Decade of progress in motor functional neurological disorder: continuing the momentum

Agreement and disagreement in pediatric functional neurological symptom disorders: Comparing patient reported outcome measures (PROMs) and clinician assessments

Youth with functional neurological symptom disorder (FNSD) often perceive themselves as having limited capabilities, which may not align with clinical evaluations. This study assessed the disparities between clinician evaluations and patient-reported outcome measures (PROMs) regarding pain, motor function, and learning difficulties in youth with FNSD. Sixty-two youths with FNSD participated in this study, all of whom reported experiencing pain, motor problems, and/or learning difficulties. Clinicians also assessed these domains, resulting in a two-by-two categorization matrix: (1) agreement: child and clinician report "problems"; (2) agreement: child and clinician report "no problems"; (3) disagreement: child reports "problems" while the clinician does not; and (4) disagreement: clinician reports "problems" while the child does not. Agreement/disagreement differences were analyzed. No significant differences in prevalence were observed between the evaluators regarding pain (clinician-85%, child-88%), motor (clinician-98%, child-95%), or learning problems (clinician-69%, child-61%). More than 80% of the children and clinicians report pain and motor disorders. Instances in which children and clinicians reported learning problems (40.3%) exceeded cases in which both reported no problems (9.6%) or only the child reported problems (20.9%). Overall, the agreement between pain and motor function assessments was high (>90%), whereas that concerning learning difficulties was moderate (49.9%). Disagreement in pain/motor assessments was minimal (<5%), whereas for learning difficulties, disagreement rates were high (>20%). In conclusion, a significant concordance exists between PROMs and clinician assessments of pain and motor problems. However, the higher frequency of disagreements regarding learning difficulties emphasizes the importance of incorporating patient and clinician evaluations in pediatric FNSD treatment.

The role of neuropsychology in the care of patients with functional neurological symptom disorder

OBJECTIVE

Functional neurological symptom disorder (FNSD) is a neuropsychiatric condition characterized by signs/symptoms associated with brain network dysfunction. FNSDs are common and are associated with high healthcare costs. FNSDs are relevant to neuropsychologists, as they frequently present with chronic neuropsychiatric symptoms, subjective cognitive concerns, and/or low neuropsychological test scores, with associated disability and reduced quality of life. However, neuropsychologists in some settings are not involved in care of patients with FNSDs. This review summarizes relevant FNSD literature with a focus on the role of neuropsychologists.

METHODS

A brief review of the literature is provided with respect to epidemiology, public health impact, symptomatology, pathophysiology, and treatment.

RESULTS

Two primary areas of focus for this review are the following: (1) increasing neuropsychologists' training in FNSDs, and (2) increasing neuropsychologists' role in assessment and treatment of FNSD patients.

CONCLUSIONS

Patients with FNSD would benefit from increased involvement of neuropsychologists in their care.

Specialist physiotherapy for functional motor disorder in England and Scotland (Physio4FMD): a pragmatic, multicentre, phase 3 randomised controlled trial

BACKGROUND

Functional motor disorder-the motor variant of functional neurological disorder-is a disabling condition that is commonly associated with poor health outcomes. Pathophysiological models have inspired new treatment approaches such as specialist physiotherapy, although evidence from large randomised controlled trials is absent. We aimed to assess the clinical effectiveness of a specialist physiotherapy intervention for functional motor disorder compared with treatment as usual.

METHODS

In this pragmatic, multicentre, phase 3 randomised controlled trial at 11 hospitals in England and Scotland, adults with a clinically definite diagnosis of functional motor disorder, diagnosed by a neurologist, were included. Participants were randomly assigned (1:1, stratified by site) using a remote web-based application to either specialist physiotherapy (a protocolised intervention of nine sessions plus follow-up) or treatment as usual (referral to local community neurological physiotherapy). Individuals working on data collection and analysis were masked to treatment allocation. The primary outcome was the physical functioning domain of the 36-item short form health questionnaire (SF36) at 12 months after randomisation. The primary analysis followed a modified intention-to-treat principle, using a complete case approach; participants who were unable to receive their randomised treatment due to the suspension of health-care services during the COVID-19 pandemic were excluded from the primary analysis. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN56136713, and is completed.

FINDINGS

Recruitment occurred between Oct 19, 2018, and March 11, 2020, pausing during the COVID-19 lockdown, and resuming from Aug 3, 2021, to Jan 31, 2022. Of 355 participants who were enrolled, 179 were randomly assigned to specialist physiotherapy and 176 to treatment as usual. 89 participants were excluded from the primary analysis due to COVID-19 interruption to treatment (27 were assigned to specialist physiotherapy and 62 to treatment as usual). After accounting for withdrawals (n=11) and loss to follow-up (n=14), the primary analysis included data from 241 participants (138 [91%] assigned specialist physiotherapy and 103 [90%] assigned treatment as usual). Physical functioning, as assessed by SF36, did not differ significantly between groups (adjusted mean difference 3·5, 95% CI -2·3 to 9·3; p=0·23). There were no serious adverse events related to the trial interventions. 35 serious adverse events were recorded in the specialist physiotherapy group by 24 participants (17·0%), and 24 serious adverse events were recorded in the treatment as usual group by 18 participants (17·0%); one death occurred in the specialist physiotherapy group (cause of death was recorded as suicide). All were considered unrelated to specialist physiotherapy.

INTERPRETATION

Although more participants who were assigned specialist physiotherapy self-rated their motor symptoms as improved and had better scores on subjective measures of mental health, the intervention did not result in better self-reported physical functioning at 12 months. Both the specialist and community neurological physiotherapy appeared to be a safe and a valued treatment for selected patients with functional motor disorder. Future research should continue to refine interventions for people with functional motor disorder and develop evidence-based methods to guide treatment triage decisions.

FUNDING

National Institute for Health and Care Research and Health Technology Assessment Programme.

Observational cohort study of 100 patients presenting with functional visual loss: clinical characteristics and comparison with other functional neurologic disorders

OBJECTIVE

Recent research has helped to develop a more detailed understanding of many functional neurologic disorders. The aim of this study was to increase our knowledge of functional visual loss and to compare the findings with those of other functional syndromes.

DESIGN

Prospective and retrospective observational cohort study.

METHODS

This study took place at neuro-ophthalmology clinics at 3 major hospitals in London, United Kingdom, over a 12-month period. The study population consisted of 157 participants, 100 with functional visual loss, 21 pathologic control subjects with organic visual loss, and 36 healthy nonpathologic control subjects. All participants had their diagnosis confirmed with a full neuro-ophthalmic examination, neuroimaging, and visual electrophysiology. A full assessment of all participants' medical history was obtained from their general practitioner, and all participants completed a series of questionnaires assessing relevant associations.

RESULTS

Data were obtained on 157 participants, 100 with functional visual loss, 21 pathologic control subjects with organic visual loss, and 36 healthy nonpathologic control subjects. Participants with functional visual loss were typically female (74%) with a mean age at vision loss of 40.0 ± 16 years. Sixty-four percent of participants had bilateral vision loss; the remainder, unilateral loss. Twenty-six percent of the total cohort had organic visual loss with functional overlay. Fifty percent of participants with functional visual loss had a preexisting psychiatric diagnosis, the most common being a depressive disorder. Sixty-two percent of participants had an ocular history, and 87% had a previously diagnosed medical illness, most commonly neurologic (45%). Thirty-five percent of participants self-reported at least 1 additional functional symptom.

