Download The Effects of Operant Behavioral Management of Movement

The Effects of Operant Behavioral Management
of Movement Patterns in Individuals Diagnosed
with Conversion Disorder
By:
Vanessa Frangos
Doctorate Candidate
University of New Mexico School of Medicine
Physical Therapy Program
Class of 2013
Advisor:
Beth M. Jones, PT, DPT, OCS
Printed Name
Signature
Date
Approved by the Program in Physical Therapy, School of Medicine,
University of New Mexico in partial fulfillment of the requirements for
the degree of Doctor of Physical Therapy.
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ABSTRACT
Background/Purpose: Conversion disorder is a poorly understood diagnosis that is frequently demonized
and often misinterpreted as malingering. Conversion disorder is not malingering. Instead it is a coping
mechanism of the brain in response to stress. Patients with conversion disorder will present with
neurologic-like symptoms, but demonstrate no organic neurological explaination. The purpose of this study
is to examine the available literature assessing operant behavioral management of conversion disorder, by
physical therapists, in patients presenting with positive motor findings referencing a case study from a
personal clinical experience.
Case Description: The case report describes a 34-year-old male with an initial presentation of symptoms
and diagnosis of Multiple Sclerosis. Mr. E, as he shall henceforth be referenced, was diagnosed with an
MS flare, as well as a urinary tract infection (UTI), prior to admission to the hospital for this episode of care.
Due to impairments in mobility and self-care, along with medical complexity, which include the UTI,
hypertension, and bipolar fisorder, the patient was admitted to inpatient rehabilitation. During his
hospitalization, Mr. E was seen by a neurologist and repeat studies were conducted to confirm the MS
diagnosis. However, the repeat studies revealed that Mr. E had no spinal cord or brain lesions to suggest a
true MS diagnosis, at which point his diagnosis was changed to possible conversion disorder. At the time
of discharge the patient’s symptoms continued to wax and wane, as he was prematurely discharged due to
current insurance policies.
Outcomes: The literature highlights many different treatment options for conversion disorder, which can be
grouped as psychiatrically oriented, modality-oriented, or behaviorally oriented1. However, the pertinent
evidence is considered to be relatively low ranking and includes: expert opinion, case series, and case
reports. Evidence suggests that treatment of conversion disorder is best suited for physical rehabilitation,
in conjunction with psychological treatment, in an inpatient setting. The environment can be effectively
controlled for relational and circumstantial stressors, as well as facilitate a socially acceptable treatment
setting by allied health professionals. Key elements of treatment highlighted are positive and negative
behavioral modification techniques, both of which have proven to have astounding functional outcomes.
However, in situations where behavioral modification techniques are either not practical or effective at
resolving the patients’ symptoms, a variety of other treatments are available.
Discussion/Conclusion: Despite the low levels of evidence, the relevant research does demonstrate that
physical therapy using behavioral modification techniques can provide effective short-term symptom
resolution in patients with positive motor findings, when combined with psychological treatment in an
inpatient setting, in a fairly short period of time.
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TABLE OF CONTENTS
ABSTRACT ................................................................................................................................................... 2
CHAPTER 1: BACKGROUND AND PURPOSE ........................................................................................... 4
CHAPTER 2: CASE STUDY ......................................................................................................................... 6
CHAPTER 3: EVIDENCE BASED ANALYSIS ........................................................................................... 11
LITERATURE REVIEW .................................................................................................................. 13
CHAPTER 4: DISCUSSION / CONCLUSION ............................................................................................. 32
REFERENCES ............................................................................................................................................ 34
APPENDICES ............................................................................................................................................. 35
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CHAPTER 1: BACKGROUND AND PURPOSE
At least one-third of physical symptoms that present for medical care are medically unexplained 2.
Conversion disorder is one such condition and has many definitions, but in general it is the presence of one
or more neurological-like symptoms affecting voluntary motor or sensory function3. The diagnosis was
historically termed ―hysteria‖ as its cause was believed to be only in women and due to a wondering uterus.
However, it was later determined to affect males and females equally and was consequently renamed.
Hysteria became ―conversion disorder‖ based upon the concept that it was triggered by an unconscious
psychological mechanism, which ―converts‖ conflicting aspects of an individual’s mental life into
neurological signs and symptoms 3. Conversion disorder is currently classified under the Diagnostic and
Statistical Manual for psychiatry as a subtype of Somatoform Disorder 4.
Conversion disorder is present in between 11- 48 per 100,000 people in the general population 3.
Typical symptom presentation includes either positive motor findings, like tremor, dystonia, and gait
disturbance; or negative motor findings, like paralysis, or diminished normal movement patterns.
Presentation of these symptoms suggests a neurological condition, however, consistent neurological or
musculoskeletal pathologies or patterns are absent 3. While the cause of conversion disorder is unknown
and the underlying brain mechanisms remain uncertain, current literature suggests that the main focus of
treatment should not be on why the symptoms are occurring but rather on how to resolve them. An initial
treatment hurdle involves overcoming the patients’ anger about being given a psychiatric diagnosis when
they consider their problem to be entirely physical. It is important to remember that conversion symptoms
are not under the patient’s voluntary control and instead, are due to an unconscious expression of a
psychological conflict or need 3.
Potential contributors to motor conversion disorder may include both positive and negative
emotional events, major personally relevant crises or minor repeated daily stressors 5. Based on these
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contributors, it is easily understood why the primary recommendation for treatment is psychologically
founded. However, in recent years numerous reports have suggested the need for physical therapy
management of this disorder, specifically suggesting that psychological treatment alone is not effective 3.
Disability, as a result of conversion disorder, is similar to disability resulting from organic causes in that it
affects occupation and social aspects of the person’s life 6. As a consequence, the person often requires
comprehensive assessment, treatment and rehabilitation.
When the physical symptoms are not addressed, secondary complications like muscle weakness
and joint contracture occur in addition to the already disabling physical symptoms. Appropriate functional
management is vital for alleviating the conversion symptoms and preventing complications from physical
dysfunction 6. While use of physical therapy as treatment for conversion disorder is apparent, it is not
funded by most insurances. Furthermore, it remains unclear the exact approach physical therapist should
take to yield the best outcomes for their patients. A case study of a 34 year-old male with diagnosed
conversion disorder, presenting with positive motor findings, treated by a multidisciplinary team, including
physical therapy, is reported in conjunction with this literature analysis is to answer the following clinical
question: In adults diagnosed with conversion disorder, presenting with positive motor symptoms,
will operant behavioral management of movement patterns, by physical therapists, provide
effective symptom resolution better than psychiatric management alone?
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CHAPTER 2: CASE STUDY
Introduction
The case subject is a 34-year-old male, married, who lives at home with his wife of 13 years, and
their 8-year-old son. Mr. E, as he shall henceforth be referred, was seen for his most recent episode of
care, in the Emergency Department in October 2012, after a fall in which he hit his back on the step of his
wheelchair and his head on the floor. He developed new onset back and neck pain that required medical
attention. Mr. E reported that he was experiencing increased extremity weakness and general decline two
days prior to the fall. Mr. E was diagnosed with a Multiple Sclerosis (MS) flare up, two days prior to
admission by his primary care physician, and subsequently diagnosed and treated for a urinary tract
infection (UTI). Due to impairments in mobility and self-care, along with medical complexity including the
UTI, hypertension, and bipolar disorder, the patient was admitted to the hospital for inpatient rehabilitation.
In rehabilitation, he was treated with a multidisciplinary approach including physiatry, rehabilitation nursing,
physical therapy, occupational therapy, recreational therapy, and social work for discharge planning.
Examination
Mr. E’s past medical history, pertinent to his MS diagnosis, began 3 years ago. In February 2009,
Mr. E was evaluated for complains of headache and symptoms of left-sided weakness and numbness.
Symptoms were reported to be ―purely functional‖ as a MRI scan of the brain and cervical regions were
negative for neurological findings. In June 2009, patient presented again with similar symptoms, noted for
―breakaway weakness‖, and negative MRI findings. Nine months later, March 2010, Mr. E was readmitted
and evaluated for a neurogenic bladder that was subsequently treated with a supra-pubic catheter prior to
discharge. Spinal tap with a CSF MS panel was completed in October 2010, but results continued to be
classified as normal. Symptoms reoccurred, with increased weakness in his lower extremities in November
2011, again with a normal MRI. In March 2012, Mr. E sought treatment from an outside facility. MRI scans
were performed with an Open MRI machine, and several lesions were noted in his brain and spinal cord,
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resulting in an official diagnosis of MS. The open MRI images were requested and reviewed during this
episode of care. Nevertheless repeat studies were conducted by the admitting hospital, including a MRI of
the cervical and brain regions, and a CSF MS panel, all of which yielded normal results with no lesions, or
other indications to explain Mr. E’s symptoms.
Various practitioners completed Mr. E’s physical examinations, all noting non-significant findings
for cardiovascular, pulmonary, and abdominal systems. However, there are notable inconsistencies
between clinicians for the remaining systems to include: musculoskeletal, coordination, sensory, strength,
and reflexes. Furthermore, anatomical patterning was also absent or inconsistent between examinations.
One clinician reports ―gross sensory loss to the bilateral face, upper arms, and lower extremities‖ bilaterally,
severe spasticity with intentional movements, normal resting tone in all extremities, and hyperreflexive
responses, 3+, at the biceps tendon, brachioradialis, and patellar regions bilaterally. Meanwhile the
neurology examination yielded the following findings; sensory loss at approximately T9, but not necessarily
reproducible, more rigid tone than noted in true spasticity, a non cerebellar tremor that improves as he
reaches his endpoint, ―significant break away type weakness‖, noting difficulty evaluating ―true weakness‖
in manual muscle testing, and ―brisk but symmetrical‖ reflexes, 2 to 3+. A psychiatry consult was
requested to explore alternate diagnoses based on inconsistencies in the medical examinations and lack of
physical evidence to indicate a true MS diagnosis.
The Psychiatric Evaluation Team saw Mr. E in November 2012, and per their evaluation, Mr E. was
considered to have risk factors associated with the onset of conversion disorder. Mr E’s father committed
suicide when he was 5 years old, while his mother was pregnant with his younger brother. Her reports
taking his little brother under his wing, and feeling a bit envious of the other children in town whose fathers
would take them to do things, as he did not have a father to do similar things with. He eventually went on
to finish high school, and start college, but shortly there after was diagnosed with Bipolar Disorder,
manifested by a manic episode. Mr. E reports he was admitted to a psychiatric facility for two weeks. He
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currently denies any associated depression, suicidal ideation, or psychosis since. However, he does admit
that he is currently quite frustrated and confused because he recently lost his job, and believed that he was
on short-term disability but recently discovered that he was not. By observation Mr. E has a complex and
unsupportive relationship with his wife, as she was witnessed reprimanding patient about being a ―terrible
father‖ and a ―faker‖.
Evaluation
Mr. E presents with very strange neurological symptoms. He has a tremor, but it is non-cerebellar,
as it actually improves as he reaches his endpoint. There is a similar type of tremor in his upper and lower
extremities, which is fairly gross and seems to fluctuate in intensity and frequency. However, is no clinical
or diagnostic information to suggest that Mr. E has Multiple Sclerosis. On November 1, 2012, Mr. E’s
diagnosis was changed from MS to Conversion Disorder (ICD-9-CM 300.11). The new diagnosis of
conversion disorder is not specifically listed in the Guide to Physical Therapist Practice. Nevertheless, the
symptoms experienced by Mr. E, weakness, balance/strength difficulties, and in-coordination, do fit under
the practice pattern 5A: Primary prevention and risk reduction for loss of balance and falling.
