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The impact of lockdown on Functional Motor Disorders patients during the first COVID-19 outbreak: acase-control study

2021; Elsevier BV; Volume: 93; Linguagem: Inglês

10.1016/j.parkreldis.2021.11.007

ISSN

1873-5126

Autores

Ilaria Antonella Di Vico, Marianna Riello, Angela Marotta, Michela Colombari, Angela Sandri, Michèle Tinazzi, Maria Elisabetta Zanolin,

Tópico(s)

Body Image and Dysmorphia Studies

Resumo

Functional Motor Disorders (FMDs) are frequent and disabling neurological disorders characterized by motor abnormalities that are inconsistent over time, altered by distraction and clinically incongruent with classical movement disorders [[1]Espay A.J. Aybek S. Carson A. Edwards M.J. Goldstein L.H. Hallett M. LaFaver K. LaFrance Jr., W.C. Lang A.E. Nicholson T. Nielsen G. Reuber M. Voon V. Stone J. Morgante F. Current concepts in diagnosis and treatment of functional neurological disorders.JAMA Neurol. 2018 Sep 1; 75 (PMID: 29868890; PMCID: PMC7293766): 1132-1141https://doi.org/10.1001/jamaneurol.2018.1264Crossref PubMed Scopus (424) Google Scholar]. Non-motor symptoms (NMS), including anxiety, pain, fatigue and so forth, common to the general population, are often part of the clinical spectrum [[1]Espay A.J. Aybek S. Carson A. Edwards M.J. Goldstein L.H. Hallett M. LaFaver K. LaFrance Jr., W.C. Lang A.E. Nicholson T. Nielsen G. Reuber M. Voon V. Stone J. Morgante F. Current concepts in diagnosis and treatment of functional neurological disorders.JAMA Neurol. 2018 Sep 1; 75 (PMID: 29868890; PMCID: PMC7293766): 1132-1141https://doi.org/10.1001/jamaneurol.2018.1264Crossref PubMed Scopus (424) Google Scholar]. Traditionally viewed as "psychogenic", FMDs raise important concerns in terms of increased susceptibility to stressful conditions and environmental dramatic events [[2]Edwards M.J. Fotopoulou A. Pareés I. Neurobiology of functional (psychogenic) movement disorders.Curr. Opin. Neurol. 2013 Aug; 26 (PMID: 23823467; PMCID: PMC4196785): 442-447https://doi.org/10.1097/WCO.0b013e3283633953Crossref PubMed Scopus (105) Google Scholar]. The 2019-Coronavirus disease (COVID-19) pandemic and the severe restrictions adopted during lockdown to limit virus diffusion, might have been expected to exacerbate functional symptoms, also given the increased psychological distress, depression and stress reported in the general population [[3]Brooks S.K. Webster R.K. Smith L.E. Woodland L. Wessely S. Greenberg N. Rubin G.J. The psychological impact of quarantine and how to reduce it: rapid review of the evidence.Lancet. 2020 Mar 14; 395 (Epub 2020 Feb 26. PMID: 32112714; PMCID: PMC7158942): 912-920https://doi.org/10.1016/S0140-6736(20)30460-8Abstract Full Text Full Text PDF PubMed Scopus (9573) Google Scholar]. Interestingly, despite increased levels of NMSs in FMDs, particularly anxiety [4Delgado C. Pareés I. Jiménez-Huete A. Kurtis M.M. Impact of the coronavirus disease 2019 pandemic on functional movement disorders: lessons from a specialized clinic.Mov. Disord. 2020 Oct; 35 (Epub 2020 Sep 14. PMID: 32833238; PMCID: PMC7461187): 1723-1724https://doi.org/10.1002/mds.28278Crossref PubMed Scopus (7) Google Scholar, 5Nisticò V. Goeta D. Gambini O. Demartini B. The psychological impact of COVID-19 among a sample of Italian patients with functional neurological disorders: a preliminary study.Park. Relat. Disord. 2020 Sep; 78 (Epub 2020 Jul 22. PMID: 32745981; PMCID: PMC7374122): 79-81https://doi.org/10.1016/j.parkreldis.2020.07.019Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 6Kanaan R.A. Chen G. Olver J. How has the COVID pandemic affected functional neurological disorder? A mixed-methods analysis.Gen. Hosp. Psychiatr. 