CONCLUSIONS

Our population of functional visual loss subjects shares many similarities with the majority of patients with other functional neurologic disorders. They are generally young and female and have a greater than expected rate of psychiatric, medical, and coexisting ocular conditions. We found increased rates of precipitating stressors, clinical depression, and organic eye problems in subjects with functional visual loss.

How Does Postural Control in Patients with Functional Motor Disorders Adapt to Multitasking-Based Immersive Virtual Reality?

BACKGROUND

Motor symptoms in functional motor disorders (FMDs) refer to involuntary, but learned, altered movement patterns associated with aberrant self-focus, sense of agency, and belief/expectations. These conditions commonly lead to impaired posture control, raising the likelihood of falls and disability. Utilizing visual and cognitive tasks to manipulate attentional focus, virtual reality (VR) integrated with posturography is a promising tool for exploring postural control disorders.

OBJECTIVES

To investigate whether postural control can be adapted by manipulating attentional focus in a 3D immersive VR environment.

METHODS

We compared postural parameters in 17 FMDs patients and 19 age-matched healthy controls over a single session under four increasingly more complex and attention-demanding conditions: simple fixation task (1) in the real room and (2) in 3D VR room-like condition; complex fixation task in a 3D VR city-like condition (3) avoiding distractors and (4) counting them. Dual-task effect (DTE) measured the relative change in performance induced by the different attention-demanding conditions on postural parameters.

RESULTS

Patients reduced sway area and mediolateral center of pressure displacement velocity DTE compared to controls (all, P < 0.049), but only under condition 4. They also showed a significant reduction in the sway area DTE under condition 4 compared to condition 3 (P = 0.025).

CONCLUSIONS

This study provides novel preliminary evidence for the value of a 3D immersive VR environment combined with different attention-demanding conditions in adapting postural control in patients with FMDs. As supported by quantitative and objective posturographic measures, our findings may inform interventions to explore FMDs pathophysiology.

Elevated Mortality Rate in Patients With Functional Seizures After Diagnosis and Referral

Background and Objectives

To evaluate the standardized mortality ratio (SMR) of patients in the United States referred to a multidisciplinary clinic for treatment of functional seizures.

Methods

We identified patients who had or had not died based on automated retrospective review of electronic health records from a registry of patients referred to a single-center multidisciplinary functional seizures treatment clinic. We calculated an SMR by comparing the number of observed deaths with the expected number of deaths in an age-matched, sex-matched, and race-matched population within the same state, and year records were available.

Results

A total of 700 patients with functional seizures (mean age 37 years, 78% female) were followed up for 1,329 patient-years for a median of 15 months per patient (interquartile range 6-37 months). We observed 11 deaths, corresponding to a mortality rate of 8.2 per 1,000 patient-years and an SMR of 2.4 (95% confidence interval: 1.17-4.22). Five of 9 patients with identified circumstances around their death were in hospice care when they passed. None of the identified causes of death were related to seizures directly.

Discussion

These data provide further evidence of elevated mortality in functional seizures soon after diagnosis and referral to treatment. These data from the decentralized health care system of the United States build on the findings from other countries with large-scale health registries.

Exploring the role of attention towards balance in chronic dizziness: Development of the Balance Vigilance Questionnaire

BACKGROUND AND PURPOSE

Vigilance towards balance has been proposed to underpin various chronic dizziness disorders, including persistent postural-perceptual dizziness (PPPD). The objective of this study was to develop (through patient input) a validated balance-specific measure of vigilance that comprehensively assesses the varied ways in which this construct may manifest.

METHODS

We developed the Balance Vigilance Questionnaire (Balance-VQ) through patient and clinician feedback, designed to assess vigilance towards balance. We then validated the questionnaire in 497 participants consisting of patients diagnosed with chronic dizziness disorders (including 97 individuals diagnosed with PPPD) and healthy controls.

RESULTS

The final six-item Balance-VQ was shown to be a valid and reliable way to assess vigilance towards balance. Scores were significantly higher in individuals diagnosed with PPPD compared to controls. Although scores were also higher in the PPPD group compared to individuals with diagnosed vestibular disorders other than PPPD, Balance-VQ scores did not discriminate between the two groups when confounding factors (including dizziness severity) were controlled for. Scores did, however, independently discriminate between the PPPD group and individuals who experience dizziness in daily life, but who have not been diagnosed with a neuro-otological disorder.

CONCLUSIONS

Our findings confirm that the Balance-VQ is a valid and reliable instrument for assessing vigilance towards balance. As symptom vigilance has been identified as a key risk factor for developing chronic dizziness following acute vestibular symptoms or balance disruption, we recommend using the Balance-VQ as a screening tool in people presenting with such symptoms.

The influence of postural threat-induced anxiety on locomotor learning and updating

The ability to adapt our locomotion in a feedforward (i.e., "predictive") manner is crucial for safe and efficient walking behavior. Equally important is the ability to quickly deadapt and update behavior that is no longer appropriate for the given context. It has been suggested that anxiety induced via postural threat may play a fundamental role in disrupting such deadaptation. We tested this hypothesis, using the "broken escalator" phenomenon: Fifty-six healthy young adults walked onto a stationary walkway ("BEFORE" condition, 5 trials), then onto a moving walkway akin to an airport travelator ("MOVING" condition, 10 trials), and then again onto the stationary walkway ("AFTER" condition, 5 trials). Participants completed all trials while wearing a virtual reality headset, which was used to induce postural threat-related anxiety (raised clifflike drop at the end of the walkway) during different phases of the paradigm. We found that performing the locomotor adaptation phase in a state of increased threat disrupted subsequent deadaptation during AFTER trials: These participants displayed anticipatory muscular activity as if expecting the platform to move and exhibited inappropriate anticipatory forward trunk movement that persisted during multiple AFTER trials. In contrast, postural threat induced during AFTER trials did not affect behavioral or neurophysiological outcomes. These findings highlight that actions learned in the presence of postural threat-induced anxiety are strengthened, leading to difficulties in deadapting these behaviors when no longer appropriate. Given the associations between anxiety and persistent maladaptive gait behaviors (e.g., "overly cautious" gait, functional gait disorders), the findings have implications for the understanding of such conditions.NEW & NOTEWORTHY Safe and efficient locomotion frequently requires movements to be adapted in a feedforward (i.e., "predictive") manner. These adaptations are not always correct, and thus inappropriate behavior must be quickly updated. Here we showed that increased threat disrupts this process. We found that locomotor actions learned in the presence of postural threat-induced anxiety are strengthened, subsequently impairing one's ability to update (or "deadapt") these actions when they are no longer appropriate for the current context.

