Leveraging Physical and Rehabilitation Medicine in the interdisciplinary care of persons with Functional Neurological Disorder

Dear Editor, Recognizing the complex nature of functional neurological disorder (FND), there is mounting evidence that an effective patient-centered approach for this population hinges on interprofessional and interdisciplinary collaboration1–3. While the care of persons with FND traditionally involves neurology and psychiatry, physical and rehabilitation medicine (PRM) can also help manage these patients. Presenting with a myriad of functional complaints, patients with FND often present with various rehabilitation needs, and many of the common comorbidities in FND (eg, chronic fatigue, chronic pain4, postconcussion5, and long coronavirus disease 20196) can benefit from a physiatric consultation. There are currently no data available specific to the frequency with which FND presents to PRM, although we can extrapolate that it is quite prevalent from the fact that it ranks as the second most common reason for a new ambulatory general neurology consult7. Defined as altered voluntary motor or sensory function incompatible with recognized neurological or medical conditions8, FND rarely presents as an isolated physical manifestation and is often associated with significant disability impacting one’s personal, working, and family life9. Its incidence ranges from 4 to 12 per 100,000 per annum10, making it as common as multiple sclerosis; however, available data may be an underestimate due to under/misdiagnosis and lack of high-quality epidemiologic studies8,9. While neurologists and psychiatrists may be more likely to diagnose FND through a “rule in” rather than a “rule out” diagnosis8,11, physiatrists can also leverage their ability to distinguish FND from other neurological or psychiatric conditions that they have encountered in the past and pragmatically approach its formulation and management. Given the generally limited number of physicians in most health care settings, physiatrists can take a more active role in the interdisciplinary care of persons presenting with FND symptoms by assisting with diagnosis and treatment. The specific skill set unique to PRM can be leveraged to improve the quality of care for individuals experiencing FND. Trained to lead and coordinate holistic, individualized, and patient-centered rehabilitation interventions12, physiatrists can translate these competencies to FND care as well. Throughout the longitudinal care of FND, they can ensure that all aspects of each patient’s interdisciplinary treatment are well-integrated and up-to-date tailored to individual progress and changing rehabilitation needs. PRM is a medical specialty highlighting leadership and team dynamics as highly fundamental aspects of training, and these can be leveraged in FND care as the quality of teamwork correlates with improved outcomes13. To illustrate a physiatrist working with rehabilitation therapists attending to a patient with postconcussion syndrome presenting with dizziness, headaches, and brain fog may guide the team in distinguishing which persistent symptom/s may have functional mechanisms14, if any. Depending on the team’s collective assessment, the rehabilitation prognosis and plan of care are adjusted accordingly. The physiatrist can also reassure the team that the patient is medically well and safe to proceed and progress with their therapy programs, while medically optimizing symptoms such as musculoskeletal pain that might otherwise hinder rehabilitative progress. Challenges remain to enhancing FND rehabilitation services, which are currently largely “fragmented” because of limited rehabilitation providers and programs that could meet the needs of the “heterogeneous population of people with FND.”15 Some physiatrists may not have a high level of confidence or comfort in approaching this population for several reasons. A survey of French junior neurologists, psychiatrists, and physiatrists revealed nearly 90% of respondents did not receive sufficient training on FND during their medical education and residency training16. Existing curricula in health care, including PRM, and relevant continuing medical/professional education programs are lacking in topics related to FND, such as evaluating patients and looking for positive “rule-in” signs on clinical examination, confirming and explaining the diagnosis following evidence-based approaches, triaging patients to appropriate treatments, assessing patients’ readiness for rehabilitation therapies, and intervening where appropriate to ensure patients’ engagement and success in their therapy programs15. Some patients may need a course of cognitive behavioral therapy or other educational resources to address underlying issues, such as lack of self-agency and suboptimal willingness to participate in therapy, before a course of physical, occupational, and/or speech and language therapy15. Despite the availability of a few consensus recommendations for FND, there are only limited guidelines and research specifying the role of physiatrists in FND rehabilitation17. Consensus recommendations are currently available for physiotherapy for functional motor disorders18, occupational therapy assessment and intervention for FND and commonly associated problems19, and speech and language therapy for functional communication, swallowing, cough, and related disorders20. Furthermore, people with lived experiences of FND, including patients and care partners, may have prior negative experiences with the health care system, making it difficult for them to engage/reengage in rehabilitation. Current and future clinicians without proper education on FND may have a limited understanding of the disorder and a “tendency to disbelieve, blame, or shame patients,” potentially resulting in an endless cycle of patients’ health-seeking and health-rejecting behaviors and consequently increasing overutilization of already limited health care resources15,17. Lastly, physiatrists may feel under-supported in providing FND-focused therapeutic services, which are significantly lacking because of insufficient funding and few interested, skilled, and committed rehabilitation clinicians among other factors15. De-stigmatization of FND among stakeholders (including health care providers, policymakers, and potential funders), adequate education and training, further research, and research translation are some of the strategies needing urgent attention and more active involvement of physiatrists and other rehabilitation clinicians. An example of a method to improve FND awareness and education among students, trainees, and clinicians is creating “hub-and-spoke” programs, such as through Project ECHO (Extension for Community Healthcare Outcomes), which has been gaining popularity in the context of virtual care and interdisciplinary collaborations21. A Project ECHO model of FND could be conducted through regular videoconference meetings and include didactics from experts, presentations of anonymized cases requiring remote support, and open fora facilitating the exchange of best practices. Another example is adopting an interdisciplinary care model, such as the “Brain Medicine Clinic,”22 that provides cross-training benefits among brain-related specialties (eg, neurology, psychiatry, PRM, geriatric medicine, neurosurgery, and family medicine) by “equipping clinicians with skills that permit an integrated approach to complex brain disorders,” such as FND. FND is an untapped area of education, training, clinical practice, and research in the field of PRM. Given its complexity, stigma, incidence, unmet needs, and disease burden, it requires a nuanced and comprehensive approach that calls for stronger interdisciplinary collaborations with a focus on rehabilitation that should include PRM specialists. Ethical approval This paper did not require ethical review or registration. Sources of funding This research was supported by the Azrieli Scholarship & Research Catalyst Grant funded by a donation of the Azrieli Foundation to the Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto. Author contributions All authors contributed to the writing of the paper and have approved the final version. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) Not applicable. Guarantor Not applicable.

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