2021 Mar-Apr; 69 (Epub 2020 Dec 28. PMID: 33451858; PMCID: PMC7959885): 129-130https://doi.org/10.1016/j.genhosppsych.2020.12.014Crossref PubMed Scopus (6) Google Scholar], functional motor symptoms have not been clearly reported to worsen during lockdown [4Delgado C. Pareés I. Jiménez-Huete A. Kurtis M.M. Impact of the coronavirus disease 2019 pandemic on functional movement disorders: lessons from a specialized clinic.Mov. Disord. 2020 Oct; 35 (Epub 2020 Sep 14. PMID: 32833238; PMCID: PMC7461187): 1723-1724https://doi.org/10.1002/mds.28278Crossref PubMed Scopus (7) Google Scholar, 5Nisticò V. Goeta D. Gambini O. Demartini B. The psychological impact of COVID-19 among a sample of Italian patients with functional neurological disorders: a preliminary study.Park. Relat. Disord. 2020 Sep; 78 (Epub 2020 Jul 22. PMID: 32745981; PMCID: PMC7374122): 79-81https://doi.org/10.1016/j.parkreldis.2020.07.019Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 6Kanaan R.A. Chen G. Olver J. How has the COVID pandemic affected functional neurological disorder? A mixed-methods analysis.Gen. Hosp. Psychiatr. 2021 Mar-Apr; 69 (Epub 2020 Dec 28. PMID: 33451858; PMCID: PMC7959885): 129-130https://doi.org/10.1016/j.genhosppsych.2020.12.014Crossref PubMed Scopus (6) Google Scholar]. However, the available studies were limited by the lack of a control group [4Delgado C. Pareés I. Jiménez-Huete A. Kurtis M.M. Impact of the coronavirus disease 2019 pandemic on functional movement disorders: lessons from a specialized clinic.Mov. Disord. 2020 Oct; 35 (Epub 2020 Sep 14. PMID: 32833238; PMCID: PMC7461187): 1723-1724https://doi.org/10.1002/mds.28278Crossref PubMed Scopus (7) Google Scholar, 5Nisticò V. Goeta D. Gambini O. Demartini B. The psychological impact of COVID-19 among a sample of Italian patients with functional neurological disorders: a preliminary study.Park. Relat. Disord. 2020 Sep; 78 (Epub 2020 Jul 22. PMID: 32745981; PMCID: PMC7374122): 79-81https://doi.org/10.1016/j.parkreldis.2020.07.019Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 6Kanaan R.A. Chen G. Olver J. How has the COVID pandemic affected functional neurological disorder? A mixed-methods analysis.Gen. Hosp. Psychiatr. 2021 Mar-Apr; 69 (Epub 2020 Dec 28. PMID: 33451858; PMCID: PMC7959885): 129-130https://doi.org/10.1016/j.genhosppsych.2020.12.014Crossref PubMed Scopus (6) Google Scholar] or by a small sample size [4Delgado C. Pareés I. Jiménez-Huete A. Kurtis M.M. Impact of the coronavirus disease 2019 pandemic on functional movement disorders: lessons from a specialized clinic.Mov. Disord. 2020 Oct; 35 (Epub 2020 Sep 14. PMID: 32833238; PMCID: PMC7461187): 1723-1724https://doi.org/10.1002/mds.28278Crossref PubMed Scopus (7) Google Scholar, 5Nisticò V. Goeta D. Gambini O. Demartini B. The psychological impact of COVID-19 among a sample of Italian patients with functional neurological disorders: a preliminary study.Park. Relat. Disord. 2020 Sep; 78 (Epub 2020 Jul 22. PMID: 32745981; PMCID: PMC7374122): 79-81https://doi.org/10.1016/j.parkreldis.2020.07.019Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 6Kanaan R.A. Chen G. Olver J. How has the COVID pandemic affected functional neurological disorder? A mixed-methods analysis.Gen. Hosp. Psychiatr. 