While it was difficult for Mr. E, and his family to accept the new diagnosis, it also brought with it
hope. MS is a progressive disease with a fairly discouraging prognosis, while conversion disorder bears
with it the possibility of a full recovery. While a full recovery is possible, it depends on several variables
including family support, treatment approach, financial availability to pay for treatment, and intrinsic desire
to move away from the ―sick role‖ in life to a healthy one. Mr. E, unfortunately, does not have a strong
support system, his insurance did not cover inpatient physical therapy as a means of treatment, nor did it
include coverage for mental health. He recently lost his job creating an incredible financial strain, which
increased his psychological stress, and possibly even exacerbated his condition. Finally, Mr. E himself is
the only one who can truthfully assess his intrinsic desire to recover. Prognosis for full recovery is poor for
MR. E. However, improvement in functional independence can be improved upon as the activity
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restrictions placed on his life by MS are now lifted. Adaptations were made to his physical therapy
sessions for the remainder of his stay to encourage normal movement and build confidence and self worth.
Interventions
The rehabilitation team treated Mr. E under the MS diagnosis for 16 of his 21-day stay with special
care given to prevent over fatigue, and over heating, while addressing his weakness, balance/strength
difficulties, and in-coordination. Once his diagnosis was changed to conversion disorder, the approach to
physical therapy immediately changed to include; encouragement of gait training with body weight support,
use of a manual wheelchair over his power wheelchair for mobility, and discontinued use of his orthoses.
Positive reinforcement of progress and effort was provided as often as possible to include reinforcement of
the idea that a full recovery is now possible. Unfortunately Mr. E’s insurance did not cover inpatient
treatment for conversion disorder, and he was discharged from the hospital after only 4 days of treatment,
as treatment is not provided on discharge days. Given the complexity of Mr. E’s case, it was recommended
that he seek a second opinion from a multispecialty center such as the Mayo Clinic.
Outcomes
Functionally Mr. E reported upon admission that he was easily fatigued, unable to walk more than
15 steps on most days, and had required a power wheelchair for most mobility for the last year. He wore a
left wrist splint to help with contractures of the left hand, and had bilateral AFO’s, and KAFO’s available as
needed to accommodate varying levels of symptom exacerbation. From a therapy stand point, at the time
of discharge the patient progressed from moderate assistance to supervision with rolling supine to sit and
sit to supine, and minimum assist to supervision for a low pivot transfer from bed/mat table to his
wheelchair. Dependent to modified independent for toileting/toilet transfers, from moderate assistance to
modified independent with bathing and moderate assistance to modified independent with dressing.
Complete scores from Functional Independence Measure (FIM) in Table 1. While Mr. E demonstrates
improved functional mobility at the time of discharge, his full rehab potential was not achieved.
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KEY - Scores Reported
by
Occupational
Therapy
Speech Therapy
Physical Therapy
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CHAPTER 3: EVIDENCE BASED ANALYSIS
Methods
An extensive evidence based literature search was conducted for the literature review. The summary of
the search can be found in Figure 1. Four different databases, which included PubMed®, CINAHL Plus,
Cochrane, and ISI Web of KnowledgeSM, were used in order to search for the answer to the clinical
question. A keyword search was conducted in each database with various combinations of the following
key words: Conversion Disorder, Somatoform Disorder, Behavioral Management, and Positive Motor
Symptoms. Limits were placed on the initial keyword search to include only articles available in full text,
composed in English, and conducted with human subjects. The total number of collected articles was 169.
Of the 169 articles, 45 were selected based on the appropriateness/relevance of the title in relation to the
PICO question. Thirty-seven articles were excluded for one of the following reasons; the topic was not
closely related to the PICO question, or the patient population was not similar. The 8 remaining articles
were reviewed and analyzed using article analysis worksheets (see Appendix A). Each article was then
assigned an Oxford Levels of Evidence and the Physiotherapy Evidence Database (PEDro) score if
appropriate, and summarized in the Literature Review section.
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Figure 1. Articles Included and Excluded for Analysis
PubMed
CINAHL
Cochrane
Web of
Knowledge
Some keywords:
CD or SD;
CD or SD & Behavioral
Management
76
27
3
63
Keyword Search
Keyword Search
One keyword
Keyword Search
One keyword
combination
Title Search
Searched cited
references
1
10
Two Different keyword
combinations & 5 limits
19
combinations & 3 limits
15
Selected based on
appropriateness/
relevance of title
in relation to
PICO question
45
37 Excluded:
Total Articles (Relevant to Topic)
Case
Report
4
+
Literature
Review
2
+
Retrospective
Cohort Study
1
12
Topic not closely
related, Non-similar
population
+
Experimental
Study
1
=
8 Total Studies
-Reviewed
-Analyzed
-Compared to PICO
Literature Review
1. Campo, J. V., & Negrini, B. J. (2000). Case study: Negative reinforcement and behavioral
management of conversion disorder. Journal of the American Academy of Child and Adolescent
Psychiatry, 39(6), 787-790.
Level of Evidence: 5 – Case Report
Pedro Score: N/A
Purpose:
Most researchers have emphasized positive reinforcement for healthy behavior, involving minimizing the
rewards associated with the ―sick role‖ they have taken on. Less well described has been the use of
negative reinforcement. In this case study, completed on a 12-year-old boy, diagnosed with conversion
disorder, after 3 months of persistent right arm pain and immobility. He failed conservative treatment of
ibuprofen and physical therapy. A psychological consult reported significant psychological stressors in the
past year to include the following; his mother was diagnosed with thyroid cancer, his father lost job and was
being treated by a physical therapist for arm pain, he recently received D’s in several subjects at school
and was receiving special education services for reading. The purpose is not clearly stated, however it can
be deduced that the purpose of this paper is to explore negative reinforcement as a component of
behavioral modification techniques to treat his conversion disorder.
Methods:
It was recommended that strict bed rest be maintained when the subject was not performing critical
functions, like using the bathroom, eating, or directly involved in physical therapy, until the symptoms
resolved. The subject was placed on a no stimulation protocol which did not allow reading or television,
with the rationale being that all of his energy needed to be focused on getting well.
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Results:
After several hours of the no stimulation protocol, the subject excitedly informed his parents that he was
regaining some mobility in his arm. His parents were reassuring, but they sent him back to his room to
continue resting. Within 24 hours, he had regained complete mobility of his arm without any pain
Critique/Bottom Line:
This case study is a relatively low level of evidence with an n of 1. Relevant background and research is
presented with emphasis on positive reinforcement effectiveness, with a lack of pertinent research on
negative reinforcement, and effectiveness in children under the age of 18. This case study illustrates how
behavioral interventions, incorporating the use of negative reinforcement, can be just as powerful in treating
conversion disorder as positive reinforcement. It can also be seamlessly implemented at a low cost with a
rehabilitative approach that encourages a return to usual activities and discourages sick-role behaviors.
This treatment approach involves significant familial support to implement, and reinforce compliance.
Typically those with conversion disorder do not have this much support, as the immediate family is almost
always contributors to the initial onset of symptoms. Consequently this approach in the home setting may
be limited based on familial support.
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2. Ness, D. (2007). Physical therapy management for conversion disorder: Case series. Journal of
Neurological Physical Therapy, 31, 30-39.
Level of Evidence: 4 – Retrospective Case Series
Pedro Score: N/A
Purpose:
Healthcare providers may be unaware of the important role of physical therapy in the management of
patients with conversion disorder. While numerous reports have suggested the need for physical therapy
management of this disorders, there is a lack of reports outlining specific physical therapy management
principles or daily treatment progression. The purpose of this series of case reports is to increase
awareness of conversion disorder and to provide interventions by proposing patient management
guidelines.
Methods:
Retrospective chart review of 3 female patients, between the ages of 18-35, all presenting with positive
motor symptoms, carrying a diagnosis of conversion disorder, with a history of abuse and a stressful life
event that preceded the onset of their symptoms. Treatment consisted of 3-5 hours per day, 6-7 days a
week of physical, occupational and speech therapies in an inpatient setting. Behavioral modification
techniques were used throughout all therapies, consisting of ignoring abnormal movement patterns and
reinforcing correct movement patters using feedback and praise. Functional Independence Measure (FIM)
scores were obtained at admission, discharge, and 3-month follow up.
Results:
All three patients demonstrated rapid improvement in function within their 8-day mean length of stay in
inpatient rehabilitation. The mean discharge FIM score of the three patients was 124/126, with a mean gain
in score from admission to discharge of 48 points. All three patients gained complete return of physical
functioning and were symptom free at the 3-month follow up.
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Critique/Bottom Line:
This retrospective case series does not note how the patients were selected (inclusion/exclusion criteria,
how many cases were reviewed etc.) which challenges the internal validity of the study. Furthermore with
an n of 3, the external validity and application to similar populations is also limited. However, due to the
social acceptance of physical therapy intervention vs. psychological treatment alone, the feasibility and
willingness of patients to participate increases the effectiveness of the intervention. It allows the individual
to move away from the ―sick role‖ and to return to healthy roles socially, and physically with gentle guidance
through re-establishment of normal movement patterns. Despite the small sample size and lack of
comparison using just psychological treatment, this intervention is low in cost, can be implemented within
the normal treatment parameters for inpatient rehab, and decreases length of stay with outcomes lasting a
minimum of 3 months.
Table 2: Functional Independence Measure, Ness D.
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3. Oh, D., Yoo, E., & Yi, C. (2005). Case report: physiotherapy strategies for a patient with
conversion disorder presenting abnormal gait. Physiotherapy Research International, 10(3), 164168.
Level of Evidence: 5 – Case Report
Pedro Score: N/A
Purpose:
The objectives of this paper are to describe a structured physiotherapy procedure for a patient with gait
disturbance secondary to conversion disorder and then to report the result of behavior modification
techniques. This article showcases a case report of a 20-year-old male diagnosed with gait disturbances
and balance abnormalities attributed to conversion disorder. Preliminary psychology reports suggested
that the subject was ―mentally immature, and lacked adaptability to different situations‖. At the time of
treatment the subject was 2 months away from recruitment to the Army.
Methods:
The subject was given a full explanation of the functional training process before the start of treatment, and
goals were set. He was not allowed to walk except during functional training. At all other times he was
required to use a wheelchair for mobility. Treatment sessions consisted of individual two hour functional
training twice a day, 5 days a week, and a single hour session on Saturdays, for 5 weeks. The subject’s
abnormal behavior and communication were ignored, and appropriate skills were rewarded with positive
verbal responses. He was rewarded with freedom to walk around the hospital ward when he was able to
ambulate normally.
Results:
The Gait Abnormality Rating Scale (GARS) was used to assess gait function at admission and discharge.
After 5 weeks of functional rehab and gait training, the subject demonstrated an improvement in the total
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GARS score from 22, at initial assessment, to 4 at discharge. He continued to improve for two weeks after
discharge, but continued follow up was unavailable because he was recruited to military service.
Critique/Bottom Line:
Case reports are Level 5 evidence, and lack both external and internal validity. However, the systematic
structured functional rehabilitation, combined with behavior modification techniques utilized in this case
study appear to be helpful in reducing symptoms and restoring normal function in this patient, and could
reasonably be applied to others with similar symptoms. The principle of providing motivation and reducing
reinforcement of abnormal movement is a cost effective and powerful way to encourage a transition back to
a ―healthy‖ role in life. Especially, if the patient is already being treated in the inpatient setting, by a
multidisciplinary team.
