A Functional Movement Disorder (FMD) is defined by abnormal involuntary movements or body positions that are not caused by organic disease. The Northwestern Medicine Functional Movement Disorders Clinic addresses disabling functional movement disorders by using motor reprogramming strategies and pairing rehabilitation with cognitive behavioral techniques to improve symptoms for patients with FMD.
Kathrin LaFaver MD discusses what makes this program unique and that it is that it is one of the few programs in the country that has an active collaboration between many interdisciplinary specialists, including neurology, psychology, behavioral medicine and physical therapy. The Northwestern Medicine Functional Movement Disorders Clinic is committed to conducting intensive research to increase our knowledge and understanding of the condition, allowing us to provide advanced, individualized treatment to every patient.
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Therapeutic Options for Patients with Functional Movement Disorders
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Learn more about Kathrin LaFaver, MD
Kathrin LaFaver, MD
Kathrin LaFaver, MD is an Associate Professor of Neurology, Northwestern Medicine.Learn more about Kathrin LaFaver, MD
Transcription:
Therapeutic Options for Patients with Functional Movement Disorders
Melanie Cole, MS (Host): Welcome. This is Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole and today we’re discussing therapeutic options for patients with functional movement disorders. Joining me is Dr. Kathrin LaFaver. She’s an associate professor of neurology at Northwestern Medicine. Dr. LaFaver, it’s a pleasure to have you joining us today. Please start by telling us a little bit about yourself and how you came to Northwestern Medicine.
Kathrin LaFaver, MD (Guest): I've been at Northwestern since August of last year. I joined the movement disorder group. It’s been a great experience so far. One of my main motivations for joining Northwestern was to start a specialized assessment and treatment program for functional movement disorders, which has been one of my long standing interests. I was trying to focus more on these disorder for which not a lot of treatment option exist around the country.
Host: Well thank you for that. It is such an interesting topic. So for other providers, what is a functional movement disorder?
Dr. LaFaver: Functional Movement Disorder, also FMD, can present with loss of control over normal body movements. The symptoms are quite variable and can include tremor, jerking movements, painful muscle spasms or dystonia, weakness, and gait and balance problems. FMD often start pretty suddenly and can be quite disabling. As opposed to different or other movement disorders we treat, the symptoms are often caused by abnormal brain processing versus permanent brain lesions and can be reversible with treatment.
Host: Oh that’s so interesting. So as many people know, functional movement disorders can be difficult tom manage and treat. Why are these conditions often misunderstood? Tell us what Northwestern Medicine’s functional movement disorder clinic is doing to help advance the understanding and treatment of these conditions.
Dr. LaFaver: So FMD can be difficult to diagnose, as you said, and the reason is that they can really mimic virtually any disorder in neurology. Patients are often initially seen in the ER because the disorder presents to acutely. They might get a workup for stroke initially. People who are not trained in seeing patients with movement disorders can often not be sure of what’s really going on. However there have been diagnostic criteria determined for FMD and for movement disorder specialists. The most important thing to reach a diagnosis is indeed a history and bedside examination. So we often don’t need a lot of additional testing but really a good examination by an experienced movement disorder specialist is key. So once the diagnosis is made their treatment needs to be started as soon as possible for the best outcomes. Unfortunately access to treatment is a huge problem really throughout the U.S.. What our clinic provides, we see patients at the Shirley Ryan AbilityLab twice a month with a multidisciplinary team which includes myself, a psychologist, and a rehab team including physical, occupational, and speech therapists. We not only assess patients but provide a detailed plan forward that can include either outpatient treatment or a more intensive approach, usually in a day rehab setting.
Host: Well, I'm glad you mentioned the multidisciplinary team. Tell us a little bit more about why this is so important for these patients specifically for the evaluation and for treatments.
