Parkinsonism and Related Disorders 18 (2012) 247e251

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Parkinsonism and Related Disorders

journal homepage: www.elsevier.com/locate/parkreldis

Functional movement disorders: Successful treatment with a physical therapy

rehabilitation protocol
Kathrin Czarnecki a, Jeffrey M. Thompson b, Richard Seime c, Yonas E. Geda c, d, Joseph R. Duffy a,
J.Eric Ahlskog a, *
a

Department of Neurology, Mayo Clinic, Rochester, MN 55905, United States

Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, United States
Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, United States
d
Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, United States
b
c

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 19 July 2011
Received in revised form
5 September 2011
Accepted 14 October 2011

Background: Functional (psychogenic) gait and other movement disorders have proven very difcult to treat.
Objectives: Describe the Mayo Clinic functional movement disorder motor-reprogramming protocol
conducted in the Department of Physical Medicine and Rehabilitation (PMR), and assess short-term and
long-term outcomes.
Design: Historical-cohort-study assessing non-randomized PMR intervention.
Setting: Tertiary care center.
Patients: Interventional group: 60 consecutive patients with a chronic functional movement disorder that
underwent the PMR protocol between January 2005 and December 2008. Control group: age- and sexmatched patients with treatment-as-usual (n 60).
Interventions: An outpatient, one-week intensive rehabilitation program based on the concept of motorreprogramming following a comprehensive diagnostic neurological evaluation, including psychiatric/
psychological assessment.
Main outcome measures: Improvement of the movement disorder by the end of the week-long program
(patient- and physician-rated), plus the long-term outcome (patient-rated).
Results: Patient demographics: median symptom duration, 17 months (range, 1e276); female predominance (76.7%); mean age 45 years (range, 17e79). Physician-rated outcomes after the one-week treatment program documented 73.5% were markedly improved, nearly normal or in remission, similar to the
patient-ratings (68.8%). Long-term treatment outcomes (patient-rated; median follow-up, 25 months)
revealed 60.4% were markedly improved or almost completely normal/in remission, compared to 21.9%
of controls (p < 0.001).
Conclusions: Short-term and long-term successful outcomes were documented in the treatment of
patients with functional movement disorders by a rehabilitative, goal-oriented program with intense
physical and occupational therapy. The rapid benet, which was sustained in most patients, suggests
substantial efcacy that should be further assessed in a prospective, controlled, clinical trial.
2011 Elsevier Ltd. All rights reserved.

Keywords:
Psychogenic movement disorder
Conversion disorder
Functional movement disorder
Physical therapy

1. Introduction
Functional movement disorders (FMD) are characterized by
abnormal motor behaviors that are inconsistent with an organic
etiology. These may resemble organic tremor, dystonia, other
hyperkinetic conditions, gait disorders, paresis or combinations.
These may account for 3% [1] to 15% [2] of patients seen by

* Corresponding author. Tel.: 1 507 284 2511; fax: 1 507 538 6012.
E-mail address: eahlskog@mayo.edu (J.Eric Ahlskog).
1353-8020/$ e see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.parkreldis.2011.10.011

neurology movement disorder specialists but are also common in

general neurology clinics.
These conditions are often categorized as psychogenic, and
this term is sometimes used interchangeably with functional. The
lay-dictionary denes psychogenic as, originating in the mind or
in mental or emotional conict. [3]. This obviously implies
a primary psychological cause and this may not be strictly applicable to many patients. Moreover, telling patients their life-altering
disorder is psychogenic, with all the implications, may sabotage
the working relationship with the clinician. In this manuscript, we
will avoid that term, preferring functional.

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K. Czarnecki et al. / Parkinsonism and Related Disorders 18 (2012) 247e251

