FND Flashcards
FND is the _ most common neuro diagnosis in neurology clinics
2nd most common
does FND affect women or men more?
women (3:1)
FND is a _ problem, not a _ problem
software (functional changes)
not a hardware (structural)
A group of neurons working together across structural/anatomical boundaries. Thought to be 7-17 known neural networks in the brain, that are continuously communicating.
neural network
ommon neuropsychiatric condition that can vary significantly
in presentation and include numerous symptoms such as…
weakness, seizures; sensory, speech, and cognitive changes.
age range for FND
4-94 years
mean onset late 30s
FND: level of physical disability similar to _
MS or epilepsy
*wide range of presentations, functional impairment depending on what subtype they present with
What are subtypes of FND
- Functional movement disorder
(We’ll likely see most frequently) - Functional seizures
- Functional cognitive disorders
- Persistent perceptual postural dizziness (3PD or PPPD)
- Persistent post concussion symptoms (PPCS)
- Complex regional pain syndrome (CRPS)
who is the founder of modern neurology?
Charcot (described patterns of neurological symptoms, used hypnosis as a popular treatment strategy in 19th centruy)
Who recognized painful emotion with functional symptoms and start of epidemiology in the 19th century?
Briquet
T or F: Freud and PTSD from WW1 (shell shock) were influencers for concept of FND
TRUE
*neuro and psychology –> leading to symptoms
What do brain scans look like for someone with functional paralysis vs feigned paralysis?
- Feigned Paralysis: Primary motor cortex
- Functional paralysis: Primary motor cortex with connections to precuneus and vmPrefrontal cortex
What are 4 key patterns of signs and symptoms of FND?
rule IN signs (+ dx)
1. variable (stiff leg one day, paresis leg another day AND how long, where, and when CHANGES
2. distractible
3. entrainable
4. suppressible
symptoms can be altered by saying “can you copy me” or by asking them to tap their foot (example: hand tremor changes tempo to match foot tempo, can pause or stop)
entrainable
T or F: FND improves with dual tasking
true: distractible, suppressible and entrainable
T or F: FND is a DX of exclusion
T or F: FND is a purely psych condition/ONLY occurs with psych history
F and F
Diagnosis of inclusion of 4 signs
can occur without a psych comorbidity or prior stressful life event
DSM-5 criteria for FND diagnosis
1 or more symptoms of altered voluntary motor or sensory function
*Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions
What may a subjective history of FND look like?
- waxing/waning
- complete remission at times
- altered types of movments
- migration through body
What may testing look like in a patient with FND?
variable
* entrainment test
* whack a mole test
* varying frequency and/or direction of tremor
external focus
* Hoover’s sign
* change in performance with dual task
* attention to body increases abnormal mvmt/weakness
What are other positive tests of FND?
- drift without pronation
- cocontraction around joint without spasticity
- collapsing weakness (buckle without fall)
- delayed and/or excessive startle
- dragging leg gait without circumduction ( or walking on ice)
- sensory loss pattern changing, perfect midline split down sternum
- speech struggle behaviors
- Over mouthing
- Excessive and/or exaggerated eye blinking
- facial contortions
- Effortful breathing
Which are validated motor signs for a positive diagnosis of FND?
- distractibility when engaging in motor/cog task
- variability: observe for changes/periods of unexplained improvement
- Hoover sign: weakness of hip extension resolved during resisted contralateral hip flexion
- Monoplegic leg dragging gait: weak leg dragging like piece of wood
General FND patterns: what to look for with diff Dx
- variable
- distractible
- sudden onset
- global weakness w/ no pattern
- suppressible
- entrainable
- full remissions
- Hoover signs
What are common co-morbid diagnoses with FND?