Dr. LaFaver: In previous times, we often referred patients simply to psychiatry because the condition was often understood to be purely psychologic in its ology. Now our research in thinking about these disorders causally shifted. There have been trials mostly coming from the UK showing good benefit from physical therapy with the caveat that it needs to be modified to this condition. A large trial from the UK is actually currently underway where the outcomes look very, very promising. But again, the treatment, I kind of like to describe it as psychologically informed rehabilitation treatment. So we’re really trying to marry mind and body medicine with the treatment in this condition to help patients regain the control over their movements. So an integrative approach can be very, very successful and really trying to teach patients movement control coming from both rehabilitative approaches as well as cognitive behavioral therapy informed approaches.
Host: So as the recently open Northwestern Medicine functional movement disorder clinic, tell other providers what they can expect when they refer patients to your clinic and what makes it really unique.
Dr. LaFaver: So we have a two tiered referral process. For patients who do not have a diagnosis yet or who want a second opinion about their diagnosis, we would see them at the Northwestern movement clinic either myself or one of my colleagues and essentially review all records, get a history and examination, and help and reach a diagnosis. Once a diagnosis has been made and the patients are interested in treatments, we see them at Shirley Ryan AbilityLab and the multidisciplinary lab that I mentioned and determine best treatment. We will also plan to have more research options available to help us understand the condition better. We have a referral process in place where we review medical records and then decide which patient is best seen.
Host: Well tell us then some of the exciting advances that we should know about, some of the innovative technologies supporting your work. What treatments are you using now? Tell us about your outcomes? Are they effective? What are you seeing?
Dr. LaFaver: So before I came to Northwestern I was in charge of the movement disorder clinic at University of Florida. There we had an inpatient rehabilitation program that actually was only a one week very intensive program. We saw very encouraging outcomes. We had indeed over 75 patients achieving significant improvement in their movement symptoms with just a very short treatment intervention. Things are often more complicated in the long term. In addition to the movement symptom, patients often have associated mood problems, chronic pain, and fatigue that can require longer treatment interventions. So one of the hopes that’s associated with the new clinics here, I'm in the process of establishing multicenter collaborations. We try to learn more about what commonalities patients share but also what differences and integrate more imaging into kind of an assessment of patients and other markers to learn how patients differ, develop biomarkers for disease monitoring, and also help us to individualize treatment better and achieve best outcomes.
Host: So tell us a little bit about any research that would impact the future of treating those with FMD and what else you’d like providers to know and take forward to help their patients.
Dr. LaFaver: We have definitely learned a lot about these conditions over the past five to ten years. Especially newer imaging has been shedding very new perspectives on our thinking of functional movement disorders. So many imaging studies have shown differences in limbic and motor pathways. They're, for example, showing increased connectivity between the amygdala and motor planning centers. We can sort of think a bit of a superhighway of how emotions can drive abnormal movements. More research is definitely needed not only in imaging work but also understanding differences in sensory processing and interception in these disorders. Many patients are very easily over stimulated by lights, by noises, by crowds which makes it very difficult for them to navigate in the world and live their life. So I think of it as abnormal brain balancing. It’s kind of an overload of sensory information that effects a processing of information and motor planning and emotional processing. So I think there's several different ways where we can still learn and refine our understanding and treatment approaches. One very interesting modality has been transcranial magnetic stimulation. There’s several groups trying to directly influence brain pathways that way. Although this is still in its infancy it holds promise for future applications.
So what I would like providers to take away from our conversation is that I would really encourage every neurologist specifically who sees patients with movement disorders or with weakness to educate themselves about functional movement disorders and learn how to diagnose it and education patients about it. Many patients need to see multiple providers before getting a diagnosis, get often conflicting information which contributes to the stigma about the diagnosis and delays the treatment process.
Host: Well thank you for speaking about advances in radiologic imaging and how they’ve helped augment your diagnosis and therapy capabilities. Before we wrap up, can functional movement disorders be cured? What do you see happening for these patients?
