Objective: We describe initial experiences using virtual rehabilitation in a specialized outpatient functional movement disorder (FMD) clinic.

Background: Specialized rehabilitation programs have been shown to be an effective treatment option for patients with FMD. Access to such programs is limited due to a scarcity of specialized FMD centres. The Covid-19 pandemic has forced neurorehabilitation programs to deliver care in novel ways. While telerehabilitation has been used in other neurological conditions, virtual rehabilitation for FMD has not been well explored, presenting an opportunity to bridge this service delivery gap.

Method: Between March 2020-2021 FMD patients seen in our virtual integrated clinic were triaged to receive either integrated therapy (IT) or physiotherapy alone (PT). Patients received 6-10, biweekly 45-minute therapy sessions over 3 months. Therapy was delivered using a hybrid model of in-person and virtual sessions. The IT intervention was delivered by a neurologist, neuropsychiatrist and physiotherapist simultaneously and all patients received hybrid therapy (4 in-person and 2 virtual sessions). The PT intervention consisted of motor retraining delivered by a physiotherapist. 6 patients received hybrid therapy and 6 were treated entirely virtually.

Results: Twenty-two patients (14 women; mean age 46.6±17.4 years, mean symptom duration 6.1±6.7 years) were enrolled into a treatment stream (IT, n=10; PT, n=12). Two-thirds of patients (59%) had a mixed phenotype with >1 functional movement symptom. The most common phenotypes were gait disorder (50%), tremor (36%) and weakness (27%). Pre-morbid psychiatric diagnoses were present in 73% (9/10 in IT, 7/12 in PT). 41% were unable to work due to their symptoms. The most common therapeutic strategies in both IT and PT included FMD education (100%) and breathing exercises (86%). Gait retraining was used in 10 patients (IT, PT). Integrative psychotherapy was most commonly used in the IT intervention and task-specific motor retraining was most commonly used in the PT intervention. Upon program completion, 12/19 (63%) patients had “much” or “very much” improved on the clinical global impression scale.

Conclusion: Virtual rehabilitation is a feasible treatment option for patients with FMD and offers additional benefits to traditional in-person care. Challenges include lack of appropriate equipment, safety concerns and the “digital divide.” Future research aims to better capture patient outcomes.

References: [1] Lidstone, S., MacGillivray, L., & Lang, A. Integrated Therapy for Functional Movement Disorders: Time for a Change. Mov Disord Clin Pract 2020; 7. [2] Nielsen G, Stone J, Matthews A, et al. Physiotherapy for functional motor disorders: a consensus recommendation. J Neurol Neurosurg Psychiatry 2015; 10:1113–1119. [3] Aybek S, Lidstone SC, Nielsen G, MacGillivray L, Bassetti CL, Lang AE, Edwards MJ. What Is the Role of a Specialist Assessment Clinic for FND? Lessons From Three National Referral Centers. J Neuropsychiatry Clin Neurosci. 2020;32(1):79-84.

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