Factors Influencing Triage to Rehabilitation in Functional Movement Disorder

ABSTRACT

Background

Treatment of functional movement disorder (FMD) should be individualized, yet factors determining rehabilitation engagement have not been evaluated. Subspecialty FMD clinics are uniquely poised to explore factors influencing treatment suitability and triage.

Objectives

To describe our approach and explore factors associated with triage to FMD rehabilitation.

Methods

We conducted a retrospective chart review of 158 consecutive patients with FMD seen for integrated assessment by movement disorders neurology and psychiatry, with the purpose of triage to rehabilitation. Demographic and clinical variables were compared between patients triaged to therapy versus no therapy, and logistic regression was used to explore factors predictive of triage outcome. Change in primary outcome scores were analyzed.

Results

Sixty‐six patients (42%) were triaged to FMD therapy from July 2019 to December 2021. Patients triaged to therapy were more likely to have a constant movement disorder, gait disorder and/or tremor, hyperarousal, readiness for change, and people pleasing traits. Patients triaged to no therapy demonstrated persistent diagnostic disagreement, an inability to appreciate motor symptom inconsistency, low self‐agency, a propensity to dissociate, and cluster B traits. 90% of patients triaged to rehabilitation had improved outcomes.

Conclusions

The ability to “opt‐in” to FMD rehabilitation relies on different factors than those relevant to establishing a diagnosis. Unlike many other neurological disorders, a triage and treatment planning step is recommended to identify those likely to meaningfully engage at that time. Holistic assessment through a transdisciplinary lens, and working collaboratively with the patient is essential to prioritize symptoms, determine engagement, and identify treatment targets.

Functional movement disorder (FMD) is a common subtype of functional neurological disorder (FND), a complex and potentially disabling neuropsychiatric condition. ¹ Patients with FMD have a motor‐dominant presentation, frequently with combinations of multiple motor and non‐motor symptoms. ² FMD is best conceptualized using a biopsychosocial framework, with identifiable risk factors and triggering events that are relevant for functional symptom onset, and perpetuating factors that are relevant for symptom maintenance. ³

Growing evidence exists for various treatments for FMD including motor retraining/specialist physiotherapy (PT), occupational therapy, speech‐language therapy, multidisciplinary or integrated rehabilitation, and specialist cognitive behavioral therapy or psychotherapy. ⁴ , ⁵ , ⁶ , ⁷ , ⁸ Across most studies, two‐thirds of patients demonstrate improvements in physical function and quality of life. ⁸ However, a portion of patients do not respond to treatment, and it is not known if this is a result of treatment modality, if there are factors intrinsic to the individual neuropathology conferring a poor response to treatment, or both. Indeed, the vital role of patient selection when offering FMD rehabilitation is reflected in the high proportion of patients deemed ineligible for therapy at any given time, as high as 68% in one study. ⁹ , ¹⁰ , ¹¹ Treatment eligibility and FMD triage processes have not been formally described, with patient selection often an ill‐defined, high‐level judgment that varies across clinicians. Common reasons for ineligibility have not been systematically studied, but exclusion criteria commonly cited in the field include interfering pain or fatigue, significant psychological symptoms requiring treatment, cognitive symptoms interfering with therapy carry‐over and persistent diagnostic ambivalence or disagreement. ⁹

In partnership with movement disorders clinics, specialist FMD clinics provide in‐depth interprofessional patient assessments, education, triage, treatment planning, and rehabilitation, and tend to focus on aspects outside of traditional neurological or psychiatric consultation. ¹² Such clinics are therefore uniquely poised to explore the various factors influencing treatment suitability and outcomes. ⁷ FMD is unique among neurological disorders in that it is diagnosed by neurologists, yet is often treated by other disciplines, including psychiatry and allied health. Whereas neurological treatments generally follow a medical model (ie, diagnosis x = treatment y), psychiatry and rehabilitation treatments involve therapies which require meaningful engagement and participation from patients. The intake assessment must therefore ascertain what factors may be playing a role in symptom maintenance, identifying any barriers to engagement, and crucially, identify factors that are targetable with the types of therapy and expertise offered by the team. ¹⁰ , ¹³ Importantly, these relevant factors are likely subject to change over time, implying that rehabilitation potential is not fixed.

We aimed to describe our clinical process used to determine FMD rehabilitation suitability and explore additional potential factors associated with the decision to triage to rehabilitation in a specialist FMD clinic, with factors spanning three domains: neurological factors (ie, movement disorder characteristics), psychiatric factors, and FMD‐ and rehabilitation‐relevant factors (including physical and psychological features). We predicted that factors relevant to meaningful treatment engagement, such as self‐agency, agreement with FMD diagnosis, and demonstration of readiness to change would be more meaningful to triage than traditional neurological or psychiatric characteristics.

