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

功能性运动障碍（FMD）患者表现为与明确定义的神经系统疾病症状不相容的异常运动，且与神经系统结构异常无关。重要的是，口蹄疫的临床诊断可以基于特征体征，包括解剖学和生理学上的症状不一致、可变现象学和注意依赖。口蹄疫非常常见，可占到运动障碍门诊患者的20%。然而，这些患者的护理模式是高度不一致的，大多数患者对他们接受的治疗感到不满意。这一令人不满意的情况的一个原因是没有普遍接受的口蹄疫治疗指南。患者通常会向不同的专家寻求建议，并经常接受不必要的、高成本的诊断程序。因此，迫切需要治疗策略。由于口蹄疫的临床症状具有高度异质性，寻找有效的治疗方法变得十分复杂。有趣的是，最近的神经生理学研究表明，口蹄疫患者共同的潜在疾病机制，特别是注意力资源的异常分配。从概念上讲，这需要治疗方法，其中训练注意力重新集中。在这方面，神经物理疗法（NPT）是基于身体运动的再训练，通过证明正常的运动是可能的，以促进患者对自己的运动能力的信心。根据目前的文献，我们认为NPT是口蹄疫人群可行和有效的治疗方案。然而，完全接受和改善NPT的患者比例有限。如果提供额外的专业心理治疗方法，例如元认知疗法（MCT），口蹄疫患者可能更容易接受NPT。MCT关注的是患者对自身心理和认知（元认知）的信念。它解释了功能失调的思维模式和自我意识如何导致和维持口蹄病，特别是训练患者有意识地（重新）集中注意力，远离不愉快或令人不安的心理过程。因此，除了NPT之外，我们的目的是研究NPT和MCT联合治疗的可行性和疗效。我们将经常进行治疗（每周2次，每次1小时，持续10周），并指导患者进行额外的家庭培训。干预后12个月，将通过经过验证的、针对口蹄疫的盲法视频评分来分析有效性。重要的是，口蹄疫患者已被证明，如果给予充分的治疗，有可能完全康复。因此，我们的临床可行性试验的治疗方法，如果成功，预计将对口蹄疫患者的护理产生直接和强烈的影响，包括改善生活质量，并减轻卫生保健系统的负担。

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.