Clinical Insight: Treatment Reflection

Introduction

Two years ago, our 24-year-old female patient was diagnosed with Functional Neurological Disorder (FND).

One of the symptoms that our patient experiences is seizures that sometimes cause her temporary paralysis in her legs. In August 2022, she had a seizure that caused longer term paralysis in her legs.

Treatment

Our team treated this patient for four months, from March to June 2023 with very encouraging results for the patient. She made steady improvement each week until she reached her rehabilitation goal. Her FND is now currently stable and she feels able to manage it.

The patient’s treatment followed the general treatment principles outlined in the paper ‘Physiotherapy for functional motor disorders: a consensus recommendation’, published in the Journal of Neurology, Neurosurgery & Psychiatry.

Our patient’s description of her treatment can be mapped against these treatment principles, demonstrating how this approach has worked for our patient.

1. Treatment Principle: Build trust before challenging/pushing the patient and project confidence, making it clear that the physiotherapist knows about FND.

Patient reflection: “Before I met my Physiotherapist, I didn’t know what I should be doing to get better. I had a feeling of dread like I would be in the wheelchair forever.

“My Physiotherapist was excellent; she was really supportive and she knew a lot about FND. I’ve found that to be quite unusual in health care; I find doctors generally don’t know much about the condition.

“I have non-epileptic seizures and in the early days, my partner would take me to A&E and I would just be sent back home because they didn’t know what was wrong.

“It was amazing that she knew all about my condition. She had worked with other people in a similar position to me and she knew how to approach my treatment. She explained things to me really well.”

1.Treatment Principle: Goal directed rehabilitation focusing on function and automatic movement (eg, walking) rather than the impairment (eg, weakness) and controlled (‘attention-full’) movement (eg, strengthening exercises).

Patient reflection: “In our first session, we talked about my goals and what I wanted to achieve in the short and longer term. My partner and I were going on holiday to Spain in June and my main goal was to be out of my wheelchair for that. I wanted to be able to walk around and to go swimming.”

2. Treatment Principle: Encourage early weight bearing. ‘On the bed strength’ will not usually correlate with ability to stand in functional weakness.

Patient reflection: “In the second half of our first session, we went through some exercises with me to help me start standing. This included leaning against a table or a bed frame so I could practice standing up. I hadn’t stood up at all since August 2022 so I found it quite difficult.

“My Physiotherapist advised me that it would help if I was distracted while I practiced standing. She gave me a colouring book to do while I was doing my exercises, because I had mentioned to her that I liked art. She encouraged me to give it a go and I saw a dramatic improvement.

“I could stand for longer because I wasn’t constantly thinking about it. When I thought too much about trying to stand, my legs would start shaking. The distraction really helped. I’m still using the techniques that I learned in those sessions.”

3. Treatment Principle: Involve family and carers in treatment. Recognise and challenge unhelpful thoughts and behaviours.

Patient reflection: “We took videos and photos of my progress so that I could share these with my family. If I was ever having a hard time, or I thought I was going backwards, I could look at the videos and remind myself how far I had come. That’s what my Physiotherapist told me to do and it really helped. It was very motivating.

“My family live in Lincolnshire, while I live in Poole, so it was great to show them my progress this way. The first time I got up out of my wheelchair and took some steps, my mum was so happy she cried.”

4. Treatment Principle: Develop a self-management and relapse prevention plan. Foster independence and self-management.

Patient reflection: “The work that I have done makes me feel more confident that if this happens to me again, I have strategies that will help me cope with it. It was really scary when it first happened but it’s less on my mind now and I can focus on other things.

“My last session was at the beginning of June. My partner and I really enjoyed our holiday. I brought my wheelchair with me, but for the most part I could walk around and swim. I was so pleased about that.

“I’d really like to get back to work now that my FND is starting to be more under my control. I’ve started volunteering one day a week at a charity shop to help get myself back into a work environment.

“To anyone in the position I was in, I would say: don’t lose hope. I had been feeling like this would be my life forever, but once I started doing the Physiotherapy, it gave me hope.”

Conclusion

This case is a really interesting one, as the patient’s description of her treatment can be closely related to the treatment principles outlined in the paper by Nielsen et al. This treatment approach worked well for our patient and it was encouraging to see her make progress.

References

Nielsen, G. et al. (2015) Physiotherapy for functional motor disorders: A consensus recommendation, Journal of Neurology, Neurosurgery & Psychiatry. Available at: https://jnnp.bmj.com/content/86/10/1113.long (Accessed: 06 October 2023).