Neuropsychological evaluation of functional cognitive disorder: A narrative review

Objective: To critically review contemporary theoretical models, diagnostic approaches, clinical features, and assessment findings in Functional Cognitive Disorder (FCD), and make recommendations for neuropsychological evaluation of this condition. Method: Narrative review. Results: FCD is common in neuropsychological practice. It is characterized by cognitive symptoms that are not better explained by another medical or psychiatric disorder. The cognitive symptoms are associated with distress and/or limitations in daily functioning, but are potentially reversible with appropriate identification and treatment. Historically, a variety of diagnostic frameworks have attempted to capture this condition. A contemporary conceptualization of FCD positions it as a subtype of Functional Neurological Disorder, with shared and unique etiological factors. Patients with FCD tend to perform normally on neuropsychological testing or demonstrate relatively weak memory acquisition (e.g. list learning trials) in comparison to strong attention and delayed recall performance. Careful history-taking and behavioral observations are essential to support the diagnosis of FCD. Areas of ongoing controversy include operationalizing "internal inconsistencies" and the role of performance validity testing. Evidence for targeted interventions remains scarce. Conclusions: Neuropsychologists familiar with FCD can uniquely contribute to the care of patients with this condition by improving diagnostic clarity, richening case formulation, communicating effectively with referrers, and leading clinical management. Further research is needed to refine diagnosis, prognosis, and treatment.

Neurometabolic alterations in children and adolescents with functional neurological disorder

OBJECTIVES

In vivo magnetic resonance spectroscopy (MRS) was used to investigate neurometabolic homeostasis in children with functional neurological disorder (FND) in three regions of interest: supplementary motor area (SMA), anterior default mode network (aDMN), and posterior default mode network (dDMN). Metabolites assessed included N-acetyl aspartate (NAA), a marker of neuron function; myo-inositol (mI), a glial-cell marker; choline (Cho), a membrane marker; glutamate plus glutamine (Glx), a marker of excitatory neurotransmission; γ-aminobutyric acid (GABA), a marker of inhibitor neurotransmission; and creatine (Cr), an energy marker. The relationship between excitatory (glutamate and glutamine) and inhibitory (GABA) neurotransmitter (E/I) balance was also examined.

METHODS

MRS data were acquired for 32 children with mixed FND (25 girls, 7 boys, aged 10.00 to 16.08 years) and 41 healthy controls of similar age using both short echo point-resolved spectroscopy (PRESS) and Mescher-Garwood point-resolved spectroscopy (MEGAPRESS) sequences in the three regions of interest.

RESULTS

In the SMA, children with FND had lower NAA/Cr, mI/Cr (trend level), and GABA/Cr ratios. In the aDMN, no group differences in metabolite ratios were found. In the pDMN, children with FND had lower NAA/Cr and mI/Cr (trend level) ratios. While no group differences in E/I balance were found (FND vs. controls), E/I balance in the aDMN was lower in children with functional seizures-a subgroup within the FND group. Pearson correlations found that increased arousal (indexed by higher heart rate) was associated with lower mI/Cr in the SMA and pDMN.

CONCLUSIONS

Our findings of multiple differences in neurometabolites in children with FND suggest dysfunction on multiple levels of the biological system: the neuron (lower NAA), the glial cell (lower mI), and inhibitory neurotransmission (lower GABA), as well as dysfunction in energy regulation in the subgroup with functional seizures.

Functional neurological disorder in Saudi Arabia: A retrospective study

OBJECTIVES

To describe the clinical profile of a sample of Saudi patients with Functional Neurological Disorder (FND).

METHOD

A retrospective review of charts of FND patients seen from 2021-2023 at a neuropsychiatry clinic at an academic tertiary care center in Jeddah, Saudi Arabia.

RESULTS

Out of 473 patients seen in the clinic, 52 (11%) had FND. Their mean age was 34 (standard deviation = 10.7), and 77% were female. Family disputes (39%) were the most reported risk factor, followed by sexual abuse (15%). The most common FND symptoms were nonepileptic seizures (61.5%) and abnormal movements (30.8%). Pain was reported by 57.7% and cognitive symptoms by 36.5%. FND symptoms were frequently attributed to supernatural causes (67.3%). During the last follow up visit, 53.9% of patients reported FND symptom improvement, whereas 21.2% reported no change, 10.2% reported worsening, and 15% were lost to follow-up. The proportion of patients without symptom improvement was higher among patients with cognitive symptoms (45.5% vs 18% respectively, X2 = 10.08, df = 3, P = .018). The mean number of visits was highest in patients reporting worsening and lowest among patients reporting no change (F = 4.21, P = .017).

CONCLUSION

The role of family disputes in FND in the Middle East, the role of supernatural concepts in how FND is perceived, and the relatively high rate of subjective improvement within this sample of Saudi FND patients merit exploration. Cognitive symptoms may be a prognostic indicator. Prospective multicenter research using standardized assessment scales is needed.

Setting up Functional Neurological Disorder Treatment Services: Questions and Answers

Functional neurologic disorder (FND) is commonly encountered across outpatient and inpatient medical settings. Given the potential for a high burden of disability in some patients and mounting evidence for the efficacy of FND-specific multidisciplinary treatment services, expanding clinical services for this population is a necessity. In this perspective article, we discuss considerations for creating FND services, including the types of services that exist, how to start, how to identify appropriate referrals, and how to develop and monitor individualized treatment plans. In addition, we discuss how this effort can be done sustainably - balancing patient needs with limited healthcare resources.

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.

Illness-Promoting Psychological Processes in Children and Adolescents with Functional Neurological Disorder

Previous studies suggest that subjective distress in children with functional neurological disorder (FND) is associated with stress-system dysregulation and modulates aberrant changes in neural networks. The current study documents illness-promoting psychological processes in 76 children with FND (60 girls and 16 boys, aged 10.00-17.08 years) admitted to the Mind-Body Program. The children completed a comprehensive family assessment and self-report measures, and they worked with the clinical team to identify psychological processes during their inpatient admission. A total of 47 healthy controls (35 girls and 12 boys, aged 8.58-17.92 years) also completed self-report measures, but were not assessed for illness-promoting psychological processes. Children with FND (vs. controls) reported higher levels of subjective distress (total DASS score, t(104.24) = 12.18; p ˂ 0.001) and more adverse childhood experiences across their lifespans (total ELSQ score, t(88.57) = 9.38; p ˂ 0.001). Illness-promoting psychological processes were identified in all children with FND. Most common were the following: chronic worries about schoolwork, friendships, or parental wellbeing (n = 64; 84.2%); attention to symptoms (n = 61; 80.3%); feeling sad (n = 58; 76.3%); experiencing a low sense of control (helplessness) in relation to symptoms (n = 44; 57.9%); pushing difficult thoughts out of mind (n = 44; 57.9%); self-critical rumination (n = 42; 55.3%); negative/catastrophic-symptom expectations (n = 40; 52.6%); avoidance of activities (n = 38; 50%); intrusive thoughts/feelings/memories associated with adverse events (n = 38, 50%); and pushing difficult feelings out of mind (n = 37; 48.7%). In children with FND-disabled enough to be admitted for inpatient treatment-illness-promoting psychological processes are part of the clinical presentation. They contribute to the child's ongoing sense of subjective distress, and if not addressed can maintain the illness process. A range of clinical interventions used to address illness-promoting psychological processes are discussed, along with illustrative vignettes.

