#83: OT and Functional Neurological Disorder with Naoya Ogura

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Learn more about our guest: Naoya Ogura, OTD, OTR/L

Functional neurological disorder (FND) has been called a “silent epidemic,” a “crisis” in neurology, and psychiatry’s “blind spot.”

And, I have to admit it has been a huge personal blind spot for me.

Luckily, others in the OT community have been hard at work standardizing care for these patients. Multidisciplinary treatment, including referral to OT is a best practice for these patients. And, today we will look at expert recommendations for OT assessment and treatment.

:white_check_mark: Agenda

Intro and breakdown of journal article

Discussion on practical implications for OTs

  • 00:12:28 How Naoya learned about FND
  • 00:14:15 How his clinic earned a reputation for specializing in FND
  • 00:21:43 Article impressions
  • 00:22:48 Client education on FND
  • 00:27:17 Approaching FND differently from other neuro cases
  • 00:33:53 Assessment for FND
  • 00:39:08 Naoya’s treatment approaches
  • 00:48:20 Advice for navigating functional seizures
  • 00:50:53 What does discharge look like?
  • 00:53:32 Not enough people with FND make it to OT. How do we change that?

:white_check_mark: Supplemental Resources

Handouts from The Clinical Resources Hub

Websites

Research articles

:white_check_mark: Article Review

Read Full Text: Occupational therapy consensus recommendations for functional neurological disorder
Journal: Journal of Neurology
Year Published: 2020
Ranked 35th on our 2019-2023 list of the 100 Most Influential OT Journal Articles

Functional neurological disorder (FND) has been called a “silent epidemic,” a “crisis” in neurology, and psychiatry’s “blind spot.”

And, I have to admit, it has been a huge personal blind spot for me.

I knew nothing about this condition before reading this paper. Luckily, others in the OT community have been hard at work standardizing care for FND patients. Multidisciplinary treatment of functional neurological disorder, including referral to OT, is a best practice. Here, we will look specifically at expert recommendations for OT assessment and treatment.

Then, next week, we will welcome to the podcast Naoya Ogura, OTD, OTR/L, West Los Angeles Clinic Director at Re-active, who specializes in neurological conditions like POTS, EDS, MCAS, and FND.

Let’s dive in.

What is functional neurological disorder?

Functional neurological disorder is a common, costly, and disabling condition. While FND was marginalized in the 20th century, there has been a renewed interest in this disorder, catalyzed by improved diagnosis and treatment as well as an embrace of the biopsychosocial model.

In the simplest sense, FND is marked by connectivity issues, where different parts of the brain have difficulty communicating with each other, leading to neurological symptoms. While people sometimes think of FND as a “wastebasket” diagnosis, there are clear rule-in signs, and is not a diagnosis of exclusion. (For a full on update on diagnosis of FND, I recommend this paper.)

Two important things for OTs to note are:

  1. In the DSM-V, functional neurological disorder is used interchangeably with “conversion disorder.” But, it is now widely accepted that functional neurological disorder the updated term.
  2. There is a large variety of symptoms associated with FND. The DSM-V gives the following subcategories of FND based on how the disorder presents:
    a. with motor symptoms,
    b. with seizures,
    c. with sensory symptoms, and
    d. with mixed symptoms.

What treatment is recommended?

Multidisciplinary treatment is considered the optimal approach. This can include neurological assessment, PT, OT, SLP, and psychiatric care.

The specific evidence supporting any one of those treatments—occupational therapy included—is limited, but OT shows strong face validity due to our biopsychosocial approach to care.

An important step toward increasing OT-specific research on FND is to standardize our treatment of it, which leads us to this paper.

What was the intent of this paper?

In this paper, the authors sought to develop a broad set of consensus recommendations to guide OT practice for people with FND.

What were their methods?

Following the Delphi Method, data collection and analysis occurred in 4 key stages:

  1. 12 OTs from different countries who had extensive experience in FND were invited to complete an online survey about assessment and intervention.
  2. A face-to-face meeting was held in Scotland in 2018, during which participants discussed and debated the data.
  3. Recommendations were drafted based on the meeting.
  4. Participants either endorsed each recommendation or provided suggestions. This feedback process went on until consensus was reached.

Recommendations for OT

This is such a rich section! I encourage anyone working with this population to read it in full. But here are the highlights.

Referral to OT

The group suggested that OT intervention for FND is more likely to be successful if the client:

  • Has some degree of understanding and agreement with the diagnosis.
  • Has agreed to the referral.
  • Can identify rehabilitation goals.
  • Understands that the initial focus of OT is to improve function.

Assessment

Below is a structure that may be useful in guiding an initial assessment. (The full paper gives slightly more detail.)

