FND - A Focussed Rehabilitation Perspective

Objectives

• Introduction
• Suggested Approach
• Initial rehab contact
• Suggested rehab approach
• When things don't go to plan
• Conclusion and references

Functional neurological disorder is

• Umbrella term at the interface b/w neurology and psychiatry
• RULE IN NOT a rule out diagnosis

FND diagnosed based on

• One or more symptoms of altered voluntary motor or sensory function
• Findings and Deficits -Not better explained by other neurological or medical condition
• Causes significant distress or impairment

Subtypes (most - least)

• Nonepileptic seizure
• Functional limb weakness
• Functional movement disorders (Gait, Tremor,Jerks/twitches, Dystonia
• Functional speech,swallowing

Subtypes (most - least)

• Functional sensory symptoms
• Functional cognitive symptoms
• Functional visual symptoms
• Can be mixed

incidence

• Australia -50 per 100,000
• 15% Neurology outpatient clinic attendances
• Australian Government National Mental Health Commission Report 2019

prognosis

• 14 yr follow up - UK
• Improve - 51%
• No change -23%
• Worse -14%

epidemiology

• F:M = 3:1
• All ages - rare under 10 yrs. Up to 80 yrs. Mean age of presentation 40 yrs
• Comorbid neurological conditions in about 20% of cases

FND

• Currently FND does not encompass pain/fatigue altough these are commonly seen in FN

Untitled Slide

• insert pictoralBMJ 2020 recognising functional neurological disorder -practice pg 2

Clinical characteristics

• Abrupt onset - secs upto 24 hrs
• Most movement disorders gradual onset (excpt CVA)
• Rapid progressio

characteristics

• Common precipitants - illness, medical procedure, physical injury, emotional even
• Often >1 type of movement disorder present (diagnostic clue
• Sx may be constant or episodic- 'good/bad days
• Pain,Fatigue,Cognitive Sx commonly assiociate

characteristics

• PotentialPerpetuating factors
• Pain, physical deconditioning
• Ongoing psychosocial stressors ,anxiety, other psychiatric disorders (* patients may NOT have an associated mental health diagnosis
• Intercurrent illnes
• L

characterisitics

• Litigation/Financial benefit
• Life stress resolved by onset of FND and likely return if FND resolve

history

• How and when did the symptoms first appear - List the symptoms-for each symptoms ask aggravating, relieving, variability
• Ask about fatigue, pain, sleep , memory, concentration
• Describe a typical day
• Do they have care needs,how and by whom are the needs being met

history

• Impact on relationships, finances, work, study
• Detailed social history- roles, responsibilities and meaningful activitie
• Home access, use of aid
• What are patient's ICE- Ideas (understanding of their condition and do they agree with it),Concerns, Expectation

initial rehab contact

• Usually diagnosis already made before rehab referral
• What have you been told of your diagnosis and what is your understanding and what do yo think should be done

initial rehab contact

• Name the condition - Functional Neurological Disorder
• Explain that physical examination and observation are the basis for diagnosis

initial rehab contact

• State that FND is real and treatable
• Emphasise thatPatient is not crazy or making it up

initial rehab contact

• Provide explaination - FND is 'software rather than hardware problem' or
• The train and the tracks are both working properly but the train is off the tracks and only run smoothly when properly aligned

initial rehab contact

• Advisable not to go into details when asked why this has happened-ususally this is not always clear

initial rehab contact

• Leave time for the patient and family to ask questions

initial rehab contact

• Determine agreement to rehab referral
• Can identify rehab goals and is motivated towards goals

initial rehab contact

• If ambivalent- early emphasis on education to aid understanding and exploring barriers with mental health
• Provide resources (see references)

initial rehab contact

• If possible - form a verbal agreement at the start - this could reduce potential difficulties when concluding treatment
• Explain that treatment includes close collaboration with neurosciencs and rehabilitation teams

initial rehab contact

• If possible - form a verbal agreement at the start - this could reduce potential difficulties when concluding treatment - time limited
• Explain that treatment includes close collaboration with neurosciencs and rehabilitation teams

initial rehab contact

• Address pain, fatigue and cognitive symptoms

initial rehab contact

• Early case conference - claify goals and therapist allocation- experience, interest in field of FND

rehab therapeutic approach

• Language - avoid blame, fault or implications of voluntariness
• Your brain is attending to your body in an abnormal way
• Allow your leg to come forward vs move your leg forward

rehab therapeutic approach

• Emphasis on functional ability for independence and self management
• Build trust and create an expectation of improvement
• Involve family and carers in treatment where appropriate
• Open and consistent communication between MDT and patient
• Minimise adaptive aids and equipment