Functional Neurological Disorder in Saudi Arabia: An Update

Functional neurological disorder (FND) is characterized by neurological symptoms that lack congruence with traditional neurological diagnoses. Historically viewed through a Freudian psychoanalytic lens, FND has been conceptualized as a purely psychogenic disorder. However, the contemporary biopsychosocial perspective on FND emphasizes contributions of cognitive and neural circuit dysfunction and the disabling and involuntary nature of the illness. In Saudi Arabia, evidence suggests the prevalence of FND is significant. However, clinical programs and research focused on FND have been lacking. Studies from the region indicate that practitioners may have outdated views of FND. To address this, this narrative review provides an updated perspective on FND that is relevant to Saudi Arabia and the region. It delves into the evolving perception of FND, its underlying pathophysiology, risk factors, clinical presentations, and recent diagnostic and management advances. Unique features of FND in Saudi Arabia may include a significant role for family disputes as a risk factor, prevalent supernatural perceptions of FND, high prevalence of somatization, and cognitive dysfunction, and a potential favorable prognosis. The article concludes by providing the following recommendations related to FND in Saudi Arabia and the region: i) building educational programs to update clinicians about contemporary biopsychosocial perspectives on FND; ii) emphasizing a positive diagnostic approach based on clinical findings in FND; iii) instituting multidisciplinary programs to care for FND patients; iv) supporting systematic research efforts to explore culture-specific FND risk factors, patient outcome measures, and attitudes toward the disorder; v) developing national FND clinical practice guidelines; and vi) launching awareness campaigns to reduce FND stigma.

Functional neurological disorder is a feminist issue

Functional neurological disorder (FND) is a common and disabling disorder, often misunderstood by clinicians. Although viewed sceptically by some, FND is a diagnosis that can be made accurately, based on positive clinical signs, with clinical features that have remained stable for over 100 years. Despite some progress in the last decade, people with FND continue to suffer subtle and overt forms of discrimination by clinicians, researchers and the public. There is abundant evidence that disorders perceived as primarily affecting women are neglected in healthcare and medical research, and the course of FND mirrors this neglect. We outline the reasons why FND is a feminist issue, incorporating historical and contemporary clinical, research and social perspectives. We call for parity for FND in medical education, research and clinical service development so that people affected by FND can receive the care they need.

The Financial Burden of Functional Neurological Disorders

PURPOSE OF REVIEW

Functional neurological disorder (FND) is a common and severely debilitating condition lacking clinical ownership, existing between neurology and psychiatry. This article reports the findings of recent research investigating the economic costs of FND diagnosis and management. We define what the costs are, why they exist, and suggest actionable steps to reduce them.

RECENT FINDINGS

The financial burden of FND exists across the globe characterized by high healthcare utilization resulting in exorbitant direct and indirect costs for the patient, healthcare system, and society. Inadequate medical education and stigmatization of the disorder prolong the time to diagnosis, during which cyclical utilization of inpatient and emergency department services drive up costs. Despite being cost-effective, lack of accessible treatment compounds the issue, leaving patients without a reliable exit. Recent findings support an increased awareness and the need for a cultural shift to overcome the financial burden associated with this underserved population.

Motor cortex hemodynamic response to goal-oriented and non-goal-oriented tasks in healthy subjects

Background

Motor disorders are one of the world's major scourges, and neuromotor rehabilitation is paramount for prevention and monitoring plans. In this scenario, exercises and motor tasks to be performed by patients are crucial to follow and assess treatments' progression and efficacy. Nowadays, in clinical environments, quantitative assessment of motor cortex activities during task execution is rare, due to the bulkiness of instrumentation and the need for immobility during measurements [e.g., functional magnetic resonance imaging (MRI)]. Functional near-infrared spectroscopy (fNIRS) can contribute to a better understanding of how neuromotor processes work by measuring motor cortex activity non-invasively in freely moving subjects.

Aim

Exploit fNIRS to measure functional activation of the motor cortex area during arm-raising actions.

Design

All subjects performed three different upper limbs motor tasks: arm raising (non-goal-oriented), arm raising and grasping (goal oriented), and assisted arm raising (passive task). Each task was repeated ten times. The block design for each task was divided into 5 seconds of baseline, 5 seconds of activity, and 15 seconds of recovery.

Population

Sixteen healthy subjects (11 males and 5 females) with an average (+/- standard deviation) of 37.9 (+/- 13.0) years old.

Methods

Cerebral hemodynamic responses have been recorded in two locations, motor cortex (activation area) and prefrontal cortex (control location) exploiting commercial time-domain fNIRS devices. Haemodynamic signals were analyzed, separating the brain cortex hemodynamic response from extracerebral hemodynamic variations.

Results

The hemodynamic response was recorded in the cortical motor area for goal-oriented and not-goaloriented tasks, while no response was noticed in the control location (prefrontal cortex position).

Conclusions

This study provides a basis for canonical upper limb motor cortex activations that can be potentially compared to pathological cerebral responses in patients. It also highlights the potential use of TD-fNIRS to study goal-oriented versus non-goaloriented motor tasks. Impact: the findings of this study may have implications for clinical rehabilitation by providing a better understanding of the neural mechanisms underlying goal-oriented versus non-goal-oriented motor tasks. This may lead to more effective rehabilitation strategies for individuals with motor disorders and a more effective diagnosis of motor dysfunction supported by objective and quantitative neurophysiological readings.

Psychiatrists' attitudes towards functional neurological disorders: results from a national survey

Introduction

Functional neurological disorder (FND) presents motor, sensory, and cognitive symptoms characterized by clinical signs incongruent with known neurological disease. Together with other health professionals, like neurologists, psychiatrists can play an essential role in diagnosing and managing these disorders. Hence, understanding their opinion and clinical experience with FND is of utmost importance to catch potential educational needs and improve healthcare services for patients. This study aims at assessing the knowledge, opinion, and clinical approach of Italian psychiatrists to FND.

Methods

Members of the Italian Society of Psychiatry completed a 14-item web-based survey investigating their approach to FND. Results. Overall, 174 questionnaires were completed. Our main findings suggest that Italian psychiatrists have a psychogenetic conceptualization of FND. "Conversion disorders", in fact, is the term most frequently used by Italian psychiatrists to refer to FND, thus implying a psychological etiology of these disorders. Congruently with this view, psychotherapy associated with pharmacological therapy is considered the most appropriate treatment by psychiatrists, while physiotherapy is an under-recognized treatment option for FND.

Discussion

The present study highlights that a psychogenetic view of FND dominates among Italian psychiatrists. This could be due to out-of-date knowledge about the pathophysiology of this group of disorders. Promoting education about novel approaches to FND would be of crucial importance to improving care for patients suffering from this condition.

Clarifying the Differences between Patients with Organic Tics and Functional Tic-Like Behaviors

Due to the global increase in the number of patients with Functional Tic-Like Behaviors (FTLB), it has become increasingly important to find reliable differences between this patient group and patients with organic tics (OTs), which can be used in differential diagnosis. The purpose of this retrospective study was to critically examine both established and suggested differences between the patient groups. A total of 53 FTLB patients and 200 OT patients were included. Several findings from the current literature were replicated in this study: Compared to patients with OTs, patients with FTLB had significantly more complex tics, were older at symptom onset, were more likely to be female, and were less likely to have family members with tics. Furthermore, the study also revealed new differences between the groups: Patients with FTLB had significantly more family members with a psychiatric disorder, were more likely to have experienced an adverse psychosocial event immediately before symptom onset, and had significantly fewer simple tics. Finally, this study was unable to replicate the previously found differences in comorbidities between patients with OTs and FTLB. These findings could contribute significantly to the understanding of FTLB's etiology and to improve diagnosis, as including the presence of simple tics and comorbidities in the diagnostic criteria might be discussed in future studies.

