurologists. Another issue identified was that some physiotherapists (14%) were concerned that they were working outside the boundaries of their profession and that psychological therapy was not available to complement physical intervention.

Against this background we present the results of a systematic review of the use of physiotherapy in the treatment of patients with FMS in order to explore the evidence base for physical interventions in this condition and to determine directions for future research.