Methods

A retrospective chart and video review was performed for all consecutive patients with a diagnosis of FMD assessed at the Toronto Rehabilitation Institute Integrated Movement Disorders Program (IMDP) in Toronto, Canada between July 2019 and December 2021. This study was approved by the University Health Network Research Ethics Board (REB 21‐6172, approved February 11, 2022).

FMD was diagnosed prior to IMDP referral, and confirmed at the IMDP assessment based on clinical interview and examination by an experienced movement disorders specialist (SCL) based on positive clinical signs. ¹⁴ , ¹⁵ Inclusion criteria included: (1) clinical diagnosis of FMD, agreed upon by two movement disorders neurologists; (2) at least one assessment in the IMDP; and (3) age ≥ 18‐years‐old.

Rehabilitation Triage Process

Patients with a confirmed diagnosis of FMD underwent in‐depth integrated evaluation at the IMDP by a movement disorders neurologist (SCL) and a psychiatrist (LM). Patients completed a standardized FMD intake form prior to the visit that was used to identify symptoms, measure initial diagnostic agreement, and obtain a full health and psychosocial history. After the visit, treatment suitability was determined in a team case conference based on global impression. In some cases, a follow‐up visit was required to understand the degree of patient engagement. Eligible patients were enrolled in either integrated therapy (IT) which included neurology, mental health and physiotherapy together providing therapy ⁷ or motor‐retraining physiotherapy alone (PT), ⁶ depending on the treatment targets, both of which were provided at no cost to the patient. Details regarding PT and IT interventions are documented elsewhere. ⁶ , ⁷ Ineligible patients were offered education and treatment recommendations in the community.

Data Extraction

Records reviewed included IMDP assessment with video examination, and patient self‐report questionnaire. Data was extracted by a single reviewer (GSG) and verified by two additional reviewers (SCL and LM) on a case‐by‐case basis if variables were not explicitly stated in the chart. Data extracted included demographic variables, movement disorders phenotype, psychiatric diagnoses using DSM‐5 criteria, FMD‐relevant features, triage decision with rationale from clinicians, and treatment outcomes. Data was extracted from the intake forms. See Supplemental Methods for additional details.

FMD phenotypes were classified from chart and video data into the following categories based on common FMD presentations: gait disorders, tremor, appendicular jerks/myoclonus, axial jerks/myoclonus, fixed dystonia, weakness, parkinsonism, facial movements, and tics. If multiple functional movement phenotypes were present, each phenotype was noted. Functional motor symptoms were further classified as episodic or constant (Table 1). ¹⁶

TABLE 1.

Characterization of episodic and constant movement symptoms determined by combining patient‐reported historical details with clinician‐observed examination features

Clinical feature	Episodic motor symptoms	Constant motor symptoms
Definition	Motor symptoms occurred intermittently or in discrete “attacks,” separated by definable periods without motor symptoms, recognized and reported by the patient	Motor symptoms were reported by the patient to be continuously present
Examination findings	Motor symptoms may or may not be present during examination, symptoms may occur spontaneously or be triggered	Motor symptoms were consistently visible throughout the entire assessment to the examiner
Examples	Paroxysmal attacks of functional movement symptoms with or without features of dissociation Intermittent symptoms described on history, characterized by clear periods of time without motor symptoms, with/without identifiable triggers Symptoms occurring only with action or in specific situations that interfere with activities, with recognition of symptom absence when at rest or in certain situations Symptoms that occur only in response to identifiable triggers, with clear evidence of periods of time without motor symptoms Evidence of substantial portions or entirety of assessment without observable functional movement symptoms Abnormal movements may only be evident in assessment when triggered	Patients are unable to describe periods of time without motor symptoms (excluding sleep) Use of bracing/gait aids/wheelchair indicating continuously present impairment Motor symptoms are evident throughout the entirety of the assessment, often observable in the waiting room and upon discharging the patient Non‐distractible continuously present movements containing other positive signs consistent with FMD
Caveat	Positive signs on examination such as inconsistency and distractibility are not sufficient to determine if the motor symptom was episodic or constant. In other words, the presence of distractibility would not indicate episodic FMD.

Abbreviation: FMD, functional movement disorder.

FMD‐relevant factors and rehabilitation‐relevant factors are recurrent behavioral patterns observed in FMD drawn from the literature and subspecialist clinical experience. ¹⁰ , ¹⁷ , ¹⁸ These factors were identified based on interprofessional clinical impression at the time of the assessment, with findings explicitly documented during the history and examination. Although readily identifiable, most of these factors currently lack standardized scales. See Table 2 for detailed list and description of proposed FMD‐relevant and rehabilitation‐relevant factors. Somatic preoccupation and health anxiety are distinct entities, but have been lumped together here for pragmatic purposes.

