Physiotherapy for functional motor disorder is not conventional neurorehabilitation. Consensus recommendations built on a biopsychosocial framework specify that treatment should address illness beliefs, redirect self-directed attention away from the affected limb, and retrain normal automatic movement patterns, all delivered within an explicitly positive and non-judgemental explanation. Strengthening exercises and instructions to concentrate on each step are counterproductive because they increase attention to the limb, which is the very mechanism generating the abnormal movement.
Practical techniques include using automatic movements such as walking backwards, side stepping, walking to a rhythm or on a treadmill, and weight shifting tasks that bypass conscious control of the affected limb. Aids are weaned rather than added because they reinforce the illness model and entrench disability. A randomized feasibility study of a specialist physiotherapy programme for functional motor symptoms showed markedly better outcomes than treatment as usual, and a randomized trial of adapted physical activity in functional gait disorder also demonstrated benefit, supporting an active rather than a passive approach.
On the ABPN blueprint this maps to the Treatment and management axis, because the item tests selection of the correct therapeutic strategy for an established diagnosis. Note that physiotherapy and psychological treatment are complementary rather than alternatives, and multidisciplinary programmes combining them are increasingly the standard.
Incorrect Answers
- A. Strengthening and bracing address a weakness that is not the problem and increase attention to and dependence on the limb.
- B. Psychological therapy has a role, particularly where there is comorbid depression, anxiety or trauma, but withdrawing physical treatment removes the intervention with the strongest evidence for motor symptoms.
- C. Functional motor symptoms respond to appropriately designed physiotherapy; therapeutic nihilism is not supported by the randomized data.
- E. Providing a powered wheelchair and pursuing permanent benefits reinforce disability and are associated with worse long-term outcome.
Testing Pearls
- Functional motor disorder physiotherapy targets beliefs, attention and automatic movement, not strength.
- Instructing the patient to concentrate on the limb worsens functional movement.
- Use automatic tasks such as backwards or sideways walking and rhythmic cueing.
- Wean walking aids rather than adding them.
- Randomized data support specialist physiotherapy over conventional rehabilitation.
References
- Jankovic J, Mazziotta JC, Newman NJ, Pomeroy SL, editors. Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Philadelphia, PA: Elsevier; 2022. p. 2090.
- Nielsen G, Stone J, Matthews A, Brown M, Sparkes C, Farmer R, et al. Physiotherapy for functional motor disorders: a consensus recommendation. J Neurol Neurosurg Psychiatry. 2015;86(10):1113-1119.
- Nielsen G, Buszewicz M, Stevenson F, Hunter R, Holt K, Dudziec M, et al. Randomised feasibility study of physiotherapy for patients with functional motor symptoms. J Neurol Neurosurg Psychiatry. 2017;88(6):484-490.