Socioemotional self- and co-regulation in functional seizures: comparing high and low posttraumatic stress

Functional seizures (FS) are seizure-like symptoms without electroencephalogram (EEG)-based epileptic activity. Those with FS often show emotion-related dysfunction and disrupted interpersonal relationships, in which posttraumatic stress disorder symptoms (PTS) may play a role. We sought to better understand trauma comorbidities and socioemotional processes in FS, including affectionate touch, a form of social connection linked to emotion regulation and awareness. We administered questionnaires online to a community sample of 89 trauma-exposed FS participants (FS diagnoses were self-reported), 51 with and 38 without clinical-level PTS (FS-PTShi, FS-PTSlo) and 216 seizure-free matched trauma-exposed controls (TCs), 91 with and 125 without clinical-level PTS (TC-PTShi, TC-PTSlo) per the Posttraumatic Stress Disorder Symptom Checklist (PCL). As hypothesized, both FS-PTShi and FS-PTSlo reported more emotional avoidance (Brief Experiential Avoidance Questionnaire), more emotion regulation difficulties (Difficulties in Emotion Regulation Scale), and more perceived stress (Perceived Stress Scale) than PTS-matched counterparts. FS-PTShi also reported less reappraisal (Emotion Regulation Questionnaire), more loneliness (UCLA Loneliness Scale), and less frequent affectionate touch (Physical Affection Scale) during waking and surrounding sleep than TC-PTShi, whereas FS-PTSlo and TC-PTSlo did not differ. Neither FS group differed from PTS-matched controls in emotion suppression (Emotion Regulation Questionnaire) or comfort with social touch (Social Touch Questionnaire). Among FS, FS-PTShi reported more difficulties than FS-PTSlo on nearly all measures (non-significant trend for social support). Findings underscore potential synergistic effects of FS and PTS clinical symptoms in shaping experiences of one's emotions and social world, suggesting fostering meaningful connections with others, including via affectionate touch, is an important treatment target.

Panic Attack, Severe Hypophosphatemia and Rhabdomyolysis in the Setting of a Motor Functional Neurological Disorder

(1) Background: panic attack is often regarded as a benign disorder with variable physical and psychological symptoms. (2) Case Presentation: We here report the case of a 22-year-old patient known for an episode of motor functional neurological disorder a year earlier who presented a panic attack with hyperventilation causing severe hypophosphatemia and rhabdomyolysis, as well as mild tetraparesis. Electrolyte disturbances quickly resolved after phosphate substitution and rehydration. However, clinical signs suggesting a relapse of a motor functional neurological disorder appeared (improved walking with dual tasks). Diagnostic workup, including brain and spinal magnetic resonance imaging, as well as electroneuromyography and genetic testing for hypokalemic periodic paralysis, was unremarkable. Tetraparesis, lack of endurance, and fatigue eventually improved after several months. (3) Conclusions: the present case report highlights the intertwined relationship between a psychiatric disorder, leading to hyperventilation and acute metabolic disturbances, and functional neurological manifestations.

Functional Gait Disorders: Clinical presentations, Phenotypes and Implications for treatment

BACKGROUND

Functional Gait Disorders (FGD) are a common presentation of motor-Functional Neurological Disorders (motor-FND) that affect walking ability.

AIM

To provide a narrative review of the current literature on FGD.

METHODS

A narrative overview of published literature was undertaken, based on a systematic search of relevant databases, authoritative texts and citation tracking.

RESULTS

FGD is multidimensional and disabling, with numerous phenotypes described in the literature, including 'knee buckling,' 'astasia-abasia' and 'excessive slowness.' Motor symptoms such as weakness or tremor, and non-motor symptoms, such as pain and fatigue may contribute to the disability and distress in FGD. Phenotypic features and clinical signs are seen in FGD that demonstrate inconsistency and incongruity with structural disease. A limited number of treatment studies have specifically focussed on FGD, however, reporting of outcomes from motor-FND cohorts has demonstrated short and long-term improvements in walking ability through multidisciplinary rehabilitation.

CONCLUSIONS

The relative contribution of motor and non-motor symptoms in FGD remains unknown, but it is likely that non-motor symptoms increase the illness burden and should be considered during assessment and treatment. Recommended treatment for FGD involves multidisciplinary rehabilitation, but optimum treatment elements are yet to be determined.

Functional neurological disorder: Clinical manifestations and comorbidities; an online survey

Functional Neurological Disorder (FND) is common and is often accompanied by multiple comorbid symptoms and conditions. There have been no large-scale studies exploring the change of its clinical manifestations and comorbidities. We used an online survey to assess FND patient characteristics, changes to fatigue, sleep and pain and comorbid symptoms and diagnoses, as well as treatment strategies. The survey was shared via the charities FND Action and FND Hope. 527 participants were included in the analysis. Most (97.3%) reported experiencing more than one core FND symptom. Many respondents reported associated pain (78.1%), fatigue (78.0%) and sleep disturbances (46.7%) before FND diagnosis which often increased thereafter. Rates of obesity were higher (36.9%) than in the general population. Obesity was associated with increased pain, fatigue and sleep difficulties. There was frequent weight gain after diagnosis. 50.0% of participants reported having other diagnoses prior to FND, while in 43.3% new comorbidities arise after FND diagnosis. Many respondents reported being dissatisfied with their care, expressing a wish for further follow-up from mental health (32.7%) and/or neurological services (44.3%). This large online survey further supports the phenotypic complexity of FND. High rates of pain, fatigue and sleep disturbance exist before diagnosis but monitoring for change is worthwhile. Our study identified major gaps in service provision; we highlight the importance of an open mind regarding change in symptoms; this could aid the early identification and management of co-morbidities, including obesity and migraine, which possibly have a negative impact on FND.

Classification of Functional Movement Disorders with Resting-State Functional Magnetic Resonance Imaging

Introduction: Functional movement disorder (FMD) is a type of functional neurological disorder characterized by abnormal movements that patients do not perceive as self-generated. Prior imaging studies show a complex pattern of altered activity, linking regions of the brain involved in emotional responses, motor control, and agency. This study aimed to better characterize these relationships by building a classifier using a support vector machine to accurately distinguish between 61 FMD patients and 59 healthy controls using features derived from resting-state functional magnetic resonance imaging. Materials and Methods: First, we selected 66 seed regions based on prior related studies, then we calculated the full correlation matrix between them before performing recursive feature elimination to winnow the feature set to the most predictive features and building the classifier. Results: We identified 29 features of interest that were highly predictive of the FMD condition, classifying patients and controls with 80% accuracy. Several key features included regions in the right sensorimotor cortex, left dorsolateral prefrontal cortex, left cerebellum, and left posterior insula. Conclusions: The features selected by the model highlight the importance of the interconnected relationship between areas associated with emotion, reward, and sensorimotor integration, potentially mediating communication between regions associated with motor function, attention, and executive function. Exploratory machine learning was able to identify this distinctive abnormal pattern, suggesting that alterations in functional linkages between these regions may be a consistent feature of the condition in many FMD patients. Clinical-Trials.gov ID: NCT00500994 Impact statement Our research presents novel results that further elucidate the pathophysiology of functional movement disorder (FMD) with a machine learning model that classifies FMD and healthy controls correctly 80% of the time. Herein, we demonstrate how known differences in resting-state functional magnetic resonance imaging connectivity in FMD patients can be leveraged to better understand the complex pattern of neural changes in these patients. Knowing that there are measurable predictable differences in brain activity in patients with FMD may help both clinicians and patients conceptualize and better understand the illness at the point of diagnosis and during treatment. Our methods demonstrate how an effective combination of machine learning and qualitative approaches to analyzing functional brain connectivity can enhance our understanding of abnormal patterns of brain activity in FMD patients.