Once diagnosed, FMD present an enormous therapeutic challenge. Prognosis is often characterized as poor, with most patients
failing to substantially improve, especially among those with
symptoms persistent beyond one year [4e6]. Even among series
that are more optimistic, substantial numbers of patients have
persistent disability [2].
With the notoriety accorded similar disorders by Freud more
than a century ago [7], therapeutic strategies have focused
especially on psychiatric/psychological interventions. In the
current era, psychotherapy, antidepressant and other psychoactive medications are typically an early treatment approach
[8e10]. Although many publications have attested to the benets
of psychotherapeutic and other psychological/psychiatric strategies, our experience has not been as gratifying, and the pessimistic outcomes from movement clinics are consistent with that
perception [4e6].
Physical therapy has also been advocated for such patients,
although specic strategies have been left to individual
treating therapists [11]. In our experience many of these
patients have already undergone physical therapy, but failed
to substantially benet; thus, generic physical therapy in the
absence of a specic treatment-program has not been
successful.
In fact, there is no consensus about treatment of FMD [12].
Clinicians generally nd this to be a very unsatisfying aspect of their
practice, with frustration among both patients and physicians. This
was our collective experience for many years; we could diagnose,
but not effectively treat.
A number of years ago, we recognized that functional speech/
voice disorders were highly responsive to a behavioral motor reprogramming approach by our Mayo Speech-Language Pathology
colleagues [13,14]. In fact, a parallel approach was being used
successfully, but inconsistently in our Physical Medicine and
Rehabilitation (PMR) Department as treatment for FMD. Encouraged by these outcomes, we developed a more structured motorreprogramming treatment protocol for FMD patients implemented in the PMR Department.
Such motor-reprogramming in the context of physical medicine
has been used for treatment of FMD with limited precedents
[15,16]. The approach involves specically focusing on the aberrant
movements and postures, breaking these down into the individual
motor components and gradually reconstructing more normal
motor patterns. With this strategy, appropriate motor pattens are
reinforced and inappropriate movements are ignored (extinguished). By gradually rebuilding or re-shaping motor movements,
more normal pattens can be achieved. Our initial treatment
protocol arbitrarily conned this to one intensive week of twicedaily physical and occupational therapy, after the physiatrist had
initially designed the therapy program for that patient. Our initial
experience suggested that one week was sufcient. This has been
utilized as the primary therapeutic strategy for the treatment of
FMD patients diagnosed in our movement disorders clinic since
2005.
We now describe our experience with the rst 60 consecutive
patients who were diagnosed with an FMD in our Neurology
Department and subsequently treated with this approach. This was
exclusively designed as a therapeutic PMR protocol for the benet
of our patients, and we had no a-priori plan to formally study/
report the outcomes. The initial follow-up called for reassessment
only at the end of the treatment week. As substantial efcacy
became apparent, we elected to better assess outcomes, which
included adding phone- and letter-follow-up to tabulate longerterm responses. For comparison we also included a control-group
of patients who were similarly diagnosed, but not treated with
this approach.

2. Patients and methods

2.1. Study-design
For this historical-cohort-study, we retrospectively identied from our Mayo
computer-database all patients who had been evaluated between 1/1/2005 and 12/
31/2008 in the Mayo Clinic Department of Neurology and given a nal diagnosis of
an FMD. These included varied functional motor disorders: gait, tremor, other
hyperkinetic movements, or paresis. From this group we then identied all those
subsequently treated during this period in the Mayo PMR Department utilizing this
motor-reprogramming protocol. This retrospective study was approved by the Mayo
Clinic Institutional-Review-Board.

2.2. Treatment-group
The rst 60 consecutive patients who met the following criteria constituted the
treatment group: (a) given an clinically-established diagnosis of a functional
movement disorder, consistent with criteria of Fahn and Williams [17], and counseled about this; (b) completed whatever diagnostic testing thought appropriate
prior to initiating the treatment protocol; (c) completed at least 3 days of the 5-day
PMR treatment protocol. Excluded from this analysis were cases where the diagnosis
was unclear (n 16), or where there were major departures from the PMR protocol
(n 21).

2.3. Control-group (treatment-as-usual)

For comparison of long-term outcomes, we selected 60 age- and sex-matched
patients evaluated in the Department of Neurology and given a diagnosis of an
FMD who did not undergo the rehabilitation program. Reasons for not undergoing
the PMR protocol included: lack of insurance coverage; logistic reasons (e.g., travel,
hotel expense, family-time away from work); non-acceptance of the diagnosis;
neurology-staff unaware of this treatment program early-on.

