Functional neurological disorder (FND) is a condition at the intersection of neurology and psychiatry that is commonly encountered across clinical settings.1–4 Functional neurological disorder–related health care costs rival other major neurological conditions and many patients remain chronically symptomatic1,5,6; these issues are also further compounded by widespread provider uncertainty regarding good management approaches in this population.7 Renewed interest in FND has been promoted by the use of positive “rule-in” signs specific for the diagnosis.8–10 Furthermore, an international, multidisciplinary professional FND Society has been created with physical therapists among its founding members, and an authoritative FND textbook has been published.11 In this context, physical therapy (PT) is at the forefront of emerging first-line treatments for motor functional neurological disorder (mFND), which includes the spectrum of functional movement disorder and functional weakness. To date, there are 2 small randomized controlled trials demonstrating the efficacy of PT in patients with mFND,12,13 and a large multicenter trial is currently underway.14 In addition, 2015 consensus recommendations helped operationalize the therapeutic role of PT in this patient population.15
Despite the growing evidence base for PT, the majority of treatment studies have been in the inpatient or intensive outpatient day program settings.12,16–18 The Massachusetts General Hospital FND Unit focuses on an outpatient multidisciplinary and interdisciplinary (nonintensive) care model informed by PT consensus recommendations.3,15,19 Across health care settings, access to outpatient care is generally more available.
In this article, we provide expert reflections on lessons learned from an experienced neurological clinical specialist in PT practicing in an FND program. To complement themes previously discussed within the PT literature, this article specifically discusses the following 4 topics: (1) use of the biopsychosocial formulation to guide longitudinal treatment; (2) the importance of team-based care; (3) telehealth in mFND; and (4) using the emerging neuroscience of mFND to inform PT.
USE OF THE BIOPSYCHOSOCIAL FORMULATION TO TRIAGE CHALLENGES AND GUIDE LONGITUDINAL CARE
The biopsychosocial model arose from Engel's20 work to adopt a medical approach that embodied the whole patient. At the time of his initial publication, the prevailing biomedical model aimed to match physical symptoms with biological mechanisms largely in isolation.20 The biomedical model explains diagnoses through a pathophysiologically focused lens, looking for deviations from the norm as the driving force of illness. Although the emphasis on disease mechanisms is foundational to medical advances, the biomedical model does not adequately account for psychological and sociocultural influences and determinants of health.21 The biopsychosocial model was proposed to account for the interplay between disease mechanisms, psychological factors, and the sociocultural context in which the patient lives and is being cared for.22
The biopsychosocial formulation, a dynamic and interactive model, is a prevailing perspective through which to conceptualize mFND.23,24 Although the viewpoint put forth in this article leverages the biopsychosocial formulation consistent with our programmatic philosophy, it is important to note that there are other multifaceted perspectives such as those developed in the chronic pain literature that offer alternative framings (eg, the enactive approach).25,26
In mFND, the biopsychosocial model identifies relevant biological, psychological, and social factors that act as predisposing vulnerabilities, acute precipitants, and perpetuating factors for a given patient.27 Consensus recommendations by Nielsen et al15 outline the use of the biopsychosocial model as a framework for personalizing PT interventions by considering a range of factors and how they relate to the patient's presentation. We encourage using this model to frame initial PT assessments, triage challenges, and guide longitudinal care (see Figure 1). At the early treatment stages, identification of these factors optimizes targets for patient and family education. In addition, this framing aids communication across team members including with occupational therapy (OT) and speech and language pathology colleagues.28–30 Although outside the PT scope of practice to comprehensively address all issues in a given patient's biopsychosocial formulation for mFND, identification of concerns will nonetheless help optimize decision making around the timing and focus of PT, while guiding referrals to other disciplines. This formulation can also assist physical therapists in identifying and understanding reasons for suboptimal treatment response. Such factors can include unhelpful behavioral patterns, prominent pain, and illness beliefs among other considerations.6,19,31 These themes are discussed further later.
