Metacognitive therapy and neuro-physiotherapy as a treatment for functional movement disorders – a randomized, observer-blinded feasibility trial

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Patients with functional movement disorders (FMD) present with abnormal movements incompatible with symptoms of well-defined neurological disorders and are not associated with structural abnormality of the nervous system. Importantly, FMD can reliably be diagnosed clinically on the basis of characteristic signs including incongruency of symptoms regarding anatomy and physiology, variable phenomenology, and attention dependency. FMD are very common and can account for up to 20% of patients seen in movement disorders clinics. However, the pattern of care of these patients is highly inconsistent and most patients feel dissatisfied with the treatment they receive. One reason for this unsatisfactory scenario is that there are no generally accepted therapeutic guidelines for FMD. Patients typically seek advice from different specialists and often receive unnecessary, highly cost intensive diagnostic procedures.Therefore, treatment strategies are urgently needed. Finding effective treatment is complicated by the fact that clinical symptoms of FMD are highly heterogeneous. Interestingly, recent neurophysiological studies suggest common underlying disease mechanism across FMD patients, particularly abnormal allocation of attentional resources. Conceptually, this calls for therapeutic approaches, in which attention re-focusing is trained. In this respect, neuro-physiotherapy (NPT) is based on the physical movement retraining by demonstrating that normal movement is possible, to facilitate patients’ confidence into the own movement capacity. Based on the current literature, we suggest that NPT is a feasible and effective treatment options in FMD population. However, the proportion of patients fully accepting and improving from NPT was limited. FMD patients might be more receptive to NPT if additional specialized psychotherapy approaches, e.g., metacognitive therapy (MCT) is offered. MCT focusses on patients believes about their own mind and cognition (metacognition). It explains how dysfunctional patterns of thinking and self-awareness can lead to and maintain FMD and in particular trains patients to consciously (re-)focus their attention away from unpleasant or disturbing mental processes. Thus, we aim to investigate, in addition to NPT only, the feasibility and treatment efficacy of a combination of NPT and MCT.We will apply therapy frequently (2 times 1 hour sessions per week over 10 weeks) and patients will be instructed for an additional home-based training. Effectiveness will be analyzed up to 12 month after the intervention by validated, FMD-specific, blinded video ratings.Importantly, FMD patients have been shown to have the potential for a full recovery if sufficient treatment is applied. Therefore, the therapeutic approaches of our clinical feasibility trial, if successful, are expected to have immediate and strong impact on the care of FMD patients including an improvement in quality of life, and to reduce health care system burdens.