2.4. Intervention
The patients specic PMR program was initially designed by the physiatrist on
the rst protocol day. We suspected that a crucial component for success was the
initial PMR interaction and counseling before the motor therapy ensued. This
counseling included expressed condence that this approach had a good likelihood
of succeeding, which was important for two reasons: (a) many patients had already
failed physical therapy programs; (b) promoting a positive attitude. The PMR
strategy was described in operational terms, such as the presence of a disconnect
between the patients normal brain motor program and the normal nerves/muscles
used to carry out the movement; thus, the therapy would focus on eliminating that
disconnect. No attempt was made to explain how the disconnect initially
occurred, but rather the emphasis was on re-establishing the normal motor
program.
Following the initial counseling, the PMR treatment plan was implemented with
twice-daily physical/occupational therapy for 5 consecutive days. If a functional
speech disorder was present, consultation and therapy with a speech-language
pathologist was also done during this week (N 7; speech outcomes not included
in current analysis).
An evaluation by a psychiatrist or psychologist was part of the protocol, usually
done after the diagnostic workup was completed and typically early in the treatment
week. This focused on identifying: (a) possible causes or contributory factors, such
as an abuse history; (b) other psychological issues, such as depression or anxiety,
that might interfere with the program and recovery. While most of the patients met
DSM-IV criteria for a conversion or somatoform disorder [18], the psychologist/
psychiatrist reinforced the program model that targeted relearning normal motor
function, rather than focusing on psychological factors that preceded the motor
problem.
The rehabilitation program was aimed at establishing normal movement
patterns, while ignoring abnormal movements, taking a step-by-step strategy,
modied from schemes previously described in the PMR literature [15,16]. Motor
dysfunction was objectied in operational rather than psychological terms. The
motor reprogramming strategy began with establishing very elementary movements in the affected limb or body region, and building on those. Often, distracting
motor tasks were employed to extinguish abnormal movements (such as tapping
the ngers of the unaffected hand in a patient with unilateral tremor, or bouncing
a balloon while working on trunk stability/standing balance). As simple movements were satisfactorily performed, appropriate motor complexity was added,
gradually approximating motor-normality. Positive gains were verbally reinforced.
Abnormal movements were ignored, although major and frequent adventitious
intrusions during the PMR sessions suggested the advisability for rest periods.
Repetition was thought important to lock-in the gains. The necessity of continued/
ongoing practice of these principles beyond completing the PMR week was
emphasized.

K. Czarnecki et al. / Parkinsonism and Related Disorders 18 (2012) 247e251

2.5. Outcome-measures, end of the week-long PMR protocol
Patients were reassessed by the primary Mayo neurologist at the end of the
treatment week. The primary outcome measures at this time were patient- plus
physician-rated improvement in the movement-disorder after the end of the weeklong rehabilitation program. A secondary outcome was self-rated level of disability.
As the treatment program continued, videotaping was incorporated, with 19
patients (31.7%) videotaped before and after completion of the program (representative examples in the supplementary le). When the therapy week was
successful, therapists often used the before-and-after videos to reinforce responses.
2.6. Longer-term outcomes, assessed by mail and phone
An outcome questionnaire was mailed to all patients in both groups during
October, 2009. Patients failing to return the questionnaire were sent a second letter
and if still non-responding, we attempted to conduct a phone interview.
The questionnaire graded the outcomes with a rating-scale: 0 not improved
or worse (25% improved); 1 mildly improved (26e50% improvement);
2 moderately improved (51e75% improvement); 3 markedly improved
(76e95% improvement) and 4 almost completely normal/in remission (>95%
improved). Good outcome was dened as rating scores 3 or 4. Disability in daily
activities due to the FMD was graded as severe, moderate, mild or none.
2.7. Data-analysis
Demographic and outcome data of patients and controls was compared using
the Wilcoxon-rank-sum test (continuous data) or Chi-square (categorical data).
Odds-ratios were calculated to predict factors associated with good outcomes, using
a 95% condence-interval. A two-sided p-value <0.05 was considered statistically
signicant. JMP 8.0 (SAS Institute, Cary, NC) was used for statistical analysis.

3. Results
3.1. Demographics (Table 1)
The mean age of the 60 patients in the treatment cohort was 46
years (range 17e79), with female predominance (76.7%) and

Table 1
Baseline demographic data and characteristics of study patients and controls.
Variables

Patients
(n 60)

Controls
(n 60)

Gender F, n (%)
Age, mean (range)
Second neurological opinion, n (%)
Referral diagnosis, n (%)
Neurologic disorder
Conversion disorder
Indeterminate
Categories of movement disorders, n (%)
Gait disorders
Hyperkinetic disorders
Paresis
Paroxysmal disorders
Symptom duration in months,
median (range)
Onset less than 12 months, n (%)
Acute onset, n (%)
Trigger factor, n (%)
Acute depression, n (%)
Lifetime history of depression, n (%)
Other psychiatric diagnosis (e.g. anxiety,
personality disorder, PTSD), n (%)
Current treatment with antidepressive
medication, n (%)
Diagnosis of chronic pain disorder, n (%)
Employment status, n (%)
Employed
Unemployed
Work disabled
Other (e.g. retired, student)
History of sexual abuse, n (%)
Family history of alcohol abuse in
parents or siblings, n (%)