Boom/Bust Activity Pattern and Symptom Avoidance
Two commonly encountered themes in mFND are avoidance of symptom exacerbation and the boom-and-bust activity pattern.32 Avoidance pertains to patients limiting activity based on symptom exacerbation concerns, resulting in diminished participation in activities of daily living and reduced quality of life. Boom-and-bust behavior patterns refer to an individual who overparticipates in activities when feeling well, with resultant “crashing” and limited activity for a period thereafter.33 Both patterns can be identified as perpetuating factors that can impede PT progress. In our experience, the boom-and-bust activity pattern tends to occur more often in those with perfectionistic traits, including individuals who find reward in task completion; of note, higher rates of obsessive-compulsive personality disorder have been described in mFND.34 A key strategic challenge in such a patient is to enhance understanding that limiting the amount that they push during relatively symptom-free periods, while slightly suboptimal from peak performance, will help prevent the “crash” phase and therefore facilitate greater overall productivity.32,35 In contrast, those who are avoidant tend to be stuck in a negative experiential learning pattern wherein prior experience has reinforced the prospect that certain environmental exposures or activities can worsen symptoms. This type of patient will need different guidance reinforcing that the provocation of symptoms is not a sign of poor treatment response and rather that we are working to normalize response to activity that sometimes requires symptoms to get worse before they get better. Eliminating the idea that symptom provocation is dangerous is also beneficial, leveraging, in part, exposure-type interventions. Education is imperative in both scenarios, with early attempts to understand whether a patient falls into either category and continued monitoring for these patterns longitudinally, as certain tendencies may become apparent only after several treatment sessions.
Therapeutic PT strategies to address unhelpful boom-and-bust activity patterns include (1) implementing daily structure with dedicated times for activity/exercise and rest, including education around stopping prior to onset of worsening symptoms; (2) helping patients identify the early bodily “warning” signs that they are reaching a threshold, that when crossed, tends to result in symptoms; (3) identifying what activity periods will look like and what activities are involved. Examples include exercise, household tasks or a hobby that is cognitively or physically active; and (4) identifying relaxation or low-output activities to balance higher activity times. Given patient heterogeneity, what is considered active versus low output will vary.
Therapeutic PT strategies to address avoidance patterns include (1) implementing graded exposure to activities in a structured manner that includes modest exercise as well as activities of daily living; (2) providing education on a patient's activity schedule, while not basing the degree of activity performed solely on symptoms; and (3) setting short-term goals around increasing active time and providing expectations for improvement.
Pain is a common co-occurring symptom in many mFND patients, along with other physical symptoms including fatigue and gastrointestinal distress.36 The presence of other bodily symptoms such as pain has been linked to poor outcomes.6,19 Given the frequent co-occurrence of core sensorimotor mFND symptoms and other bodily complaints, there have been recent calls to think holistically about mFND with prominent somatic symptoms, potentially akin to a FND plus syndrome.31 Physical therapists should get a sense of the balance of motor versus pain/other somatic symptoms in each patient. Early discussions with patients will help outline which of their multiple symptoms is more distressing and subsequently identify the appropriate next steps. If pain is the main concern, our approach is to first consider a referral to a multidisciplinary pain program. Multidisciplinary pain programs have been successful in patients with mFND, demonstrating both improved pain-related disability and improved functional mobility.37 In such cases, initiation of mFND-focused motor retraining can then be reconsidered upon completion of a pain program. Conversely, for patients presenting with pain as part of their constellation but also identifying motor symptoms as chief concerns, we would consider initiating mFND-specific PT, with modifications to address the pain component concurrently. In such patients, providing pain science education focusing on reducing thoughts that identify pain as an indicator of tissue level damage can be helpful, as well as reinforcing the concept that exercise with discomfort is not inherently dangerous.38
Physical therapy strategies to address concurrent pain symptoms include (1) use of a slow and graded approach to activity with focus on whole-body movements and functional activities—this group may benefit from cardiovascular exercise to gradually increase activity level; (2) mutual goal setting around return to activities versus elimination of all pain; and (3) collaborating toward the construction of a daily schedule to target avoidance behaviors.
Certain unhelpful illness beliefs, as understood by the patient and the family, can serve as perpetuating factors.39 For example, take a patient with a prior back injury that recovered, who goes on to have a fall. Following the fall, the patient develops right lower extremity numbness/tingling and diffuse whole-body weakness. Physical examination reveals giveaway weakness and spine imaging shows no relevant abnormality. The patient is diagnosed with mFND using rule-in signs and presents to PT. Upon discussion with the patient, there is clear connection of symptoms to the fall and back injury, with concern that this “was bound to happen,” given their previous back issues. The patient states that they were diagnosed with mFND, but they do not believe that diagnosis explains the ongoing difficulties. They comment that they are worried that more tests may be necessary. This commonly encountered scenario indicates that the patient does not understand and/or accept the mFND diagnosis. As discussed in the consensus recommendations, the initiation of PT should ideally occur after the patient agrees with the diagnosis and demonstrates some readiness for treatment.15 We propose a clear discussion in the beginning of PT care to gauge openness and awareness of the mFND diagnosis. In our clinic, this is addressed with an open conversation as well as 3 structured self-report questions that are included along with a case example in the Appendix.3
The goal of this discussion is to gauge the understanding/belief that a patient has about their diagnosis and potential for change. Themes that may emerge include an early lack of understanding, lack of acceptance despite understanding, and belief that symptoms are permanent or irreversible. Early dialogue is essential to guide education and identify areas for concern. It is also important to keep in mind that an early lack of understanding is distinct from feeling strongly that an alternate diagnosis explains symptoms. Education that symptoms are potentially reversible in tandem with patients observing a positive change in symptoms during treatment can be helpful in changing a patient's expectation around their diagnosis/prognosis. Overall, such dialogue allows for targeted communication and appropriate timing/delivery of care.