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4. Rosebush, P., & Mazurek, M. (2011). Treatment of conversion disorder in the 21st century: have
we moved beyond the couch?. Current Treatment Options in Neurology, 13(3), 255-266.
Level of Evidence: 3a - Literature review (not a systematic review)
Pedro Score: N/A
Purpose:
There is no Class I evidence supporting the efficacy of any treatment for conversion disorder; most
information is at the Class IV level— expert opinion, case series, case reports, and open studies. While the
purpose of this study is not clearly stated, one may deduce that the purpose is to evaluate current
treatment options for conversion disorder, their effectiveness, and barriers to treatment, to identify key
elements that increase the success of treatment.
Methods:
Relevant information from current literature was cited on psychotherapy, hypnotherapy, narcotherapy or
abreaction, and pharmacotherapy. The method for selecting literature reviewed was not specifically stated.
Results:
Various treatment options are available for treating conversion disorder, however regardless of treatment,
the healthcare provider must be supportive, open-minded, and create a nonjudgmental environment that
will allow in-depth inquiry and exploration. This alleviates the patients suspicion that their physicians
suspect he or she may be consciously feigning symptoms, and allows the patients specific concerns to be
addressed. It is also important to ensure that all appropriate medical and neurologic investigations have
actually been carried out, maintaining an open mind to the possible need for further tests, especially if new
symptoms develop.
Critique/Bottom Line:
While this literature review did not specifically denote the search methods, it does explicitly name numerous
treatment options and relevant research available on the respective treatment option. Regardless of the
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treatment option utilized the key appears to lie with the attitude of the healthcare provider. Treatment
begins with the healthcare provider and their willingness to add conversion disorder as a real possibility to
the differential diagnosis in a timely manner. There is mounting evidence to suggest that patients with an
earlier diagnosis and treatment have a greater chance of reversal of symptoms regardless of the treatment.
This article suggests that goals of the diagnostic assessment should include identification of the
psychosocial circumstances in which the conversion symptoms first occurred and then determine which
patients are likely to benefit from psychological exploration and insight-oriented psychotherapy as opposed
to more physically based interventions and modalities such as physiotherapy, deep breathing and
relaxation techniques. There are a variety of treatment options available to treat conversion disorder based
on the individual needs of the patient. Selecting the correct treatment approach may effect the outcome
and prognosis.
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5. Speed, J. (1996). Behavioral management of conversion disorder: Retrospective study. Archives
of Physical Medicine and Rehabilitation, 77, 147-154.
Level of Evidence: 2b – Retrospective case series
Pedro Score: N/A
Purpose:
Physiatrists have seen patients with conversion disorder for years during the initial evaluation stages due to
the nature of the disorder and the corresponding gait and functional deficits. However, it is only recently
that physiatrists have been allowed to continue treating patients post diagnosis of conversion disorder.
Typically when organic causes of the symptoms have been ruled out patients are referred to psychiatry.
The purpose of this study is to assess whether operant behavioral treatment of conversion disorder by
physical therapists provides effective and durable symptom resolution, and to evaluate the prognostic value
of duration of symptoms, as to the time required to effect symptom resolution.
Methods:
A retrospective case series investigation was conducted on the first 10 patients, seen by the author, for gait
abnormalities secondary to diagnosed conversion disorder. All patients were treated with behavioral
modification techniques to include confinement to a wheelchair at all times when not directly involved in
therapy, no correction or mention of abnormal gait patterns, and consistent copious positive reinforcement
from all members of the interdisciplinary therapy team. Subjects were then evaluated monthly for 7 to 36
months as available. One subject was unavailable immediately after discharge, thus follow up reports were
not feasible. Furthermore, the study reviewed 18 articles and summarized their findings regarding various
treatment approaches for conversion disorder.
Results:
All 10 subjects made significant gains in FIM gait scores demonstrating effectiveness of behavior treatment
of conversion disorder. However, treatment effect was only effective over long periods of time for 7 of the 9
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patients available for follow up.
Critique/Bottom Line:
Limitations of this study include its retrospective, non-blinded design, and the fact that different observers
collected FIM ambulation scores. Follow-up times were unable to be standardized and sample size and
lack of a control group are obvious weaknesses. However, the conclusions drawn from the data appear
valid. At least initially, physical therapy intervention using behavior modification techniques can greatly
improve functional independence and normalize gait patterns in a relatively short inpatient rehabilitation
stay when paired with a multidisciplinary approach.
22
6. Sumathipala , A. (2007). What is the evidence for the efficacy of treatments for somatoform
disorders? A critical review of previous intervention studies. Psychosomatic Medicine, 69, 889-900.
Level of Evidence: 1A – SR of SR’s and RCT’s
Pedro Score: N/A
Purpose:
Patients presenting with medically unexplained symptoms to include all functional problems, rather than
just the sub-groups meeting the operational criteria for somatization disorder, conversion disorder, or
symptoms syndromes, were identified for review. This review attempted to answer the question; what is
the highest level of evidence available for the efficacy of pharmaceutical and non-pharmaceutical
interventions for patients with medically unexplained symptoms and where have these studies been carried
out? The aim was to identify the gaps and then to report any recent advances made since the last
systematic review.
Methods:
An extensive literature review was conducted using electronic databases to include: Cochrane library
databases (up to 2007), Medline (1966 –2007), PsychINFO (1974 –2006), and EMBASE (1980 –2007).
The following key words were used first individually in the abstract, key words, and title: ―medically
unexplained symptoms,‖ ―somatisation,‖ ―somatization,‖ then in combination with psychological therapies,
cognitive behavior therapy, pharmacological therapies, management, therapy, drug therapy, and
antidepressants, and ―somatoform disorders‖. To ensure a comprehensive review, search for literature was
supplemented by examining the reference lists of the papers generated from the original searches.
Inclusion criteria included Systematic Reviews (SR) and Randomized Controlled Trails (RCT) of
psychological, pharmacological, or any other type of intervention involving an adult, with defined medically
unexplained symptoms, written in English. Articles were excluded for the following reasons: duplicates,
23
SR’s or RCT’s exclusively on symptom syndromes (irritable bowel syndrome or fibromyalgia), and studies
focusing on children or adolescents.
Results:
Search results from Medline, PsychINFO, and EMBASE did not yield any suitable SR’s. The Cochrane
Library yielded 13 relevant SR abstracts, six of which were potentially relevant and were studied in detail.
Search results from all 4 databases yielded 108 RCT abstracts, 14 of which were selected for this review.
Five systematic reviews have shed light on the use of cognitive behavioral therapy, showing varying
success in the management of patients with medically unexplained symptoms, while only one systematic
review on antidepressant medication could be effective in improving outcome, including symptoms and
disability.
Critique/Bottom Line:
The review reveals that two types of interventions, antidepressant medication and cognitive behavioral
therapy are supported by Level I evidence as benefiting patients with medically unexplained symptoms.
There is more Level I evidence for cognitive behavioral therapy compared with other approaches and the
evidence is increasing. Cognitive behavioral therapy seems to be effective in the reduction of a wide range
of physical symptoms and associated mood disturbance, as well as in producing improvements in overall
physical and social functioning. Antidepressants are moderately effective for medically unexplained
symptoms and effect sizes are homogenous across functional syndromes but are associated withdrawal
symptoms and side effects. There are currently no trials comparing antidepressants with cognitive
behavioral therapy.
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7. Tocchio, S. (2009). Treatment of conversion disorder: A clinical and holistic approach. Journal of
Psychosocial Nursing, 47(8), 42-47.
Level of Evidence: 5 – Case Report
Pedro Score: N/A
Purpose:
The author of the article reports treating multiple cases of conversion disorder, typically with behavioral
modification techniques. However, in this case typical treatment techniques were not displaying the same
level of effectiveness demonstrated in prior cases. The purpose of this article is to encourage other
healthcare providers to attempt alternative medicine techniques without cynicism, by showcasing the
success of one patient with conversion disorder while emphasizing the value of nursing as a part of a team
approach.
Methods:
A 19-year-old woman presented to the inpatient rehabilitation unit with a two-year history of medically
unexplained symptoms of spontaneous seizures, paralysis from the mouth down, blindness, inability to
ambulate and vomiting after all attempts at eating. The patient had the diagnosis of conversion disorder
and was treated with a multidisciplinary approach to include psychiatry, and neurologist.
Results:
Behavioral modification with set rules and schedules failed to resolve symptoms in this case. Biofeedback,
meditation and hypnosis were added to the plan of care. Symptoms resolved, and patient regained ability
to ambulate independently prior to discharge.
Critique/Bottom Line:
Every patient with diagnosed conversion disorder will present with various symptoms and respond to
treatments to differently. This particular patient rejected behavioral modification techniques and positive
verbal encouragement stating that it ―increased her level of stress‖ and initiated her symptoms more
25
frequently. It is important to consider these variations and keep an open mind to a variety of treatment
options to include holistic therapies. This study is limited as it is a single case report with limited external
validity. Physical therapy was not specifically mentioned as an element of care in the disciplinary team,
however, biofeedback is a tool Physical Therapists can use to assist in treatment of conversion disorder if
applicable.
26
8. Voon, V., Brezing, C., Gallea, C., Ameli, R., Roelofs, K., LaFrance Jr, W., & Hallett, M. (2010).
Emotional stimuli and motor conversion disorder. Brain, 133, 1526-1536.
Level of Evidence: 2b - Individual cohort study (including low quality RCT; <80% f/up)
Pedro Score: 4/10
Purpose:
Currently there is no way to conclusively diagnose conversion disorder vs. malingering. Literature suggests
a potential role between arousal and conversion disorder that may play a role in modulating motor
networks, resulting in positive motor symptoms. The purpose of this study is to investigate the relationship
between affect, or arousal, and conversion disorder with positive motor symptoms, by investigating
amygdala activity in association with viewing affective stimuli, using an affective task that has been
extensively investigated in healthy volunteers and in patients with psychiatric disorders. The amygdala was
a target of this investigation based on its critical role in modulating motivated attention in preparation for
action, and its possible influence on the supplementary motor area downstream, involved in motor initiation
and non-conscious response inhibition.
Methods:
Patients with motor conversion disorder were recruited from the Human Motor Control Section clinic at the
National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH). Inclusion
criteria included diagnostic confirmation by at least two neurologists and one psychiatrist, no movement
symptoms at rest for the imaging study, movement symptoms not affecting the head or neck, no history of
traumatic brain injury, and 19 years of age or older. Exclusion criteria included having a serious medical or
neurological illness, current major depression, panic disorder, post-traumatic stress disorder, substance
abuse or other major affective or psychotic disorders, being on antidepressants and contraindications for
MRI. Functional Magnetic Resonance Imaging (fMRI) study using a block design incidental affective task
with fearful, happy, and neutral face stimuli and compared valence contrasts between 16 patients with
27
conversion disorder and 16 age- and gender-matched healthy volunteers recruited from the NIH healthy
volunteer database.