Clinicians' implicit and explicit attitudes about the legitimacy of functional neurological disorders correlate with referral decisions

OBJECTIVES

Uncertainty regarding the legitimacy of functional neurological disorder (FND) remains among some health care professionals. Despite treatment guidelines and consensus recommendations, variability in clinical practice referral decisions persists. Evidence from other conditions suggests such clinical decision making is impacted by practitioners' implicit and explicit attitudes. We aimed to identify whether health care professionals hold implicit and/or explicit attitudes about the legitimacy of FND and whether these attitudes are associated with referral decision making.

DESIGN/METHODS

We included 66 health care professionals who work with people with neurological conditions: n = 37 medical doctors, mainly neurologists (n = 18) and psychiatrists (n = 10), and n = 29 doctoral level practitioner psychologists. Participants completed an Implicit Association Test (IAT), Implicit Relational Assessment Procedure (IRAP), a referral decision-making vignette task and self-report measures of explicit attitudes on FND-legitimacy, therapeutic optimism and clinician confidence. Multiple Sclerosis (MS) was used as a comparator condition.

RESULTS

Participants self-reported strong explicit FND-legitimate and MS-legitimate attitudes but demonstrated an implicit FND-illegitimate/MS-legitimate bias. Deeper examination provided by the IRAP data indicated pro-FND-legitimate attitudes, but no bias for or against FND-illegitimate-contrasting the pro-MS-legitimate, anti-MS-illegitimate attitudes for the comparator condition. Attitudes about FND-illegitimacy were negatively associated with likelihood of referral to physical interventions such as physiotherapy. Medical doctors had lower treatment optimism and stronger explicit attitudes that FND is illegitimate than psychologists.

CONCLUSIONS

At an implicit level, clinicians are uncertain about the illegitimacy of FND, and such attitudes are associated with lower likelihood of referral to physiotherapy in particular. Improved education on FND among health care professionals is indicated.

Speech and language therapy: A treatment case series of 20 patients with functional speech disorder

BACKGROUND

While expert consensus recommendations support the use of speech and language therapy (SLT) for patients with functional speech disorder (FND-speech), there are limited published data on clinical outcomes.

OBJECTIVE

To retrospectively report the treatment outcomes and clinical characteristics of patients with FND-speech that attended outpatient SLT as part of a multidisciplinary program for functional neurological disorder (FND).

METHODS

In this case series, we included adult patients with FND-speech that consecutively participated in outpatient SLT at our institution between October 2014 and September 2021. Baseline demographic and neuropsychiatric characteristics were extracted from the medical records, along with data on FND-speech phenotypes, number of treatment sessions received, and clinician-determined outcomes. Only descriptive statistics were used to report findings.

RESULTS

Twenty patients met inclusion criteria; ages ranged from 21-77, with a mean of 51.6±16.2 years. 85% of the cohort presented with mixed FND-speech symptoms. Patients attended a range of 2-37 visits, with an average of 9.2±8.0 visits over 4.4±3.5 months. At the last treatment session, 3 patients were asymptomatic, 15 had improved, and 2 had not improved; 8 individuals that improved received video telehealth interventions.

CONCLUSION

This case series lends additional support for outpatient SLT in the assessment and management of individuals with FND-speech, and may help clarify patient and provider treatment expectations. Additional prospective research is needed to investigate baseline predictors of treatment response and further define the optimal frequency, intensity, duration, and clinical setting for SLT delivery in this population.

Use of non-invasive neurostimulation for rehabilitation in functional movement disorders

Functional movement disorders (FMD) are a subtype of functional neurological disorders which involve abnormal movements and include multiple phenomenologies. There is a growing interest in the mechanism, diagnosis, and treatment of these disorders. Most of the current therapeutic approaches rely on psychotherapy and physiotherapy conducted by a multidisciplinary team. Although this approach has shown good results in some cases, FMD cause a great burden on the health system and other treatment strategies are urgently needed. In this review, we summarize past studies that have applied non-invasive neurostimulation techniques, such as transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS) and peripheral nerve stimulation as a treatment for FMD. There is an increasing number of studies related to TMS including randomized controlled trials; however, the protocols amongst studies are not standardized. There is only preliminary evidence for the efficacy of non-invasive neuromodulation in reducing FMD symptoms, and further studies are needed. There is insufficient evidence to allow implementation of these techniques in clinical practice.

Emotional arousal in patients with functional movement disorders: A pupillometry study

OBJECTIVE

Pathophysiology explanations for functional movement disorders often assume a role for emotional hyperarousal. Pupillometry is a validated method for evaluation of emotional arousal by detecting changes in pupil size in response to emotional stimuli. In a case-control study design, we aimed to study objective and subjective emotional arousal using pupillometry and affective ratings. To assess attentional engagement by affective stimuli, we used videooculographic tracking of eye movement patterns (scanpath).

METHODS

Twenty-five female patients with functional movement disorders (mean age: 40.9 [SD 12.7] years) and 23 age matched healthy female controls participated in the study. Using infrared high-resolution eye-tracker, both pupil size and eye movement pattern in response to emotionally charged erotic, adventure, threat, victim, and neutral pictures were recorded along with subjective ratings of emotional valence and arousal of the presented pictures.

RESULTS

A between-group comparison showed significantly smaller pupil dilation to adventure stimuli compared to neutral stimuli in patients compared to controls (P < 0.004, bootstrap, uncorr., adj. η2 = 0.00). No significant difference in pupillary response to other stimuli and scanpath parameters was found between the groups. Patients rated significantly lower emotional arousal to erotic pictures than controls (P < 0.001, bootstrap, uncorr., adj. η2 = 0.09).

CONCLUSION

This study did not find evidence of autonomous or subjective emotional hyperarousal. The mismatch between objective autonomic measures and subjective arousal ratings in patients is of pathophysiological interest and in line with recent findings of impaired interoception in functional movement disorders.

Diagnosis and Management of Functional Tic-Like Phenomena

Over the past 3 years, a global phenomenon has emerged characterized by the sudden onset and frequently rapid escalation of tics and tic-like movements and phonations. These symptoms have occurred not only in youth known to have tics or Tourette syndrome (TS), but also, and more notably, in youth with no prior history of tics. The Tourette Association of America (TAA) convened an international, multidisciplinary working group to better understand this apparent presentation of functional neurological disorder (FND) and its relationship to TS. Here, we review and summarize the literature relevant to distinguish the two, with recommendations to clinicians for diagnosis and management. Finally, we highlight areas for future emphasis and research.

Functional neurologic disorder (FND) in pediatrics: A clinical review with discussion of FND in the era of COVID-19

ABSTRACT

Functional neurologic disorder is a complex disorder of truly experienced neurologic symptoms without evidence of underlying neurologic disease. This clinical review focuses on the pediatric population and includes the impacts of the COVID-19 pandemic. Clinician knowledge and early identification can substantially improve patient outcomes.

