Physical Therapy for FND (Functional Neurological Disorder)

Welcome back! It's been a while since my last post, so here's a quick recap, as well as additional information on FND. My previous blog outlined the neurological nature of FND, the outdated psychiatric misconceptions related to conversion disorder, and the turmoil of navigating the healthcare system with this diagnosis.  I cringe every time I read something that labels FND as a “rare disease.” Did you know it is the second most common reason for an outpatient neurology consultation? The notion that it is rare adds to the widespread lack of understanding, and makes it easy for many providers to dismiss it.  FND occurs in a wide range of ages.  It’s been documented in people as young as 4, all the way up to 94 years old. It tends to affect women more than men. In the last blog, I outlined the distinction between diagnostic criteria and risk factors.  Risk factors are not diagnostic but can make one more likely to develop FND.  Risk factors like anxiety, panic disorders, OCD-like tendencies, bodily hypervigilance, and other psychiatric challenges seem to get the spotlight. Many often don’t realize there are other types of risk factors.  I have many patients who experienced FND after a psychologically traumatizing event.  I also have many patients who experienced FND symptoms after viral infections, surgeries, injuries, after the diagnosis of other neurological conditions, having loved ones with neurological conditions or illness.  Over 50% of people with FND don’t have a history of significant psychological trauma. Not everyone with psychological trauma develops FND, just like there are those with FND who haven’t experienced severe, psychological trauma.

The treatments for FND are multi-faceted.  Research, (and my experience), show that best outcomes happen with a complete care team.  A complete care team can include neurology, psychotherapy for assistance in reframing thought processes, behaviors, and relationship dynamics that could be undermining your ability to manage symptoms more optimally. Psychiatry can also be useful if there are co-existing psychological challenges that could benefit from medication.  The care team should absolutely include rehab services.  Physical therapy is a first line treatment for FND.  

A common question I’m asked is, “Why do I need to see an FND specialist?  Isn’t seeing a neurological physical therapist sufficient?” A unique and specific approach is of the utmost importance and ties directly to studies supporting the neurological nature of FND.  A study by Nielsen et al. in 2017, included a group of people with FND, who were split into 2 groups.  One group received FND-specific physical therapy, and the other group received standard neurological physical therapy.  At a 6 month follow-up, the group who received FND-specific physical therapy reported a 72% improvement in symptoms vs the standard neurological physical therapy group who only reported an 18% improvement in symptoms.

The next question I get is usually, “Well, what does FND-specific physical therapy entail?”  Physical therapy for FND relates back to research showing how brains with FND activate differently.  Researchers used a special type of imaging called functional MRI or fMRI.  This type of MRI is different from what’s used for placing clinical diagnoses of other neurological conditions. It goes beyond the structure of the brain and shows how different areas of the brain are lighting up/activating, or not activating.  The researchers took a group of people with FND and a group of people without FND, exposed them to similar circumstances and watched how the participants’ brains responded.  The brains activated very differently in those with FND compared to those without FND.  People with FND had certain areas of the brain that were commonly overactive, and other areas that were commonly underactive.  These findings connect directly to what PT experts do to address FND.  

Areas of the brain that are overactive (this is not an all-inclusive list for simplicity’s sake):

1. Dorsolateral prefrontal cortex: One of the many roles of this part of the brain, includes attentional control. When this area is overactive, it can manifest as increased FND symptoms when the person with FND looks at, focuses on, talks about the symptom–essentially drawing more attention to symptoms, causing the actual symptoms to increase.  When adequately distracted, the symptoms can reduce or dissipate.

The PT approach to this is using distractive techniques to better regulate this part of the brain and reduce or suppress symptoms.  Distractive techniques may seem simple in theory, but each individual requires a very nuanced approach, with activities specifically chosen and dosed in a way to elicit the desired response.  It requires a great deal of knowledge, experience, and problem solving.

2. The amygdala is also an area of the brain that is highly overactive in people with FND.  The amygdala is responsible for emotional regulation, and plays an essential role in the fight/flight/freeze system.

The PT approach for this includes different techniques for nervous system quieting.  Again, this can seem simple but it has to be highly tailored to each individual.  PT and psychotherapy have good complementary approaches for this, and is an area that highlights the need for the whole team approach.

Areas for the brain that are underactive (again, not an all-inclusive list):

1. Movement centers can be underactive.  This can look like not enough movement or too much movement due to a lack of activation in the movement filters of the brain.

The PT approach can include automatic movements, altering the speed of a movement, using external focuses, novel movement, and goal-oriented tasks.  It can also include layering the distractive techniques into movement experiences for accumulating more “normalized” movement practice and strengthening brain pathways.

2. The right temporoparietal junction is shown to be underactive.  This part of the brain, in oversimplified terms, helps compare what is expected to happen with a movement, to what actually happens once the movement is performed.  It lends itself to a sense of agency and control.  

The PT approach can include sensory retraining to help the brain receive more accurate information of what’s happening when a movement is performed; subsequently promoting more accurate predictions of future movements.  This is also where we try to wean people away from excessive help from family/friends, from assistive devices (unless they are needed for other conditions), and talking to family about how to best support their loved ones in a way that promotes improved self-efficacy for the patient.  People with FND need to recognize that even small moments of symptom success are attributed to themselves and not something external, like another person or piece of equipment.  

Another vital PT approach includes screening for common comorbidities of FND.  If other conditions are present and irritating the nervous system, it can be extremely difficult to experience the full and intended benefits of FND-specific strategies.  This is quite comprehensive and will be a topic for a future blog or educational video.

There is solid evidence with great recommendations for addressing FND.  The challenge for any clinician is figuring out how to apply those recommendations to actual human beings– people who are varied, individualized, and unique.  I’ve been fortunate to have an abundance of practice and effort spent on this process over the years.  I’m regularly discovering new strategies and techniques.  Although we don’t know what causes FND, it is an area of research that is rapidly growing.  I don’t thrive in stagnation and am excited to engage in this continuous learning process.  I look forward to serving my patients and facilitating an empowering, informative, healing process, tailored to each person I encounter. Please reach out and stay tuned for more educational information.

Lennie Swenson

Movement is Medicine Neurologic and Vestibular Physical Therapy, LLC