Sensory Processing Difficulties in Patients with Functional Neurological Disorder: Occupational Therapy Management Strategies and Two Cases

Sensory Processing Difficulties and Occupational Therapy Outcomes for Functional Neurological Disorder: A Retrospective Cohort Study

Background and Objectives

Occupational therapy (OT) consensus recommendations and articles outlining a sensory-based OT intervention for functional neurological disorder (FND) have been published. However, limited research has been conducted to examine the efficacy of OT interventions for FND. We performed a retrospective cohort study aimed at independently replicating preliminarily characterized sensory processing difficulties in patients with FND and reporting on clinical outcomes of a sensory-based OT treatment in this population. We hypothesized that (1) a history of functional seizures, anxiety, and/or post-traumatic stress disorder would be associated with increased sensory processing difficulties and (2) the number of OT treatment sessions received would positively relate to clinical improvement.

Methods

Medical records were reviewed for 77 consecutive adults with FND who received outpatient, sensory-based OT care. Data from the Adolescent/Adult Sensory Profile characterized self-reported sensory processing patterns across 4 quadrants (low registration, sensory sensitivity, sensory seeking, and sensory avoidance) in this population. Following univariate screenings, multivariate linear regression analyses were performed to identify neuropsychiatric characteristics associated with discrete sensory processing patterns. Clinical improvement was quantified using an estimated, clinician-determined improvement rating ("improved" vs "not improved"), and relationships between clinical participation, baseline neuropsychiatric factors, and outcomes were investigated.

Results

Patients with FND reported sensory processing patterns with elevated scores in low registration, sensory sensitivity, and sensation avoidance compared with normative values; differences in sensory processing scores were not observed across FND subtypes (i.e., motor, seizure, and speech variants). In linear regression analyses, lifetime history of an anxiety disorder, history of migraine headaches, current cognitive complaints, and a comorbid major neurologic condition independently predicted individual differences in sensory processing scores. Following a sensory-based OT intervention, 62% of individuals with FND were clinician determined as "improved." In a multivariate logistic regression analysis controlling for baseline characteristics associated with improvement ratings, number of treatment sessions positively correlated with clinical improvement.

Discussion

These findings support the presence of sensory processing difficulties in patients with FND and provide Class IV evidence for the efficacy of an outpatient, sensory-based OT intervention in this population. Controlled prospective trials are warranted.

Predictive Processing and the Pathophysiology of Functional Neurological Disorder

The contemporary neuroscience understanding of the brain as an active inference organ supports that our conscious experiences, including sensorimotor perceptions, depend on the integration of probabilistic predictions with incoming sensory input across hierarchically organized levels. As in other systems, these complex processes are prone to error under certain circumstances, which may lead to alterations in their outcomes (i.e., variations in sensations and movements). Such variations are an important aspect of functional neurological disorder, a complex disorder at the interface of brain-mind-body interactions. Thus, predictive processing frameworks offer fundamental mechanistic insights into the pathophysiology of functional neurological disorder. In recent years, many of the aspects relevant to the neurobiology of functional neurological disorder - e.g., aberrant motor and sensory processes, symptom expectation, self-agency, and illness beliefs, as well as interoception, allostasis, and emotion - have been investigated through the lens of predictive processing frameworks. Here, we provide an overview of the current state of research on predictive processing and the pathophysiology of functional neurological disorder.

Neuro-behavioural changes after acquired brain injury: The role of the occupational therapist; the interventions they use and why

INTRODUCTION

Almost half of the people living with acquired brain injury experience behavioural changes, yet there is lack of clarity both in the literature, and through major stakeholders internationally, regarding how occupational therapists contribute to neuro-behavioural rehabilitation and what their role is in this context.

METHODS

This study answers the research question: What do occupational therapists perceive as their role in behavioural rehabilitation with adults living with acquired brain injury, and what treatment approaches, if any, are they using to promote occupation? A national, qualitative, bounded case study design using semi-structured interviews was used to explore what the role of the occupational therapist is in neuro-behavioural rehabilitation across subacute brain injury units in Australia.

FINDINGS

Four themes were identified which provide clarification on the role of the occupational therapist in neuro-behavioural rehabilitation: You change the task, you change the environment, change the person; build a safe rapport; the sensory stuff is huge and, finally, owning how we think.

CONCLUSION

This bounded case study provides insight into how occupational therapists perceive their role and the interventions they use to promote occupational engagement. The lack of recognition of the occupational therapist role is a barrier to providing appropriate neuro-behavioural rehabilitation. This case study identified sensory approaches, building safe rapport and adapting the environment as the main interventions used in neuro-behavioural rehabilitation by occupational therapists.

Toward a Precision Medicine Approach to the Outpatient Assessment and Treatment of Functional Neurological Disorder

Functional neurological disorder (FND) is a neuropsychiatric condition. In this field, prospective psychotherapy trials and consensus recommendations for physiotherapy, occupational therapy, and speech language therapy have been published. However, significant clinical complexities remain. "Rule in" signs - while critical for making a positive diagnosis - do not equate to a personalized treatment plan in many instances. Here, we propose that the neuropsychiatric assessment and real-time development of a work-in-progress biopsychosocial clinical formulation aids the development of a patient-centered outpatient treatment plan. This precision medicine approach is based on the literature, expert opinions and our clinical experience working in an interdisciplinary FND service.

Outpatient Approach to Occupational Therapy for Paroxysmal Functional Neurologic Symptoms: Sensory Modulation Training as an Emerging Treatment

Occupational therapy (OT) is an important treatment modality for patients with paroxysmal functional neurologic disorder (FND) symptoms. In our clinical experience, an outpatient, OT-based sensory modulation treatment can address sensory processing difficulties often endorsed by patients with paroxysmal motor FND and functional seizures. This article aims to describe in detail the goals and treatment strategies for occupational therapists to replicate this approach. This article is also an important first step in aiding the development and execution of clinical trials to further evaluate the effectiveness of sensory-based treatment in patients with FND.

Lessons Learned in Outpatient Physical Therapy for Motor Functional Neurological Disorder

BACKGROUND AND PURPOSE

Motor functional neurological disorder is a prevalent and costly condition at the intersection of neurology and psychiatry that is diagnosed using positive "rule-in" signs. Physical therapy is a first-line treatment and consensus recommendations exist to guide clinical care. Nonetheless, optimal outpatient treatment of adults with functional motor symptoms requires an expanded physical therapy tool kit to effectively guide care.

SUMMARY OF KEY POINTS

In this article, lessons learned from a physical therapist practicing in a multidisciplinary and interdisciplinary outpatient functional neurological disorder clinic are highlighted. In doing so, we discuss how use of the biopsychosocial model and neuroscience constructs can inform physical therapy interventions. The importance of team-based care and the delivery of physical therapy through video telehealth services are also outlined.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Use of the biopsychosocial formulation to triage clinical challenges and guide longitudinal care, coupled with application of neuroscience to aid intervention selection, allows for patient-centered physical therapy treatment across the spectrum of functional motor symptoms.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A400 ).