Functional Movement Disorders (FMD) are characterized by unwanted movements, such as spasms, shaking or jerks. This can involve any part of the face, neck, trunk or limbs. In some people, there may be bizarre gait or difficulties with their balance. These types of movement disorders are often caused by underlying stress or a psychological condition.
Speech and voice disorders are also relatively common in patients with functional movement disorders, in which patients may experience stuttering or lower speech volume.
How is it diagnosed?
Functional Movement Disorders are essentially a diagnosis of exclusion, in that all physical or organic causes of the movement difficulty are ruled out. Although a FMD may resemble or accompany an organic disorder, a skilled and experienced neurologist should be able to differentiate the two types of disorders.
What distinguishes FMD from other movement disorders is that it is not caused by any damage to the brain, spinal cord or nerves, but it is a manifestation of how the body responds to stress. Just as stress can cause elevation in blood pressure, palpitations and nausea, stress can also manifest as disorders of movement.
Patients are unconsciously manifesting movements or other abnormalities that can be quite disabling. Some clients do not readily recognize or acknowledge that these are stress-induced (functional) and may disagree with the diagnosis.
The continued assessment of the motor issue via referrals to specialists, MRI's and diagnostics, can actually make the disorder worse over time as the individual continues to seek an organic reason for the movement disorder. The issue is that being told something is functional or "psychogenic" may cause the person to feel disbelieved.
However, understanding and accepting the diagnosis can be the first step in recovery.
What happens when you combine a Functional Movement Disorder with an Accident Benefits or Legal claim? This can become very complicated as clients may be unfairly accused of faking or malingering with their symptoms.
In this case study, we will explore a situation where a catastrophic brain injury was combined with the functional movement disorder. For the sake of client confidentiality, we will call our client Susan, which is not her actual name.
Susan was injured as a pedestrian when she was struck by a vehicle while crossing the street. She had the right of way and the driver was charged. At the time, she was deemed to have sustained a catastrophic impairment as a result of a brain injury.
As Susan began her recovery journey, she found that the brain injury affected her executive functions. This limited her higher level thinking skills, though she appeared to others as fairly able-bodied. We often refer to these injuries as "hidden disabilities".
As Susan worked through her recovery, she experienced significant stress. Susan lost her job, she had to move in with her family for support and her insurance company had a habit of delaying and denying her claims for health and income benefits.
She began to develop a pattern of walking whereby she would hitch forward at the waist with every step. First it was a small movement that later developed into a full, forward swing of her torso with every step. Her head and chest would uncontrollable pike forward causing loss of balance. She now needed to use a walker for mobility.
As with any significant physical change in mobility, Susan sought answers from her medical team. She was referred for MRI's, nerve conduction studies, CAT scans of her brain and other specialists. This journey took over a year and half of referrals and waiting for appointments.
Meanwhile, an assessor for the insurer, who met briefly with Susan, claimed falsely in a report that she was malingering regarding her symptoms. The insurance adjuster was then denying all claims for attendant care, income and rehabilitation benefits.
Susan remained dedicated to rehabilitation, attending physio, eager to get answers so that some day she could return to work. Through an out-patient brain injury program, Susan was referred to a joint neurology-physiatry program run by Dr. Michel Rathbone and Dr. Dinesh Khumbare. At the appointment and following a series of medical investigations, Susan was diagnosed with a Functional Movement Disorder, and ongoing cognitive impairments secondary to traumatic brain injury.
Dr. Rathbone skillfully explained to Susan, that a Functional Movement Disorder is a problem of the mind as opposed to the brain and often brought on due to extreme stress. Susan's mind was sub-consciously creating a pattern of movement that it needed to "unlearn".
Susan struggled to understand how such a disabling gait disorder could have no organic or physical causes. Dr. Rathbone and Dr. Khumbare explained that the movement disorder was like a computer, whereby the hardware was working, there is a software issue.
Due to the stress of the accident, her disability from brain injury and lack of support by the insurer, Susan's mental health was so severely impacted that it was manifested as a Functional Movement Disorder. Susan finally understood the diagnosis and felt supported by her medical team. This moment was a crucial first step in recovery.
Over the following months, Susan's physical therapy team took a novel approach to re-training her gait. Instead of trying to walk, they got Susan to dance. They had her toss a ball and listen to music while making steps, distracting her mind from the pattern of movement it had created. They bypassed the functional movement disorder with distractions.
In the meantime, the psychology team focused on supporting her mental health. The personal injury lawyer was able to get her benefits paid for, due to excellent supporting medical documentation and skilled advocacy. Within a year, Susan no longer needed her walker and was walking normally. Resolving this issue allowed her to focus on more on her brain injury recovery and next steps.
With Functional Movement Disorders, when there has also been a traumatic, organic injury from an MVA, clients may struggle to understand this diagnosis. Understandably, it can be a sensitive matter both for physicians as well as patients. It is imperative to have skilled and experienced specialists, to provide expert opinion in these cases.
Often insurers are too-quick to accept "there is no evidence of" arguments by IE assessors when there are functional or psychogenic issues. This can significantly complicate the client's recovery as denial of benefits only exacerbates psychological distress.
In follow up, it is fair to ask: Are there aspects of the Auto Insurance Injury claims system that could predispose or magnify a Functional Movement Disorder?
Further reading:
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0172502
https://www.neurosymptoms.org/
https://practicalneurology.com/articles/2017-mar/its-not-in-your-head-navigating-the-challenges-of-a-functional-movement-disorder-diagnosis