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Management of Disorders > Physical Rehabilitation for FND > Flashcards

Physical Rehabilitation for FND Flashcards

1
Q

How does the ICD11 classification of FND differ from the DSM?

A

DSM = Functional Neurological Symptom Disorder

ICD11 = Dissociative Neurological Symptom Disorder

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2
Q

What are functional neurological symptoms?

A

▪️Neuro symptoms (e.g. motor, sensory)
▪️Experienced as involuntary
▪️Altered functioning of networks, NOT structural damage

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3
Q

What is PPPD?

A

Persistent perceptual postural dizziness

(functional dizziness)

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4
Q

What are the five core categories of functional neurological symptoms?

A

▪️Motor
▪️Sensory
▪️Functional seizures
▪️Cognitive symptoms
▪️PPPD

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5
Q

What are the most commonly described secondary physical symptoms in FND?

A

▪️Chronic pain
▪️Fatigue

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6
Q

What are some of the most commonly described psychological symptoms in FND?

A

▪️Anxiety
▪️Depression
▪️Depersonalisation and dissociation
▪️PTSD
▪️Interpersonal difficulties

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7
Q

What are the main typical presentations of functional motor disorder?

A

▪️Weakness/paralysis
▪️Tremor
▪️Gait disturbance
▪️Jerks
▪️Dystonia

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8
Q

How does weakness in FMD usually differ from in stroke?

A

Patients more commonly show hypertonia

(compared to hypotonic in stroke)

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9
Q

What signs might indicate a tremor is functional?

A

▪️Variation in speed and symmetry
▪️Can change with distraction
▪️Entrainable

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10
Q

What signs might indicate a gait disturbance is functional?

A

▪️Distraction may alter it (e.g. turning around)
▪️Monoplegic dragging gait

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11
Q

What is propriospinal myoclonus?

A

Movement disorder characterised by repetitive, irregular jerks originating from middle of spine

Often functional and in the context of back pain

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12
Q

What are the main signs of functional dystonia?

A

▪️Fixed (e.g. inversion at ankle)
▪️Overlap with complex regional pain syndrome
▪️Asymmetric development
▪️Often precipitated by injury such as sprained ankle

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13
Q

What presentation of FMD is the hardest to treat and has the worst prognosis?

A

Dystonia

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14
Q

What is the general prognosis for FMD?

A

▪️~80% stay symptomatic
▪️Higher than expected mortality (~11%)

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15
Q

Why might FMD be associated with an increased risk of premature death?

A

Lifestyle factors (e.g. sedentary and dependent on wheelchair, cardiovascular disease)

Other associated secondary factors

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16
Q

What is the biopsychosocial understanding of FMD?

A

Disorder of sensorimotor processing (predictive processing)

Top-down expectations distort bottom up somatosensory experiences

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17
Q

Top-down ______________ distort bottom-up _____________________

A

▪️Expectations
▪️Somatosensory experiences

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18
Q

What facilitates the disruption between expectation and somatosensory experience?

A

Excessive attention directed towards the body

Hence they can be distracted and redirected

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19
Q

Biological, psychological, and social events can act as…

A

▪️Risk factors
▪️Triggering factors
▪️Maintaining factors

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20
Q

What is the gold standard for FND management?

A

Multidisciplinary care

21
Q

What are the main barriers to FND care?

A

▪️Misdiagnosis is common
▪️Only ~30 specialist services in UK

22
Q

What are the 6 main components of physical rehabilitation for FND?

A

▪️Education
▪️Movement retaining
▪️Addressing secondary problems (e.g. pain, fatigue)
▪️Self-management
▪️Vocational rehab
▪️Follow-up

23
Q

What are some of the main targets for physical rehabilitation?

A

▪️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

24
Q

What is the first key step to FND treatment?

A

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!

25
Q

What can movement and posture retraining be used for?

A

Addressing maladaptive habitual postures

26
Q

How might maladaptive habitual postures arise?

A

▪️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

27
Q

What approach is usually taken with movement retraining?

A

Sequential motor learning

E.g. help one element of walking then another, building up

28
Q

What techniques can be used for movement retraining?

A

▪️Sequential motor learning
▪️Get them to think about moving differently to direct focus of motor attention
▪️Mirror feedback

29
Q

How does mirror feedback work for movement retraining?

A

Redirects attention from the internal self into the external self/environment

30
Q

What percentage of FMD cases show improvement with movement retraining?

A

40%

31
Q

What is self-management?

A

Tasks one must undertake to live with their condition (e.g. medical, emotional etc.)

32
Q

What can be used to help with self-management of FND?

A

Rehabilitation workbooks

▪️Info on FMD
▪️Reflections from treatment
▪️Management strategies
▪️Plans for managing difficult days
▪️Chart progress
▪️Future goals

33
Q

Why mignt TMS show benefit alongside treatment for FND?

A

Placebo

34
Q

What can be used alongside regular management strategies?

A

▪️Management of other symptoms e.g. pain, fatigue
▪️EMG biofeedback
▪️Therapeutic sedation
▪️TMS
▪️Hypnosis
▪️Group interventions

35
Q

What is the evidence for treatment adjuncts for FND?

A

Very little

36
Q

What should you avoid with FND treatment?

A

▪️Passive treatments
▪️Adaptive aids
▪️Focus on impairments
▪️Neglecting secondary factors (e.g. fatigue, pain)

37
Q

What should be encouraged during FND treatment?

A

▪️Focus on activities
▪️Redirection of attention
▪️Maximum independence
▪️Family involvement
▪️Maintenance and relapse prevention plans

38
Q

Why should splints and aids generally be avoided?

A

▪️Can affect illness beliefs and movement patterns.
▪️Can cause secondary sources of pain.
▪️Can draw more attention to an area - symptoms exacerbation and maintenance!

39
Q

What should you do if aids are not avoidable?

A

▪️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

40
Q

Should casting me used in fixed dystonia?

A

Not really - immobilisation can be very harmful, maintaining illness belief so should be avoided

41
Q

According to a large systematic review of physiotherapy for FND, what are it’s main outcomes?

A

▪️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

42
Q

What were the main findings of Czarnecki’s 2012 evaluation of a 5-day intensive OT and PT treatment?

A

▪️69% rated markedly improved
▪️60% at follow up

43
Q

What are the main limitations of the evidence for physical rehabilitation in FND?

A

▪️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

44
Q

What did Jordbru (2014) find in their study of a 3 week inpatient rehab for functional gait?

A

▪️Physical activity combined with educational and cognitive behavioural frame
▪️Significant difference in functional mobility
▪️Benefit sustained at 12 month follow up

45
Q

In Nielsen’s feasibility study of PT in FMD, how many showed improvement of some kind?

A

71% in intervention compared to 19% in control

46
Q

In Nielsen’s feasibility study of PT in FMD, what domains of the SF 36 show most improvement?

A

▪️Physical function
▪️Physical role
▪️Social function

47
Q

In Nielsen’s feasibility study of PT in FMD, what domains of the SF 36 did NOT show change?

A

▪️Bodily pain
▪️General health
▪️Mental health (as well as HADS)
▪️Vitality
▪️Emotional role

48
Q

How do physical interventions appear to effect illness perception and threat value?

A

Improves it as they are attending less to the problem/body part

(decreased threat value)

49
Q

What are the three main goals of physical rehabilitation in FND?

A

▪️Education (beliefs and expectations)
▪️Movement retraining with redirection of attention
▪️Teaching self management strategies

Management of Disorders (28 decks)

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