- autism (at least 1 symptom reported in 86.7%)
- EDS/HDS
- chronic pain (17% of ppl with chronic pain)
What constructs and neural circuits are related to FND?
agency: TPJ-based circuit
emotional processing: salience, limbic circuits
attention: fronto-parietal circuits
What areas of the motor control brain are affected with FND?
abnormal activation in _ and _
increased activity in _
- SMA (motor preplanning
- right temporal-parietal junction (feedforward signaling, self agency- predictive brain)
- increased cingulate gyrus activity (self monitoring and motor inhibition)
problems of agency and attention that are impaired in FND
- predictions abnormally strong, overpowers contradictory sensory info (TPJ, prefrontal, cerebellum)
- misdirected attention is hallmark issue
- interoception changes
- heightened/reduced awareness
- lower accuracy with HR recognition, lower accuracy with measuring POSTURAL SWAY
- abnormal sensory processing (low registration, sensory sensitivity, sensory avoiding behaviors)
- decreased sensory attenuation
- increased MIRROR NEURON activation
what are psychological aspects of FND
- ACEs (more common but not in all with FND)
- anxiety/depression
- impaired: emotional processing
- impaired vigilance
- impaired inference
- impaired self-agency
- perfectionism
- amygdala hyper-activation
what are autonomic aspects of FND?
- low HRV
- increased resting HR (decreased PNS)
- increased cortisol, c-reactive protein
- hyperactive startle
- increased arousal
inpatient intensive rehab models for FND: key is that they are _
MULTI-DISCIPLINARY
outpatient intensive model for FND: _ days a week, _x/day
5 days/week, 2x/day PT/OT
what are key components for pediatric FND treatment?
- multidisciplinary
- psych informed PT
- mind-body interaction
- integration of play
- role of exercise!!!
What are key psych components of treating FND?
- regain control
- change learned behavior
- address underlying anxiety, depression, trauma
- understand self/emotional health
- tolerate/communicate emotions/stress
What are 4 CORE INTERVENTION RECOMMENDATIONS for FND PT
- education
- retraining mvmt with diverted attention
- demonstration that normal mvmt can occur
- changing maladaptive behavior related to symptoms
With FND treatment, PT should focus on function: goal on optimal task, not self.
most common motor/non motor symptoms
non-motor:
fatigue
somatosensory symptoms
cognitive symptoms
motor:
weakness and impaired balance
subjective history: what is the 2 most important things to ask with FND?
- what symptoms are most problematic
- what are patient goals?
BE WHOLISTIC
ask about SLEEP
activity/exercise
support
OG injury
- “My body part feels disconnected”
- difficult moving their body the way they want to move
- ss flare or fatigue in particular environment
these are all _ clues
sensory clues
In your objective, you as a PT will look at changes with _ _ and _
dual task
balance
mvmt analysis
transitions
postures
environment
thinki about autonomy
external focus
enhanced expectancies
changes in sensory experience and weighting can help with this population. What kinds of modalities?
- compression
- vibration
- taping
- change in position
- vestibular exam, visual sensitivity
What autonomic concerns will you watch for with FND?
- vital signs: OTHN and POTS
- breathing
- aerobic exertion testing
COMPASS-31 for outcome measure
currently recommended outcome measures in FND
- clinical global impressions (CGI)
- PHQ-15: physical health questionaire
- psych symptoms: hospital anxiety and depression scale (HADS)
- life impact: short form 36 (SF-36)
link outcome measures with patient’s key problems
PT treatment of FND:
most important thing is
patient education!
-build resilience
-enhanced expectancies
find ways to unlock automatic mvmts for FND. What are methods?
- graded motor imagery (R/L discrimination, imagined mvmt, mirror therapy)
-graded exposure - add external focus + enhanced expectancy
- add manual/cog dual task
- ## add visual input of normal mvmt
FND treatment: assess and treat sensory system to a person’s _
GOALS
* identify general patterns
* education/awareness –> sensory ladder of ‘just right’ level of arousal
* sensory checklist: what is energizing, calming, annoying?
* graded sensory exposure
sensory regulation
What can be used for compression/sensory input with gait?
Body braid
or weighted vest
Fatigue is a major problem with FND.
What should you do for exercise treatment?
GRADED
(aerobic ex –> BDNF –> enhanced motor learning–> facilitate neuroplasticity)