Results:
Behaviorally, there was no difference in reaction time between patients with motor conversion disorder and
healthy volunteers and there was no difference in amygdala activity when the neutral condition was
compared between patients with motor conversion disorder and healthy volunteers. However, imaging did
reveal that patients with motor conversion disorder had greater right amygdala activity compared to healthy
volunteers when exposed to happy and fearful stimuli. There was also a significant positive correlation in
the path from the right amygdala to the right supplementary motor area during both the happy and the
fearful conditions. Thus it can be concluded that motor conversion disorder is characterized by greater
amygdala activity to arousal and potential impairments in habituation to arousing stimuli.
Critique/Bottom Line:
While this article does not specifically address physical therapy intervention to treat conversion disorder, it
does provide a way to more conclusively diagnosis conversion disorder. More conclusive diagnosis will
allow for better, higher level evidence to be conducted on patients with MRI studies to confirm their
diagnosis, as well as encourage further research towards biological or psychological treatments targeting
arousal as an alternative form of treatment for conversion disorder.
28
Table 2. Results / Article Summaries
#
1
Study
&
Origin
Campo, J.V.
and Negrini,
B.J.
(2000)
Oxford
Level of
Evidence
Pedro
Score
5
N/A
The purpose is not clearly
stated, however it can be
deduced that the purpose of
this paper is to explore
negative reinforcement as a
component of behavioral
treatment of conversion
disorder.
Amount of upper
extremity
movement and
pain as
reported/demonstr
ated by case
subject.
Full resolution of symptoms with in 24 hours.
4
N/A
The purpose of this series of
case reports is to increase
awareness of conversion
disorder and to provide
interventions by proposing
patient management
guidelines.
Functional
Independence
Measure (FIM)
taken at
- Admission
- Discharge
- 3 Month
Follow-up
All three patients gained complete return of
physical functioning and were symptom free at
three-month follow-up.
To describe a structured
physiotherapy procedure for a
patient with gait disturbance
secondary to conversion
disorder and report the result
of treatment.
Gait Abnormality
Rating Scale
(GARS)
Significant functional gains were
achieved with a improvement in total
GARS score, with significant gains in
general and lower extremity function.
Gains continued to be made after the
conclusion of therapy for two weeks
after. Continued follow up was
unavailable as subject was recruited
to military service.
US
Ness, D.
(2007)
2
US
Oh, D.W., et. al.
(2005)
3
Korea
5
N/A
Purpose of
Study
Outcome
Measures
29
Results
Accept
Results to
Answer
Clinical
Question
Yes
Yes
Statistical significance cannot be determined
based on study design, but clinical significance
is possible due to low costs to implement and
good functional gains in a short period of time.
Yes
4
Rosebush, P.I.,
and Maxurek,
M.F.
(2011)
3a
N/A
The purpose of this study is not
clearly stated. One may
deduce that the purpose is to
evaluate current treatment
options for CD, their
effectiveness, barriers to
treatment, and identify key
elements that increase
success of treatment.
Current literature,
and its evaluation
of specific
treatment options
It is important to create a supportive, openminded, and nonjudgmental environment that
will allow in-depth inquiry and exploration, in
which the patients concerns that doctors
suspect he or she may be consciously feigning
symptoms can be addressed.
It is also important to ensure that all
appropriate medical and neurologic
investigations have actually been carried out,
maintaining an open mind to the possible need
for further tests, especially if new symptoms
develop
Yes
Speed, J.
(1996)
2b
N/A
To assess whether operant
behavioral treatment of
conversion disorder provides
effective and durable symptom
resolution, and to evaluate the
prognostic value of duration of
symptoms, as to the time
required to effect symptom
resolution.
Functional
Independence
Measure (FIM)
Ambulation Score
At least initially, physical therapy intervention
using behavior modification techniques, can
greatly improve functional independence and
normalize gait patterns in a relatively short
inpatient rehabilitation stay when paired with a
multidisciplinary approach.
Yes
Sumathipala, A.
(2007)
1A
N/A
This review attempted to
answer the question, what is
the highest level of evidence
available for the efficacy of
pharmaceutical and nonpharmaceutical interventions
for patients with MUS and
where have these studies been
carried out? The aim was to
identify the gaps and then to
report any recent advances
made since the last systematic
review.
Primary outcomes
were physical
symptoms,
psychological
distress studies, or
functional status
but some had
more than one
primary outcome
There is more level I evidence for CBT
compared with other approaches and the
evidence is increasing. CBT seems to be
effective in the reduction of a wide range of
physical symptoms and associated mood
disturbance, as well as in producing
improvements in overall physical and social
functioning.
Yes
Canada
5
6
London
30
Tocchino, S.L.
7
5
N/A
The stated purpose of this
article is to encourage others
by describing the success that
psychiatry and alternative
medicine can offer to patients
with conversion disorder and to
emphasize the value of nursing
as a part of that team.
Symptom
resolution by
observation, and
use of a device for
ambulation.
2b
4/10
To investigate the relationship
between affect or arousal and
conversion disorder with
positive motor symptoms by
investigating amygdala activity
in association with viewing
affective stimuli.
Functional MRI
during neutral,
fearful and happy
conditions
/stimulus.
(2009)
Voon, V. et. al.
(2010)
8
US
Reaction time to
affective
conditions
Beck Depression
Inventory (BDI)
and Beck Anxiety
Inverntory (BAI)
scores
31
Every patient with diagnosed Conversion
Disorder will present with various symptoms
and respond to treatments to differently. This
particular patient rejected behavioral
modification techniques and positive verbal
encouragement stating that it increased her
level of stress and initiated her symptoms
more frequently. It is important to consider
these variations and keep an open mind to a
variety of treatment options to include holistic
therapies.
Patients with motor conversion disorder had
greater right amygdala activity compared to
healthy volunteers when exposed to happy
and fearful stimuli, with no difference in
amygdala activity when the neutral condition
was compared between groups.
No
No
CHAPTER 4: DISCUSSION
The majority of the research conducted on conversion disorder, or similar medically unexplained
symptoms, are low quality articles with the majority of literature composed based on case reports.
However, the research is effective in describing the types of treatments available and currently being
utilized in various fields of practice. Treatment options include psychiatry, pharmacologically
(antidepressants, antianxiety), biofeedback, and behavioral modification therapy by a variety of
practitioners. Each treatment has proven to be effective to some extent, at least initially. However, follow
up studies are also limited.
Conversion disorder is a complex and variable diagnosis that is difficult to diagnosis conclusively,
arduous for some practitioners to assign and treat without bias, and even more laborious to conduct high
quality research on. This is an unfortunate truth as many insurance companies assign higher value to better
quality studies with long term follow up to fully back a treatment practice. In the case of Mr. E, he was
treated for 23 days in the inpatient setting under the false diagnosis and limited treatment intensity of MS.
When he was re-diagnosed it was only a matter of days before his insurance benefits were removed and
he was prematurely discharged prior to reaching his full rehab potential due to inadequate funds.
According to Ness, Mr. E, pending an initial diagnosis of conversion disorder and the use of behavioral
modification techniques, could have made a full functional recovery of at least Modified Independent on his
FIM’s in just 9 days3.
CHAPTER 5: CONCLUSION/ BOTTOM LINE
Despite psychiatric care named as the current primary intervention for conversion disorder, the
patient’s physical symptoms are still just as real and relevant as they were prior to the official diagnosis.
Rosebush suggests that the foremost barrier to treatment is the failure of physicians to include conversion
disorder into differential diagnosis in a timely manner4. The delay of the initial diagnosis can affect the
prognosis of the patient as they become more and more convinced that the symptoms are in fact physical,
32
and that their medical team has simply given up. One significant delay in diagnosis is due to the inability to
conclusively distinguish conversion disorder from malingering. The message patients often hear from their
medical team is, ―I don’t really believe your signs and symptoms and, because there is nothing wrong, I’m
sending you to a psychiatrist‖4. However because treatment strategies for conversion disorder can also be
applied to patients suspected of malingering, with similar outcomes, it can be approached with the same
behavioral modification techniques, and presented in a way that is less threatening to the patient. The
presentation of the new diagnosis is absolutely critical to facilitating a successful recovery.
It is important to reassure the patient that their symptoms are real, and are not under voluntary
control, that this is the best diagnosis for their symptoms because it also comes with the chance to recovery
fully, and that the medical team is still actively seeking the best path to assist in recovery. A
multidisciplinary approach, in an inpatient setting, to include physical therapy, is not just a more socially
accepted intervention; it is also justifiable based on evidence for effective symptom resolution. Because
patients with conversion disorder place a heavy burden on the health system due to their disproportionate
consumption of health resources, effective symptom resolution is critical2. Most insurance companies do
not cover an inpatient stay for treatment of conversion disorder, as demonstrated in Mr. E’s case.
Nevertheless, physical therapy combined with behavioral modification techniques, using both positive and
negative reinforcement, is a cost effective, socially accepted, and low risk form of treatment for conversion
disorder.
33
REFERENCES
1. Speed, J. (1996). Behavioral management of conversion disorder: Retrospective study. Archives of
Physical Medicine and Rehabilitation, 77, 147-154.
2. Sumathipala , A. (2007). What is the evidence for the efficacy of treatments for somatoform
disorders? A critical review of previous intervention studies. Psychosomatic Medicine, 69, 889-900.
3. Ness, D. (2007). Physical therapy management for conversion disorder: Case series. Journal of
Neurological Physical Therapy, 31, 30-39.
4. Rosebush, P., & Mazurek, M. (2011). Treatment of conversion disorder in the 21st century: have
we moved beyond the couch?. Current Treatment Options in Neurology, 13(3), 255-266
5. Voon, V., Brezing, C., Gallea, C., Ameli, R., Roelofs, K., LaFrance Jr, W., & Hallett, M. (2010).
Emotional stimuli and motor conversion disorder. Brain, 133, 1526-1536.
6. Oh, D., Yoo, E., & Yi, C. (2005). Case report: physiotherapy strategies for a patient with conversion
disorder presenting abnormal gait. Physiotherapy Research International, 10(3), 164-168.
7. Campo, J. V., & Negrini, B. J. (2000). Case study: Negative reinforcement and behavioral
management of conversion disorder. Journal of the American Academy of Child and Adolescent
Psychiatry, 39(6), 787-790.
8. Tocchio, S. (2009). Treatment of conversion disorder: A clinical and holistic approach. Journal of
Psychosocial Nursing, 47(8), 42-47.
34
APPENDICES
Appendix A. Evidence Based Article Appraisal Worksheets
Appendix A.1 Intervention – Evidence Appraisal Worksheet
Citation:
Campo, J. V., & Negrini, B. J. (2000). Case study: Negative reinforcement and behavioral
management of conversion disorder. Journal of the American Academy of Child and Adolescent
Psychiatry, 39(6), 787-790.
Level of Evidence (Oxford scale): 5 – Case Report
Is the purpose and background information sufficient?
Appraisal Criterion
Reader’s Comments
Study Purpose
The purpose is not clearly stated, however it can be
deduced that the purpose of this paper is to explore
negative reinforcement, as a component of
behavioral treatment of conversion disorder.
Stated clearly?
Usually stated briefly in abstract and in greater
detail in introduction. May be phrased as a question
or hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider
how the study can be applied to PT and/or your own
situation. What is the purpose of this study?
Literature
Most researchers have emphasized positive
reinforcement for healthy behavior, involving
minimizing the rewards associated with the sick
role. Less well described has been the use of
negative reinforcement. Negative reinforcement
produces an increase in the frequency of a desired
response by removing an aversive event
immediately after the desired response has been
performed
Relevant background presented?