46 (76.7)
45 (17e79)
57 (95.0)

46 (76.7)
47 (21e85)
58 (96.7)

24 (42.1)
14 (24.6)
19 (33.3)

24 (41.4)
3 (5.2)
31 (53.4)

24
26
6
4
17

(40.0)
(43.3)
(10.0)
(6.7)
(1e276)

31
17
6
6
18

(51.7)
(28.3)
(10.0)
(10.0)
(1e252)

24
21
18
18
26
25

(40.0)
(35.5)
(30.0)
(30.0)
(43.3)
(41.7)

25
22
12
11
44
13

(41.7)
(36.7)
(20.0)
(18.3)
(73.3)
(21.7)

p-value
1.0
0.38
0.65
0.001

249

median symptom duration, 17 months (range 1e276). Most

patients (95%) were seen for a second neurological opinion and 45%
were either unemployed or work-disabled at time of evaluation.
Patients had previously carried a diagnosis of a neurologic
disorder (42.1%), conversion disorder (24.6%) or indeterminate
disorder (33.3%) and underwent prior unsuccessful treatment trials
with antidepressants (56.7%), psychotherapy (6.7%) or physical
therapy (36.7%). The movement-disorders were heterogeneous and
included abnormal gait; hyperkinetic movements resembling
tremor, chorea, myoclonus, or dystonia; paresis or a paroxysmal
movement disorder (Table 1).
All patients were evaluated by a Mayo Clinic neurologist and
80% were seen by a Mayo Movement Disorder specialist. Diagnostic
testing included Movement Neurophysiology Laboratory assessment, as appropriate (50% of cases). According to Fahn and Williams criteria, the diagnosis of a psychogenic movement-disorder in
the treatment group was documented in 43.3%, clinically
established in 45% and probable in 11.7% [17].
Psychiatric/psychologic consultation was completed in 91.7%
(controls 41.7%). All subjects met the psychiatric diagnosis of
conversion disorder or somatoform disorder and none were
believed to be malingering.
The control group consisted of 60 patients diagnosed with an FMD
by a Mayo neurologist (65% evaluated by a Mayo movement
specialist), who did not undergo this protocol (treatment-as-usual).
They had very similar baseline demographics and clinical characteristics to the PMR treatment group, with a few exceptions (see Table 1).
These control subjects did not undergo the PMR program for various
reasons: program not offered (n 22); not suitable/no insurance
(n 12); disagreement with diagnosis (n 11); predominant pain
problem (n 8); spontaneous improvement (n 2); other (n 5).
3.2. Outcomes, end of the PMR treatment week
The end-of-treatment rating was classied as markedly
improved or almost completely normal/in remission (good
outcome) in 73.3% based on physician assessment and 68.8% by
patient assessment, as shown in Fig. 1A; three representative video
examples are shown in the supplementary les. The mean number
of days engaged in the 5-day program was 4.7. Only ve patients
completed less than 4 days and in all ve, this was because they
were in complete remission.
Supplementary video related to this article can be found at doi:
10.1016/j.parkreldis.2011.10.011.

0.37

3.3. Longer-term outcomes (questionnaire, phone) vs control-group

0.89
0.85
0.84
0.21
0.14
<0.001
0.02

34 (56.7)

30 (50.0)

0.46

19 (31.7)

17 (28.3)

0.69
0.21

20
9
18
13
17
19

18
3
26
13
13
20

(33.3)
(15.0)
(30.0)
(21.7)
(28.3)
(31.7)

(30.0)
(5.0)
(43.3)
(21.7)
(21.7)
(33.3)

0.48
0.85

The questionnaire was sent to the treatment-group a median of

25 months after completion of their PMR week and to the controlgroup a median 33 months after the nal diagnostic visit (Table 2).
Long-term followup was completed via mailed questionnaire or
phone in 80% of the treatment-group and 53.3% of the controlgroup. Reasons for non-response included inability to contact
subjects (8 treated patients, 22 controls) or decline in participation
(4 treated patients, 6 controls).
In the treatment group, 60.4% of patients were markedly
improved, almost completely normal or in remission at this longerterm follow-up; 25% were treatment failures (no better than mildly
improved). This contrasts with the control group: 21.9% were markedly improved, almost completely normal/in remission (p < 0.001;
Table 2, Fig. 1B). Of the ve patients completing the protocol early
(3e3.5 days), 3 patients maintained their initial response on longterm follow up, whereas two were lost to follow up.
The vast majority of treated patients continued to have some
degree of abnormal movements, identical in frequency to the

