Functional Neurologic Disorder (FND) Flashcards
how does Mayo Clinic define FND
neuro sx that can’t be explained by a neuro dz or other medical condition
pt demonstrates physical sx w/o organic cause
FND is considered a condition at the intersection of what 2 healthcare practices
neurology
psychiatry
“neuropsychiatric” disorder
what are risk factors for FND
females > males
anxiety disorders
possible psych trauma
what are the 3 main reasons to change the name from conversion disorder to FND
new dx criteria
dx of inclusion - tests to be used
look at fMRI evidence
conversion disorder vs FND
conversion disorder:
- dx of exclusion
- direct result of trauma (physical or psych)
- no physio theory or evidence behind dx
FND:
- dx of inclusion
- may have a “trigger”
- fMRI evidence
- “secondary gain” - pt gets something (+) out of being sick
what are 3 subsets of FND
nonepileptic sz
functional weakness
functional mvmt disorders
what are examples of the nonepileptic sz subset of FND
pseudo sz
functional
sz sx without any electrical correlate in EEG
what are 2 types seen in the functional weakness subset of FND
inconsistent weakness
paralysis
what are 3 types seen in the functional mvmt disorders subset of FND
functional tremor
- more common in adults
functional gait disorder
- more common in kids
functional coma
which 3 structures are altered in FND when viewed w an fMRI
insula
amygdala
dorsal prefrontal cortex
how does someone w FND’s insula look different on a fMRI and what does this mean
dec volume in R and L insula
R insula dec connectivity w:
- R temp/parietal junction
- R sensorimotor cortex
- (B) supplementary motor area
= dec connectivity to things that plan, execute, and monitor motor output
how does someone w FND’s amygdala look different on a fMRI and what does this mean
inc volume of amygdala
- amygdala = emotional stability, forming emotional memories
inc connectivity to motor cortex
- see motor output disturbances
how does someone w FND’s dorsal prefrontal cortex look different on a fMRI and what does this mean
dec dorsal prefrontal cortex when performing motor task
-> dec ability to respond flexibly to tasks and adjustments
-> dec agency
what is agency and why is it significant that this is dec in FND
agency is knowing you are the cause of whatever mvmts and consequences
d/t dec in dorsal prefrontal cortex activity, there is dec agency in FND
–> connectivity is missing
–> if moved passively, motor cortex tells them they did it themselves
–> when moved actively, brain tells them someone else did it
overall the changes seen on a fMRI lends to what physio characteristics of FND
regulating emotions
processing emotions
planning and acknowledging voluntary mvmts
what needs to be done first in the process of dx FND
r/o organic dx
- get some imaging!!
what steps are involved in r/o an organic dx
appropriate imaging
appropriate blood tests
possible spinal tap
EMG
EEG
before going into the eval, what do you need to find out from the team
what they have told the pt and family
- did they hear the dx and how was it explained
what tests have been completed and which tests are currently ordered to be performed
what are 4 steps to r/i a FND dx
hx
physical exam - impairments
functional skill assessment
specific test pertaining to hypothesis of FND dx
what are components to their hx that you might start to r/i FND
abrupt onset
intermittent spontaneous cure or remission
secondary gain
psychiatric comorbidities
what is an important thing to consider if someone has psychiatric comorbidities
this shouldn’t have more weight than anything else in their hx
what are components looked at in a physical exam for FND
strength
sensory testing
coordination
gait
functional mobility
special tests
how is motor control assessed in FND
MMT
observational analysis
Hoover’s sign
how will MMT present in FND
give way weakness
- cuts off any motor engagement
what will an observational analysis of motor control likely show in FND
can’t move limb confrontationally (on command)
can move limb observationally (unconsciously)
what does a hoover’s sign tell us for FND
r/i test for this dx
- if (-), don’t have FND
what is a consideration for pt ed while conducting the physical exam
verbally acknowledge what you are seeing
what will a sensory exam in FND likely reveal
non-anatomical sensory changes
- sensory loss
- dec sensation
- inc sensation/perception of pain –> hyperalgesia on confrontation is common (often not as painful when they are distracted)
may vary throughout assessment or day or day to day
what are characteristics of a functional tremor
distractible
variable
suggestible
able to be entrained
what does it mean that a functional tremor could be entrained
any change in direction, frequency of tremor w distraction (cog, auditory, physical)
what are characteristics of a functional gait pattern
variable step length
variable BOS
single leg being dragged
astasia-abasia (trunk mvmt)
slow, effortful
follows no neuro pattern
what are 3 factors in determining a positive outcome
acceptance of dx
educating the pt
time b/w sx onset and FND dx
what is a good way to deliver the results of your eval to pt w your dx of FND
verbally acknowledging all you saw throughout eval & recap it:
- these are (+) signs for FND
- share fMRI FND findings (validates it for them)
- share neuro and psych part
what are 3 things our dx should contain
objective physical findings
physio to support dx
“trigger” events
what are 3 things to avoid in our dx and why
life stress
emotional disorder
neurotic personality
avoid talking ab psych part of dx, not our scope, can muddy waters
psych support and hx not needed to effectively treat
PT eval specific to FND: impairment testing, neuro screen, FND tests
impairment:
- strength
- ROM
- motor control
neuro screen/assessment
- somatosensation
- balance
- oculomotor
- CN testing
FND test/dx
- functional skills assessment
- functional gait assessment
- hoover’s sign
- entrainment, suggestibility, and distractibility of tremor
what is the significance of pt ed in FND
pts who were told dx and outcomes, got better
PT facilitation technique in FND
don’t touch them, no facilitation
have them do wildly hard, dual task, difficult thing, super distracting - and guard as best you can w/o touching them
what are Nielson’s 4 core areas for PT intervention in FND
- education
- retraining mvmt
- demonstrating normal mvmt w/i therapy session (distraction)
- change maladaptive behaviors as it pertains to mvmt
what are components that Nielson suggests to include in education for pt w FND
dx
physio behind dx
expectation of recovery
relative common dx for PTs
retraining normal mvmt
what were Nielson’s 5 recommendations for rehab
- build trust before challenging
- repeat expectation of recovery in all convos
- limit “hands on” intervention and become more instructional
- avoid adaptive equipment (whenever possible/safe)
- goal directed rehab w focus on functional activities (pt goals to inc motivation)
what are characteristics our PT interventions should have for FND (5)
activities to work towards pt goals
- daily
- weekly
- monthly
multi-tasking
distraction
high level
repetition