TABLE 2.

Description of FMD‐relevant factors and factors influencing potential for engagement in rehabilitation

FMD‐relevant factors

Cluster B personality disorder traits: Not formally diagnosed with borderline, narcissistic or histrionic personality disorder, but demonstrates overlapping traits including emotional dysregulation, help‐seeking‐help‐rejecting patterns, impulsivity, unstable self‐image and relationships. Emotional avoidance: Tendency to avoid experiencing or expressing uncomfortable emotions, either directly expressed by the patient, evident as a pattern in the history, or clearly visible during the clinical interaction when discussing uncomfortable emotions. “Go‐go‐go” coping style: Self‐report of constantly keeping busy, highly productive, and discomfort with free time or when not attending to a goal. Hyperarousal: Findings of elevated and sustained nervous system activation including: hyper‐talkativeness, diffuse hyperreflexia without upper motor neuron signs, diaphoresis, frequent darting eye movements, visible muscle tension, and body language such as fidgeting, fist clenching or repeated leg crossing. Propensity to dissociate: Tendency toward disconnection from one's thoughts, feelings, actions, sense of self. May be directly observed or described by patients from experience. Somatic preoccupation/health anxiety: Preoccupation and excessive worry/attention to bodily symptoms, time and energy spent on symptoms, worry of potential for serious illness. Evident when asked “how much time do you spend thinking or worrying about your symptoms?” Tendency toward people pleasing: Self‐reported strong urge to attend to others’ needs and wants at the expense of their own; high responsibility taking. Tendency toward perfectionism: Self‐reported striving for perfection, critical self‐evaluation, pressure to achieve often unrealistic goals.

Rehabilitation‐relevant factors

Activity avoidance: Limiting activities due to the fear of symptom exacerbation either during or after the activity. Low self‐agency: Feeling of a lack of control over self or environment, tendency to allow others to provide care needs. Evident by historical behavior patterns, including a tendency to project helplessness and attribute responsibility for successes and failures to others, failure to improve despite multiple treatment courses, and expressing statements such as “how will you fix me” to treatment team. Persistent diagnostic disagreement: Ongoing doubt or ambivalence of FMD diagnosis, limited uptake of provided education at follow‐up (even over multiple appoints and/or different clinicians), sought alternate diagnoses, sought further investigations and referrals. Readiness for change: Active engagement in diagnostic discussion, engagement with provided educational reading materials, spontaneously made mind‐brain–body connections, practiced provided therapy strategies, proactively took next steps. Symptom inconsistency not appreciated: Present if the patient is unable to appreciate their own motor symptom inconsistency, including distractibility, augmentation with attention, and normal movement with automatic tasks either on history or when directly demonstrated by the clinician.

Abbreviation: FMD, functional movement disorder.

Extracted treatment outcomes included the Clinical Global Impression‐Improvement (CGI‐I) scale (7‐point scale, from 1 = very much improved to 7 = very much worse) at program completion, completed independently by two clinicians and averaged, and Simplified Functional Movement Disorders Rating Scale (S‐FMDRS) change in score from baseline. The S‐FMDRS is a validated outcome scale developed for FMD. ¹⁹

Statistical Analysis

The objective was to compare demographic and clinical variables between patients triaged to therapy and those triaged to no therapy. Patients were classified based on primary outcome triage decision to either triage to therapy (IT or PT) or triage to no therapy. All analyses were performed for the entire study population and subdivided by triage decision of therapy or no therapy. Skewness in continuous variables was assessed. Values are expressed as mean (standard deviation) or median and interquartile range (Q1, Q3), as appropriate, for continuous variables, and as counts and percentages for categorical variables. For group comparisons, t tests were used for continuous variables, Mann–Whitney U‐tests for ordinal variables, and Fisher's exact tests for categorical variables. Change in primary outcome scores were analyzed with signed rank tests. For predictors of triage outcome, exploratory multivariable logistic regression models were built to estimate odds ratios (OR); 95% confidence interval (CI) of triage outcome (dependent variable, triage to no therapy was reference group) in relation to clinical characteristics (independent variables) using a backwards variable selection method. Factors that were homogeneous at response level or had sparse cell counts were excluded. Multicollinearity was assessed. A P‐value < 0.05 was considered statistically significant. All statistics were performed on SAS 9.4 (SAS Institute, Cary, NC, USA) for Windows.