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K. Czarnecki et al. / Parkinsonism and Related Disorders 18 (2012) 247e251

strategies for terminating or limiting the motor disorder if it

recurred, which may account for the high percentage of treated
patients with residual movements (87.5%), but good outcomes
(60.4%) and no or mild disability (62.4%).
Additional therapies relevant to the movement-disorder were
utilized in 81.3% of control subjects, including pharmacotherapy,
psychotherapy or alternative medicine strategies (Table 2); the
minority of PMR-treated patients reported using additional treatments in the interim (43.8%; p < 0.001 vs controls).
Three patients and four controls reported a new diagnosis of
neurological disease made elsewhere after their Mayo clinic evaluation. These were specied as neuropathy (2 patients), dystonia (1
patient, 1 control), multiple sclerosis (1 patient) and neuroborreliosis (2 controls). This information was obtained per selfreport only, and was not objectively conrmed.
We analyzed numerous factors that we thought might inuence
outcome in the treatment group. However, as shown in Table 3A
and B, female-gender was the only variable signicantly associated
with a good outcome in the longer-term followup.
4. Discussion

Fig. 1. Short & long-term outcomes after completion of PMR protocol. 1A. Initial
outcomes (after completion of PMR program; values in percent). 1B. Self-rated longterm outcomes (questionnaire, phone followup; values in percent).

control group (87.5%, each group). Self-assigned level of disability

due to the movement-disorder differed signicantly between
groups (p 0.019; Table 2), with 62.4% of treated patients rating
their disability level as mild or none, compared to 43.8% of
controls. Patients undergoing the protocol were instructed in

Table 3
Predictors of successful outcome with the PMR protocol.
3A. acute outcome (end of treatment week; n 60)

Table 2
Long-term follow up of patients and controls.
Variable

Patients
(n 48)

Time to followup, months, median (range)

Benet from rehabilitation program, n (%)
Current presence of abnormal
movements, n (%)
Interval change, n (%)
0 - Not improved or worse
1 - Mildly improved
2 - Moderately improved
3 - Markedly improved
4 - Almost completely normal
or in remission
Good outcome, n (%)
Disability in daily activities, n (%)
0 - Severe
1 - Moderate
2 - Mild
3 - None
Additional therapy for movement
disorder in interim, n (%)
Additional therapy for depression, n (%)
Alternative neurological diagnosis
for movement disorder, n (%)

25 (10e64) 33 (11e57)
43 (89.6)
e
42 (87.5)
28 (87.5)

*Wilcoxon rank sum test used.

Patients in the PMR treatment group presented with long

durations of functional movement problems (median duration, 17.5
months), and hence the outcomes at the end of the PMR week were
quite notable: approximately 70% were rated as markedly
improved, nearly completely normal, or in remission. Although
these evaluations were unblinded, clinicians frequently noted that
the improvement was quite striking and gratifying to patients.
Outcomes were reportedly sustained in 60% of those responding to
the questionnaire/phone followup approximately two years later
(10e64 months followup).
Most previously published series have concluded that
psychogenic movement disorders often have poor outcomes,
especially those persisting beyond a year [4e6]. Outcomes in our
control patients are consistent with these observations, with most
(62.5%) no better than mildly improved at followup, despite additional treatment attempts in a little over 80%.

Controls
(n 32)

(8.3)
(16.7)
(14.6)
(22.9)
(37.5)

29 (60.4)
3
15
15
15
21

(6.3)
(31.2)
(31.2)
(31.2)
(43.8)

15 (31.3)
3 (6.3)

14
6
5
3
4

0.002
1.0

(43.8)
(18.7)
(15.6)
(9.4)
(12.5)

7 (21.9)
11
7
8
6
26

(34.3)
(21.9)
(25.0)
(18.8)
(81.3)

16 (50.0)
4 (12.5)

Good outcome,a Odds ratio (95% CI) p-value

in %

Female gender
Age under 60
Symptom onset < 1 year
Acute onset
Trigger factor
Absence of acute depression
Absence of depression history
Absence of chronic pain
Sexual abuse history

