Development of an inpatient rehabilitation pathway for motor functional neurological disorders: Initial reflections, 2022, Polich, Perez, Baslet et al

Abstract

BACKGROUND:
Emerging research supports a primary role for rehabilitation therapy alongside psychoeducation and psychotherapy in the treatment of functional neurological disorder (FND).

OBJECTIVE:
While consensus recommendations for physical therapists, occupational therapists, and speech and language pathologists treating FND have been published, specific recommendations for multidisciplinary FND care delivered on an inpatient rehabilitation unit are yet to be established.

METHODS:
This report describes one inpatient rehabilitation facility’s efforts to design and implement a clinical pathway for patients with acute-onset motor FND—patients recently hospitalized for work-up of new neurological symptoms subsequently deemed functional.

RESULTS:
Detailed descriptions on defining admission criteria and delivering consensus- and evidence-based multidisciplinary inpatient rehabilitation are provided.

CONCLUSIONS:
In the context of prospective research studies, considerably more work is needed to delineate the optimal duration and intensity of inpatient rehabilitation treatment for the management of patients with motor FND.

Open access, https://content.iospress.com/articles/neurorehabilitation/nre228006

 

I just had a look. The article consists of a description of a plan for treating people diagnosed with motor FND as part of a two-week in-patient rehabilitation programme. Its hard to make much of it because it doesn't go into detail about what treatments were actually offered and whether they work. Apparently, that crucial information must be held back because, well, we wouldn’t want to waste all our efforts on just one publication when we could split the whole thing up and get two!

There was a lot of talk about multidisciplinary teams and they adopted special names for some services - for example, patients engaged in both physical rehabilitation, which was called "motor reprogramming" and psychotherapy which was cutely called "brain reprogramming". Patients had to display some buy into the idea of FND as a sort of "software problem" in order to qualify. There is an assumption throughout that psychological factors are "known" to play a causal role in FND and that addressing these is "known" to ameliorate the condition. I don't think either of those things is "known".

In general, there may be some good things about being able to offer a diagnosis of FND to people who would otherwise fall through the cracks or get a DSM diagnosis (somatic symptoms disorder or such like). And there may be something to be said for recognising and attempting to help these people with a rehab stay. But the whole FND thing seems to come with a lot "psychological" baggage - that is, assumptions about the major role that thoughts, feelings and behaviours play in maintaining symptoms, and assumptions about how addressing these can make the whole thing go away.

It never ceases to amaze me how confident neurologists are in making sweeping claims about psychological causation despite not having any relevant background. I think they might “mean well”, in the sense that they think they are offering something to a much-ignored group, but I worry about the damage that their assumptions can do if incorrect. When the much-hyped psychological treatments don't work, the person is left to wonder what they did wrong.

 

Wouldn't the equivalent of a "software problem" in a human body be a genetic disorder?

 

I agree. But maybe 'meaning well' is only an excuse if it includes the humility needed to know when you don't know whether what you are doing will be helpful.

 

If "meaning well" were good enough, alternative medicine would be just as valid and legitimate as scientific medicine since they obviously also mean well, in the same general terms anyway. It obviously isn't, most people mean well when they're ruining other people's lives. Experts, however, are not supposed to ruin other peoples' lives, even if they feel warm and fuzzy inside while doing it.

I cannot accept this as "meaning well" when the responses to reports of harm and unfitness for purpose are dismissed with hostility. Cases where it's OK to coerce people with good intent are very rare, coercion needs a far higher burden of evidence than this ideological mumbo jumbo.

 

Hardware vs. software

Yes, talk about dualistic. Its pure cartesian dualism!

 

Sound bite medicine. It sounds good until you try to think what it really means ... wait, it means we are full of bugs - a viral illness, yay!

 

And Stone et al have published studies that show there are also so-called "hardware" or structural changes associated with FND. But they tend to ignore this finding, or else speculate that the hardware changes are downstream consequences of FND rather than causal--although as far as I know no explanation was provided for this explanation of the association.

 

This does indeed sound exactly like classical mind-body dualism...

I've read those studies/reviews coauthored by Stone and the findings are equivocal/unreplicated so I'm not sure what to conclude.

 

Reminds me of a comment from Brian Hughes, during his talk to the Norwegian ME Association* - (from memory) if ME/CFS is psychological then you would expect psychological treatments to work - but the evidence is weak, typically from unblinded studies with subjective outcome criteria ---.

So, it's the same with these folks, FND is psychological but there's no evidence that psychological treatments work --- but we know it's psychological and we know our psychological treatments work. Sound familiar? Do they teach this shit and/or are you required to profess your belief in the (alternative) truths in order to be admitted to the profession?

*

https://www.youtube.com/watch?v=D8ayxBSsk_M