A review of the literature should provide background
for the study by synthesizing relevant information
such as previous research and gaps in current
knowledge, along with the clinical importance of the
topic. Describe the justification of the need for this
study
35
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
N/A. Single subject case study.
 Discuss possible threats to internal
validity in the research design. Include:
 Assignment
 Attrition
 History
 Instrumentation
 Maturation
 Testing
 Compensatory Equalization of
treatments
 Compensatory rivalry
Are the results of this therapeutic trial valid?
Appraisal Criterion
Reader’s Comments
1. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this
assignment process for the
study’s results?
2. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
3. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
differences existed?
b. Do you consider these
differences a threat to the
research validity? How might the
differences between groups
affect the results of the study?
N/A. Single subject case study.
N/A. Single subject case study.
N/A. Single subject case study.
36
4. Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
5. Did the investigators know to which
treatment group subjects were
assigned?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
6. Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
7. Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
8. Did all the subjects originally enrolled
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the authors
do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
9. Were all patients analyzed in the groups
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Yes, single subject case study.
Yes, single subject case study.
N/A. Single subject case study.
No follow up was completed.
The only subject involved completed the study.
N/A. Single subject case study.
37
Are the valid results of this RCT important?
Appraisal Criterion
Reader’s Comments
10. What were the statistical findings of this There is no statistical analysis completed for this
study?
case study.
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
here
11. What is the meaning of these statistical
N/A
findings for your patient/client’s case?
What does this mean to your practice?
12. Do these findings exceed a minimally
N/A
important difference? Was this brought
up or discussed?
a. If the MCID was not met, will you
still use this evidence?
Can you apply this valid, important evidence about an intervention in caring for your patient/client?
What is the external validity?
Appraisal Criterion
Reader’s Comments
13. Does this intervention sound appropriate
for use (available, affordable) in your
clinical setting? Do you have the
facilities, skill set, time, 3rd party
coverage to provide this treatment?
This treatment approach involves significant familial
support to implement, and typically those with CD
do not have this much support, as the immediate
family is almost always contributors to the initial
onset of symptoms. Consequently this approach
may be limited based on familial support.
However it is cost effective, and not time intensive
from the physical therapy stand point.
14. Are the study subjects similar to your
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
I do not typically work with pediatric cases, but
based on the conversion disorder diagnosis and the
common presence of CD in adolescence it is not
unlikely to see similar subjects in my setting.
38
15. Do the potential benefits outweigh the
potential risks using this intervention
with your patient/client?
The subject was still able to complete his basic
needs of eating and toileting, as well as get
supplementary mobility exercises and treatment
with physical therapy preventing unnecessary
atrophy and decreased ROM of uninvolved limbs.
In the event that the intervention was not yielding
powerful results within a week or so it would be
necessary to try a different approach to avoid
unnecessary deconditioning.
16. Does the intervention fit within your
patient/client’s stated values or
expectations?
a. If not, what will you do now?
Yes. The subject presented for treatment with
expectations to get better.
17. Are there any threats to external validity
in this study?
The main threat to external vailidity is the low
sample size which prevents the results from being
applicable to a larger population.
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score
N/A
Summarize your findings and relate this back to
clinical significance
Behavioral interventions incorporating the use of
negative reinforcement can be just as powerful in
treating conversion disorder, as positive
reinforcement. It can also be easily implemented at
a low cost in addition to a rehabilitative approach
that encourages a return to usual activities and
discourages sick-role behaviors.
39
Appendix A.2 Intervention – Evidence Appraisal Worksheet
Citation:
Ness, D. (2007). Physical therapy management for conversion disorder: Case series. Journal of
Neurological Physical Therapy, 31, 30-39.
Level of Evidence (Oxford scale): 4 – Retrospective Case Series
Is the purpose and background information sufficient?
Appraisal Criterion
Reader’s Comments
Study Purpose
The purpose of this series of case reports is to
increase awareness of conversion disorder and to
provide interventions by proposing patient
management guidelines.
Stated clearly?
Usually stated briefly in abstract and in greater
detail in introduction. May be phrased as a question
or hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider
how the study can be applied to PT and/or your own
situation. What is the purpose of this study?
Literature
The incidence of individuals with conversion
disorder has been reported to be between 11 and
48 per 100,000 people in the general population.
Conversion disorder can occur in individuals of any
age, race, ethnic, or social background. Some
studies report a higher frequency in women than in
men other studies have found no difference
between the sexes. There tends to be a higher
incidence of first-degree relatives with psychiatric or
medical disorders in individuals with conversion
disorder. An association also has been found with
conversion disorder and a history of sexual or
physical abuse. Recent work suggests
psychological treatment alone is not effective in
treating conversion disorder
Relevant background presented?
A review of the literature should provide background
for the study by synthesizing relevant information
such as previous research and gaps in current
knowledge, along with the clinical importance of the
topic.
Describe the justification of the need for this study
40
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
 Discuss possible threats to internal
validity in the research design. Include:
 Assignment
 Attrition
 History
 Instrumentation
 Maturation
 Testing
 Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression
Study design: retrospective chart review.
The article does not note how the patients were
selected (inclusion/exclusion criteria, how many
cases were reviewed etc. ) and this significantly
challenges the internal validity of the study.
Are the results of this therapeutic trial valid?
Appraisal Criterion
Reader’s Comments
1. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this
assignment process for the
study’s results?
2. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
3. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
No. Retrospective case study, random assignment
into groups does not apply.
Researchers were not blinded as to the selection of
cases to be reviewed.
Cases selected were similar with positive motor
findings and diagnoses of CD, and all were treated
similarly.
41
4.
5.
6.
7.
differences existed?
b. Do you consider these
differences a threat to the
research validity? How might the
differences between groups
affect the results of the study?
Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
Did the investigators know to which
treatment group subjects were
assigned?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
No control studies reviewed.
No. Retrospective case study, blinding subjects
does not apply.
Investigators were not blinded to treatment applied
when assessing outcomes.
No control cases included.
Subject follow up time was 3 months, and is
sufficient to answer short-term efficacy of treatment.
Future studies should evaluate treatment technique
and long term efficacy of treatment to determine
benefits to decreasing cost in health care
8. Did all the subjects originally enrolled
Unable to determine based on information given.
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the authors
do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
9. Were all patients analyzed in the groups No control cases included.
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
42
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Are the valid results of this RCT important?
Appraisal Criterion
Reader’s Comments
10. What were the statistical findings of this
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
here
No statistical data presented.
11. What is the meaning of these statistical
N/A
findings for your patient/client’s case?
What does this mean to your practice?
12. Do these findings exceed a minimally
N/A
important difference? Was this brought
up or discussed?
a. If the MCID was not met, will you
still use this evidence?
Can you apply this valid, important evidence about an intervention in caring for your patient/client?
What is the external validity?
Appraisal Criterion
Reader’s Comments
13. Does this intervention sound appropriate
for use (available, affordable) in your
clinical setting? Do you have the
facilities, skill set, time, 3rd party
coverage to provide this treatment?
14. Are the study subjects similar to your
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
Yes. While it is not an exceptional study the
intervention is low cost, time effective, and
correlates well with current PT interventions.
Yes. In the neurological setting it is not uncommon
to run across medically unexplained conditions or
specifically classified conversion disorder.
43
15. Do the potential benefits outweigh the
potential risks using this intervention
with your patient/client?
Intervention has no foreseeable associated risks. In
fact, it would be worse to withhold physical therapy
intervention in the event of misdiagnosis, in which a
person without CD and a undiagnosed neurologic
condition, than to treat CD and continue to rule out a
true neurological condition.
16. Does the intervention fit within your
patient/client’s stated values or
expectations?
a. If not, what will you do now?
Yes. Patients with true conversion disorder typically
do want to get better.
17. Are there any threats to external validity
in this study?
Yes. Due to the nature of conversion disorder, the
difficulty diagnosing it, and the inability to truly
distinguish it from malingering, as well as, the poor
design specification and sample size.
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score
N/A
Summarize your findings and relate this back to
clinical significance
Physical therapy is a more socially accepted
intervention or cure to their illness, than
psychological treatment alone. It allows the
individual to move away from the ―sick role‖ and to
return to healthy roles socially, and physically with
gentle guidance through re-establishment of normal
movement patterns. Despite the small sample size
and lack of comparison using just psychological
treatment, this intervention is low in cost, can be
implemented within the normal treatment
parameters for inpatient rehab, and decreases
length of stay with lasting effects.
44
Appendix A.3 Intervention – Evidence Appraisal Worksheet
Citation:
Oh, D., Yoo, E., & Yi, C. (2005). Case report: physiotherapy strategies for a patient with conversion
disorder presenting abnormal gait. Physiotherapy Research International, 10(3), 164-168.
Level of Evidence (Oxford scale): 5 – Case Report
Is the purpose and background information sufficient?
Appraisal Criterion
Reader’s Comments
Study Purpose
The objectives of this paper are to describe a
structured physiotherapy procedure for a patient
with gait disturbance secondary to conversion
disorder and then to report the result of treatment.
Stated clearly?
Usually stated briefly in abstract and in greater
detail in introduction. May be phrased as a question
or hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider
how the study can be applied to PT and/or your own
situation. What is the purpose of this study?
Literature
Relevant background presented?
A review of the literature should provide background
for the study by synthesizing relevant information
such as previous research and gaps in current
knowledge, along with the clinical importance of the
topic.
Describe the justification of the need for this study
Yes, especially relevant to the application of
physical therapy as a primary treatment to address
physical symptoms of CD. The study states that the
treatment of conversion disorder is well suited to the
physical rehabilitation setting because of the
potential for successful environmental control, and
because of the experience of the multidisciplinary
team in treating analogous organic conditions with
similar types of functional losses
45
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
N/A. Single subject case study.
 Discuss possible threats to internal
validity in the research design. Include:
 Assignment
 Attrition
 History
 Instrumentation
 Maturation
 Testing
 Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression
Are the results of this therapeutic trial valid?
Appraisal Criterion
Reader’s Comments
1. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this
assignment process for the
study’s results?
2. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
3. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
differences existed?
b. Do you consider these
differences a threat to the
N/A. Single subject case study.
N/A. Single subject case study.
N/A. Single subject case study.
46
4.
5.
6.
7.
8.
9.
research validity? How might the
differences between groups
affect the results of the study?
Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
Did the investigators know to which
treatment group subjects were assigned
?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
Did all the subjects originally enrolled
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the authors
do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
Were all patients analyzed in the groups
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Yes, single subject case study.
Yes, single subject case study.
N/A. Single subject case study.
Follow up was limited to two weeks due to
recruitment to the military.
The only subject involved completed the study.
N/A. Single subject case study.
47
Are the valid results of this RCT important?
Appraisal Criterion
Reader’s Comments
10. What were the statistical findings of this There is no statistical analysis completed for this
study?
case study.
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
here
11. What is the meaning of these statistical
N/A
findings for your patient/client’s case?
What does this mean to your practice?
12. Do these findings exceed a minimally
N/A
important difference? Was this brought
up or discussed?
a. If the MCID was not met, will you
still use this evidence?
Can you apply this valid, important evidence about an intervention in caring for your patient/client?
What is the external validity?
Appraisal Criterion
Reader’s Comments
13. Does this intervention sound appropriate
for use (available, affordable) in your
clinical setting? Do you have the
facilities, skill set, time, 3rd party
coverage to provide this treatment?
