Functional Neurological Disorder Treatment

Expert Functional Neurological Disorder in Delhi

What is Functional Neurological Disorder ?

Functional Neurological Disorder (FND), previously known as conversion disorder, is a complex and often misunderstood neurological condition. It is characterized by genuine neurological symptoms (like weakness, tremors, seizures, or sensory changes) that cannot be explained by a structural neurological disease or other medical condition. Instead, FND is understood as a problem with the functioning of the nervous system, specifically how the brain sends and receives signals. Think of it as a “software” problem in the brain, rather than a “hardware” issue.

Causes of Functional Neurological Disorder

The exact cause of FND is not fully understood, but it is increasingly recognized as a complex interplay of biological, psychological, and social factors. It is crucial to understand that symptoms are not intentionally produced or “made up” by the patient.

Contributing factors include:-

Brain Network Dysfunction: Research suggests that FND involves abnormalities in brain networks responsible for movement, sensation, emotion regulation, and self-awareness. There may be disrupted communication between different brain areas, leading to impaired control over voluntary movements or sensory processing. For example, areas of the brain involved in predicting and planning movement might become disconnected from areas that execute movement.
Stress and Trauma: While not always present, psychological factors often play a significant role. FND symptoms can appear suddenly after:
- Stressful life events: Acute or chronic psychological stress, anxiety, or emotional trauma.
- Physical injury or illness: A minor physical injury or illness can sometimes act as a trigger, even if the injury itself doesn’t fully explain the neurological symptoms. The brain might “learn” an abnormal movement pattern in response to pain or injury, and this pattern persists even after the initial physical cause has resolved.
- Psychological trauma: A history of childhood abuse, neglect, or other significant trauma is reported in a subset of FND patients.
Predisposing Factors: Certain individuals may be more susceptible to FND:
- Having another neurological condition (e.g., migraine, epilepsy, multiple sclerosis).
- Having certain mental health conditions (e.g., depression, anxiety, personality disorders, PTSD).
- Chronic pain or fatigue conditions.
- Genetic predisposition is being explored, but it’s not a primary cause.
Impaired Sense of Agency: Some theories propose that FND involves a disrupted “sense of agency,” where the brain loses the feeling of control over its own actions. This can lead to movements or sensations that feel involuntary.
Attentional Processes: There’s evidence that increased self-focused attention on a body part can sometimes exacerbate symptoms, while distraction can alleviate them.

Symptoms of Functional Neurological Disorder

FND can manifest with a wide range of neurological symptoms, which can fluctuate in severity and may affect different parts of the body at different times. These symptoms are real and can be very disabling.

Common categories of symptoms include:-

Motor Symptoms
- Weakness or paralysis: Often affecting one side of the body (hemiparesis/hemiplegia) or a single limb, but not following typical neurological patterns. A classic sign is “Hoover’s sign” for functional leg weakness, where attempting to push down with the weak leg results in increased downward pressure from the unaffected leg.
Abnormal movements
- Functional tremor: Involuntary, rhythmic shaking that may vary in amplitude and frequency, often reducible with distraction or entrainment (matching the rhythm of the unaffected limb).
- Functional dystonia: Sustained muscle contractions leading to abnormal postures or repetitive movements, often fluctuating and sometimes relieved by “sensory tricks.”
- Functional jerks (myoclonus) or tics: Sudden, brief, involuntary movements.
- Gait (walking) disorders: Unsteadiness, “dragging” a leg, bizarre or dramatic walking patterns that don’t fit typical neurological conditions, often improving when not observed.
- Speech problems: Dysarthria (slurred speech), aphonia (loss of voice), or dysphonia (difficulty speaking).
Sensory Symptoms
- Numbness or loss of sensation: Often affecting a limb or part of the body, but not following a typical dermatomal (nerve root) pattern.
- Altered touch or pain sensation: Increased sensitivity or strange sensations.
- Vision problems: Double vision, tunnel vision, or even temporary blindness.
- Hearing problems: Hearing loss or tinnitus.
Seizure-like Episodes (Functional Seizures / Psychogenic Non-Epileptic Seizures – PNES):
- Episodes that resemble epileptic seizures but are not caused by abnormal electrical activity in the brain. They may involve shaking, thrashing, unresponsiveness, or apparent loss of consciousness. Clinical features often help distinguish them from epileptic seizures (e.g., eye closure, side-to-side head movements, pelvic thrusting, prolonged duration, crying).
Cognitive Symptoms: Difficulties with memory, concentration, and attention.
Other Associated Symptoms
- Fatigue: Often profound and debilitating.
- Pain: Chronic pain, including headaches or widespread body pain (e.g., fibromyalgia-like symptoms).
- Sleep problems: Insomnia, disturbed sleep.
- Dissociative symptoms: Feeling disconnected from one’s body, thoughts, or surroundings.
- Anxiety and depression: Very common comorbidities.

Advanced Physiotherapy for Functional Neurological Disorder

Neurobiological Explanation: Using analogies (like the “software bug” in the brain) helps patients understand the functional nature of their symptoms, which can reduce anxiety and improve engagement in therapy.

Positive Framing: Emphasizing that the brain has the capacity to “relearn” normal movement patterns is vital for instilling hope and motivation.

Movement Retraining with Diversion of Attention:

Core Principle: FND symptoms often worsen with conscious effort or attention to the affected movement. Physiotherapy aims to bypass this by focusing on automatic, effortless movements.
Techniques:
- Distraction Tasks: Instead of focusing on moving a weak leg, the therapist might ask the patient to kick a ball, step over an imaginary object, or focus on a visual target.
- “Automatic” Movements: Using movements that are typically automatic and less consciously controlled, such as swaying, walking backwards, or marching.
- External Focus of Attention: Directing the patient’s attention away from the affected body part and towards an external goal (e.g., “walk to the door” instead of “lift your leg”).
- Rhythmic Movement: Encouraging rhythmic, smooth movements (e.g., swinging arms while walking, tapping feet to music) as these can help override erratic functional movements like tremors.
Harnessing Positive Clinical Signs:
- Leveraging Inconsistencies: Therapists use the specific, inconsistent patterns seen in FND to demonstrate to the patient that normal movement is possible.
- Examples:
  - Hoover’s Sign: For functional leg weakness, the therapist can show the patient that their “weak” leg can push down strongly when they focus on lifting the other leg. This demonstrates latent strength.
  - Tremor Entrainment: The therapist can show that a functional tremor can be temporarily stopped or change its rhythm when the patient attempts to match a different rhythm with the unaffected limb or a finger.
  - Astasia-Abasia (Functional Gait Disorder): While the patient might have a bizarre or collapsing gait when trying to walk “normally,” they might be able to walk more fluidly when distracted (e.g., running, walking sideways, or even doing complex turns).
Graded Activity and Exposure:
- Addressing Avoidance: Many FND patients develop fear-avoidance behaviors due to their symptoms, leading to deconditioning and further disability.
- Techniques:
  - Graded Exposure: Gradually exposing the patient to movements or activities they fear, starting with small, achievable steps and progressively increasing difficulty.
Sensory Retraining and Proprioception:
- Addressing Sensory Symptoms: While less directly addressed by movement retraining, some sensory symptoms can benefit from activities that improve sensory discrimination and body awareness.
- Techniques:
  - Tactile Discrimination: Exercises using different textures, temperatures, or pressure.
  - Proprioceptive Drills: Activities that challenge the sense of joint position and movement, often with eyes closed.

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