Functional Disorders Flashcards
Aims
- Introduction to FND
- Consider the role of physiotherapy
- Evidence for treatment approach
- Consider the approach to take with patients with FND
- Practical tips for this patient group
What is FND?
Functional Neurological Disorder (FMD = Motor Disorder)
NEUROLOGICAL SYMPTOMS
(such as limb weakness, numbness, shaking or blackouts) which are
- REAL (and not imagined)
- caused by a PROBLEM with the FUNCTIONING of the nervous system
- not due to damage or structural disease of the nervous system
- causing difficulties for the person who experiences them
How prevalent is FND
16% of pop its the second most common neurological disorder after headaches.
What are the symptoms of FND?
- reinforcement
- Altered body schema
- Plastic changes
- Central sensitisation
- Soft tissue shortening
- Deconditioning
- Fatigue
Mostly affects autonomic movements.
Very important to be clear and explain their diagnosis, how can you do this?
- Use clear language.
- Normalise it its very common.
- Explain the diagnosis e.g. Hoover’s sign, distraction of a psychogenic movement disorder.
- Recommendations read trick or treat article (Stone & Edwards 2012)
WHY PATIENTS NEED PHYSIOTHERAPY
Short-term and long-term successful outcomes were documented in the treatment of patients with functional movement disorders by a rehabilitative, goal-oriented program with intense physical and occupational therapy. The rapid benefit, which was sustained in most patients, suggests substantial efficacy that should be further assessed in a prospective, controlled, clinical trial. (Czarneck, 2011)
Physiotherapists in general are interested in treating such patients and feel physiotherapy to be an appropriate treatment. However, inadequate service structures, knowledge and support from non-physiotherapy colleagues are judged to be barriers to provision of care. (Edwards., 2012)
There are specific interventions and approaches that seem to work, and are amenable to study e.g. unlearning maladaptive motor programs, ignoring negative movements, focusing on complex motor programs as a whole (i.e. not focusing on a paralysed leg, for example, that might be the case for a non-specialised physiotherapist) (Nielsen et al., 2013)
The most successful programs appear to do this by conceptualizing the FMD as a problem with abnormally learned “motor programs” in the brain that have to be “unlearned” (Nielsen et al., 2013)
Most physiotherapists questioned in a study felt that they could do more to help FND patients, but felt poorly supported by neurologists and existing service structure (Edwards et al., 2012b)
FND Hope conducted a study of patients experience of services https://fndhope.org/fnd-hope-research/Out of 503 patient 225 reported that they had felt discrimination of stigma from physio or OT
Approach to physiotherapy in functional motor disorders
- Functional and automatic movements (sit to stand, walking)
- Early weight-bearing
- Avoid adaptive equipment and aids
- Distraction techniques (including visualisation)
- Use of videos and mirrors
- Graded exercise
Faul et al 2020, Neural activity in functional movement disorders after inpatient rehabilitation
Evidence:
Motor retraining (MoRe) rehabilitation reduces movement disorder severity by 63.5%.
Pre-treatment primary motor cortex activity associates with treatment response.
Bilateral amygdala shows greater connectivity with premotor regions after MoRe.
Results reflect reorganized emotional and motor pathways following treatment.
Physiotherapy for FND -Examples
Functional Movement symptoms needs attention to be maintained.
When there is a distraction there is an improvement
Show this as a positive sign to the patient and help them to understand how distraction and retraining movement can help their movement patterns.
Examples –
- walking when doing cognitive task e.g months of the year backwards.
- Doing a task in a different way e.g walking backwards sideways.
- Doing an upper limb task at the same time e.g throwing and catching ball.
- Change the focus e.g sit to stand focus on sensation through upper limbs
- Practical ways of doing this (with patient’s consent) video them so they can reflect on their movement and how they changed when attention of altered.
How can gait retraining help?
- Weight shift with focus on COG
- Use of mirrors/videos
- Side to side weight shift and lateral weight shift
- Trailing walking backwards
- Foot sliding initially
- Treadmill can be useful to help automatic stepping
- Distraction/cognitive tasks.
- Focus on arm swing rather than lower limbs
Outcome measures
Pick et al 2020 carried out a systematic review of the use of outcome measures in FND
- 5 FND specific measures were identified
- 3 clinician rated
- 2 patient rated
- No single measure used across the range of symptoms in adults
- Physio specific measures in outcome in FND patients difficult as the act of measuring draws more attention to symptoms and can worsen them.
See LC at 30min for case studies.
- essentially people mis diagnosed as muscle weakness when it was a cognitive pattern issue which was eventually detected.
- then she was added to a trial for Botulinum injections, which last 3-4 months then received re-training during this time which was effective.
- Vestibular retraining is key
Functional Dizziness/Chronic Dizziness = PPPD- Persistent Postural Perceptual Dizziness
see LC around 35min slide 31.
Care plan for managing functional eye and muscle spasms
Symptoms:
- I experience a spasms in which my eyes close and my mouth twists
- I experience muscle spasms in lower face and neck.
- Both symptoms can be brief lasting seconds or minutes. Very rarely it can last for up to an hour at a time.
- These symptoms are often triggered when I am anxious or stressed in a situation. They are likely to show up when I feel unable or do not want to cope with a situation I find challenging. For example, this often happens when I am talking to other people, disrupted plans or unexpected changes.
- I do not always have a warning signs and sometimes I have these symptoms without an identifiable trigger.
What I will do:
- When I experience twitching symptoms, I try not to pay too much attention to them and it’s helpful not to focus on that part of my body. Instead I will try to focus on something that I am doing or another task (shoulder setting), taking tongue to roof of mouth.
I will try to use my relaxation techniques (box breathing)
- I may also try to take a break if my symptoms increase significantly e.g 10 minutes before returning to what I was doing.
- How my family and colleagues can help me:
- If the spasm movements are small and last a matter of seconds then it is most helpful not to pay attention to them.
- You could suggest I try one of the strategies above.
What if there is no improvement?
- Some people despite their and your best efforts do not improve with treatment.
- 60-70% of people will see some improvement
- Conversely this means that 30-40% do not improve.
Reasons:
- Related health problems
- Fatigue
- Having symptoms for along time can make recovery more difficult
- Other social factors effecting ability to engage in rehab.
This may not be the right time for rehab other factors may need to be addressed first – leave the door open to consider review after input for other factors.
Do more research on FND!
Check FND hope and there’s a lot of videos on twitter.
