Twisted in Pain: The Multidisciplinary Treatment Approach to Functional Dystonia

Khachane, Yogesh; Kozlowska, Kasia; Savage, Blanche; McClure, Georgia; Butler, Gretel; Gray, Nicola; Worth, Andrea; Mihailovich, Samantha; Perez, David L.; Helgeland, Helene; Chrousos, George P.

doi:10.1097/hrp.0000000000000237

Cited by 17 publications

(16 citation statements)

References 69 publications

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“…Nonmotor symptoms also differentiated FD from OD. FD more frequently endorsed pain on presentation and cognitive symptoms 12 . The strong association between pain and FD is noteworthy, as concurrent pain is correlated with poor clinical outcomes 17,35 .…”

Section: Discussionmentioning

confidence: 96%

“…FD more frequently endorsed pain on presentation and cognitive symptoms. 12 The strong association between pain and FD is noteworthy, as concurrent pain is correlated with poor clinical outcomes. 17,35 However, pain is not infrequent in OD, and is a common symptom in cervical dystonia 36,37 and a powerful determinant of disability.…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, the prescription of opiates/benzodiazepines in patients with FD speaks to a larger issue beyond FD itself, which is the misuse of these medications in the management of chronic pain, which may be particularly resistant to treatment in FD with concurrent CRPS. 12,13 Although we assessed multiple EMRs, potentially relevant records were not always available, which may have precluded full identification of investigations prior to the first visit, and neurological consultations following their assessment at the MGH Dystonia Center. We were also unable to accurately record data regarding adherence to treatment recommendations (PT/OT/SLP and mental health care), as patients frequently engaged in treatment outside of our medical center or shared EMR record access.…”

Section: Discussionmentioning

confidence: 99%

“…We acknowledge that the high prescription of controlled drugs in the FD patients may reflect the higher rates of pain in this population, as well as at times of inadequate treatment in the community of chronic, intractable pain. Furthermore, the prescription of opiates/benzodiazepines in patients with FD speaks to a larger issue beyond FD itself, which is the misuse of these medications in the management of chronic pain, which may be particularly resistant to treatment in FD with concurrent CRPS 12,13 . Although we assessed multiple EMRs, potentially relevant records were not always available, which may have precluded full identification of investigations prior to the first visit, and neurological consultations following their assessment at the MGH Dystonia Center.…”

Section: Discussionmentioning

confidence: 99%

“…1 Typical historical features include sudden symptom onset, fixed dystonia at onset, inconsistent and variable phenomenology, spontaneous remission/recurrence, atypical precipitating/relieving factors (including placebo response to medications), and age of onset inconsistent with other primary dystonias (OD). 11 FD is frequently associated with pain, 12 especially in fixed dystonia, which can be associated with complex regional pain syndrome (CRPS) type I. 13,14 While useful, the predictive ability of these historical features has not been comprehensively investigated.…”

Section: Introductionmentioning

confidence: 99%

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Functional dystonia: A case‐control study and risk prediction algorithm

Stephen

Perez

Chibnik

et al. 2021

Ann Clin Transl Neurol

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Objective Functional dystonia (FD) is a disabling and diagnostically challenging functional movement disorder (FMD). We sought to identify historical predictors of FD vs. other primary dystonias (ODs) and develop a practical prediction algorithm to guide neurologists. Methods 1475 consecutive new patient medical records were reviewed at an adult/pediatric tertiary‐referral dystonia clinic from 2005 to 2017. Ninety‐nine met criteria for clinically established FD (85 adults and 14 pediatric), paired with 99 age/dystonia distribution‐matched OD. Univariate and multivariate regression analyses were performed to identify predictors of FD and disability. We formed a prediction algorithm, assessed using the area under the receiver operating curve (AUC). Results Multivariate logistic regression analysis investigating independent predictors of FD (P < 0.001) followed by development of a prediction algorithm showed that the most robust predictors included abrupt onset, spontaneous resolution/recurrence, pain, cognitive complaints, being on or pursuing disability, lifetime mood/anxiety disorder, comorbid functional somatic disorders, and having ≥3 medication allergies. The prediction algorithm had utility for both adult and pediatric FD, with excellent sensitivity/specificity (89%/92%) and an area under the curve (AUC) 0.95 (0.92‐0.98). Greater disability (modified Rankin Scale) independently correlated with a number of functional examination features, unemployment/not attending school, number of medication allergies, and younger age of presentation. FD patients were high health‐care utilizers and were more frequently prescribed opiates/opioids and benzodiazepines (P < 0.003). Interpretation This case‐control study provides an algorithm to guide clinicians in gauging their index of suspicion for a FD, with diagnostic confirmation subsequently informed by neurological examination. While this algorithm requires prospective validation, health‐care utilization data underscore the importance and need for more research in FD.

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Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Functional dystonia: A case‐control study and risk prediction algorithm

Stephen

Perez

Chibnik

et al. 2021

Ann Clin Transl Neurol

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Rehabilitation for Functional Dystonia: Cases and Review of the Literature

Gros,

Bhatt,

Gilmour

et al. 2024

Movement Disord Clin Pract

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BackgroundFunctional dystonia (FD) is a common subtype of functional movement disorder. FD can be readily diagnosed based on positive signs and is potentially treatable with rehabilitation. Despite this, clinical outcomes remain variable and a gold standard approach to treatment is lacking.CasesHere we present four cases of axial and limb functional dystonia who were treated with integrated rehabilitation and improved. The therapy approach and clinical outcomes are described, including videos.Literature reviewA literature review evaluated the published treatment strategies for the treatment of functional dystonia. Out of 338 articles, 25 were eligible for review and included mainly case reports and case series. Most patients received more than one treatment modality. Non‐invasive therapies, commonly physiotherapy and psychological approaches were mostly associated with positive outcomes. Multiple treatments commonly used in dystonia were used, including botulinum toxin injections, pharmacotherapy and surgery, leading to variable outcomes.ConclusionTherapy should be personalized to the clinical presentation. In challenging cases, initiation of a multidisciplinary approach may provide benefit regardless of etiology. Pharmacotherapy should be used judiciously, and surgical therapy should be avoided.

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The Brain Stress Systems I: The Implicit Level of Brain Operations

Kozlowska

Scher

Helgeland

2020

Functional Somatic Symptoms in Children and Adolescents

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In this chapter we continue our exploration of the neurobiology of functional somatic symptoms by considering the role of the brain. The brain plays a key role in regulation, in coordinating the stress response, and in helping the child adapt to the circumstances of living over time. Every component of the body stress system-the HPA axis, autonomic nervous system, and immune-inflammatory system-is regulated by the brain or connected to it, or communicating with it, in some way. When a child is exposed to stress that is chronic, uncontrollable, unpredictable, cumulative, recurrent, or overwhelming, it leads to activation of brain systems that are involved in managing stress and in stress-related adaptations. Because these regions interact with and modulate motor-, sensory-, pain-, and fatigue-processing regions, the sustained activation of the brain stress systems changes patterns of neural activation and connectivity across and between these systems, and sets up the necessary conditions for generating functional 11 The Brain Stress Systems I: The Implicit Level of Brain Operations

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Twisted in Pain: The Multidisciplinary Treatment Approach to Functional Dystonia

Abstract: In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the expression functional neurological symptom disorder has replaced conversion disorder. 1

Cited by 17 publications

References 69 publications

Functional dystonia: A case‐control study and risk prediction algorithm

Functional dystonia: A case‐control study and risk prediction algorithm

Rehabilitation for Functional Dystonia: Cases and Review of the Literature

The Brain Stress Systems I: The Implicit Level of Brain Operations

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