Results

Charts were reviewed for all consecutive 159 patients assessed with referring diagnosis of FMD. One patient was excluded due to revision of diagnosis during this evaluation to Parkinson's disease, without evidence of co‐existing FMD. In total, 158 patients were included in the final analysis.

General Patient Characteristics and Triage Outcomes

General clinical and FMD characteristics are found in Table 3. Most patients were female (71%) with a mean age of 47.3 (SD 14.6) years, and mean duration of FMD of 75.0 (SD 99.7) months. Episodic movement symptoms (62%) were more common than constant symptoms (36%). The most frequent functional movement phenotypes were gait disorder (42%), tremor (37%), and appendicular jerks (35%).

TABLE 3.

Clinical characteristics of patients triaged to rehabilitation and those triaged not to rehabilitation

Clinical feature	n	Total	Triaged to therapy	Triaged to no therapy	Triaged therapy versus triaged no therapy
		n = 158	n = 66	n = 92	P‐value
Female sex	158	112 (71%)	44 (67%)	68 (74%)	0.086
Age (years)	158	47.3 (14.6)	48.4 (14.1)	46.4 (14.3)	0.397
Duration of FMD (months)	158	75.0 (99.7)	63.5 (90.9)	83.3 (104.3)	0.219
Functional movement disorder phenotype
Episodic symptoms	158	98 (62%)	42 (64%)	56 (61%)	0.124
Constant symptoms	158	57 (36%)	28 (42%)	29 (32%)	0.050*
Gait disorder	158	67 (42%)	37 (56%)	30 (33%)	0.002*
Tremor	158	59 (37%)	29 (44%)	30 (33%)	0.047*
Appendicular jerks/myoclonus	158	55 (35%)	23 (35%)	32 (35%)	0.134
Weakness	158	33 (21%)	15 (23%)	18 (20%)	0.139
Facial movements	158	23 (15%)	8 (12%)	15 (16%)	0.141
Axial jerks/propriospinal myoclonus	158	13 (8%)	6 (9%)	7 (8%)	0.215
Fixed dystonia	158	8 (5%)	2 (3%)	6 (7%)	0.190
Parkinsonism	158	5 (3%)	4 (6%)	1 (1%)	0.086
Tics	158	4 (3%)	0	4 (4%)	0.112
DSM‐5 diagnosis
Generalized anxiety disorder	152	84 (55%)	36 (59%) n = 61	48 (53%) n = 91	0.099
Major depressive disorder	152	46 (30%)	17 (28%) n = 61	29 (32%) n = 91	0.126
Post‐traumatic stress disorder	152	36 (24%)	9 (15%) n = 61	27 (30%) n = 91	0.016*
Bipolar disorder	152	12 (8%)	5 (8%) n = 61	7 (8%) n = 91	0.237
Somatic symptom disorder	152	10 (7%)	2 (3%) n = 61	8 (9%) n = 91	0.116
Cluster B personality disorder	152	9 (6%)	1 (2%) n = 61	8 (9%) n = 91	0.055
Panic disorder	152	8 (5%)	6 (10%) n = 61	2 (2%) n = 91	0.039*
Cluster A personality disorder	152	1 (1%)	0 n = 61	1 (1%) n = 91	0.599
Active psychiatric disorder precluding rehabilitation	152	9 (6%)	0 n = 61	9 (10%) n = 91	0.008*
FMD‐relevant features
Somatic preoccupation/health anxiety	157	114 (73%)	45 (68%) n = 66	69 (76%) n = 91	0.082
Hyperarousal	157	87 (55%)	42 (64%) n = 66	45 (49%) n = 91	0.028*
Emotional avoidance	157	68 (43%)	41 (47%) n = 66	37 (41%) n = 91	0.095
Activity avoidance	157	47 (30%)	22 (33%) n = 66	25 (27%) n = 91	0.102
Propensity to dissociate	157	41 (26%)	9 (14%) n = 66	32 (35%) n = 91	0.001*
Cluster B personality traits	157	31 (20%)	5 (8%) n = 66	26 (29%) n = 91	0.001*
Tendency toward people pleasing	157	29 (18%)	16 (24%) n = 66	13 (14%) n = 91	0.048*
“Go‐go‐go” coping style	157	25 (16%)	14 (21%) n = 66	11 (12%) n = 91	0.054
Tendency toward perfectionism	157	18 (12%)	9 (14%) n = 66	9 (10%) n = 91	0.149
Rehabilitation‐relevant factors
Readiness for change	156	100 (64%)	60 (91%) n = 66	40 (44%) n = 90	<0.0001*
Persistent diagnostic disagreement	155	55 (35%)	7 (11%) n = 66	48 (54%) n = 89	<0.0001*
Low self‐agency	157	51 (32%)	14 (21%) n = 66	37 (41%) n = 91	0.005*
Symptom inconsistency not appreciated	86	31 (36%)	3 (10%) n = 31	35 (64%) n = 55	<0.0001*
Self‐reported data
Degree of disability from ADL checklist (/10)	136	3.2 (2.9)	2.8 (2.6) n = 54	3.5 (3.2) n = 82	0.299
Symptom count from checklist (/49)	135	19.3 (10.6)	17.6 (9.8) n = 53	20.4 (11.1) n = 82	0.140
Top 3 symptom: movement	143	127 (89%)	55 (96%) n = 57	72 (84%) n = 86	0.012*
Top 3 symptom: pain	143	63 (44%)	23 (40%) n = 57	40 (47%) n = 86	0.117
Top 3 symptom: fatigue	142	25 (18%)	10 (18%) n = 56	15 (17%) n = 86	0.178
Diagnostic agreement (/10)	127	7.0 (IQR 5–9)	8 (IQR 5–9) n = 48	6 (IQR 5–8) n = 79	0.011*
Expectation of improvement (/10)	125	7.0 (IQR 5–8)	7 (IQR 5–9) n = 48	6 (IQR 5–8) n = 77	0.052