2021 Mar-Apr; 69 (Epub 2020 Dec 28. PMID: 33451858; PMCID: PMC7959885): 129-130https://doi.org/10.1016/j.genhosppsych.2020.12.014Crossref PubMed Scopus (6) Google Scholar]. In Italy, the worst-hit European Country by the first outbreak of COVID-19, a strict lockdown of all unnecessary activities was imposed from March to the end of April 2020, with radical measures for social distancing and limitations of all outdoor activities, including physical activity. In our study, we explored the impact of lockdown on motor, numerous NMS and global health status (GHS) in a large cohort of FMDs patients and compared the results with those obtained in healthy controls (HC), matched for age and sex. Patients with an established diagnosis of FMDs followed at our specialized FMDs clinic in Verona and HC, who were friends or relatives of researchers, matched for age and sex, were contacted in October 2020, via phone or mail and given the link for a semi-anonymous Survey and two weeks to complete it. All provided informed consent, and the local Ethics Committee approved the study. We employed a 39-item Survey divided into three sections: i) socio-demographics ii) patient-estimated severity of symptoms during lockdown: motor and NMS, assessed through a 5-point Likert scale (1 = none to 5 = severe) and GHS, assessed using a 5-point scale (1 = excellent to 5 = poor) iii) changes in symptoms severity compared to pre-lockdown (February 2020), assessed through a 3-point Likert scale (improved/unchanged/worsened) and changes in adherence to home based physical exercise, if prescribed. Results are shown in Table 1 and main demographics and clinical data are reported in the Supplementary material. We recruited 73 out of 96 contacted patients (response rate 76%) and 101 HC.Table 1Clinical variables in FMD and HC and their associations with worsening in severity of motor symptoms.Motor symptoms, NMS and GHS during lockdownFMDHCTestP-value Z value (Mann-Whitney Test) X-squared (Chi-squared Test) OR (Fisher Test)Motor symptoms (5-point Likert)---Mean ± SD2.90 ± 1.15;Median (IQR)3.00 (2–4)None11% (n = 8)Minimal26% (n = 19)Mild36% (n = 26)Moderate16% (n = 12)Severe11% (n = 8)I do not Know-I felt anxious (5-point Likert)Mann-WhitneyMean ± SD2.53 ± 1.142.54 ± 0.95p = 0.863Median (IQR)3.00 (2–3)3.00 (2–3)Z = −0.172I felt depressed (5-point Likert)Mann-WhitneyMean ± SD2.73 ± 1.292.64 ± 1.02p = 0.875Median (IQR)3.00 (2–4)3.00 (2–3)Z = −0.157I felt physically fatigued (5-point Likert)Mann-WhitneyMean ± SD3.04 ± 1.212.36 ± 1.20p = 0.017Median (IQR)3.00 (2–4)2.00 (1–3)Z = −2.379I felt mentally fatigued (5-point Likert)Mann-WhitneyMean ± SD2.90 ± 1.222.56 ± 1.13p = 0.075Median (IQR)3.00 (2–4)3.00 (2–3)Z = −2.379I felt demotivated (5-point Likert)Mann-WhitneyMean ± SD2.46 ± 1.312.34 ± 1.16p = 0.728Median (IQR)2.00 (1–3)2.00 (1–3)Z = −0.347I felt pain (5-point Likert)Mann-WhitneyMean ± SD2.76 ± 1.291.50 ± 0.78p < 0.001Median (IQR)3.00 (2–4)1.00 (1–2)Z = −6.783I had trouble sleeping (5-point Likert)Mann-WhitneyMean ± SD2.64 ± 1.451.99 ± 1.09p = 0.004Median (IQR)3.00 (1–3)2.00 (1–3)Z = −2.893Global Health Status (5-point Likert)3.02 ± 0.81 3.00 (3-3)Mann-WhitneyMean ± SD2.19 ± 0.97p < 0.001Median (IQR)2.00 (1–3)Z = −5.416Changes in motor symptoms, NMS and GHSSymptomsFMDHCTestP value X-squared (Chi-squared test)Severity of Motor symptoms n (%)---Worsened30% (n = 22)Unchanged56% (n = 41)Improved14% (n = 10)Frequency of Motor symptoms n (%)---Worsened27% (n = 20)Unchanged63% (n = 46)Improved10% (n = 7)Anxiety n (%)Fisher Testp = 0.002Worsened34% (n = 25)58% (n = 59)Unchanged59% (n = 43)41% (n = 41)Improved7% (n = 5)1% (n = 1)Depression n (%)Fisher Testp < 0.001Worsened41% (n = 30)72% (n = 73)Unchanged48% (n = 35)25% (n = 25)Improved11% (n = 8)3% (n = 3)Physical Fatigue n (%)Chi-squaredp = 0.96Worsened45% (n = 33)47% (n = 48)X-squared = 0.092Unchanged47% (n = 34)45% (n = 45)Improved8% (n = 6)8% (n = 8)Mental Fatigue n (%)Fisher Testp = 0.47Worsened49% (n = 36)58% (n = 59)Unchanged45% (n = 33)36% (n = 36)Improved6% (n = 4)6% (n = 6)Apathy n (%)Chi-squaredWorsened38% (n = 28)55% (n = 56)Unchanged50% (n = 37)40% (n = 40)p = 0.055Improved12% (n = 9)5% (n = 5)X-squared = 5.79Pain n (%)Fisher Testp < 0.001Worsened33% (n = 24)15% (n = 15)Unchanged57% (n = 42)84% (n = 85)Improved10% (n = 7)1% (n = 1)Quality of Sleep n (%)Fisher Testp = 0.085Worsened32% (n = 23)42% (n = 42)Unchanged60% (n = 44)56% (n = 57)Improved8% (n = 6)2% (n = 2)General Health Status n (%)Fisher Test0.089Worsened32% (n = 23)30% (n = 30)Unchanged58% (n = 42)67% (n = 68)Improved11% (n = 8)3% (n = 3)Adherence to Physical Exercise (prescribed in n = 55) n (%)Not performed31% (n = 17)-Lower frequency36% (n = 20)-Same frequency26% (n = 14)-Higher frequency7% (n = 4)-Associations of NMS and adherence to rehabilitation with worsening in severity of motor symptoms in FMDsSingle comparisonMultivariable Logistic modelNMS Changes during lockdown in FMDsOdds ratiop-valueOdds ratiop-valueAdherence to rehabilitation3.81 [0.94–15.4]0.0611.98 [0.24–16.3]0.52Anxiety3.51 [1.23–10]0.019*1.21 [0.16–9.13]0.86Depression5.14 [1.75–15.2]0.003**0.63 [0.08–5.03]0.66Physical Fatigue29.23 [6–142]<0.001***2.16 [0.15–30.7]0.57Mental Fatigue50.4 [6.21–409]<0.001***30.82 [2.11–450]0.012*Apathy3.47 [1.22–9.82]0.019*2.38 [0.35–16.1]0.37Pain14.33 [4.3–47.8]<0.001***1.46 [0.18–11.8]0.72Quality of sleep4.36 [1.49–12.7]0.007**1.36 [0.22–8.56]0.74Abreviations: FMD, Functional Motor Disorders; HC, Healthy Controls. NMS, Non-motor Symptoms; GHS, General Health Status.Legend: the Table shows motor symptoms, non-motor symptoms (NMS), general health status during lockdown (March–April 2020), their changes compared to pre-lockdown (February 2020) and regression analyses between changes in NMS in FMD and worsening in motor symptoms severity. All variables were classified as 0 or 1 (0 = unchanged, improved; 1 = worsened).*p value adjusted for multiple comparisons (Bonferroni correction) p < 0.007 was statistically significant. Statistically significant results are given in bold. Open table in a new tab Abreviations: FMD, Functional Motor Disorders; HC, Healthy Controls. NMS, Non-motor Symptoms; GHS, General Health Status. Legend: the Table shows motor symptoms, non-motor symptoms (NMS), general health status during lockdown (March–April 2020), their changes compared to pre-lockdown (February 2020) and regression analyses between changes in NMS in FMD and worsening in motor symptoms severity. All variables were classified as 0 or 1 (0 = unchanged, improved; 1 = worsened). *p value adjusted for multiple comparisons (Bonferroni correction) p < 0.007 was statistically significant. Statistically significant results are given in bold. During lockdown, motor symptoms were minimal to mild in 62%. Compared to controls, patients showed comparable levels of anxiety, depression, apathy, physical and mental fatigue and suffered from more severe levels of pain and sleep disturbances (Mann-Whitney, p < 0.005). Compared to pre-lockdown, most patients reported stability of motor symptoms (severity and frequency) and NMS, except for mental fatigue that worsened in ∼ 50% of patients. In particular, motor symptoms remained stable in ∼60% of patients, worsened in about one third and 18% of patients reported new-onset motor symptoms. Worsening in severity of motor symptoms was significantly predicted by mental fatigue in a multiple regression analysis (Table 1). Compared to pre-lockdown, pain worsened significantly more in patients than controls, while anxiety and depression worsened significantly more in controls than in patients (all, Fisher test p < 0.001). Patients reported a significantly worse GHS than controls (Mann-Whitney, p < 0.001), but it did not change due to lockdown, as in HC. Almost 70% of patients who were prescribed with home based physical exercise plan continued exercising, although 36% of them less frequently than the pre-lockdown period. In line with previous studies, our results confirm that motor symptoms remained stable in the majority of patients [4Delgado C. Pareés I. Jiménez-Huete A. Kurtis M.M. Impact of the coronavirus disease 2019 pandemic on functional movement disorders: lessons from a specialized clinic.Mov. Disord. 