Rehab therapeutic approach

• Liaise with psychologists to recognise and challenge unhelpful thoughts and beliefs
• Ref - Table 3 Examples of ways of speaking to patients - Nielsen et al J Neurol Neurosurg Psychiatry 2014 - supplement

rehab therapeutic approach

• Allied health - Consensus (not Guidelines) as lack of available evidence
• PT/OT/Speech - Journal of Neurology Neurosurgery Psychiatry - references

relapse minimisation

• Common for symptom exacerbation
• Review with patient -any triggers for relapse
• What are the most helpful strategies you have learnt-what can you do if you notice getting worse
• What were the most unhelpful strategies that were making things difficult

When things aren't going well - usually-

• Inability to repeat back diagnosis despite repeated explaination - BUT having confidence in the diagnosis will not in itself lead to improvement
• Very fixed view on alternative diagnosis
• Possible underlying personality disorders
• Presence of litigation or benefits
• Long standing or disabling symptoms

When things aren't going well - usually-

• Inability to repeat back diagnosis despite repeated explaination - BUT having confidence in the diagnosis will not in itself lead to improvement
• Very fixed view on alternative diagnosis
• Possible underlying personality disorders
• Presence of litigation or benefits
• Long standing or disabling symptoms

What if

• Patient angry about diagnosis and unable to shift despite team efforts - consider suspending rehab
• Patient says they cannot do a rehab task - Response - progress can be slow - every task you do is helping your brain and nerves to work normally- best to keep working with your therapists

What if

• Therapy is not working but can't find a way to discharge patient -
• Teams have to be pragmatic and agree that efforts have to be focussed where they are likely to have some impact

what if

• Consider saying to patient - You and your therapists have worked hard, we are sorry that we have not been able to help -perhaps further treatment at this time may not be helpful, but remember that there is always potential to improve at a later time

what if

• Patient asks if their symptoms will get better- response
• Symptoms come and go but almost always get at least a bit better when you do your rehab. Sometimes pain, fatigue get worse before getting better
• Without rehabilitation - spending long time in a chair or bed will always lead to deterioration

fnd myths

• FND is a diagnosis of exclusion - now it is ruled in on positive signs
• Patients have either FND or another neuro dx - FND commonly exists with other neurlogical disorders

fnd myths

• FND symptoms are voluntary - No they are involuntary
• Treatment of FND is solely referral to psychiatrist or psychologist - Psychological factors are one of the possible risk factors and should not be considered the sole cause - Not all FND patients have a psychiatric diagnosis

conclusion

• " I have excluded disease - its not my problem"
• Managing FND -Changing mindset, collaborative approach, being pragmatic when things don't work out

references

• Neurosymptoms.org
• fndaustralia.com.au- learning guide
• fndaustralia - FND workbook - updated 2020 version
• A practical review of functional neurological disorder for the general physician . Bennett et al. Clinical medicine 2021 Vol21,No 1:28-36

references

• Diagnosis and management of functional neurological disorder. Aybek S et al. BMJ2022;376:o64. 1-19
• Recognising and explaining functional neurological disorder. Stone J et al. BMJ2020;371:m3745

references

• Physiotherapy for functional motor disorders a consensus recommendation (Long version) Nielsen G et al. J Neurol Neurosurg Psychiatry 2014;0:1-16 supplement

references

• Occupational therapy consensus recommendations for functional neurological disorder. Nicholson C et al. Journal Neurol Neurosurg Psychiatry 2020;91:1037-1045

references

• Functional movement disorders. Lidstone S. UpToDate - updated Feb 2022
• Management of functional communication, swallowing, cough and related disorders :consensus recommendations for speech and language therapy.Baker J et al. Journal Neurol Neurosurg Psychiatry 2021;92:1112-1125

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