Therapeutic PT strategies to address potentially unhelpful illness beliefs include (1) pointing patients toward appropriate educational resources and publicly available patient testimonials (www.neurosymptoms.org); (2) maintaining open communication, allowing the patient to express doubts, as long as they are willing to listen to education provided and participate in treatment; (3) utilizing change in symptoms with strategies as evidence that supports diagnosis and symptom reversibility; and (4) if patient's lack of buy-in is not improving, having a nonjudgmental yet transparent conversation that identifies that now may not be the best time for PT. If an individual expresses strong disbelief or concern about the diagnosis, it may be prudent to pause and direct the patient to the referring physician for additional discussion prior to engaging in PT.
Good management of mFND in many instances involves a coordinated, team-based approach with regular communication among team members. Inpatient models of care have shown success with multidisciplinary treatment; however, access to these settings is limited.2,12,18,40 Outpatient care is more accessible and has also shown treatment benefit.3 In recent years, the publication of the consensus recommendations for PT has been complemented by consensus recommendations in OT and speech and language pathology.15,28,30 Similarly, expert opinions have been published regarding the neuropsychiatric approach to the assessment of patients with FND.41,42 Our multidisciplinary team also utilizes interdisciplinary care, emphasizing the importance of shared expertise and close exchange of knowledge and clinical formulations. We strive for a horizontal (as opposed to hierarchical) structure among providers, with an understanding that each provider has a unique perspective of the patient. In our program, patients have access to time-limited cognitive behavioral therapy, OT, speech and language pathology, and/or PT, driven by their symptoms and clinical formulation.19,43 An initial evaluation in our outpatient FND program is performed by a neurologist or neuropsychiatrist who following diagnostic confirmation aims to develop an individualized (biopsychosocial-informed) treatment plan, referring to PT and other physical rehabilitation disciplines based on clinical phenotype and concurrently to psychotherapy in most cases.26 Our group participates in monthly FND clinical rounds to discuss patients—emphasizing challenging cases to problem solve; we also use this setting to discuss clinical successes to consolidate positive therapeutic approaches. Our program also allows for a more modular approach, attempting to tailor treatments to individual patients. Although most patients can benefit from numerous services, others may need a more staggered approach to mitigate the risk of the patient feeling overwhelmed from the range of treatments being offered concurrently.
ROLE OF TELE-PT
Telemedicine expanded exponentially during the COVID-19 pandemic. With return to in-person care, questions remain regarding the role for telehealth for those with mFND. A telemedicine PT pilot performed prior to the pandemic demonstrated efficacy in a small sample.44 They performed an in-person evaluation, followed by once weekly virtual visits, with an in-person visit at the halfway point and end of care. Approximately 77.8% of patients reported that they felt “better” or “much better” following treatment. One significant advantage of telemedicine is the expansion of access to specialty care,45 as patients without access to metropolitan areas generally experience challenges receiving up-to-date mFND care. Our anecdotal experience during the pandemic was that follow-up telehealth visits for those with mFND were a helpful way to engage with patients in their own environment, with implementation of previously reviewed strategies. Currently, a hybrid (mixed in-person/virtual) model has proven successful for those coming from a considerable distance—prioritizing in-person initial evaluations where possible. This initial in-person session lays the foundation for treatment engagement, goal setting, expectations, and objective data collection. We find that bringing patients in for a visit intermittently between virtual visits is valuable, as it allows for reassessment opportunities. Tele-PT also allows for tapering visits closer to discharge and empowers patients to utilize treatment techniques independently in their homes to build their self-management tool kit. Given the distance that many patients travel, the virtual option has seemingly optimized care by allowing for improved access to specialty PT for mFND.
