The future impact of the Physio4FMD trial is to be determined. An important potential impact will be supporting people with FMD to access rehabilitation on the NHS. Patient-led charity, FND Hope UK, submitted a freedom of information request to Clinical Commissioning Groups and Health Boards in England, Wales and Scotland, that asked for information regarding commissioning agreements for FND.49 The exercise found that 14% (England), 21% (Scotland) and 43% (Wales) of services did not accept physiotherapy referrals for people with FND. We argue that FND has been unfairly excluded from rehabilitation services on unfounded grounds. The findings of the Physio4FMD trial show that physiotherapy was safe and that both randomised groups improved; this makes exclusion of FND difficult to justify. Support for the argument that people with FND should have access to rehabilitation therapies comes from the National Institute for Health and Care Excellence, who are in the development phase of a guidance document on ‘Rehabilitation for chronic neurological disorders including acquired brain injury’.50 Following stakeholder consultation, the document scope was updated to include FND. As one of very few randomised studies of FND, the findings from the Physio4FMD trial will be important to inform recommendations of this guideline.
Since participating in the trial, the physiotherapists from each site continue to provide treatment for people with FMD informed by the intervention protocol. Some sites have since secured additional funding for specialist FMD physiotherapy posts. There was consensus among the physiotherapists delivering specialist physiotherapy in the trial (manuscript in preparation) that several important ingredients are needed to set up a specialist physiotherapy for FMD service. These included (1) training for the specialist physiotherapist; (2) experienced clinicians to select patients for whom specialist physiotherapy is most suited and direct patients who are unlikely to benefit to more suitable treatment; and (3) a supportive multidisciplinary team to help with cases of high complexity. However, the trial interventions can be applied to settings outside of specialist services, and the trial materials are available to inform interventions of physiotherapists and other health professionals.
We found high health and social care costs at baseline, that were similar to people with advanced Parkinson’s disease and moderate-severity multiple sclerosis.51,52 Hospital inpatient and outpatient services accounted for a substantial proportion of total costs. We suggest that this is a reflection of the complexity and multicomorbidity of the patient population. Although many of these hospital contacts may have been necessary and appropriate, the data suggest that there is further potential for cost savings with early diagnosis and treatment.
We have shown that it is possible to conduct a large, randomised trial in people with FMD. Future trials will need to consider what is the most meaningful outcome measure for rehabilitation in FMD. Our chosen primary outcome, SF-36 Physical Functioning, improved over 12 months in both groups, but it is unclear from the current study whether or not this change can be attributed to physiotherapy (from both randomised treatments) or natural recovery. Alternative assessment tools should be considered in research involving people with FMD. A recent expert consensus statement on core outcomes for FND research suggested that the CGI-I is currently the most suitable assessment of FND symptom severity. An alternative assessment tool is the Simplified Functional Movement Disorders Rating Scale,53 which would require in-person assessments and therefore has cost implications.
Other metrics to assess the future impact of the Physio4FMD trial will include uptake of future training and downloads for the physiotherapy training resource manual and intervention workbook.