Outcomes of specialist physiotherapy for functional motor disorder: the Physio4FMD RCT
Background Functional motor disorder often causes persistent disabling symptoms that are associated with high healthcare costs. In recent years, specialist physiotherapy, informed by an understanding of functional motor disorder, has emerged as a promising treatment, but there is an absence of evide...
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| Main Authors: | , , , , , , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
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NIHR Journals Library
2025-07-01
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| Series: | Health Technology Assessment |
| Subjects: | |
| Online Access: | https://doi.org/10.3310/MKAC9495 |
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| Summary: | Background Functional motor disorder often causes persistent disabling symptoms that are associated with high healthcare costs. In recent years, specialist physiotherapy, informed by an understanding of functional motor disorder, has emerged as a promising treatment, but there is an absence of evidence of its effectiveness from large randomised controlled trials. Methods We conducted a pragmatic, multicentre, randomised controlled trial, comparing specialist physiotherapy for functional motor disorder to treatment as usual, which was defined as community neurological physiotherapy. The primary outcome was the Short Form questionnaire-36 items Physical Functioning domain at 12 months (scale range 0–100, with 100 indicating optimum health). The trial was powered to detect a 9-point difference in the primary outcome with 90% power at the 5% level of significance. Secondary domains of measurement included a patient perception of improvement, health-related quality of life, mobility, anxiety, depression and illness perception. We also completed a health economic analysis with the primary aim of calculating the mean incremental cost per quality-adjusted life-year over 12 months. In prespecified analysis plans, we excluded participants from the primary analysis if they were unable to receive their trial-allocated treatment due to COVID-19 lockdown restrictions. Sensitivity analysis explored the impact of this decision. Results Between 19 October 2018 and 31 January 2022, 355 adults with functional motor disorder were randomised (1 : 1) to specialist physiotherapy (n = 179) and treatment as usual (n = 176). Eighty-nine participants were excluded due to COVID-19 disruptions. Retention for the primary analysis was 90% for both groups, leaving 241 participants in the primary analysis. At 12 months, there was no between-group difference in the primary outcome (adjusted mean difference 3.5, 95% confidence interval −2.3 to 9.3). However, several secondary outcomes favoured specialist physiotherapy, including the participant perception of improvement, Short Form questionnaire-36 items Mental Health domain, confidence in the diagnosis and two subscales (Personal Control and Illness Coherence) of the Revised Illness Perception Questionnaire. There were no differences in the remaining outcomes. At 6 months, the following outcome measures were significantly different, in favour of specialist physiotherapy: participant perception of improvement, the Short Form questionnaire-36 items Physical Role Limitations, Short Form questionnaire-36 items Social Functioning, Short Form questionnaire-36 items Mental Health, EuroQol-5 Dimensions five-level version utility score, confidence in the diagnosis and three subscales (Timeline Cyclical, Personal Control and Treatment Control) of the Revised Illness Perception Questionnaire. No outcomes significantly favoured treatment as usual. In the health economic analysis, the incremental cost per quality-adjusted life-year gained from a health and social care cost perspective was £4133 with an 86% probability that specialist physiotherapy is cost-effective compared to treatment as usual at a cost-effectiveness threshold of £20,000 per quality-adjusted life-year gained. There were no adverse events related to physiotherapy. Conclusion Specialist physiotherapy was not superior to treatment as usual for the primary outcome, the Short Form questionnaire-36 items Physical Functioning domain at 12 months. However, a number of secondary outcome measures favoured specialist physiotherapy at 6 and 12 months. There is a high probability that specialist physiotherapy is cost-effective. Limitations Participants in treatment as usual waited longer to start physiotherapy, which resulted in a shorter time between concluding treatment and completing the primary outcome. Most outcome measures, including the primary outcome, were participant reported, which may have been biased by perceptions of the randomised treatment allocation. Future work Future work should identify or develop more suitable outcome measures for functional motor disorder research, explore who is most likely to benefit from specialist physiotherapy and identify alternative interventions for those unlikely to benefit from this treatment. Additional work is needed to adapt treatment to meet the needs of minority groups and young people. Funding This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 16/31/63.
Plain language summary Why did we do this trial? Functional motor disorder causes persistent disabling symptoms, for which there are few treatment options. Physiotherapy is widely considered to be an important part of treatment, but there is little evidence to prove that it is effective. We, therefore, wanted to test the effectiveness of specialist physiotherapy for people with functional motor disorder. What did we do? We conducted a randomised controlled trial, comparing specialist physiotherapy to standard physiotherapy suitable for people with neurological symptoms. Between 19 October 2018 and 31 January 2022, we recruited 355 adults with functional motor disorder to participate in the trial. Participants were randomly assigned to receive specialist physiotherapy or standard physiotherapy for neurological symptoms. We used a range of questionnaires to compare the outcomes from the two treatments. We also explored the cost-effectiveness (value for money from the perspective of the National Health Service) of specialist physiotherapy. What did we find? There were 241 people in our final analysis, 89 were excluded because the COVID-19 pandemic interrupted their treatment and 25 were lost to follow-up. After 12 months, we found that specialist physiotherapy for functional motor disorder was no more effective than usual physiotherapy treatment, as both groups improved in our main measurement, which asked participants to rate their physical function (ability to walk, climb stairs, and complete moderate and vigorous activities). On average, there was no difference between the groups on this measurement. Participants were more likely to report improvement in their motor symptoms if they received specialist physiotherapy compared to standard physiotherapy (59% receiving specialist physiotherapy reported improvement compared to 38% receiving standard physiotherapy). There were other benefits in specialist physiotherapy over standard physiotherapy, including slightly better mental health scores, and it was very likely to be more cost-effective, in that the cost for improvement was lower. Both physiotherapy treatments appeared to be safe with no dangerous complications found. What does this mean? Physiotherapy is a safe and potentially useful treatment for a proportion of people with functional motor disorder. Physiotherapy specifically designed to help functional motor disorder may be more cost-effective than standard neurological physiotherapy. |
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| ISSN: | 2046-4924 |