Functional Neurological Disorder Case Study

Author/s

Whitney Greene, Kayla Foster, Scott Gwinn, Jesse Koerner from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.

Abstract

In patients diagnosed with conversion disorder, physical therapy can be an important part of a quicker recovery. During physical therapy the focus should be on what the patient is doing correctly and emphasis is placed upon the physical gains of the patient. The patient must be progressively challenged while integrating behavior modifications among functional mobility programs. Research shows the most productive interventions include gait training, strengthening, neuromuscular re-education and balance training, with a full recovery expected for most patients. Conversion disorder may also be referred to as functional gait disorder, hysterical paralysis, psychomotor disorder, conversion reaction, or chronic neurosis.

Patient Characteristics

• Demographic Information: (occupation/vocation, gender, age, etc.)
• Left side of bodySevere weaknessParesthesiaDifficulty walking, loss of balance

Difficulty swallowing, “a lump in the throat”

Non-epileptic/pseudo seizures or convulsion

Episode of unresponsiveness

Slurred speech

Double vision

Hearing problems

Headache

• Medical diagnosis if applicable
• Co-morbidities
• Previous care or treatment

Examination

• Subjective : Patient History and Systems Review (chief complaints, other relevant medical history, prior or current services related to the current episode, use relative dates i.e. years or months or days relative to onset of injury or start of treatment, patient/family goals)

Subjective :patient/family goals) Patient History:

A 20 year old female reported to physical therapy with numbness and severe weakness on the left side of her body, specifically her leg. The patient was recently involved in a bicycle collision with a motor vehicle 3 days ago when she was on her way home from school at a small community college. The patient reports the vehicle clipped the front of her bike while crossing an intersection, causing her to crash hard on her left side. The patient doesn’t remember if she hit her head, but she was wearing a helmet. She only recalls feeling very startled and dizzy after the collision with a couple of scrapes on her left leg from the pavement. The patient was taken to the local, rural hospital to screen for a concussion, which came back negative, where she was then released from the hospital. Since the injury 3 days ago, the patient reports her dizziness has converted to double vision and difficulty swallowing like there is a lump in her throat.

Patient reports having increased stressed and difficulty completing school work in the past couple of weeks.

Systems Review:

Cardiac:

Shortness of breath

   Chest pain

   Gastrointestinal: 
   Difficulty swallowing
   Nausea

   Musculoskeletal: 
   Pain in the legs or arms

   Neurological: 
   Headaches
   Dizziness

Diplopia

Tinnitus

Muscle weakness LLE

Paresthesia in LLE

   Urogenital: 
   None to report

Medical History: No medical history to report

Chief Complaint: Difficulty walking and loss of balance

Prior or Current Services Related to Current Episode: (use relative date days, months, years)

MRI, labs, and EMG reports all normal

Self Report Outcome Measures LEFS

FABQ

Outcome measures

• 4 Square Balance Test:

• BERG: 26/56

• 10MWT: 1.04m/sec (Normative for female 20yo: 2.47m/sec)

• STS x 5: 14.2sec (Normative for 19-49yo: 6.2 +/- 1.3 sec)

Objective: slurred speech, trouble hearing PT during eval while speak at normal volumes; patient presented with difficulty walking with decreased gait speed, a limp on her left side, during questioning pt grinded teeth and gave very painful expressions during MMT

Physical Exam

• Neurological: negative, however patient complains of agitation with wearing long pants

• Vitals - normal

• No reproduction of symptoms

• DTR: normal

• ROM: WNL passively, but difficulty with full hip & knee ROM to march in place

• MMT:

•Left quadriceps, hamstrings, gluteal muscle group, dorsiflexion: 4/5

Note: During MMT of quadriceps, hamstring contracted in opposition and vice versa with hamstring MMT

•All of other muscles on left side and right side: 5/5

• Gait: Ataxic with tremors, gait did not follow normal pattern of deficit, limped on L side with shorter step length on L, movement was jerky and exaggerated

Summarization of Examination Findings

Working Diagnosis and Targeted Interventions

Intervention

• Phases of Interventions (e.g. protective phase, mobility phase, etc.)
• Dosage and Parameters
• Rationale for Progression
• Co-interventions if applicable (e.g. injection therapy, medications)

Outcomes

Findings Over time

Discussion

Summary Statement which should include related findings in the literature, potential impact on clinical practices

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