Yes, I believe that inpatient rehab is the best place
to treat CD due to environmental control, and
because of the experience of the multidisciplinary
treatment in treating analogous organic conditions
with similar types of functional losses.
Yes. In the neurological setting it is not uncommon
to run across medically unexplained conditions or
specifically classified conversion disorder.
14. Are the study subjects similar to your
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
15. Do the potential benefits outweigh the
potential risks using this intervention
with your patient/client?
The potential benefit of treatment is full recovery
where the risk of not using this intervention would
be a possible increase in muscle weakness and
joint contracture.
48
16. Does the intervention fit within your
patient/client’s stated values or
expectations?
a. If not, what will you do now?
Yes. Patients with true conversion disorder typically
do want to get better.
17. Are there any threats to external validity
in this study?
Yes. Due to the nature of conversion disorder, the
difficulty diagnosing it, and the inability to truly
distinguish it from malingering, it is difficult to
ascertain that the treatment is the determining factor
in recovery.
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score
N/A
Summarize your findings and relate this back to
clinical significance
The systematic structured functional rehabilitation,
combined with behavior modification techniques
utilized in this case study appear to be helpful in
reducing symptoms and restoring normal function in
this patient, and could reasonably be applied to
others with similar symptoms. The principle of
providing motivation and reducing reinforcement of
abnormal movement, which contributes to the
disabled state, is a cost effective and powerful way
to encourage return to the ―healthy‖ role in life.
49
Appendix A.4 Intervention – Evidence Appraisal Worksheet
Citation:
Rosebush, P., & Mazurek, M. (2011). Treatment of conversion disorder in the 21st century: have
we moved beyond the couch? Current Treatment Options in Neurology, 13(3), 255-266.
Level of Evidence (Oxford scale): 3a - Literature review (not a systematic review)
Is the purpose and background information sufficient?
Appraisal Criterion
Reader’s Comments
Study Purpose
Stated clearly?
Usually stated briefly in abstract and in greater
detail in introduction. May be phrased as a question
or hypothesis.
The purpose of this study is not clearly stated. One
may deduce that the purpose is to evaluate current
treatment options for CD, their effectiveness,
barriers to treatment, and identify key elements that
increase success of treatment.
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider
how the study can be applied to PT and/or your own
situation. What is the purpose of this study?
Literature
There is no Class I evidence supporting the efficacy
of any treatment for CD; most information is at the
Class IV level— expert opinion, case series, case
reports, and open studies. CD patients present
with a wide range of neurologic signs and symptoms
and are typically referred to psychiatry after
investigations fail to yield a medical or neurologic
diagnosis that can adequately explain their
disability. The cause of CD is unknown and the
underlying brain mechanisms remain uncertain.
Relevant background presented?
A review of the literature should provide background
for the study by synthesizing relevant information
such as previous research and gaps in current
knowledge, along with the clinical importance of the
topic.
Describe the justification of the need for this study
50
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
 Discuss possible threats to internal
validity in the research design. Include:
 Assignment
 Attrition
 History
 Instrumentation
 Maturation
 Testing
 Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression
No. Relevant information from current literature was
cited on psychotherapy, hypnotherapy,
narcotherapy or abreaction, and pharmacotherapy.
However, the method for selecting literature
reviewed was not specifically stated. At the end of
the article it did yield the following disclosure
statement: No potential conflicts of interest relevant
to this article were reported.
Are the results of this therapeutic trial valid? N/A
Appraisal Criterion
Reader’s Comments
1. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this
assignment process for the
study’s results?
2. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
3. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
N/A
N/A
N/A
51
4.
5.
6.
7.
8.
9.
differences existed?
b. Do you consider these
differences a threat to the
research validity? How might the
differences between groups
affect the results of the study?
Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
Did the investigators know to which
treatment group subjects were assigned
?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
Did all the subjects originally enrolled
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the authors
do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
Were all patients analyzed in the groups
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
N/A
N/A
N/A
N/A
N/A
N/A
52
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Are the valid results of this RCT important?
Appraisal Criterion
Reader’s Comments
10. What were the statistical findings of this
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
here
N/A
11. What is the meaning of these statistical
N/A
findings for your patient/client’s case?
What does this mean to your practice?
12. Do these findings exceed a minimally
N/A
important difference? Was this brought
up or discussed?
a. If the MCID was not met, will you
still use this evidence?
Can you apply this valid, important evidence about an intervention in caring for your patient/client?
What is the external validity?
Appraisal Criterion
Reader’s Comments
13. Does this intervention sound appropriate
for use (available, affordable) in your
clinical setting? Do you have the
facilities, skill set, time, 3rd party
coverage to provide this treatment?
The resulting information is appropriate for any
practitioner who encounters a patient with CD. The
focus is more on the attitude of the practitioner and
recognizing the validity of the diagnosis than the
treatment.
14. Are the study subjects similar to your
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
Yes. They either have conversion disorder,
malingering, factitious disorder in which all would be
treated similarly.
53
15. Do the potential benefits outweigh the
potential risks using this intervention
with your patient/client?
Absolutely. All patients could benefit from a
practitioner who is supportive, open-minded, and
non judgmental.
16. Does the intervention fit within your
patient/client’s stated values or
expectations?
a. If not, what will you do now?
Yes the values of the patients with diagnosis want to
get better.
17. Are there any threats to external validity
in this study?
Yes, not all treatments will work for everyone with a
diagnosis of CD. The treatment is as individual as
the patient.
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score
N/A
Summarize your findings and relate this back to
clinical significance
Treatment begins with the healthcare provider and
their willingness to add CD as a real possibility to
the differential diagnosis in a timely manner. There
is mounting evidence to suggest that patients with
an earlier diagnosis and treatment have a greater
chance of reversal of symptoms regardless of their
treatment. Goals of the diagnostic assessment
should include identification of the psychosocial
circumstances in which the conversion symptoms
first occurred and a determination of which patients
are likely to benefit from psychological exploration
and insight-oriented psychotherapy as opposed to
more physically based interventions and modalities
such as physiotherapy and deep breathing and
relaxation techniques.
54
Appendix A.5 Intervention – Evidence Appraisal Worksheet
Citation:
Speed, J. (1996). Behavioral management of conversion disorder: Retrospective study. Archives of
Physical Medicine and Rehabilitation, 77, 147-154.
Level of Evidence (Oxford scale): 2b - Retrospective case series
Is the purpose and background information sufficient?
Appraisal Criterion
Reader’s Comments
Study Purpose
The purpose is clearly stated as follows: To assess
whether operant behavioral treatment of conversion
disorder provides effective and durable symptom
resolution, and to evaluate the prognostic value of
duration of symptoms, as to the time required to
effect symptom resolution
Stated clearly?
Usually stated briefly in abstract and in greater
detail in introduction. May be phrased as a question
or hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider
how the study can be applied to PT and/or your own
situation. What is the purpose of this study?
Literature
Relevant background presented?
A review of the literature should provide background
for the study by synthesizing relevant information
such as previous research and gaps in current
knowledge, along with the clinical importance of the
topic.
Describe the justification of the need for this study
Yes. I8 articles were reviewed and summarized
regarding various treatment approaches for CD.
The majority of studies were 1-2 subject case
studies, a relatively low level of evidence.
55
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
 Discuss possible threats to internal
validity in the research design. Include:
 Assignment
 Attrition
 History
 Instrumentation
 Maturation
 Testing
 Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression
Assignment: the first 10 patients diagnosed as
having conversion disorder treated by the author in
an inpatient rehab setting. All patients had CD
diagnosed by a physician other than the author. All
patients had gait abnormalities
Attrition: Retrospective case study. All patients
were evaluated into the group they were assigned.
Exclusion Criteria: clearly stated but no subjects
were excluded based on criteria.
Treatment location: Inpatient rehab
Explanation provided to the patient: A ―tests and
examination established that the brain, spinal cord,
nerves, and muscles were intact, and that the
messages allowing normal muscle movement were
being blocked.‖ It was explained that appropriate
physical therapy can reestablish the normal flow of
messages, and that sometimes certain stressors
can make the problem worse, opening the door to
psychological evaluation of the patient once the
treatment regimen is underway.
Patient was confined to a wheelchair at all times
when not directly involved in physical therapy.
There was no discussion with the patient about their
abnormal gait.
The conversion disorder patient must demonstrate
consistent mastery of one step before proceeding to
the next. Copious praise was given to the patient for
mastery of each step, and no reinforcement was
provided for abnormal movement or gait.
56
OT and Recreational Therapy were used for positive
reinforcement. Psychological intervention began
within a few days after treatment started and was
directed at identifying stressors within the patient’s
life and evaluating the patient’s typical way of
responding to these.
Attrition/Followup: All patients followed after
discharge were reevaluated by the author on an
outpatient basis. In 2 cases, the patient was referred
to a mental health care provider in their own region
for stress management and supportive counseling.
No Control Group was noted.
Are the results of this therapeutic trial valid?
Appraisal Criterion
Reader’s Comments
1. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this
assignment process for the
study’s results?
The first 10 patients diagnosed as having
conversion disorder treated by the author in an
inpatient rehab setting. All patients had CD
diagnosed by a physician other than the author. All
patients had gait abnormalities
2. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
3. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
differences existed?
b. Do you consider these
differences a threat to the
research validity? How might the
differences between groups
There was no blinding. The author was the one
providing the intervention, but the study was done
retrospectively and included the first 10 patients to
meet the criteria, thus the consequences were
minimized from this element.
All patients had a similar diagnosis of CD with gait
abnormalities from a practitioner other than the
author/provider of intervention. There were 5 men
patients and 5 women patients. Age ranged from 19
to 69 years, with a mean of 32.7 years and a
median of 28. Years of education ranged from 10 to
16, with a mean of 13.6. Five subjects were married
and 5 were single. Duration of conversion disorder
57
affect the results of the study?
symptoms ranged from 0.5 to more than
I12 weeks, with a mean duration of symptoms
before onset of treatment of 27.75 weeks, and a
median duration of 12 weeks
4. Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
5. Did the investigators know to which
treatment group subjects were assigned
?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
6. Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
7. Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
8. Did all the subjects originally enrolled
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the authors
do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
9. Were all patients analyzed in the groups
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
The subjects were unaware they were participants
in a study at the time of intervention, thus there
were no consequences regarding blinding of
subjects.
Investigators at the time of the intervention may or
may not have known they would later conduct a
study on the subjects.
There was only an intervention group and yes they
appeared to be managed similarly.
Follow up time was different for each subject.
Subjects were evaluated monthly for anywhere
between 7 and 36 months.
All ten subjects completed the intervention, and one
was lost for follow up information.
All subjects were evaluated in the intervention
group. No control group was utilized.
58
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Are the valid results of this RCT important?
Appraisal Criterion
Reader’s Comments
10. What were the statistical findings of this
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
here
Using a Wilcoxon signed rank test (n = 10). This
demonstrates a significant change in FIM
ambulation scorefrom pretreatment to posttreatment
(p = .002).
11. What is the meaning of these statistical
findings for your patient/client’s case?
What does this mean to your practice?
While behavioral modification therapy can be
effective for resolution of gait abnormalities in
conversion disorder, the lasting effects are not
statistically significant. Furthermore, there is a
significant correlation between the duration of
symptoms prior to treatment and the length of time
required to normalize gait.
