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 quick recovery from conversion disorder through experiencing improvement in physical function. 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.) 
• Student
• Female
• 20 years old
• Caucasian

Medical diagnosis if applicable
Diagnosed with Generalized Anxiety Disorder

Co-morbidities
None in medical hx or pt reported

Previous care or treatment
None reported

Examination

Subjective:

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, has difficulty swallowing like there is a lump in her throat, and notices occasional slurred words. Patient continues to have difficulty walking and loss of balance since the accident. Patient reports having increased stress 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 LLE
Neurological
• Headaches over left eye 
• Dizziness with standing and gait 
• Intermittent diplopia
• Intermittent tinnitus
• Constant muscle weakness LLE
• Constant paresthesia in LLE
Urogenital
• None to report

Medical History:
Diagnosed with Generalized Anxiety Disorder

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: 24/80
FABQw: 37/42
FABQpa: 20/24

Objective : Physical Examination Tests and Measures
Patient presented with slurred speech and had difficulty hearing PT during the evaluation. During ambulation, patient presented with a limp on her left side and a decreased gait speed of 1.04 m/sec. Patient also displayed painful facial expressions during LLE MMT.

Physical Exam
Neurological: Inconsistent paresthesia in dermatomes of LLE; patient complains of agitation with wearing long pants
Vitals: Normal
Palpation: No reproduction of symptoms
DTR: Normal
ROM: WNL passively, but difficulty with active full hip & knee ROM while marching in place
MMT: Left quadriceps, hamstrings, gluteal muscle group, dorsiflexors: 4/5
          Note: During MMT of left quadriceps, hamstring contracted in opposition and vice versa with hamstring MMT
          All other muscles on left side and right side: 5/5

Outcome measures
• 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)

Clinical Impression

Based upon the exam findings, the clinical impression is unclear based on a physical therapy diagnosis. The patient has no apparent lesion in her CNS, yet she is experiencing weakness and parasthesia. Inconsistent findings that cannot be explained by an organic or neurological problem would lead the physical therapist to consider conversion disorder. The patient had a non trivial accident of falling from her bike. Although she was tapped by a car, concussion testing came back negative and she only suffered from scrapes on her legs. In cases of converson disorder patients can experience paralysis or parasthesia even when they are not physically harmed enough to cause this impairment. 

Summarization of Examination Findings

There are inconsistencies among repeated testing of sensation and muscle strength, the MMT ranges are not reflected in functional abilities, and sensation deficits are inconsistent with anatomical patterns. Because of these inconsistencies, it is important that we are able to rule out any other possible diagnoses that may reflex these signs and symptoms. Some of the other possible differential diagnoses, but not limited to, are multiple sclerosis, SLE, Guillain-Barre, post-encephalitis syndrome, and brain/spinal tumors. These, as well as any other possible diagnoses identifying an organic cause for the signs and symptoms, must be ruled out in order to assume the patient is suffering from conversion disorder. It is important that the patient understands that the other tests were negative without confrontation, and that a full recovery can be expected.

Plan of Care

Intervention

Balance/Coordination:

• Tandem Stance
• Balloon Volleyball
• Wobbleboard

Gait

• Parallel bars
• Weight shifts A-P, M-L
• Gait with obstacles 

LE Strengthening

• Sit-to-stands
• 4-way hip with theraband
  

Phases of Interventions (e.g. protective phase, mobility phase, etc.)

Treatment Progression:
Build Rapport

• Let the patient know you believe they have a problem 
• Make the patient want to work with you and take ownership of the problem
• Reward wanted behaviors and give positive reinforcement
• Ignore unwanted behaviors, but do not punish for them
• Emphasize quality over quantity
• Develop goals in collaboration with the patient
• Do not focus on their deficits, but focus on their positives
• Introduce patient to full collaborative team that will be involved in their care

Pre-gait and strengthening

• Weight shifts
• Balance
• Sit-to-stands
• Transfer training
• Decrease BOS
• Dynamic sitting balance
• Tandem stance
• Single-leg stance
• Bed mobility 

Gait

• Standing and gait in parallel bars
• Step over obstacles
• Side-stepping 
• Retro gait

General Mobility

• Gait outside of parallel bars
• Maneuvering obstacles
• Endurance training
• Multi-tasking
• Seated weight shifts

Community Integration

• Walking outside
• Curb management
• Uneven terrain
• Ascending/descending stairs
• Navigating architectural barriers
• Community/job/recreation incorporation
• Walking while carrying books
• Discharge planning

Dosage and Parameters

3x per week for 4 weeks 

Rationale for Progression
A patient with conversion disorder needs to see improvements in physical therapy to help the patient believe they are getting better. The progression follows the same progression as for someone with a neurological disease with known origins because research has shown conversion disorder follows similarly to the progression of a neurological disorder. Research further suggests following PT Practice Pattern 5A: Primary Prevention/Risk Reduction for Loss of Balance and Falling for this diagnosis.

Co-interventions if applicable (e.g. injection therapy, medications)

Pharmaceutical interventions, psychologist, occupation therapy, speech therapy, recreational therapy, nursing

Outcomes

Patient was able to completely recover functionally and integrate back into everyday life with normal gait and balance with abolishment of prior symptoms.

Outcome Measures at Discharge:

Berg Balance Scale: 52/56
10MWT: 2.49 m/sec
STS x 5: 5.9 sec

Discussion

Add Discussion Here.

Related Pages

Conversion Disorder Web Page

References

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