Functional neurologic disorders

T/F: you have to exclude malingering to diagnose functional neurologic disorders?

false

is it possible for patients with FND to score normal range on psychological questionnaires?

yes, 39% of patients diagnosed scored within normal range

do symptoms usually come on gradually or rapidly?

rapid and suddenly

what are potential contributing factors to FND? (5)

- early life stresses (including in utero)

- injury

- illness with fatigue/bed rest

- anesthesia

- post panic attack

is it common for there to be spontaneous remission?

yes

can multiple functional symptoms occur concurrently?

yes

what is the overall treatment protocol?

- PT and OT 2x/day for 5 consecutive days

- SLP if needed

- eval by psychiatrist or psychologist early in the week

- assessment by neurologist at end of the week

what outcome measures should be done? (3)

- video at beginning and end of week

- patient and physician rated outcomes

- self rated disability scale

how can long term outcome measures be done?

- can mail questionnaires and phone call to follow up

what are positive diagnostic signs for functional limb weakness? (2)

- hoovers sign = hip ext weakness that improves with contralateral hip flexion contraction

- hip abductor sign = abductor weakness that improves with contralateral abduction contraction

what are positive diagnostic signs for functional movement disorders? (3)

- functional dystonia presenting in a clenched fist or inverted ankle

- facial dystonia presents with episodic contraction of orbicularis oculi

- left wrist tremor stops when copying examiners movements with right hand

what is the big picture on what you should look for when diagnosing?

- look for variability of symptoms especially when the patient is distracted

T/F: multidisciplinary approach is best?

true

what medications can be helpful?

- antidepressants

- anti-anxiety

T/F: it is important to acknowledge that the symptoms are real and that they are common?

true

can symptoms improve with FND? why or why not?

- yes because there is no irreversible damage to the nervous system

what are some factors that can trigger symptoms? (6)

- stress

- anxiety

- depression

- trauma

- illness

- injury

what is the goal of therapy?

re-training the nervous system

is every patient with FND appropriate for therapy?

no

how might you treat breathing techniques with a distraction component of FND treatment? (3)

- blowing bubbles

- blowing a pinwheel

- blowing with a straw

T/F: FND often occurs with other neurological disorders?

true

T/F: FND is exclusively a psychological problem caused by psychological problems?

false

T/F: prognosis of FND is usually good?

false

T/F: FND treatment is individualized and involves careful explanation and combinations of physical and psychological rehabilitation?

true

is there a consensus for frequency and duration of treatment OUTSIDE OF PROGRAMS?

- no consensus

- maybe 1-2x/week for 12-16 weeks

what is the physio4FMD trial?

- looking at a specialist physiotherapy protocol alone to treat rather than a multidisciplinary approach

- 9 sessions/3weeks

- found that there were better subjective reports of improvements despite there still being impairments

T/F: FND is an umbrella term?

true

what is FND?

- neurological condition caused by changes in how the brain networks work

- not changes in the structure of the brain

can physical symptoms of FND be explained by changes in brain structure?

-no, but that doesn't mean the symptoms aren't genuine

what 2 neurologic conditions is FND compared to?

- MS and ALS

can FND overlap with a neurologic disease?

yes

what is the diagnostic criteria for FND (4)

- 1+ symptoms of altered voluntary motor or sensory function

- clinical findings provide evidence for incompatibility between symptoms and recognized medical conditions

- another medical or mental disorder does not explain the symptoms presenting

- symptom or deficit results in clinically significant impairment in social, occupational, or other functional spaces

what is a functional movement disorder?

- involuntary but learned habitual movement pattern driven by abnormal self-directed attention due to a complex combination of physical, mental, and social influence on brain function

what is a common trigger of functional movement disorder?

- commonly triggered by physical or emotional event

- 40% of people dont have psychiatric history

what is a common presentation of adult with functional movement disorder? (5)

- tremor

- gait disorder

- dystonia

- weakness

- paralysis

what is a common presentation in children with functional movement disorder? (3)

- seizures

- sensory loss

- motor symptoms

what is ongoing research saying about FMRIs?

- FMRI are showing changes in brain structure with FND

what is agency?

- experience of being the cause of our own actions

- depends on comparison of sensory feedback with what was predicted

what happens with impaired self agency?

- brain is over aware of attention without voluntary control

what 2 events must occur to produce self agency?

1. the person must have the sense of willing the movement

2. the movement has to happen

what is interoception?

- perception of internal signals from the body

what is attention dysregulation?

- inappropriate self directed attention

what are key regions of the brain that are involved? (5)

- insula

- amygdala

- prefrontal cortex

- temporo-parietal junction

- supplementary motor area

what is the function of the insula? (5)

- sensory processing/interoception

- emotional functions/limbic system

- motivation/reward/defense systems

- cognitive systems

- neuromodulation

what is the amygdala?

- in the limbic system of the brain

- at the epicenter for emotions (mostly fear)

T/F: FND causes a top-down prediction error?

true

T/F: FND causes impaired integration of bottom up sensory imput?

true

what is entrainment?

- tremor changes to the same frequency as a cued rhythmic movement

what is a whack-a-mole sign?

- with restraint of affected body part, involuntary movement emerges or worsens in other parts of the body

what is a wheelchair sign?

- patient can sit and walk the wheelchair while seated but is unable to stand up and walk

what is the riverbanks analogy?

T/F: physical therapy for FND emphasizes task based interventions and self efficacy?

true

T/F: FND is associated with autonomic factors?

- true

- reports of fainting, rapid HR, dizziness, sweating, bowel and bladder issues

T/F: people with FND tend to have a decrease in PSNS activity

true

what can be done to measure increase in SNS?

- decreased PSNS means increased SNS

- if increased SNS, wrist or chest HR monitor can be used to gather objective data (HR and HR variability)