Continuous values are means (standard deviation) or median and interquartile range (Q1, Q3), as appropriate. Categorical data are n (percentage).

^* P‐value < 0.05.

Abbreviations: ADL, activities of daily living; IQR, interquartile range.

Of 158 patients assessed, 66 (42%) were triaged to rehabilitation (35 were triaged to IT, and 31 to PT streams). Of those triaged to rehabilitation, 17 completed IT and 23 completed PT prior to completion of this study. Ninety‐two (58%) were not deemed eligible for rehabilitation at the time of assessment for various reasons (Fig. 1). Other treatment recommendations for both triage groups included psychotherapy (46% of group not eligible for rehabilitation, 35% of group triaged to rehabilitation) and pain clinic referral (7% not eligible for rehabilitation, 3% triaged to rehabilitation).

FIG. 1.

Flowchart of patients assessed in Integrated Movement Disorders Program.

Patients Triaged to Rehabilitation Versus No Rehabilitation

The comparison between patients triaged or not to rehabilitation revealed no differences in sex, age or duration of FMD (Table 3). A number of characteristics were common in the whole sample, therefore relevant to FMD in general, but not relevant to triage decision. These features included: somatic preoccupation/health anxiety (73%), generalized anxiety disorder (55%), emotional avoidance (43%), major depressive disorder (30%), and activity avoidance (30%).

Patients triaged to therapy were significantly more likely to have a constant movement disorder (42% triaged to therapy vs. 32% triaged to no therapy, P = 0.050) (Fig. 2A). Regarding specific phenomenologies, patients triaged to therapy were more likely to have a gait disorder (56% vs. 33%, P = 0.002), and/or tremor (44% vs. 33%, P = 0.047). DSM‐5 diagnoses were common in the sample and in general did not influence triage decision, apart from post‐traumatic stress disorder which was associated with triage to no therapy (15% triaged to therapy vs. 30% triaged to no therapy, P = 0.016), and panic disorder which was associated with triage to therapy although with very small sample size (10% vs. 2%, P = 0.039) (Fig. 2B).

FIG. 2.

Variables significantly associated with triage decision across (A) neurological variables, (B) psychiatric comorbidities, and (C) functional movement disorder (FMD)‐relevant features (physical and psychological). *P‐value < 0.05; *P‐value < 0.005; ***P‐value < 0.0001.

Several factors were highly relevant to triage outcome, likely acting as surrogate markers to the extent to which a patient may meaningfully engage in rehabilitation (Fig. 2C). “Readiness for change” was significantly associated with triage to therapy (91% vs. 44%, P < 0.0001). Factors significantly associated with triage to no therapy included persistent diagnostic disagreement (11% triaged to therapy vs. 54% triaged to no therapy, P < 0.0001), inability to appreciate symptom inconsistency (10% vs. 64%, P < 0.0001), and low agency (21% vs. 41%, P = 0.005). Several other FMD‐relevant features, not classically considered in traditional triage processes, were significantly associated with triage to rehabilitation: hyperarousal (64% triaged to therapy vs. 49% triaged to no therapy, P = 0.028) and people pleasing trait (24% vs. 14%, P = 0.048). The factors significantly associated with triage to no therapy included: cluster B traits (8% vs. 29%, P = 0.001) and propensity to dissociate (14% vs. 35%, P = 0.001).