USING THE NEUROSCIENCE OF mFND TO PERSONALIZE TREATMENT
Although a comprehensive review of the neurobiology of mFND is beyond the scope of this article and covered elsewhere,46,47 a focused understanding of some of the emerging neuroscience principles implicated in the pathophysiology of mFND can prove helpful in understanding the rationale for treatment and identifying additional therapeutic interventions. Multiple neuroscience constructs have been postulated in the pathophysiology of mFND.46 These constructs map on to specific brain networks (or interactions across multiple brain networks), including involvement of sensorimotor, attentional, salience, limbic, and default mode networks.48,49 In addition, there is substantial heterogeneity in the mFND neurobiological literature, suggesting that multiple mechanisms (constructs and networks) are implicated, and that mechanistic explanations may be distinct across different patients. Later, we delve briefly into 3 constructs of interest in mFND (biased attention, emotion processing, and self-agency) and relate these constructs to important PT therapeutic concepts (see Figure 2).
Misdirected attention is a core component of mFND for many patients, with individuals demonstrating increased attention toward bodily symptoms, heightened self-monitoring, and a relative lack of ability to shift focus.46 Brain networks involved in attention, which have been identified to be functionally and/or structurally altered in mFND, include the ventral frontoparietal, salience, and executive control networks.46,47,50 The presence of involuntary attentional biases can negatively impact movement in patients with mFND, and diverting attention away from the body through use of cognitive or dual-task distractions can facilitate symptom improvement.
In PT, distraction and dual-task completion interventions allow the engagement of already matured motor patterns to reemerge. This distraction can come in numerous forms and often requires trial and error prior to successful change in movement. Exploring dual-task strategies falls into numerous categories, including cognitive, motor, and sensory strategies with examples listed in Figure 2. The goal is to drive attention away from bodily symptoms, a process that can also be achieved by encouraging an external focus. This perspective shares similarities with the Optimizing Performance Through Intrinsic Motivation and Attention for Learning (OPTIMAL) theory, which includes an emphasis on external focus to aid motor performance.51 In addition, the task can be broken down into a similar but different task that elicits more typical movement. Modulating sensory input (eg, cinnamon candy in the mouth or soft/spiky object in the hand) can be explored as a distraction strategy and also as a way to address sensory-processing difficulties that can hinder movement.29 The goal of a dual task is to create a change in movement and utilize that change to provide education about symptom reversibility. The patient should be included in future strategy selection to increase autonomy in actively improving their symptoms. Considering the inherent difficulty in shifting attention, patients often need assistance to recognize when typical movement emerges, and they also need repetition to practice this pattern and allow it to become predominant.
Altered emotion processing can also be appreciated in some patients with mFND. Increased arousal and emotional reactivity, alexithymia (having difficulty putting emotions into words), dissociation, fear/threat avoidance, and altered emotion regulation have all been identified.23,46 On a neurocircuitry level, alterations have been observed in the salience and limbic networks; such findings have included increased resting-state and/or task-based functional connectivity between emotion-processing areas (amygdala, insula, anterior cingulate cortex) and motor control regions.23,46 One can think of this as abnormal cross talk between areas responsible for movement and affective responses. An alternative framing can be that salience/limbic circuits “hijack” motor control brain areas.52
Recognition of emotion-processing difficulties can inform the selection/implementation of PT treatment. For example, for the patient with fear of falling/freezing episodes, simply shifting attention through dual task may not alleviate symptoms or atypical patterns. Providers may therefore need to identify strategies that allow for some degree of “grounding,” such as adding weight to lower extremities, cueing patient to feel toes pushing into the ground, or adding visual feedback, all of which will increase sensory input. These techniques work to connect the person to their sensory inputs, which can help improve their sense of motor control. This patient may also need relaxation training to minimize hyperarousal, which can be achieved through diaphragmatic breathing or slow rhythmic weight shifting. For patients concurrently in cognitive behavioral therapy, it can also be helpful to ask about the specific relaxation strategies they are learning and encourage them to use such strategies when hyperarousal or overt anxiety is noted. These strategies can be applied on an as needed basis but can also become a part of their regular routine. Working in conjunction with mental health and OT colleagues can provide additional insights into the use of relaxation strategies, as well as helping identify psychologically relevant triggers and perpetuating factors impacting movement.53,54 In our program, the majority of patients are concurrently undergoing psychotherapy in parallel to PT, given their commonly encountered neuropsychiatric complexity.3