78.3
73.5
83.3
81.0
83.3
78.6
82.4
78.1
76.5

p-value

<0.001
4
8
7
11
18

Variable

2.7
1.0
2.5
1.9
2.2
2.3
2.9
2.1
1.3

(0.8e9.6)
(0.2e4.5)
(0.7e8.9)
(0.5e6.8)
(0.6e9.1)
(0.7e7.7)
(0.9e9.5)
(0.6e6.8)
(0.3e4.6)

0.12
0.96
0.15
0.33
0.25
0.16
0.07
0.23
0.73

3B. long-term outcome (questionnaire/phone interview; n 48)

<0.001
0.019

<0.001
0.09
0.33

Variable

Good outcomea
in %

Odds ratio

p-value

Female gender
Age under 60
Symptom onset < 1 year
Acute onset
Trigger factor
Absence of acute depression
Absence of depression history
Absence of chronic pain
Sexual abuse history

68.4
67.6
70.0
66.7
76.9
61.1
62.9
61.8
71.4

5.1
3.6
2.0
1.5
2.8
1.1
1.3
1.2
1.9

0.03
0.06
0.25
0.49
0.15
0.86
0.68
0.76
0.32

(1.1e23.0)
(0.9e14.9)
(0.6e6.7)
(0.5e5.1)
(0.7e11.9)
(0.3e4.2)
(0.4e4.1)
(0.3e4.3)
(0.5e7.6)

a
Good outcome markedly improved, almost completely normal or in
remission.

K. Czarnecki et al. / Parkinsonism and Related Disorders 18 (2012) 247e251

Comorbid psychiatric illness and psychological stress factors

were documented in many patients (Table 1). However, some of the
psychopathology may have simply been reactive to the disability
from the movement-disorder. Major psychopathology, apart from
conversion disorder, did not surface in most patients, based on the
assessments by psychiatry or psychology. Although we had speculated that sexual abuse may have been common, it was documented in only 28.3% of the treatment group; how that compares
with similar subjects without a movement-disorder is unknown.
This has implications for counseling patients: jumping to the
conclusion that psychopathology is the substrate for the functional
movement disorder may be incorrect, create an adversarial relationship, and may sabotage the therapeutic relationship with the
patient.
Insurance coverage for the PMR treatment week was not
uniformly approved by insurance carriers and several of our
patients were denied (hence, ending up in the control group).
However, this may represent a false economy. Note that 45% of
our treatment cohort patients were either on long-term disability
or unemployed when initially seen at Mayo for the diagnostic
opinion. This is similar to a recent study from the United
Kingdom [19], highlighting the substantial economic burden of
these disorders.
We suspect that the events in the neurology clinic leading up to
the treatment protocol are important for treatment success. These
were not initially standardized but were more consistently applied
as we gained experience. These principles include the following.
1. Diagnostic testing may or may not be necessary, but if done, it
should be completed before nalizing the diagnosis with the
patient. Premature conclusions may raise the suspicion among
patients they are not being taken seriously.
2. Counseling should not be rushed, and should avoid pejorative
or loaded terms. Hence, we favor characterizing this as
a functional movement disorder rather than psychogenic.
Emphasis of a pragmatic therapeutic approach directed at the
movement keeps the discussion positive and forward-moving
3. The role of the psychiatrist or psychologist is two-fold: (1)
Explore whether there are any past/present psychosocial
insults/vulnerabilities that are contributing, or which may
impede recovery; (2) Help the patient bridge back to
normality, which requires that the psychiatrist/psychologist
understands the pragmatic therapeutic approach and reinforce
the motor-relearning model.
4. The patient needs to perceive unanimity of opinion between
the neurologist and the treating physiatrist, and that the
treatment approach follows logically from the diagnosis.
5. Avoid psychotropic drugs to treat the movements, except as
required for independent psychiatric problems. Sedating drugs
may make it difcult for the patient to work diligently with the
therapist.
Not all patients are necessarily good candidates for this treatment approach. First, episodic movement-disorders with long
quiescent intervals do not lend themselves to this strategy; motorreprogramming cannot effectively be utilized during times of
neurologic normality. Second, patients with severe pain have
difculty focusing and engaging in the motor rehabilitation. Third,
patients whose FMD is only one problem on a long list of somatic

251

symptoms (somatization disorder) may be too distracted by their

many other symptoms to benet.
In summary, this treatment protocol for FMD focuses on
a pragmatic rehabilitative approach with reshaping of aberrant
movements through repetition of normal movement patterns in
a supportive environment. The preliminary results of this retrospective report suggest substantial promise, justifying further
study in a randomized prospective clinical trial.
Financial disclosures
None.
Conicts of interest
None.
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