We assessed to what extent patient self‐reported data influenced triage decision. Identifying at least one of the top three most bothersome symptoms as a motor symptom was associated with triage to therapy (96% triaged to therapy vs. 84%, P = 0.012), as was higher self‐reported agreement with the diagnosis of FMD [median 8.0/10 (IQR 5–9) triaged to therapy vs. 6.0/10 (IQR 5–8), P = 0.011]. Expectation of improvement with treatment trended to significance [median 7.0/10 (IQR 5–9) triaged to therapy vs. 6.0/10 (IQR 5–8), P = 0.052]. Self‐reported degree of disability and total symptom count were not significantly associated with triage outcome (P = 0.299 and P = 0.140, respectively).

Predictors of Triage Outcome

To further study possible predictors of triage outcome, we built exploratory multivariable logistic regression models using the outcome of triage to therapy as the dependent variable (Table 4). There was a strong positive relationship between “readiness for change” and triage to therapy persisted (OR 500.38, 95% CI 1.61– >999.99). The negative relationship between propensity to dissociate and triage to therapy also remained (OR 0.07, 95% CI 0.01–0.99). Other explored variables showed no substantial association with triage outcome.

TABLE 4.

Multivariable logistic regression model

Independent variable	OR	95% CI
Constant symptoms	3.24	0.36–29.56
Gait disorder	9.71	0.79–119.75
Tremor	1.94	0.39–9.63
Post‐traumatic stress disorder	1.12	0.15–8.50
Readiness for change	500.38	1.61– >999.99
Persistent diagnostic disagreement	0.79	0.05–12.06
Variability not noticed	0.28	0.02–3.43
Hyperarousal	0.95	0.14–6.34
Tendency toward people pleasing	1.51	0.24–9.54
Low self‐agency	0.19	0.03–1.33
Cluster B personality traits	5.07	0.08–338.47
Propensity to dissociate	0.07	0.01–0.99
Top 3: pain	0.28	0.05–1.79
Diagnostic agreement	0.73	0.46–1.16

Dependent variable: triage to therapy.

Abbreviations: CI, confidence interval; OR, odds ratio.

Outcomes from Rehabilitation

Forty patients completed rehabilitation prior to completion of this study. Most patients triaged to rehabilitation had an excellent outcome, with 70% having a CGI‐I of 1 or 2 (n = 28), while 20% had minimal/some improvement with CGI‐I of 3 (n = 8). Therefore 90% of patients enrolled in rehab experienced some improvement, with a median CGI‐I of 2 (IQR 1–3). Only 4 patients had no change, and no patients experienced worsening of their symptoms. Most patients (93%) had an improvement in S‐FMDRS score, with a median change of 6 points (IQR −14, −2.75, P < 0.0001).

Discussion

This retrospective chart review explored factors associated with triage to rehabilitation in a sample of 158 consecutive patients undergoing dedicated evaluation for FMD treatment suitability. In addition to describing our triage process, we aimed to identify the clinical factors that suggest meaningful rehabilitation engagement. We observed: (1) the majority of patients (about 60%) were not considered eligible at the time of assessment, but those who were improved substantially with therapy; (2) constant motor symptoms were perceived to be more amenable to rehabilitation than episodic motor symptoms; (3) movement phenomenology, age, and disease duration were not relevant to treatment triage, rather new concepts including readiness to change and the ability to notice symptom inconsistency were more relevant; and (4) patient‐reported data aided triage decision‐making when combined with clinical assessment. These results suggest that a dedicated evaluation for triage and treatment planning is an important intermediary step when considering treatment for FMD.

Similar to other studies, less than half of patients assessed were offered rehabilitation. ⁹ , ²⁰ The main reasons for ineligibility included disagreement by patient with FMD diagnosis, movement disorder phenotype not felt to be amenable to rehabilitation strategies, (eg, facial movements), improvement in FMD, and interfering pain and/or fatigue. This finding challenges the traditional medical model that a specific diagnosis is linked to a particular treatment that is administered to a patient, and aligns more with rehabilitation or mental health treatment models that depend on reciprocal patient engagement for success. It is therefore of great practical value to develop triage processes that identify patients with therapeutic potential and allocate resources for rapid treatment initiation in those patients. Furthermore, recovery potential is unlikely to be fixed and can shift over time depending on the perpetuating factors that maintain illness. Successful outcomes therefore depend on the right patient engaging in the right treatment at the right time (Fig. 3).

FIG. 3.