Self-Agency, Predictive Processing, and Inference
The concepts of self-agency, predictive processing, and inference are interconnected. All of these concepts involve some degree of matching between feed forward and feedback information (ie, top-down and bottom-up information). Self-agency reflects the notion that when an individual moves volitionally, they also perceive themselves as the author of their own movements.55 Patients with hyperkinetic functional movements experience difficulties in this area, given that movements are experienced as involuntary. Voluntary movement that has a sense of self-agency occurs through matching of feed forward/predictive signals and feedback information, and in mFND, a mismatch contributes to decreased action-authorship perceptions. The right temporoparietal junction is a region responsible for matching these signals, and neuroimaging has shown decreased connectivity between the right temporoparietal junction and sensorimotor areas.49,55 Inference refers to how one creates beliefs about bodily experiences, and perceptually, this can be influenced by a mismatch between predictions and incoming sensory inputs.46 These expectations or “predictions” form the basis of predictive processing, in which the brain creates a predictive model and then utilizes sensory input to alter the model/identify prediction errors. In mFND, these difficulties could potentially be related to abnormal top-down predictions, impaired weighting of incoming sensory input, or impairments in prediction error learning.56
In PT, self-agency can be provided by allowing patients to experience episodes of returned voluntary control over movement. An example is a patient who does not exhibit ankle dorsiflexion during gait but is then able to achieve appropriate ankle dorsiflexion during anterior/posterior swaying activity. By pointing out the control noted during sway activity and encouraging repetition of this, the provider assists in promoting patient self-agency. This change in activation of musculature can also serve to interrupt aberrant predictive processing, as it differs from what the patients expect to occur during gait. As the patient sees changes in symptoms and muscle activation, they can be empowered to self-select strategies that alter symptoms. The autonomy that comes with guided self-selection of strategies can also aid in building self-efficacy.
PT has emerged as a first-line treatment for mFND, and physical therapists should be at the forefront of these clinical and research pursuits. This article highlights the need for an expanded PT tool kit to treat mFND utilizing existing consensus recommendations as an important foundation. An enhanced understanding of how to utilize the biopsychosocial model and a greater understanding of the neuroscience behind mFND add to this tool kit. Furthermore, it seems likely that a continued role for tele-PT will remain as we work on optimizing care delivery. As research in the field continues to expand, we will learn more about mFND and how to further optimize PT interventions.
1. Stone J, Carson A, Duncan R, et al. Who is referred to neurology clinics?—the diagnoses made in 3781 new patients. Clin Neurol Neurosurg. 2010;112(9):747–751.
2. Jacob AE, Kaelin DL, Roach AR, Ziegler CH, LaFaver K. Motor Retraining (MoRe) for functional movement disorders: outcomes from a 1-week multidisciplinary rehabilitation program. PM R. 2018;10(11):1164–1172.
3. Maggio JB, Ospina JP, Callahan J, Hunt AL, Stephen CD, Perez DL. Outpatient physical therapy for functional neurological disorder: a preliminary feasibility and naturalistic outcome study in a U.S. cohort. J Neuropsychiatry Clin Neurosci. 2020;32(1):85–89.
4. Nielsen G, Stone J, Edwards MJ. Physiotherapy for functional (psychogenic) motor symptoms: a systematic review. J Psychosom Res. 2013;75(2):93–102.
5. Stephen CD, Fung V, Lungu CI, Espay AJ. Assessment of emergency department and inpatient use and costs in adult and pediatric functional neurological disorders. JAMA Neurol. 2021;78(1):88–101.
6. Gelauff JM, Carson A, Ludwig L, Tijssen MAJ, Stone J. The prognosis of functional limb weakness: a 14-year case-control study. Brain. 2019;142(7):2137–2148.
7. Barnett C, Davis R, Mitchell C, Tyson S. The vicious cycle of functional neurological disorders: a synthesis of healthcare professionals' views on working with patients with functional neurological disorder. Disabil Rehabil. 2022;44(10):1802–1811.
8. Espay AJ, Aybek S, Carson A, et al. Current concepts in diagnosis and treatment
of functional neurological disorders. JAMA Neurol. 2018;75(9):1132–1141.
9. Stone J, LaFrance WC Jr, Levenson JL, Sharpe M. Issues for DSM-5: conversion disorder. Am J Psychiatry. 2010;167(6):626–627.
10. Daum C, Hubschmid M, Aybek S. The value of “positive” clinical signs for weakness, sensory and gait disorders in conversion disorder: a systematic and narrative review. J Neurol Neurosurg Psychiatry. 2014;85(2):180–190.
11. Nielsen G. Physical treatment
of functional neurologic disorders. Handb Clin Neurol. 2016;139:555–569.
12. Jordbru AA, Smedstad LM, Klungsoyr O, Martinsen EW. Psychogenic gait disorder: a randomized controlled trial of physical rehabilitation with one-year follow-up. J Rehabil Med. 2014;46(2):181–187.