2020 Oct; 35 (Epub 2020 Sep 14. PMID: 32833238; PMCID: PMC7461187): 1723-1724https://doi.org/10.1002/mds.28278Crossref PubMed Scopus (7) Google Scholar, 5Nisticò V. Goeta D. Gambini O. Demartini B. The psychological impact of COVID-19 among a sample of Italian patients with functional neurological disorders: a preliminary study.Park. Relat. Disord. 2020 Sep; 78 (Epub 2020 Jul 22. PMID: 32745981; PMCID: PMC7374122): 79-81https://doi.org/10.1016/j.parkreldis.2020.07.019Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 6Kanaan R.A. Chen G. Olver J. How has the COVID pandemic affected functional neurological disorder? A mixed-methods analysis.Gen. Hosp. Psychiatr. 2021 Mar-Apr; 69 (Epub 2020 Dec 28. PMID: 33451858; PMCID: PMC7959885): 129-130https://doi.org/10.1016/j.genhosppsych.2020.12.014Crossref PubMed Scopus (6) Google Scholar]. In contrast with previous findings, our cohort of patients showed stable NMS [4Delgado C. Pareés I. Jiménez-Huete A. Kurtis M.M. Impact of the coronavirus disease 2019 pandemic on functional movement disorders: lessons from a specialized clinic.Mov. Disord. 2020 Oct; 35 (Epub 2020 Sep 14. PMID: 32833238; PMCID: PMC7461187): 1723-1724https://doi.org/10.1002/mds.28278Crossref PubMed Scopus (7) Google Scholar, 5Nisticò V. Goeta D. Gambini O. Demartini B. The psychological impact of COVID-19 among a sample of Italian patients with functional neurological disorders: a preliminary study.Park. Relat. Disord. 2020 Sep; 78 (Epub 2020 Jul 22. PMID: 32745981; PMCID: PMC7374122): 79-81https://doi.org/10.1016/j.parkreldis.2020.07.019Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 6Kanaan R.A. Chen G. Olver J. How has the COVID pandemic affected functional neurological disorder? A mixed-methods analysis.Gen. Hosp. Psychiatr. 2021 Mar-Apr; 69 (Epub 2020 Dec 28. PMID: 33451858; PMCID: PMC7959885): 129-130https://doi.org/10.1016/j.genhosppsych.2020.12.014Crossref PubMed Scopus (6) Google Scholar]. Moreover, compared to controls, only pain worsened significantly more in patients, possibly representing a specific manifestation of the stress related to COVID-19 in FMD patients, while anxiety and depression worsened significantly more in controls. Although with inevitable recall bias, this study suggests that patients with an established diagnosis of FMDs have shown a substantial stability of functional motor, MNMS and GHS during lockdown. In the context of social isolation and home confinement, decreased operational demands and lower psychosocial strains, compared to everyday life, could have prevented worsening of symptoms. Moreover, FMDs are known to be affected by self-attention/monitoring [[3]Brooks S.K. Webster R.K. Smith L.E. Woodland L. Wessely S. Greenberg N. Rubin G.J. The psychological impact of quarantine and how to reduce it: rapid review of the evidence.Lancet. 2020 Mar 14; 395 (Epub 2020 Feb 26. PMID: 32112714; PMCID: PMC7158942): 912-920https://doi.org/10.1016/S0140-6736(20)30460-8Abstract Full Text Full Text PDF PubMed Scopus (9573) Google Scholar] and the diverted attention toward external events due to a global pandemic might have further influenced our findings. We are now facing unpredictable phases of a longstanding pandemic and future studies are needed to elucidate long-term effects of COVID-19 pandemic on FMDs. The following are the Supplementary data to this article: Download .docx (.01 MB) Help with docx files Multimedia component 1 Download .docx (.01 MB) Help with docx files Multimedia component 2

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