Factors to consider when selecting candidates for functional movement disorder (FMD) rehabilitation and making treatment plans. (1) Is rehabilitation the right treatment? Constant FMD including gait disorders and tremor are most amenable to physiotherapy‐based treatment. Equally important is that the patient identifies a motor symptom among their top concerns and are able to appreciate their own symptom inconsistency. (2) Is this the right time for rehabilitation? Motivation for change and diagnostic agreement should be present, as well as the absence of interfering symptoms that would otherwise limit engagement at that time. (3) Holistic treatment plans should also include therapy elements targeting psychiatric, psychological and physical symptoms commonly seen in FMD. Importantly, these should not be considered barriers to rehabilitation if present.

Constant motor symptoms were perceived to be more amenable to rehabilitation than episodic symptoms, likely due to evidence in the literature, and the opportunity to directly address and modify symptoms. The division of constant and episodic FMD is an important phenotypic modifier and is a crucial early step for treatment planning. Constant FMD tends to present as gait disorders, weakness, and/or fixed dystonia, that can be targeted with motor retraining physiotherapy. ⁶ , ¹⁶ By contrast, episodic FMD presents as intermittent, hyperkinetic movements, and is associated with anxiety and hyperarousal. ¹⁶ This requires a fundamentally different therapeutic approach. Borrowing techniques and concepts used in functional seizures can be helpful including trigger identification, recognizing and countering avoidance patterns, anxiety treatment and sympathetic nervous system regulation, and modified cognitive behavioral therapy. ²¹

The single feature predictive of triage to therapy was “readiness for change,” indicating that the patient is beyond the pre‐contemplative stage of recovery. FMD physiotherapy places a strong emphasis on patient‐directed functional goals, while shifting the focus away from bodily symptoms and deficits. ⁶ Readiness for change is a gestalt factor that is difficult to measure, but in practice, looks like patients actively engaging in the diagnostic discussion and with educational materials, practicing therapy strategies and articulating what works and why, and proactively seeking next steps. This may require one or more follow‐up appointments to evaluate, and can be evaluated by inviting the patient to try something small (eg, a daily relaxation exercise).

In contrast, persistent diagnostic disagreement, a low sense of self‐agency, cluster B traits and propensity to dissociate may interfere with engagement in rehabilitation. Persistent diagnostic disagreement was relatively common, present in a third of our sample despite patients being provided the diagnosis and education at least twice by different, skilled neurologists experienced in diagnosing FMD. This finding is worth exploring in future studies, to better understand what factors may be contributing to entrenched diagnostic disagreement such as prior negative health care experiences, ongoing reinforcement of alternate illness beliefs, self‐stigma, or the inherent FMD pathophysiology, and to what degree this is shiftable. Low self‐agency is an important neuropathological mechanism in FND and is challenging to measure using validated scales; yet is readily identifiable by patterns unearthed in the personal history, coping style, and interactions with the team. Cluster B traits and propensity to dissociate indicate difficulties with coping or emotional regulation. Importantly, these factors are often overlooked since they fall below the threshold for DSM‐5 major axis diagnoses, and if present, can negatively impact the therapeutic relationship and impede treatment engagement. By contrast, hyperarousal and people‐pleasing traits were additional clinical features found to favor triage to rehabilitation. Hyperarousal is often identified as part of a mental status exam, commonly associated with hyperkinetic FMD. ¹⁶ A dysregulated arousal/stress response is implicated in the pathophysiology of FMD, and is readily treatable using body relaxation techniques. ²² , ²³ People‐pleasing traits reflect a behavioral pattern of deprioritizing one's own needs at the expense of others and a tendency for poor boundaries. When present, therapeutic strategies include helping patients learn to set boundaries, to identify and prioritize their own emotional needs, and to schedule self‐care. These results emphasize the importance of a holistic approach to triage and treatment in FMD that includes non‐pathological psychological factors, which are important drivers of treatment suitability. ²⁴

An interesting observation was that an inability to notice symptom inconsistency was a significant indicator of poor rehabilitation suitability. A key strategy in FMD physiotherapy is helping the patient recognize that periods of normal function can occur, usually when distracted or performing automatic tasks. ⁶ This can be identified by the clinician on history or directly demonstrated on examination. ¹² If the response of a patient to symptom inconsistency is relief or curiosity, this generally indicates an openness to engaging in therapy. Conversely, an inability to appreciate temporary improvement of symptoms when directly pointed out suggests that motor retraining strategies may not be effective. Such patients may require further education and time to notice symptom variability before embarking on rehabilitation.