13. Nielsen G, Buszewicz M, Stevenson F, et al. Randomised feasibility study of physiotherapy for patients with functional motor symptoms. J Neurol Neurosurg Psychiatry. 2017;88(6):484–490.
14. Nielsen G, Stone J, Buszewicz M, et al. Physio4FMD: protocol for a multicentre randomised controlled trial of specialist physiotherapy for functional motor disorder. BMC Neurol. 2019;19(1):242.
15. Nielsen G, Stone J, Matthews A, et al. Physiotherapy for functional motor disorders: a consensus recommendation. J Neurol Neurosurg Psychiatry. 2015;86(10):1113–1119.
16. Czarnecki K, Thompson JM, Seime R, Geda YE, Duffy JR, Ahlskog JE. Functional movement disorders: successful treatment
with a physical therapy rehabilitation protocol. Parkinsonism Relat Disord. 2012;18(3):247–251.
17. Nielsen G, Ricciardi L, Demartini B, Hunter R, Joyce E, Edwards MJ. Outcomes of a 5-day physiotherapy programme for functional (psychogenic) motor disorders. J Neurol. 2015;262(3):674–681.
18. Demartini B, Batla A, Petrochilos P, Fisher L, Edwards MJ, Joyce E. Multidisciplinary treatment
for functional neurological symptoms: a prospective study. J Neurol. 2014;261(12):2370–2377.
19. Glass SP, Matin N, Williams B, et al. Neuropsychiatric factors linked to adherence and short-term outcome in a U.S. functional neurological disorders clinic: a retrospective cohort study. J Neuropsychiatry Clin Neurosci. 2018;30(2):152–159.
20. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129–136.
21. Dhand A, Luke DA, Lang CE, Lee JM. Social networks and neurological illness. Nat Rev Neurol. 2016;12(10):605–612.
22. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137(5):535–544.
23. Pick S, Goldstein LH, Perez DL, Nicholson TR. Emotional processing in functional neurological disorder: a review, biopsychosocial model and research agenda. J Neurol Neurosurg Psychiatry. 2019;90(6):704–711.
24. Saxena A, Paredes-Echeverri S, Michaelis R, Popkirov S, Perez DL. Using the biopsychosocial model to guide patient-centered neurological treatments. Semin Neurol. 2022;42(2):80–87.
25. Coninx S, Stilwell P. Pain and the field of affordances: an enactive approach to acute and chronic pain. Synthese. 2021;199(3):7835–7863.
26. Finkelstein SA, Adams C, Tuttle M, Saxena A, Perez DL. Neuropsychiatric treatment
approaches for functional neurological disorder: a how to guide. Semin Neurol. 2022;42(2):204–224.
27. Saxena A, Godena E, Maggio J, Perez DL. Towards an outpatient model of care for motor functional neurological disorders: a neuropsychiatric perspective. Neuropsychiatr Dis Treat. 2020;16:2119–2134.
28. Nicholson C, Edwards MJ, Carson AJ, et al. Occupational therapy consensus recommendations for functional neurological disorder. J Neurol Neurosurg Psychiatry. 2020;91(10):1037–1045.
29. Ranford J, MacLean J, Alluri PR, et al. Sensory processing difficulties in functional neurological disorder: a possible predisposing vulnerability? Psychosomatics. 2020;61(4):343–352.
30. Baker J, Barnett C, Cavalli L, et al. Management of functional communication, swallowing, cough and related disorders: consensus recommendations for speech and language therapy. J Neurol Neurosurg Psychiatry. 2021;92(10):1112–1125.
31. Maggio J, Alluri PR, Paredes-Echeverri S, et al. Briquet syndrome revisited: implications for functional neurological disorder. Brain Commun. 2020;2(2):fcaa156.
32. Sharpe M, Walker J, Williams C, et al. Guided self-help for functional (psychogenic) symptoms: a randomized controlled efficacy trial. Neurology. 2011;77(6):564–572.
33. King E, Beynon M, Chalder T, Sharpe M, White PD. Patterns of daytime physical activity in patients with chronic fatigue syndrome. J Psychosom Res. 2020;135:110154.
34. Demartini B, Petrochilos P, Ricciardi L, Price G, Edwards MJ, Joyce E. The role of alexithymia in the development of functional motor symptoms (conversion disorder). J Neurol Neurosurg Psychiatry. 2014;85(10):1132–1137.
35. Williams C, Carson A, Smith S, Sharpe M, Cavanagh J, Kent C. Overcoming Functional Neurological Symptoms: A Five Areas Approach. 1st ed. Boca Raton, FL: CRC Press; 2011.