Affective States and Virtual Reality to Improve Gait Rehabilitation: A Preliminary Study

Over seven million people suffer from an impairment in Mexico; 64.1% are gait-related, and 36.2% are children aged 0 to 14 years. Furthermore, many suffer from neurological disorders, which limits their verbal skills to provide accurate feedback. Robot-assisted gait therapy has shown significant benefits, but the users must make an active effort to accomplish muscular memory, which usually is only around 30% of the time. Moreover, during therapy, the patients' affective state is mostly unsatisfied, wide-awake, and powerless. This paper proposes a method for increasing the efficiency by combining affective data from an Emotiv Insight, an Oculus Go headset displaying an immersive interaction, and a feedback system. Our preliminary study had eight patients during therapy and eight students analyzing the footage using the self-assessment Manikin. It showed that it is possible to use an EEG headset and identify the affective state with a weighted average precision of 97.5%, recall of 87.9%, and F1-score of 92.3% in general. Furthermore, using a VR device could boost efficiency by 16% more. In conclusion, this method allows providing feedback to the therapist in real-time even if the patient is non-verbal and has a limited amount of facial and body expressions.

Improvement in motor symptoms, physical fatigue, and self-rated change perception in functional motor disorders: a prospective cohort study of a 12-week telemedicine program

Background

Functional motor disorders (FMDs) are highly disabling conditions associated with long-term disability, poor quality of life, and economic burden on health and social care. While multidisciplinary 5-days rehabilitation programs have been shown to reduce motor and non-motor symptoms, long-term management and monitoring in FMDs remain an unmet need.

Aim

To compare a 12-weeks telemedicine program against a 12-weeks self-management program after a 5-days rehabilitation program for improving motor, non-motor symptoms, quality of life, and perception of change in patients with FMDs.

Methods

The study population was 64 consecutive patients with a definite diagnosis of FMDs who underwent a 5-days in-person rehabilitation program followed by either a self-management (the first 32 patients) or a telemedicine program (the latter 32 patients). Validated measures of motor and non-motor symptoms such as fatigue and pain, quality of life, perception of change, gait, and postural control were recorded before (T0), after completion of rehabilitation (T1), and then again at 3 months (T2).

Results

Improvement at 3-month follow-up assessment of motor symptoms (p < 0.001), physical fatigue (p = 0.028), and self-rated change perception (p = 0.043) was greater in the telemedicine group. No different between-groups effect was found on other dimensions of fatigue, pain, physical and mental health, and gait and postural control.

Conclusions

Long-term management and expert monitoring of patients with FMDs via telemedicine may enhance long-term outcomes in motor symptoms and physical fatigue, with a positive long-term impact on self-rated health perception of change.

Bridging structural and functional biomarkers in functional movement disorder using network mapping

BACKGROUND

There are gaps in our neurobiological understanding of functional movement disorder (FMD).

OBJECTIVES

We investigated gray matter volumetric profiles in FMD, and related findings to resting-state functional connectivity (rsFC) profiles using Human Connectome Project data.

METHODS

Volumetric differences between 53 FMD patients and 50 controls were examined, as well as relationships between individual differences in FMD symptom severity and volumetric profiles. Atrophy network mapping was also used to probe whether FMD-related structural alterations preferentially impacted brain areas with dense rsFC.

RESULTS

Compared to controls without neurological comorbidities (albeit with mild depression and anxiety as a group), the FMD cohort did not show any volumetric differences. Across patients with FMD, individual differences in symptom severity negatively correlated with right supramarginal and bilateral superior temporal gyri volumes. These findings remained significant adjusting for FMD subtype or antidepressant use, but did not remain statistically significant adjusting for depression and anxiety scores. Symptom severity-related structural alterations mapped onto regions with dense rsFC-identifying several disease epicenters in default mode, ventral attention, and salience networks.

CONCLUSIONS

This study supports that FMD is a multinetwork disorder with an important role for the temporoparietal junction and its related connectivity in the pathophysiology of this condition. More research is needed to explore the intersection of functional neurological symptoms and mood.

A Shift in Approach: Assessment and Treatment of Adults With Functional Neurological Disorder

Functional neurological disorder (FND) is a complex condition involving an interaction of psychological, physiological, and social factors. Despite high utilization of medical services, people with FND often suffer from poor long-term health and psychosocial outcomes, and experience stigmatization and marginalization within the medical community. Health service psychologists are well positioned to help patients with FND through the lens of the biopsychosocial model of health. Psychologists can facilitate appropriate assessment and treatment, and advocate for the needs of patients diagnosed with FND within multidisciplinary teams. This article reviews best practices for assessment and treatment of individuals diagnosed with or suspected of having FND and presents some clinical and ethical challenges associated with this complex population.

Functional neurological disorder: new subtypes and shared mechanisms

Functional neurological disorder is common in neurological practice. A new approach to the positive diagnosis of this disorder focuses on recognisable patterns of genuinely experienced symptoms and signs that show variability within the same task and between different tasks over time. Psychological stressors are common risk factors for functional neurological disorder, but are often absent. Four entities-functional seizures, functional movement disorders, persistent perceptual postural dizziness, and functional cognitive disorder-show similarities in aetiology and pathophysiology and are variants of a disorder at the interface between neurology and psychiatry. All four entities have distinctive features and can be diagnosed with the support of clinical neurophysiological studies and other biomarkers. The pathophysiology of functional neurological disorder includes overactivity of the limbic system, the development of an internal symptom model as part of a predictive coding framework, and dysfunction of brain networks that gives movement the sense of voluntariness. Evidence supports tailored multidisciplinary treatment that can involve physical and psychological therapy approaches.

The Role of Physiotherapy in the Management of Functional Neurological Disorder in Children and Adolescents

Children and adolescents with functional neurological (conversion) disorder (FND) present with symptoms of impaired motor and sensory function. FND involves complex interactions between the brain, mind, body, and lived experience of the child. The gold standard for treatment is therefore a holistic, biopsychosocial approach with multimodal interventions delivered by a multidisciplinary team. In this narrative review we examine the role of physiotherapy in managing FND in children. We searched Embase, Medline, PsycINFO, and PubMed (back to 2000) for relevant physiotherapy articles and also manually searched their reference lists. Two review articles and ten observational studies were identified. Data were extracted concerning the type of study, therapies involved, outcome measures, and comorbid mental health outcomes. FND symptoms resolved in 85% to 95% of the patients, and about two-thirds returned to full-time school after completing the multidisciplinary intervention. Ongoing mental health concerns at follow-up were associated with poorer functional outcomes. Key themes included the following: use of psychological interventions embedded in the physiotherapy intervention; integration of play, music, and dance; role of physical exercise in modulating physiological, neural, and endocrine systems; need for FND-specific outcome measures; ethical issues pertaining to randomized trials; and need to develop alternate study methodologies for assessing combined treatments. Clinical vignettes were included to highlight a range of physiotherapy interventions. In conclusion, the emerging literature suggests that physiotherapy for children with FND is a useful intervention for improving motor dysfunction and for addressing other concurrent issues such as physical deconditioning, neuroprotection, chronic pain, disturbed sleep, anxiety and depression, and resilience building.