Valuable information was obtained from a self‐reported intake form. Diagnostic agreement is a crucial pre‐requisite for FMD treatment, and can be quantified on a Likert scale. Ensuring a motor symptom is among the patient's “top 3” most bothersome symptoms determines alignment between the patient's concerns and what is offered by the treating team. Higher levels of self‐reported disability and number of symptoms were not found to impact triage decision, despite the traditional belief that patients with higher disability have worse outcomes. ²⁵

Age and disease duration did not predict triage outcome, despite being classically considered relevant to prognosis. ¹¹ , ²⁶ , ²⁷ , ²⁸ , ²⁹ These data also reinforce that psychiatric diagnoses are common in FMD and should not be considered contraindications to rehabilitation, but can instead be seen as treatment targets that may be perpetuating FMD. Indeed, as our understanding of FMD evolves, it is becoming evident that long‐term recovery relies on self‐management of modifiable perpetuating factors rather than exclusive focus on the surface neurological symptoms. ³⁰ Triage to no therapy does not mean no therapy at all; rather, suitability for rehabilitation is based on a fit between the patient's priority symptoms and concerns, health care provider assessment, and the skill set of the treatment team. ³¹ There is no “one size fits all” in FMD, and pragmatic treatment plans must meet the patient where they are, and target what is important with the resources available.

This study has several limitations. Most importantly, the primary outcome was triage to rehabilitation only. Analysis of those patients undergoing rehabilitation demonstrated excellent outcomes, but patients triaged to no therapy did not have systematic assessments of outcome and therefore may have also experienced improvement in their symptoms, limiting conclusions of the triage process itself. The triage process described herein is reflective of the treatment offered in our center, which is a physical rehabilitation‐based model, free to the patient, with or without the addition of mental health strategies, and may not be reflective of what is offered at other programs. All patients were assessed by the same clinicians which may have introduced bias with respect to triage decision, likely influenced by clinical experience. Under‐ascertainment of comorbid psychiatric diagnoses is a potential limitation, given retrospective nature of chart review and time‐restrictions. This study is retrospective in nature, with a modest sample size, and designed primarily for hypothesis generation for future, prospective studies. The identified FMD‐relevant factors are subjective, and not measured using validated tools, which in most cases do not exist, introducing possible bias related to triage outcome. The list of possible FMD‐relevant factors is by no means complete. These factors are not suggested to be etiological, nor are they necessarily relevant to outcome based on the current data. Rather, this is a list of factors potentially influencing potential for engagement. The population was sampled from a subspecialty clinic, and therefore includes complex and persistent FMD cases. Regardless, this study is the first to comprehensively evaluate broad neuropsychiatric features relevant to triage for FMD rehabilitation.

Conclusions

The potential for engagement in treatment by patients with FMD, ie, the ability to “opt‐in” to rehabilitation, is a multifaceted issue best approached from a rehabilitation perspective, rather than the traditional medical model. Although approximately only 40% of patients assessed are eligible for therapy at a given time, those patients demonstrate excellent outcomes. A dedicated assessment focused on identifying perpetuating factors provides the opportunity to evaluate for “readiness for change,” the ability to notice symptom inconsistency, and the absence of “persistent diagnostic disagreement.” Importantly, holistic evaluation through an interprofessional lens reveals a wider array of factors beyond the movement disorder that are most relevant for symptom maintenance and hence recovery potential. Further prospective research is required to define these concepts and develop scales/questionnaires, systematically evaluate their impact on prognosis and treatment response, and explore how patients can be optimized for treatment engagement. Ideally, a decision tool may be developed to aid clinicians in triaging patients to rehabilitation. Triage processes for treatment in FMD is a new and important area of study, but what is agreed is the necessity to collaborate with patients to provide timely therapy and enhance clinical outcomes and quality of life.

Author Roles

(1) Research Project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript Preparation: A. Writing of the First Draft, B. Review and Critique.

G.S.G.: 1A, 1B, 1C, 2A, 2C, 3A, 3B

L.K.L.: 2A, 2B, 2C, 3B

H.B.: 1B, 3B

L.M.: 1A, 3B

S.C.L.: 1A, 2A, 2C, 3B

Disclosures

Funding Sources and Conflicts of Interest: This work was supported by an anonymous donation to the Toronto Western Hospital Movement Disorders Clinic for Multidisciplinary Care. The authors declare that there are no conflicts of interest relevant to this work.

Financial Disclosures for Previous 12 Months: Dr. Lidstone receives royalties from UpToDate. Dr. Gilmour, Ms. Langer, Mr. Bhatt and Dr. MacGillivray declare that there are no additional disclosures to report.

Ethical Compliance Statement: The article received approval by the University Health Network Research Ethics Board (REB 21‐6172, approved February 11, 2022). Informed consent was not necessary for this work. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines.

Supporting information

Data S1. Supplemental methods providing details of intake form.