Dr. LaFaver: A cure is always our ultimate goal for any disease. Fortunately with FMD many patients can have good outcomes with appropriate treatment and better understanding of the conditions. Unfortunately this is not always possible and for some patients this remains a chronic condition at this time. Because there is no permanent lesion in the brain, no permanent structural damage, there is a lot of hope that we will be able to achieve good outcomes in the majority of patients in the future.
Host: That’s great. Thank you so much Dr. LaFaver for joining us today and sharing your incredible expertise. Thank you, again. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine, please visit our website at nm.org to get connected with one of our providers. Please also remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.
Therapeutic Options for Patients with Functional Movement Disorders
Melanie Cole, MS (Host): Welcome. This is Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole and today we’re discussing therapeutic options for patients with functional movement disorders. Joining me is Dr. Kathrin LaFaver. She’s an associate professor of neurology at Northwestern Medicine. Dr. LaFaver, it’s a pleasure to have you joining us today. Please start by telling us a little bit about yourself and how you came to Northwestern Medicine.
Kathrin LaFaver, MD (Guest): I've been at Northwestern since August of last year. I joined the movement disorder group. It’s been a great experience so far. One of my main motivations for joining Northwestern was to start a specialized assessment and treatment program for functional movement disorders, which has been one of my long standing interests. I was trying to focus more on these disorder for which not a lot of treatment option exist around the country.
Host: Well thank you for that. It is such an interesting topic. So for other providers, what is a functional movement disorder?
Dr. LaFaver: Functional Movement Disorder, also FMD, can present with loss of control over normal body movements. The symptoms are quite variable and can include tremor, jerking movements, painful muscle spasms or dystonia, weakness, and gait and balance problems. FMD often start pretty suddenly and can be quite disabling. As opposed to different or other movement disorders we treat, the symptoms are often caused by abnormal brain processing versus permanent brain lesions and can be reversible with treatment.
Host: Oh that’s so interesting. So as many people know, functional movement disorders can be difficult tom manage and treat. Why are these conditions often misunderstood? Tell us what Northwestern Medicine’s functional movement disorder clinic is doing to help advance the understanding and treatment of these conditions.
Dr. LaFaver: So FMD can be difficult to diagnose, as you said, and the reason is that they can really mimic virtually any disorder in neurology. Patients are often initially seen in the ER because the disorder presents to acutely. They might get a workup for stroke initially. People who are not trained in seeing patients with movement disorders can often not be sure of what’s really going on. However there have been diagnostic criteria determined for FMD and for movement disorder specialists. The most important thing to reach a diagnosis is indeed a history and bedside examination. So we often don’t need a lot of additional testing but really a good examination by an experienced movement disorder specialist is key. So once the diagnosis is made their treatment needs to be started as soon as possible for the best outcomes. Unfortunately access to treatment is a huge problem really throughout the U.S.. What our clinic provides, we see patients at the Shirley Ryan AbilityLab twice a month with a multidisciplinary team which includes myself, a psychologist, and a rehab team including physical, occupational, and speech therapists. We not only assess patients but provide a detailed plan forward that can include either outpatient treatment or a more intensive approach, usually in a day rehab setting.
Host: Well, I'm glad you mentioned the multidisciplinary team. Tell us a little bit more about why this is so important for these patients specifically for the evaluation and for treatments.
Dr. LaFaver: In previous times, we often referred patients simply to psychiatry because the condition was often understood to be purely psychologic in its ology. Now our research in thinking about these disorders causally shifted. There have been trials mostly coming from the UK showing good benefit from physical therapy with the caveat that it needs to be modified to this condition. A large trial from the UK is actually currently underway where the outcomes look very, very promising. But again, the treatment, I kind of like to describe it as psychologically informed rehabilitation treatment. So we’re really trying to marry mind and body medicine with the treatment in this condition to help patients regain the control over their movements. So an integrative approach can be very, very successful and really trying to teach patients movement control coming from both rehabilitative approaches as well as cognitive behavioral therapy informed approaches.
