From the Guidelines
Functional neurological deficit (FND) is a condition that should be diagnosed by a neurologist using 'positive clinical signs' and treated with a multidisciplinary approach, prioritizing rehabilitation and psychological support. The diagnosis of FND is based on the presence of positive clinical features, such as Hoover's sign, distractibility, entrainment of tremor, and variability in symptoms during function, rather than the exclusion of structural damage or disease 1.
Key Principles of Treatment
The treatment of FND involves a combination of:
- Psychotherapy, particularly cognitive behavioral therapy
- Physical therapy
- Addressing underlying psychological factors, such as anxiety or depression
- Medications, including SSRIs for mood disorders or low-dose antipsychotics in specific cases, although there is no standard medication regimen
- Patient education, emphasizing that symptoms are real despite the absence of structural damage
Occupational Therapy Recommendations
Occupational therapy plays a crucial role in the management of FND, with recommendations including:
- Education about the diagnosis and symptoms
- Introduction of self-management techniques at initial assessment
- Focus on activity-based (functional) rather than impairment-based goals and interventions
- Avoidance of compensatory aids and techniques in the acute phase or during active rehabilitation 1
Speech and Language Therapy Recommendations
Speech and language therapy is also essential in the management of FND, particularly for patients with functional communication, swallowing, and cough disorders. Recommendations include:
- Addressing psychosocial predisposing and perpetuating factors
- Providing supportive discussion about the role of anxiety or the impact of symptoms on relationships and everyday life
- Encouraging ongoing involvement of family, friends, and caregivers in treatment and support 1
Prioritizing Morbidity, Mortality, and Quality of Life
In the treatment of FND, it is essential to prioritize morbidity, mortality, and quality of life outcomes. This involves:
- Early diagnosis and treatment that validates the patient's experience
- Focusing on rehabilitation and psychological support
- Addressing underlying psychological factors and providing patient education
- Using a multidisciplinary approach to treatment, including occupational therapy, speech and language therapy, and psychotherapy.
From the Research
Definition and Prevalence of Functional Neurological Deficit
- Functional neurological disorder (FND) is a common and disabling disorder that can cause severe disability in some individuals 2.
- FND is prevalent, generally affecting young and middle-aged adults 2.
- It is characterized by the presence of neurological symptoms that cannot be explained by a neurological disease or condition 3.
Diagnosis of Functional Neurological Deficit
- FND is now considered a rule-in diagnosis, with available treatments, rather than a diagnosis of exclusion 2.
- Validated rule-in examination signs can be used to guide diagnosis, with high specificities of clinical signs (64-100%) reported in studies 2.
- The diagnosis of FND can be made using a combination of clinical evaluation, laboratory tests, and imaging studies to rule out other conditions 3.
Treatment of Functional Neurological Deficit
- Psychotherapy is an emerging evidence-based treatment for FND, with cognitive-behavioral therapy (CBT) and psychodynamic therapy (PDT) showing medium-sized benefits for physical symptoms, mental health, well-being, function, and resource use 4.
- Rehabilitative interventions, such as physical and occupational therapy, are treatments of choice for functional motor symptoms 2.
- A multidisciplinary and interdisciplinary team approach is recommended for the management of FND, with the involvement of neurologists, psychologists, physical therapists, and other healthcare professionals 5.
- The optimal timing of specific therapeutic interventions is important, with a patient-centered perspective emphasizing the need for individualized treatment plans 5.
Challenges and Future Directions
- Despite the availability of treatments, some patients with FND do not respond to currently available interventions, highlighting the need for further research and the development of novel treatments 5, 2.
- More research is needed to individualize treatments and develop novel interventions for FND, with a focus on improving outcomes and reducing disability 5, 2.
- The heterogeneity of responses to treatment in FND underscores the importance of continued research and the need for more effective and personalized treatment approaches 2.