  1. Ask the person how their symptoms started.
  2. Create a list of current symptoms.
  3. Clarify the person’s understanding of the diagnosis.
  4. Ask the person about their medical history and any other health problems.
  5. Take a detailed social history.
  6. Gain a picture of their 24-hour routine.
  7. Determine if they have care needs—and how those needs are being met.
  8. Ask about access to the home, work, or school environment.
  9. If applicable, ask about the impact of symptoms in the person’s school or work environment.
  10. Observe the person’s daily activities. Note distractibility and variability of symptoms.

Standardized assessments
The authors recommend the following standardized assessments:

Treatment

With regard to treatment, the authors highlight two overarching themes:

1.) The importance of supporting self-management of symptoms.
2.) The value of establishing an internal locus of control, rather than placing control in the hands of clinicians and family members.

The authors go on to provide detailed recommendations in the following areas:

  • Goal setting
  • Education
  • Vocational rehab
  • Aids and adaptations
  • Splinting
  • Symptom-specific treatments for:
    • Functional motor symptoms
    • Functional visual impairment
    • Functional cognitive impairment
    • Dissociative (non-epileptic) seizures
  • Common problems associated with FND:
    • Hypersensitivity
    • Anxiety
    • Fatigue and pain management
    • Psychological trauma
    • Risk management
    • Disability management

Concluding treatment

Discharge should not be framed as a conclusion of treatment, but rather the point at which the person should implement self-management strategies.

To create a relapse prevention/wellness plan that the patient can carry forward after discharge, the following questions should be collaboratively considered:

  1. What have you learned about your condition?
  2. What makes your symptoms worse? What might trigger setbacks?
  3. What are the most helpful management strategies that you have learned?
  4. What were the unhelpful coping strategies that actually made it difficult for you to improve?
  5. What can you do if you notice your symptoms and functions are getting worse?
  6. What are your goals for the next 3, 6, 9, and 12 months?

Booking a follow-up appointment to review progress, troubleshoot issues, and reset goals is advised.

Conclusion

FND is a complex condition that has far-reaching consequences on physical and psychological health. Multidisciplinary rehab—including OT—is the current treatment best practice. This paper provided OT assessment and treatment recommendations for people with FND, considering their journey of managing the acute stage and gaining support in the community.

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Please share any other feedback below! Including, ideas for future programming, and most importantly, how you feel this podcast will impact your practice!

3

It has been over 10 years since I worked in an inpatient pediatric rehab setting and treated patients with “conversion” disorder. I always found it fascinating, but never truly received any formal training on the condition. I now work in early intervention and I’m probably much less likely to see this, but I found this podcast super interesting and I am grateful to have learned some new things about FND …even if I do not have current clients with FND. This podcast reminds me to KEEP LISTENING…and it inspires me to stay up to date on current topics, whether I see patients with FND or not… it feels good to keep learning and I am SO GRATEFUL FOR THIS PODCAST!!

4

Great conversation! And a needed one too - I hadn’t learned about FND other than a brief mention of conversion disorder in abnormal psych classes years ago. Seeing FND as primarily a connectivity disorder rather than a psychological one was a big “aha” moment for me. And now I feel more prepared to recognize and understand these symptoms in future clients. Thanks to Naoya for his insights from practice!

2 Likes
5

This podcast achieves the goal of translating research into practice. I had a patient our facility couldn’t serve and was really discouraged. I referred him to Naoya Ogura, and the patient is receiving top notch treatment and feels very hopeful now.

I would have never known where to refer him without this podcast.

3 Likes
6

Oh, that makes me feel emotional :heart: ! I feel like this episode really tugged at the heart strings, because as OTs we all know clients who have reached the point of discouragement and never find the right services.

I’m so thankful you were able to help this person!

2 Likes
7

I am so happy that FND was discussed on this podcast, actually was the first podcast I listened to. Naoya and those at Re+active therapy are so well versed in FND care, I love the advocacy of OT in its care. I hope we can get more OT’s interested and engaged in treating the FND population because this patient population needs us and our holistic treatment approach. Thank you for this content!

1 Like
8

@JasonKreuzman Phew! I’m so thankful that someone like you who is so well-versed in FND liked the podcast! I definitely felt the weight of creating helpful content, given that there is so little OT info out there about this diagnosis!

@naoya have you met @JasonKreuzman yet?

I just found Jason’s instagram, and I’m excited to follow!

9

You did great! There really is limited OT research out there. I have an OT practice article coming out later this year on FND. Would love to collaborate with other OT’s to create more FND awareness in our profession.
I actually have met him and had a phone conversation a number of months back. He has such amazing knowledge of FND! I am on a committee through the FND Society with the owner of Re+active therapy. Such an amazing group, I wish there were more groups like them.

1 Like
10

Oh wow! I love what a small world it is! I’m really curious how we can promote more practices like re-activ? And, I wonder what the main barrier is to people starting more practices like this. One over-comeable barrier seems like simply embracing our identity as pain experts, and really putting that front and center in our marketing…

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