Host: So as the recently open Northwestern Medicine functional movement disorder clinic, tell other providers what they can expect when they refer patients to your clinic and what makes it really unique.
Dr. LaFaver: So we have a two tiered referral process. For patients who do not have a diagnosis yet or who want a second opinion about their diagnosis, we would see them at the Northwestern movement clinic either myself or one of my colleagues and essentially review all records, get a history and examination, and help and reach a diagnosis. Once a diagnosis has been made and the patients are interested in treatments, we see them at Shirley Ryan AbilityLab and the multidisciplinary lab that I mentioned and determine best treatment. We will also plan to have more research options available to help us understand the condition better. We have a referral process in place where we review medical records and then decide which patient is best seen.
Host: Well tell us then some of the exciting advances that we should know about, some of the innovative technologies supporting your work. What treatments are you using now? Tell us about your outcomes? Are they effective? What are you seeing?
Dr. LaFaver: So before I came to Northwestern I was in charge of the movement disorder clinic at University of Florida. There we had an inpatient rehabilitation program that actually was only a one week very intensive program. We saw very encouraging outcomes. We had indeed over 75 patients achieving significant improvement in their movement symptoms with just a very short treatment intervention. Things are often more complicated in the long term. In addition to the movement symptom, patients often have associated mood problems, chronic pain, and fatigue that can require longer treatment interventions. So one of the hopes that’s associated with the new clinics here, I'm in the process of establishing multicenter collaborations. We try to learn more about what commonalities patients share but also what differences and integrate more imaging into kind of an assessment of patients and other markers to learn how patients differ, develop biomarkers for disease monitoring, and also help us to individualize treatment better and achieve best outcomes.
Host: So tell us a little bit about any research that would impact the future of treating those with FMD and what else you’d like providers to know and take forward to help their patients.
Dr. LaFaver: We have definitely learned a lot about these conditions over the past five to ten years. Especially newer imaging has been shedding very new perspectives on our thinking of functional movement disorders. So many imaging studies have shown differences in limbic and motor pathways. They're, for example, showing increased connectivity between the amygdala and motor planning centers. We can sort of think a bit of a superhighway of how emotions can drive abnormal movements. More research is definitely needed not only in imaging work but also understanding differences in sensory processing and interception in these disorders. Many patients are very easily over stimulated by lights, by noises, by crowds which makes it very difficult for them to navigate in the world and live their life. So I think of it as abnormal brain balancing. It’s kind of an overload of sensory information that effects a processing of information and motor planning and emotional processing. So I think there's several different ways where we can still learn and refine our understanding and treatment approaches. One very interesting modality has been transcranial magnetic stimulation. There’s several groups trying to directly influence brain pathways that way. Although this is still in its infancy it holds promise for future applications.
So what I would like providers to take away from our conversation is that I would really encourage every neurologist specifically who sees patients with movement disorders or with weakness to educate themselves about functional movement disorders and learn how to diagnose it and education patients about it. Many patients need to see multiple providers before getting a diagnosis, get often conflicting information which contributes to the stigma about the diagnosis and delays the treatment process.
Host: Well thank you for speaking about advances in radiologic imaging and how they’ve helped augment your diagnosis and therapy capabilities. Before we wrap up, can functional movement disorders be cured? What do you see happening for these patients?
Dr. LaFaver: A cure is always our ultimate goal for any disease. Fortunately with FMD many patients can have good outcomes with appropriate treatment and better understanding of the conditions. Unfortunately this is not always possible and for some patients this remains a chronic condition at this time. Because there is no permanent lesion in the brain, no permanent structural damage, there is a lot of hope that we will be able to achieve good outcomes in the majority of patients in the future.
Host: That’s great. Thank you so much Dr. LaFaver for joining us today and sharing your incredible expertise. Thank you, again. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine, please visit our website at nm.org to get connected with one of our providers. Please also remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.