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 high anxiety

Co-morbidities

None in medical hx or pt reported

Previous care or treatment

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 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

Physical Performance Measures 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 : Physical Examination Tests and Measures 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, dorsiflexors: 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

Clinical Impression

Based upon the exam findings, the clinical impression would lead to conversion disorder.

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 Volley Ball

Wobble board

Gait

Parallel bars

Weight shifts A/P, M/L

Walking around objects

Strengthing of LE

STS

4-way hip with TBw

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

Treatment Progression:

Build Rapport

Let the patient know you think they have a problem

Make the pt want to work with you and take ownership of the problem

Reward wanted behaviors and give positive reinforcement

Ignore unwanted behavior, but do not punish

Emphasize quality over quantity

Develop goals in collaboration with the patient

Don't focus on their deficits, focus on their positives

Introduce patient to full collaborative team involved in their care

Pre-gait and strengthening

Weight shifting

Balance

STS

Transfer training

Decrease BOS

Dynamic sitting balance

Tandem stance

SLS

Bed mobility

Gait

Standing and gait in parallel bars

Step over objects

Side stepping and backwards stepping

General Mobility

Gait outside of parallel bars

Maneuvering obstacles

Endurance training

Multitasking

Seated weight shifting

Community Integration

Walking outside

Curb management

Uneven terrain

Ascending/descending stairs

Architectural barriers

Community/job/recreation incorporated

Walking while carrying books

D/C 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 pt believe they are getting better. The progression follows the progression of someone with neurological disease with known origins because research shows conversion disorder follows similarly to the progress of a neurological disorder. Research 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)

Outcomes

Patient was able to completely recover and integrate back into everyday life with normal function and gait.

Discussion

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

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