To evaluate permanence of treatment effect, n = 9
and (p = .1016)
Duration of symptoms (in wks) against the amount
of time (days) required to attain normal gait. There
is a significantly positive correlation between these
two factors (Spearman correlation coefficient 682. p
= .0296).
The behavioral treatment of conversion disorder
symptoms clearly appears to be effective (in 100%
of this study population), and treatment effect was
maintained over lengthy periods of follow-up in 7 of
9 (78%) patients followed, although this did not
reach statistical significance.
12. Do these findings exceed a minimally
important difference? Was this brought
up or discussed?
a. If the MCID was not met, will you
still use this evidence?
MCID was not reference in article.
59
Can you apply this valid, important evidence about an intervention in caring for your patient/client?
What is the external validity?
Appraisal Criterion
Reader’s Comments
13. Does this intervention sound appropriate
for use (available, affordable) in your
clinical setting? Do you have the
facilities, skill set, time, 3rd party
coverage to provide this treatment?
Behavioral treatment of conversion disorder, based
on the model described by Trieschmann, appears to
be both effective and cost-effective when compared
with other treatments described in the literature.
14. Are the study subjects similar to your
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
Yes the study subjects are similar to my patients.
They are all presenting with gait abnormalities,
some are positive motor findings while others are
negative motor findings.
15. Do the potential benefits outweigh the
potential risks using this intervention
with your patient/client?
Treatment of CD is expensive in general, but not
treating these subjects is not a reasonable option
seeing that many of them are functionally impaired
limiting their ability to work and function in society.
What studies are showing is that treating the
physical symptoms while treating the psychological
symptoms may actually decrease overall health
care costs as well as assist the subject in returning
to a more functional and contributory role in society.
16. Does the intervention fit within your
patient/client’s stated values or
expectations?
a. If not, what will you do now?
Yes as patients with conversion disorder do typically
want to get better, and preferably without the stigma
associated with purely psychological treatment.
17. Are there any threats to external validity
in this study?
Not all patients diagnosed with conversion disorder
actually have conversion disorder. However, I
believe that treating similar diagnoses, to include
malingering, with similar treatment behavioral
modification techniques can yield similar results.
60
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score (see scoring at end of form)
N/A
Summarize your findings and relate this back to
clinical significance
Limitations of this study include its retrospective,
non-blinded design, and the fact that different
observers collected FIM ambulation scores. Followup times were unable to be standardized and
sample size and lack of a control group are obvious
weaknesses. However, the conclusions drawn from
the data appear valid. At least initially, physical
therapy intervention using behavior modification
techniques, can greatly improve functional
independence and normalize gait patterns in a
relatively short inpatient rehabilitation stay when
paired with a multidisciplinary approach.
61
Appendix A.6 Systematic Review – Evidence Appraisal Worksheet
Citation:
Sumathipala , A. (2007). What is the evidence for the efficacy of treatments for somatoform
disorders? a critical review of previous intervention studies. Psychosomatic Medicine, 69, 889-900.
Level of Evidence (Oxford scale): 1A – SR of SR’s and RCT’s
Does the design follow the Cochrane method?
Appraisal Criterion
Reader’s Comments
Step 1 – formulating the question
The term Medically Unexplained Symptom (MUS)
and patients presenting with MUS, to include all
functional problems rather than just the sub-groups
who met the operational criteria for somatization
disorder, conversion disorder, or symptoms
syndromes were identified for review. This review
attempted to answer the question, what is the
highest level of evidence available for the efficacy of
pharmaceutical and non-pharmaceutical
interventions for patients with MUS and where have
these studies been carried out? The aim was to
identify the gaps and then to report any recent
advances made since the last systematic review.
•
•
Do the authors identify the focus of the
review
A clearly defined question should
specify the types of:
• people (participants),
• interventions or exposures,
• outcomes that are of interest
• studies that are relevant to
answering the question
Step 2 – locating studies
 Should identify ALL relevant literature
 Did they include multiple databases?
 Was the search strategy defined and
include:
o Bibliographic databases used as
well as hand searching
o Terms (key words and index
terms)
o Citation searching: reference
lists
o Contact with ‘experts’ to identify
‘grey’ literature (body of
materials that cannot be found
easily through conventional
channels such as publishers)
o Sources for ‘grey literature’
An extensive literature review was conducted using
electronic databases to include: Cochrane library
databases (up to 2007), Medline (1966 –2007),
PsychINFO (1974 –2006), and EMBASE (1980 –
2007). The following key words were used first
individually in the abstract, key words, and title:
―medically unexplained symptoms,‖ ―somatisation,‖
―somatization,‖ then in combination with
psychological therapies, cognitive behavior therapy,
pharmacological therapies, management, therapy,
drug therapy, and antidepressants, and
―somatoform disorders‖. To ensure a
comprehensive review, search for literature was
supplemented by examining the reference lists of
the papers generated from the original searches.
62
Part 3:Critical Appraisal/Criteria for Inclusion
• Were criteria for selection specified?
• Did more than one author assess
the relevance of each report
• Were decisions concerning
relevance described; completed
by non-experts, or both?
• Did the people assessing the
relevance of studies know the
names of the authors,
institutions, journal of
publication and results when
they apply the inclusion criteria?
Or is it blind?
Abstracts eligible for inclusion were systematic
reviews or randomized trials of a psychological,
pharmacological, or any other type of intervention
involving an adult, with patients defined as medically
unexplained symptoms, unexplained symptoms,
somatoform disorders, somatisation, somatization,
functional somatic symptoms, and the abstract was
written in the English language. All abstracts
selected were checked for duplications, which, if
found were excluded. Systematic reviews or RCTs
exclusively on
symptom syndromes, such as irritable bowel
syndrome, chronic fatigue syndrome (CFS), and
fibromyalgia, were excluded. Systematic reviews of
MUS incorporating symptom syndromes, however,
were included. Papers focusing on children and
adolescents were also excluded.
Literature review, this section does not apply
Part 3 – Critically appraise for bias:
• Selection –
• Were the groups in the study
selected differently?
• Random? Concealed?
• Performance• Did the groups in the study
receive different treatment?
• Was there blinding?
• Attrition –
• Were the groups similar at the
end of the study?
• Account for drop outs?
• Detection –
• Did the study selectively report
the results?
• Is there missing data?
Part 4 – Collection of the data
 Was a collection data form used and is it
included?
 Are the studies coded and is the data
coding easy to follow?
 Were studies identified that were
excluded & did they give reasons why
(i.e., which criteria they failed).
Charts are provided for search results, with
explanation of which articles were selected for
analysis.
63
Are the results of this SR valid?
Appraisal Criterion
Reader’s Comments
18. Is this a SR of randomized trials? Did
they limit this to high quality studies at
the top of the hierarchies
a. If not, what types of studies were
included?
b. What are the potential
consequences of including these
studies for this review’s results?
19. Did this study follow the Cochrane
methods selection process and did it
identify all relevant trials?
a. If not, what are the
consequences for this review’s
results?
Yes, only SR and RCT’s were included. This
increases the quality of the study and provides more
reliable and valid conclusions drawn from results.
All relevant trails were identified, making this an
exhaustive review of the current research. Even
articles that were referenced in the selected articles
were reviewed for relevance and possible inclusion
to confirm this.
20. Do the methods describe the processes
and tools used to assess the quality of
individual studies?
a. If not, what are the
consequences for this review’s
results?
21. What was the quality of the individual
studies included? Were the results
consistent from study to study? Did the
investigators provide details about the
research validity or quality of the studies
included in review?
22. Did the investigators address
publication bias
Are the valid results of this SR important?
Yes. Methods and charts include analysis of
number of subjects, treatment conditions vs control
conditions, and reports and conclusions drawn by
authors.
Appraisal Criterion
Reader’s Comments
Each study was ranked either as Level 1 evidence
or Level 2 evidence and analyzed appropriately in
the group it was ranked.
No this was not specifically addressed.
23. Were the results homogenous from
study to study?
a. If not, what are the
consequences for this review’s
results?
Results between studies varied but generally
trended towards at least short term efficacy of
cognitive behavioral therapy and use of
antidepressants for symptoms of MUS.
24. If the paper is a meta-analysis did they
report the statistical results? Did they
include a forest plat? What other
statistics do they include? Are there
CIs?
Not a meta-analysis.
64
25. From the findings, is it apparent what the No. While the finding suggests significant decrease
cumulative weight of the evidence is?
in medical cost pending alternative treatments for
MUS, the general conclusion of the paper is that
more pragmatic controlled trials are necessary to be
significant.
Can you apply this valid, important evidence from this SR in caring for your patient/client? What is
the external validity?
Appraisal Criterion
Reader’s Comments
26. Is your patient different from those in
this SR?
No. My patient demonstrated MUS, and multiple
very expensive interactions with the health care
system to try and decipher what the issue was.
While he was on anti-depressants he was not
covered by insurance to attempt CBT in the physical
therapy setting. Physical therapy is not specifically
referenced in this paper.
27. Is the treatment feasible in your setting?
Do you have the facilities, skill set, time,
3rd party coverage to provide this
treatment?
28. Does the intervention fit within your
patient/client’s stated values or
expectations?
a. If not, what will you do now?
Yes, CBT can be implemented at low cost, at low
risk to the patient.
Yes.
What is the bottom line?
Appraisal Criterion
Reader’s Comments
Summarize your findings and relate this back to
clinical significance
The review reveals that two types of interventions,
antidepressant medication and CBT are supported
by level I evidence as benefiting patients with MUS.
There is more level I evidence for CBT compared
with other approaches and the evidence is
increasing. CBT seems to be effective in the
reduction of a wide range of physical symptoms and
associated mood disturbance, as well as in
producing improvements in overall physical and
social functioning. Antidepressants are moderately
65
effective for MUS and effect sizes are homogenous
across functional syndromes but are associated
withdrawal symptoms and side effects. There are
currently no trials comparing antidepressants with
CBT.
66
Appendix A.7 Intervention – Evidence Appraisal Worksheet
Citation:
Tocchio, S. (2009). Treatment of conversion disorder: A clinical and holistic approach. Journal of
Psychosocial Nursing, 47(8), 42-47.
Level of Evidence (Oxford scale): 5 – Case Report
Is the purpose and background information sufficient?
Appraisal Criterion
Reader’s Comments
Study Purpose
The intent of this article is to encourage others by
describing the success that psychiatry and
alternative medicine can offer to patients with
conversion disorder and to emphasize the value of
nursing as a part of that team.
Stated clearly?
Usually stated briefly in abstract and in greater
detail in introduction. May be phrased as a question
or hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider
how the study can be applied to PT and/or your own
situation. What is the purpose of this study?
Literature
Yes. The history of the diagnosis, and prevalence
was discussed. Treatment options by
psychologist’s tends to be secondary with initial
treatments provided by neurologists or other
medical professionals were also described.
Relevant background presented?
A review of the literature should provide background
for the study by synthesizing relevant information
such as previous research and gaps in current
knowledge, along with the clinical importance of the
topic.
Describe the justification of the need for this study
67
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
N/A. Single subject case study.
 Discuss possible threats to internal
validity in the research design. Include:
 Assignment
 Attrition
 History
 Instrumentation
 Maturation
 Testing
 Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression
Are the results of this therapeutic trial valid?
Appraisal Criterion
Reader’s Comments
1. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this
assignment process for the
study’s results?
2. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
3. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
differences existed?
b. Do you consider these
differences a threat to the
N/A. Single subject case study.
N/A. Single subject case study.
N/A. Single subject case study.
