Physical Rehabilitation for FND Flashcards
How does the ICD11 classification of FND differ from the DSM?
DSM = Functional Neurological Symptom Disorder
ICD11 = Dissociative Neurological Symptom Disorder
What are functional neurological symptoms?
▪️Neuro symptoms (e.g. motor, sensory)
▪️Experienced as involuntary
▪️Altered functioning of networks, NOT structural damage
What is PPPD?
Persistent perceptual postural dizziness
(functional dizziness)
What are the five core categories of functional neurological symptoms?
▪️Motor
▪️Sensory
▪️Functional seizures
▪️Cognitive symptoms
▪️PPPD
What are the most commonly described secondary physical symptoms in FND?
▪️Chronic pain
▪️Fatigue
What are some of the most commonly described psychological symptoms in FND?
▪️Anxiety
▪️Depression
▪️Depersonalisation and dissociation
▪️PTSD
▪️Interpersonal difficulties
What are the main typical presentations of functional motor disorder?
▪️Weakness/paralysis
▪️Tremor
▪️Gait disturbance
▪️Jerks
▪️Dystonia
How does weakness in FMD usually differ from in stroke?
Patients more commonly show hypertonia
(compared to hypotonic in stroke)
What signs might indicate a tremor is functional?
▪️Variation in speed and symmetry
▪️Can change with distraction
▪️Entrainable
What signs might indicate a gait disturbance is functional?
▪️Distraction may alter it (e.g. turning around)
▪️Monoplegic dragging gait
What is propriospinal myoclonus?
Movement disorder characterised by repetitive, irregular jerks originating from middle of spine
Often functional and in the context of back pain
What are the main signs of functional dystonia?
▪️Fixed (e.g. inversion at ankle)
▪️Overlap with complex regional pain syndrome
▪️Asymmetric development
▪️Often precipitated by injury such as sprained ankle
What presentation of FMD is the hardest to treat and has the worst prognosis?
Dystonia
What is the general prognosis for FMD?
▪️~80% stay symptomatic
▪️Higher than expected mortality (~11%)
Why might FMD be associated with an increased risk of premature death?
Lifestyle factors (e.g. sedentary and dependent on wheelchair, cardiovascular disease)
Other associated secondary factors
What is the biopsychosocial understanding of FMD?
Disorder of sensorimotor processing (predictive processing)
Top-down expectations distort bottom up somatosensory experiences
Top-down ______________ distort bottom-up _____________________
▪️Expectations
▪️Somatosensory experiences
What facilitates the disruption between expectation and somatosensory experience?
Excessive attention directed towards the body
Hence they can be distracted and redirected
Biological, psychological, and social events can act as…
▪️Risk factors
▪️Triggering factors
▪️Maintaining factors
What is the gold standard for FND management?
Multidisciplinary care
What are the main barriers to FND care?
▪️Misdiagnosis is common
▪️Only ~30 specialist services in UK
What are the 6 main components of physical rehabilitation for FND?
▪️Education
▪️Movement retaining
▪️Addressing secondary problems (e.g. pain, fatigue)
▪️Self-management
▪️Vocational rehab
▪️Follow-up
What are some of the main targets for physical rehabilitation?
▪️Retraining attention
▪️Change expectations and illness beliefs
▪️Address fears of falling
▪️Improve pain management
▪️Address soft tissue problems
▪️Improve physical fitness
▪️Psychosocial benefits of activity
▪️Change maladaptive behaviours
What is the first key step to FND treatment?
Education!
▪️Acknowledge and explain the problem
▪️Explain how diagnosis was made
▪️Explain how attention drives it
▪️Discuss risk factors
▪️Explain how treatment works
▪️Language is key!
What can movement and posture retraining be used for?
Addressing maladaptive habitual postures
How might maladaptive habitual postures arise?
▪️Schema of body changes when sat in a position for a long tiken
▪️May lose insight and believe they’re say normally if eyes are closed
What approach is usually taken with movement retraining?
Sequential motor learning
E.g. help one element of walking then another, building up
What techniques can be used for movement retraining?
▪️Sequential motor learning
▪️Get them to think about moving differently to direct focus of motor attention
▪️Mirror feedback
How does mirror feedback work for movement retraining?
Redirects attention from the internal self into the external self/environment
What percentage of FMD cases show improvement with movement retraining?
40%
What is self-management?
Tasks one must undertake to live with their condition (e.g. medical, emotional etc.)
What can be used to help with self-management of FND?
Rehabilitation workbooks
▪️Info on FMD
▪️Reflections from treatment
▪️Management strategies
▪️Plans for managing difficult days
▪️Chart progress
▪️Future goals
Why mignt TMS show benefit alongside treatment for FND?
Placebo
What can be used alongside regular management strategies?
▪️Management of other symptoms e.g. pain, fatigue
▪️EMG biofeedback
▪️Therapeutic sedation
▪️TMS
▪️Hypnosis
▪️Group interventions
What is the evidence for treatment adjuncts for FND?
Very little
What should you avoid with FND treatment?
▪️Passive treatments
▪️Adaptive aids
▪️Focus on impairments
▪️Neglecting secondary factors (e.g. fatigue, pain)
What should be encouraged during FND treatment?
▪️Focus on activities
▪️Redirection of attention
▪️Maximum independence
▪️Family involvement
▪️Maintenance and relapse prevention plans
Why should splints and aids generally be avoided?
▪️Can affect illness beliefs and movement patterns.
▪️Can cause secondary sources of pain.
▪️Can draw more attention to an area - symptoms exacerbation and maintenance!
What should you do if aids are not avoidable?
▪️Involve patient in decision making and document it
▪️Ideally maintain thought that this is a temporary solution
▪️Keep the opportunity for patients to move without it
Should casting me used in fixed dystonia?
Not really - immobilisation can be very harmful, maintaining illness belief so should be avoided
According to a large systematic review of physiotherapy for FND, what are it’s main outcomes?
▪️55-70% ‘good’
▪️Moderate to large effect
▪️Some loss of effects but benefits largely sustained 1-2 years later (unclear after that)
▪️Little change for mental health
What were the main findings of Czarnecki’s 2012 evaluation of a 5-day intensive OT and PT treatment?
▪️69% rated markedly improved
▪️60% at follow up
What are the main limitations of the evidence for physical rehabilitation in FND?
▪️Most selected for treatments are less severe - exclusion of those with dominant pain, fatigue or psychiatric comorbidity)
▪️Unclear how long benefits stay
▪️Unclear data on return to work
What did Jordbru (2014) find in their study of a 3 week inpatient rehab for functional gait?
▪️Physical activity combined with educational and cognitive behavioural frame
▪️Significant difference in functional mobility
▪️Benefit sustained at 12 month follow up
In Nielsen’s feasibility study of PT in FMD, how many showed improvement of some kind?
71% in intervention compared to 19% in control
In Nielsen’s feasibility study of PT in FMD, what domains of the SF 36 show most improvement?
▪️Physical function
▪️Physical role
▪️Social function
In Nielsen’s feasibility study of PT in FMD, what domains of the SF 36 did NOT show change?
▪️Bodily pain
▪️General health
▪️Mental health (as well as HADS)
▪️Vitality
▪️Emotional role
How do physical interventions appear to effect illness perception and threat value?
Improves it as they are attending less to the problem/body part
(decreased threat value)
What are the three main goals of physical rehabilitation in FND?
▪️Education (beliefs and expectations)
▪️Movement retraining with redirection of attention
▪️Teaching self management strategies