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

Functional neurological disorder (FND) is a condition at the intersection of neurology and psychiatry, with some patients experiencing sensory hypersensitivities and other sensory processing difficulties. It has been postulated that poor integration and modulation of sensory information with cognitive, affective and behavioral processes may play a role in the pathophysiology of FND. In this article, we first succinctly review the role for occupational therapy (OT) in the multidisciplinary therapeutic approach to managing patients with FND. After highlighting previously published data identifying sensory processing difficulties in patients with FND, we subsequently outline the components of the sensory-based outpatient OT program for FND at the Massachusetts General Hospital. Here, we detail how occupational therapists assess and treat sensory modulation difficulties with the aid of resources like the Adolescent/Adult Sensory Profile (AASP), The Canadian Occupational Performance Measure (COPM), and the Sensory-Motor Preference Checklist. We then report on 2 clinical cases representative of the sensory modulation difficulties endorsed by some patients with FND, illustrating how developing an individualized, sensory-based treatment plan can help improve functional neurological symptoms and overall participation in activities of daily living. Prospective, controlled research is needed to further operationalize OT-based sensory modulation interventions, as well as define the tolerability and efficacy of this intervention for pediatric and adult populations with FND.

Treatment Approaches for Functional Neurological Disorders in Children

Purpose of Review

Functional neurological disorder (FND) is a multi-network brain disorder that encompasses a broad range of neurological symptoms. FND is common in pediatric practice. It places substantial strains on children, families, and health care systems. Treatment begins at assessment, which requires the following: the medical task of making the diagnosis, the interpersonal task of engaging the child and family so that they feel heard and respected, the communication task of communicating and explaining the diagnosis, and the logistical task of organizing treatment.

Recent Findings

Over the past decade, three treatment approaches—Retraining and Control Therapy (ReACT), other cognitive-behavioral therapies, and multidisciplinary rehabilitation—have been evaluated in the USA, Canada, and Australia. Of children treated in such programs, 63 − 95% showed full resolution of FND symptoms. The common thread across the programs is their biopsychosocial approach—consideration of biological, psychological, relational, and school-related factors that contribute to the child’s clinical presentation.

Summary

Current research strongly supports a biopsychosocial approach to pediatric FND and provides a foundation for a stepped approach to treatment. Stepped care is initially tailored to the needs of the individual child (and family) based on the pattern and severity of FND presentation. The level of care and type of intervention may then be adjusted to consider the child’s response, over time, to treatment or treatment combinations. Future research is needed to confirm effective treatment targets, to inform the development of stepped care, and to improve methodologies that can assess the efficacy of stepped-care interventions.

The use of rhythmic auditory stimulation for functional gait disorder: A case report

BACKGROUND: Functional gait disorders (FGD) are a common and disabling condition. Consensus-based rehabilitation techniques for treating FGD and other functional neurological disorder presentations at large utilize a variety of therapeutic strategies, including distraction, novel approaches to movement, entrainment, stress/hypervigilance modulation, and psychotherapy. CASE REPORT: Here we present a case of a 24-year-old woman with a complex history of anxiety, depression, left frontal astrocytoma, postural orthostatic tachycardia syndrome (POTS) and FGD. During a multidisciplinary inpatient rehabilitation stay for FGD, the patient underwent rhythmic auditory stimulation (RAS) delivered by a neurologic music therapist in conjunction with physical therapy, occupational therapy, and psychotherapy. RESULTS: The RAS intervention appeared to play a significant role in symptom resolution for this patient. Improvement in the patient’s truncal displacement, foot dragging, and well as overall gait speed occurred following serial RAS trials performed over a single treatment session. Benefits persisted immediately following the intervention and upon subsequent reassessment. Although at four-year follow-up the patient’s FGD symptoms remained resolved, fatigue continued to limit her ambulatory capacity and overall endurance. CONCLUSION: RAS represents a unique therapeutic approach for treating FGD, complementary to existing consensus-based rehabilitation recommendations, and may warrant further consideration by the field.

Functional seizures are associated with cerebrovascular disease and functional stroke is more common in patients with functional seizures than epileptic seizures

PURPOSE

To characterize the relationship between functional seizures (FSe), cerebrovascular disease (CVD), and functional stroke.

METHOD

A retrospective case-control study of 189 patients at a single large tertiary medical center. We performed a manual chart review of medical records of patients with FSe or epileptic seizures (ES), who also had ICD code evidence of CVD. The clinical characteristics of FSe, ES, CVD, and functional stroke were recorded. Logistic regression and Welch's t-tests were used to evaluate the differences between the FSe and ES groups.

RESULTS

Cerebrovascular disease was confirmed in 58.7% and 87.6% of patients with FSe or ES through manual chart review. Stroke was significantly more common in patients with ES (76.29%) than FSe (43.48%) (p = 4.07 × 10^-6). However, compared to nonepileptic controls FSe was associated with both CVD (p < 0.0019) and stroke (p < 6.62 × 10^-10). Functional stroke was significantly more common in patients with FSe (39.13%) than patients with ES (4.12%) (p = 4.47 × 10^-9). Compared to patients with ES, patients with FSe were younger (p = 0.00022), more likely to be female (p = 0.00040), and more likely to have comorbid mental health needs including anxiety (p = 1.06 × 10^-6), PTSD or history of trauma (e.g., sexual abuse) (p = 1.06 × 10^-13), and bipolar disorder (p = 0.0011).

CONCLUSION

Our results confirm the initial observation of increased CVD in patients with FSe and further suggest that patients with FSe may be predisposed to developing another functional neurological disorder (FND) (i.e., functional stroke). We speculate that this may be due to shared risk factors and pathophysiological processes that are common to various manifestations of FND.

Economic Costs of Delayed Diagnosis of Functional Motor Disorders: Preliminary Results From a Cohort of Patients of a Specialized Clinic

Background: Functional motor disorders (FMDs) are prevalent and highly disabling conditions in young adults that can result in reduced independence. Despite advances in diagnosis and treatment, the economic burden of FMDs is largely unknown.

Objective: This pilot retrospective study provides a real-world overview of the economic costs related to delayed diagnosis of FMDs from a cohort of patients of a specialized clinic in Italy, based on Italian healthcare costs.

Methods: Sociodemographic data, clinical history, healthcare service utilization, and associated direct costs were collected for a period of up to 5 years before a definite diagnosis of FMDs in 40 patients.

Results: The mean time lag between the onset of FMDs symptoms and diagnosis was 6.63 years (±8.57). The mean annual use of recourses per patient was three specialist visits (95% CI 2.4–3.4) and three diagnostic examinations (95% CI 2.2–3.6) that made up a total of six investigations and over seven (95% CI 5.5–9.7) rehabilitation contacts per year per patient were used before a diagnosis of FMDs was established. In more than 50% of the cases, patients had been hospitalized or made an ER visit at least once before receiving the correct diagnosis. The average annual costs for delayed diagnosis, taking into account only direct healthcare costs (without medications), was about €2,302 (CI 95% €1,570–2,830) per patient [€1,524 covered by the NHS (CI 95% €1,214–1,834) and € 778 by the patient (CI 95% €606–960)]. Hospitalization accounted for €916 (CI 95% €670–1,160) per patient per year, followed by rehabilitation €493 (CI 95% €345–641) and diagnostic tests € 387 (CI 95% €314–460).

Conclusion: These preliminary results shed some light on the high healthcare services volume and direct healthcare costs from clinic to clinic for visits, unnecessary tests, and prescribed treatments in a real-world overview from a cohort of patients of a specialized clinic in Italy. It may represent a starting point for future studies to statistically test and quantify cost reduction after implementing appropriate healthcare pathways.