36. Butler M, Shipston-Sharman O, Seynaeve M, et al. International online survey of 1048 individuals with functional neurological disorder. Eur J Neurol. 2021;28(11):3591–3602.
37. Jimenez XF, Aboussouan A, Johnson J. Functional neurological disorder responds favorably to interdisciplinary rehabilitation models. Psychosomatics. 2019;60(6):556–562.
38. Booth J, Moseley GL, Schiltenwolf M, Cashin A, Davies M, Hubscher M. Exercise for chronic musculoskeletal pain: a biopsychosocial approach. Musculoskeletal Care. 2017;15(4):413–421.
39. Sharpe M, Stone J, Hibberd C, et al. Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome. Psychol Med. 2010;40(4):689–698.
40. Saifee TA, Kassavetis P, Parees I, et al. Inpatient treatment
of functional motor symptoms: a long-term follow-up study. J Neurol. 2012;259(9):1958–1963.
41. Perez DL, Aybek S, Popkirov S, et al. A review and expert opinion on the neuropsychiatric assessment of motor functional neurological disorders. J Neuropsychiatry Clin Neurosci. 2021;33(1):14–26.
42. Baslet G, Bajestan SN, Aybek S, et al. Evidence-based practice for the clinical assessment of psychogenic nonepileptic seizures: a report from the American Neuropsychiatric Association Committee on Research. J Neuropsychiatry Clin Neurosci. 2021;33(1):27–42.
43. Jalilianhasanpour R, Ospina JP, Williams B, et al. Secure attachment and depression predict 6-month outcome in motor functional neurological disorders: a prospective pilot study. Psychosomatics. 2019;60(4):365–375.
44. Demartini B, Bombieri F, Goeta D, Gambini O, Ricciardi L, Tinazzi M. A physical therapy programme for functional motor symptoms: a telemedicine pilot study. Parkinsonism Relat Disord. 2020;76:108–111.
45. Perez DL, Biffi A, Camprodon JA, et al. Telemedicine in behavioral neurology-neuropsychiatry: opportunities and challenges catalyzed by COVID-19. Cogn Behav Neurol. 2020;33(3):226–229.
46. Drane DL, Fani N, Hallett M, Khalsa SS, Perez DL, Roberts NA. A framework for understanding the pathophysiology of functional neurological disorder. CNS Spectr. 2020:1–7. doi:10.1017/S1092852920001789.
47. Baizabal-Carvallo JF, Hallett M, Jankovic J. Pathogenesis and pathophysiology of functional (psychogenic) movement disorders. Neurobiol Dis. 2019;127:32–44.
48. Voon V, Cavanna AE, Coburn K, Sampson S, Reeve A, LaFrance WC Jr. Functional neuroanatomy and neurophysiology of functional neurological disorders (conversion disorder). J Neuropsychiatry Clin Neurosci. 2016;28(3):168–190.
49. Diez I, Larson AG, Nakhate V, et al. Early-life trauma endophenotypes and brain circuit-gene expression relationships in functional neurological (conversion) disorder. Mol Psychiatry. 2021;26(8):3817–3828.
50. Marek S, Dosenbach NUF. The frontoparietal network: function, electrophysiology, and importance of individual precision mapping. Dialogues Clin Neurosci. 2018;20(2):133–140.
51. Wulf G, Lewthwaite R. Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning. Psychon Bull Rev. 2016;23(5):1382–1414.
52. Perez DL, Edwards MJ, Nielsen G, Kozlowska K, Hallett M, LaFrance WC Jr. Decade of progress in motor functional neurological disorder: continuing the momentum [published online ahead of print March 15, 2021]. J Neurol Neurosurg Psychiatry. doi:10.1136/jnnp-2020-323953.
53. Goldstein LH, Chalder T, Chigwedere C, et al. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT. Neurology. 2010;74(24):1986–1994.
54. Maclean J, Finkelstein SA, Paredes-Echeverri S, Perez David L, Ranford J. Sensory processing difficulties in patients with functional neurological disorder: occupational therapy management strategies and two cases. Semin Pediatr Neurol. 2022;41:100951.
55. Maurer CW, LaFaver K, Ameli R, Epstein SA, Hallett M, Horovitz SG. Impaired self-agency in functional movement disorders: a resting-state fMRI study. Neurology. 2016;87(6):564–570.
56. Lin D, Castro P, Edwards A, et al. Dissociated motor learning and de-adaptation in patients with functional gait disorders. Brain. 2020;143(8):2594–2606.
