Functional Neurologic Disorder Charts

Question 1

Definition and examples of variable strength with FND

Answer 1

Def: give-away weakness is inconsistent
Ex: collapsing weakness, as the examiner applies different levels of force, the patient’s resistance varies
present in FND

Question 2

Definition and examples of Hoover’s Sign with FND

Answer 2

Def: the expected response is that the normal limb heel pushes down against the examiner’s hand as the patient tries to raise the weak leg’s hip
Ex: positive = if examiner does not feel the normal leg’s heel pushing down as the patient flexes the hip of the “weak” limb — suggests functional weakness
present with FND

Question 3

Examples of inconsistent examination with FND

Answer 3

Patient can rise from a chair but is unable to lift either leg off the exam table
present with FND

Question 4

Definition and examples of co-contraction with FND

Answer 4

Def: when both agonist and antagonist muscles are activated
Ex: when asked to flex the elbow, both biceps and triceps are activated
present with FND

Question 5

Examples of hemiparesis in a non pyramidal pattern with FND

Answer 5

Ex: pyramidal weakness = extensors are weaker than flexors in the arm and flexors are weaker than extensors in the leg.
diffuse weakness with FND

Question 6

Is babinski sign present or absent with FND?

Answer 6

Absent

Question 7

What are our motor clues that a patient has a functional disorder?

Answer 7

• variable strength
• Hoover sign
• inconsistent examination
• co-contraction
• hemiparesis in a non pyramidal pattern
• babinski sign

Question 8

What tremor signs are clues that a patient has a functional disorder?

Answer 8

• entrainment tremor
• distraction affecting the tremor
• variability in tremor

Question 9

What is entrainment tremor?

Answer 9

present with FND
- tremor frequency switches to match the frequency of a voluntary rhythmical movement performed by the unaffected limb

Question 10

What does distraction affecting the tremor look like?

Answer 10

significant with FND
- the tremor changes when the examiner has the patient perform tasks like counting backwards

Question 11

What does variability in tremor look like?

Answer 11

significant with FND
- the amplitude and characteristics of the tremor vary during the examination.

Question 12

What are some sensory clues that a patient with functional disorder might have?

Answer 12

• pattern of numbness
• splitting the midline
• splitting of vibration

Question 13

How does pattern of numbness present with FND?

Answer 13

• not anatomic
• sensation normalizes at the hip or shoulder

Question 14

Splitting the midline sensory presentation is?

Answer 14

present with FND
- sensory nerves do not end precisely at midline!! So abnormal finding

Question 15

Splitting of vibration presents???

Answer 15

present with FND
- frontalis is a single bone - so vibration sense should be the same bilaterally

Question 16

What are the possible gait impairments present with people with FND?

Answer 16

• Dragging leg
• Excessively slow gait
• Inconsistent with known neurological disease
• Consistently falls to or away from examiner

Question 17

Examples of dragging leg?

Answer 17

present with FND
- Patients with pyramidal weakness circumduct their leg.

Question 18

Examples of excessively slow gait?

Answer 18

present with FND
- typically slowness in all aspects of gait
- Patients with Bradykinesia display the most prominent slowness with gait limitation

Question 19

What does inconsistent gait with known neurological disease mean?

Answer 19

present with FND
- typically noneconomic, requires more rather than less effort
- Knee buckling without a fall requires more strength at knee extensors.

Question 20

What does consistently falling to or away from the examiner look like with FND?

Answer 20

present with FND
- test with the rhomberg maneuver
- significant sway, often after a latency

Question 21

What are movement strategy techniques to normalize movement for leg weakness in FND?

Answer 21

• early weight bearing with progressively less per limb support. (Finger tip support, preventing the patient from taking weight through walking aids/supporting surfaces)
• standing in a safe enviornment with side to side weight shift
• crawling in 4 point then 2 point kneeling
• increase walking speed
• treadmill walking (with or without a body weight support harness and feedback from a mirror)

Question 22

What are movement strategy techniques to normalize movement for ankle weakness in FND?

Answer 22

• elicit ankle DF activity by asking the patient to walk backwards with anterior/posterior weight shift while standing or by asking the patient to walk by sliding their feet, keeping the plantar surface of each foot in contact with the floor
• use of electrical muscle stimulation

Question 23

What are movement strategy techniques to normalize movement for upper limb weakness in FND?

Answer 23

• elicit upper limb muscle activity by asking the patient to bear weight through their hands (4 point kneeling or standing with hands resting on table) weight bearing with weight shift or crawling
• minimize habitual non use by using the weak upper limb functionally to stabilize objects during tasks, for example stabilize paper when writing, a plate when eating
• practice tasks that are very familiar or important to the individual, that may not be associated with symptoms (use of phone, computer, tablet)
• stimulate automatic upper limb postural response by sitting on an unstable surface such as a therapy ball, resting upper limbs on a supporting surface

Question 24

What are movement strategy techniques to normalize movement for gait disturbances in FND?

Answer 24

• speed up walking (sometimes this can worsen the walking pattern)
• slow down walking speed
• walk by sliding feet forward, keeping plantar surface of foot in contact with the ground. Progress toward normal walking in graded steps
• build up a normal gait pattern from simple achievable components that progressively approximate normal walking. (Look at table for examples)
• walk carrying small weights/dumbbells in each hand
• walking backwards or sideways
• walk to a set rhythm
• exaggerated movement like walking with high steps
• walking up or down the stairs

Question 25

What are movement strategy techniques to normalize movement for upper limb tremor in FND?

Answer 25

- make the movement “voluntary” by actively doing the tremor, change the movement to a larger amplitude and slower frequency, then slow the movement to stillness - teach the patient how to relax their muscles by actively contracting their muscles for a few seconds, then relaxing - changing habitual postures and movement relevant to symptom production - perform a competing movement, for ex. Clapping to a rhythm or a large flowing movement of the symptomatic arm as if conducting an orchestra - focus on another body part, like tapping the other hand or foot - muscle relaxation exercises for ex. Progressive muscle relaxation techniques, eMG biofeedback from paper trapezius muscle or using minor feedback

Question 26

What are movement strategy techniques to normalize movement for lower limb tremor in FND?

Answer 26

- side to side or anterior to posterior weight shift. When the tremor has reduced slow weight, shift to stillness - competing movements such as toe tapping - ensure even weight distribution when standing. This can be helped by using weighting scales and/or a mirror for feedback - changing habitual postures relevant to symptom production for ex. Reduce forefoot weight bearing

Question 27

What are movement strategy techniques to normalize movement for fixed dystonia in FND?

Answer 27

- change habitual sitting and standing postures to prevent prolonged periods in end of range joint positions and promote postures with good alignment - normalize movement pattern with an external or altered focus of attention - Discourage unhelpful protective avoidance behaviors and encourage normal sensory experiences - prevent or address hypersensitivity and hypervigilance - teach strategies to turn overactive muscles off in sitting and lying - the patient may need to be taught to be aware of maladaptive postures and overactive muscles in order to use strategies - consider examination under sedation, especially if completely fixed or concerned about contractures - consider a trial of electrical muscle stimulation or functional electrical stimulation to normalize limb posture and movement

Question 28

What are movement strategy techniques to normalize movement for functional jerks/myoclonus in FND?

Answer 28

- movement retraining may be less useful for intermittent or sudden jerky movements. Instead, look for self-focused attention or premonitory symptoms prior to a jerk that can be addressed with distraction or redirected attention - when present, address pain, muscle over-activity or altered patterns of movement that may precede a jerk.