What is the recommended treatment approach for Functional Neurological Disorder (FND)?

Treatment Approach for Functional Neurological Disorder

Multidisciplinary rehabilitation centered on occupational therapy and physical therapy, grounded in a biopsychosocial framework with patient education and self-management strategies, represents the recommended first-line treatment for FND. 1, 2

Core Treatment Framework

The treatment approach must be based on a biopsychosocial etiological model that addresses predisposing, precipitating, and perpetuating factors across biological, psychological, and social domains. 1, 2 This framework recognizes that FND symptoms are real and disabling, not imagined, and require active rehabilitation rather than traditional neurological approaches. 1, 3

Essential Components of Treatment

Patient Education (Therapeutic in Itself)

Education about the diagnosis has direct therapeutic value and should include: 2

• Taking the problem seriously and validating that symptoms are real and cause genuine disability 2
• Explaining this is a positive diagnosis based on specific clinical findings, not exclusion of other diseases 2, 3
• Using understandable analogies such as "a software problem, not a hardware problem" or "the train is off the tracks" 2
• Providing written materials and links to resources 2
• Demonstrating clinical signs during consultation, which can be a positive experience for patients 2

Rehabilitative Therapies (Primary Treatment Modality)

Occupational therapy and physical therapy are the treatments of choice for functional motor symptoms. 3, 4 These interventions differ fundamentally from standard neurorehabilitation approaches: 1

Key rehabilitation principles include: 1

• Retraining normal movement within functional activities rather than isolated exercises 1
• Graded reintroduction to daily activities with progressive complexity 1
• Focus on activity-based (functional) goals rather than impairment-based goals 1
• Use variability of symptoms positively in treatment 1
• Integrate specific treatment techniques into function and teach independent carryover 1
• Avoid compensatory aids and techniques in the acute phase or during active rehabilitation 1
• Never use splints or devices that immobilize joints 1

Intensive therapy with several sessions per week may be more successful in helping patients recover normal function. 2

Psychological Interventions

Cognitive behavioral therapy (CBT) is an emerging evidence-based treatment across FND subtypes. 3, 4 A recent randomized trial demonstrated that combined physiotherapy plus CBT significantly improved physical aspects of quality of life (SF-36 PCS) at 5 months with a mean difference of 5.62 points. 4

Anxiety management techniques should include: 2

• Breathing techniques 2
• Progressive muscle relaxation 2
• Grounding strategies 2
• Visualization and distraction 2
• Reframing thoughts 2
• Mindfulness 2
• Integration of pleasant activities 2

Self-Management Strategies

Teaching self-management is central to intervention and must include: 1

• Reestablishment of structure and routine 1
• Completion of a relapse prevention plan as part of treatment 1
• Ongoing self-management plan for long-term symptom control 1

Treatment Sequencing and Team Approach

A multidisciplinary team is necessary for comprehensive management, involving neurologists, psychiatrists, speech therapists, occupational therapists, physical therapists, and caregivers. 5, 6, 7 The team should work in an interdisciplinary fashion with coordinated care plans. 5

Communication must be open and consistent in both verbal and written communications with the patient and other healthcare professionals. 1

Addressing Specific Symptom Domains

For Cognitive Symptoms

Address contributing factors including: 2

• Fatigue 2
• Pain 2
• Anxiety 2
• Sleep deficiency 2

For Seizure-Type Symptoms

Psychotherapy is an emerging evidence-based treatment for functional seizures (dissociative seizures). 3

Common Pitfalls to Avoid

Critical errors in FND management include: 1, 2

• Treating FND like other neurological conditions using standard neurorehabilitation strategies 1
• Relying primarily on pharmacological approaches when non-pharmacological strategies should be first-line 8
• Using compensatory devices prematurely rather than retraining normal function 1
• Focusing on impairment-based rather than functional goals 1
• Failing to recognize and sensitively challenge unhelpful thoughts, beliefs, and behaviors 1

Expected Outcomes

Multidisciplinary studies report improvements in physical function and quality of life immediately after treatment and at follow-up periods of 12-25 months. 1 However, treatment response is heterogeneous, and not all patients respond to currently available interventions. 3, 7 High levels of patient acceptability have been demonstrated, with OT comparing favorably to other treatments. 1

Treatment Setting Considerations

Treatment should be delivered across the continuum of care: 1

• Hospital settings for acute presentations 1
• Rehabilitation wards for intensive therapy 1
• Community settings for ongoing management 1