Appendix. Narrative Example of Team-Based Care Utilizing the Biopsychosocial Model
|A.M. is a 44-year-old male groundskeeper presenting to physical therapy (PT) with a functional leg weakness. Onset of symptoms (ie, back pain, sense of disconnection, and right lower extremity weakness) was sudden and occurred at work following lifting a heavy box. He was transported to the emergency department (ED), where a neurological examination showed give-way weakness and a positive Hoover's sign on the right. Spine magnetic resonance imaging was unremarkable, and symptoms improved over several hours. He was discharged with a suspected functional neurological disorder (FND) and referred to outpatient neurology. Once home, symptoms reoccurred prompting another ED visit, where rule-in signs for FND were again verified. He was discharged in a wheelchair. Thereafter, he remained symptomatic, anxious to return to work and perplexed about his symptoms.
|During the neurology clinic visit, he continued to show examination signs of functional leg weakness. On his neuropsychiatric screening, it was noted that A.M. had prior panic attacks and past posttraumatic stress disorder (PTSD) symptoms. He reported experiencing physical abuse as a child, and ongoing marital and financial difficulties. Given this presentation, he was referred to outpatient PT and placed on the psychotherapy wait list. Electromyography/nerve conduction study showed no evidence of radiculopathy.
|During his outpatient PT evaluation, A.M. reported diagnostic ambivalence but noted that www.neurosymptoms.org was helpful. He arrived with a rolling walker and had knee buckling—endorsing concurrent back pain. Following the unstructured interview, he was asked 3 questions:
|Question 1: On a 0-10 scale, how well do you understand your diagnosis of FND: 10 indicates full understanding and 0 indicates no understanding.
|Question 2: Of the following statements, pick the one that best describes you:
|a. I do not think the diagnosis of FND is correct; I think there is something else wrong with me.
|b. I am willing to think about FND as a diagnosis for my symptoms but am still not sure it is correct.
c. I think the diagnosis of FND is correct.
|Question 3: On a 0-10 scale, to what extent do you expect to recover from FND? 10 equals full recovery and 0 indicates no recovery.
|During manual muscle testing, he exhibited give-way weakness in his right leg. He could perform sit to stand but relied heavily on his left leg and walker. He stated, “this whole thing is so strange, it is nuts that my leg just won't move,” followed by “I have always been able to push through injuries.” Seeing the reversibility in symptoms by pointing out his improved ambulation using dual-task distraction helped him further understand the diagnosis and improvement potential. When discussing his daily activities, he reported a physically demanding job and a passion for exercise. He asked, “what do you think, how many weeks before this is better?” noting that he needed to return to work as soon as possible.
|Initial PT-Focused Treatment
|Based on the assessment, impressions suggest that A.M. is buying into the diagnosis, with an evolving understanding. A.M.'s initial comments indicated that he had a general tendency to push through adversity. This information prompted the PT to keep pacing in mind, as A.M. likely had potential to overexert himself (a perpetuating factor). In addition, prior panic attacks and PTSD symptoms can be framed as predisposing vulnerabilities, while back pain could be seen as a relevant precipitating factor, and his urgency to return to work as another perpetuating factor.
|Thus, initial treatment considerations were targeted to focus on achieving equal weight bearing and gait improvement through diverted attention. In addition, pain science education was provided with the goal of minimizing guarded movements. Being mindful of exercise intensity and incorporating structured rest breaks was an additional intervention. To increase self-efficacy, A.M. was encouraged to utilize self-selected strategies that provided positive change in movement outside of PT.
|Longitudinal PT Care
|Over the course of 7 sessions, his knee buckling and pain decreased and he was ambulating without an assistive device. By visit 4, he began to recognize boom-and-bust behavior patterns. However, he continued to comment on how he “only knew how to get better by pushing forward.” He began to experience periods of symptom resolution but struggled to identify early bodily warning signs of symptom reoccurrence. In sessions, the addition of an external focus improved gait, but successful use of such strategies outside of clinic proved more challenging. Around this time, he started psychotherapy. Given his treatment plateau, the PT initiated a discussion with his psychotherapist—detailing insights into the patient's biopsychosocial formulation. Concurrent psychotherapy identified a more pervasive pattern of all-or-none tendencies, as well as limited verbalization of emotional distress. This allowed the psychotherapist to further explore connections between behaviors, emotions, thought patterns, life events, and functional neurological symptoms. Thereafter, PT sessions were spaced out to once a month sessions with weekly psychotherapy. Over the course of 3 additional months, A.M. was able to achieve sustained multiday periods of symptom resolution with brief relapses that he was able to manage on his own.