68
4.
5.
6.
7.
8.
9.
research validity? How might the
differences between groups
affect the results of the study?
Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
Did the investigators know to which
treatment group subjects were assigned
?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
Did all the subjects originally enrolled
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the authors
do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
Were all patients analyzed in the groups
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Yes, single subject case study.
Yes, single subject case study..
N/A. Single subject case study.
There was no follow up, thus one cannot conclude if
the treatment was effective in the long term.
The only subject involved completed the study.
N/A. Single subject case study.
69
Are the valid results of this RCT important?
Appraisal Criterion
Reader’s Comments
10. What were the statistical findings of this
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
here
There is no statistical analysis completed for this
case study.
11. What is the meaning of these statistical
findings for your patient/client’s case?
What does this mean to your practice?
12. Do these findings exceed a minimally
important difference? Was this brought
up or discussed?
a. If the MCID was not met, will you
still use this evidence?
N/A
N/A
Can you apply this valid, important evidence about an intervention in caring for your patient/client?
What is the external validity?
Appraisal Criterion
Reader’s Comments
13. Does this intervention sound appropriate
for use (available, affordable) in your
clinical setting? Do you have the
facilities, skill set, time, 3rd party
coverage to provide this treatment?
Biofeedback and guided imagery seems relevant to
the PT setting, and may be justifiable to insurance.
Biofeedback mechanisms can be purchased for
home use for continued assistance outside the
skilled therapy session.
14. Are the study subjects similar to your
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
Yes. The patient has diagnosed conversion
disorder. Her symptoms are more associated with
negative motor findings, while my patient had
positive motor findings, but the root cause is the
same.
70
15. Do the potential benefits outweigh the
potential risks using this intervention
with your patient/client?
Yes. The general trend of the health care system in
the US is leaning more towards holistic approaches,
and in the diagnosis of CD, and other MUS,
standard medical treatment may be less effective
than holistic treatments. Risks to the patient are
low, in this case the costs are high due to lack of
insurance coverage.
16. Does the intervention fit within your
patient/client’s stated values or
expectations?
a. If not, what will you do now?
Yes, the patients in general are seeking symptom
resolution, which was demonstrated through this
study.
17. Are there any threats to external validity
in this study?
Yes, it is only one patient. The care was paid for
out of pocket by the parents of the patient, and not
covered by insurance.
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score (see scoring at end of form)
N/A
Summarize your findings and relate this back to
clinical significance
Every patient with diagnosed Conversion Disorder
will present with various symptoms and respond to
treatments to differently. This particular patient
rejected behavioral modification techniques and
positive verbal encouragement stating that it
increased her level of stress and initiated her
symptoms more frequently. It is important to
consider these variations and keep an open mind to
a variety of treatment options to include holistic
therapies. This study is limited as it is a case report
with limited external validity. Physical therapy was
not specifically mentioned as an element of care in
the disciplinary team, however, biofeedback as a
tool to assist in treatment of Conversion Disorder,
by a physical therapist, is applicable.
71
Appendix A.8 Intervention – Evidence Appraisal Worksheet
Citation (use AMA or APA format):
Voon, V., Brezing, C., Gallea, C., Ameli, R., Roelofs, K., LaFrance Jr, W., & Hallett, M. (2010).
Emotional stimuli and motor conversion disorder. Brain, 133, 1526-1536.
Level of Evidence (Oxford scale): 2b – Individual cohort study (including low quality RCT; <80% f/up)
Is the purpose and background information sufficient?
Appraisal Criterion
Reader’s Comments
Study Purpose
Purpose is not clearly stated, however it can be
deduced that their intention was to ―We sought to
investigate the relationship between affect or
arousal and conversion disorder with positive motor
symptoms (herein referred to as motor conversion
disorder) by investigating amygdala activity in
association with viewing affective stimuli in a large
patient sample size.‖
Stated clearly?
Usually stated briefly in abstract and in greater
detail in introduction. May be phrased as a question
or hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider
how the study can be applied to PT and/or your own
situation. What is the purpose of this study?
Literature
Relevant background presented?
Relevant background evidence is presented.
Functional imaging studies have focused on
conversion paralysis or the absence of movement.
In this study, they focused on conversion disorder
with positive motor symptoms such as tremor,
dystonia, chorea, tics and gait disorders rather than
conversion paralysis.
A review of the literature should provide background
for the study by synthesizing relevant information
such as previous research and gaps in current
knowledge, along with the clinical importance of the
topic.
Describe the justification of the need for this study
72
Does the research design have strong internal validity?
Appraisal Criterion
Reader’s Comments
Clear inclusion/exclusion and control group
matching noted below, and study was approved by
the National
 Discuss possible threats to internal
validity in the research design. Include:
 Assignment
 Attrition
 History
 Instrumentation
 Maturation
 Testing
 Compensatory Equalization of
treatments
 Compensatory rivalry
 Statistical Regression
Institutes of Health Institutional Review Board and
all subjects signed informed consent:
Inclusion criteria for patients with motor conversion
disorder Included diagnostic confirmation by at least
two neurologists and one psychiatrist, no movement
symptoms at rest for the imaging study, movement
symptoms not affecting the head or neck, no history
of traumatic brain injury and not on antidepressants
and 19 years of age or older.
Exclusion criteria including having a serious medical
or neurological illness, current major depression,
panic disorder, post-traumatic stress disorder,
substance abuse or other major affective or
psychotic disorders, being on antidepressants and
contraindications for MRI.
Age- (+5 years) and gender-matched healthy
volunteers were recruited from the National
Institutes of Health healthy volunteer database.
Are the results of this therapeutic trial valid?
Appraisal Criterion
Reader’s Comments
18. Did the investigators randomly assign
subjects to treatment groups?
a. If no, describe what was done
b. What are the potential
consequences of this
assignment process for the
study’s results?
No. Groups were separated into those with the
diagnosis and those without diagnosis, and all were
provided the same stimulus and imaging protocol.
73
19. Did the investigators know who was
being assigned to which group prior to
the allocation?
a. If they were not blind, what are
the potential consequences of
this knowledge for the study’s
results?
20. Were the groups similar at the start of
the trial? Did they report the
demographics of the study groups?
a. If they were not similar – what
differences existed?
b. Do you consider these
differences a threat to the
research validity? How might the
differences between groups
affect the results of the study?
21. Did the subjects know to which
treatment group they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
Allocation was not concealed from those collecting
data or analyzing findings.
22. Did the investigators know to which
treatment group subjects were assigned
?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s
results
23. Were the groups managed equally, apart
from the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
24. Was the subject follow-up time
sufficiently long to answer the
question(s) posed by the research?
a. If not, what are the potential
consequences of this knowledge
for the study’s results?
25. Did all the subjects originally enrolled
complete the study?
a. If not how many subjects were
lost?
b. What, if anything, did the authors
Blinding was not used in this study, and it could very
well affect the outcome analysis based on
preconceived notions regarding the diagnosis.
Groups were similar, age and gender matched, all
right handed individuals except 1 left handed
subject with CD, 16 subjects in each group.
Each group received the same treatment and they
were aware of their diagnosis or lack there of. I do
not believe this to be a threat to internal validity due
to the design of the study being a comparison of
diagnosis vs no diagnosis.
Groups were managed equally, receiving the same
intervention and the same analysis between groups.
No follow up was completed. Treating the
conversion disorder and repeating the MRI testing
and questionnaires would be a great way of taking
this research to the next level.
All subjects originally enrolled in the study
completed the study.
74
do about this attrition?
c. What are the implications of the
attrition and the way it was
handled with respect to the
study’s findings?
26. Were all patients analyzed in the groups
to which they were randomized (i.e. was
there an intention to treat analysis)?
a. If not, what did the authors do
with the data from these
subjects?
b. If the data were excluded, what
are the potential consequences
for this study’s results?
Are the valid results of this RCT important?
All subjects were analyzed in the groups they were
assigned.
Appraisal Criterion
Reader’s Comments
27. What were the statistical findings of this
study?
a. When appropriate use the
calculation forms below to
determine these values
b. Include: tests of differences With
p-values and CI
c. Include effect size with p-values
and CI
d. Include ARR/ABI and RRR/RBI
with p-values and CI
e. Include NNT and CI
f. Other stats should be included
here
28. What is the meaning of these statistical
findings for your patient/client’s case?
What does this mean to your practice?
Behavioral effects: There was no difference in
reaction time between patients with motor
conversion disorder and healthy volunteers.
Imaging effects: Patients with motor conversion
disorder had greater right amygdala activity
compared to healthy volunteers in healthy and
fearful vs. neutral and rest. There was no difference
in amygdala activity when the neutral condition was
compared between patients with motor conversion
disorder and healthy volunteers.
Results may show that in patients with CD either a
role for generalized increased arousal or
alternatively, a failure of adaptation of the attentional
process in evaluating salience relevance with
repeated presentations. Arousal on the amygdala
activity may influence motor symptoms either
through a general effect on initiation of the motor
conversion symptom or possibly through failure of
inhibition of the motor conversion symptom. This
suggests that our attitude and emotions present
when treating patients may affect their symptoms
and outcomes.
75
29. Do these findings exceed a minimally
The MCID was not discussed, but this information is
important difference? Was this brought
still relevant to my practice as general information
up or discussed?
on CD and the brain function in response to stimuli.
a. If the MCID was not met, will you
still use this evidence?
Can you apply this valid, important evidence about an intervention in caring for your patient/client?
What is the external validity?
Appraisal Criterion
Reader’s Comments
30. Does this intervention sound appropriate
for use (available, affordable) in your
clinical setting? Do you have the
facilities, skill set, time, 3rd party
coverage to provide this treatment?
This intervention is not appropriate for the scope of
physical therapy. It may later be useful as a means
of diagnosis of CD, or developing biological or
psychological treatments targeting arousal.
31. Are the study subjects similar to your
patient/ client?
a. If not, how different? Can you
use this intervention in spite of
the differences?
The study subjects are similar to my patient
population all subjects with CD presented with
positive motor symptoms mimicking neurological
conditions.
32. Do the potential benefits outweigh the
potential risks using this intervention
with your patient/client?
Utilizing varying arousal levels for interaction with
patients based on their response as part of a
behavioral management approach to therapy is cost
effective, and would require little to no extra time to
implement.
33. Does the intervention fit within your
patient/client’s stated values or
expectations?
a. If not, what will you do now?
The intervention does fit with the patients stated
values as it may assist in decreasing their
symptoms.
34. Are there any threats to external validity
in this study?
Conversion disorder also manifests as negative
motor symptoms. However, the effects of arousal
stimulus on the brain are probably similar based on
this study.
76
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score (see scoring at end of form)
4/10. Blinding of subjects is not applicable in this
design, but blinding researchers would be
beneficial.
Summarize your findings and relate this back to
clinical significance
Motor conversion disorder is characterized by
greater amygdala activity to arousal and potential
impairments in habituation to arousing stimuli.
These study results may not only identify functional
MRI as a form of secondary confirmation of
conversion disorder, but also encourage further
research towards biological or psychological
treatments targeting arousal as an alternative form
of treatment for conversion disorder.
77
Pedro Scoring System for Voon et. al.:
x
x
x
x
x
x
x
x
x
x
x
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones and Bartlett
Publishers, Sudbury, MA 2008
78
Appendix B. Oxford Centre For Evidence Based Medicine
79
Appendix C. Physiotherapy Evidence Database
80